General Hospital Psychiatry
Volume 21, Issue 4 , Pages 239-248 , July 1999

Captive patients, captive doctors: clinical dilemmas and interventions in caring for patients in managed health care

This paper is based in part on two presentations by Dr. Bursztajn: “Medical Historical Perspectives Regarding Managed Care and Medical Necessity: True and False” (American Psychiatric Association Annual Meeting, San Diego, CA, May 19, 1997); “Medical Necessity, Managed Health Care Denial of Benefits, and the Nuremberg Code” (Princeton University 250th Anniversary Symposium, Princeton, NJ, May 29, 1997).

  • Harold J Bursztajn, M.D.

      Affiliations

    • Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
    • Corresponding Author InformationAddress reprint requests to: Harold J. Bursztajn, M.D., 96 Larchwood Drive, Cambridge, MA 02138
  • ,
  • Archie Brodsky, B.A.

      Affiliations

    • Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA

References 

  1. Schreter RK, Sharfstein SS, Schreter CA. Managing Care, Not Dollars (The Continuum of Mental Health Services). Washington, DC: American Psychiatric Press; 1997;
  2. Stone AA. Paradigms, pre-emptions, and stages (understanding the transformation of American psychiatry by managed care). Int J Law Psychiatry. 1995;18:353–387
  3. Reinhardt UE. Wanted (a clearly articulated social ethic for American health care). JAMA. 1997;278:1446–1447
  4. Emanuel EJ, Brett AS. Managed competition and the patient-physician relationship. N Engl J Med. 1993;329:879–882
  5. Wolf SM. Health care reform and the future of physician ethics. Hastings Cent Rep. 1994;24(2):28–41
  6. Council on Ethical and Judicial Affairs, American Medical Association . Ethical issues in managed care. JAMA. 1995;273:330–335
  7. Mechanic D. Changing medical organization and the erosion of trust. Milbank Quart. 1996;74:171–189
  8. Appelbaum PS. Legal liability and managed care. Am Psychol. 1993;48:251–257
  9. Bursztajn HJ, Brodsky A: Responsibility without scapegoating. Health Decisions, May 1997, p 3
  10. Benesch K: Managed care liability: an expansion of familiar theories. Health Lawyer 9(3):8–14, 21, 1996
  11. DeLuca AA. Holding HMOs liable for medical negligence. Prof Negligence Law Reporter. 1996;11:53–55
  12. Mariner WK. Liability for managed care decisions (the Employee Retirement Income Security Act (ERISA) and the uneven playing field). Am J Public Health. 1996;86:863–869
  13. Appelbaum PS: Managed care’s responsibility for decisions to deny benefits: the ERISA obstacle. Psychiatr Serv 49:461–462, 472, 1998
  14. Miller TE. Managed care regulation (in the laboratory of the states). JAMA. 1997;278:1102–1109
  15. Benjamin M: Congressman introduces ERISA reform. Psychiatric Times, Feb 1998, p 52
  16. Rundle RL: HMOs brace themselves for ‘avalanche’ of new laws: California bills on dispute-resolution process could be model for U.S. Wall Street Journal, Feb 20, 1998, p B4
  17. Bursztajn HJ, Brodsky A. A new resource for managing malpractice risks in managed care. Arch Intern Med. 1996;156:2057–2063
  18. Health care in America: your money or your life. The Economist, Mar 7, 1998, p 23–26
  19. Schmittdiel J, Selby JV, Grumbach K, Quesenberry CP. Choice of a personal physician and patient satisfaction in a health maintenance organization. JAMA. 1997;278:1596–1599
  20. Kahneman D. New challenges to the rationality assumption. Legal Theory. 1997;3:105–124
  21. Meissner WW. The Therapeutic Alliance. New Haven: Yale University Press; 1996;
  22. Horowitz MJ. Introduction to Psychodynamics (A New Synthesis). New York: Basic Books; 1988;
  23. Bursztajn HJ, Feinbloom RI, Hamm RM, Brodsky A. Medical Choices, Medical Chances (How Patients, Families, and Physicians Can Cope With Uncertainty). New York: Routledge; 1990;
  24. Gutheil TG, Bursztajn H, Brodsky A. Malpractice prevention through the sharing of uncertainty (informed consent and the therapeutic alliance). N Engl J Med. 1984;311:49–51
  25. Goleman D. Vital Lies, Simple Truths (The Psychology of Self-Deception). New York: Simon & Schuster; 1985;
  26. Siegler M. Pascal’s wager and the hanging of crepe. N Engl J Med. 1975;293:853–857
