Accordingly, Gekkonians come at managed care from an entirely different direction. Historically, they have little claim to the managed care peerage. Gekkonians spent decades decrying managed care as socialist heresy. “Freedom and competition” is their battle cry, and managed care smacks too much of social engineering.

Since the 1980s, however, Gekkonians have co-opted the term “managed care” and changed its meaning. As managed care techniques derive from industrial management principles, they hold, managed care is actually a child of the open marketplace. Thus, Gekkonians seem to be saying, what managed care is really about is applying the principles of free enterprise to the business of healthcare.

Managed care to Gekkonians is dog-eat-dog, compete until you die, for-profit healthcare. Any actual relationship between Gekkonian managed care and classic managed care is incidental. (Sometimes standard managed care techniques can be useful, but only if they give you a competitive advantage.)
Managed care is a means of establishing stronger regulations on one hand and a means of maximizing profits on the other. Wonkonians and Gekkonians are both prominent today, and both groups are actively and loudly advancing their respective points of view. A lot of the turmoil we have seen over the past decades can be explained by the competition and interplay as they each try to advance their visions for American healthcare.

In the next few posts we will see how the Wonkonians are employing their concept of managed care in their continuing efforts to control the American healthcare system. But for more than a decade it has been the Gekkonians - armed with their chief weapon, the Gekkonian HMO - who have held center stage. Gekkonian managed care will be the main emphasis of this post.

But first a brief history of American healthcare - observing how the American healthcare system has drifted, across the healthcare landscape as defined by the GUTH - will help us to place into better perspective the reasons Gekkonians became ascendant in the mid-1990s, will help us understand why their flight path is now looking more parabolic than orbital, and will prepare us for the re-ascendancy of Wonkonians.

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Wonkonian managed care

Wonkonians believe, you will recall, that the problems in our healthcare system can be traced to human weaknesses (greed on the part of physicians, patients, and corporations). Fixing these problems depends on setting public policy and promulgating governmental regulations. Managed care offers to remove some of the choices humans have to make in delivering healthcare (choices easily colored by greed) and to replace them with externally generated processes and procedures. Philosophically, it’s a good fit.

Because Wonkonians like and believe in the ideas behind managed care, the people who conceived of and developed those ideas - academics, healthcare experts, government commissions, economists and editorialists - tend to gravitate to the Wonkonian camp. Wonkonians espousing the ideals of managed care tend to sound like purists. They are proselytizers who believe in applying continuous quality improvement, critical pathways, information management, and other efficiencies of industrial management to healthcare. Because of their obvious sincerity, and because many of their ideas have considerable merit, it is easy for right-minded folks to fall in with this crowd.

What differentiates Wonkonians from true managed care purists is in what they mean by the word “managed.” In classic managed care, “manage” refers to the application of management principles such as standardization. To Wonkonians, “manage” means “regulate.” Managed care is a convenient tool for advancing their basic belief in policies and regulations to control human behavior. The specific recommendations put forth by Wonkonians have much more to do with establishing a centralized regulatory structure for healthcare than they do with managed care principles. To them, a system of strict regulations has become synonymous with managed care.

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