Jewish World Review May 3, 2002 / 21 Iyar, 5762

Drs. Michael A. Glueck & Robert J. Cihak

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Consumer Reports

Medicine's Vietnam | For thirty-five years, Ron Glasser has pursued two passions. The Minneapolis physician has enjoyed a distinguished career as a pediatric nephrologist, or kidney specialist. And he has authored six books, including two New York Times bestsellers; he's even been nominated for the Pulitzer Prize.

But his most important book may be the one that no publisher will touch -- the book that demonstrates a connection between the kind of thinking that lost the Vietnam War, and the rise and imminent collapse of "managed care" and the whole HMO system.

First, a little history, then the HMO/'Nam nexus, then some final thoughts.

After World War II, medicine was getting better and better; and more people wanted more and more of it.

Unfortunately, health care is not a normal industry. Modern medicine is inherently expensive because it's high-tech and because it's a service that has to be performed by highly trained practitioners -- one patient at a time.

After 1963, cost escalation became a way of life as Medicare and Medicaid made medical care essentially free at the point of service for the two groups that use it most heavily in America, the elderly and the poor.

By the 1970s, escalating insurance premiums (plus government inflation of the money supply) were destroying American competitiveness. Government, business, and the insurance companies were looking for a way out.

Enter managed care.

The HMO (Health Maintenance Organization) Act of 1973, ugly progeny of Richard Nixon and Teddy Kennedy, passed into law because it offered -- or seemed to offer -- something for everyone. Managed care, itself the brainchild of a non-practicing Minneapolis physician, Paul Ellwood, would wring the waste out of the system by encouraging people to stay healthy, offering routine services, and setting objective standards for the providing of other forms of care. Best of all, HMOs would achieve their miracles by "competing in the market" for business.

That they would be competing for large corporate and government insurance contracts, not patients, seemed unimportant then. So did the facts that "wringing out the waste" was a one-time affair, and that, once HMOs had offered cheap contracts that pledged them to provide all necessary services, they might reach a point where the only way they could make money would be to ration and deny care.

Enter Alain Enthoven, one of the chief systems analysts in Robert McNamara's Pentagon. After spending seven years applying cost-benefit analysis and advanced micro-management techniques to everything from nuclear weapons to the Vietnam War, "Whiz Kid" Enthoven left the Pentagon for a brief stint in the private sector. After that, he landed at Stanford, where he devoted the next three decades trying to make managed care succeed by applying the techniques that had failed so miserably in Vietnam:

1. Centralized micro-management by a self-anointed executive command team who felt that they knew more about the war against disease than the physicians who had to wage it.

2. The reduction of medical problems to statistical problems, i.e., the notorious "body-count" mentality applied to the rationing of medical care.

3. Endless second-guessing of practicing doctors to the point that, if a physician's diagnosis or recommendations deviated from the computer's, it was the physician who had to spend endless hours -- inefficiently -- justifying his decisions, usually to some clerk at the other end of an 800 number.

Ron Glasser's book, originally titled THE MEDICINE WARS, then CARE DENIED, has found no takers -- despite the author's literary record, and despite the fact that yet another unholy alliance (George W. Bush and, once again, Teddy Kennedy) are pushing for a "patient's bill of rights" to rectify problems that government intervention and perverted capitalism caused in the first place.

Glasser now wonders whether it may be too late to alert people to the Vietnam connection, if only because the strategic geniuses of the HMO industry have moved on to another model.


"The Vietnam connection," Glasser says, "is old history. We've moved beyond all those pompous pronouncements to a system where today premiums are going up 15 [percent] to 20 percent a year while services are being cut back; and those hospitals left standing are increasing rates 20 percent every chance they get. The only possible interest of those Vietnam economists who set all this up, is the same interest people are having today who taught all those business school graduates at Enron and Andersen how to lie, steal, and screw everyone but themselves."

That interest, we suspect, is just this: Proving that nothing was ever their fault.

Like Lyndon Johnson, Richard Nixon, and the Pentagon, the managed-care industry now finds itself in the midst of a full- fledged backlash. HMOs today are in full retreat, but they're still there, and they want to make some more money before the Feds or the employers put them out of business. Unlike five years ago, today they know the system is dying; they're just scrambling to keep it alive a little longer so they can extract another year's sickening salary and bloated bonus.

Some tactics just don't work in war, business, or medicine. Patients will have no confidence or peace of mind until managed care either dies or is humanely euthanized.

Michael Arnold Glueck, M.D., of Newport Beach, Calif., writes on medical, legal, disability and mental health reform. Robert J. Cihak, M.D., of Aberdeen, Wash., is president of the Association of American Physicians and Surgeons. Both JWR contributors are Harvard trained diagnostic radiologists who write numerous commentaries and articles for newspapers, newsletters, magazines and journals nationally and internationally. Comment by clicking here.


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