Foreword Review — Jan / Feb 1999
A practicing Internist, with a sub-specialty in rheumatology, Makover chronicles the rise of Health Maintenance Organizations (HMOs), beginning with non-profits Kaiser-Permanente and Health Insurance Plan in the 1940s, through the HMO Act of 1973, to the managed health plans common today.
Corporate America has taken control of health care, Makover explains, which has led to HMOs withholding treatment in order to increase profits for shareholders. Makover says that some HMO physicians routinely earn 10% of the cost of all care that they deny to the patient. What’s more, Makover illustrates how HMOs routinely deny admission to the hospital the night before surgery; refuse to refer patients to specialists in order to save money; limit the number of tests given each patient, all in order to increase profits. He believes that the circumstances that led to the current HMO near-monopoly included escalating health care costs, increased societal health care needs, and the greed of a small number of physicians.
Makover is best when he proposes alternatives to HMOs, including a two-tier payment system based on income/asset levels, and his suggestion for curtailing spending by consolidating the administrations of Medicare, Medicaid and the Veterans Administration. Makover’s comments are generally sound, backed by his 34 years experience as a physician. This is not meant to be an objective work; Makover is clearly against HMOs, although he does list a few ways in which they have improved the field of medicine, such as reducing obsolete and unnecessary procedures, and providing innovative outreach programs. Included is an appendix on how to make the most of an HMO, along with suggested texts on how to navigate within the system.
It must be noted, however, that Makover has never worked for an HMO, and an underlying subtext of this work is his anxiety regarding the loss of autonomy physicians experience within an HMO. (“Doctors have been demoted to little more than deck hands [on the medical ship].”) Still, this is a solid primer, designed for the lay reader that wants to learn more about managed care in today’s economy. (Statistical tables not seen by reviewer.)