Commentary on Managed Care
(licensed vs. non-licensed de facto practice of medicine)



"Managed care is a social experiment involuntarily imposed upon a group of unconsenting subjects... the physician and his patient." Anon.

Friday, 18 April 1997

Commentary by
Roger S Case, MD

(Health Officer, Island County & Commissioner, Whidbey General Hospital)


This is the first of a series of commentaries that will speak to the subject of the funding of medical care, and what the average citizen (and businesses) can and must do to regain control of his/her healthcare dollar.


Friday, 18 April 1997

Saturday, 26 April 1997

Saturday, 11 April 1998

Friday, February 15, 2002

Friday, 11 July 2003

Saturday, 7 January 2006

Friday, 10 November 2006

Sunday, 18 March 2007

Wednesday, 13 February 2008

Wednesday, 30 April 2008

Tuesday, 30 December 2008

Monday, 29 June 2009

Sunday, 16 August 2009

Monday, 26 April 2010

Monday, 15 November 2010







Top of Pg.













I have long been concerned — as have others in the health care field and the public — with the fundamental changes that managed care has brought to the delivery of care and to the traditional physician-patient relationship. My basic concern is that the business model of managed care, as implemented by some insurance plans, may inappropriately restrict the physician’s ability to practice quality medicine, and may thus have negative consequences for the patient. Managed care plans may, at times, determine the delivery of care using a corporate business model rather than a medical model. This can delay, or even deny, critically needed medical services. 

The Washington State Health Professions Quality Assurance Division’s mission to protect consumers through proper licensing of physicians and surgeons and certain allied health professionals is being thwarted as more and more medical decisions are removed from the hands of physicians and placed in the hands of plan administrators and their employees. Decisions of medical necessity or the appropriateness of treatment constitute the practice of medicine, and in this state, require a license for such practice. I invite the Board of health in its licensing role to more closely review the operative controls being imposed by certain plans in this decision making process. 

The physician has certain medical-legal and ethical obligations to his or her patients. In summary form, these include:

The relationship between a physician and a patient must be based on trust, and must be considered inviolate. This relationship must not be affected by any contractual obligations on the part of the physician. Open communication and patient advocacy are vital elements of the relationship.

This relationship is not to be constrained by any consideration other than what is best for the patient. Other financial or contractual concerns must be secondary.

Any act, or failure to act, by a physician who violates this trust and jeopardizes this relationship places that physician at risk for being found in violation of the Medical Malpractice Act.

The Washington State Board of Health is charged with the oversight of individual licensees, but who is overseeing the corporate practice of the managed care plans? It is of the utmost importance to the citizens of our communities that medical care continues to be available and delivered with a high level of quality, as determined by licensed professionals. All who are interested in and responsible for the quality of care in a managed care environment must insure that this in indeed the case, and that such care be primarily conducted not for a profit motive, but in the best interests of the patient (the premium payer).  

While it is clear that managed care has been a positive force in the provision of coverage to expanded populations, it also gives rise to the grave concerns noted above. The continued expansion of this model, whether through merger or growth, requires careful consideration of the issues of the physician-patient relationship and of the placement of medical decision-making authority. Such authority must remain with the physician and his or her patient – the only individuals immediately and profoundly involved with the treatment outcome. 

Experience shows that selecting the right medical program is much more involved than choosing a plan based merely upon premium and ‘benefits’. The quality and timeliness of a patient’s treatment may well depend upon the program selected, almost all of which are now ‘managed care plans’.

Managed care means exactly that. The real questions are “who is doing the managing” and “is the treatment timely”. Are physicians truly still in charge of their patient’s care?  

Each person has a right to know everything about their managed care plan, and they can, with their physician’s counsel, select that program which best serves their needs. It is incumbent upon each person to inform him or herself — to learn all that they can about this very important factor in their life — and to select their medical insurance very carefully… very wisely.

It is equally incumbent upon the Washington State Board of Health to clarify, in this era of managed care, just what constitutes the practice of medicine in this state, and to monitor all medical insurance plans to assure that it is the physician responsible for the patient who  determines in a timely manner the services required for his or her patient — not a lesser qualified nor a legally less responsible individual, i.e., a non-physician Plan employee reading from a Plan rule-book.

Quite clearly, the only decision being made by representatives of the Plan administrators is whether the Plan will or will not authorize payment for the requested treatment/ procedure, not whether or not the physician may proceed with the proposed regimen. The latter would still be the physician’s decision… only the payment would not be forthcoming. While the former is not technically “making the decision to treat or to not treat” (and is therefore technically not  ‘practicing medicine’), without adequate funding, care deemed necessary by the physician may not be rendered because it would then become entirely the financial responsibility of the physician or his patient.

This is the very heart of the issue with managed care programs. The true health risk is always the patient’s to bear, and the true financial risk has once again become the provider’s. Wasn't this financial risk what "health insurance" was supposed to resolve? Where is the risk to the Plan handling all the funds… the entity that has no real stake in this scenario except their bottom line? And, when there are not enough funds for the Plan to generate a profit, either the premiums are raised, or the provider payments are diminished! This isn't 'managed care', it's managed financing!

Something is very wrong here. Indeed, why does the public even need the “Plans”? What do Plans really do beyond accepting funds (premiums) from person A and ‘paying’ a portion of those funds to provider C, retaining a substantial portion to pay their staffs, board members and CEOs, to pay for their towering offices, and to insure a profit for their shareholders… all with little risk to  themselves. And why should there be so many Plans, or administrating staffs, or the mountains of paperwork or administrative loopholes to jump through… for both the patient and provider?  This is a very profitable business for insurance companies. (Do you ever wonder why the major buildings in our cities belong to either banks or insurance  companies – all built with other people’s money?) Think about it. There certainly must be a better way!

I close with these provocative questions. Does your managed care Plan give your physician final authority in providing for your treatment? Ask him or her when next you visit the clinic. And while you ponder just which medical plan would best serve you and your family, consider just who will be making the major decisions in your care… will it be your physician,  fully trained and licensed? Or will it be an ABC Insurance Plan employee who is reading the ‘rules’ from a Plan instruction booklet — a Plan which is, in effect, vicariously practicing medicine by controlling the funding, all in the name of controlling costs? Costs to whom?

It's time for a change. The individual paying the bill should be the one directing the show. Just how much directing is being done by the patient?

Roger S Case
, MD, FAAFP, retired Family Practitioner

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