Dr. Jacobsen replies: I regret that some readers may have interpreted my article as a blanket endorsement of all HMOs. The intent of my article, as stated in the title, was to show that cost control and quality are not contradictory concepts in health care. I offered my HMO as an example of an organization which, in my experience, is doing a superb job of providing quality, personal health care at lower cost.
"Managed care" is an unfortunate phrase to the extent that it implies that health care choices are being made by someone other than the patient and his health care provider. I have no "plan" for health care in the United States. I believe in a market system of evolutionary development in which consumers must be the ultimate arbiters. The challenge is to determine, to the best of our imperfect ability, what constitutes optimal health care for each of us; how much of this health care we want; and finally, how much we can afford. To the extent that government regulations, licensure requirements, and tax policies thwart this challenge, they ought to be abolished. The choice is not between HMOs and fee-for-service--these may well be just way stations in the evolution of health care delivery.
The question of innovation is an important and complex one. Certainly, the innovations I outlined are not unique to HMOs. No responsible health care delivery system can simply offer its patients or its providers a blank check to foray into the unknown and unproven at whim. Science demands evidence before it can embrace innovation as a standard of care. My HMO endows a large research fund to help us define such evidence. Innovation and cost-consciousness are certainly not incompatible.
Why do medical costs increase with improved technology? Not all do. The inguinal hernia repair is much cheaper now than it was 20 years ago. Before the development of the artificial hip joint, the cost of this procedure was zero. The current cost of hip replacement is a welcome increase. In between these examples is a muddle in which new procedures and new technology have added to medical costs without always improving medical care. Getting out of this muddle will require that consumers and providers inform themselves of the costs and benefits of medical care and make their own decisions.
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