Managed Care, Managing Uncertainty

THE "MANAGED care" paradigm has challenged most aspects of conventional health systems. Debate abounds on the efficacy,¹ethics,²and finance³of these systems. Meanwhile, enrollment in managed health systems continues to rise⁴as employers urge employees to opt for lower-cost health plans and as states reform Medicaid systems to control governmental budgets.⁵ To understand the issues that managed care presents to the health care endeavor, it is important to understand what is managed. The implied object may be the budget, the physician, health care resources, or, more optimistically, the care of the patient. In this essay, we suggest that one object that is managed is uncertainty. UNCERTAINTY IN MEDICAL PRACTICE Uncertainty is a fact of life in medical practice. We, as physicians, usually do not know unequivocally the full extent of a patient's disease and even less often do we know the best single approach