Claudia Mills, one Pill Makes You Smarter: An Ethical Appraisal of the Rise of Ritalin

Allen Buchanan's article entitled "Managed Care: Rationing without Justice, But Not Unjustly" detailed on the most cited three ethical criticisms of management. Managed care is first and foremost, criticized to fail in discharging their obligations when it comes to improving access, or at least, not to worsen the already bad situation. Secondly, managed care organizations engage in rationing. This kind of practice prohibits patients to access care to which they are entitled. Lastly, managed care, as in pressures physicians to engage in rationing care, they affect physician's fulfillment of their fiduciary obligations to give the best care to each patient. However, Buchanan in this article, claimed that the three criticisms stem from misconceptions and misintepretation of the managed care institutions. The second and third criticisms assume incorrectly that the United States had already taken its first step in making sure there would be equitable access to care for all. They assume that there is already a standard level of care that must be achieved. And yet, these are not in existence yet. The criticisms did not recognize the fundamental flaw of managed care: the fact that managed care institutions operate in a setting in which there is no significant relationship between rationing activity and the basic requirements of justice.

The article by Allen Bunchanan could not be timelier. It was written more than a decade, but it could still be relevant to what is happening now, more than ever. The problem of managed care is highlighted everyday in different media forms. According to a New York Times article, the problem in the healthcare delivery has to do with what is happening in the economy. Workers who are unfortunate to lost their jobs suffered a double whammy. Not only did they lost their incomes, they lost their employer-based health insurance as a result as well. Millions are forced to let go of the medical care that they cannot pay more. When the people lost their jobs, they also find it hard to look for affordable coverage from insurance companies; some have their application rejected. Therefore, most of them would choose to go with managed care. Managed care is a health care program that is intended to reduce unnecessary costs of healthcare such as costs of care, inpatient admission costs, and inpatient surgery costs. In managed care, more emphasis is given to preventive care and early intervention or diagnosis instead of providing care after an illness or injury has occurred. The responsibility of limiting services is placed on the service provider rather than the patients. Usually they adopt some techniques such as contracting with health care providers, controlling impatient admissions and the length of hospital stay, giving incentives to physicians and patients to choose less costly forms of healthcare and more.

The thing is, it could be observed that what is actually happening is that medical care has been transformed into a commercialized form, a marketplace. Managed care involves a young reimbursement payment method, which could lead to some benefits and problems. Some of the problems comes from the insured customers. Specifically, some of them do not have the motivation nor the means to select their healthcare providers and services. With this inability, comes inflationary distortions in the purchasing system. Those who are unemployed would have no control of the negative consequences of this.

On the other hand, there are problems on the providers' side as well. They provide insufficient incentives, which consist of irrational restrictions on payer and provider behavior, as manifested by the stringent insurance rules and bans on advertising. According to White, turning the managed care scenario into a marketplace, where market forces are harnessed could resolve some of these problems, because the forces could enhance the performance and preserve access ad choice. The rationale and effectiveness of managed care as a marketplace could be discerned in this paper, as well as the weaknesses of this phenomenon.

Although there are good selling points given to managed care, there are also some disadvantages of the program. Giving insurance companies more responsibility introduced new problems: incentives to under provide care, avoidance of high risk patients, coordination problems, and the risk of inflexibility in the provision of services. It appeared that there were several costs saving initiatives created by establishing managed care. Consumers making poor choices, lack of consumer incentives, providers overcharging, and providing competition to control health care costs were problems to be solved by managed care. Some managed care program also involves "risk contracts". The risk contract, through a provider works this way: The managed care organization receives a certain amount of money from the payor (employer, Medicare, private individual) for each insured patient. For a specific number of patients, a certain amount is given to the physicians, another amount to the hospital. An agreement is settled and the providers agree to take care of these patients for the amount of money they receive. Losses are absorbed by the care providers if the costs to the providers are greater. However, if the costs to the providers are less, they keep the "excess" for profit.

Another disadvantage is that some HMO's don't adhere to their promised services. Services are limited based upon what the payor agrees to pay. Usually, the number of visits or the amount of money that will be paid for certain types of procedures are already outlined by the employers. Some complain that services are usually more limited in managed care. In terms of physician service, some provide therapists with less training than expected. At times, the assigned physicians are not accessible nor available at one's chosen time. Processing of appointments may take for some time.

Another disadvantage is that before a patient can be treated, a pre-approval must be presented, which puts a "hassle" to the patients concerned. Some concerned patients may have to change physicians because not all physicians participate in all managed care plans and some physicians take only a few of patients with a specific managed care organization. Because the managed care program has adopted a "selling" approach, some of the promised services have just become a "lip service". (Managed care plan enrollees expect increased efficiency, improved overall standards, reduced costs and better quality of service. It appears that there is no consistent, direct correlation between the cost of care and its quality. Some critics have also observed that managed care has not been a successful health policy, because it has contributed to higher health care costs , such as higher overhead costs

...