Kassirer, Ginzberg, Ostow asked "Is Managed Care Here To Stay?" [N Eng J Med., 4/3/97.] I believe, at least in principle, it is. The inequities created by virtually any system of health care coverage can be daunting; even counterproductive (meaning it can hurt patients). Clearly managed care has had its problems, but it is here for a number of reasons: health care costs are ever spiraling upwards. Also, the variation in medical practices is intolerable. Finally, accessibility to and the quality of care are variable, at best (over 40 million of us are uninsured).

Health care management in the U.S. and elsewhere leaves a lot to be desired. First, consider its three main foci--cost, quality and access. Like the 3-legged stool with uneven legs, it wobbles. Forget quality assuranc--it's all about process, not outcome. Health care cost containment is shaky, as well; the analogy of the balloon applies here--squeeze it in one place and it pops out in another.

What has been done over the past few decades to improve the value of health care?: first dollar coverage--the patient is happy for it, but bears no responsibility; capitation (paying doctors by the head count rather than what they do or how well they do it)--that encourages less service, and occasionally less than optimal care. What about traditional fee for service? it fosters the opposite--more visits and interventions one doesn't necessarily need; the kind of care that actually may cause harm ("iatrogenesis," we call it). How about the managed care technique of insurers' cost-sharing with doctors--that even reduces some non-discretionary care. We've also seen a flurry of cost-shifting to patients (three- and four-tiered pharmacy "benefits," huge deductibles and co-pays, the "doughnut hole in Health Savings Accounts, etc.).

It is this authors' opinion that putting a financial barrier in the way of proper, timely and necessary health care is an anathema, and if all managed care is is bureaucratic interference, get rid of it.

Nevertheless, managed care has had its proud moments: data collected and transformed into information and then used in utilization review and management, network development, continuous quality improvement (CQI), case and disease state management, diagnostic related groups and other forms of case mix adjustment, early discharge planning, preventive medicine and outreach programs, to name a few advances it has fostered. All this can be summarized in the acronym--REACH--Respectful treatment at the Right time and place, Efficient and Efficacious care that is Accommodative, yet Appropriate, CQI and Caring, and Helpful Healthcare.

"Information is nothing special; it is found wherever causes leave effects. What is special is information processing." [From Steven Pinker, "How the Mind Works." W.W. Norton & Co., NY 1997; p. 65-66.] Dr. Russell J. Ricci, general manager of IBM Global Healthcare said something similar and as profound: health care is a cottage industry that still hasn't figured out how to turn data into actionable information. [Business Week E.biz — "Curing an Industry's Ills." Special Report: E-Health. Dec. 11, 2000.] The secret to managing care is just that--actionable information; one cannot manage what one does not measure (and visa versa).