Managed-care plans have become the nation's whipping boys, under attack from consumers, policymakers and some physicians alarmed by charges of treatment information being withheld and life-threatening denials of medical care. The issue of drive-through deliveries became a lightning rod for politicians who rushed to pass legislation requiring minimum stays for new mothers and their babies. Reports of forced outpatient treatments for mastectomy patients has reignited criticism. A new book by Wall Street Journal reporter George Anders promises to be a pivotal publication in the debate.
Health Against Wealth: HMOs and the Breakdown of Medical Trust, a timely new book by Wall Street Journal reporter George Anders, skillfully assembles the elements of the explosive controversy surrounding managed care.
A good, fast-paced read, the book builds almost novelistically on detailed accounts of inadequate treatment and short-sighted policies, all liberally laced with greed.
The book's power derives from its unblinking focus on the dark side of managed care and the indisputable suffering of patients harmed by an evolving healthcare system.
Karen Ignagni, president of the American Association of Health Plans, an HMO trade group, complains that the book isn't fair to the nation's HMOs and their success "at the dual task of controlling healthcare costs without compromising healthcare quality."
And Susan Pisano, AAHP director of communications, says the book doesn't capture the "spirit of commitment" among those who have worked to develop and improve HMOs through the years.
But those are moot points, given the author's intent to vividly itemize abuses that need to be fixed, considering HMOs' increasing penetration of the healthcare market. About 600 HMOs now serve nearly 60 million enrollees-about a quarter of the U.S. population.
Here is where Anders is coming from: "Managed-care plans see all patients as essentially alike. They are units of production in a medical/insurance factory, to be handled cost-effectively as they move through various treatments. . . . When serious illness strikes, though, we want to be treated as someone special. Managed-care plans haven't always been able to do that," he writes.
This is mostly a black-and-white book, and readers who work in the healthcare industry will need to call upon their judgment and experience to decide which gripping details to take with a grain of salt. The book doubtless will alarm the general reader without inside knowledge. It would take hard investigative journalism-more than a book review-to check out Anders' abundant evidence.
He describes a healthcare scene in which patients' health and safety, championed by their doctors, are pitted against profiteering HMOs. Publicly traded plans are dominated by the need to boost shareholder return and are milked by executives with multimillion-dollar salaries like Health Systems International's Malik Hasan, M.D.
In one of his excesses, Hasan paid $3.8 million for a 14-bedroom stone castle in Colorado and spent another fortune remodeling it.
The book argues that the industry's image is tarnished by having multimillionaires-Anders calls them "the Barons of Austerity"-at the helm of a system that scrimps on hospital days and specialist visits. Even if there is no clear relation between executive compensation packages and inferior healthcare, his descriptions of "doctors in pinstripes (with) a raw hunger for wealth" fuel outrage.
In Anders' scenario, inept, compromised and understaffed regulatory agencies tolerate abuses by health plans. Employee benefit managers, enamored of HMO cost cutting, do HMOs' lobbying for them and undertake the feeblest monitoring programs while patients die from denial of needed services.
Time for that grain of salt: Responding to Anders' charge about benefit managers, Helen Darling, the formidable manager of healthcare strategy and programs at Xerox Corp., said, "Nonsense! We're not patsies for anyone.
"There are no more aggressive message-senders to the HMOs than companies like Xerox, GTE, CalPERS. We're all over those health plans all the time," requiring National Committee for Quality Assurance accreditation, annual membership satisfaction studies by external bodies and other monitoring, she said.
"We're fully committed to good-quality HMOs," Darling emphasized.
Anders devotes the last chapter to "Building a Better System," in which he concedes: "The theoretical appeal of managed care remains immense: a well-planned system that will steer patients to the appropriate level of care whether they are healthy or sick, instead of leaving them to grope randomly for medical help in a crisis." And he offers 10 suggestions on how to improve the dismal scene. For example: "Consumers need to know how to file effective complaints," and "Employers, doctors and regulators need to establish better report cards on the quality of health plans."
But coming after 13 chapters depicting the rotten core of managed care, these helpful hints seem weak. The book actually ends with a prophesy of HMOs' demise.
The real cure for what ails HMOs, Anders argues finally, is "direct government oversight," paralleling the regulation of financial markets by the Securities and Exchange Commission and air travel by the Federal Aviation Administration.
"None of these ideas is likely to be embraced willingly by the HMO industry," he writes.
No matter-HMOs may be on their way to extinction anyway, he says. "Over the next few years employers and doctors will be asking the question that changes everything: `Do we really need HMOs standing between us?' The answer may well be `No, we don't.'
"Expertise about the most worthwhile parts of managed care is developing among doctors, employers and patients' rights groups, rather than remaining the secret preserve of HMOs."
Eventually, the HMO middlemen may very well fade into history, like the corporate raiders of the 1980s, Anders writes.
"At some point doctors will figure out how to run a cost-effective medical system without abandoning compassion," and HMOs "will be left with much less to do."
If the reader can suspend objections to Anders' singleminded thesis, the book will prove full of historical information and a good read.
Health Against Wealth: HMOs and the Breakdown of Medical Trust, by George Anders (Houghton Mifflin, $22.95, 288 pages).