Treatment for Managed Care Pain
by Harold J. Bursztajn, MD, Harvard
Medical Alumni Bulletin, Autumn 1999:pg. 9
During the early 1900's my paternal grandmother founded one of the first
insurance trusts to provide medical care for employees and their families.
With the support of my grandfather, a major employer in the lumber industry
of Eastern Europe, she acted in the spirit that one could do well by
doing good. She believed that it was both ethical and good business sense
for the industry to invest in access to health care for workers and their
families. A mother of eight, she died shortly after my father's birth
in 1916. In an unusual display of community, labor unionists and businessmen
rubbed shoulders at her funeral. She left a legacy for my father which
he summarized for me as 'I could trust everyone who worked for us.' This
legacy of trust became life-sustaining when World War II and the Shoah
came and my father became a leader in the Underground, where knowing
who to trust and being trusted all too often meant the difference between
life and death.
Today in America, health care, rather than being a wellspring of alliance
and community building, has become a source of mistrust and division
among physicians, patients, and patients' employers. As physicians we
can help to reverse the erosion of trust in the community among patients,
physicians, and employers precipitated by health care becoming dominated
by managed care organizations (MCOs) by educating the general public,
business interests, and our political leadership during the upcoming
electoral campaign as to community-building, community cost-effective
yet individual choice-preserving alternatives to MCO domination of health
care. Familiarity with the history of health insurance benefits is a
useful starting point for such educational efforts.
Health care insurance benefits came to the United States in the 1940s,
when World War II increased the need for skilled labor at the same time
that wage controls were in effect. The war effort demanded that maximum
productivity be achieved by uniting workers and employers with a common
sense of mission and purpose. With the support of President Franklin
Roosevelt's psychologically sophisticated advisors, American industry
became a willing third-party payor with pretax dollars for health care
insurance. Employers thereby became united with labor unions to effectively
circumvent the existing wage controls. Any additional employer costs
were more than offset by employers benefiting from increased worker productivity.
Productivity benefited both directly via increased worker health as well
as indirectly via increased worker loyalty, morale, and trust garnered
via the 'halo' effect of their employers being identified as contributing
sponsors to the wellspring of trust known as the doctor-patient relationship
as well as to increasing employee choices and access to first-class medical
care. As so well described in the writings of the physician-poet William
Carlos Williams, well into the first two-thirds of the twentieth century
the doctor-patient relationship continued as an oasis of trust in American
life where access and choice of physician were often guaranteed by employer
contributions to traditional insurance plans.
By the late 1970s, however, fears of inflation and competition with employers
in developing countries led U.S. employers to believe the claims of managed
care organizations (MCOs) that rising medical costs were an indication
that patients and their doctors could not be trusted. Among the most
attractive of MCOs' promises was that money could be saved by contracting
with MCOs to keep health care costs down and to promote prevention. However,
since MCOs became immunized from organizational malpractice by overly
broad court interpretations of the Employment Retirement Income Security
Act (ERISA), it has taken decades for employers to begin to realize that
MCOs have maximized their own profit margins and consolidated, reducing
employer/employee health provider choices to the point where the MCOs
are fast becoming a target of antitrust litigation, with little lasting
benefit to overall employer costs and much harm to the doctor/patient
alliance.
As the new millennium approaches, physicians and patients need to encourage
employers to exercise leadership again, but this time in building a system
which provides socially cost-effective, trust-restoring, quality health
care. Recent polls indicate that quality of health care is one of today's
vital issues for voters. At the same time, concerned state and federal
courts have begun to chip away at the earlier overly broad ERISA interpretations
upholding the malpractice immunity that MCOs claim. Even as this editorial
is being written the Supreme Court has taken the question under review.
Moreover, the low American unemployment rate, combined with an increasingly
high-tech, expensive-to-train job market, makes retention of skilled
employees—including the preservation and enhancement of their health—increasingly
cost-effective. The sheer enormity of the billions lost in productivity
due both (directly) to undertreated worker illness and consequent disability
and (indirectly) to such factors as worker demoralization, inefficiency,
and figurative as well as literal absences in the face of undertreated
or untreated family illness defies precise quantification. However, one
can extrapolate social or community costs from a recent New York Times
article, 'Study Details Sacrifices In Caring for Elderly Kin' (11/27/1999,
A8). The article reported a follow-up to 1997 survey results which indicated
that 1 in 4 American families had at least one adult who had provided
care for an elderly relative or friend in the prior 12 months. In the
follow-up, the financial effect per individual who could provide precise
figures was $659,139 in lost wages, Social Security and pension benefits
over the caretakers' lifetimes. It is a reasonable inference that per
affected wage earner, the cost to both employers and taxpayers of undertreated illness
due to a lack of family health care coverage or MCO restriction of care
alone far exceeds the costs to the employee.
