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Health care evolution. Or is it?

A MEDICAL JOURNAL COVER SHOWS A TYRANNOSAURUS rex skeleton, "Jurassic Park" style, with the question: "Are publicly traded for-profit HMOs headed for extinction?" (1)

Psychiatrist Charles Atkins writes an opinion piece titled "To sink or to swim: Darwinism and managed care" in which he concludes: "The current rate of change, not quite up to the meteor theory of dinosaur extinction, is radically reshaping the delivery of health care. When the dust settles, it will be interesting to see what has evolved." (2)

Evolutionary language does not seem particularly unusual; we use it all the time. The concepts and language of evolution are such common tender that any of us can accept thoughts such as these without giving the phraseology any notice. Unthinkingly, we use evolutionary language and, therefore, evolutionary theory to explain today's changes in the medical marketplace. But should we be using evolution as our theory for understanding the radical changes overtaking the industry today?

Explaining change

Evolution is a theory for explaining changes in biological systems. The power and simplicity of evolutionary theory have made it the major scientific framework for looking at why certain animals and plants dominate ecosystems rather than others, and why one species dies out only to be replaced by another.

Health care is a socio-economic system, not a biological one. Changes occur because of scientific, economic, and political reasons--they are not biological and, therefore, they are not due to evolution. Using evolutionary jargon and examples to explain changes in medicine can lead us astray.

We need a different way of thinking about and understanding medical marketplace changes that affect us all. We need a non-biological theory of change. Happily, the German philosopher, Georg W.F. Hegel (1770-1831), proposed a theory for understanding changes in human institutions even before Darwin penned On the Origin of Species in 1859. Hegel called his theory the dialectic. If we try to understand health care change dialectically, at least we use an organizing theory designed to explain change in socio-economic systems. This seems more appropriate.

With apologies to all those who have made careers of the serious study of either Hegel or Darwin, let us briefly compare evolutionary and dialectic theories. Then we can consider the implications for understanding medical marketplace changes using each theory.


Evolution is essentially linear. Animals and plants evolve in response to outside forces, such as climate changes and disasters, as well as internal, random genetic mutations. For example, organism A evolves into organism B, which in turn splits into two new organisms C and E. Each of these continue to evolve along their own paths (see Figure 1). Evolutionary changes occur randomly and persist only if they confer some competitive advantage to the affected organism. Evolution is not teleologic; it does not strive toward a goal of improvement. Evolution is adaptive and opportunistic. The survival of the fittest applies to current environmental conditions. When these conditions change, the organism that is "most fit" may be very different than that which dominated before. The theory of evolution was never proposed to explain human institutions, although it has been twisted to do so, such as "Social Darwinism."


The dialectic

Hegel developed his dialectic theory explicitly to explain the growth and development of ideational entities, such as human institutions. The dialectic occurs when a dominant idea (the thesis) creates the need for its opposite (the antithesis), because the thesis is incomplete or flawed. The thesis and antithesis struggle against each other in such a way that neither survives. But out of their opposition, a new synthesis is created that contains elements of both and becomes the new thesis. Over time, the new thesis creates the need for a new antithesis, and the dialectic begins again (see Figure 2). This process is a quest towards improvement, it is teleological.


These summaries represent very severe simplifications of both theories, but for our purpose we can use them to analyze past and current changes in health care economics.

Medicine as evolution

The economic changes of 20th Century medicine seen through an evolutionary lens look something like this: In the first half of this century, fee-for-service medicine was all that existed. The medical contract was solely between the doctor and his patient. After World War II, health insurance plans began to appear and proliferate as a natural consequence of the increase in medical technology and rise in medical costs (i.e., environmental changes). Fee-for-service medicine thrived in an environment of increasing technology and overall capital growth. Indemnity health insurance was the dominant player in the marketplace from the 1950s through the 1980s, although prepaid health insurance also grew, especially on the West Coast in organizations such as Kaiser and Group Cooperative of Puget Sound.

