Wednesday, July 26, 2006

Unwritten Law

“No written law has ever been more binding than unwritten custom supported by popular opinion.”

That quotation, attributed to American feminist Carrie Chapman Catt (1859-1947), appeared as a filler in the Living Section of the July 19, 2006 issue of the Omaha World Herald. It neatly encapsulates what may well be the single most important barrier to the effective redesign of our health care system.

For example, take the unwritten law that gives people an unrestricted right to use whatever physician they might choose. Or the one against interfering in the doctor/patient relationship.

The result of those laws is that whoever undertakes to remedy what ails our health care system starts with one hand tied behind his back and the other in a boxing glove.

That was the experience of the so-called managed care era of the 1980’s and 90’s. Managed care companies negotiated with providers, and contracted only with those who offered the most acceptable terms. Their subscribers were fully covered only if they obtained care from the contracted providers. Beyond that, managed care companies refused to pay for services they determined to be unnecessary or inappropriate.

Cost escalation was effectively stopped in its tracks. Furthermore, no convincing evidence has ever been developed that demonstrated that subscribers were physically harmed to any significant extent by denied services. Since every medical procedure involves some risk, it may even be that subscribers benefited from being denied services that they did not need.

But the public rebelled at this infringement of unwritten laws. Managed care was largely abandoned and costs resumed their upward spiral.

The lesson to be learned from all this is that those who would redesign our health care system must first find a way to amend, repeal or replace the unwritten laws that keep it from happening.

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