Diagnosis Without a Cure

...on the economics profession...

...No arena of public policy is more perplexing...

...The confusion is so pervasive that no single source offers a coherent and well-reasoned overview for the intelligent layman...

...Fuchs is an ardent devotee of prepaid group practices, on the model of New York's hip or, more notably, the Kaiser-Permanente Plan that has been so popular on the West Coast...

...Yet, after insisting on the need for choice, Fuchs refrains from saying very much about the actual choices to be made...

...So while economic techniques are useful for diagnosis in the area of medicine, their therapeutic potential is less substantial...

...Most notably, it was the central thesis of the Forward Plan for Health prepared in the office of the assistant secretary for health at HEW—and then suppressed by an Office of Management and Budget (OMB) unwilling to grapple with the budgetary implications...

...But once the initial quantum leaps?such as the control of infectious diseases and the reduction in infant mortality—have been made, each additional increment of medical care produces diminishing marginal benefits when measured by life expectancy...

...Having the eminent good sense to begin with fundamentals, Fuchs establishes two themes at the outset: the tenuousness of the relationship between medical care and health, and the necessity for social choice in an area where it is becoming apparent that there can never be enough resources to go around...

...The hard choices OMB was trying to evade are precisely the ones Fuchs is trying to promote...

...Like the melodies of a sonata, these themes run throughout the book, and give it its greatest strength...

...Fuchs perceptively identifies the hidden secret of modern American medicine: that many people seek help not because there is any realistic prospect of controlling illness, but because our other social institutions that are supposed to provide "caring"—schools, churches, extended families, etc.—are failing to do so...

...Early in his book Fuchs argues: "It is impossible to understand the problems of medical care without understanding the physician...

...Much the same criticism can be leveled against the book's examination of health-care services...

...The tenuousness of the connection between medical care and health, the key role of the physician in the economics of medicine, the influence of the drug industry—these are the inescapable building blocks for constructing a sound health policy, and credit should be given to those who insist on their importance...

...And it is impossible to make significant changes in the medical field wtihout changing physician behavior...

...Neither of these tendencies are more endemic to economists than to any other group that writes about health...

...A similar weakness vitiates what could have been the book's most original chapter, "Drugs: The Key to Modern Medicine...

...Indeed, one is almost tempted to declare that the virtues and weaknesses of Who Shall Live...

...More distressingly, he seems largely to have swallowed the ideological nonsense of the Nixon Administration, which sold "Health Maintenance Organizations" (HMOs)—a version of prepaid group practice—as a force for introducing "competition" into the health sector...

...The second is whether the almost classically oligopolistic behavior of the drug companies—with their enormous profits, collusive activities and huge expenditures on advertising and promotion—has much relation to, or is perhaps outweighed by, the new drugs that are produced...

...In the end, Who Shall Live...

...Indeed, it has attracted its own schools of specialists, who tend to polarize around two issues...

...For the average American, diet, smoking, lifestyle, and environment are probably more important in determining how long he will live than anything having to do with the practice of medicine...

...Reviewed by Bruce C. Vladeck Center for Community Health Systems, School of Public Health, Columbia University Victor Fuchs has sought to perform an indispensable task...

...and since economists have been preoccupied with scarcity and alternative resource uses, Fuchs is able to carry out the diagnostic lour de force that constitutes his first few chapters...

...To meet both of these objectives without being sloppy or superficial requires a feat of tightrope walking—and Fuchs, alas, keeps falling off...

...Fuchs tells us "this book approaches the problems of health and medical care from a specific point of view?that of the economist...

...Nowhere are there more startling deficiencies in essential information, more panaceas thrown out for mass consumption, more paradoxes and seeming contradictions—or more objectively serious problems...

...No apologist for the American system, he avoids equating statistical aggregates with the problems of individuals...

...Yet ultimately it is unsatisfying...

...The conviction that it is becoming senseless to devote increasing resources to relieving chronic conditions like emphysema or coronary disease, rather than attempting to control their environmental or behavioral causes, is hardly unique to Fuchs...

...Thus, he never looks closely at the trade-offs between prevention and amelioration, nor does he consider the possibility that alternatives to relying on the health sector might need to be promoted...

...There is, finally, a kind of flabbi-ness to Who Shall Live...

...What he offers are three tired panaceas economists have been promoting for years: capitation, the payment of physicians on the basis of the number of patients under care (as is done in the British National Health Service), rather than on a fee-for-service basis...

...Still, it would be neither accurate nor fair to blame all the shortcomings of Who Shall Live...

...Fuchs' random flights of silly rhetoric on the history of Western civilization or on the eternal conflicts between freedom and order stand in embarrassing contrast to his frequent inability or unwillingness to present a careful defense of important value-judgments on policy matters...

...But supply and demand in the health sector are far more complex than, say, exchanging Portuguese wine for English corn, the transactions that form the foundation of the market economics on which Fuchs relies...

...The first is the impact of Federal licensing regulations of new drugs on the pace of innovation in the industry...

...Advances in medical care, Fuchs rightly argues, have accounted for the enormous differences in health between citizens of modern industrial societies and their pre-20th-century forebears, or inhabitants of the still underdeveloped world...

...health care—reflect far more on the way we live than on the kind of medical treatment we receive...

...comes close to filling that need...

...He is, in addition, aware of the deprivations experienced by blacks and other minorities, and of the special needs of particular groups, such as pregnant mothers...

...But he mainly ignores the fact that attempts by the Federal government to foster the development of such plans in the last several years have not succeeded...

...are due to the discipline of economics itself...

...Some of the failings are distinctly the author's...

...The reluctance to pursue conclusions is still more apparent in the discussion of doctors...

...He has tried to make sense out of the chaos of health care, and thinking about health care, in the United States...

...Fuchs is careful not to overstate this centrally important point...

...Yet that audience, by its nature, demands a solution to every new dilemma or crisis identified...

...But nowhere does he consider how present practices might be altered, and he never analyzes in any systematic way the reasons physicians now behave as they do...

...And it is, moreover, an irritating failure, not only because we badly need a study like it, but also because it will probably be, for a number of years, the best one we have...

...and, similarly, the use of "physician extenders" and other subphysicians to perform routine tasks...

...Rather than seizing the self-created opportunity to integrate these questions into his general framework, Fuchs merely reiterates both sides' old, ho-hum contentions...

...is a failure primarily for aiming too high...

...Whereas advances in pharmacology have been perhaps the single most important feature of treatment today, the pharmaceutical industry has never occupied a central place in people's thinking about healthcare policy...

...Thus the oft-mentioned contrasts in life expectancy between Americans and citizens of other advanced nations—frequently proffered as evidence of the failures of U.S...

...Yet the thrust of his discussion of health dovetails nicely with his other major theme, the necessity for social choice...

...The consumers' inability to make rational choices about health care means that a free-market model does not apply to medicine, and only an economist conditioned by professional mores to salivate every time the bell of "competition' is rung could take the HMO propaganda seriously...

...that must be attributed either to Fuchs' intellectual laziness or, less unhappily, to his inability to resolve a crucial structural problem...

...These complexities necessarily involve matters of institutional design and social and cultural values that contemporary economics is particularly ill-equipped to deal with...

...institutional licensure, permitting hospitals and other facilities to employ specially trained personnel without regard to the rigidities and irrationalities created by existing licensing procedures...

...Since he is addressing a lay audience, Fuchs may have been hesitant to argue anything in too great detail, to examine too many divergent possibilities, or to include too many scholarly references...