THE REAL ISSUE IN AMERICAN MEDICINE
Chase, Edward T.
The Real Issue in American Medicine by EDWARD T. CHASE The nation's press recently carried photographs of President Kennedy and Secretary of Health, Education, and Welfare Abraham A. Ribi-coff in...
...But the EDWARD T. CHASE has written and lectured widely on the organization of medical care...
...Only a negligible fraction are well-off...
...Obviously the doctors were pictured with the President as part of the concerted effort by the Administration to rally support for the King-Anderson bill...
...His articles on this and other subjects have appeared in Harper's, The Atlantic, The Commonweal, and Saturday Review...
...Esselstyn, Cherkasky, and Dully, uncommitted to the concept of medicine as a form of business, cannot become exercised at these alleged threats of the King-Anderson bill...
...The avowed and doubtless sincere fear of the AMA is that this bill would establish two precedents the AMA considers anathema: the possibility of some degree of government limitation on the doctors' financial rewards for services rendered, and possible government enforcement of minimal standards of service because of the involvement of public funds held in trust...
...Drs...
...In medicine, technological change has dramatized three radical developments in modern practice: the extraordinary accomplishments in modern scientific medicine...
...An instructive way to an understanding of the AMA's behavior might start with a look at some of the doctors supporting the President—for a sample, the three most prominently photographed...
...two-fifths of the cases received inferior care...
...They endorse it as the logical way to organize medical practice so as to realize to the fullest the advantages of technological progress...
...If a doctor's income depends to a substantial extent on his relationship with other physicians— on getting referral business from them—he is not liable to alienate them by refusing to cooperate with the accepted system...
...President Kennedy's supporters, Drs...
...Thus conceived, the practice of medicine is competitive and profit-motivated, with emphasis on the doctor's role in the market system as simply another rugged individualist, rather than as a professional uniquely obligated to confer the benefits of modern medical science on the public...
...Forced by the publicity over the elder-care problem to offer some kind of national solution, the "Blues" have just gone through the rigors of "pricing out" what it would cost to cover the aged...
...Only government participation can suffice and Social Security is the sensible instrument...
...What has precipitated the need for a prompt answer is the same force that has stirred up controversy in so many other areas in our national life—'n agriculture, in mining and the extractive industries, in transportation, and in manufacturing generally, where there are profound dislocations of people and processes...
...The clear-cut evidence that real doctors ("some of the most distinguished members of the medical profession in the United States," said the President) were joining with the Administration to support the Social Security approach was excellent publicity for the health care measure...
...The incentive to jeopardize hospital privileges is nil...
...Here are their findings: One-fifth of the hospital admissions were unnecessary...
...The AMA allegation of "seventy per cent covered by insurance" is a fantastic dissimulation achieved by subtracting from the total all those on public assistance—the large proportion of the elderly who are driven to welfare in the first place because of illness and the high cost of health care...
...Why do doctors tolerate, or actively support, the AMA brass and its disingenuous and insufferably superficial staff functionaries who articulate its "line...
...The facts are that Kerr-Mills has been a failure...
...Without hospital privileges, no practitioner can make the grade...
...What Blue Cross and Blue Shield have done is to make even clearer the absolute necessity of government subsidy if we expect to provide for the health care needs of our older citizens...
...The group's spokesman, pictured addressing the President, was Dr...
...Adequate care is not and will not be forthcoming from a profit-inspired market system, simply because the elderly are generally too poor to provide anyone a profit...
...it is an actuarial impossibility...
...All three are unusually articulate...
...It is both pathetic and infuriating to witness our most highly-trained class of professionals tolerate in the AMA an organizational leadership characterized by stupidity, arrogance, hypocrisy, superficiality, and an eventually suicidal contempt of contemporary facts—suicidal because there is a real chance that the bitter controversy over the King-Anderson bill may finally expose the AMA leadership to the point that the profession may begin to disown it...
...Therefore, it is irresponsible for the AMA to plead that "in time" private health insurance will be able to take care of the elderly or that "they can afford private insurance on their own...
...The review of the records of these cases and interviews with the patients was conducted by outstanding physicians...
...As the showdown in the House over the King-Anderson program approaches, the AMA is holding the line...
...In the light of these facts and developments, the intransigence of the dominating hierarchy of the AMA— in refusing to acknowledge the nature of the problem, in pretending that the status quo will meet the need, in falsely describing the provisions and intent of the King-Anderson bill—has taken on the menacing quality of fanaticism...
...51 Less than fifty per cent have any kind of health insurance, and what those "covered" have is fragmentary at best, generally lacking provision for nursing home care, home health services, outpatient diagnostic procedures, physician home and office visits, drugs, and dental care...
