PHYSICIAN, BEWARE
DeYOUNG, DR. VERNON R. Jr.
PHYSICIAN, BEWARE by DR. VERNON R. DeYOUNG, JR. History is a mirror which reflects current problems in the light of the past. It has a habit of repeating itself. Form and circumstance vary with...
...Of course, fire fighting and sickness fighting are not identical...
...The first efforts of the insurance companies to offset losses from ineffective fire control and incendiarism came in 1866 when 75 companies convened and organized the National Board of Fire Underwriters...
...The second is the organization of the Academy of General Practice...
...As with the National Board of Fire Underwriters 90 years earlier, the most urgent problem was that of arriving at some uniformity in medical fees to be paid and rates to be charged...
...Anything that results in reducing or eliminating consultations grades downward the level of medical practice...
...In 1954 an informal poll of insurance executives on the question, "Should insurance companies have the right to determine uniform medical fees...
...However, within their ranks rage the bitter battles between general practitioner and the specialist, the solo practitioner and the specialist group...
...Free choice of physician" is one of their battle cries...
...From the many comments that have been written about the misuse of the medical profession's own health plans it is obvious that there are "arsonists" among physicians...
...By 1876, 275 cities, towns, and villages had paid, full-time fire departments with an adequate standard of equipment...
...From before the Revolution until after the Civil War fire fighting was done by volunteer fire brigades, with haphazard, often inadequate, equipment...
...On the contrary, the insurance industry considers itself the main bulwark against the invasion of the free enterprise system of medical practice...
...Furthermore, the scale of high surgical fees in contrast to low medical fees has alarmed both the American Academy of Pediatrics and the American College of Physicians...
...The rivalry between brigades also included hiding the source of the water supply, or damaging the other brigade's equipment...
...revealed that almost all answered in the affirmative...
...His suggestion was that the policyholder's doctor be required to discuss his proposed course of treatment beforehand with an insurance company's physician...
...Rate-cutting, one of the scourges of the 1865 fire insurance companies, is plaguing the health insurance field now...
...And this is where history may be confounded instead of repeated...
...Yet a North Carolina study of the quality of medical care rendered by general practitioners revealed that there were tremendous variations in the quality of medical care, with more than 44 per cent doing "poor" work...
...This aspect of Blue Shield is at present a main source of irritation to doctors...
...These plaques were known as "fire marks," and have become collectors' items...
...For more than 25 years the medical profession in the United States has feared that this change may come about through the sinister work of politicians manipulating it through government channels...
...Probably the worst defect of this free enterprise system was that some of the brigades were too enterprising...
...DeYoung considers himself a "member of the loyal opposition" in the field of medical economics...
...For instance, some Blue Shield plans will pay only one physician in any one case, making no allowance for the payment of consultants or assisting physicians...
...Another slogan is "High quality of medical care...
...As a result the Health Insurance Association of America was formed, representing 243 companies that write health insurance...
...And the sickness fighters are consistent in this by supporting only high quality medical schools and numerous post graduate courses for physicians...
...Is there any indication that sickness fighters may feel the same kind of pressure from a relative source, the health insurance industry...
...Even from the medical profession's leaders have come some pretty strong words...
...Currently they glory in the fact that 72 per cent of the population is now covered by "some form of health insurance," and predict that this proportion can be raised to 80 per cent...
...There is no choice of physician there...
...He is pediactric consultant to the division of services for crippled children at the University of Illinois and a fellow of the American Academy of Pediatrics...
...It was only after the Chicago Fire in 1871 that full time municipally paid fire departments came into being generally...
...Will they find that severe illnesses cared for by the well-trained internist are less expensive to them than those cared for by the general practitioner...
...One of the accomplishments of the 1866 National Board of Fire Underwriters was to propose legislation that would provide punishment for incendiarism and arson...
...Thus if the sickness fighters hope to control their work on a free enterprise basis they will have to be sure that the preventive and the early care stages are adequately managed...
...Will they hold the threat of underwriting boycott until standards are met...
...Specifically this meant fire prevention in all of its ramifications...
...Form and circumstance vary with the changing years, but basic issues continue fundamentally the same...
...Two important developments in the last 40 years point to unmistakable improvement in the quality of physicians: first, the development and recognition of the American Specialty Boards, a means of certifying the qualifications of medical specialists...
...A management consultant writing in 1953 predicted that future health insurance policies will include some protection against unnecessary medical expense, whether caused by patient or doctor...
...Incendiarism by the very brigades who later were to collect from the insurance company became a tremendous burden to the underwriters...
...The history of the change from the volunteer brigade to the professional organization with modern equipment might be repeated in the change that may take place in medicine from the private enterprise solo practitioner to the full time paid medical expert, part of a governmental department with high standards and the most advanced equipment...
...Enlightened self-interest" is the contemporary term for this form of the milk of human kindness...
...If history is to repeat itself and develop as in the case of the fire fighters, the forces that bring a change will not be political, but will come from a source few doctors would suspect...
...It is charity service, and physicians generously give their services...
...The services of these fire brigades were not available to all who needed them, but only to the property owner who was insured and indicated his insurance by an ornate plaque attached prominently to the front of his building...
...It is probable that the Health Insurance Association of America is aware that there are no such laws against misuse of health insurance...
