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Motorcycle Book Store > Motorcycle books beginning with H
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The Health Care Mess: How We Got Into It and What It Will Take To Get Out |
Author: Julius B. Richmond
Published: 2005-09-06 |
List price: $26.95
Our price: $21.56
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As of: July 04th, 2009 06:46:56 PM
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Customer comments on this selection.
 Excellent reading for students of medicine and public health
In reading the previous reviews, I must say that they are quite accurate in many of their findings - the style of writing tends to be verbose and there isn't much in the ways of "how to do fix the US health care system." But that is not what this manuscript is about.
Let me quickly rebut a few points from each of the previous reviews.
From Mr. Weston: " When I bought the book, I was hoping the authors' would answer the question "What is equitable health care?" Is it equitable for the government to pay for medications that control blood pressure, insulin response, and bone density when all of these could be managed by diet and exercise? Americans have a problem giving welfare to those who can work. Why give "healthfare" to those who can diet and exercise? "
First of all, equity is in the eye of the beholder. This is an area where even the most brilliant health economist cannot give a true answer. Our basis for equity depends upon our own moral upbringing.
Secondly, it is obvious from the latter half of his comment that he does not have anything to do with the health care delivery system. Lifestyle modifications for hypertension, diabetes, and osteopenia/osteoporosis, while certainly beneficial, are not effective to the degree needed to prevent stroke, heart attack, or hip fractures. However, I will concede that doctors often over-utilize healthcare resources of limited benefit.
Moving on to Ms. Clendenen's excellent review:
" The three that immediately come to mind are the complete neglect in discussing the impact that the cost of pharmaceuticals has had on the overall cost of health care, the impact that malpractice litigation and the threat of malpractice suits have had, and the incredible cost of the administrative labyrinths that exist for most providers. "
It would appear that for her, a serious health economist, this book misses the mark. There, however, is a brief discussion of malpractice litigation in Chapter 7. I believe the authors spent considerably less time on this subject than on the subjects of medical education and "orgranized medicine" because malpractice litigation appears to have limited effect on total national health expenditures (estimated to be about 1/2 of 1%).
I agree with her that this book does little to explain the impact of administrative complexities on physicians. I can firmly attest that I spend far too much time doing paperwork than seeing patients. However, in the concluding chapter, the authors suggest a system - albeit a system closer to the single-payer edge of the political spectrum - that naturally would result in less administrative hassles for everyone involved compared to our current "nonsystem".
And now onto Ms. Craig: Her thoughtful review begins to introduce the concept, not discussed in this book, that a small percentage of patients represent the largest percentage of medical expenditures. She also refers to ICU stays - where I have witnessed survival rates less than 30% - that account for a tremendous fraction of our health care dollar. As a nation we do spend too much money on care in the last 6 months of life. Unfortunately, we often times cannot tell when someone will die. Additionally, even when death is virtually around the corner (by that I mean, when there is no chance for a "meaningful" life) we have families who want doctors to keep their loved ones "alive" for extended periods of time. As a nation, our culture of life may be in opposition to our appropriate use of health care resources.
Okay, enough of the rebuttals (I only do it because I liked this book). I believe the point of "The Health Care Mess" is to introduce the layman to the history of the American healthcare system. It does this while addressing issues relevant to physicians - medical education and the American Medical Association's persistent interference with progressive health reform. I believe this book may not be best geared towards the practicing health economist or the policy maker. "The Health Care Mess" is best designed for motivating a sleeping constuency - medical professionals and medical students. These folks are far too overburdened with their work to realize that they also need to be involved in the health care debate. Perhaps that is why the authors suggest making our current disorganized health care system focus attention on the academic medical centers as "hubs" for healthcare.
You will not find answers in this book. But you will find that political stumbling blocks are typically the reasons why most recommendations to modify our current system have failed. It is the politics, not the science, that is important in changing health policy. This is where the focus lies in "The Health Care Mess."
