Enormous changes have recently swept through the organization and delivery of medical care. Scholars and students of the health care system and its politics try to make sense of the shift in power to identify and allocate needed resources away from physicians and toward corporate firms. I suggest that we cannot understand managed care unless we understand its power as at least substantially due to its reliance on a claim to be better science. In this way, managed care needs to be placed within an analytic historical tradition that is concerned with how accounts of scientific objectivity become convincing and support (and are confirmed as scientific by) social and political objectives. In this way, managed care reflects what I call the technocratic wish: an appeal to objective measures to resolve contentious issues and/or clothe their resolution as scientifically logical and natural.

The technocratic wish: making sense and finding power in the "managed" medical marketplace.

In the late 19th century, American neurologists directed an inordinate amount of energy toward developing and adopting a wide variety of diagnostic and therapeutic technologies. They readily adopted the instruments and techniques developed by their European colleagues and in addition developed numerous gadgets to facilitate or quantitate every conceivable aspect of the neurologic examination. The emphasis on technology can best be understood by considering the process of specialization at that time.

The role of technology in neurologic specialization in America

A rich academic literature exists about issues of informed consent in medical care, and, to a lesser extent, about a variety of issues posed by human experimentation. Most commentators regard patient autonomy as a desirable— though in practice often unattainable—goal, and near unanimity exists about the necessity for even fuller disclosure before experimenting on subjects. Although this Article intentionally side-steps the broader debate about informed consent, it challenges the conventional wisdom that special disclosure rules should apply in the experimental context.
 Clinical trials have become big business. Estimates suggest that as many as twenty million Americans have enrolled in formal biomedical studies, though, as a measure of the full scope of medical experimentation on humans, that figure may represent only the proverbial tip of the iceberg. Historically, sponsors of clinical trials recruited subjects informally, counting on word of mouth among physicians and also perhaps posting flyers around college campuses.

Informed consent and the elusive dichotomy between standard and experimental therapy.

https://www.econstor.eu/bitstream/10419/47385/1/232002592.pdf

Managed Care: Medizin zwischen kommerzieller Bürokratie und integrierter Versorgung. Das Beispiel USA

INTRODUCTION Modern American medicine is far from ideal. Physicians practice by rules learned in medical school, rules often based on anecdotes or untested hypotheses. Medical opinion leaders shape practice by their own experience even though anecdotes are no substitute for clinical studies. Pressures to diagnose and treat come from pharmaceutical companies, equipment manufacturers, hospitals and managed care organizations (MCOs). The end result is often too much medicine or too little, but rarely the appropriate amount. Patients can end up suffering iatrogenic effects of infections picked up during hospital stays, complications from surgery or drug side effects or "cascade effects" that occur when several interventions fail in succession.1 In many areas of medicine, information regarding appropriate practice is missing or incomplete.2 Research on appropriateness indicates that from one-quarter to one-third of medical services may be of no value to patients.3 One 1988 study concluded that 21% of pediatric hospital use is medically inappropriate.4 Other studies have found that between 20 and 40% of hospital ancillary services are unnecessary.5 For example, carotid enterectomies, procedures that remove clots in arteries leading to the brain, were judged as appropriate in only 35% of the cases surveyed.6 In one study, researchers looked at implantation of permanent cardiac pacemakers in a large population.7 They found that 44% of the implants were properly indicated, that 36% were possibly indicated and that 20% were not indicated.8 Seventy-three percent of the hospitals had an incidence of 10% or more unwarranted implantations, regardless of hospital.9 A recent review of the research literature concluded: there are large gaps between the care people should receive and the care they do receive. This is true for all three types of carepreventive, acute and chronic-whether one goes for a check-up, a sore throat, or diabetic care. It is true whether one looks at overuse or underuse. It is true in different types of health care facilities and for different types of health insurance. It is true for all age groups, from children to the elderly. And it is true whether one is looking at the whole country or a single city.10 Surgery is performed on those who do not need it and not performed on those who do;II medications are prescribed inappropriately or not used when an informed physician should use them;lz prevention is not offered when it will save future pain and suffering.l3 Much medical care simply does not meet professional standards.l4 As Mark Schuster et al. write, "[a] large part of our quality problem is the amount of inappropriate care provided in this country."15 They estimate that about 50% of people receive recommended care, 70% receive recommended acute care and 30% receive contraindicated acute care.16 For chronic conditions, about 60% got recommended care and 20% contraindicated care.17 Neither has the debate over the benefits of fee for service (FFS) versus managed care plans been productive. Studies have found little meaningful difference in quality or outcome, and quality was often disappointingly poor for both FFS and health maintenance organizations (HMOs).is What can one make of these contradictory and discouraging observations? This Article argues that a major source of improvement of medical practice will be the dissemination and proliferation of clinical practice guidelines on the Internet. Such guidelines provide physicians with access to authoritative sources grounded in solid clinical research.19 If physicians can be induced to notice and alter practice to reflect these guidelines, the practice of medicine will improve. The use of Internet websites to provide easy and friendly access to practice guidelines and other sources of medical information will have at least two effects: such access (1) will promote ready adoption of evidence-based guidelines by larger numbers of physicians; and (2) will give patients the opportunity to cross-check specific standards of care and where gray areas exist in diagnosis and practice. …

Gary S. Belkin

Papers

The new science of medicine.