HEALTH MAINTENANCE: 25 Years In Review
Today's Journal of the American Medical Association takes a look at changes in health care since President Nixon brought managed care to the national stage with the HMO Act of 1973. At the time, Nixon warned that the nation was "fac[ing] a health care crisis because of high costs generated by the still-new Medicare program" and sought a "national strategy ... to move health care coverage from indemnity to privately operated prepaid health care." After much initial resistance from the American Medical Association, JAMA reports, the bill passed and managed health care has been a buzzword ever since. A number of experts weigh in on the impact of the 1973 legislation and the transformation of the industry since:
- Joel Shalowitz of Northwestern University said the act "legitimize[d] the concept of prepaid health care, making it easier for employers to embrace." He noted, "There was a federal qualification element in the act that at least put forth some standards."
- Dr. Alan Hillman, director of the Center for Health Policy at the University of Pennsylvania, said that along with the 1973 standards came "mandates and other rules that made the concept unattractive." He says that because of the restrictions, managed care plans didn't really "start to take off until the early 1980s, when the constraints on them were lifted."
- Karen Ignagni, president of the American Association of Health Plans, noted, "Health plans were built on the principle that they should be held accountable, that they should provide quality care while containing costs."
- Paul Ellwood, who coined the term health maintenance organization, said so far HMOs have neglected their potential for improving "quality and competition."
- Dr. Nancy Dickey, president of the AMA, said the act's passage "had a profound effect on medicine." Since 1973, Dickey said, the health market has "literally" been "transformed." She noted, "I think some of it has been good -- accountability and integration of services, for example. But the bottom-line mentality ... and changes in incentives that alter how physicians treat patients have created at least as much angst as the positives have created good."
- Princeton University's Uwe Reinhardt said, "HMO is a misnomer. Most don't engage in health maintenance. The tenure of the enrollee isn't long enough to make those up-front investments worthwhile." But Ellwood predicts that won't last. He said, "The next phase of the evolution will involve another power shift. This time consumers and patients will gain the upper hand by exercising choices based on objective comparisons of quality" (Mitka, JAMA, 12/23 issue).