- The Washington Times - Sunday, October 15, 2000

Ron Glasser is a Minneapolis physician and the author of five books. Thirty years ago, he was an Army doctor in Japan, treating the shattered bodies pouring through the Vietnam MedEvac pipeline. From that experience came his still-in-print best-seller, "365 Days."

Today, Ron Glasser is writing another book: "The Medicine Wars." It's a devastating counterpoint of analysis and vignette, of anger and sorrow. His thesis is simple. American medicine is being destroyed by the same mindset and practices that guaranteed failure in Vietnam the same economic approach, the same reliance on experts as abstractly brilliant as they are real-world idiots, the same failed "systems" obsessions.

Writes Dr. Glasser:

"The irony of today's medicine is precisely the same as the irony of our war in Southeast Asia. At a time when a lieutenant or captain was able to call in gun ships, fighter bombers, radar-directed artillery, B-52 strikes, napalm, and rocket attacks to literally pound to death any company or regiment of North Vietnamese Regulars, we managed to lose the war. Today, despite an arsenal of new medical and surgical techniques that allow physicians to cure any number of conditions that only a few years ago were barely diagnosable, victory is again beginning to slip away.

"The failure of today's health care has no more to do with the ability of physicians to care for the sick than our failure in Vietnam had to do with the courage of the American soldier. The causes of the failure of the war in Vietnam and the failure of managed [medical] care are the same: self-serving analysis, hidden agendas, a refusal to accept the realities of the situation, and a lack of common sense."

And, Dr. Glasser points out, there's an additional link. One of the founding fathers and chief intellectual gurus of managed medical care, Alain Enthoven, was once the Best and Brightest of Robert S. Mcnamara's Whiz Kids the folks who gave us the Vietnam body count. Says Dr. Glasser:

"What Enthoven did not understand in the 1960s and seems to be incapable of understanding today is that neither war nor disease is easily measured or conveniently controlled."

The indictment is correct.

When Robert McNamara left the Ford Motor Co. (where he had presided over the Edsel disaster) to become John Kennedy's defense secretary, he brought with him a passion for computerized quantitative analysis. Fine. Problems that respond to quantitative analysis should be quantified.

The dilemma came when quantitative analysis and the micromanagement style derived thereby were extended into endeavors where they had no business, i.e., the actual conduct of human conflict. Mr. McNamara arrogantly proclaimed that there is no such thing as strategy anymore, only crisis management. Mr. Enthoven held that merely military experience kept the brass from seeing "the larger picture."

Perhaps. But men don't rush into battle shouting "Cost-effective." And when an entire nation (North Vietnam) is fighting a total war at once civil, ideological and anti-imperial, "rational" calculations of just how much punishment rational people might endure don't avail. It wasn't that the North Vietnamese and Viet Cong didn't get the message of American ability to inflict pain. They got the message. They kept on coming. They were, by Whiz Kid standards, irrational. They won.

But there are folks in this world who seemingly live by the motto, "Mess Up and Move Up." Mr. McNamara went on to wreck the World Bank. Mr. Enthoven, at the request of a group of corporate and insurance executives, birthed managed care. Its defining characteristics:

Medical care is not an intense and intensely personal human activity. It is a commodity to be "provided" and "consumed" in the most efficient manner possible … efficient from the administrator's perspective. This means treatment must accord with the detailed, economically based dictates of the quantitative analysts, not with the desires of doctor or patient. Further, health care providers must accept compensation levels decreed by the administrators and keep their overall costs below a preset limit. The ultimate measure of success is neither patients physically cured nor doctors professionally fulfilled it is all those statistics (and happy-face PR campaigns) proving the efficiency of the system.

But efficiency and victory are not the same, in medicine or war. Efficiency is a relationship between input and output: X number of patients seen by Y number of doctors in Z amount of time and cost was anybody helped? X number of bombs producing Y amounts of death and destruction in Z amount of time and cost We must be winning, we've met the goals.

It took 10 years of winning in Vietnam to lose. Today, says Dr. Glasser, after 10 years of managed care, the medical system is producing the opposite of the intended results: soaring costs (regulations require regulators), deteriorating care, and, as in Vietnam, human rebellion. Asks Dr. Glasser:

"Did these [managed care] people really think that people who were really ill would stay within the net? Did they really think the drug companies would cave in forever? Did they really think the hospitals would keep taking patients at a discount just to keep their beds filled? These companies are headed for insolvency. This book is an opportunity to push them over the edge."

If anybody ever publishes it. Ron Glasser, a nationally prominent physician with two New York Times best sellers on his resume, can't find anybody to take it on. "I'm baffled," he says. "It's either too controversial or too … I don't know."

Something to ponder, the next time you visit your health care provider … or open a bill.



Philip Gold is president of Areta, a Seattle cultural affairs center.

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