Ethics and managed care

The rise of managed care represents a shift of power away from consumers and providers of health services and towards those who pay the bills. In effect, managed care is redistributing society's resources. Of course, there is nothing unique to health care about the ethical problem of how to distribute the world's goods. Food, housing, education, and so forth are all distributed in such a way that some have more than others. Indeed, through no fault of their own, children may find themselves deprived of necessities. Given this situation, society is now looking at the decision-making process for determining which medical services actually are necessary. Health care providers have not heretofore had to compete for societal priorities with choices such as corporate profits, employee wages, public education, or other ways of using resources. This process of allocating resources ultimately requires thoughtful people to examine carefully the available data regarding outcomes (ie, benefits) and costs of medical services. Sadly, up to now the medical community has not made collecting such obviously useful information a significant priority. Not surprisingly, commercial entrepreneurs have exploited this vacuum by developing managed-care systems. To influence the resource-allocation process appropriately, healthcare providers must produce justification to use dollars for health care rather than for other essential services. Clinical impressions are not sufficient; data are required. Society is now demanding that health-care providers take up new roles as data collectors and evaluators. If clinicians fail to respond to this challenge these decisions inevitably will be made by others. This topic is addressed more fully in another article in this issue pertaining to the ethics of health care rationing.