Thirty years ago, managed care in the form of medical insurance carriers known as health maintenance organizations, HMOs, became a large part of the medical care system. This moved the American medical care system in the direction of what is known as the corporate model.  HMOs became unpopular because insurance coverage was predicated on pre-approval of a doctor's treatment plan.  The unwelcome insertion of a third party between patients and their physicians, in many instances, was shown to be inefficient and, at times, damaging as a result of administrative interference delaying treatment or restricting treatment options.   In a not completely unrelated action, at the same time, an American Medical Association policy was changed that permitted physicians to advertise their services and fees.
The savings achieved by HMOs came in no small part as a result of significant reductions in physician reimbursement as well as in the allowable hospital charges for care of patients with a given diagnosis.  Although slow to recognize that they could no longer monopolize the medical care market, the loss of income led physicians to embrace the use of physician extenders such as physician assistants, nurse practitioners and the hospitalist program for providing care to hospitalized patients. Patients came to recognize that the introduction of these intermediaries resulted in their having less face time with their doctor. 
The combination of these changes in the structure of the doctor-patient relationship with the resultant reduction of access to physicians provided the impetus for the development of alternative sources of information for patients. The venue with the most impressive impact is the rapidly expanding online Internet medical information industry.
This widely-used resource was quickly embraced as a marketing tool by such prestigious medical care providers as Mayo Clinic, Johns Hopkins, Harvard, Cleveland Clinic and the National Institutes of Health. At no charge, anyone can sign on to the websites of these institutions and have instant access to the latest information on a specific disease provided by leading authorities at major academic medical centers. Subsequently, medical information websites were developed by a variety of agents including independent groups as well as solitary physicians. While a few of these sites provide answers to questions without charge, most involve the payment of a fee for the service. The patient asks a question, chooses a provider, pays a fee and gets a response online or by email often with 100 percent satisfaction guaranteed.
Recently, this model of simply answering patient questions has been extended, with many website operators taking advocacy positions with regard to the selection of the appropriate method of treatment for the disease in question and occasionally recommending a specific medical care provider. These activities motivated the development of a National Association of Physician Advisors with physician and non physician members.
The primary issue when using the Internet as a source of medical information concerns the accuracy and validity of the material. Patients should be aware that there is no quality control mechanism or measure in place that certifies the reliability of the information presented by these websites. In the absence of such certification, patients are cautioned not to take any action based on this information without independent confirmation of what they have been told.
2. Barron, B.A., (1999), Outsmarting Managed Care, Times Books, Random House, New York.
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