In his criticism of my support of managed care (letters, April 2), Howard Zeft ’58, M.D., reflects a bygone era in which American society granted physicians full professional autonomy, on the theory that physicians would be aware at all times of best clinical practices and always practice them. In effect, physicians were given the keys to sundry government and private-insurance treasuries and trusted to be modest in their taking from these treasuries and always to deliver the highest value for the dollar taken.
A mountain of solid empirical research in the intervening years has destroyed this trust. We now know, for example, that the per-capita cost of health care for statistically similar populations varies by a factor of up to three across the United States, without commensurate variations in the process- or outcomes-quality of health care, or even of patient satisfaction (just Google Dartmouth Atlas). In 2003, Elizabeth McGlynn and her research associates reported in The New England Journal of Medicine (vol. 348 (26): 2635-45) results from a two-year landmark study according to which, on average, individuals in a large random sample living in 12 metropolitan areas in the United States received the recommended treatments for their medical conditions only 55 percent of the time. It is now widely agreed that, left to its own devices, the medical profession cannot and will not always deliver the highest value for the dollar. The concept of externally managed care grew out of that realization although, admittedly, the concept was not invariably well applied during the 1990s.
Finally, I was amused by Dr. Zeft’s dig at my service as a paid director of a for-profit hospital. As chance would have it, the April 2 issue of PAW arrived in our home on the day The Wall Street Journal featured on its front page the headline that, on average, American nonprofit hospitals book larger profits than do investor-owned for-profit hospitals. Besides, the typical private medical practice is a for-profit enterprise as well. So what is Dr. Zeft’s point with this ad hominem?