Now, enough about me (and my life in managed care). Let’s look more into the two topics of our presentation, human rights and managed care.
To my chagrin, realizing that even if I had come to know a lot about managed care, I didn’t know much about the evolution of human rights, so I began to investigate. If the upcoming ACOs were to be HMOs on steroids, as many, including myself, have suggested, understanding this association might be central to our future.
Here’s some of what I found, at least as it seems to related to managed care. In the USA, it was FDR (President Roosevelt) who explicitly stated that health care was a human right. In 1944, not long before he died, he called for a second Bill of Rights, which were to include “the right to adequate medical care and the opportunity to achieve and enjoy good health” and “the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment”. Not long after, in 1948, came the Universal Declaration of Human Rights. This came out of World War II, and thereby that Nazi connection again, and the obvious international goal was to avoid similar atrocities in the future. These prior atrocities, which most of us know about, included torture, unethical medical experimentation, concentration camps, and mass killings of those deemed undesirable to the government. As just one example of how hard this would be to put into practical effect, not long after this declaration, the laws that were to begin Apartheid in South Africa were passed, with virtually no international response.
What astonished me about the Universal Declaration, once I read it, is that while it covered the extreme affronts to human rights, it also covered the everyday needs of everyday life in its 30 Articles. Two of the Articles in the Declaration seemed to be especially apropos to healthcare in general, and maybe managed care in particular.
Article 3: “Everyone has a right to life, liberty, and security of person”.
Article 25: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, and medical care . . .” (I assume this sexist language was intended to include “herself”)
Honing in on healthcare, then, we need to examine how managed care may influence one’s life as far as the prevention and treatment of illness (from Article 3) and how it may influence medical care contributing to health and well-being (Article 25).
Historically, managed care actually predates the Universal Declaration. Over a hundred years ago, it was founded as a not-for-profit way to organize cost-effective care for a group of workers. It was viewed as a socialistic kind of development until President Nixon helped pass legislation beneficial to the emergence of for-profit HMOs and modern managed care. Now, managed care was clearly capitalistic.
Of course, there was no managed care per se in Nazi Germany. Or Stalinist Russia. Or Mao’s China. Or in South Africa (though after apartheid ended, the Archbishop Desmond Tutu at one time would come to advocate for the global spread of managed care). In those countries, it would become common to forcibly hospitalize political dissidents and drug them against their will. We in the United States have not gone to that extreme, yet we could be accused of the torture of political detainees post 9/11 and the related psychological harassment to elicit confessions in jails.
As far as psychiatry per se goes, human rights have been obviously violated with long hospital commitments and unnecessary use of physical and chemical restraints. Currently, the worse may be the enforced, for-profit treatment of adolescents in residential settings. Moreover, a startling percentage (1/6) of adolescents are being medicated with antipsychotics in foster homes. Of course, there are situations of much subtler abuses of human rights, which could include misleading diagnoses, overuse of medication, subtle coercion through the power of the clinician, and lack of adequate informed consent. If we reflect back to Article 3 and “Life” and “Liberty”, maybe the unifying principle, which we we’ll see played out in managed mental healthcare, is the loss of freedom of choice, not only for the patient, but for the clinician.
At its essence, managed care is part of a system of healthcare where some organization is given the authority to manage what healthcare is available, paid for, and delivered. In the USA, the decision to use managed care companies is made by governments or businesses and put into operation via contracts. And, by now, it can be any system that adapts managed care principles without calling itself managed care, due to the Hawthorne effect and need to control costs.
Translating such examples into Article 3 of the Universal Declaration of Human Rights, does managed care help prevent illness? Well, at the beginning, HMOs, aka Health Maintenance Organizations, actually did emphasize prevention. Then, for some time, hardly at all as most companies concluded that the higher initial costs of prevention were not worth the long-range perspective in saving costs, since what could be prevented over many years would likely not still be under the same managed system. More recently, as it became more commonly accepted that behavior was at the root of many chronic illnesses, the trend has shifted back a little as inexpensive wellness programs have emerged.
As to treatment which helps extend and save lives, the conclusion must be inconclusive. There is data and research that unnecessary treatment has been reduced and poor treatment curtailed, but whether better quality of care has also increased seems dubious.
Turning to Article 25, does managed care contribute to health and well-being? The answer remains uncertain, even after 25 years of managed care dominance. Some think managed care companies use the business concept of “trade secrets” to hide whatever data they have that they don’t want to get out. That is similar to what we have found out with many pharmaceutical companies.
So, if you’ve stuck with me so far, and not been worn down (as managed care seems to try to do in practice!), you may anticipate that one can make a case that managed care in the USA has violated some essential human rights. And, in one respect, it has. But, not so fast! Perhaps in another respect, it has not. Due to our unique capitalistic system of healthcare, where those who work are often covered for healthcare by their workplace, complemented by Medicaid and Medicare for many of those not working, there have been increasing numbers of uninsured without any coverage, up recently to more than 50 million, which seems at its best, could be cut in half if healthcare reform completes its gradual emergence. Without health insurance, morbidity and mortality (illness and deaths) increase, along with such social problems as homelessness.
Now, one of the reasons managed care gained such a foothold is that healthcare costs for USA businesses was adversely effecting their competitiveness around the world. That could be controlled if costs were controlled, and drastic increases in healthcare costs were indeed contained for many years, though eventually the backlash against managed care put the brakes on that. Therefore, a reasonable assumption might be that without managed care, the numbers of the uninsured would have been well over the embarrassing 50 million, as companies would refuse to provide healthcare coverage. The most recent complication in all of this, which parenthetically probably could have been addressed by a universal single payer system, is the economic recession in the USA. That has had a ripple effect on obtaining adequate healthcare and insurance, and most dramatically on our stigmatized mental healthcare, where downsizing and closings of clinical and hospitals, from Louisiana to LA (where jails and prisons are the largest mental healthcare “system”) seems unprecedented in my lifetime.
(To be continued in Part 4, where I hone in on psychiatry in particular).
Sad in Psychiatry: Affectionately called a “gadfly,” and known as “da man in psychiatric ethics,” Steven Moffic writes about what makes him sad about modern day psychiatry, and how to “treat” that condition so that we will become glad about what psychiatrists can do to help.