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March 3, 1999

Defining a "Patients' Bill of Rights" for the Next Century

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JAMA. 1999;281(9):856. doi:10.1001/jama.281.9.856

As the millennium approaches, the health care delivery system in the United States remains in a period of transformation. The commercialization of medicine has challenged the professional dominance of physicians.

Corporate organizations emerged under the assumption that the principles that defined US industry were applicable to health care. They offered efficiency through vertical and horizontal integration. Initially, tremendous cost reductions were achieved. Organizing provider services into competitive networks resulted in the lowest rate of health care expenditure growth in seven years: 4.4%.1 The market was ostensibly beginning to solve the problems of a system that had experienced explosive inflation and failed to provide services to the entire population.

The introduction of an active third party, however, fragmented fundamental relationships. Because physicians have a virtual monopoly over medical practice, they can exert enormous influence. This includes the right to define what constitutes a disease and how to treat it.2 Consequently, overuse of resources became a primary cost-driver. Managers were required to intercede in treatment decisions to control spending. The final denial rate of physician recommendations was no more than 3% overall and 1% for hospitalization and surgical requests.3 However, some of those failures to treat were the basis for the woeful tales retold to Congress this past summer.

Our health care system delivers 4 million babies, witnesses 762 million visits to physicians, and facilitates 539 million days in the hospital.4 But it does so at a cost of $1 trillion, 13.6% of the gross domestic product.1 A "patients' bill of rights" is about establishing a situation in which all members of the community can seek professional services and receive high-quality care at reasonable costs. By defining a standard of care, it promotes the development of innovative, cost-effective organizations that focus on clinical quality improvements, patient satisfaction, and access to information.

This month, MSJAMA considers the meaning of a "patients' bill of rights" from several viewpoints. Throughout the history of this country, physician-legislators have been active in securing rights in health care. This unique US claim to rights appears rooted in a culture of independence. In 1998, when the President of the United States issued an executive order defining a set of standards for treating individuals in federal health plans, he incited the political system to address the revolutionary changes in the health care delivery system. The resultant congressional efforts, however, became more of an attempt to secure consumer rights than patient rights. Furthermore, these political discussions focused on increased regulations to protect those with insurance and made little mention of how to solve the problem of the uninsured.

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