Dear Editor
Dear Editor Where Does It Hurt? For anyone who harbors any doubts about the nonsystem of health care in this country, the special issue by Richard J. Margolis, "Where Does It Hurt?: America's...
...However, since my Director of Health-Lobby Relations is out to lunch, I shall try to do the honors...
...Instead, you muddy the waters...
...Professor of Surgery, Harvard Medical School Richard J. Margolis replies: To Charles Cogen: You are right about consumer representation in HIP...
...In point of fact, you are looking at an inflationary process fueled by rising public expectations for better medical care coupled with the rising costs of labor, food, services, complicated equipment, and technical help...
...Who told you we have twice as many doctors as England...
...Specialists, medical scientists, and general practitioners are all needed...
...The unit fee charge-what the consumer pays for a given service-has in many cases, including most surgical services and most house calls, increased very little in the last 25 years...
...Are such afflictions not worth discussing...
...It would, therefore, be fruitless to go on since 600 words would, at this rate, only take us to your 10th paragraph, leaving perhaps a couple hundred more paragraphs of misstatements...
...In your castigation of the American health care system, you mention Sweden's wonderfully low infant mortality but make no mention of that country's different criteria for live births...
...How am I to respond to your institutional paranoia...
...The second defect is the focus of reimbursement mechanisms on procedures rather than on thorough, reliable, and efficient personal care...
...But when this is multiplied by the total number of services demanded by a population that has almost doubled in the last 30 years, you naturally find a considerable rise...
...I believe that most of the present health insurance proposals will be a fiscal disaster unless these defects can be corrected...
...His summary history of the attempts at reform or progress remind one of the difficulties in treating an addict-every suggestion for improvement is seen as too threatening to be tolerated...
...No one is arguing that the problems are simple, but who needs more obfuscation...
...Thus, again, still on the first page of your 36-page polemic, you call Dr...
...That is a surprising goal, however, in face of the fact that the principal proponent of the bill, Senator Edward Kennedy, has bowed to fiscal and political responsibility and has abandoned that plan...
...I myself recently participated in such a review...
...Why all those cheap shots...
...One cannot fault Margolis for just briefly alluding to this, since no adequate proposal to restructure the health care delivery system has been put forward...
...For anyone who harbors any doubts about the nonsystem of health care in this country, the special issue by Richard J. Margolis, "Where Does It Hurt?: America's Medical Crisis and the Politics of Health Reform" (NL, April 15), should put the matter to rest...
...Francis D. Moore: I expected better from you, a Harvard man...
...And that takes us to your fifth paragraph and our 300th word...
...Also, it is no longer true that "patients do not assist in making policy decisions...
...On a per capita basis, we have about one-third more...
...Fishbein, as a former editor of the AMA Journal, has never been more than an employe of the association...
...Yet the fact remains that although much scientific progress has been made in the past 50 years, the capacity of the delivery system has not kept pace with these advances...
...For starters, the comparison of hospital room rates with those of a plush New York hotel is very ancient, platitudinous and specious...
...Yet it suffers from a bad case of "language of the Old Left": that is, a kind of "scare headline" rhetoric, flaying about with a sharpened pencil and trying to find some sort of villain-presumably either all those rich doctors or the great big rich hospitals...
...Dean, College of Medicine, University of Tennessee You impose upon our reply to your special issue the restriction of 600 words...
...It is a remarkably knowledgeable, discerning and clearly organized account of the status of this sadly neglected area of our lives...
...Is there anything to be said when a professional propagandist in the pay of a rampantly propagandist association accuses a writer of propaganda...
...How can educators influence students in this direction when many choose to be specialists instead...
...Acting Dean, Albert Einstein College of Medicine, Yeshiva University I found the special health issue of The New Leader particularly well done...
...it has been getting better, as I tried to make clear...
...Richard J. Margolis commits a few errors of fact, too...
...it merely pointed out that infant mortality had many causes, including poverty, and that in any case there were other indices of health care, like life expectancy, which ought to be considered...
...And you end with a truly stunning peroration that smears any future national health insurance program with the ordure of Watergate...
...For all his talk about the various bills and their sponsors, he fails to consider that when one of these measures is passed all medical care in the United States will in effect be turned over to the Federal bureaucracy...
...Morris Fishbein a "former AMA president...
...A bit of a difference, what...
...One of the principal differences is that if you have a cardiac arrest in a hotel, the only person called in is the coroner...
...Finally...
...It's a small point, but I erred in calling Dr...
...If it happens in a hospital, however, the chances are very good that because of all that horribly expensive equipment and personnel you will be resuscitated to live a few more happy years...
...HIP has had subscriber representatives on its central Board of Directors for many months...
...Surely you are familiar with HEW figures showing that in the 1960s doctors' fees rose twice as fast as did the overall consumer price index...