...A great many doctors would withdraw their support of the AMA if they fully appreciated the dishonesty of its campaign of distortion in the King-Anderson fight...
...Visible behind him in one of the pictures was Dr...
...There is scattered evidence that the time is ripe for revolt...
...only a "trouble-maker" would believe it worthwhile to take loud public issue with the AMA line...
...This recent survey dramatizes the current state of medical care...
...The Real Issue in American Medicine by EDWARD T. CHASE The nation's press recently carried photographs of President Kennedy and Secretary of Health, Education, and Welfare Abraham A. Ribi-coff in Washington with several of a group of forty doctors...
...A conventional condition for the privilege of practicing in a given hospital includes membership within "organized" medicine, generally the local medical society plus the AMA...
...Quite the contrary...
...First, given the present business-model structure of American medicine, referral business is a prime consideration...
...The answer is long and complex but at least two points should be made...
...The King-Anderson bill would provide limited (essentially hospital) care to the elderly through Social Security...
...Given their commitment to reorganizing practice so as to realize medical technology's fruits through specialization and prepaid group practice, these men face no barrier of self-interest to prevent them from recognizing that the Social Security mechanism is the most efficient and equitable device for financing modern hospital care for that segment of the population needing it most and least able to pay for it—the aged...
...Medical costs continue to rise faster than the incomes of the elderly, and the insurance industry is simply barred from covering them at a cost they can afford...
...Baldly stated, the underlying issue is by which of two methods is medical care to be provided: % By a solo practitioner operating under no formal procedures which subject his services to the surveillance of other medical doctors, and who is paid on a piecework basis comparable to a small businessman—that is, the traditional fee-for-service method— or, 1f By practitioners organized as a group, so that services to the patient do come under the scrutiny of fellow-physicians, are rationally divided up in teamwork fashion so that the appropriate specialists bring their special knowledge to bear upon the individual, with the doctors being compensated on a formula basis such as capitation or salary from prepaid funds...
...This finding exposes the weakness of the AMA's insistence upon the sacredness of "free choice of physician," a dictum invariably invoked when prepaid group or panel practice is suggested...
...It continues to contend that the Kerr-Mills Act, the measure which provides additional funds to the states' welfare departments for their public assistance programs to help the aged ill who are destitute or medically indigent, is working just fine...
...for the most part they are too busy to find out...
...These doctors are eager to see the King-Anderson bill enacted because demonstrably the elderly must have subsidized health care...
...This is what the uproar is really about and hardly an issue dividing the medical profession, even the elder-care question, can be adequately comprehended without reference to it...
...It is highly doubtful that most doctors would be comfortable with the AMA's position, however, if they knew that the most respected and thorough national surveys (for example, by the Census Bureau) substantiate those same financial facts about our elderly population which are incessantly challenged by the AMA: ¶ About half of those over sixty-five have incomes of less than $1,000 annually...
...He disclosed results of an intensive review of 406 cases of hospitalization among members of a union welfare fund...
...Benedict Duffy, professor of preventive medicine at Seton Hall Medical School, across the river from New York City in New Jersey...
...Of considerably greater significance, all three have demonstrated a grasp of social and economic theory and of the specific facts about the health care problems of the elderly far beyond that of the average doctor...
...until now only twenty-eight states have participated in the program to any extent...
...Another significant point brought out by this survey is that the patients almost invariably were under the delusion they had received the best of modern medical care regardless of how they had been treated...
...For at the heart of the great medical debate in the United States is the question of the organization of medical care...
...It is this fact that brings us to the nub of the story...
...These doctors are impatient to get this secondary issue out of the way and to cope with the real need— reorganization of the medical care system...
...Martin Cherkasky, director of the outstanding Montefiore Hospital located in the Bronx...
...The doctors all stem from the greater New York metropolitan area...
...one-third of the hysterectomies were unnecessary and a "question could be raised about the advisability of the operation in another ten per cent...
...In addition to dramatizing these points, this technological change in medicine has brought rapidly rising costs and with them the imperative for prepayment, essentially a budgeting device...
...Apart from their participation in this group, these doctors have a number of things in common, some superficial, some of the utmost significance to the point of this report...
...The nation's most powerful lobby, the American Medical Association, is going all out to defeat the bill and would have the public believe that every doctor in the land shares its views...
...All authorities agree that medical care costs, as the result of increasingly complex technology, will continue to rise and that as automation increases the elimination of the elderly from the productive work force as a trend will never be reversed...
...Esselstyn, Cherkasky, and Duffy, enthusiastically favor group practice, preferably on a prepayment basis...
