Serving Two Masters?

James P. Weaver, MD
Article Type: 
Feature Article
Spring 1996
Volume Number: 
Issue Number: 

Medical care delivery is currently undergoing rapid pivotal changes in this country. Since the defeat of the Clinton national health plan, the “market” has taken over and managed care has become the sweetheart of the health care reformers. Believed by politicians, businesses, and patients alike, to be the answer to rising medical costs, it is being welcomed by all with zealous advocacy. As potentially important as this movement may be to these groups, however, there is one group to whom these changes may mean its very demise, the physicians.

Yes, the survival of physicians as professionals is at stake in this economic imbroglio. Caught in the middle of this revolution, physicians are choosing sides and making decisions which will influence what society thinks of them and what they think of themselves, for managed care is tampering with the fundamental defining parameter of their professionalism, the patient-physician relationship.

The Transformation of the Patient-Physician Relationship

Until the late 1930s in this country, the patient-physician relationship was relatively unfettered. There were no third-parties. Under these circumstances, physicians and patients related as supplier and consumer: The physician supplied a service, and the patient, the receiver of that service, reimbursed the physician as best he could. Without interference, the physician was viewed as the patient's advocate and trust was the essential ingredient in this interaction.

Following World War II and the introduction of the federal tax laws which fueled the explosion in medical insurance, third-parties entered the picture in force. At first, they were merely silent players behind physicians and patients, and relieved the patient’s fear of medical expenses by supplying the needed money to cover hospital bills and physician charges. During this honeymoon period, third-parties had little to do with the patient-physician relationship. They stayed in the background and actually acted as a “third party.” Under these circumstances, the patient could continue to trust the physician who remained the patient’s irrefutable advocate.

Beginning in the 1970s, however, a new element began to emerge in this patient-physician, third-party triangle. At first, it was only a ripple, maybe a second opinion or just pre-approval for admission, but as expenses rose, third-parties looked for more controls and the intrusions became more strident. Soon, it became not only a “second opinion,” but “approval for surgery.” Now, it is not only “precertification for admission,” but  “precertification for X- days of hospitalization” and “certification for any additional days considered medically necessary.” And today, in the managed care arena, it has become approval of the doctor one may go to, the hospital one may enter, the type of operation that’s “approved,” the prosthesis one may have inserted, the “appropriate” day for your discharge after operation, and the number of follow-up visits you may have with your surgeon. And all of this, in the patients’ eyes, is arranged through the physician. So much of this restrictive arranging is done through the physician, that patients are beginning to wonder, “Who is my advocate?”

The classic patient-physician relationship is crumbling under managed care. No longer does the patient go to a physician based on reputation or trusted referral, but because the physician is merely “on the panel.” Additionally, the doctors on that “panel” know the patients may not have wanted to come to them, but they were forced to choose a doctor from the list given them by the policy chosen for them by their employer. This initial meeting between patient and physician, once a positive interaction by choice, is now frequently an arranged encounter occurring on tainted soil. Unfortunately, that  encounter is only the beginning.

With a managed care plan, the patient’s first visit to a professional is to a “gatekeeper.” And, it would not be long before the patient begins to wonder, “Is this person working for me and my benefit, or for the insurance company? Is this person there to help with my medical problems, or to slow the expenditure of dollars on this ‘covered life?’ Is this provider going to put saving dollars ahead of my well-being?”

The Physician Under Managed Care: The Negative Gatekeeper

Managed care organizations (MCOs), the newest darlings of health care reform, are flourishing. Because many employers believe MCOs will solve their health care cost problems, they are forcing their employees into them at increasing rates. Today, roughly 56 million or about 20% of all Americans with health insurance, have their coverage through some type of MCO. And, as Medicare reform makes its way through Congress, this number is likely to continue to grow not only in the private sector, but in the Medicare age group as well.

Paralleling this growth in the number of MCO enrollees is the number of physician providers signing contracts with the MCOs to provide care for their enrolled patients. Physicians, afraid of being left out of the system, have signed up and ceded their professional autonomy for the promise of access to patients. This influence of the MCOs over physician behavior is dominant and growing stronger.

By signing  MCO contracts, physicians have been forced to speak out of both sides of their mouths. Contradictory statements such as, “I want to work for the managed care company,”  while at the same time remarking, “These rules and regulations are hurting my ability to practice as a professional,” are now common utterances in the physician community. Physicians feel trapped: No contract, no access to patients, no work. And once signed, if you don't cooperate, or if you speak out against the MCO, you can be “deselected.” This intimidation has been persuasive enough that physicians, primary care and specialist alike, saddled with managed care contracts, are falling in line and becoming the gatekeepers for the company.

