Introduction

In recent years, insurance organizations in the United States have increasingly adopted managed care strategies in an effort to control the steadily rising costs of health care. The strategies employed by these managed care organizations (MCOs) have in many cases challenged the ethical integrity of physicians caring for patients enrolled in them (Kassirer 1993).

Most healthcare delivery systems pose some challenge to the physician's primary obligation to seek the good of the patient. Payment methods – fee for service, salary, per-capita prepayment – can and do affect how medical professionals pursue the delivery of health care (Hillman 1987, Hillman et al. 1989, Hemenway et al. 1990). Traditional healthcare delivery with physician reimbursement on a fee-for-service basis provides an incentive for physicians to utilize unnecessary or marginally beneficial diagnostic and therapeutic interventions, sometimes to the point of causing harm. Managed care changes the nature of the incentives. Both fee-for-service and managed care challenge physician integrity by creating a potential conflict of interest. In fee-for-service, providing overtreatment has the potential to increase physician income. Under managed care, physician financial welfare is often tied to reducing utilization of consultation, diagnostic, and therapeutic modalities.

Managed care does not inherently lead physicians to put their own welfare above that of their patients any more than fee-for-service systems. However, the challenge to the physician's primary obligation to his or her patient changes form.