Psychiatrist, Advocate for Patient Care

Chapter 3: The Evolution of Top-Down Medical Care


If in my practice I had been forced to restrict my interaction with Joyce only to the diagnoses of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the imposition of managed care administrators, it is unlikely she would ever have achieved joy and peace in her life – and for certain, our relationship would have been short-lived.


Maybe I am old-fashioned, but in my view, medical care is supposed to benefit patients, not systems.


The March


For decades, we have witnessed the United States’ medical and mental health care systems evolve from the simpler days of Dr. Welby to today’s incomprehensible complexity. After all, Dr. Welby was originally filmed in black and white. Today, Dr. House practiced in living color inside a highly regulated top-down centrally-managed hospital which is paid and evaluated by a myriad of third parties. Dr. House, not coincidentally, picked fights with administrators on behalf of his
patients, and, on TV, at least, he usually won.


Medical care has evolved dramatically during my 75-plus years of life. Today, the federal government, either explicitly or implicitly drives the way we deliver and pay for nearly all medical care.


Historical markers show how the federal government slowly insinuated its way into determining how medical care would be delivered and how to pay for it. The federal government, in 1942, began allowing employers to provide hospital and major medical care insurance to employees
as an employment benefit without violating wage and salary laws.


In 1954, Congress opened the door for IRS intervention into medical care finance by providing employers and employees tax deductibility of their hospital and major medical insurance premiums. Congress had thereby begun building a nearly incomprehensible set of regulations by which it directed employer behavior and decision-making related to the provision of financing for medical care. BenefitsLink.com lists 124 “Internal Revenue Code Sections Affecting
Employee Benefit Plans.”2 Granted, these IRS code sections go beyond direct tax implications, but professional benefit managers know they must take all of it into account when consulting with employers about employee health insurance plans.


Stated plainly, employer tax preferences distort the marketplace as decision-making moves from doing what is best for the employer and employees to how best to abide by and take advantage of the IRS code.


When Congress passed the Medicare and Medicaid laws in 1965, the United States took two giant steps toward an increase in federal oversight of individual medical care. Each of these laws insinuated federal and state overseers into the decision-making process of how and how much medical professionals would be paid and eventually, how they would practice medicine.


Congress passed the 1973 Health Maintenance Organization Act ostensibly to provide more efficiency and value for the health insurance dollar, and in so doing, created prepaid health care plans that became subject to the heavy hand of administrators.


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