from the editor • • •

A look to the future is already here

Mr. S, a successful businessman, came to my office for a second opinion related to a complica­tion of his cataract surgery. For more than 20 years, he had regularly scheduled eye examinations per­formed by an ophthalmologist with whom he en­joyed a good relationship and freely acknowledged his satisfaction with the quality of his care. About three years ago, Mr. S noted visual symptoms af­fecting his right eye that were beginning to hinder his visual function. After an examination and con­sultation with his ophthalmologist, he was informed that he had a cataract that was responsible for his visual symptoms; the treatment options were ex­plained to him. He decided to postpone surgery until his symptoms worsened. In the ensuing pe­riod, Mr. S's company enrolled with a managed care plan. Mr. Snow decided it was time to have his cataract surgery, but since his ophthalmologist of 20 years was not a member of the managed care plan's panel, he could not perform the surgery. In­stead, Mr. S was instructed to select an ophthalmol­ogist from a list provided to him. He selected an ophthalmologist whose office was close to his home. He went to the ophthalmologist, who confirmed the diagnosis of cataract and scheduled Mr. S for sur­gery. During the course of the procedure a compli­cation arose that was adequately managed intraoperatively but had postoperative sequela.

This scenario is not unique and will occur with greater frequency as time progresses and managed care plans penetrate the market to a greater degree. Long-term patient-physician relationships will van­ish, to be replaced by more casual encounters. The fact that Mr. S's ophthalmologist was a more expe­rienced surgeon possessing greater skill was not a factor in the ultimate health care decision made by

the managed care plan for the patient. This is not to suggest that a complication might not have occurred in the hands of his original ophthalmologist, but speaks more fundamentally to the erosion of stable, satisfactory patient-physician relationships and their replacement by economically expedient encounters.

There is little doubt that managed care is emerg­ing as the way health care will be delivered in the future. There is also little argument that some form of health care reform is necessary and welcome. Regrettably the question of individual patient choice in selecting a physician is being subverted by the managed care process. The choice offered a pa­tient, who is now called a consumer, is a plan and not necessarily a physician. Exclusionary action fees eliminating relationships between patients and their physicians are acknowledged as acceptable because they satisfy the economic scheme of a particular plan. Patients should be made aware of these reali­ties regarding physician choice when they enter managed care plans. The concept of point of ser­vice options must be presented to allow patients to seek the physician of their choice should they wish to avail themselves of this option.

One might conjecture what Mr. S's course would have been had his long-term, trusted ophthalmolo­gist performed the surgery. Clearly, the scenario of complicated surgery, frequent postoperative office visits, increased use of medicines, and the need for a secondary surgical intervention can not be consid­ered cost effective quality care nor should it be con­sidered a model of health care delivery for the future.

Stephen A. Obstbaum, M.D.

J CATARACT REFRACT SURG-VOL 20, MARCH 1994 113