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Why Primary Care Physicians Should Not Be Restrictive Gatekeepers Aaron Manson, MD

ew p r o p o s i t i o n s a b o u t t h e m e d i c a l p r o f e s s i o n have g a i n e d s u c h r a p i d a c c e p t a n c e , w i t h so little j u s t i f i cation, a s t h e n o t i o n t h a t g e n e r a l i s t p h y s i c i a n s s h o u l d be g a t e k e e p e r s . S i n c e 1972 w h e n C o n g r e s s p a s s e d t h e HMO Act, t h r o u g h r e c e n t p r o p o s e d r e f o r m s t h a t e n d o r s e m a n a g e d c o m p e t i t i o n , t h e n o t i o n t h a t t h e c e n t r a l figure in t h i s delivery s y s t e m s h o u l d b e t h e p r i m a r y care phys i c i a n h a s b e e n widely accepted. As one a u t h o r i t a t i v e textbook notes, " t h e r e is g e n e r a l a g r e e m e n t t h a t t h e g a t e k e e p e r s h o u l d be a g e n e r a l i s t p h y s i c i a n , u s u a l l y a family/general p r a c t i t i o n e r , a g e n e r a l i n t e r n i s t , or a pediatrician." By "restrictive g a t e k e e p i n g " I m e a n a s y s t e m of paym e n t t h a t u s e s b o n u s e s , p e n a l t i e s , or c a p i t a t i o n to link p h y s i c i a n i n c o m e to r e s t r i c t i n g u s e of m e d i c a l services. M a n a g e d care i n c l u d e s m a n y different p r a c t i c e a r r a n g e m e n t s , i n c l u d i n g c a p i t a t i n g g r o u p s of p h y s i c i a n s on salary or fee for service. My c o n c e r n is w i t h p l a n s t h a t capitate individual p h y s i c i a n s a n d t h a t provide direct r e w a r d s for l i m i t i n g m e d i c a l care. I exclude from t h i s d e f i n i t i o n p r e p a i d p l a n s t h a t p a y p h y s i c i a n s a s a l a r y or fee for service w i t h o u t w i t h h o l d i n g s : t h e s e p l a n s do n o t directly r e w a r d p h y s i c i a n s for r e s t r i c t i n g a c c e s s to m e d i c a l care.

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GATEKEEPING VS COST CONTAINMENT: A CONFLICT OF INTEREST? All good p h y s i c i a n s , i n c l u d i n g p r i m a r y care p h y s i cians, s h o u l d be good case m a n a g e r s b y a v o i d i n g u n necessary tests a n d p r o c e d u r e s a n d wasteful u s e of scarce resources. Social a n d professional s a n c t i o n s s u c h a s peer review a n d q u a l i t y a s s u r a n c e have b e e n relatively ineffective in controlling costs a n d m a i n t a i n i n g quality; these s a n c t i o n s s h o u l d be s t r e n g t h e n e d . However, from its i n c e p t i o n , t h e c o n c e p t of g a t e k e e p e r h a s b e e n l i n k e d to r e s t r i c t i o n of a c c e s s to m o r e costly s p e c i a l t y care. As B a r b a r a S t a r f i e l d h a s p o i n t e d out:

Received .from the Department of Medicine, Columbia-Presbyterian Medical Center, New York, New York. Address correspondence and reprint requests to Dr. Manson: Atchley Pavilion--Room 540, 161 Fort Washington Avenue, New York. NY 10032.

There is widespread suspicion that in some plans the basis for gatekeepers is cost-containment rather than rationality of organization.