In this context it is important that physicians have begun to provide
alternative models to the dominance of managed care organizational control
for communities and employers concerned with both health care cost and
quality. One such model can be seen in a recent article published by
alumnus Dr.William Bayer, HMS '79 (Archives of Family Medicine November/December
1999; 8:546-549) which describes a prevention-centered community-physician
partnership in urban Rochester, New York. Specifically: 'A newly created
community advisory board called Patients and Community Together (PACT)
and the medical director (Dr. Bayer) of the practice in Rochester, NY,
collaborated on all phases of the...project. Papanicolaou smear and mammography
screening, childhood immunizations, diabetes control, and smoking cessation
were targeted for intervention. A practice/community awareness campaign
was instituted and individual and group incentives were developed. Progress
was monitored through a computerized medical record that included all
active patients in the practice. (Results included): Rates of annual
Papanicolaou smears increased from 46% to 71%; annual mammography for
women older than age 50 years, from 56% to 86%; completed childhood immunizations
when younger than 6 years, from 78% to 97%; and performance of semiannual
glycosylated hemoglobin, from 85% to 92%. Rates of patients with glycosylated
hemoglobin values under 10% improved from 56% to 77%.' The cost savings
to employers, employees, and taxpayers of such private practice-community
prevention-oriented efforts are in keeping with the principle that an
ounce of prevention is worth a pound of cure. At the same time, rather
than delegating prevention to managed care organizations, this is a demonstration
that we don't need the overhead of managed care organizations, nor MCO
for-profit motivation (and additional profit margins), to achieve significant
increases in health care quality. Instead, we can implement prevention
efforts which have a reasonable likelihood of reducing future health
care costs even while building community-wide trust.
In contrast, the cost controls imposed by managed care undermine both
care and choice. MCO-sponsored capitation plans penalize health care
providers for delivering services and spending time with patients. MCOs
have restricted clinical practice in various ways. They have denied authorization
for comprehensive services, limited prescribing options with dated formularies,
and enforced economic credentialing of providers. Together these practices
hinder effective treatment. Thus, denial of authorization for pain rehabilitation
services, ranging from physical and psychotherapy to the newest anti-inflammatory
agents with their more tolerated side-effect profiles, is a prime example
of being 'penny wise' and 'dollar foolish.' When managed care restricts
acute and chronic pain services, for example, the inadequate treatment
of pain can lead to increased impairment, loss of work productivity,
higher employee turnover, and an increasing number of work-related disability
claims from otherwise treatable conditions. Chronic pain patients who
are denied health care services are more likely to seek relief by pursuing
workers' compensation claims even if their conditions are unrelated to
work.
Physicians are impeded even when their patients are experiencing acute
pain after surgery. There are restrictions on new pain-reducing medications,
such as the anti-inflammatory prostaglandin, Cox-2 receptor inhibitors.
These new medications are still not approved by many MCOs, yet they are
reported to have a lower risk of postoperative bleeding than more dated
non-steroidal anti-inflammatories. Such MCO restrictions can also diminish
patients' and physicians' autonomy. Yet autonomy itself can be helpful
in providing the empowerment and hope which promote self-care and healing
which can speed recovery. On the other hand, when services are restricted,
physicians often must make 'tragic choices' about narcotics and other
potentially dependency-enhancing, mobility-decreasing medications for
postoperative pain and anxiety relief. The dual hazards of acute postoperative
complications and residual chronic pain, complicated by depression and
dependency, thereby increase. As patients suffer, their freedom to work
and lead meaningful lives suffers as well. Both employer and social costs
mount.
Even now, too few employers are aware that many managed-care practices
lead to cost shifting rather than cost savings. Thus, the woman who is
prematurely discharged from a hospital after a difficult pregnancy (having
been toxemic) and a cesarean section is likely not only to suffer as
far as her own ability to return to being productive at home and at work,
but also to suffer from a family-wide demoralization resulting in other
members of her household becoming impaired in both their work and social
lives. As with the elderly, it is a reasonable inference that the lifetime
costs to the community of such family demoralization far exceed the cost
of providing comprehensive care.
In considering the following, the reader should know that personally
I have begun to serve as a health care advisor to Bill Bradley's presidential
campaign. I hope that all alumni concerned with health care issues will
make the time to work for the candidate of their choice. Whichever candidate
we individually choose to support, the big idea of Bradley's comprehensive
health care proposal to encourage a unified physician-patient-employer
partnership, while respecting individual choices, can with physician
support become part of both major parties' presidential platforms. Although
largely partisan objections have been raised as far as the costs of providing
choices for comprehensive health care coverage not just for children,
the elderly, and the poor, but for 95% of Americans, making the same
comprehensive health care and choice of plans as is currently available
to Federal employees available across life cycle and class is most cost-effective.
It is most likely to reduce actual overall costs of illness to the community
by increasing community unity, trust, and productivity. As my grandmother
realized at the beginning of the century, today, with renewed employer
leadership, a significant alliance of employers, physicians, and patients
can emerge to support the promotion of that social good which is founded
on accessible quality health care delivered by a doctor-patient relationship
of mutual trust and choice.
Harold J. Bursztajn '76 is associate professor of psychiatry and co-Director
of the Program in Psychiatry and the Law at HMS.
I owe my understanding of the important role of employer leadership in
remedying the current health care crisis to Patricia Illingworth's seminal
work on this topic. The author thanks William Bayer'79, Archie Brodsky,
Paula Byron, Andre Churchwell '79, Nancy Dearman, A. Stone Freedberg,
Thomas Gutheil '67, Howard Corwin'58, Montieth Illingworth, John Kotter,
Merloyd Ludington, Robin Paul, Lilly Scher, Elaine Shiang '76, Richard
Sobel, Howard Stein, Alan Stone, and members of the HMS Program in Psychiatry
and the Law at the Massachusetts Mental Health Center.