Gatekeeping is not something new to medicine. Dr. Edmond Pellegrino, of Georgetown University, distinguishes three types.(1)

Obligatory gatekeeping is something that physicians have always done. The physician does not treat the patient with everything available, but selects only those treatments that are both effective and beneficial. Physicians have an obligation to “screen” out those treatments that are not so. We have been doing this since the beginning of the profession; it is our obligation.

Positive gatekeeping occurs when the physician is constrained to increase rather than decrease access to services. The purpose, however, is to increase profits. This is the type of gatekeeping that proponents of managed care accuse the fee-for-service doctors of practicing. Although it does occur, positive gatekeeping is not a common practice among physicians.

Negative gatekeeping occurs when the physician is under constraints of self-interest to restrict the use of medical services of all kinds, but especially those that are most expensive. This is the typical gatekeeping of the MCO. It is not the opposite of positive gatekeeping — it is more insidious.

Positive gatekeeping can sometimes be discovered by the patient. After all, a third MRI scan in two months might be questioned. But, with negative gatekeeping, the patient will have a more difficult time discovering he should have been offered a femoral-dorsal-pedis-bypass rather than an amputation, or that a chest x-ray should have been ordered rather than more antibiotics. It is intrinsically more difficult for the patient to discover or know when something is being withheld or not even offered. That is why negative gatekeeping is deceptive, and what the new managed care enforcers are all about.

Financial Conflicts for the Physician In Managed Care

In joining MCOs, the physicians, both primary care and specialists, are submitting themselves to the negative gatekeeper role. Economic credentialing, hospital capitation, and a perverse system of withholds and bonuses are the methods by which the MCO pits the economic interests of the physician against their offering of medical resources to patients.

Under a system with economic credentialing, the physicians function in an environment where they take care of patients under the threat of “deselection” if the costs of their care decisions exceed the restrictions imposed by the third-party. In this type of practice situation, every test, every procedure, and every additional hospital day would be offered to the patient with the knowledge that it is potentially injurious to the “economic profile” of the physician. Patients who require tests, multiple procedures, or many hospital days are not patients these physicians will want to treat. The sicker patients, those that under the “old” system might have surgery but need three or four weeks to recover, will find it more difficult to locate a surgeon who will operate and risk ruining a good economic profile.

With hospital capitation, the hospital will decide who gets paid and how much for each physician involved in the care of a patient. It all depends on how expensive it is to treat the patient and how much is left after therapy. Here, the sick patients, because they cost the system more, are resented by all the physicians in the plan because they use more than their allocated share of the “pie.” And when time comes for consultation with another specialist, the fee of the consultant will also leave less for other physicians’ reimbursement. Who will freely use (particularly in gray-zone areas and borderline cases) their specialty colleagues in a system of this sort? More important, what will happen to the quality of care?

Finally, there are the withholds and bonuses. Under this perverse system, a physician gets more by spending less on the patient. There is little doubt that the meaning of the term “medically necessary” will change in the physician’s mind when the final common denominator is the wallet. The shame is that physicians will begin to believe what they are doing is proper, because in this new role as gatekeeper it is their duty to withhold treatment and expenditures for the good of the plan and society.

And so, physicians are learning a new ethic, the ethic of cost containment. This ethic weighs the needs of the individual patient against the absolute cost of each item of treatment, the needs of other covered lives in the plan, and the needs of society as a whole. This is what physicians are abjectly learning as they become the agents of rationing for the managed care companies.

The Loss of the Hippocratic Ethic: The Social Consequences

When the new cost containment ethic is contrasted with the traditional model as described by Dr. Edmond Pellegrino, the disparity becomes apparent. “The Hippocratic ethic,” says Dr. Pellegrino, “centers on the welfare of the individual and not of society.”(2) In addition, “If the physician is primarily the patient’s advocate, agent and minister, then the physician must protect the patient’s interests against the system, even with some risk or damage to the physician’s own interests.”(3) These are principles which cannot be fulfilled by physicians in the current managed care environment. Their new ethic and their managed care contracts will not allow it.

And with managed care, patients are losing their only true historic advocate, the physician. Worse yet, the younger generation of physicians, trained in the ethic of cost containment, may not even be aware that they are being trained to forsake the individual patient for the goals of the cost containers.

