PRESERVING COMMUNITY IN HEALTH-CARE

There are two prominent trends in health care today: first, increasing demands for accountability, and second, increasing provision of care through managed care organizations. These trends promote the question: What form of accountability is appropriate to managed care plans? Acc ountability is the process by which a party justifies its actions and policies. Components of accountability include parties that can be hel d or hold others accountable, domains and content areas being assessed , and procedures of assessment. Traditionally, the professional model of accountability has operated in medical care. In this model, physici ans establish the standards of accountability and hold each other acco untable through professional organizations. This form of accountabilit y seems outdated and inapplicable to managed care plans. The alternati ves are the economic and the political models of accountability. In th e economic model, medicine becomes more like a commodity, and ''exit'' (consumers changing providers for reasons of cost and quality) is the dominant procedure of accountability. In the political model, medicin e becomes more like a community good, and ''voice'' (citizens communic ating their views in public forums or on policy committees, or in elec tions for representatives) is the dominant procedure of accountability . The economic model's advantages affirm American individualism, make minimal demands on consumers, and use a powerful incentive, money. Its disadvantages undermine health care as a nonmarket good, undermine in dividual autonomy, undermine good medical practice, impose significant demands on consumers to be informed, sustain differentials of power, and use indirect procedures of accountability. The political model's a dvantages affirm health care as a matter of justice, permit selecting domains other than price and quality for accountability, reinforce goo d medical practice, and equalize power between patients and physicians . Its disadvantages include inefficiency in decision making, capture b y extremists or experts, intractable value conflicts, fragmentation of community, and oppression of minorities. The political model is the m odel we should endorse. Its disadvantages can be minimized by proper i nstitutional design. In addition, recent research on managed care plan s suggests that the political model may be the best for a competitive marketplace because it can ensure that tough allocation decisions are addressed and improve health through changes in nonmedical aspects of community life.