Now we are witnessing the passing of indemnity health care coverage as managed care (i.e., capitation, gatekeepers, closed panels, etc.) becomes dominant and displaces indemnity health care, much as mammals replace marsupials in an isolated ecosystem. This evolution is in response to environmental changes, such as the stagnation of the U.S. economy, which cannot accommodate continued growth of the health care sector, and globalization of trade, which puts U.S. industries at an economic disadvantage.

The implications of such an evolutionary view are clear: Large scale, profit-driven managed care is the wave of the future. Fee-for-service medicine will go the way of the dodo. Medicine is evolving from a cottage industry to an industrialized enterprise with all its attendant efficiencies and loss of individuality, much as manufacturing did one time. Survival of the fittest means those with enough access to capital will drive out the less well-funded opposition. This view is not entirely wrong, but the implications may be misleading.

Medicine as a dialectic struggle

Considering the same span of events dialectically, we see fee-for-service medicine (the thesis) grow into a major economic force, but one with several problems, among the worst being its inability to contain costs, despite every effort by the government and private payers. For several decades after World War II, the flaws and inequities of fee-for-service medicine were acceptable to most people, but over time, these unaddressed problems have become increasingly severe. The tension in the medical marketplace has created a situation where an antithesis of managed care came into existence as a needed counterbalance to the inequities and costs of fee-for-service medicine. Thus, managed care arose as a response to the problems of fee-for-service medicine and as a method to take advantage of the economic "fat" in the system.

In this view, we are living through major dialectic struggle from which neither fee-for-service medicine nor managed care will triumph. In the coming years, a new synthesis should emerge that will contain some of the attributes of both systems. Presently, no one can say what this new form of medical delivery will look like, but continued and complete industrialization of medicine is not a given. This new synthesis will become the dominant methodology of the medical marketplace until it, too, creates the need for an antithesis.

Evolution or dialectic?

Neither an evolutionary nor a dialectic scenario predicts a return to the "good old days" of fee-for-service medicine. In the evolutionary scenario, we are destined to practice capitated, at-risk medicine in a world of industrial giants. People might well ask, "Who will be the General Motors of medicine?" With such a prospect, no wonder so many physicians are demoralized. Individual physicians and organized medicine will have little chance to stand up to such industrial might. We can see which way the river of evolution is flowing, but if we don't like it, too bad. We cannot escape the current.

The dialectic view can be less pessimistic. It does not promise that conditions will be better in the future, but it leaves a door open for such a possibility. A dialectic view sees good and bad in both fee-for-service medicine and managed care and acknowledges that neither is going to be the exclusive model for our future. The dialectic view encourages all interested parties to stay active in shaping the future of medicine, because that future is not determined yet.

We can choose our theories of change

Today's massive changes in the medical marketplace are like a war without shooting. Many innocent people are getting hurt. These may be exciting times, but they are harrowing, as well. We can choose to see the end point of all this change as predetermined and inevitable. In this case, we are nothing more than helpless victims, and we should run for shelter, wherever we can find it.

Alternatively, we can view our current ferment in medicine as a titanic, dialectical struggle, whose outcome is truly in doubt. No one knows what the medical marketplace of the future will be like; conditions are still very fluid. Such a future begs each of us to stay involved and fight the good fight for our patients and ourselves. In such a scenario, our efforts can make a difference if we do not give up hope.

Evolution or dialectic? These theories explain the same set of facts and occurrences. Each can be a road map for understanding our current situation and future possibilities. We need to choose our organizing theories thoughtfully. Adopting an evolutionary or dialectic view leads to different conclusions. Choosing our road map carefully can help determine our journey and destination.


(1.) California Physician, June 1996.

(2.) Atkins, Charles; To sink or to swim: Darwinism and managed care; American Medical News; Jan. 6, 1997, pg. 21-22.

Earl R.Washburn, MD, FAAP, is an Administrative Physician at El Dorado Pediatric Medical Group, Inc., in Placerville, California. He can be reached at 916/626-1144 or via fax at 916/626-7146.
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Title Annotation:Health Care Change
Author:Washburn, Earl R.
Publication:Physician Executive
Geographic Code:1USA
Date:Mar 1, 1997
Previous Article:Breaking the glass ceiling.
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