 Misses the biggest problems
This book does a good job at pointing out how broken the American health care system is. I really enjoyed the retrospective look at how we got where we are today. Some of the reasons for the problems are pointed out well, as in the discussion of community rating of insurance. Unfortunately, the book misses some of the most important reasons for the health care mess. The solutions proposed also strike me as at best unworkable.
The book's authors are big fans of national health insurance. As they point out, national health insurance does have some things going for it. However, I just don't see how national health, if implemented in today's health care climate, would bring about any savings at all. The Medicare program is the closest thing we have now to national health insurance; far from saving us money, from what I see its costs are completely out of control and headed through the roof. The book never discusses this. The book makes no mention at all of how to deal with bringing down costs at the high end; the 5% or so of patients who create probably 80% or more of all health care costs. The fact is that at some point you have to be willing to say no, we are going to send this patient to a hospice to die instead of treating him, because his treatment is just too expensive.
I see the American health care system as caught in a trap of diminishing returns. In terms of quality of life, we get by far the most benefit from the first few dollars spent on a patient. By the time you get up to spending millions of dollars on a single patient, you are getting next to nothing for your money. Keep in mind that money has to come from somewhere; taxes, or premiums, or cuts in quality of service. Spend a million dollars on a one-pound micro-preemie in a neonatal ICU, and it will take hundreds of overburdened nurses scrimping on their time with other patients to make up for it. Some of those neglected patients will die as a result. No amount of money is going to relieve the human condition. All of us are going to die someday, no matter what is spent on our care. The authors never seem to realize this.
The book also misses the biggest problem with medical research today, which is that a treatment available only at exorbitant cost is actually worse than no treatment at all. Take the use of heart transplants to treat heart failure. By definition, each heart transplant requires at least two complex and expensive surgeries and decades of follow-up care due to immunosuppression. Many transplant patients die on the operating table or in the postoperative period, which pushes the cost per successful outcome even higher. There are also huge costs from maintaining the system to allocate donated organs. When you look at how else the money could be used, treatments like this hurt more people than they help. Research focused on complicated high-tech medicine is making public health worse.
As I see it, we have only two choices if we really want to cut medical costs: we can regulate the industry to outlaw the most costly procedures; or we can get rid of medical insurance altogether. I don't see much hope of the former. We may end up getting the latter by default. Medical insurance suffers from the basic problem that the doctors who are the ones who make the decisions over what care will be provided aren't the ones who have to deal with the people who pay the bills. This leaves us in a fog filled with conflicts of interest. Our current legal standards for malpractice cases, which don't allow cost considerations to enter into medical decisions, only make the problem worse.
The authors also ignore the reasons behind Americans' poor lifestyle decisions. Doctors are always telling us to eat less and exercise more. Somehow the doctors never mention that sweet and greasy foods are subsidized by our government to the tune of billions of dollars every year. Agricultural subsidies are what make corn syrup, bread, rice, cooking oil, hamburger, and cheese cheaper than fruits and vegetables. Government subsidies, crazy zoning laws, and parking requirements are why we live so far from our jobs and end up driving everywhere.
For a far more interesting perspective on the health care mess than the one provided by this book, I would suggest Hadler's "The Last Well Person." For more on what the automobile is really costing us, see Kunstler's "The Geography of Nowhere" and Shoup's "The High Cost of Free Parking."
 Faults of Style and Substance
As a student of health care economics (due to being employed in a managerial position in a health care enterprise,) I embarked on reading this book with great anticipation and was left with great disappointment. My disappointment stemmed from faults in both style and substance.
As to style, the writing is replete with complex sentences with subordinate clause following on subordinate clause until one can no longer remember what the subject or the verb is, much less make any sense of the meaning of the sentence. I read extensively in professional journals as part of my employment and feel that the stylistic mannerisms of this book significantly diminished its impact. There were a number of simpler grammatical errors that should have been caught by the editors at Harvard Press. I was dismayed that two so presumably eminent scholars should write in such a confusing and obfuscating way.
