344 pp, $24.95
Nashville, TN, Vanderbilt University Press, 2007
In medicine, as in politics, timing is everything. After the massive policy depolarization of the Clinton Plan, health care reform entered a refractory period. The debate was downsized, moving away from global solutions, adopting a more incremental approach. Where there was once debate about universal access, recent discussions have centered about smaller questions such as the hardly contentious use of electronic medical records or the more ambitious Medicare drug benefit plan.
All of this has changed with the approach of the presidential primaries. The opening act of the debate is taking shape in the battle over the State Children''s Health Insurance Plan (SCHIP). President Bush''s veto and Congress'' ill-fated attempt to override him foreshadows the next wave of debate and the competing visions of reform that shape the political landscape.
With SCHIP as prologue, health care reform is alive, though not well. This stirring of interest creates a ready market for up-to-date books that are more than just a rehash of past policy failures or postmortems of the Clintons'' flawed Health Security Act of 1994.
Rx for Health Care Reform, by Ken Terry, a journalist and senior editor of Medical Economics Magazine, is such a book. From the helpful primer in the first chapter on the competing political visions of health care reform that will be debated in the primaries, to sections arguing for modified managed competition among large primary care practices, Terry has kept his focus on making his book relevant for the current political season.
The initial chapters contain some of the finest contributions. In a concise fashion, Terry traces the evolution of the US health care system and takes the reader through the maze of ill-fitting acronyms that litter the policy landscape, fads that history will critique for the certitude with which they were promoted. Terry''s review concludes with a précis of reform proposals advanced by leading presidential hopefuls, distinguishing the market-based approach of Republicans, more intent on reducing costs, with the expanded government role favored by Democrats, more focused on expanding access.
Terry is to be lauded for his neutral approach, which promotes a politically middle ground rather than inflaming partisan passions that are more ideological than pragmatic. He asserts that consensus and a moderation of goals and means will be necessary if health care reform is to be achieved. Politically, oxymoronic constructs such as government entitlements, employer mandates, and individual responsibility will have to coexist under a public-private partnership to realize the competing goals of improving access, enhancing quality, and reducing cost.
Despite Terry''s eye for compromise, the analysis is politically shrewd and bold in its prescription for reform. He asserts that health care insurance cannot be transformed gradually, "because the insurance industry would find ways to counter any measure that merely changed how it did business. The only way to ensure radical transformation—short of a government takeover—is to take rapid steps that fundamentally redefine insurance companies." (p 196)
Terry''s plan to "end of insurance as we know it" is to create regional "utility" insurers that would work in tandem with large primary care practices. Under his proposal, these practices would compete within markets for patients on the basis of cost and quality of care. Each practice group would assume financial risk for their cohort of patients as well as the cost of specialty referrals. (Hospital costs would be outside the risk pool.) This version of managed competition differs from that offered by the Clinton Plan''s Ira Magaziner because it involves market competition between primary care groups instead of between insurance plans.
Under Terry''s proposal there would be a single regulated insurer in each region; these insurers could be either private for-profit companies or not-for-profit organizations. Each would serve as a "conduit between payers and providers and as a financial reservoir" providing stop-loss insurance for distressed plans. They would also be responsible for measuring provider performance.
The federal government''s role would be limited. It would not run the system, which would operate regionally. Instead, its major contribution would be sponsorship of a "national technology assessment board" that would articulate a national benefit package to which all plans would have to adhere. The federal government would be responsible for setting the rules that would establish and constitute "regional health boards" that would choose and oversee the local "utility insurer."
Although the role of government is understated, the reader is still left wondering how a "national benefit package" would be determined. This would not be a trivial or simply bureaucratic task but one that would become value-laden and sociologically complex. As the medical ethicist Daniel Callahan has observed, determining interventions that have utility is especially challenging in a country that remains unable to delineate what constitutes medical futility.
Moreover, Terry does not adequately explain how his plan would not repeat real-world failures of physician-assumed financial risk or mitigate conflicts of interest. These are important concerns, because practice groups that historically have taken on risk and become profitable have been vulnerable to rate cuts that eventually undermine fiscal viability. Terry acknowledges that this was the case for California health maintenance organizations in the late 1990s and that these pressures can lead to unhealthy incentives to withhold care.
Terry''s proposal is worthy of additional study. It is creative and should have significant appeal for policy makers on both sides of the aisle. Because of this promise, it is unfortunate that Terry''s plan did not have a more rigorous presentation. Beyond my substantive concerns, I found his concluding chapters'' treatment of policy minutiae distracting and a disservice to his instructive appeal for reform. Although informative as stand-alone essays, these chapters seemed tangential to a main argument that needs more detail for fuller assessment.
These faults unfortunately rest as much with the subject of this book as with its author. The health care system is a topic that resists political and editorial organization. Terry is to be commended for his effort to rein in the disorder of a fragmented system in need of repair.
Joseph J. Fins, MD, Reviewer
Division of Medical Ethics
New York Presbyterian-Weill Cornell Medical Center
New York, New York
"Health care reform once again is front and center as a national concern. In the run-up to the presidential election, proposals are being offered by candidates of both political parties. The need for change is being voiced by many sectors—the government, employers, and, most intensely, the public. Therefore the book Rx for Health Care Reform by Ken Terry comes at a propitious time. Terry, a senior editor of Medical Economics Magazine, uses his business savvy and extensive knowledge of health care policy and financing to present a comprehensive and well-researched description of past and current health reform proposals, and, even more important, to present a model of health care reform that shows real promise of working.
"Psychologists reading the book not only will gain a better knowledge and appreciation of the forces influencing the health care system and their own health care costs but also will understand better what is needed for true health care reform. Future-oriented
psychologists can glean how changes in the health care system might affect the practice of psychology and opportunities to integrate with
primary and specialty health care…"
From review by Mary Beth Kenkel
From review by Mary Beth Kenkel
PsycCritiques, American Psychological Association
"Rx for Health Care Reform is just the kind of bold analysis needed today to put reason and common sense back into health policy. The bond between primary care physicians and patients provides a basis for sound decision making in the delivery of care. Ken Terry reviews with great detail and examples why so many American proposals for health care reform have not worked. America can afford high quality health care for everyone without massive administrative costs if we return to the best patient-physician relationship. I hope health policy leaders and health care organizations will take a serious look at this book. It does offer a way out of the mess and chaos we are in.”
--JOSEPH E. SCHERGER, MD ; Professor of Family & Preventive Medicine, University of California, San Diego
"U.S. health care is a mess. This very readable book hits the nail on the head in terms of diagnosing the problems and in prescribing some real solutions for the future. This book should be required reading for all clinicians, managers, policymakers and especially patients"
"A provocative and stimulating book that examines where U.S. health care is broken, and provides concrete suggestions for the fix. In writing this book, Ken Terry has done more than just good research; as a senior editor for Medical Economics, Mr. Terry has conducted in-depth interviews with many of the people at the center of today’s health care problems and controversies. A ‘must read’ for doctors, nurses, health plan executives, health policy makers, and, most importantly, for consumers."