...Both The New Leader and Richard J. Margolis deserve kudos and hearty thanks for the special issue on health care, "Where Does It Hurt...
...And you pretend that my background reference to the increase in hospital beds since 1923 is presented as a criticism...
...In sharp contrast, the unit cost, as well as the totality, of hospital services has risen dramatically...
...The New York City Department of Health monitors HIP's services and centers by means of careful interviews and analysis of records...
...You appear to think that the price of hospital cardiac care is included in the price of the room...
...It certainly would take a naive economist or sociologist not to relate this to the fact that since 1923 the population has more than doubled and not to conclude that the number of hospital beds per capita has probably not changed significantly in that time...
...You begin by attributing to me the "language of the Old Left," a sally which tells as much about your feel for language as it does about your grasp of politics...
...Francis D. Moore, M.D...
...Fishbein a "former AMA president" when he is really a former AMA editor...
...How do you explain your disinclination to confront the main issue, which is the clear and present failure of our health care system -the accountability vacuum, the misplaced emphasis on hospital-sponsored crisis medicine, the shortage of primary-care physicians, the needless and sometimes shoddy surgery, the cruel price gouging, and the shockingly thin insurance coverage...
...Infant mortality rankings, "unnecessary operations," these are misinterpretations and distortions of fact...
...continued on next page Dear Editor On page 17 we are presented with the surprising statistic that there are 1.7 million hospital beds in the U.S...
...I would like to note that we are aware of the problems facing the consumer of health services and are grappling with the related educational issues...
...I therefore suggest that you devote a forthcoming issue to critically analyzing the role of government in medicine as incisively as you have attacked all the terrible things that hospitals, doctors and insurers are doing...
...It is the obvious intention of your special issue to advance the prospects of the Kennedy-Griffiths Bill...
...Why do health care comparisons with other countries upset you so...
...I am not convinced, though, that any of the present health bills before Congress really confronts the issue of prepaid group practice versus the fee-for-service form of practice...
...The incentive placed on expansion of hospital services is clearly responsible for the escalation of costs, and a significant change in strategy and policy regarding reimbursement procedures for out-patient care will be required to reverse this trend...
...His claim that 40 per cent of all first-year medical residencies and fellowships are in surgery is just plain wrong (I refer you to the article by Levit, et al, in the New England Journal of Medicine, March 7, 1974, p. 545...
...Though the section on new and proposed legislation is very good, it probably should note that Kaiser-Permanente does not provide some complicated services like intracranial and open-heart surgery or prolonged psychiatric treatment...
...Rather, they select any one of a number of centers within a wide geographic area, and they may change centers as well as physicians at will...
...Here's another fact of which you might not be aware: Swedes live longer in Minnesota than they do in Sweden...
...Moore, is that you know so much about our health care system yet you tell us so little...
...Cambridge, Mass...
...To Dr...
...Shouldn't the process of reform begin with full and clear explanations to the public...
...The average waiting period for a hernia operation in England is two years...
...These are the kinds of questions we are struggling to find answers to...
...His exposition of the political process involved in effecting change points to the need for a much stronger popular thrust in that direction...
...One example we have of how the government operates in the medical area, the Veterans' Administration, is hardly reassuring...
...Finally, and most exasperatingly, you would have us believe that rocketing doctors' prices are somewhat different in kind from rocketing hospital prices-the latter inflationary, the former a function of increased services...
...The U.S...
...The figures refer to unit prices for services, not to "the totality of doctors' fees," and cannot simply be explained away by new services or additional patients...
...To give a simplistic reply to your simplistic comparison, still on the first page, of American and British surgical rates: There are fewer per capita operations in Britain than in America because the British don't have adequate facilities...
...It seems to be the record that where doctors are involved suggestions for basic change invariably evoke all manner of excuses, self-justifications, and a mien of injured pride...
...Another problem cited in your report is the lack of primary-care physicians...
...One major area not dealt with sufficiently either in the Congress or in the special issue is the need to restructure the delivery system in a manner that will bring at least primary care not only within the financial but also the geographical reach of everyone in the country...
...It appears to me that we will go through many expensive and not necessarily cost-effective Health Maintenance Organization (HMO) experiments prior to the establishment of any significant policy...
...today, as against 756.000 in 1923...
...The physician and the patient are currently being led into self-delusion about the value of various procedures...
...should serve to focus public awareness on the site of the problem, and to indicate that it will take more than a kiss to make it disappear...
...And if one makes this assumption, then it seems to me imperative that at least two major lesions in our present system be corrected as quickly as possible since they have much to do with the predicament we are now in...
...The first of these defects is that reimbursement for ambulatory health services has not been adequately balanced with reimbursement for hospital services...
...That would get us only past the misinterpretations and inaccuracies found on the first page...
