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Epidemic
Of Care: A Call For Safer, Better, and More Accountable Health
Care
By
George C Halvorson and George J Isham, MD
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pdf >>
Review
by Vincent J Felitti, MD
San
Francisco (CA): Jossey-Bass; 2003. ISBN: 0787968889 271 pages;
$30.00
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Epidemic
of Care is an important book for Permanente physicians to read because
it provides insight into the thinking of George Halvorson, the new CEO
of Kaiser Foundation Health Plan. The book is a simple, clearly written
treatise on the complex subject of delivering and paying for medical
care in the United States. The tone of the writing is encouraging and
suggests that the Health Plan may have its most forceful and outspoken
leader of the past 35 years. George Isham, MD, the book's coauthor,
is medical director of HealthPartners in Minnesota.
Epidemic
of Care is basic in its approach to the problems of delivering medical
care in the United States. The authors' medical economics methodology
is helpful because insofar as medicine is a metaphor for human concern,
economics can be viewed as social psychology in which the units of measurement
are dollars. Halvorson and Isham are excellent guides through the complex
issues underlying our current problems with delivering medical care
as well as how those problems came about. The authors suggest possibilities
for change and explain current resistance to change. The problems described
are not intellectually complex but are emotionally disturbing and thus
are often misinterpreted and misunderstood.
In some
ways, the authors have written a modern version of Victor Fuchs' fine
old book, Who Shall Live.1 This update was needed
because in the 30 intervening years since the Fuchs book first appeared,
total annual US expenditures for medical care have risen from $450 per
American1 to $4930,2 and medicine's portion of
the gross national product has risen from 8% in 19731 to
14% more recently.2 With the book's title, the authors make
the point that the quantity of health care delivered has become a major
problem--especially because no equivalent increase exists either in
the quality of care or in its outcome. Rene Dubos' comment is particularly
relevant: "To ward off disease or recover health, men as a rule
find it easier to depend on healers than to attempt the more difficult
task of living wisely."3p110
Most of
us in The Permanente Medical Groups have been shielded from the realities
of community medical practice; indeed, we usually are even unaware of
the extent of that shielding. This book provides needed understanding
of medical care issues extending far beyond our own specialized areas
of practice. Much to their credit, the authors provide this understanding
clearly and interestingly while presenting an intelligent, perceptive
analysis of a major political problem facing our country generally and
Permanente physicians specifically. This problem--how to deliver high-quality
medical care consistently, efficiently, and affordably--confronts us
whether or not we choose to pay attention to it.
The book
begins by outlining our expectations for medical care and how our sense
of entitlement developed: "We get what we pay for. There are over
eight thousand billing codes set up for various units of care. There
isn't one single billing code set up for a cure. There is no fee for
preventing a disease. The system does what it is paid to do. That really
shouldn't surprise anyone."2:pxxiv We are also given
an interesting, necessary description of insurance processes--how insurance
works--and of the implications of those processes for various proposals
aiming to change the way medical care is paid for and delivered. The
authors make helpful comparisons with medical care, expectations of
it, and its costs in Britain, Canada, and Germany.
Because
Permanente physicians experience relatively little fallout from the
complicated issue of community competition, they will be particularly
interested by the discussion of the usual competition between hospitals,
insurers, and physicians. The discussion suggests that the Health Plan
under Halvorson may expect The Permanente Medical Groups to actively
partner with the Health Plan to solve these problems. That increased
expectation would be a profound and probably healthy change in the relationship
between Kaiser Foundation Health Plan, Kaiser Foundation Hospitals,
and The Permanente Medical Groups. (Did you know that no entity exists
called Kaiser Permanente? "Kaiser Permanente" is not the name
of an organization but is instead the name applied to a
function contracted yearly between three legally distinct organizations:
Kaiser Foundation Hospitals, Kaiser Foundation Health Plan, and The
Permanente Medical Groups.)
Halvorson
and Isham emphasize the importance of an emerging application of technology:
the electronic medical record. By his recent actions, Halvorson has
made clear that he expects rapid arrival of the electronic medical record
at Kaiser Permanente facilities. The rumor that $1 billion has been
spent on this project during the past 17 years or so is not an encouraging
piece of our history.
The authors
point out that we absolutely must retain Health Plan members who use
little or no care, because these least frequent users are the economic
motor driving the entire operation; by contrast, 5% of our member population
uses 50% of the medical care. By dismissively referring to these low-utilizing
patients as "the worried well," we often fail to do them justice.
Drug costs and the subtle forces supporting increased prices also are
perceptively discussed. So too are the developing shortages in support
personnel, the expanding role of the Internet in medical practice, and
the problem of providing insurance coverage for experimental medical
treatment.
Epidemic
of Care openly addresses many impending realities from which we
have been largely shielded thus far by the protective nature and size
of our organization. For this reason--among the others given here--this
small, excellent book deserves to be read by all Permanente physicians
and indeed by all people working within the Program.
References
- Fuchs
VR. Who shall live?: health, economics, and social change. New York:
Basic Books; 1974.
- Halvorson
GC, Isham GJ. Epidemic of care: a call for safer, better, and more
accountable health care. San Francisco (CA): Jossey-Bass; 2003.
- Dubos
R. The mirage of health: utopias, progress and biological change.
New York: Harper; 1959.
Vincent
J Felitti, MD, has been with the Southern California Permanente
Medical Group since its opening in San Diego in the late 1960s.
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