...It was then that the five-year-old National Board realized that the insurance companies could no longer remain solvent when dependent upon amateur, dishonest, unreliable fire fighting organizations...
...However, if history is to repeat itself by following the experience of the National Board of Fire Underwriters, in about six years there will be a change in the emphasis of the objectives of the Health Insurance Association of America...
...With "free enterprise" our present economic god, the insurance companies may win...
...In certain definite ways the profession's own Blue plans have paved the way for the insurance industry's control over medical practice...
...The fireman extinguishes a fire, and then walks off to let others repair the damage...
...A homeowner whose fire mark indicated an insurance company which drove a hard bargain in the payment following a fire sometimes found it necessary to fight a fire himself...
...However, most of the brigades worked free lance and responded to as many fires as they could...
...Sometimes they were met at the fire by a rival brigade, and before either could get down to the business of extinguishing the fire a fight ensued to eliminate one of the brigades...
...To become really influential in furthering their own interests, the underwriters had learned that their emphasis would have to be in terms of "public service...
...Otherwise they will have to follow the lead of the people through their government or through their insurance companies...
...In 1873 the National Board realized that it was stagnating in the "limited scope of rates, commissions, policy forms, and legislation...
...It was then that the lot of the individual volunteer brigadier began to change, and he ultimately became a fully trained, full-time professional, ready to serve all who needed him, day or night, rich or poor, paid by his community through the governmental agency responsible for this service...
...It has proven this in increasing by almost 30 per cent the amount of privately held voluntary health insurance in the brief period of three and one-half years between 1953 and mid-1956...
...In 1954 a past president of the AMA urged that fixed fees and proper usage of Blue Cross and Blue Shield become mandatory "upon penalty of expulsion from organized medicine...
...Through the years this pressure set the standards of fire fighting facilities until the underwriting of fire insurance became a profitable enterprise...
...Is there a possibility that the larger companies in the big cities will organize their own "brigades...
...they were assured of payment for their work by the insurance company indicated by the fire mark...
...But somehow they seem not to realize that in a democracy all persons should have the choice of their physicians, not just the paying patients...
...At present there are no indications that the insurance industry has any intention of proposing governmental-ization of the medical profession to further its own ends...
...Above all, is there any evidence that the insurance forces will go so far as to insist that the medical profession become govern-mentalized to bring about actuarial soundness...
...Oregon's Blue Shield asks for refunds from physicians who have collected fees above an average, or asks them to drop out as participants...
...The sickness fighter stops the disease process but also stays around to do what he can to help restore the invalid to health...
...Its most important contribution to the quality of medical service is that to hold membership in the organization a certain amount of post-graduate work is compulsory...
...But in a city like Chicago they seem totally insensitive to the fact that about a million people a year have to get their medical services at Cook County Hospital...
...But in a democracy you can't ignore 20 per cent of the population, and "some form of health insurance" may not be at all adequate...
...Each national convention sees the glorification of the "general practitioner of the year...
...Some of the insurance companies in the large cities formed their own brigades in an effort to bring some reliability to fire fighting...
...tober 8, 1871, the great Chicago fire brought bankruptcy to more than 100 fire insurance companies...
...Another slogan is "Greater distribution of medical services...
...Will the insurance industry find that indemnities following the services of a well-trained surgeon are less than the payments made after the use of a poorly trained surgeon...
...On OcVERNON R. DeYOUNG, M.D., has been a practicing pediatrician for 25 years, certified by the American Board of Pediatrics...
...Because the care of the human body is of such a personal nature and requires such a high sense of integrity and responsibility, it undoubtedly would be better if the sickness fighters would take the lead in organizing the best type of service...
...Professionally trained and properly equipped fire departments were necessary...
...Then they may have the opportunity to bargain with the patient about his repairs...
...Recently Blue Shield entered the highly competitive field of "major medical coverage," but success is dependent on the expected cooperation of doctors in adhering to an equitable fee schedule...
...All this came not at the insistence of politicians or the government, but as the result of pressure from the insurance companies through the National Board of Fire Underwriters...
...These were organizations in which the colorful uniform and the social functions were as much a part of their activity as was the fire fighting they were called upon to do...
...In early 1956 a call was issued to insurance companies to send representatives to a health insurance underwriters conference...
...Now that the medical profession's insurance, Blue Shield, has proven to commercial companies that health insurance is sound, and competition for this business becomes intense, is the practitioner going to be affected...
...Such a trend should certainly not be expected from the profession's own health plans...
...There is great viewing with alarm over the fact that from 80 per cent to 90 per cent of present day medical students are planning to specialize...
...If in these slogans, and in others that the sickness fighters use, they could add "What is good for the goose is good for the gander," they would show signs of a social maturity that would give the public a feeling that doctors should have a leading role in controlling this important service...
...They already have excellent Slogans...
...Until 90 years ago fire fighting in the United States was conducted on a private enterprise basis...
...Will their surveys show that treatment by physicians attached to certain types of hospitals is more desirable from a profit viewpoint than by those attached to less adequate hospitals...
...There has never been any serious consideration of governmental participation in the repair phase of fire damage...
...Straws in the wind previous to 1956 indicate some of the areas in which the Health Insurance Association may become interested...
Vol. 22 • December 1958 • No. 12
