The advance of medical science in recent decades has accustomed the public to expect expert medical attention, while at the same time it has antiquated the traditional structure of medical practice.
Complex technology has pushed doctors into medical specialties. The doctor no longer practices with his black bag alone. Increasingly, he calls on the services of large general hospitals with their mass of supporting personnel, and these establishments, along with new equipment the doctor must have in his office, add a high fixed overhead to the cost of medical care.
Furthermore, with the conquest of infectious diseases, the incidence of acute illness has declined relative to that of chronic illnesses which require prolonged care and often cause permanent disability. In addition, doctors are more aware than ever of the relations between physiological and mental illness. Illness involving psychological maladies is not susceptible to quick cures; instead, it entails high and continued expense.
For a time the problem presented by rising demands on increasingly expensive medical care was met by private insurance.
In 1929 a school teacher in Dallas, Texas, broke her leg and was nearly ruined financially by the cost of medical care. Outraged by this situation, she organized local teachers into a group insurance plan with Baylor University Hospital. The plan, under the name Blue Cross, quickly spread to other parts of the country. During the Depression hospital administrators pushed Blue Cross to keep their institutions solvent when private charity declined with the stock market.
Blue Cross, which pays hospital bills, and Blue Shield, its counterpart for covering doctors' bills, both employ the traditional insurance concept of protecting the individual by spreading the risk of financial loss among many people.
Some groups, however, are not attractive risks for private insurance plans. To provide for these people, service plans were devised which emphasize obtaining complete care rather than minimizing financial risk. For a fixed sum, service plans will provide an individual or family with complete medical care.
Mr. Goldstein's case is his own, and does not represent the views of the CRIMSON.
In 1946 the United Mine Workers led by John L. Lewis demanded the establishment of a welfare and retirement fund. After bitter strikes and the opposition of local medical societies, the Fund was put into operation in 1950.
The Fund hires some doctors directly; on a contractual basis, it pays other doctors a fee for each service rendered. By constructing hospitals the Fund attracted young doctors and raised the standards of medical care in the coal fields of Kentucky, Pennsylvania, and West Virginia--areas long marked by high mortality rates and low doctor-patient ratios.
In recent years unemployment in the coal mines has caused the Fund to run large deficits. To remain financially sound, it has closed some of the hospitals and terminated coverage of the unemployed. This experience demonstrates that even large private funds cannot cover groups in financial difficulty.
New York's HIP
The high quality of care which can be provided under pre-paid doctors' service plans is illustrated by the Health Insurance Plan of Greater New York. HIP covers 550,000 people and employs more than 1,000 physicians practicing in 32 groups. Subscribers pay $31.80 per year for office and house calls, vaccinations, and laboratory tests. Doctors practice singly or in partnerships which may add members as the need arises.
HIP's success in providing effective preventive medicine is indicated by statistics. Compared with New York Blue Cross-Blue Shield subscribers, HIP members have lower hospitalization rates and lower rates of infant mortality.
The most recently devised service plan is the Community Health Association of Detroit. Organized by the United Auto Workers as a substitute for Blue Cross-Blue Shield, the Health Association provides care in a large general hospital with a fulltime group of doctors. Coverage under the plan includes 120 days of semi-private care yearly or 30 days of care for mental illness or tuberculosis; nursing visits are also covered.
Membership in the Association is not restricted by age, but the rates are high, starting at $8 monthly for single members. And this is not the only cost to the subscriber for he must also pay $1 per office call, $4 for a house call made during the day and $6 for a house call made at night. The $1 fee (called a "deductable") for an office visit is designed to discourage abuse of available medical care. The $4 and $6 charges on house calls, however, represent a judgment that house calls probably are not necessary for adequate care; thus, the plan places a heavy additional charge on a practice which many people have regarded as one of the most desirable aspects of the traditional doctor-patient relationship.
A striking feature common to all progressive medical care plans is the imitative taken by private groups and the lack of leadership from the medical profession. Unfortunately, the rising cost of drugs and hospitalization makes it doubtful that private initiative can provide comprehensive coverage for all groups requiring care.
