Book Reviews

Beyond Managed Care: How Consumers and Technology Are Changing the Future of Health Care by Dean C Coddington, Elizabeth A Fischer, Keith D Moore, Ronald L Clarke Book Review by Vincent J Felitti, MD

This easy-to-read book¹ will appeal to physicians and others interested in becoming more knowledgeable about the social, political, and economic problems facing medical practice. Insulated and protected though we are by the size, integrated nature, and prepayment system of our own health care environment, the Kaiser Permanente Medical Care Program, we are only less problem-laden than our colleagues in the community; we are not problem-free. The problems facing all of medical practice are difficult ones about which to become knowledgeable; those physicians who come away from Board report meetings feeling confused by the current jargon may find some relief in the understandable approach provided by the editors of this book.

The book starts with a brief review of how medical practice has changed in recent times and of the role Kaiser Permanente played in changing the dynamics of medical care. A graph^1:9 shows how the past 20 years have brought about a distinct decrease in number of hospital days--a decrease coincident with a major increase in number of outpatient visits. Why is this? In part, of course, this phenomenon reflects a shift in location of care, but are other explanations possible? Might the present system of symptom-driven primary care be showing its weaknesses more prominently now that this care has become more widely available (ie, because of the distinctly increased number of physicians^1:84 practicing during the same period)? Why have advances in medical technology increased costs whereas advances in the electronics industry have decreased costs? How do Kaiser Permanente measurements on these points compare with those of the community?

Especially useful are the book's discussions of various actual and proposed payment plans. The closing chapters propose and analyze four different health care scenarios and present a memorable graph^1:235 in which the proposed scenarios are plotted against axes of legislative effort and individual control and responsibility. To say that everyone in a wealthy country should have adequate health care is easy, but defining this care is difficult--especially when legislatures impose piecemeal coverage requirements on private insurers.

Beyond Managed Care is worth a quick read for its analysis of problems from the standpoint of consumer and health care payer. The book is not designed to provide answers but does clarify the questions and the key issues from which those questions arise. As the book clearly shows, being a technically astute clinician is no longer sufficient for successful medical practice.

Reference
1. Coddington DC, Fischer EA, Moore KD, Clarke RL, editors. Beyond managed care: how consumers and technology are changing the future of health care. San Francisco: Jossey-Bass; 2000.

335 p $49.95 ISBN 0787953830. San Francisco: Jossey-Bass, 2000.

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