Education to defend professional values in the new corporate age.

The corporate transformation of medicine raises questions about the basic purposes and values of the profession and the physician's social role that have not been adequately considered in medical school and residency curricula. Medical schools and graduate programs need to make students and trainees more aware of the conflict between traditional professional values and the imperatives of the market, so they will be better prepared to defend these values in the new business climate. Otherwise, medical schools and teaching hospitals could simply become trade schools, turning out sophisticated technicians, future entrepreneurs, and managers. As a starting point for educational reform, the author suggests that students (1) learn the social and political history of the medical profession of the United States over the past 200 years; (2) be introduced to the economic dimensions of health care--where the money comes from and how it is spent; (3) learn the history of health maintenance organizations, and understand the different forms of managed care and how they work; (4) become familiar with the health care reforms proposed by the Clinton Administration in the early 1990s, and understand why they were defeated and what has happened to health care reform since then; (5) examine the conflict between the culture of business managers and that of practicing physicians, and consider the recent efforts to achieve "quality control" as a balance to the emphasis on price; (6) be challenged to think about the important ethical, legal, and professional issues raised by the industrialization of health care; and (7) consider the political and professional options that might preserve the most important principles of medical professionalism while still addressing the social objectives of cost control, community service, and universal access. The author concludes that to prevent medicine from becoming merely a technologic business, the medical profession will have to become more actively involved with other policymakers and representatives of the public in efforts to improve the health care system, while preserving professional and social values. To do this, physicians will need a better knowledge of the health care system and its problems than most of them possess. This is a challenge medical educators must now address.

The future of medical practice.

Managed care of some kind will dominate the future of health care, but the unresolved crucial question concerns ownership of the managed care plans. An investor-owned managed care industry now holds sway, but I do not expect it to last very long. In the long run, physicians must be in charge of medical care, but they must live within budgets and be accountable to payers and to their patients. The only solution that makes sense to me is one based on multiple local physician networks, organized on a not-for-profit basis. I predict that staff and group-model HMOs will be the mainstay of the medical care delivery system within a few decades.

Finding a lasting cure for U.S. health care.

In "Making Competition in Health Care Work" (July-August 1994), Elizabeth Olmsted Teisberg, Michael E. Porter, and Gregory B. Brown ask a question that has been absent from the national debate on health care reform: How can the United States achieve sustained cost reductions while at the same time maintaining quality of care? The authors argue that innovation driven by rigorous competition is the key to successful reform. A lasting cure for health care in the United States should include four basic elements: corrected incentives to spur productive competition, universal insurance to secure economic efficiency, relevant information to ensure meaningful choice, and innovation to guarantee dynamic improvement. In this issue's Perspectives section, eleven experts examine the current state of the health care system and offer their views on the shape that reform should take. Some excerpts: "On the road to innovation, let us not forget to develop the tools that allow physicians, payers, and patients to make better decisions." I. Steven Udvarhelyi; "Health care is not a product or service that can be standardized, packaged, marketed, or adequately judged by consumers according to quality and price." Arnold S. Relman; "Just as antitrust laws are the wise restraints that make competition free in other sectors of the economy, so the right kind of managed competition can work well in health care." Edward M. Kennedy "Biomedical research should be considered primarily an investment in the national economic well-being with additional humanitarian benefits." Elizabeth Marincola.