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Book Review   |    
Mismanaged Care: How Corporate Medicine Jeopardizes Your Health
Ellen R. Fischbein, M.D.
Psychiatric Services 2000; doi: 10.1176/appi.ps.51.3.401
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by Michael E. Makover, M.D.; Amherst, New York, Prometheus Books, 1998, 300 pages, $24.95

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Whenever I hear someone claim to have a sound, workable solution for a problem an entire nation has been unable to fix, I think that person either must be another Einstein or has a bridge in Brooklyn to sell on a Web site. Although Michael E. Makover's Mismanaged Care is a nonfiction book, it will elicit a full range of emotions from physicians and other clinicians who may recognize scenarios familiar in their everyday practice.

An internist who repeatedly states that he has never been a provider in a managed care health plan, Dr. Makover writes extensively on the details of how the managed care system works and does not work. A large portion of the book details the inequities, injustices, inadequacies, and ineffectiveness of our current health care system. As a physician who proclaims his practice to be unaffected by encumbrances of managed care, Dr. Makover is somewhat self-aggrandizing in his claim that caring physicians such as he, who give high-quality care, spend an average of an hour with each patient.

Let us be honest. Managed care companies were not the first to introduce clinicians to the concept that more patients per hour means more income per hour. One reason the public embraced the early concept of managed care was that not all doctors were more dedicated to their patients than to the bottom line on the day's ledger sheet. A significant portion of the public felt their doctors did not give them enough time or concern. They looked to managed care to ensure that they received both and that they were charged a "reasonable" fee for it. One cannot disagree with Dr. Makover that the system is not only not working the way patients and some clinicians hoped it might, but that it is plainly messed up.

The author makes one point that cannot be overlooked: the patient must share more fully in the responsibility for deciding when to obtain care. When copayments are low, patients tend to be indiscriminate about going to their physicians for minor complaints. It is the patient's undoing, according to Makover, that managed care companies reinforce this behavior by readily covering "minor" problems but then by heavily managing care for serious problems.

The essence of the book is found in the final section, where Dr. Makover presents and discusses his health care plan. The basis of his plan for rehabilitating our ailing health system is the assumption that people are more careful about "buying" care when the payment comes out of their own pockets. He suggests instituting a combination of a medical savings account for "less serious" illnesses and catastrophic insurance with a high deductible for "major" illnesses. For his plan to work, insurance companies would have to forget about being nearly autonomous and unregulated. The plan would establish diverse boards of honest individuals who would arrive at fees the public and the physicians would accept. Patients would seek care only when they really needed it. (No small feat in this "give me—I want it now" society.)

A nonclinician reader might find some of the descriptions about our current system difficult to assimilate but interesting. Mismanaged Care inspires us to use our energy and ingenuity to look at an alternative system that might serve both provider and patient better. It provides stimulation to not just accept the problems with our current system, but to look further to see what might actually work better.

Dr. Fischbein is chair of the department of behavioral health care services at St. Mary's Hospital in Waterbury, Connecticut, and is in private practice.




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