Castration: an abbreviated history of western manhood

adequate remuneration and professional autonomy. Unfortunately, the economic cost of these idealized features became too high. Health care costs as a percentage of America's gross domestic product rose from 5.2 per cent in the 1950s to a peak of 13.7 per cent in 1993. This came about because of a combination of general factors found in many western countries (including an ageing population, and innovation in medical technology), with ones more specific to the USA (such as hospital cost inflation, patient-driven insurance and personnel shortages). Since 1993 managed care organizations have grown rapidly to cover four-fifths of the American working population. Containment of health care costs has been achieved, but this has been offset by related disadvantages. The de-personalized character of managed care has still to win the trust of American patients, and to overcome their suspicion that cost reduction has compromised the quality of care. A recent bout of merger mania amongst providers has also reduced patients' choices, but seemingly without significantly increasing their efficiency. The author concludes that better data on providers' costs, and clinical outcomes, are needed before this will show improvement. What is termed "the shopping problem"-which health care option the consumer should choose still operates in managed care as it did earlier in traditional medicine. Dranove is intolerant of patients' poor knowledge base and their ignorance of the rankings of managed care organizations. He argues that this means that not only do patients get a less than optimal outcome, but that the efficiency and effectiveness of managed care organizations remain unimproved. One reason for what the author terms the "wilful indifference" of consumers (p. 168), and their ab,dication of responsibility in choosing health care options, is the intricacy of managed care. American managed health care involves different kinds of non-profit and with-profit businesses that range from prepaid group practices to indemnity insurance firms. The author's well-balanced and up-to-date review of the data on their efficiency and effectiveness shows their ambiguous and complex character. There appear to be no easy answers and quick fixes in the policy options for health care reform.