Genes, Risk, and Managed Care Medicine
There is an increasing need for physicians to thoughtfully analyze and
address with their patients the implications of new diagnostic technologies
whose findings are most understandable in the language of probabilities
and risk factors rather than certainties and rigid categories. Unfortunately,
all too many managed health care practices militate against translating
these new advances into more effective and personal health care.
For example managed care practices include the pernicious profiling
and economic deselection of those physicians as reimbursable providers
who spend the additional resources to formulate a probabilistic differential
diagnosis and to translate such information into a meaningful dialog
with patients. The end result is that physicians and patients are
denied the resources for anything more than at best a pro forma consideration
of diagnostic and treatment alternatives and outcome probabilities.
By the same token, the prevalence of such methods of monitoring as
bureaucratic and categorical reporting forms which are used by managed
care companies to build individual physician practice profiles for
the purpose of profiling and deselection, is a further intrusion
into the privacy patient-physician encounter which threatens patient
autonomy in conjunction with the consequences of unanalyzed and therefore
untreated or undertreated risk factors for illness.
The managed care promoted fiction that patients consent to such intrusions
when they sign a pro forma informed consent form which is a condition
for their obtaining insurance coverage and reimbursement, is a band
aid for the hemorrhage of patient autonomy which itself unduly reduces
diagnostic analysis and clinical dialog. Rather than patients and
physicians settling for such pro forma band aids, what is needed
with today's advances in medicine and genetics is a system of health
care delivery which values the work involved for physicians to engage
in a meaningful diagnostic and informed consent process and protects
the privacy of the patient physician encounter.
--Harold J. Bursztajn, M.D.
