Managed care embodies an effort by employers, the insurance industry,
and some elements of the medical profession to establish priorities and decide
who gets what from the health care system. After a turbulent decade of trial
and error, that experiment can be characterized as an economic success but
a political failure. The strategy of giving with one hand while taking away
with the other, of offering comprehensive benefits while restricting access
through utilization review, has infuriated everyone involved. The protagonists
of managed care now are in full retreat, broadening physician panels, removing
restrictions, and reverting to fee-for-service payment. Governmental entities
are avoiding politically volatile initiatives to balance limited resources
and unlimited expectations. By default, if not by design, the consumer is
emerging as the locus of priority setting in health care. The shift to consumerism
is driven by a widespread skepticism of governmental, corporate, and professional
dominance; unprecedented economic prosperity that reduces social tolerance
for interference with individual autonomy; and the Internet technology revolution,
which broadens access to information and facilitates the mass customization
of insurance and delivery.
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