The Medical Delivery Business: Health Reform, Childbirth, and the Economic Order (review)

This book addresses three related subjects. Barbara Bridgman Perkins describes the strong influence of "elements of economic organization" on the "structure of medical care" as well as on "clinical activities" in the United States during the twentieth century (p. 3), with particular emphasis on care in childbirth. Then she adduces considerable evidence that money has been more powerful than science as an influence on policy for perinatal care since the 1970s. Finally, she offers a nuanced polemic on behalf of "scientifically and democratically match[ing] health care delivery to known needs" (p. 168).

The four chapters on perinatal care since the 1970s are an especially helpful contribution to the recent history of health policy. Perkins grounds her narrative and analysis in these chapters in her professional experience as well as in diligent reading in published sources. She makes a persuasive case that the regionalization of perinatal care has served the interests of obstetricians better than those of women and babies. She documents the contradiction between the scientific claims of the main proponents of regionalization and the best available evidence of the effectiveness of alternative ways of organizing care in pregnancy and childbirth. This reviewer's experience in the mid-1990s of trying to persuade leading obstetricians and the March of Dimes Foundation, then reformulating their approach to regionalism, to take account of the synthesis of research on care in pregnancy and childbirth by Iain Chalmers and the Cochrane Collaboration reinforces Perkins's conclusions.

However, Perkins overstates the influence of goals and models derived from business on the regionalization of health services earlier in the twentieth century. Although she acknowledges that scientific and professional models also shaped medicine, she criticizes scholars (including Paul Starr and this reviewer) who conclude that these agendas dominated proposals for change in the organization of health services during the first three-quarters of the century. Moreover, she does not address the conclusions of scholars such as Roger Cooter and Steve Sturdy who have published persuasive studies showing how beliefs about science and industrial management reinforced each other.

The regionalization of health services in hierarchies dominated by academic institutions had considerable scientific justification until the 1970s. That justification was fueled by widespread agreement that biomedical research and its coordinated dissemination would make essential contributions to the health of the public. On the other hand, most of the physicians who attacked or resisted hierarchical regionalization before the 1970s did so out of self-interest in retaining their patients in the face of competition from subspecialists, as well as defending their right to practice without accountability (called autonomy at the time).

Because Perkins insists that the regionalization of health services has always been mainly about the business of medicine, she ignores a significant implication of her evidence: As regional hierarchies in perinatal care grew in number and strength in the past quarter-century, hierarchies in other areas of health care grew weaker. Competition from community hospitals and pressure from cost-conscious public and private payers destroyed the regional control previously enjoyed by academic health centers. The efforts of these centers to preserve or reconstitute their monopolies of health services since the 1980s have, like those of the obstetricians, often been strongly motivated by financial goals, and just as often have led to financial disaster. In the current era of regionalization in the absence of very much scientific justification for it, obstetricians and their allies seem to have been among the few winners.

Despite my disagreements with it, this book exhibits scrupulous scholarship and informed advocacy. Perkins's errors are few: for example, a misdefinition of "geographic full-time" clinical salaries (p. 28), and overstatement of the role of the Milbank Memorial Fund in the work of the Committee on the Costs of Medical Care (p. 65).