Wednesday, October 24, 2007

U.S. health care system - Book Review - Fixing American Healthcare

Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare, Publish or Perish, DBS, Pittsburgh, 2007) This 326 page paperback with its off-beat subtitle is a damn fine book. Richard N. Fogoros, MD, cardiologist, professor of medicine, consultant, blogger, and writer par excellence sent the book to me in response to my recent blog on the health system.

Professor Fogoros divides the health care into two camps: the Wonkonians and the Gekkonians.

Wonkonians (wonks) are government regulators, politicians, public health officials, and political liberals who believe too many greedy doctors are using too much expensive technologies.

Gekkonians, after Gordon Gekko, who proclaimed "Greed is good," in the movie Wall Street, include the insurance industry, health care executives, many physicians, free enterprise proponents, and political conservatives.

Fogoros further separates Wonkonians and Gekkonians into four shifting interrelated quadrants, which together make up the GUT (Grand Unification Theory) of health care.

Quadrant I - Here government centrally controls health care. Wonks insist this ensures quality because decisions rest on scientific and economic information, appropriately and equitably applied, using processes open to, vetted, and monitored by the public. The bad news? This system requires overt "rationing," a word most politicians and most Americans abhor.

Quadrant II - Patients and doctors make decisions on the ground. Patients spend their own money. "Because the individuals receiving the medical services will be paying for them, healthcare economics will begin to look like other, more typical economic spheres, and the quality or purchasing decisions will be begin to increase." Rationing is transparent and automatic, like all marketplace decisions.
Quadrant III -- Here "covert" rationing by health plans and government forces.
bedside rationing by doctors. "Covert rationing requires that patients remain passive and compliant, trusting that their doctors, the insurers, and the federal authorities - but especially their doctors - have their individual welfare at heart, will do right for them, and will tell them what they need to know." This, says Fogoros, destroys patient-doctor relationships and corrupts everything it touches.

Quadrant IV- This, the Tooth Fairy Quadrant, is where we are today. Patients and doctors are free to make their own decisions, as long as somebody else is paying the bills. It has a no limits mentality, i.e., everybody should receive the best possible care without limits. The Tooth Fairy creates expectations that can't be met, and fosters the medical-industrial complex because it is assummed all new technologies will be paid for. It costs too much, and it can't be sustained.

Fogoros sums up his book with a model solution, straddling Quadant I and II, and featuring open competition for services, and thee teirs - HSA s, Universal Basic Coverage, and Optional Insurance Plans, and a series of six principles which you can read by buying the book (hint: the principles include transparency, rationing decisions by patients, and clear rationing rules).

That's my GUT check on this fine book.

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