Book Review

A Tall Order From a Cautionary Tale


Peter Boland

Mistreated is a comprehensive and brilliant analysis of American health care by Robert Pearl, the CEO of the Kaiser Permanente Medical Group. The book’s subtitle aptly summarizes the author’s point of view: “Why We Think We’re Getting Good Treatment–and Why We’re Usually Wrong.”

Mistreated by Robert Pearl

Pearl is unswerving about the necessity of preserving what is best—and even sacred—about the patient–physician relationship. He admonishes his colleagues to stand up against market forces that too often undermine what it means to be a physician today. Physicians, Pearl believes, must reassert their primacy in the health care system as unstinting advocates for better patient care. A top-to-bottom transformation must be led by physicians because physicians have the requisite moral authority as well as the “power of the pen”: They initiate and control the majority of medical spending, and must, in Pearl’s view, transition from fee-for-service payment to prepaid financing mechanisms that reward efficiency and better patient outcomes.

Pearl challenges doctors to save health care from itself by leading four transformational efforts. First, health care needs to be integrated both horizontally within specialties and vertically across primary, specialty, and diagnostic care. Second, health care needs to be prepaid in order to achieve better value and superior outcomes, rather than paying for volume through fee for service. Third, better care requires integrating information technology into everyday medical practices. This includes comprehensive electronic health records, patient access to medical information, and using mobile and video technologies to reduce cost and increase convenience. And fourth, transformation led by physicians requires far greater investment in leadership training and development by the medical profession.

Throughout his book, Pearl highlights the importance of compassion. It is an undervalued and essential cornerstone of good care, and he worries that it is being wrung out of his colleagues every day as they do battle with faceless bureaucracies and more regulations.

Readers of Mistreated will find themselves in the hands of a gifted writer with an impressive grasp of what ails our health care system. Pearl methodically dissects the political and institutional interests that impede change—namely, Congress, professional societies, insurance companies, and pharmaceutical manufacturers. He posits what physicians and consumers can do to demand more personal and convenient care with an emphasis on better outcomes, such as the ability to obtain care using mobile and video technology. However, the book is less sanguine about how costs will be reined in within the existing business model of managed care.

One of the central tenets of Mistreated is the pervasive influence of the current context of American health care: Arrangements and structures that systematically marginalize patients and doctors while maximizing revenue of insurers and hospitals. This context is fundamental to understanding the failings of the system because it influences individual decisions and behaviors. It helps us identify the underlying causes of our current problems—and why the challenges to overcoming them can be met through renewed medical leadership, expansion of primary care, group practice of medicine, technology-enabled care, and different financial incentives that reward improved patient outcomes rather than how many procedures were performed.

Peter Boland

This is a tall order given the political and institutional interests embedded in fee-for-service medicine, a financing mechanism that was designed to protect the interests of legacy players at the expense of patients and improvements in population health. Legacy players—insurers, hospitals, physician specialty societies, and drug and device companies—tip the balance of power in their favor and steadfastly resist change.

Mistreated is an inspiring book but also a cautionary tale. Either we commit as a society to put the interests of patients above those of legacy institutions holding back meaningful change or we risk losing what is best about American medicine. The clock is ticking and the stakes are enormous for everyone.

Peter Boland of Boland Healthcare is a health care consultant in Berkeley, Calif., and a member of Managed Care’s editorial advisory board.