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.