As to matters of substance, I was surprised that some of the more significant influences on the current state of the US's health care "system" were either ignored or brushed aside as being uninmportant. The three that immediately come to mind are the complete neglect in discussing the impact that the cost of pharmaceuticals has had on the overall cost of health care, the impact that malpractice litigation and the threat of malpractice suits have had, and the incredible cost of the administrative labyrinths that exist for most providers. Also glossed over is the exorbitant amount of money being taken out of the health care system in the form of profits for shareholders of for-profit healthcare entities (not just big pharma)and salaries and bonuses for the high-flying executives of these for-profits.
All in all, this book was so narrowly focused on medical schools and medical education as to be nearly useless in explaining how we have gotten to where we are. Critical Condition, by Barlett and Steele, is a much better book in describing the history behind the current state of affairs, and offers a much better solution than Richmond and Fein propose.
Couldn't Read It
Note: This review was done after only reading the first 20 pages of the book. Please keep that in mind when evaluating the reasonableness of my review.
I bought this book as an impulse purchase after hearing the authors on Al Franken's show on Air America Radio on 11/15/05 because I wanted to get an understanding of, and solutions to, the health care problem.
I stopped reading for two reasons. First: the authors immediately expressed an assumption in the book's introduction that I felt would unhelpfully bias their presentation and recommendations. Second: the writing was so wordy that I felt the author's were trying to add weight to a simple message that was buried so deep in the book that it wasn't worth my effort to dig it out.
In support of my first reason regarding the authors' bias, consider the following sentences in the second paragraph on page 4: "We deplore the wide disparities not only in health care but in income, education, housing, and other important factors that affect well-being and opportunity . . . We seek a system in which the financing and distribution of health services reflect our image of a just society, a society in which economic arrangements reflect a moral dimension."
Now I agree that there are very poor and very rich people in America. I also agree that there are very sick and very healthy people. But the existence of extremes doesn't negate the fact that most people in America are generally satisfied with their lives because they are relatively healthy and are meeting their daily needs. When I bought the book, I was hoping the authors' would answer the question "What is equitable health care?" Is it equitable for the government to pay for medications that control blood pressure, insulin response, and bone density when all of these could be managed by diet and exercise? Americans have a problem giving welfare to those who can work. Why give "healthfare" to those who can diet and exercise?
In support of my second reason regarding the authors' wordiness, consider these sentences in the second paragraph on page 20: "It would have been easy to conclude that all that was needed [regarding medical education] was a marginal adjustment here and a bit of tweaking there. Such a conclusion would have been valid if medicine and medical education could have stood apart from the society in which they were embedded. But, of course, they could not do so. They necessarily were influenced by the world outside of medicine, and that world, that external environment and its influences, was changing."
Now couldn't the authors' have assumed their readers already knew, 1) medicine and medical education are influenced by the world in which they operate, 2) the world refers to the external environment, and 3) the external environment is always changing? It was wordiness like this that forced me to put the book down rather than continue my struggle to find what new truths the authors' had to offer on the topic of health care and public policy.
Since I still want to understand the health care mess and how we can get out of it, I ordered Paul Starr's Pulitzer Prize-winning book "The Social Transformation of American Medicine." I found the book by scrolling down the product page for "The Health Care Mess" and seeing what "Customers who bought this book also bought." I clicked on the link "One Nation Uninsured: Why The U.S. Has No National Health Insurance by Jill Quadagno." I then read the Washington Post's Book World review on that product's page, which referred to Paul Starr's book.
This is what I love about shopping for books and other products on Amazon. I would have never found Paul Starr's book unless Amazon had provided those links and reviews. If you are also shopping for a book to understand the health care mess, read the reviews, the table of contents, and the excerpts for Paul Starr's book in Amazon. Notice that this information is not available for "The Health Care Mess". I googled "The Health Care Mess" and the only reviews available are those on the book's back cover, which are from prestigious individuals who no doubt didn't take the time to read the book.
The truth is out there. Seek and ye shall find.
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