...Even if all your statistical quibbles were correct-and many are not-the overall indictment would stand...
...Seattle, Wash...
...Thus, in the age of Watergate, we face the prospect of having slippery characters, big campaign contributions, perjury, and graft at all levels gently inserted into this health care system that has already come under such heavy fire...
...The UN World Health Organization never "condemned" infant mortality as an index of health care...
...I do, however, wish to indicate a few additions and modifications in the description of the Health Insurance Plan (HIP) to bring the report up to date and make it fully accurate...
...For example, you note-as if in rebuttal-that England has proportionately fewer specialists than we do, but you ignore the real point, which is the connection in America between a surplus of surgeons and a surplus of surgery...
...But one hopes he will take up the challenge...
...What bothers me most about your letter, Dr...
...What are your views on that problem...
...If so, let us not shrink from making them inadequate forthwith...
...New York City Ernest R. Jaffe, M.D...
...Consumer Councils in nearly all centers play a significant advisory and critical role...
...As for England and its alleged lack of surgical facilities, are you suggesting that the estimated 2 million needless operations performed each year in the United States are a consequence of adequate facilities...
...you may put him out of sorts...
...W. A. MacColl, M.D...
...Indeed, consumer representatives are invited to sit in on and take part in these investigations...
...First, HIP subscribers are not exactly "assigned" to medical centers "according to geographic convenience," as Margolis puts it...
...Such techniques are of great value, but not in the isolation encouraged by present reimbursement policies...
...Your jottings do not inspire a serious response...
...Memphis T. Albert Farmer Jr., M.D...
...Margolis never comes to grips with the question of government management...
...If we allow for Sweden's slightly different method of counting live births-a difference you seem to think crucial-nothing is changed: Birth for birth, America loses almost twice as many babies as does Sweden...
...Chicago Gilbert F. Martin Director of Magazine Relations, American Medical Association Your special issue on health care is a reasonably conscientious documentation with quite a lot of well-gathered facts and figures concerning some of the dilemmas of medicine and some of the proposed solutions...
...Isn't that a responsibility of leading health care professionals like yourself...
...That can only be deliberate and is an honored propaganda technique...
...You are also technically correct when you say HIP members may select their medical centers...
...It also permits you to ignore the real criticism which comes later and runs not to the number of hospital beds but to the costly duplication of hospital services in most American cities...
...Moreover, sociologists tell us that it is characteristic of the American culture to develop specialization, be it in the production of automobiles, refrigerators, stereo systems, central heating, or doctors and hospitals...
...New York City Charles Cogen Consultant and Past President, American Federation of Teachers One matter that receives little attention in your informative special issue on health care is the role of the medical schools...
...Do you lecture the AMA and the health insurance lobby about the perils of "big campaign contributions" as earnestly as you do The New Leader...
...But inaccuracy can only cast doubt on either your integrity or competence...
...The use of infant mortality as a judgment of a nation's health care has been condemned by the very United Nations agency that issued the data...
...also has a great many more psychiatrists, pediatricians, internists, and specialists of all kinds, for there are about twice as many doctors here as in England...
...He always acted like a president...
...The checks on HIP officialdom's decisions are now several-fold, too...
...If we ignore it, will it go away...
...The time an excellent physician spends analyzing a patient's chest pain must assume a higher value as a parameter of reimbursement than electrocardiography, echocardiography, and the like...
...I can only repeat a comment I made in the article: ^ . it is risky to present an AMA official with a fact...
...The question of numbers of surgeons in the United States versus Great Britain has been taken out of context...
...Must every medical school concentrate on producing graduates in all areas...
...To Gilbert F. Martin: It's nothing personal -you were only doing your job-but I had rather hoped the AMA would treat my article as something more than a "Magazine Relations" problem...
...We rank 20th in life expectancy...
...Especially impressive is the manner in which it deals with a subject of such great complexity...
...Margolis' analysis of such relatively new approaches to medical care as Group Health in Seattle, HIP, Kaiser, GHI, etc., indicates that proven mechanisms exist for changing the method of delivery...
...Those are left for other people who are willing to make the societal commitment of providing them despite their expense and unpopularity with everyone except the patients...
...This allows you to call me "naive...
...The subscriber, of course, usually chooses the center nearest his home or office...
...For example, a major source of difficulty is the distribution of physician manpower in this country, and we in the medical schools are concerned with the question of how we can influence where our graduates practice...
...His statement that doctors fees have risen faster than the cost of living index refers of course to the totality of doctors fees, that is, the amount the total population pays doctors for their work...
...For example, in the opening paragraph of your first section you bring up the old, discredited shibboleth of national rankings by infant mortality...
...This sort of carelessness detracts a good deal from the rest of the issue...
Vol. 57 • June 1974 • No. 12