  27. Simon G, Ormel J, VonKorff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry. 1995;152:352–357
  28. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life (a conceptual model of patient outcomes). JAMA. 1995;273:59–65
  29. Curtis JR, Rubenfeld GD. Aggressive medical care at the end of life (Does capitated reimbursement encourage the right care for the wrong reason?). JAMA. 1997;278:1025–1026
  30. Bursztajn HJ. From PSDA to PTSD (the Patient Self-determination Act and post-traumatic stress disorder). J Clin Ethics. 1993;4:71–74
  31. Bursztajn HJ, Brodsky A. Authenticity and autonomy in the managed-care era (forensic psychiatric perspectives). J Clin Ethics. 1994;5:237–242
  32. Bursztajn HJ, Brodsky A. Clear, convincing, and authentic advance directives in the context of managed care?. J Clin Ethics. 1994;5:364–366
  33. Bursztajn HJ, Harding HP, Gutheil TG, Brodsky A. Beyond cognition (the role of disordered affective states in impairing competence to consent to treatment). Bull Am Acad Psychiatry Law. 1991;19:383–388
  34. Bursztajn HJ, Saunders LS, Brodsky A. Medical negligence and informed consent in the managed care era. Health Lawyer. 1997;9(5):14–17
  35. Kassirer JP. Our endangered integrity—it can only get worse. N Engl J Med. 1997;336:1666–1667
  36. Asch DA, Ubel PA. Rationing by any other name. N Engl J Med. 1997;336:1668–1671
  37. Bursztajn HJ, Barsky AJ. Facilitating patient acceptance of a psychiatric referral. Arch Intern Med. 1985;145:73–75
  38. Kahana RJ, Bibring GL. Personality types in medical management. In:  Zinberg NE editors. Psychiatry and Medical Practice in a General Hospital. New York: International Universities Press; 1964;p. 108–123
  39. Bursztajn HJ, Brodsky A. Ethical and legal dimensions of benzodiazepine prescription (a commentary). Psychiatr Annals. 1998;28:121–128
  40. Gutheil TG, Havens LL. The therapeutic alliance (contemporary meanings and confusions). Int Rev Psychoanal. 1979;6:467–481
  41. Gutheil TG, Bursztajn HJ. Clinicians’ guidelines for assessing and presenting subtle forms of patient incompetence in legal settings. Am J Psychiatry. 1986;143:1020–1023
  42. Pellegrino ED. Ethics. JAMA. 1994;271:1668–1670
  43. Kilborn PT: Trend toward managed care is unpopular, surveys find. New York Times National, Sep 28, 1997, p A1
  44. Shea v. Esensten, No. 95-4029MN (8th Cir. Feb. 26)
  45. Bok S. Secrets (On the Ethics of Concealment and Revelation). New York: Pantheon; 1982;
  46. Taira DA, Safran DG, Seto TB, Rogers WH, Tarlov AR. The relationship between patient income and physician discussion of health risk behaviors. JAMA. 1997;278:1412–1417
  47. Glassman PA, Model KE, Kahan JP, Jacobson PD, Peabody JW. The role of medical necessity and cost-effectiveness in making medical decisions. Ann Intern Med. 1997;126:152–156
  48. Unger RM. False Necessity (Anti-Necessitarian Social Theory in the Service of Radical Democracy). Cambridge, United Kingdom: Cambridge University Press; 1987;
  49. Connecticut Public Act 97-99, An Act Concerning Managed Care, as amended by Public Act 97-8 June 18 Special Session (1997)
  50. In:  Casanova JE editors. Tools for the Task (The Role of Clinical Guidelines). Tampa, FL: American College of Physician Executives; 1997;
  51. Sabin JE, Daniels N. Making insurance coverage for new technologies reasonable and accountable. JAMA. 1998;279:703–704
  52. Appelbaum PS. Practice guidelines in psychiatry and their implications for malpractice. Hosp Commun Psychiatry. 1992;43:341–342
  53. Bursztajn HJ, Hamm RM. Medical maxims (two views of science). Yale J Biol Med. 1979;52:483–486
  54. Bursztajn HJ, Hamm RM. The clinical utility of utility assessment. Med Decis Making. 1982;2:162–165
  55. Frankl VE. Man’s Search for Meaning, 3rd ed. New York: Touchstone; 1984;
  56. Shuster E. Fifty years later (the significance of the Nuremberg Code). N Engl J Med. 1997;337:1436–1440
  57. Katz J. The Nuremberg Code and the Nuremberg Trial (a reappraisal). JAMA. 1996;276:1662–1666
  58. Ginther C: Managed care and the Nuremberg Code of Ethics: an interview with Michael Rie, M.D. Psychiatric Times, Mar 1998, pp 11–12

PII: S0163-8343(99)00014-6

General Hospital Psychiatry
Volume 21, Issue 4 , Pages 239-248 , July 1999