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Book and Media Reviews
March 9, 2011

Chaos and Organization in Health Care

JAMA. 2011;305(10):1036-1040. doi:10.1001/jama.2011.276

According to Thomas Lee and James Mongan, health care in the United States is in chaos because clinicians, especially physicians, are not effectively organized. Chaos is a result of the fragmentation of care, which the authors attribute to the culture of medical practice, payment policy, and the value patients place on having choices. However, the authors are optimistic that the reforms they propose will hasten “natural evolution toward a better health care system” (p 163).

Lee and Mongan present their critique and propose reforms in an introduction and 13 chapters divided into 3 sections. In the first section, “The Problem Is Chaos” (chapters 1-3), they describe fragmentation and its effects on the work of physicians and hospital staff, the experience of patients, and costs. In the second section, “The Solution Is Organization” (chapters 4-8), they define “tightly structured health care delivery organizations” and explain how these organizations prevent fragmentation (pp 97-118). Four integrated delivery systems exemplify their proposals: Geisinger Health System, Kaiser Permanente, the Veterans Health Administration, and Virginia Mason Medical Center. They also describe progress toward integration in Partners Healthcare System, where they serve as Chief Executive Officer (Mongan) and Network President (Lee). In addition, they endorse medical homes as a strategy to improve the integration of care in practices that are not, or cannot become, fully developed systems. The final chapter in the second section explains how payers, employers, and patients could stimulate organizational reform. In the third section, “How Do We Get There?” (chapters 9-13), the authors set an agenda for clinicians (mainly physicians), public and private payers, and regulators to “accelerat[e] evolution” toward better organized health care.