Epidemic of Care: A Call for Safer, Better, and More Accountable Health Care
Health care costs are out of control, the quality of health care is frightfully low, and far too many people are uninsured. The solution, according to George Halvorson and George Isham, is managed care. This is not your father's managed care. It is the new managed care, in which health plans focus more on improving the quality of care and less on rationing care. Halvorson and Isham worked together doing just that at HealthPartners, a Minnesota-based health plan. Halvorson now heads Kaiser Permanente. After exploring the behaviors of providers, consumers, and health plans that led to the current state of affairs, the authors lay out a seven-point national plan for increasing the value of health care. Not surprisingly, health plans have a large role. Improving the quality of care and patient safety tops the list. Other items include improving the efficiency of health care markets, addressing population health, developing a workable plan for the uninsured, and supporting research. Along the way, Halvorson and Isham correct some misperceptions about health maintenance organizations. The authors' focus on the value of health care is refreshing. Increasing value demands a delicate balance of frugality and innovation. The right mix of these elements is an equation that needs to be solved for each new advance in medicine, with what we gain in health weighed against the opportunities we give up to achieve those gains. Improving health outcomes is the most interesting part of Halvorson and Isham's plan for increasing the value of health care. The authors believe that automated record keeping is a prerequisite for any widespread improvement in quality. Automated medical records make information instantly available to doctors when they need it and provide a platform for real-time education about the latest treatment guidelines, possible drug interactions, and other features that can improve the quality of care in the increasingly complex and harried world that physicians inhabit. The possibilities for innovation seem almost limitless. The idea of automated record keeping, coupled with other strategies, gives a clear direction for improving treatment outcomes. Not so clear is who will pay the cost of these improvements or how they can be implemented nationwide. On the cost side, Halvorson and Isham turn to the strategies economists typically use in failed markets: enforcement of antitrust laws to make markets more competitive, improvement of information on the quality and outcomes of health care, and creation of incentives for patients and employers to shop for the best value. But their assertion that "it generally costs less to do care right," which is a pillar of their plan for increasing value, seems more wish than fact. For example, they cite a newspaper article as evidence that counseling for obesity will reduce the incidence of diabetes and its concomitant costs. A study reported in the Journal by Tuomilehto and colleagues (2001;344:1343-50) showed that counseling-based intervention to help prevent diabetes was neither simple nor inexpensive. Better health care often requires an initial investment, and the promised savings do not always materialize. There is much to like about this book. Health care providers and those who administer health plans will find many examples of what can be done to improve the quality of care by working together. Employers and others who purchase health insurance can learn how to get more value for their health care dollars. Policymakers may learn a thing or two about how insurers can help solve problems in health care. Everyone can have a role in Halvorson and Isham's plan.Robin E. Clark, Ph.D.Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.