Doctor Generic Will See You Now - 33 Rules for Surviving Managed Care by Oscar London, MD, WBD. Ten Speed Press, Berkeley, CA, 133 pages, $11.95, paperback, 1996.

Review by Del Meyer, MD

                What the Public Health Doctor fails to prevent, the Private Doctor tries to
                cure; what the Private Doctor fails to cure, the Specialist tries to improve;
                what the Specialist fails to improved, the Mortician beautifies.

                                                                                                        -- Anonymous

Dr London, author of Kill As Few Patients As Possible and Take One As Needed opens on a philosophical note. "We’re all going to die. Getting there, of course, is half the fun. It should be all fun, but life, especially in this century has become a killjoy... American medicine had greatly enhanced our ability to reach three score and ten in reasonably good shape and in pretty good humor. Then along came Managed Care, and the prospect of an untimely death suddenly became, if not attractive, certainly cost-effective." London then welcomes us to the world of Managed Care--health care managed by business school PhD’s to save bucks and fill their coffers, rather than by medical school MDs to save lives and heal their coughers.

London agrees that Fee for Service medicine was very expensive. It paid doctors according to how many patients he saw. Now doctors are paid a fixed sum per patient per year, whether or not he sees the patient or orders any tests.

London considers the immensely popular Health Maintenance Organizations (HMOs) and Managed Care synonymous. He states that millions of unsuspecting patients have signed up for HMOs, enticed by low premiums and the promise of comprehensive care. The low premiums are real--the promise of comprehensive care is science fiction.

He cites statistics that the biggest for-profit HMOs use up to 27% of their revenues from premiums for administrative costs and profits compared to only 4% reported by not-for-profit Kaiser Permanente. Also for-profit paid an average of $7 million in cash and stocks to their CEOs. And then there are the dividends paid to shareholders of MCO’s that are publicly traded.

One of the great contributions of Managed Care, in the London’s estimation, is that you must take charge of your own life before entrusting it to a doctor. He offers his own list of "33 Rules for Surviving Managed Care" which should guide your personal health care decisions before you see your doctor or visit an emergency room. "Your physician can best help those who help themselves."

London then proceeds into the 33 chapters titled Rules. In Rule 1 he tells you how to not let an HMO give you Nickel-and-Dime care for you million-dollar body. In Rule 3 he says, if you think condoms dull sensation, dying young will dull sensation even more. He then reminds us in Rule 13 that medicine may have changed in 2000 years, but patients haven’t. In Chapter 15, he actually describes his own experience as a patient under Managed Care. It’s a riot. In Chapter 21, death begins at 40. In Rule 28, he states that only bad doctors advertise. In Rule 32, he suggests that at the end of your life, ask your doctor to help you out. You never thought of doctor assisted suicide from this angle.

London said that if he were made Surgeon General for one day, he’d sentence tobacco company CEOs to a firing squad composed of dying lung cancer patients. When the CEOs request a final cigarette, he would deny it on the basis that second hand smoke is hazardous to the firing squad.

Dr London is a Bay Area internist. He wrote this book using a pseudonym to protect his identity__a telltale sign of how high the stakes really are. Perhaps for merely reviewing this book, I will suffer a mysterious bicycle accident. I hope my mortician is paid on a fee for service basis. I’ve already told my family it will be a closed casket event.