The Rise and Fall of HMOs: An American Health Care Revolution
http://www.100md.com
《新英格兰医药杂志》
What can the performance of a clinic in rural Wisconsin tell us about the successes and failures of the U.S. health care system? Although it is not evident in the title, The Rise and Fall of HMOs is the story of how the Marshfield Clinic initiated and subsequently weathered the movement to prepaid medical care. Jan Gregoire Coombs effectively chronicles the history of managed care through a detailed examination of experiences at the clinic and emphasizes the respective roles of attitudes, economics, and public policy in shaping our current health care environment.
From the start, Coombs makes it clear that the Marshfield Clinic should be considered a model, not for its financial success but for its perseverance in meeting the needs of the rural community. She has included an astounding number of references, including internal documents from the clinic's founders, that support this conviction and have the added benefit of accounting for all the major events in the history of the U.S. health care system. Most of the chapters are organized in chronologic order, with the activities at Marshfield highlighted against the backdrop of those in the rest of the nation. Early chapters emphasize the attitudes and actions of specific people, such as Dr. Russell Lewis, the president of the Marshfield Clinic in the late 1960s. Lewis and his colleagues reportedly sought to establish a health plan to provide low-cost, comprehensive health care to Marshfield-area residents. The book describes in great detail the problems encountered by the Marshfield Clinic physicians in establishing the Greater Marshfield Community Health Plan (GMCHP) in 1971. Coombs repeatedly notes the altruistic goals of these men, who were unwilling to compromise on certain features of the plan that did not make good business sense, such as community-rated premiums for both group and direct-pay enrollees. Although it is noted, she gives less emphasis to their opposition to nationalized health care as a motivating factor.
The story continues with the challenges of maintaining a successful program amid changes in the health care industry and the regulatory environment. The many topics Coombs explores include the efforts to measure quality, the perils of antitrust laws, medical malpractice and physician accountability, the State Child Health Insurance Program, and the Medicare Prescription Drug Improvement and Modernization Act of 2003. Coombs's discussion of Marshfield's problems with enrolling Medicaid and Medicare populations helps explain why health maintenance organizations (HMOs) are still reluctant to participate in these programs. These problems included "failure to adjust formulas for serving high-risk patients and unreasonably low compensation levels for cost-efficient providers." In the early 1980s, the economic recession and increasing competition required the GMCHP to abandon some of its founding principles and, ultimately, to dissolve its partnerships. Coombs notes that the plan's refusal to modify its four basic principles — community rating, open enrollment, nonidentification of enrolled patients, and absence of copayments or deductibles — resulted in premium increases of 23 percent in 1982. But employers' demands for lower health insurance premiums ultimately forced the GMCHP to abandon these principles.
Coombs's narrative is easy to follow, and I would recommend this book to anyone who wants to develop a more thorough understanding of the U.S. health care industry. However, the book is more accessible if one has a general understanding of the current environment, since some institutional details are not as well defined as others. The book will perhaps be most useful to academics who study specific aspects of the health care system, as a tool for broadening one's perspective. However, the reader should be critical of the generalizations drawn from the Marshfield case study: it represents just one example of the many different experiences with the development of managed care across the nation. Coombs cites many research articles to support her conclusions, but she also includes her own opinions, often quite frankly, throughout the book. For example, it is obvious that she favors nonprofit HMOs over those that operate for a profit. But through this analysis of Marshfield's operations, she emphasizes that "managed care has many desirable attributes that would make it an appropriate vehicle for delivering health care if the nation could resolve the unjustifiable financing inequities in the public and private sectors." Coombs's careful exploration of these issues provides valuable insight for shaping the future of U.S. health care.
Patricia H. Born, Ph.D.
California State University, Northridge
Northridge, CA 91330
patricia.born@csun.edu(By Jan Gregoire Coombs. 4)
From the start, Coombs makes it clear that the Marshfield Clinic should be considered a model, not for its financial success but for its perseverance in meeting the needs of the rural community. She has included an astounding number of references, including internal documents from the clinic's founders, that support this conviction and have the added benefit of accounting for all the major events in the history of the U.S. health care system. Most of the chapters are organized in chronologic order, with the activities at Marshfield highlighted against the backdrop of those in the rest of the nation. Early chapters emphasize the attitudes and actions of specific people, such as Dr. Russell Lewis, the president of the Marshfield Clinic in the late 1960s. Lewis and his colleagues reportedly sought to establish a health plan to provide low-cost, comprehensive health care to Marshfield-area residents. The book describes in great detail the problems encountered by the Marshfield Clinic physicians in establishing the Greater Marshfield Community Health Plan (GMCHP) in 1971. Coombs repeatedly notes the altruistic goals of these men, who were unwilling to compromise on certain features of the plan that did not make good business sense, such as community-rated premiums for both group and direct-pay enrollees. Although it is noted, she gives less emphasis to their opposition to nationalized health care as a motivating factor.
The story continues with the challenges of maintaining a successful program amid changes in the health care industry and the regulatory environment. The many topics Coombs explores include the efforts to measure quality, the perils of antitrust laws, medical malpractice and physician accountability, the State Child Health Insurance Program, and the Medicare Prescription Drug Improvement and Modernization Act of 2003. Coombs's discussion of Marshfield's problems with enrolling Medicaid and Medicare populations helps explain why health maintenance organizations (HMOs) are still reluctant to participate in these programs. These problems included "failure to adjust formulas for serving high-risk patients and unreasonably low compensation levels for cost-efficient providers." In the early 1980s, the economic recession and increasing competition required the GMCHP to abandon some of its founding principles and, ultimately, to dissolve its partnerships. Coombs notes that the plan's refusal to modify its four basic principles — community rating, open enrollment, nonidentification of enrolled patients, and absence of copayments or deductibles — resulted in premium increases of 23 percent in 1982. But employers' demands for lower health insurance premiums ultimately forced the GMCHP to abandon these principles.
Coombs's narrative is easy to follow, and I would recommend this book to anyone who wants to develop a more thorough understanding of the U.S. health care industry. However, the book is more accessible if one has a general understanding of the current environment, since some institutional details are not as well defined as others. The book will perhaps be most useful to academics who study specific aspects of the health care system, as a tool for broadening one's perspective. However, the reader should be critical of the generalizations drawn from the Marshfield case study: it represents just one example of the many different experiences with the development of managed care across the nation. Coombs cites many research articles to support her conclusions, but she also includes her own opinions, often quite frankly, throughout the book. For example, it is obvious that she favors nonprofit HMOs over those that operate for a profit. But through this analysis of Marshfield's operations, she emphasizes that "managed care has many desirable attributes that would make it an appropriate vehicle for delivering health care if the nation could resolve the unjustifiable financing inequities in the public and private sectors." Coombs's careful exploration of these issues provides valuable insight for shaping the future of U.S. health care.
Patricia H. Born, Ph.D.
California State University, Northridge
Northridge, CA 91330
patricia.born@csun.edu(By Jan Gregoire Coombs. 4)