Book Review

Health against Wealth: HMOs and the breakdown of medical trust

N Engl J Med 1997; 336:517February 13, 1997

Article

Health against Wealth: HMOs and the breakdown of medical trust
By George Anders. 299 pp. Boston, Houghton Mifflin, 1996. $22.95. ISBN: 0-395-82283-1

The central tension in managed-care systems is between policies and practices that provide all the care that is in the best interest of the patient, and only that care, and an American tradition in which all possible care is provided, especially heroic interventions involving advanced forms of technology, regardless of evidence of benefit. This book describes what happens when consumers and physicians who have been happy with “all possible care” encounter the world of “all and only the care that has benefit.”

In an early chapter, the author acknowledges that managed care came into being to solve a problem — runaway costs. He also summarizes the underlying causes of these costs: an American fondness for technological interventions, excessive numbers of hospitals and doctors, unexplained variation in processes of care from one region to another, and a definition of quality that can best be described as “trying all possible heroic measures, regardless of the evidence for effectiveness.”

Anders then proceeds to flay managed-care organizations for taking bold steps to address these problems. In so doing, he fundamentally sides with the two stakeholders in the health care arena who liked the old system the best: physicians, whose incomes and professional power were nurtured by the open-checkbook fee-for-service system, and consumers, who paid little of the bill themselves and therefore learned to like having no effort spared, even when the chances of benefit were extremely small. His indirect targets are the employers who rebelled against the costliness of the old system, but he directs most of his firepower at managed-care organizations, particularly the for-profit health maintenance organization (HMO). And while he occasionally acknowledges that HMOs may have had some good effects, he clearly believes that they have failed to protect the one aspect of the earlier health care system that was so much appreciated by patients and doctors: If you were very ill, the earlier system would spare no effort to make emergency services and high-technology interventions available.

The book begins with an anecdote about the delayed treatment of a child with meningococcemia and uses the child's poor outcome to portray the HMO as putting fiscally conservative management of the health care dollar ahead of timely care. This approach — a dramatic anecdote, usually extracted from the records of a lawsuit against an HMO, followed by a well-written analysis of flaws in the approaches of some managed-care organizations to the kind of case the anecdote describes — is repeated in most of the chapters, which cover heart disease, breast cancer and bone marrow transplantation, emergency room policies, mental illness, Medicare, and Medicaid.

For-profit HMOs provide Anders's most dramatic anecdotes, as well as his most extreme examples of questionable HMO policies. Perhaps the best chapter in the book chronicles the personal-wealth building and lavish spending of various for-profit-HMO moguls. But the casual reader would have a hard time distinguishing these Wall Street–focused HMOs from the nonprofit managed-care organizations. I found it troubling that only in the last chapter does the author acknowledge that nonprofit HMOs have generally behaved quite differently from the for-profits and that “some managed-care efficiency programs are wisely conceived and should be accepted by all.” This balanced view is missing in the bulk of the book.

Anders displays an antipathy to the principles of continuous improvement, which is puzzling, particularly since this is one method most health care organizations have never really used and since its knowledgeable application may be an excellent way to achieve savings without sacrificing quality.

I also asked myself, Where are the anecdotes, also found in malpractice files all across the nation, of serious injuries and deaths that resulted from the overly aggressive diagnostic and “therapeutic” interventions of unbridled fee-for-service medicine? Anecdotes grab at the emotions and humanize data. So it is not fair to recount the problems of the fee-for-service era with dry statistics on public health and entire populations, and then tell heart-rending stories about what is wrong with managed care. I would have preferred to have both statistics and anecdotes about both eras.

Anders, like the American public he writes for, wants an all-out effort if he gets sick, with lots of readily available hospitals, emergency rooms, pharmaceuticals, specialists, and high-tech interventions — the very things he identifies in an early chapter as causing America's runaway health care costs. Should we have our cake, or should we eat it?

If this book were presented to a jury as the case against managed care, few jurors would not be moved to anger and dismay by the stories it recounts, and undoubtedly the jury would find the defendant guilty. If, on the other hand, it were presented to an academic conference, it would be hooted down for presenting anecdotes in place of evidence. Unfortunately, the vast majority of its readers will not be skeptical researchers in the health services. So, although the book is likely to be widely read and widely quoted, it will add more heat than light to the national debate about HMOs.

James L. Reinertsen, M.D.
HealthSystem Minnesota, St. Louis Park, MN 55426