There has been only one time in recent history when physicians have abandoned the primary advocacy of their patients for another goal. It occurred in Germany in the 1920s and 1930s when young physicians were trained to first practice medicine as an instrument of the German State and to use their skills and training for the betterment of Germany.(4) As these students became mature physicians, the results of their professional misadventures became all too apparent. I am certain, that at the time, the adoption of the goals of the German State seemed logical to these bright young physicians. Looking for causes and goals is a natural characteristic of well-motivated students. But by their abandonment of historic Hippocratic principles, they had unknowingly forfeited their claim on their professionalism by violating their primary obligation to their individual patient — they had lost their society’s trust.           

In a real sense, the basis of our very professionalism as physicians is again under siege. For that professionalism, that public gift, is granted only because of the public’s belief that we can be trusted to look out, above all, for its interests. Once managed care has fashioned physicians into the agents of rationing, that public trust will evaporate, and the physician’s professional castle will certainly crumble.

The current behavior of many American physicians was accurately described by St. Mark, Chapter 8, when he said, “For what shall it profit a man, if he shall gain the whole world and lose his soul? Or what shall a man give in exchange for his soul?” I think that today, he might give a signed managed care contract!

In adopting the banner of cost containment for managed care organizations, physicians have placed their historic position of advocacy for the individual patient in jeopardy; indeed, they have placed their status as true professionals in mortal jeopardy.

And as physicians relinquish their historic Hippocratic obligation of individual patient advocacy for the corporate-imposed purpose of cost containment, they will lose society’s trust, and they risk losing their social position as autonomous professionals. How we physicians understand our professionalism at this moment in history will determine what we think of ourselves and how we view our place in, and our obligations to, society. This view of ourselves will determine who will be attracted to and who will enter the field of medicine, and this will determine the quality of medical care for generations to come.

The Appropriate Role for Physicians in Cost Containment

If physicians are not to become the agents of the managed care organizations, what then are they to do in the struggle for cost containment in medical care? We must continue to practice effective, competent medicine, avoiding unnecessary care and avoiding over treatment of the terminally ill. We must educate the public about our true position as professionals and as patient advocates, and expose the compromised position of the managed care puppets. Finally, we must continue to guard the primacy of the individual patient.

The road ahead for the physicians of the future will not be easy. The choices they face will include hardships which will pale those of the previous and current generation of physicians. Chief among those hardships will be the decision necessary to regain their full stature as professionals, to forgo any direct third-party reimbursement. The receipt of payment, be it sizable or meager, must originate from the physician’s therapeutic focus, the patient. It is only through this choice that physicians can achieve the professional freedom to once again act as society’s trusted instruments of healing.

This path may seem extreme in today’s climate, but it will become evident that it is the only road to the survival of our professionalism and noble mission, as the obligatory noose of managed care slowly chokes the breath from our beloved vocation. Once this difficult path is traversed, and the free, voluntary exchange of direct patient payments for professional services rendered is reintroduced; then, both patient and physician will be free again.

In this new environment of freedom, physicians will find they are dealing with a reborn patient. On a new stage now, physicians and patients will meet once again as individuals with their own free wills and desires, and not as pawns of the managed care companies, playing out their parts in an environment of uncertainty and lurking distrust.

As the debate continues, physicians must muster the courage to believe in and promote these fundamental ideas. Accusations of being “behind the times” and “resistant to change” should not deter us, for these cries will be plentiful and loud. In the end, our historic mission and the Hippocratic ethic must prevail, for the good of society, the profession, and most of all, for our patients.


1. Pellegrino ED. Rationing health care: The ethics of medical gatekeeping. Journal of Health Law Policy, Volume 2, pp.23-38.

2. Pellegrino ED. The metamorphosis of medical ethics. JAMA 1993;269(9):1158-1162.

3. Pellegrino ED. Chapter 22. Rationing health care: The ethics of medical gatekeeping. Medical Ethics. Aspen Publishers, 1988.

4.  Lifton RJ. The Nazi Doctors. Basic Books, 1986.

Dr. Weaver practices thoracic and vascular surgery in Durham, North Carolina, and is a member of the Board of Directors of the AAPS. This article is based in part on Dr. Weaver’s speech delivered at the 52nd Annual Meeting of the AAPS in Falls Church, Virginia, October 1995. His address is 4125 Ben Franklin Blvd., #100, Durham, NC 27704.

Originally published in the Medical Sentinel 1996;1(1):16-18. Copyright©1996 Association of American Physicians and Surgeons (AAPS)


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