Erin Dominique Williams & Leo van der Reis, Health Care at the Abyss: Managed Care vs. The Goals of Medicine (William S. Hein 1997). About the authors, acknowledgments, figures, index, preface, references, table of abbreviations. ISBN 1-57588-201-9 [242 pp. Paper.]
Health care reform is shifting decision-making toward a dynamic of shared responsibility. Four major groups are involved: individuals, underwriters, payers and providers. Business, government, the health care industry, and participants all agree that the ultimate issues posed by health care reform are access, cost and quality.
Yet, the authors’ underlying perspective seem to be that of physicians, and its premise that medical providers should build consensus to regain control of health care and return economic incentives to physicians. The title “Managed Care vs. the Goals of Medicine” goes far toward depicting this adversarial theme.
At the outset, the authors identify eleven goals: (1) access, (2) affordability (3) appropriateness of care, (4) comfortable provider-participant relationships; (5) efficient administration; (6) a user-friendly system; (7) appropriate resource distribution; (8) responsiveness to technological growth; (9) participant privacy and confidentiality; (10) appropriate incentives; and (11) group consensus building.
They then provide a useful basic primer of managed care models and definitions. The authors briefly compare and contrast various types of Health Maintenance Organizations (HMOs), including staff, network, group, and direct contract models; Preferred Provider Organizations (PPOs); Individual Practice Associations (IPAs); Physician-Hospital Organizations (PHOs) and Medical Savings Accounts (MSAs). Using the eleven “goals of medicine” as an evaluation model, various managed care models are critiqued with regard to each.
Cursory overview of these models concludes with an assessment that managed care may increase access but do not enhance progress toward the other goals of medicine. The exception in the authors’ view is the IPA, the one model predominantly under physician control.
The authors state that their “mission is to facilitate... ready access to a system of high-quality medical care for all Americans.” While most of their eleven goals fall within the access-cost-quality paradigm, their mission statement conspicuously avoids cost. To understand this and the basic premise of this book, the conclusions asserted must be analyzed with regard to the authors’ perspective, economic motivation, desire for control, and aim of group consensus building.
This book asserts that managed care ogranizations (MCOs) do not give participants what they expect from their health care system. However, the authors seem to presume that their expectations are shared by participants. This is not often true. Providers traditionally operate from an illness model, focusing on participants during the more resource-intensive period. Participants’ goals have become more focused on preventing illness and making cost-conscious care decisions.
Problems purported to be related to MCOs is supported with a few media anecdotes of medical complications. Although longitudinal research is limited, MCOs appear to have more positive effects on health outcomes than a fee-for-service, illness-oriented system. Yet, the authors consistently conclude what they perceive to be weaknesses in MCO models without acknowledging advancements made over similar weaknesses that existed in the previous physician-dominated system.
Two of the eleven goals of medicine, resource distribution and incentives, involve economic motivation. The authors admit that the primary incentive for providers is financial. It is claimed that MCOs provide the wrong incentives, i.e., none for physicians to provide, e.g., lab tests, more frequent office visits or specialist referrals. Such an assumption is misplaced because the focus under managed care is on increased access and decreased cost. Incentive is not related to how much physicians can bill participants, but to the market share of MCOs and participants that providers can win competitively.
The authors believe that appropriate incentives are those which reward providers for delivering maximum (the most) care, not necessarily optimal (efficient, cost-avoiding, risk-assuming) care. They state that “[a]n increase in physician compensation may facilitate access to care.” However, since prices are market-sensitive, in a fee-for-service type system without competition, costs (and thus resources) cannot be managed effectively. Contrary to the authors’ conclusion, managed care has decreased the cost of health care. The rate of growth of health care as a percentage of the gross domestic product has decreased due to the “deregulation” resulting from competition.
The authors argue that cost-containment is inconsistent with quality care. Yet, MCOs work to achieve fiscal goals as well as differentiate between providers in terms of quality. Providers ability to participate in revenue decision-making depends on how well they, e.g., understand costs and use a management model that reducies treatment variations.
A focus on financial incentives shows a desire for control of health care. The authors demonstrate their view of competition by asserting that MCOs, described as “holders of the purse strings,” play providers against each other, frequently to divide and conquer physicians (and hospitals), gaining effective control over both. They further claim that under managed care a decreasing number of “provider positions” may undermine appropriate care. Advocating physicians to exert more control fails to recognize that other groups of providers, e.g., physical therapists, nurse practitioners, psychologists and dieticians deliver “appropriate” care. Other providers using medical management tools, also help to assure reliable health care quality.
Arguing that financially based control of medical decision-making can be detrimental to quality medical practice posits the underlying premise of the book: physicians desire control of the health care system. To rally support for this position, the authors suggest that “if all of the groups have an opportunity to affect the delivery of health care, the system should naturally begin to support the other goals of medicine as well.” In the context of the book’s theme, this conclusion means that if physicians had more control of the health care system, physicians’ goals would gain more support.
