The idea that managed care, in principle, conforms to the Hippocratic Oath may come as a surprise to some, but fee-for-service medicine is inherently no more ethical than managed care, says a panel of physicians, health plan executives, purchasers and consumer advocates convened by the Integrated Healthcare Association, a health care policy think-tank based in Pleasanton, Calif.

IHA examined whether the principles embodied in the Hippocratic Oath are impervious to systems of payment. After debating whether managed care is ethical, the group concluded that only the challenges of practicing medicine under managed care, not the actual delivery of care, differ from fee-for-service care. A physician's ethical code — fighting for what patients need, communicating honestly with them and staying current on best practices — remains constant, regardless of payment system, the IHA team said.

In fact, some in the group thought fee-for-service medicine poses more of an ethical quandary than does managed care. "The more you did, the more invasively you did it, the more you got paid," says Beau Carter, IHA executive director. "There was a real danger that physicians could practice 'why not' medicine — that is, 'Why not do this? Some insurance company will pay for it.'"

Carter prodded the physicians on their conclusions, telling them, "You guys aren't angry enough." The doctors belong to large medical groups where, in most cases, a single physician has less direct financial connection with payers than do doctors who contract individually. Carter says their response was, "I don't make money if I deny people care. If I practice bad medicine and people get sicker, I lose money."

How will this play in Omaha or New York? "If you're a single physician capitated for a small number of patients, there's a one-to-one relationship in how you practice medicine and get paid," Carter continues. "The group thought that even with stop-loss insurance, individual capitation is a bad deal. If we picked a group of six physicians in Nebraska or six specialists in New York City, this conversation would be very different."

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