...Only 64,-700 persons had been aided by January of this year (there are seventeen million people sixty-five or over) and the great bulk of the money had been spent in just three states—Massachusetts, New York and Michigan...
...Half of them have potential liquid assets (usually the roof over their heads) of less than $610, an insufficient amount in a long illness...
...The trouble is they do not know...
...yet it is inhibited from such an evolution by its addiction to an incredibly naive and anachronistic notion of medicine as the last frontier of the individualistic entrepreneur...
...the impossibility of any one practitioner carrying all this knowledge in his head (hence the imperative of specialization...
...The President is backing the King-Anderson bill because it would incorporate such care under the Social Security system, described by these doctors as "the most practical and sound method of financing health benefits for the great majority of the aged...
...51 One-fifth have no financial resources whatever...
...But its essential points—that the commercially oriented, fee-for-service solopractitioner structure of the American medical care system all too often leads to unnecessary surgery, excessive hospitalization, inefficient diagnostic procedures, ill-considered therapy, and absence of follow-through— have been established repeatedly in studies throughout the country during the past quarter-century...
...The AMA fronts under the banner of a kind of super-Americanism, pontificating in its advertisements about the indivisibility of freedom, economic freedom, and its concept of fee-for-service solo practice...
...The truth is the AMA has become an incorrigible citadel of prejudice and hypocrisy...
...This line is cherished especially by the all-powerful senior staff men, the doctors who have the most to lose by any change in the status quo...
...and the compelling case for care to be given by means of comprehensive medical teamwork—group practice...
...It is difficult to name another organization of comparable potential to benefit the public which has come to quite such a miserable pass...
...The view of this observer and of a rising number of young doctors is that the medical profession of the United States has hobbled itself by taking a hopelessly equivocal position...
...Caldwell B. Esselstyn, medical director of the Rip Van Winkle Clinic at Hudson, New York, and, more to the point, president of Group Health Association of America...
...It is their commitment to this ideal, essentially, that differentiates them from the generality of doctors who go along with the AMA (the rule of thumb estimate is that from two-thirds to three-fourths of all doctors accept the official AMA position...
...That is why it is steadily losing ground, not only among the general populace, but among many of the doctors for whom the AMA leadership professes to speak and act...
...A dramatic instance of the kind of evidence that motivates such iconoclasts was presented recently in New York by Dr...
...Their allowances for hospital room and board charges are substantially below what is usually charged...
...Now, either a $12 or $30 price, on top of the $3.20 of Blue Shield, is hopelessly beyond the reach of the great majority of the elderly...
...The doctors had called upon the President "to pledge their support of the King-Anderson bill to provide hospital and certain other health care services to the retired of sixty-five years of age and over...
...The intrinsic nature of its calling and the pressures of scientific revolution press it to reorganize around the ideal of a rationalized system of group practice with all the reforms in procedures, facilities, and financing this implies...
...The AMA officially is committed to the perpetuation of medical practice on the solo, fee-for-service basis— medical practice modeled on a commercial business, on the entrepreneur-ship of the individual small businessman...
...What the report underscores is the palpable inability of the layman to make a rational judgment on medical competence...
...That force is technological change—the effect of applying the fruits of scientific progress...
...Forty per cent had received inferior care, yet of the 406 patients, only six felt they had had inferior care...
...most important common bond among them is this: They are fervent advocates of what is known as group practice...
...Blue Cross, with the more expensive responsibility of hospital insurance, has yet to announce a final figure but confesses it will run at least $12 monthly, and, depending on variations in the benefits, may run up to $20 or $30...
...The latest and most compelling demonstration of this has been the recent convulsions undergone by the two big non-profit health care plans, Blue Cross and Blue Shield...
...It is ironic that the profit incentive, which the AMA has deified in its propaganda as an indivisible part of free America, apparently is not a reliable force for organizing a medical care system effectively—-for the patients...
...The health care expenses of an average aged person amount to between one-fourth and one-fifth of his income...
...But it will take this kind of effort and a good deal more to persuade a reluctant Congress of the urgent need to place medical care for the aged under Social Security...
...The worst care—two-thirds of the cases were dealt with unsatisfactorily—was provided by proprietary hospitals—profit-making hospitals organized by doctors...
...All of them are spirited and have gone to the mat with the AMA time and again...
...This is the question that increasingly is bedeviling the profession...
...Second, and more important, medical practice today is increasingly carried out in hospitals...
...Blue Shield has come up with a premium of $3.20 a month for minimal doctors' services...
...Ray Trussell, the Commissioner of Hospitals and probably the nation's most outstanding health administrator...
...more than half the Caesarean sections were deemed to be of questionable need...
...A third doctor pictured was Dr...
Vol. 26 • May 1962 • No. 5