The authors continue to encourage group consensus-building among provider stakeholders (coalitions among physicians to oppose MCOs) because “providers are disenfranchised” by highly organized MCOs. They state that group consensus-building is about “leveling the playing field” between providers and holders of the purse strings. This approach would fall short of the kind of consensus necessary to achieve real health care access, cost, and quality goals because all stakeholders are not considered. The group consensus building goal omits three of the four major groups: insurance companies and MCOs; business and industry; and participants. The authors contend that “[d]iscordant forces are currently battling each other at the expense of patients.” They state that the goal of group consensus is likely unobtainable because interests of providers and payers are adverse. To clearly mark their position, the authors assert that “[t]he elimination of the third party payer [MCOs] is a sine qua non for genuine health care reform....”
Finally, the authors propose the “Quincy Model for the Delivery of Health Care” as their formulation of a strategy to achieve the goals of medicine.[1] This model envisions creation of the “American Health Care Trust” (AHCT), an autonomous public corporation which would provide: (1) universal access, voluntary participation; (2) funding through payroll and income taxes; (3) a standardized national computer network for billing/reimbursement management, quality control, health care technical support, and epidemiological research; (4) choice of provider; (5) physician salaries augmented with bonuses; (6) medical education completely funded in exchange for service payback in needed areas; (7) full funding of participating hospitals by a prospective payment or annual budgetary system; (8) coverage for formulary medications, monitored and approved via the computer network; (9) inclusion of all workers’ compensation needs; and (10) allowing commercial insurance companies to significantly downsize and continue to cover non-AHCT or elective services.
The authors declare that the goals of medicine can only be accomplished after consensus is reached by investigating differences in assumptions, and coming to an understanding by recognizing the validity of others’ perspectives. How can the “Quincy Model” achieve these goals when presented from one narrow perspective?
Michael Boggs †
Charles R. Bennett, Risks in the Environment: How to Assess Them (Burloak Publications 1996). Appendices, references for the appendices, prologue. ISBN 0-9680438-0-1 [305 pp. Paper $23.95. 277 Belvenia Rd., Burlington, Ontario.]
This book addresses statistical risk factors in the environment so as to be understood by general audiences. He points out that the primary difficulty in discussing such factors is that debate is usually emotional rather than intellectual. Many studies have shown that public risk perceptions are usually inaccurate, even among the educated. Another obstacle to objective risk assessment is that many form opinions by talking with others, equally ignorant. Also, too few people are “numerate”; many are simply unable to understand statistics and risk factors. According to Bennett, people simplify to avoid the mental overload that complexities produce and do not read deeply enough. He has thus designed this book to minimize the intellectual effort required.
He points out that certain words or phrases are used as icons that acquire their own “mythology”. Such icons become devoid of their “actual, accurate” meaning and make dissemination of accurate information more difficult.[1] Another part of the problem is that probabilities vary according to constantly changing information. Bennett believes we must teach probability theory in public schools if the electorate to make informed, rather than overly emotional, choices.
Typical of the author’s many grievances is that pollution control efforts do not seem to reflect the fact that less than 3% of all cancer deaths are caused by pollution. In that vein, he estimates the cost of safety measures for major risk categories and the number of lives sav ed, giving the cost per life saved. Many claim that a price cannot be put on human life, but Bennett’s point is not to put a monetary valuation on human life. Rather it is to show what categories of lives are most expensive to save.
The more complete the information available, the easier it is to make informed risk choices based on a cost/benefit analysis (I believe citizens are obligated to make). How do we want to allocate resources? Costs are given for a variety of medical procedures such as heart transplants, hip replacements and lung transplants. Do we want to save “fire lives”, “heart lives”, “kidney lives” or “automobile lives”?
The book provides fatality rates for a variety of industries as well as loss of life expectancy (LLE) in days and compares them to the death rates from a variety of natural disasters such as floods, earthquakes and blizzards. Of interest was the author’s categorization of poverty as a cause of death. The fact is that the impoverished have a shorter life span than the affluent due to many factors including stress, diet, lack of adequate health care and violence.
One shortcoming of the book is the apparent scope of its references. It seems to pay too little attention to mortality and other data available from governments outside of Canadian, as well as from the United Nations and other entities.
The book is rich in easy-to-read graphs and charts. One of its greatest strengths is that it simplifies what is necessary for a given study to be considered scientifically valid and provides information which allows readers, at least superficially, to evaluate future studies that purport to assess environmental risks.
If Bennett does no more than prod the electorate and policy makers into considering environmental risks less emotionally, he will have provided a great service.
Penny Dean†
Leonard W. Doob, Sustainers and Sustainability (Praeger Publishers 1995). Bibliography, index, notes. LC 95-7982; ISBN 0-275-95314-9 [167 pp. $52.95 Cloth, 88 Post Road West, Westport, CT 06881.]
In Sustainers and Sustainability, Doob provides a mindful, terrene commentary on individuals who do and do not support sustainability. He illustrates the concept of sustainability through some of its challenges including: endangered plant and animal species, pollution and the ozone layer. He suggests that sustainability has become an urgent challenge as conflicts among people and regions persist or increase and environmental damage accelerates. With this in mind, the book tackles the question: What are the principal, essential attributes of sustainers?
