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.