R e w a r d i n g p h y s i c i a n s for r e s t r i c t i n g a c c e s s to care potentially conflicts w i t h p h y s i c i a n s ' t r a d i t i o n a l fiduciary o b l i g a t i o n to p a t i e n t s . P h y s i c i a n s have a f i d u c i a r y o b l i g a t i o n to p r o v i d e e a c h p a t i e n t w i t h t h e b e s t p o s s i b l e medical care. In fee-for-service practice, p h y s i c i a n s have a n e c o n o m i c i n t e r e s t to provide m e d i c a l services. T h u s , at the r i s k of o v e r t r e a t m e n t , p h y s i c i a n s ' e c o n o m i c interest a n d t r a d i t i o n a l f i d u c i a r y o b l i g a t i o n s are cong r u e n t . W h e n private, i n v e s t o r - o w n e d h e a l t h i n s u r a n c e c o m p a n i e s offer p h y s i c i a n s f i n a n c i a l i n c e n t i v e s to l i m i t care, t h e r e is a p o t e n t i a l conflict of i n t e r e s t b e t w e e n physician and patient. Furthermore, this practice implies t h a t society's o v e r r i d i n g i n t e r e s t in h e a l t h c a r e is cost c o n t a i n m e n t . A m e r i c a n s have i d e n t i f i e d several competing, conflicting h e a l t h care goals, i n c l u d i n g c o s t cont a i n m e n t , b e t t e r access, a n d fulfillment of a n individu a l i s t i c e t h i c of m a x i m a l p e r s o n a l h e a l t h . 2 In o u r p l u r a l i s t i c society we have n o c o n s e n s u s on w h i c h goal s h o u l d come first. T h u s , b e h i n d t h e e c o n o m i c i s s u e of cost c o n t a i n m e n t lies a f u n d a m e n t a l c u l t u r a l p r o b l e m .

RESTRICTIVE GATEKEEPING AND THE MORAL AUTHORITY OF THE MEDICAL PROFESSION T h e m o s t i m p o r t a n t r e a s o n t h a t g e n e r a l i s t physic i a n s s h o u l d reject t h e role of restrictive g a t e k e e p e r is not e c o n o m i c b u t moral. T h e m o r a l p r o b l e m i n h e r e n t in restrictive g a t e k e e p i n g goes b e y o n d t h e e t h i c a l d i l e m m a confronting each individual physician gatekeeper. The role of restrictive g a t e k e e p e r r a i s e s q u e s t i o n s a b o u t t h e moral a u t h o r i t y of t h e m e d i c a l p r o f e s s i o n . Restrictive g a t e k e e p i n g i n f l u e n c e s p h y s i c i a n s to act as r a t i o n i n g a g e n t s . I n s o f a r a s p h y s i c i a n s avoid wasteful b e h a v i o r s t h e y a r e p r a c t i c i n g in a c c o r d a n c e w i t h accepted m e d i c a l p r a c t i c e . W h e n a p h y s i c i a n decides, for e c o n o m i c r e a s o n s , to l i m i t s e r v i c e s t h a t he o r s h e w o u l d o r d i n a r i l y p r o v i d e in a c c o r d a n c e w i t h a c c e p t e d practice, he or s h e is r a t i o n i n g h e a l t h care. It is t r u e t h a t we already r a t i o n c a r e b y a b i l i t y to pay, a n d I do n o t m e a n to defend t h i s form of r a t i o n i n g . However, restrictive 145