Doob’s underlying premise is that human beings possess or must acquire certain attributes to be sustained on this planet. These function within individual, unique personalities. Such attributes, the author notes, are usually referred to metaphorically and detached from people, as in “Ireland is also experiencing the emergence of an ecological consciousness.”[1] However, he suggests that much can be gained theoretically and practically from identifying traits as embodied in specific individuals. Doob isolates and analyzes attributes that he considers integral to sustainer consciousness, including:[2]
... renunciation, adequate knowledge, sensitive attitudes, and a conviction concerning controllability. These attributes interact with the sustainers’ personalities and then... do or do not lead to appropriate action.A chapter is dedicated to each “sustaining attribute.” Others are devoted, respectively, to understanding challenges, personality, patterning, action and promotion. Having identified essential sustaining attributes, Doob stresses the importance of action in conformity with those ideals. In that regard he quotes Al Gore’s Earth in Balance for the proposition that “billions of small choices by individuals... add up to an aggregate force completely dwarfing most policy decisions by governments.”[3] Actions promoting sustainability include the entire range of human activity from recycling materials to entering into treaties that reduce the risk of war.
Chapter 8 is especially useful in unmasking questionable behavior patterns and by suggesting ways to improve sustainability. It comprehensively analyzes the interrelation between personality attributes (or lack thereof), and subsequent inclinations toward certain types of inaction or selections. It engages readers by asking them to cast an eye inward — toward their own personal choices and habits — and, in doing so, sheds light on possible motives and consequences.
Overall, Sustainers and Sustainability was found thought-provoking. It not only analyzes attributes that promote sustaining behavior but also suggests ways to recognize and encourage them. It invites the reader to increase their awareness, both individually and globally. Doobs maintains that sustainers must possess gaman, a Japanese term connoting “patience, perseverance, endurance, forbearance, fortitude, stoicism”[4] and, especially, the ability to defer gratification. His book promotes the virtues of that philosophy and provides practical ways to achieve it.
Courtney J. Merrill†
Allan Mazur, A Hazardous Inquiry: The Rashomon Effect at Love Canal (Harvard University Press 1998). Abbreviations, appendices: Chronology and The Basics of Toxicology, bibliography, figures, index, photos, references. LC 97-44639; ISBN 0-674-74833-6 [255+ xiv pp. $26.00 Cloth, 79 Garden Street; Cambridge MA 02138.]
The first chapter of A Hazardous Inquiry is entitled, Rashomon. There Mazur, a Professor of Public Affairs at the Maxwell School, Syracuse University, describes a classic Japanese movie of that name in which four participants describe an event “in a way that justifies his or her own behavior while casting blame on the others.”[1] He then says:[2]
... Love Canal has become an emblem of technological disaster in the modern industrial age. The canonical version... is well put by the Columbia Encyclopedia , which I quote....Rashomon has only four characters..., so it is easy to tell the story from every person’s viewpoint. This procedure is impractical for a real event where many people and organizations are involved. I treat six key accounts in detail.
But since there were conflicting interest groups at Love Canal... there must be conflicting accounts of what happened. This book describes and contrasts alternative stories.... ....
The second part of the book is entitled “Accounts” and contains five chapters articulating the views of particular entities, such as Hooker Chemical, or individuals, such as Lois Gibbs who was a key player in getting President Carter to declare a state of emergency at Love Canal in 1980, permitting use of federal funds for relocation.[4] Also, Chapter 6 offers an account of several people whose homes were closest to the site; they are collectively called “Ring 1.”[5]
Rashomon leaves its viewers to piece together the “true” story from the four inconsistent accounts. Mazur, however, does not leave readers dangling. Perhaps he should, but, in the final part of this fascinating and fastidious book, he provides four chapters and a postscript. There, he observes:[6]
My apportioning of blame is fairly equitable. I have spread it around..., and few are exempt. .... I believe that most parties... acted reasonably well, under the circumstances, and despite some blatant lapses. Love Canal was a tragedy in the classic sense... because actions that were — for the most part — personally moral or professionally acceptable combined in unexpected ways to produce inordinate misery.Professor Mazur’s title, A Hazardous Inquiry , may contain a conscious pun. If not, there is much irony in it. Each person he mentions was given a preliminary draft; those one might expect to be most prone to protest approved.[7] A few did not,[8] and Mazur has been at least threatened with suit by some unhappy party.[9] That, too, is ironic in light of his providing the opportunity to comment.
As citizen and scholar — particularly as a lawyer — I find such a threat chilling, more than even the worst spin on a disaster which Mazur describes as “the paradigm example of a community poisoned by toxic industrial waste.”[10] Without the capacity to report on such events unfettered by the need to worry overmuch about tort liability, the entire country is sure to suffer “inordinate misery.”[11]
Thomas G. Field, Jr.†