Product Description

Product Details

• Amazon Sales Rank: #58109 in Books
• Published on: 2008-05-26
• Released on: 2008-05-26
• Original language: English
• Number of items: 1
• Binding: Paperback
• 240 pages

Features

• ISBN13: 9781586486624
• Condition: NEW
• Notes: Brand New from Publisher. No Remainder Mark.
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Review

About the Author

Customer Reviews

Utopian aspirations
This book came highly recommended to me as a practical, non-ideologically driven approach to our present healthcare delivery system woes. I agree with Dr. Emmanuel that our present system is not sustainable and will bankrupt our country if we continue on our present path. His analysis of our present system, its history, problems with employer based systems, and alternative approaches including mandate and single payer approaches is well written.

His ideas for how an ideal system might be constructed de novo are not without merit. However, his prescription for how to arrive at such an outcome is terribly flawed.

The book describes using private insurance companies which will compete for the business of every American who will receive a health care certificate, However, to avoid our present circumstances, Dr. Emmanuel proposes the creation of an entirely new infrastructure consisting of both national and regional boards which will be charged with ensuring quality of care, appropriateness of care, coordination of care, cost control, fair funding, dispute resolution, and choice. Dr. Emmanuel likely made a tactical decision to write a focused book without getting bogged down in details and at least some criticism could be deflected on this basis. However, this entire proposal is based upon infrastructure which does not exist and is not likely to come into existence for a long time.

Not only do organizations, which would be charged with these various tasks, not exist, the tools they would need to function would require years of investment and study. Outcome measures such as life or death or surrogate measures linked to the same (blood pressure, blood sugar, weight) are fairly easy to measure. As Dr. Emmanuel points out much of medicine deals with chronic conditions and suitable outcomes deal with quality of life (pain, function, depression, malaise, or overall function) where metrics are much more difficult to assess. Much of current medicine practice is not strongly evidence based, but perhaps is still effective. The development of guidelines for what is acceptable for payment and the ongoing revision will be a Herculean task...not undesirable. Do we have the trained workforce in place? Do we have the information systems in place? I don't think so. Should we invest in building this? Absolutely, but don't expect to yield much fruit for a decade or more.

The author puts forth a system where 100% of Americans are covered.. specifically not 95% or 97%. if history is any guide, the marginal costs of those last increments will be frightfully high. Perhaps Dr. Emmanuel would be best served by remembering the adage perfection is the enemy of good.

Administrative cost control may sound attractive and have a certain populist bent. However, there is essentially no historical precedent for its success. From the Emperor Diocletian to contemporary New York City rent control, the results are all the same. This perhaps is the weakest link of the entire program. Who will set the prices and on what basis? Dr. Emmanuel speaks much about getting incentives correct. Without a correct pricing systems, incentives will always be wrong. It is a major problem with our current system.

On page 89 of this book is a passage which I believe reveals much about the author and his outlook. He states that "The current health care system to so complex that no single person understands all of its inner workings." This should not be a surprise that no single person understand how it works. Under no system can I imagine that this could be the case. The classic example of the lowly pencil as described by L.E. Read illuminates this for those who pursue the most rudimentary understanding of economic systems. No single person holds all the knowledge required to make even a simple pencil. It is inconceivable that any person could ever know all the inner workings of the entire health delivery system.

Making health care work is all about coordinating human efforts whether those efforts are made by physicians, those who answer the phones, those who negotiate the contracts, those who make the drugs, those who run the power plants to generate the electricity, or those who build and maintain the buildings. This coordination cannot be choreographed like River Dance by someone or some group which aims to understand and hold all the knowledge needed to make a large and complex organization work. That is not possible. Complex systems work because we all benefit from the activity of people who we will never know, who hold knowledge that we do not know.

Dr. Emmanuel rejects an further attempts at incremental change. We are implored to seize his vision of how an ideal system might look and push for immediate implementation. The political stars are now aligned (he is probably correct). The old system, unplanned and poorly engineered has almost no merits. Reading Dr. Emmanuel's rejection of incremental change reminded me of a passage from Thomas Sowell's "Quest for Cosmic Justice". "...that is, on the extent that what currently exists as the fruits of centuries of efforts and sacrifices is inferior to what they can produce in their imagination immediately at zero cost..."

Conceptually, some of Dr. Emmanuel's ideas have merit but there are big holes (thus the two stars). Logistically, the meritorious elements (investment in IT, health outcomes research, dumping of employer based insurance) will have to implemented incrementally to have any sort of impact and avoid too much top-down control. Investment in information systems is the key element that will allow for better systems to evolve. Dr. Emmanuel's universal aspirations will be unfulfilled. Ultimately, whatever is put in place will have to rely heavily on market forces to set prices, allocate scarce resources, and coordinate human activity. Man has found no substitute as of yet.

Healthcare Reform, Understood
If the United States hasn't passed the threshold of interest in health care reform, it must be darn close. Thus, now is the time for a clear and concise argument for any particular approach. Dr. Emanuel puts forward a specific proposal for health care reform that would address the seven goals he views as essential to success. His proposal has a strong appeal to common sense, and as such, it is one that will surely suffer the slings and arrows of outrageous ideologs. But, besides presenting his own distinct proposal for reform, Dr. Emanuel gives enough background on our present plight, along with a heuristic tool to equip us to evaluate the many different reforms out there already and the many yet to come. And, he does this without resorting to the use of extreme case histories, which have become the coin of the realm for authors of books on health care reform and which can have distorting effects on any objective analysis. Even members of Congress will not be able to get away saying they do not understand the concepts in this book.

This is an important book at an important time, and one that invites everyone into the health care reform debate whether they agree with Dr. Emanuel's proposal or not (count me among those who do). But, alas, important as this work is, it would never get Dr. Emanuel tenure at a major research university; it's much too accessible. He'll have to keep his current job.

Another excellent book on the healthcare system in the USA
Dr. Emanuel has been writing for some time on the subject of health care policy, usually in collaboration with Prof. Victor Fuchs, an eminent, but now-retired, health economist. Prof. Fuchs collaborated with Dr. Emanuel on this book, as Dr. Emanuel notes in it, but apparently the final version as published is mostly the work of Dr. Emanuel.

This and two other books that I highly recommend on health care policy, A Second Opinion and Health Care Policy, are written by physicians who know the science and practice of medicine as well as the economics of medical services. Another, also very good, book, Health Care Half Truths, is co-authored by a physician.

The book is fairly short, very well-written and well-organized. Dr. Emanuel spends the bulk of the book analyzing the current medical services delivery (and to a lesser extent the funding of the system), then at the end of the book makes cogent recommendations on reform.

Although my personal opinion on the particular form that the financing of medical services should take (I strongly favor a single payer/insurer scheme) differs from Dr. Emanuel's view, Dr. Emanuel presents compelling evidence why a single payer/insurer scheme is inferior to his recommendation: a voucher system that is funded by a dedicated value-added tax. Dr. Emanuel recommends the continued existence of private health insurers, asserting that their presence furthers choice and potentially at least engenders competition. My perspective is that private insurance simply has no place in a medical services system. The forces that drive private health insurance companies are immutable. Private insurers inevitably increase the administrative cost of effecting payment for services. They also have no ethical role as deciders of what treatment should occur. In particular very expensive treatments with whatever probability of lengthening a patient's life should not be decided by an employee of a private company. They also will continue to seek to exclude the sick and try to enroll the healthy in their insurance plans. Those are unavoidable characteristics that, at least in my mind, argue for a single payer plan, regardless of the pitfalls that Dr. Emanuel correctly notes.