Reforming American healthcare: an interim report.

At the beginning of this decade, health policy analysts and health management consultants went about the United States proclaiming that the sky was falling because something called "managed care" was about to revolutionize the financing and delivery of healthcare. In the process, it would rob US physicians not only of their long accustomed clinical freedom, but also of their long accustomed handsome incomes and job security. Understandably, in the face of many negative predictions, US physicians felt as if they were in dire straits. To be sure, the odd skirmish has been waged over healthcare costs and over clinical freedom. Viewed across the United States as a whole, however, managed care so far has been, in the words of a recent magazine article, "a mouse that roared." However, it is possible that a second revolution in the US healthcare system is yet to come, as Medicare and Medicaid turn over more and more of the functions of cost and quality control to private regulators. It is likely that the private regulators will consist of physician-driven integrated healthcare delivery systems, which take full capitation from Medicare and Medicaid and therefore assume full clinical control over healthcare, along with the financial risk inherent in capitation. For rheumatologists, this approach to healthcare represents both a danger and an opportunity.