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The growing influence of managed care organizations (MCOs) in the mid-1990s has diminished the professional authority of physicians and created conflicts of interest that threaten the traditional patient-physician relationship, sometimes to the detriment of patient welfare. The covenant of trust on which medicine is grounded is significantly threatened.1 In January 1995 the Council on Ethical and Judicial Affairs of the American Medical Association identified some of the ethical problems inherent in MCOs, described how patients could be harmed as a result, and provided guidelines for all physicians to follow to minimize the risk of such harms to patients.2 Recognizing the impact of these problems, the American Society of Internal Medicine offered a number of recommendations for MCOs and physicians in a series of policy papers issued in August 1995.3 The American Academy of Neurology endorses these guidelines and recommendations insofar as they apply to neurologists in the care of their patients, with emphasis and modifications as follows:
1. The interests of patients are paramount. Access of patients to optimal neurologic care may be restricted by a variety of "gatekeeping" functions inherent in MCOs. Nevertheless, it is essential that neurologists provide the best care that modern neurology has to offer, on a timely and efficient basis. What is best care for an individual patient should be based on peer-reviewed, validated outcomes data that demonstrate effectiveness, when such data are available. Guidelines and protocols …
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