George Anders. Health Against Wealth: HMOs and the Breakdown of Medical Trust. Boston: Houghton Mifflin Company, 1996. 299 pp. $24.95 (cloth), ISBN 978-0-395-82283-8.
Reviewed by Mark Siegel (Scholar, Phoenix, Arizona)
Published on H-PCAACA (March, 1997)
In this history and analysis of the rise of managed health care in the United States, George Anders not only indicts managed care through a critical examination of the industry's policies and economics, but tells heart-wrenching stories of human tragedy resulting when dollars dictate the bottom line in health care. The indictment comes at a time when managed care--HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations)--is overwhelming traditional and more expensive health care delivery systems in which patients and doctors exercise unfettered choices. (Anders estimates managed care will cover four out of five Americans by 2000.) The strength of managed care plans is their ability to deliver reliable, cost-effective treatment in routine areas of medicine, replacing doctors' visits with call-ins to nurses, ER visits with textbook advice and next-day follow-up appointments. The great vulnerability of such a system, as Anders demonstrates so graphically, is its inability to deal with exceptional cases requiring emergency measures. The structure of Health Against Wealth, which begins with an illustrative medical tragedy, is inevitably convincing and heavily weighed toward the conclusion that the health of Americans is jeopardized by HMO systems that create too many incentives to cut costs by cutting care.
Anders recognizes that "managed-care plans have the potential to do a great many things right," ensuring that efficient treatment gets to more people at less cost. Ideally, preventive health care, such as child immunizations, regular mammograms, and annual testing of diabetics, routine in most HMOs, not only lower the over-all cost of health care by eliminating the need for later costly emergency and critical care treatment, but also improve the quality of life for HMO members. But this occurs, he argues, at the sacrifice of the "individuality of each patient," which Anders calls "the dark side of managed care." Thus, an elderly woman hoping to live out her last few months in dignity is pushed into a low-grade nursing home; a man needing heart surgery is steered to a cheap but less reliable hospital; a young woman fighting breast cancer does not get a costly long-shot treatment that is her only hope of survival; a doctor is delayed in fighting an epidemic because dispersal of a necessary but costly antibiotic requires several appeals to the HMO that has declared the drug off-limits. Instead, a new entrepreneurial class of "health Mandarins" becomes wealthy by "saving the system" money.
Anders defines the controversy in terms of classic American paradigms: the broader needs of society for more affordable and efficient care versus the right of the individual to protect himself and his family as he deems necessary. This is a subliminal Western. The great strength of his book is that Anders transcends the fixation on cultural paradox by suggesting concrete steps to better reconcile our health care needs with our wants. If employers, consumers, doctors, and regulators become more savvy and assertive, many of the dangerous flaws of the current system can be remedied. At bottom, Anders asserts that, if better prices can be negotiated, so can better care.
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Mark Siegel. Review of Anders, George, Health Against Wealth: HMOs and the Breakdown of Medical Trust.
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