A Second Opinion: Rescuing America's Health Care

This book is good mainly because it was written by a physician. As such, he knows what he is talking about when the topic is health care reform. For the views of a another real doctor, working in the trenches of private practice, fighting against the insurance companies on behalf of his patients every step of the way, see Losing My Patience: Why I Quit the Medical Game by Mickey Lebowitz, M.D.

Dr. Relman begins by asserting that America's health care system is much too expensive and its costs are rising at an unsustainable rate. Further, care is not available to many who need it most, and it is provided inefficiently and with highly variable quality. By most measures of national health we rank well below many other advanced countries that spend less. Why is this? Dr. Relman believes it is due to the extent that private enterprise governs insurance and the provision of care, rather than public regulation and social need. Dr. Relman also sees physicians as too often part of the problem - in the U.S. they are more specialized, more likely to be paid on a fee-for-service basis, and more likely to have financial interests in facilities and products than their counterparts in other western countries. Dr. Relman provides data comparing costs and outcomes from for-profit vs. not-for-profit entities. A 1997 study covering all acute-care hospitals found total hospital expenses/admission 10% higher in for-profits (administrative costs were 34% of the total, vs. 25% for non-profits; however, the for-profits provided less in-house clinical personnel. Thus, it is also not surprising that a 2002 study pooling all published data found the risk of patient death 2% higher in the for-profit hospitals. Similarly, a 1999 published study of dialysis units found mortality rates 20% higher in for-profits, as well as the likelihood of being placed on a transplantation list 26% lower (would end the center's revenues). Prior studies also found lower expenditures on care within the for-profits. Most nursing home payments are from standardized, per-diem Medicaid rates. A 1998 survey found for-profits with 40% more serious care violations than non-profits. Investor-owned insurance plans take 10-25% of premiums, vs. 5-10% for non-profits and only 3% for Medicare. G.M.'s 2005 health care costs in the U.S. added $1,525/car built in the U.S., compared to only $197 in Canada. Relman estimates that 40-45% of U.S. health care expenditures are wasted in overhead, marketing, and unneeded procedures. Canada has only 75% of the number of physicians/population in the U.S., but half are in primary care (vs. 1/3 in the U.S.). Thus, Canada ends up with 93 specialists per 100,000, vs. 150 in the U.S. This creates less pressure for high technology and associated high expenditures, and helps explain their lower overall health care costs. The provinces fund teaching hospitals, and have an incentive to hold down their numbers and production of specialists.

This book is very persuasive and informative. It is lucid with 200 short, well written pages. It is full of facts and statistics and in spite of this it is very clear. The arguments in it are extremely persuasive. It is indispensable to read this book if one wants to understand the reasons we are in such a mess in health care and the optimal solution for the mess. Read it, you will be pleased and enlighten.

I work currently as a consultant and entrepreneur in healthcare. Although my professional focus is specifically on electronic medical records and similar clinical information technology, I have read widely and done research in many aspects of healthcare and healthcare policy. Two other outstanding books which provide somewhat different perspectives. one written in the 1970s and one in the 1980s, but fully relevant today, are Who Shall Live? by an eminent economist, Victor Fuchs and The Social Transformation of American Medicine by an equally eminent sociologist, Paul Starr. I highly recommend both to anyone who reads Dr. Relman's book. There are many other good to excellent books on healthcare policy or specific aspects of healthcare financing and delivery. Dr. Relman's book provides an excellent summary and analysis of the current healthcare "system" in the USA and recommends specific, fundamental changes to how the system is financed and how care is delivered. His background as a practicing physician, author, professor and medical journal editor in addition to his native intelligence and compassion for people stand him in excellent stead to write this book. Dr. Relman analyzes succinctly and clearly the various aspects of the healthcare "industry", then recommends changes to the "system". He correctly identifies and criticizes the universally negative role of the commercialization of healthcare in its various manifestations: for-profit hospitals, for-profit health insurers, procedure-based reimbursement for physicians and so on. His recommended solution is for a single payment and single insurance system that is funded primarily through federal taxes and administered by a centralized federal government entity. He recommends the establishment of a federal agency along the lines of the SEC or the Federal Reserve System to oversee healthcare policy and healthcare delivery. He proposes that physicians work as salaried employees of multi-specialty practices. He dedicates a chapter to analyzing and discussing the Canadian healthcare system. He correctly characterizes the Canadian system as a good model - in most ways - for the USA. The book is opportune and most likely was published now because healthcare policy is a key issue at least for Democratic contenders for the Presidential election in 2008. Dr. Relman's proposals for reform are materially superior to the plans proposed by all candidates with the possible exception of Dennis Kucinich who co-authored a bill (H.R. 676) a few years ago that has some of the same features as Dr. Relman's proposal. There is so much misinformation deliberately disseminated by all the beneficiaries of our current poorly-functioning system - ranging from the AMA to large drug companies to private insurers to large for-profit hospital chains - that it is very helpful to have a relatively short, well-written book that accurately describes the current system and makes comprehensive, intelligent recommendations for c

I think of this book in two parts, the first of which is analysis of how America's healthcare system became so inadequate yet so very expensive, and the second, the author's policy recommendations. I've read a few books on this topic (including Critical Condition) and this is by far the best researched and level-headed. The author writes analytically by basing his assertions on numbers and throughout the book avoids being sensationalist. If you want to read one book about how the US healthcare system got to where it is now, this is it. As for policy recommendations (which some other books don't even have), his recommendations are not necessarily the best, but then again any ideas for real reform are going to be controversial. At the least, they are thought-provoking.