Richard Dean Smith, MD

Decline in authority of religious institutions and power of the state during the humanistic movement gave rise to the modern invention of the individual, especially during eighteenth and nineteenth centuries. The individual, freed from constraints of church and community, found himself powerless as new poor from the country encountered the new rich in cities. Concurrent with appearance of the individual came the "age of the crowd" in collective behavior of individuals formed into masses following a leader or an idea.
Individuals in a mass behave differently from individuals in isolation: sometimes in heroic, self-sacrificing actions, or in primitive, destructive behavior. When individuals form into a mass, the mass itself assumes its own character or personality.
Mass movements demonstrate certain general features depending on their underlying basic ideas: rational following reasonable principles, or irrational following an emotional and unreasonable path. Mass movements may work within existing norms of social boundaries and institutions, or discard all norms and institutions reversing in direction, a complete reversal of values.
Characters play distinct roles in mass movements: zealots, men and women-of-letters, and practical men and women-of-action.
A rational, norm-oriented movement tends to be slowly progressive and advances according to reasonable demands for day-to-day change. An irrational, concept-oriented mass movement tends to be sudden, emotional and driven by a vague promise of an idealized future.
In considering changes in American medicine, claimed to be a ‘revolution,’ here we examine the nature of the mass movement into managed medical care, and compare it to behavior of other mass movements. Systematic study of mass movements dates only to 1895 in the works of Gustave Le Bon, a French physician, and by a number of additional social scientists during the nineteenth and twentieth centuries. Similar mass movements occurred in academic and financial institutions concurrent with managed care. By examining background, development, and implementation of mass movement into managed care, whether rational and norm-oriented or irrational and concept-oriented, and the characters involved, we may gain understanding about its history, its probable course and outcome.

Preface

Chapter I. The Beginnings

1. Introduction
2. Background
3. Definition of managed care
4. Criticism of doctors and medicine

Chapter II. Expansion

1. Growth
2. Enthusiasm. Contagion
3. Exceptional return
4. The consulting industry
5. The press
6. Rhetoric of managed care
7. Fear

Chapter III. Enthusiasm. Contagion

1. Supportive
2. Basic concepts
3. Medical technology
4. Intellectual underpinnings
5. Contrary data
6. Quality
7. Competition—Madness
8. From miracle to myth

Chapter IV. Finances of the Managed Care Industry

Chapter V. Cautions

1. Resistance
2. Role of the managed care industry
3. Regulatory agencies
4. Mania feeds on itself

Chapter VI. The Bind

1. Captivity, the bind
2. Behavior of physicians
3. Beating the scheme
4. Some legal aspects
5. Money / Trust
6. Medical "inflation"

Chapter VII. Early Warnings

1. Early signs
2. Emerging criticism
3. Role of patients

Chapter VIII. Act V

1. Late signs
2. Re-capitulation
3. Historical parallels
4. Precipitating event
5. Collapse of the bubble
6. Current cultural trends

Chapter IX. After the Fall

1. Carrying on
2. Continuing problems
3. Role of business and industry
4. Coming to our senses

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