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.