The Rise and Fall of HMOs: An American Health Care Revolution

Extract

This book presents the reviewer with a difficult task. It is in practice two monographs knitted together. One is a well-documented case history of the Marshfield medical clinic's origins, growth and transformation in rural Wisconsin under the impact of changing finance and regulation of American medical care. The other is an attempt to describe American medicine in the period 1970–2000 as largely a revolution that began under the rubric of health maintenance organisations (HMOs) and was transformed and distorted over time in ways that hurt rather than helped innovative delivery and financing institutions like the Marshfield clinic.

The problem is that the first work is well done and the second one, in my view, is sadly lacking. The Marshfield story is a very competent and extended piece of scholarship, one that clearly reports who did and said what to whom and when, and which outlines the obstacles the clinic faced in getting its well intended form of pre-paid group practice financed sensibly and supported by programmes like Medicare and Medicaid. Much of this part of the book reports illuminatingly how much trouble the reform doctors had with advancing a model of pre-paid group practice and specialist care in a rural setting, and the difficulties of dealing with Blue Shield's rules, court challenges, and other difficulties of many sorts. By the l990s, the Marshfield dream was changed beyond recognition, and the author clearly finds this a tragic loss.