Book Review - A Second Opinion

"A Second Opinion" takes another complementary viewpoint from the eyes of a physician. Dr. Arnold S. Relman is widely known as former editor of the New England Journal of Medicine and for his prescient 1980 article on the commercialization of medicine, and his phrase "the new medical-industrial complex". As many of his predictions have come true, he argues for a radical change in both ends of the current system to reduce waste and administrative overhead, improve quality, and provide coverage for all.

Dr. Relman details the post World War II development of medical practice in the US, and the transition of role of the physician responsible for "care of the sick" to the varied roles they have today in the commercialized "health care industry". He describes the effects of commercialization as fragmenting the delivery of care at the expense of quality, encouraging overutilization of new technologies, and increasing inequity of care.

In "A Second Opinion" he argues for a single payer system to eliminate administrative costs in the insurance industry and waste in the overutilization of treatment. In addition, he recommends a restructuring of the delivery of care to physician multi-specialty group practices (PGPs) that resemble the integrated health systems such as Kaiser, with reimbursements based on a fixed annual dollars per patient and doctors paid on a salaried rather than fee for service basis. In this way, physicians would return to their roots as a profession of primary caregivers, without regard to the level of compensation or financial incentives to practice medicine a certain way. In addition, like the PGPs, health care delivery facilities such as hospitals would be not-for-profit entities owned by the local community.

By telling the history of how the practice for medicine has been commercialized and the effect of the growth of Medicare and the indemnity insurance industry, Dr. Relman is able to convey the ethic that has been lost in his profession that a systemic change could restore. In addition, he makes a detailed comparison with the Canadian system, recounting its history in parallel with ours. The result is that Canadians have 100% coverage and spend $3500 per person annually, or one-half the amount in the US (only 10% of GDP). He concludes with a open letter to his colleagues in the profession about the need for change and his vision of the practice of medicine in salaried not-for-profit multi-specialty group practices.

Because of his perspective as a physician and manager of health care institutions, he doesn't approach the subject with any faith in market forces or technology to correct the current situation. In fact, he believes that the movement of consumer driven health care (CDHC) will fade with time just as HMO's did. The combination of catastrophic indemnity insurance and health savings accounts (HSAs) promoted as a solution to restore consumer decision making in the market will not change the fee for service orientation of the major expenditures such as hospitalization. Thus, it will fail to contain costs and at the same time will cause hardship in paying for physician office visits for low income individuals that may forego care to save the money in their HSAs.

One issue with Dr. Relman's approach overall is that it freezes the current state of delivery of healthcare in place and makes adoption of innovation difficult, because there is no profit motive to compensate for risk taking and investment in service delivery. The rate of innovation in medical technology is increasing, not decreasing, and medical practice will need to keep up with the emergence of personalized medicine and telemedicine. But this structure would not preclude the medical device and pharmaceutical industries from remaining as for-profit suppliers to these non-profit delivery entities.