- The Medical Delivery Business: Health Reform, Childbirth, and the Economic Order
Medicine is a business. A strong, explicit theme about the centrality of the business model in the history of American medicine makes these otherwise disparate essays hang together persuasively. Perkins makes good use of her earlier frustrations as a health planner in the state of Washington, her decades-long work on women's issues, and her work as an independent scholar and health care consultant to ask fundamental questions across these domains.
Why, for example, did the efforts of health care planners and reformers in the twentieth century, whether in the 1930s or the 1980s, generate business models of health care (such as private health insurance, managed care, and medical specialization) that seemed incompatible with the values and goals they espoused in their analyses and reports? Did patterns of medical management of childbirth, distinguished by technological intervention and treating birth as a pathological condition through the twentieth century, primarily represent patterns of male dominance over female bodies, or something else? Her answer to both such questions, which she shows carefully and with style, is that the business model for medicine has been so entrenched in the United States that, almost automatically, clinical medicine has reproduced industrial, corporate, and commercial models of organization, come what may. Though she does not put it this way, business thinking has proved more powerful than the rational allocation models or fairness doctrines of planners and high-minded members of blue-ribbon commissions, and more authoritative than professional jurisdiction and gender roles. The economic organization of clinical care (not technology, policy, or male dominance of childbirth) is the key to understanding American health care, she argues; ICUs are business units.
A core message of the book is that reform can succeed only by taking these business-centric conclusions as a given. Thus reformers, including feminists and others concerned about the childbirth business, must adjust their sights accordingly. Though Perkins gives no guidance on how to do this, the message is well taken, and may at least save some time that might otherwise be wasted in pursuing health reform unrealistically, that is, outside the business ethos. She makes the related point that medical technology is a product of the business model rather than an agenda in itself. Perkins notes, for example, that the diffusion of the new MRI technology [End Page 524] (machines) in the early 1980s was primarily a business proposition for hospitals, rather than a response to any clearly demonstrated clinical value at the time. (A similar point has been made by Joel Howell and myself for hospital purchase of the early X-ray machines in the years around 1900.) Such observations may not be new to historians of medicine and technology, but they deserve renewed emphasis. What Perkins does here is depict the history of health care as a business in the United States, not as a new historical phenomenon—for example, as in the decline of the medical profession and rise of corporate medicine after 1970—but as a common attribute of health care that can be traced back at least one hundred years.
The book is well researched and referenced, with nicely chosen examples to make the central points. For business expert Frederick Winslow Taylor, the Mayo Clinic offered a successful example of scientific management in the first decade of the twentieth century. For Ray Lyman Wilbur, chair of the Committee on the Costs of Medical Care (1927–1932), medicine was one of the largest industries in the United States. Business models sanctioned the production of births through assembly-line birth procedures. Medical specialization was a recognized model of the functional division of labor. And health planning foundered on expectations of the public good that ran counter to competitive business expectations. Perkins also argues that professionalism in medicine was not an alternative to the business model, as is often claimed, but is in fundamental ways an offshoot of it. These are useful ways of thinking about the history...