Managed care and patients with cardiovascular disease.

Physicians and other healthcare professionals must become more active advocates for patients in this new era of for-profit managed care. We must, for example, add our voices to those of organizations such as the AHA and the ACC that speak out on behalf of persons with cardiovascular disease and institutions that advance knowledge through education and research. During the early 1990s, for-profit managed care swept over the American landscape like a flood, washing away medical traditions and disrupting doctor-patient relationships. By now, the fast-moving currents of managed care have reached virtually every heart specialist and every cardiac patient in the nation. The unique doctor-patient relationship, built on a centuries-old foundation of altruism and trust, has been undermined. Individual patients seeking personalized care are sometimes pushed around like pawns on a chessboard. Meanwhile, doctors sometimes confront hastily constructed but effective barriers that disrupt or destroy long-standing relationships with their patients and their peers. Most readers of Circulation would agree that American cardiology is a brilliant achievement based on the integration of research advances, technological and pharmaceutical innovations, and highly trained clinicians. Heart patients are living longer and better lives as a result of this fertile union and enhanced emphasis on risk factor reduction. Not everyone shares this optimistic view, however, especially those managed care executives whose main goal is to spend less on health care in order to reward their investors and attract new business. The most aggressive leaders of for-profit managed care often seem unconcerned with the ideals and institutions that physicians and patients used to take for granted. They discount the unique mission and special needs of America’s academic health centers, the factories of new knowledge that are a crucial component of this nation’s remarkably productive biomedical research enterprise. Health care, in this age of deprofessionalization, is portrayed increasingly as a simple commodity: physicians are providers and patients are consumers of services. Although this interpretation may appeal to some economists and investors, it surely troubles most patients, nurses, and doctors. Managed care tries to influence medical decision making as part of a strategy to encourage standardization and cut costs. The industry has promoted the concept of the “gatekeeper,” an unflattering euphemism for primary care physicians charged with controlling access to specialists, tests, and treatments. Many health maintenance organizations now expect their primary care doctors to follow referral guidelines such as those drafted by Milliman & Robertson (M&R), a Seattle-based actuarial firm that pioneered the development of proprietary healthcare guidelines a decade ago. Managed care organizations purchase M&R’s ambulatory care guidelines in part because they provide simple algorithms for helping to decide when a patient should be referred to a specialist. The lack of references and outcomes data in these guidelines does not appear to have slowed their diffusion or adoption. The AHA warned recently that many primary care physicians are now being pressured to “accept responsibility for patient care that could be substantially beyond their level of training, experience, and expertise.” M&R’s ambulatory care guidelines encourage primary care physicians who feel comfortable doing so to treat patients with angina pectoris themselves and to consult a cardiologist only if symptoms persist “despite maximal medical therapy with maximally tolerated doses of nitrates, beta-blockers and calcium channel blockers.” Given the risks associated with AMI, consultation with a cardiologist before angina becomes intractable would seem to be desirable. One unanticipated benefit of restrictive referral guidelines is that they stimulated outcomes research to assess more objectively the effectiveness of consultations, diagnostic tests, and therapeutic interventions. Cardiologists have fared well in most of the studies that have compared the outcomes of cardiac patients cared for by primary care physicians or heart specialists. But most cardiologists want to collaborate with primary care physicians, not compete with them. Managed care can take credit for encouraging some positive changes in healthcare delivery, such as the promotion of preventive medicine and the accelerated development of case management tools that help medical professionals deliver care in a more consistent and efficient manner. To be sure, the medical community was developing strategies to enhance efficiency and effectiveness before the managed care revolution. The dramatic reduction in the length of hospitalization for AMI during the past half century is a compelling example of the success that medical professionals have had in conserving healthcare resources while preserving the quality of patient care. Topol and his colleagues reported in 1988 that a brief 3-day stay was safe in carefully selected patients with uncomplicated infarctions. Managed care quickly adopted the 3-day target for some AMI patients despite a warning from these authors that further prospective studies were needed before their protocol could be recommended for clinical use. There is much to commend thoughtful and deliberate efforts to determine the optimal length of hospitalization and the ideal location of care. Most patients are willing to adapt to new strategies such as outpatient angiography and shorter stays after AMI or angioplasty because they trust the doctors and nurses who care for them. They need to know, however, The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association. From the Cardiology Department, Marshfield Clinic, Marshfield, Wis and University of Wisconsin. Correspondence to W. Bruce Fye, MD, MA, Medical Director, Marshfield Heart Care, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449. E-mail [email protected] (Circulation. 1998;97:1895-1896.) © 1998 American Heart Association, Inc.