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g a t e k e e p i n g s u b s t i t u t e s a n even less morally acceptable alternative. A socially j u s t r a t i o n i n g policy w o u l d r e q u i r e comm u n a l c o n s e n s u s on b a s i c ideals a n d values. S u c h a n a t i o n a l c o n s e n s u s does n o t c u r r e n t l y exist. As Daniel Callahan h a s observed: a satisfactory resolution of the troubled relationship between ethics and the life sciences, and technology more broadly, musl be cultural, not individual. The culture which will find a valid resolution does not yet exist. :~ A c o m m u n a l c o n s e n s u s (Callahan t e r m s it a " p u b l i c morality") s h o u l d s t i p u l a t e w h a t g o v e r n m e n t s , a n d individuals, m a y a n d m a y n o t do. In a democracy, a public morality is e s s e n t i a l if p h y s i c i a n s are to claim t h e m o r a l a u t h o r i t y to act as r a t i o n i n g a g e n t s . W i t h o u t a p u b l i c morality, no single p h y s i c i a n c a n c l a i m t h e m o r a l authority to act as society's r a t i o n i n g a g e n t w i t h j u s t i c e . Even worse, w i t h o u t a p u b l i c morality, p h y s i c i a n s are ill-advised to a c c e p t f i n a n c i a l r e w a r d s for k e e p i n g t h e gate. T h e p r a c t i c e of m e d i c i n e is i n s e p a r a b l e from its cultural context. Several s o c i o l o g i s t s have d e s c r i b e d t h e e r o s i o n of m o r a l a u t h o r i t y in A m e r i c a . 4-6 T h e i r w o r k h a s d e s c r i b e d the decline of a c u l t u r e w h o s e m o r a l a u t h o r i t y was g r o u n d e d in r e l i g i o u s values a n d the e m e r g e n c e of a m o d e r n c u l t u r e b a s e d on faith in science. J o h n Dewey has s u c c i n c t l y s u m m a r i z e d t h e r e l a t i o n s h i p b e t w e e n science a n d c u l t u r e : In truth science is strictly impersonal; a method and a body of knowledge. It owes its operation and its consequences to the human beings who use it. It adapts itself

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passively to the purposes and desires which animate these human beings. It lends itself with equal impartiality to the kindly offices of medicine and hygiene and the destructive deeds of war. 7 T h e l a n g u a g e of s c i e n c e is analytic, n o t doctrinal; s c i e n t i s t s m a k e s t a t e m e n t s of fact, n o t j u d g m e n t s of value. The public morality t h a t Callahan e n v i s i o n s would require fundamental cultural change. Scientists, and p h y s i c i a n s , c a n n o t r e n e w a c u l t u r e . S u c h c u l t u r a l renewal is n o t i m m i n e n t , while t h e p r o c e s s of b u r e a u c r a t i c r e o r g a n i z a t i o n of m e d i c i n e is already well u n d e r way. T h e sociologist Max Weber foresaw in 1904 t h e e m e r g e n t scientific c u l t u r e a n d t e r m e d it a n " i r o n cage. "'~ P e r h a p s he j u d g e d it too harshly. P e r h a p s it is n o t yet too late for p r i m a r y care p h y s i c i a n s to t r a n s f o r m the role of restrictive g a t e k e e p e r into r a t i o n a l case m a n a g e r a u t h o r ized by a well-informed public.

REFERENCES 1. Starfield B. P r i m a r y Care: C o n c e p t , E v a l u a t i o n . a n d Policy. NewYork: Oxford University Press. 1 9 9 2 ; 3 1 , 28. 2. T o n e r R. How m u c h h e a l t h - c a r e r e f o r m will the p a t i e n t go a l o n g w i t h ? New York Times. 1 9 9 3 : M a r 7:sect 4, p 1. 3. C a l l a h a n D. T h e T y r a n n y of Survival, a n d O t h e r P a t h o l o g i e s of Civilized Life. L a n h a m , MD: University P r e s s of A m e r i c a , 1 9 8 5 ; 1 5 4 . 4. Bellah RN. M a d s e n l,I. S u l l i v a n WM. S w i d l e r A, T i p t o n SM. H a b i t s of the Heart. New York: H a r p e r & Row, 1985. 5. Maclntyre A. After Virtue. Notre D a m e : University of Notre D a m e Press, 1984. 6. Rieff P. T h e T r i u m p h of the T h e r a p e u t i c . C h i c a g o : University of Chic a g o Press. 1987. 7. Dewey J. Science a n d society. In: P h i l o s o p h y a n d Civilization. New York: Minion, Balch. 1931 ;319. 8. Weber M. The P r o t e s t a n t E t h i c a n d the Spirit of C a p i t a l i s m . New York: C h a r l e s S e r i b n e r ' s S o n s . 1958.