President Kennedy's Medicare plan, while offering care to the elderly without a degrading statement of indigence, is only a first step. More comprehensive care, including drugs and psychiatric and dental care, should be provided for the whole population under Social Security. To limit abuse of pre-paid care, a Social Security health scheme might include deductables as does the Community Health Association of Detroit.
The high cost of general hospitals has already led to direct federal intervention through construction grants under the Hill-Burton Act of 1946. During its first 15 years the Act provided roughly one-quarter of all money spent in the United States on hospital construction, attempting to equalize bed-patient ratios through out the country. Its vast dimensions have stimulated the development of quality standards in all phases of hospital equipment and care.
The funds provided by the Hill-Burton Act have combined with insurance payments to change the fundamental relationship of doctors to hospital administrators. In the past, doctors regarded the hospital as their workshop and considered themselves autonomous from the hospital administrator, who often was a poorly qualified layman. The importance of the hospital today as a center for preventive medicine, research, and education has made the doctor's workshop much more of a public concern. And at some points the narrow interests of physicians may have to be subordinated to the needs of the community.
Just as the federal government acted to meet the high costs of hospital construction, it now must carry some of the heavy cost of medical education.
The logistics of medical education are straightforward. One year of medical schooling costs $20-35,000 per student. Tuition per student is roughly $1500. About 40 per cent of medical school students come from families with incomes greater than $10,000 annually. Hence, admissions are now restricted by the income of the student's family, although completely subsidizing the students would make little monetary difference to the schools and might increase the quality of applicants.
Moreover, the schools are too small. Their annual graduating classes of 7,000 do not provide even two-thirds of the 12,000 interns required in the United States each year. Their output is insufficient to maintain the present ratio of 132 doctors per 100,000 population. And they preserve the inequitable distribution of doctors which varies from 180 doctors per 100,000 population in New York to 86 per 100,000 in South Dakota and Mississippi.
Recently, Harvard Medical School has led a modest drive to increase the number of medical graduates by helping to establish two-year medical programs at Brown and Dartmouth, which send students to Harvard or some other school for the final two years of clinical training. But the cost of starting a complete new med school of only 75-100 students per class exceeds $10 million. At this price only major government action can establish the schools that are needed.
Yet, the American Medical Association--despite the urging of med school deans--continues to oppose President Kennedy's medical education bill which will supply some of the funds to overcome the need.
Opposition to Change
Resistance to each change in the structure of the medical profession has generally been defended by arguments that change would impair the quality of care and destroy the doctor-patient relationship. These arguments are weak.
The success of group practice and cooperative insurance plans has shown that third-party payment need not lower the quality of care. Indeed, removing doctors from the business of medicine might free more of their energies for the art and science of medicine. There is no a priori reason why fee-for-service is necessary for maintaining standards within a profession. Moreover, since when visiting a doctor the public knows nothing about the good which is being purchased, fee-for-service yields no index of consumer satisfaction with the care received.
Secondly, the doctor-patient relationship has no meaning for most Americans. It is ridiculous to argue that medical care is as accessible to the 30 percent of the nation's families with yearly incomes under $4,000 as to the ten per cent with incomes over $10,000. Only the well-to-do are able to pay for the time to get to know their doctor well.
The "worthy poor," cared for in charity wards as teaching material for interns, certainly never attain any close doctor-patient relationship. The large mass of people between the poor and the rich only see doctors for serious illness. Because of its high cost, these people are probably ready to accept the diagnosis proferred without quibbling about whether the doctor is an old family friend. Besides, the passing intimacy of the office can exist under any system because it basically depends upon the individual physician.
In 1953, "Medical Education Today," a report by the deans of leading American medical schools, recognized the social and economic problems which confront medicine. Unfortunately, academic medicine has not been able to lead a reconstruction of the profession because of the opposition to change of the AMA. By its failure to re-order its own affairs, medicine now invites government intervention.