This Noble Land by James A. Michener

Author:James A. Michener [Michener, James A.]
Language: eng
Format: epub
ISBN: 978-0-8041-5163-4
Publisher: Random House Publishing Group
Published: 2014-04-15T04:00:00+00:00

In recent years a promising innovation in health care has begun to proliferate, the HMO (health maintenance organization), a sample of which can be located anywhere in the United States from small town to major city. It consists of a group of doctors and nurses—often assembled and managed by an outside corporation—who practice as a unit and offer to their communities a wide mix of medical services, but not procedures as difficult as heart transplants or brain surgery. For such cases they reach out to specialists in their area or in the nearest city.

The important word in the name is maintenance, the job of keeping you well. To enroll in an HMO the patient signs a contract in advance, paying a modest entry fee whether or not a doctor’s services are needed at that moment. In most HMOs the patient is restricted to a choice among the doctors participating in his particular group. Any patient may, of course, consult with the doctor who had previously served as his family physician and pay him on the side for his help. But the experience of the ideal HMO is that the patient who signs up selects a doctor within the group who is found to be satisfactory.

By themselves the HMOs would not be a dominating force in the system, but they are backed up by guidance from a remarkable institution, Milliman & Robertson, a Seattle-based consulting firm specializing in medical economics. Milliman, roaring ahead in a field others had overlooked, quickly established itself as the arbiter not only of medical costs, about which it was an expert, but also of medical practice, about which it was formerly barely eligible to have an opinion. HMOs, insurance companies and hospitals seek guidance from Milliman on the most vital parts of their financial management. Because Milliman is not afraid to identify errors in medical practices and to issue guidelines to correct them, it has made itself the guru of triage.

Milliman’s pronouncements, published as guides for the saving of money, are being accepted as law by insurance companies, HMOs and hospitals. In The New York Times Allen R. Myerson cited some of Milliman’s edicts that have been widely adopted for patients under sixty-five without complications:

—You can’t stay in the hospital for more than one day after a normal childbirth, or two days after a Caesarean. (This is being widely contested.)

—You can’t stay in the hospital for more than three days for most strokes, even if you can’t walk out.

—You can’t have a coronary bypass unless the strongest drugs have failed to cure your chest pains.

Other consultants advise against hasty operations on the back, the prostate and the heart, and recommend that insurance companies cut back on the number of hysterectomies they allow.

The chief at Milliman and the authority in charge of the guidelines is Dr. Richard L. Doyle, a big, bearlike doctor, aged fifty-seven, with broad experience. He charges $395 an hour for individual counseling to hospitals and the like and his clients say: ‘Worth every penny.

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