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Book Review   |    
John Bischof
Psychiatric Services 2007; doi:
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by David Mechanic; New Brunswick, New Jersey, Rutgers University Press, 2006, 228 pages, $26.95

Dr. Bischof is assistant professor of psychiatry at Oregon Health and Science University and chief psychiatrist at Oregon State Hospital, Salem.

I thought as I read the title of this book, "Finally someone who knows what's what and is willing to say it." In The Truth About Health Care, David Mechanic, director of the Institute for Health, Health Care Policy, and Aging Research at Rutgers University and national director of the Robert Wood Johnson Foundation Investigator Awards in Health Policy Research, provides a thorough and thoughtful summation of the challenges we face. He starts out strong on the first page, stating the problem plainly: "American values and culture, reliance on markets, and the decentralized character of health care markets and professional groups and their local cultures prevent steps to achieve a more rational system of health promotion, health care provision, and reasonable cost constraints."

Mechanic proceeds to detail the dilemmas we face: 46 million people without health insurance and many more with glaring gaps and limitations in continuity and coverage; the challenges of chronic disease and end-of-life care; rampant medical error; soaring costs, especially of pharmaceuticals; problems of nosology and etiology, especially in mental health; the continuing trend toward specialization over primary care; growing socioeconomic, racial, and ethnic disparities; and the neglect of long-term care.

Reeling from such a list, I found myself thinking that the truth about health care is that it's an unmitigated mess. Interspersed among all this, however, are fresh insights about cultural and ideological context, issues of trust and medical leadership, and a call for "a new kind of professionalism built around evidence-based collegial processes and quality-assurance programs supported by advanced information technology, well-developed disease management programs, and a team of supporting professionals."

The book then travels quickly through a brief look at evidence-based medicine and quality improvement initiatives, both individual- and population-directed efforts, then on to a vigorous discussion of rationing—including another strong statement: "inequities in access and provision of high-quality care contribute to our embarrassingly poor performance on morbidity and mortality indicators compared with countries that are much less affluent." The author then revisits the issue of trust and makes a more specific case for a renewed culture of medical professionalism.

The book ends with a call to the challenge of change and encouraging incremental and collaborative efforts, covering the uninsured, adopting evidence-based practices, reinvigorating primary care, meeting the chronic care challenge, increasing postmarketing monitoring, regulating the pharmaceutical industry, reducing administrative costs, and developing health care facilities, workforce, and technology. On the final page, Mechanic ends with a series of blunt, declarative values statements. "Medical systems are complicated, but organizing and providing quality care is not rocket science." "The cost of extending health coverage to the 46 million people now uninsured and guaranteeing a system that is universal for all is clearly within our technical and economic capability." "American health care is not only not the best, as we like to brag; it is too often an embarrassment."

Change for the better he asserts, is "an issue of will and commitment." Commitment to what? To truth, I suppose. Now if we could only all agree on what the truth is, that would be a start.




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