Professional Point

Transitions in health care tend to be driven to some extent by political forces and to a large extent by economic forces. The current degree to which the managed-care industry is on the defensive, combined with a developing "Internet economy" in this country, may foretell drastic changes in health care.

Politically, the industry suffered a stinging defeat as the House of Representatives voted by a significant majority in favor of a series of patient protections, including a patient's right to sue a managed-care company for its negligent actions. While the federal legislative battle is far from over, even the industry's dollars being poured into advertising and lobbying could not stem the tide of a grassroots movement to demand accountability.

In the legal arena, the managed-care industry clearly is on the defensive. Besides lawsuits by health-care professionals and individual patients, a number of class action suits have been developed by what the media refer to as the "tobacco lawyers," that is, well-financed law firms that successfully brought about significant change in the tobacco industry through class actions attacking the industry's pocketbook. These firms have now turned their sights on the managed-care industry. Legal test cases, combined with such media accounts as Newsweek's recent cover story entitled "HMO Hell," are keeping managed care on the run.

Where the money is

But perhaps of greatest significance are recent signs that the managed-care industry is financially on the defensive as well. Venture capital dollars are no longer flowing into health care and managed-care companies as they

did just a few years ago. Stock prices for managed-care companies continue to fall. For the first three quarters of 1999, the stock value of HMOs was on average down 27 percent, while the stock price for all managed-care companies fell an average of 9 percent. Some large companies are finding their long-term debt far exceeds a billion dollars. And one company, United Health, has taken the seemingly drastic step of eliminating utilization review in an effort to be more competitive.

Dramatic change may actually be occurring from a different direction. Managed-care companies are beginning to gravitate toward where investment dollars are flowing--the Internet industry. The sheer number of Internet start-up companies and their ability to raise incredible sums from venture capitalists and public stock sales are attracting the managed-care industry's attention. Managed-care companies are beginning to make deals with these Internet companies, or start their own, to take advantage of available investment money to underwrite the provision of health information and services on the Internet.

Cultivation of the Internet for widespread dissemination of health-care information is likely to be quite beneficial, assuming good quality information. Unbridled provision of health-care services on the Internet, however, is an entirely different matter. Imagine the following worst case scenario: a national if not global network of mental health providers, each seated in front of a PC providing information and services on the Internet with little or no overhead to eat away at profits for the sponsoring managed-care company. Vigilance and immediate actions are necessary to prevent this worst case scenario while simultaneously working to make optimum use of Internet technology.

More than just a technology, or even an economic force, a developing "Internet culture" has the potential to significantly influence health care, behavioral health care and psychology. Some technology optimists argue that future Internet development will result in computers being able to relieve people of virtually every mundane, left hemisphere-type task. This, in turn, is hoped to free us to concentrate our time and energy on creative endeavors, enjoyable activities and improving our quality of life. While such an outcome may be possible, we must not overlook some less than ideal alternative outcomes.

Preserving relationships over the Internet

Development of an Internet culture has both significant risks and opportunities. As we replace face-to-face interactions with technology-assisted interactions, we run the risk of devaluing the role of human relationships and relatedness. For example, research is just beginning to study the phenomenon of "pseudo-intimacy" created through Internet interactions and its ability to displace genuine intimacy with significant others around us. As psychologists, we are uniquely trained in understanding and working with relationships and, therefore, are well-positioned to help preserve genuine, intimate relationships in a developing Internet culture. We have an opportunity to be a pre-eminent profession in this context.

The challenge, of course, is that if relationships become less relevant, a profession whose expertise is in relationships also becomes less relevant. With some strategic and forward thinking, however, psychology can enhance its status while serving society.