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June 1, 1994


Author Affiliations

Georgetown University, Washington, DC

JAMA. 1994;271(21):1668-1670. doi:10.1001/jama.1994.03510450040022

The ostensible goals of health system reform are morally laudable. Few could quarrel with universal access to less expensive care without a loss of quality. What is morally problematic, however, is the way the means chosen to attain these goals might alter the ethical primacy of the physician's obligation to his or her patients. This review outlines some of the unresolved ethical questions inherent in managed care and managed competition as the preferred means to attain the goal of health system reform.

Cost containment through managed care is already familiar to physicians through the operation of diagnosis related groups, preferred provider organizations, health maintenance organizations (HMOs), and utilization and claims review under indemnity plans.1 Managed competition fuses the principles of managed care with those of the market so as further to control costs. Under managed competition, health care organizations are required to compete with each other in terms of

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