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Fam Pract Manag. 1999;6(3):8

It's really a shame that the term managed care has been applied to what has been going on in health care over the past several years. As many observers have commented, managed care organizations don't, by and large, manage to manage care. Access, maybe. Professional fees, certainly. But care? Rarely.

Now, after years of having mud slung at it, the poor phrase has had its literal meaning all but obscured. For physicians, managed care means troops of suits brandishing income-strangling contracts. For the public at large, it means organized denial of care, both experimental and just expensive.

A name that's sick and tired

Even the managed care organizations seem to be tiring of the whole idea. In many cases, they are giving up any pretense of managing care for most of their members. They're retreating to the position that members can see any provider they like, as long as it's one who has agreed to discount his or her rates. (I was amused recently to learn that the “HMO” option offered as health coverage for AAFP staff members was changing its name, with a change in benefit administrators, to “the network model,” apparently in acknowledgment of the fact that it is essentially a restrictive PPO. That seems to me an emblem of the fate of “health maintenance” in today's health care system.) If managed care organizations manage any care, it's the care of their most expensive members — the ones with chronic diseases and the ones facing expensive surgery.

By any other name, would it smell?

Clearly, managed care is all but used up. Who can look at those two words and see their original meaning? And the problem is not merely one of semantics, noteworthy as the semantic challenge is. (What do you call care that is truly managed when you can't call it managed care without fear of being misunderstood?)

The more serious problem is that the whole idea of managing care will collect some of the mud thrown at the words. What if the idea of managing care is discredited simply because we've found that most insurance companies are, unsurprisingly, not very good at it? Won't true managed care efforts suffer — efforts to systematize the delivery of the right care the right way at the right time? We need a new phrase.

It may be that the new phrase is at hand, but I don't believe I've seen it yet. Evidence-based medicine comes close from one direction. Certainly, true managed care must involve identifying what really works. Quality improvement comes close from another direction. Its emphasis on improving the processes of care delivery has to be part of managed care. And its focus on more-than-satisfying the “customer” certainly fits. The best managed care available today does incorporate both a reliance on evidence and a hunger for quality, as well as a laudable economic interest in using resources responsibly. Too bad about the name. Might we be looking for “total quality care”? Perhaps “accountable care”?

Whatever it is, you will be seeing a fair amount of it in the pages of FPM over the coming months and, probably, years. (In fact, you'll find several articles on it in this issue.) Rescuing true managed care from the wreckage of what we now call managed care is an important mission for family physicians today. Not only is the right care the right way at the right time what you want for your patients; the ability to provide such care will gradually become the minimum required of health care providers. It will be what you need to ante up to play.

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Copyright © 1999 by the American Academy of Family Physicians.

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