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Capitation and HMOs “Managed care, as we know it, is inherently unethical in its organization and operation. We have an industry that can exist only through flagrant ethical violations against individuals and the public." - Dr Linda Peeno, May 30, 1996 Such harsh words may seem appropriate and expected coming from a vehemently anti-Managed Care activist. But they transform into a powerful indictment of the HMO industry when it comes from an insider. Dr Linda Peeno gave this statement as a part of her testimony before the U.S. House of Representatives Committee on Commerce on May 30, 1996. She had worked as a medical reviewer at Humana, as the medical director of a 35,000 member HMO, a medical director at a hospital, and as a physician executive at Blue Cross/Blue Shield of Kentucky. In her own words, "Whether it was non-profit or for-profit, whether it was a health plan or hospital, I had a common task: using my medical expertise for the financial benefit of the organization, often at great harm and potentially death, to some patients." Her powerful testimony began with a heartfelt admission of guilt, "In the spring of 1987, as a physician, I caused the death of a man. Although this was known to many people, I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was rewarded for this. It brought me an improved reputation in my job, and contributed to my advancement afterwards. Not only did I demonstrate I could indeed do what was expected of me, I exemplified the "good" company doctor. I saved a half million dollars. The man died because I denied him a necessary operation to save his heart. I felt little pain or remorse at the time. The man's faceless distance soothed my conscience. Like a skilled soldier, I was trained for this moment. When any moral qualms arose, I was to remember: I am not denying care. I am only denying payment. At the time, this helped avoid any sense of responsibility for my decision. Now I am no longer willing to accept this escapist reasoning that allowed me to rationalize this action. I accept my responsibility now for this man's death, as well as for the immeasurable pain and suffering many other decisions of mine caused." Unfortunately her directives in life had changed from the Hippocratic Oath in which she swore to protect the interests of her patients, to protecting the interests of the business of which she was a medical director or executive. The code of ethics so fundamental to all physicians was struck from her morality as she assumed the role of a “company” doctor.
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