Three of every four insured American workers now get their health care through some form of managed care, a new study reported last week.
The surprisingly swift shift affects millions of people - many of them not by choice - and has far-reaching economic, political, public health and personal consequences still not widely understood. It also holds unforeseen dangers and calls for new safeguards.The lure of managed care has always been that it would control the steeply spiraling costs of health insurance for employers and other providers and reduce the soaring percentage of the nation's income spent on medical care.
The apparent success of managed care in doing so has been the impetus for the dramatic change in who gets what kind of health care where, from whom and at what price. Pushing millions of employees into HMOs, preferred provider organizations and point-of-service plans has cut the growth in employers' costs to less than 3 percent annually since 1994, after years of double-digit increases.
The savings have come from restricting the doctors patients can see, limiting what physicians are paid (and sometimes providing financial incentives for minimizing high-cost care), making deals with hospitals and pharmaceutical companies to reduce charges, denying some forms of medical treatment and emphasizing preventive medicine.
But holding costs down may not be so easy. Some economic forecasters say medical costs may rise by 4 percent this year and perhaps as much as 10 percent in 1998. The reasons are obvious and many are beyond the control of managed care.
The population is aging; not only are the elderly increasing but the big generation of baby boomers is moving into middle age and requiring more medical care. New medical technology, such as organ transplants and heart bypass surgery, is expensive. So are many new drugs, such as cancer chemotherapy and the regimen of pills prescribed for AIDS. More people are surviving with chronic ailments that require continuing treatment.
There are also pressures in managed-care organizations to make profits, to increase return on equity for stockholders, to finance mega-mergers and to pay high salaries to executives. This new layer of financial costs imposed on the nation's health-care bill will grow, and will mean trying to squeeze even more money out of services to patients.
No sweeping change that involves millions of people and billions of dollars can occur so quickly without problems and abuses. As the nation adjusts to the new realities of managed care, several precautions are essential and urgent. Among them:
* Physicians must be empowered to stand up for their patients, to insist they get the best possible medical care, even if cheaper but less effective alternatives are available and pushed by HMO management.
Some physicians have submitted too readily to ''gag'' rules in their contracts that prevent them from telling patients about expensive options and to financial incentives that give them bonuses for reducing costly treatments and hospitalizations.
* Ample and continuing funding must be available for medical research. As HMOs squeeze down what they pay for drugs, pharmaceutical companies may have to cut back on the development of new medications.
Yet we urgently need new medicines and treatments for dozens of intractable illnesses. Government grants (sometimes influenced by the political pressures generated for high-profile ailments) should not be the only major source of funding.
* Managed-care organizations must make good use of the expertise of specialists instead of requiring that primary-care physicians - or gatekeepers - take on medical problems for which they are not as well trained or as experienced.
* Congress and state legislatures will have to learn when and how to intervene and regulate managed-care practices in response to complaints from patients/voters. So far, legislators have been effective in countering some of the obvious abuses - such as outpatient mastectomies and eight-hour hospitalizations for childbirth.
It's impractical and inefficient to count on legislatures to act on managed-care policies disease by disease, operation by operation. It puts illnesses in competition with each other for political attention and gives politicians too much control over our lives and health. But unless HMOs can curb their zeal for minimizing care despite the human costs, they will continue to invite political interference.
* Employers who have been the driving force in pushing workers into managed care must keep better tabs on how good the treatment is. They have more control over the evolving system than any other force.
Managed health care is now an established fact in America. Millions of us have a life-or-death interest in making it work, fixing its flaws and preserving the level of health care that has been the best in the world. It won't be easy.