From The New England Journal of Medicine
Public recognition of Alain Enthoven transcends his field. The emeritus Marriner S. Eccles Professor of Public and Private Management at Stanford University, Enthoven rose to fame as the architect of a health care strategy known as "managed competition." His watershed articles on consumer choice in health care, which appeared in 1978 in the Journal, along with the Shattuck Lecture that year, helped unleash unparalleled ferment in the financing and practice of health care and roiled the waters of national health policy for a generation. That debate reached a zenith with the rise -- and spectacular collapse -- of President Bill Clinton's national health-reform plan. At the same time, the vestiges of Enthoven's vision can be seen in the modern managed-care market, which relies on provider-network-style competing health plans to cover and arrange for health care for the vast majority of employed people, as well as for more than half of all Medicaid beneficiaries. Indeed, the principles of managed competition can be seen in the prescription-drug plans for Medicare that were established under the 2003 Medicare Prescription Drug, Improvement, and Modernization Act. For reasons that have to do far less with underlying theory than with execution, managed care not only failed to tame health care costs but also proved sufficiently unpopular that sponsors and corporations abandoned the rigorous and exclusive integration on which the model depends for its power. Yet as purchasers move away from the Enthoven vision, they appear to be headed in a deeply troubling direction, under the banner of "consumer-driven" health care. Although its name conjures up the concept of consumer choice, consumer-driven health care is, beneath its market hype, nothing less than the systemic erosion of health care coverage itself through the removal of coverage for enrollees, rather than through structural reform (as Enthoven advocated) to tame health care costs and improve quality. How a gross starvation of the health care system can lead to constructive reform remains anyone's guess, but one thing is certain: what seemed so radical in 1978, at least from an organizational and operational perspective, looks positively sensible today. As trends in insurance design unfold -- and as the number of uninsured people continues to rise inexorably -- Enthoven and Tollen have produced a collection of essays on prepaid group practice. The individual essays, with a foreword by William Roper, are written by some of the best-known names in national health policy and practice today: Helen Darling, James Robinson, Jonathan Weiner, Stephen Shortell, Harold Luft, David Eddy, Jon Christianson, and Donald Berwick. Collectively, these essays serve as a reminder of the growing chasm between health care finance and health care organization and quality. Many of the essays are excellent, particularly for readers who seek a general overview of the subject. The essays address topics such as the history, structure, financing, and performance of groups; the marriage of prepaid groups and new-technology assessment and deployment; the relationship between group practice and the development of physician leadership; prepaid groups and medical-workforce policy; and the limits of the group model. Several issues could have received more attention. First, more should have been written about the use of integrated systems in Medicaid and within the health care safety net of health centers and public hospitals. The challenges are especially great within these institutions, where the mission is to focus on the nation's poorest, sickest, and most economically vulnerable patients. Furthermore, no attention has been paid to the dynamic interaction of law and the prepaid-group-practice model. Arguably, the largest impediment to the implementation of the model today is the extraordinary (and perhaps understandable) effort by group sponsors and insurers to distance themselves from the health care structure and process in order to avoid legal liability when the quality of care goes terribly awry. This abdication of legal accountability for the quality of health care culminated with the 2004 U.S. Supreme Court decision in Aetna v. Davila to disallow all efforts of health plan members sponsored by the Employee Retirement Income Security Act to hold health insurers and plan administrators accountable for the foreseeable consequences of negligent medical conduct in connection with coverage. With financing now completely divorced from health care quality as a matter of law, advocates of the prepayment model face a long uphill battle indeed. Finally, the book would have benefited from greater discussion regarding the question of whether the promise of group practice can ever be achieved in a nation in which financing itself is so uneven and unstable, and in which health care operations must endlessly struggle with the problem of a rolling loss of insurance that affects some 80 million persons every two years. How one builds a high-quality health care system -- however it is organized -- amid such chaos remains a mystery.
Sara Rosenbaum, J.D.Copyright © 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Review
"Several of the chapters are excellent analyses of how the PGP model is responsive to current policy and delivery concerns." (
JAMA; 11/24/2004)
"This book should be required reading for every physician in the United States." (Health Affairs, Vol 23, No 4; July/August 2004)
“A brief review cannot do justice to the range of issues explored in this volume… Toward a 21st Century Health System repays careful study.” (Health Service Journal, April 2004)
