THE NATION'S HEALTH
Greenberg, Selig
THE NATION'S HEALTH by SEL1G GREENBERG 'T^he new year is unlikely to produce anywhere near the unprecedented volume and scope of significant health legislation enacted by Congress in 1965. But...
...The enormousness of the task ahead was impressively documented in November at the White House Conference on Health, which for the first time in many years brought together under one roof the representatives of the whole broad spectrum of the health professions and of the divergent views within it...
...There is a lag of anywhere from eight to a dozen years from the time a decision is made to establish a new medical school and the time its graduates are ready to hang out their shingles...
...William H. Stewart, the new Surgeon General, that the U.S...
...Anne K. Somers, a research associate in industrial relations at Princeton University and co-author with her husband, Herman M. Somers, of the authoritative Doctors, Patients and Health Insurance, made this point graphically when she said: "Once the physician and the medical educator accept the concept of health care as a Twentieth Century team enterprise, rather than a Nineteenth Century individual enterprise, and once this basic orientation permeates medical education, doors will open throughout the entire health care industry...
...But in view of the spirit of permissiveness, if not outright laxity, which has pervaded some of the Federal regulatory agencies under the Johnson Administration, it is problematical how much of a free hand he will have in enforcing the public interest...
...Arthur E. Hess, the Social Security Administration official who has been designated administrator of the Medicare program, also is an unknown quantity...
...The President's Commission on Heart Disease, Cancer, and Stroke had recommended the spending of almost $3 billion over a five-year period for the construction and operation of such regional facilities...
...But in retrospect, and in the context of the overall achievements in the health field at the 1965 session of Congress and the prospects for the future, the watering-down of the regional center program does not appear to be quite the tragedy that some of its more enthusiastic proponents claim it is...
...But even the commitment for health services for the aged alone is likely to run into serious difficulties unless steps can be taken quickly to increase the supply of doctors, nurses, and the variety of other health workers, and to provide additional hospital facilities in many places, and adequate nursing-home facilities in all places...
...Rather, we should set radically new goals designed to utilize much more effectively the physicians we actually have or are likely to have...
...Meanwhile there appears to have been a significant shift in tactics on the part of the American Medical Association—from strident, all-out opposition to a technique of boring from within—in the wake of its crushing defeat on the Medicare issue...
...Public Health Service plans to devote as much attention from now on to the promotion of more and better medical services as it has given in the past to the stimulation of research...
...The danger of a snow job on the part of the medical and hospital politicians is by no means to be underestimated at this critical juncture in the battle for more and better health care for Americans...
...In many respects, the design of the regulatory machinery for carrying out these new programs is as important as their statutory provisions...
...The effectiveness of the AMA's new approach was demonstrated last fall by its success in truncating the program for a national network of regional research and treatment centers for heart disease, cancer, and stroke...
...In view of this and of the new provision for services for the medically indigent of all ages, it is all the more essential that emphasis be laid on greater efficiency in our systems of hospital and medical care...
...Public Health Service reported in 1964 that the United States had only 325,000 "acceptable" nursing-home beds as against a need for 840,000 such beds...
...Such power can clearly be abused and can, in the long run, undermine the fiscal integrity of the program unless the government insists on retaining the right to determine the justification for the components that go to make up the costs...
...The medical schools are confronted with the dilemma of how to reduce the time it takes to train doctors in the face of the steady accretion of scientific knowledge while at the same time attuning their education more effectively to the changing dimensions of medicine and its far-flung social implications...
...He is the author of the recently published book, "The Troubled Calling: Crisis in the Medical Establishment...
...Appel even went so far as to concede that the health care now available to Americans is "not good enough...
...Money alone will not easily meet these essential requirements...
...Many more such auxiliary workers will have to be provided to take over specialized tasks under the leadership of doctors...
...The government has ample authority under SELIG GREENBERG is a prize-winning writer on medical and related problems for The Providence Journal and Evening Bulletin...
...Although internship is intrinsically a part of undergraduate medical education and should really be looked upon as the fifth year of medical school, it has often deteriorated into little more than a vehicle for providing understaffed hospitals with the low-paid services of apprentice physicians...
...HEW Under Secretary Wilbur J. Cohen has a long and distinguished record as an ardent champion of the consumer in the medical care field...
...In the eyes of the AMA, this program constitutes an even longer stride toward "socialized medicine" than does Medicare because for the first time it brings the government directly into the provision of medical services instead of merely underwriting their costs on an insurance basis...
...Considerable attention also was devoted at the White House Conference on Health to the increasingly critical problem of how busy physicians can keep up-to-date with the constant advances in medical science, so that they may apply them in their practice...
...How vigorous it will be in exercising these powers only time will tell...
...Clerks will take over virtually all of the doctor's paperwork...
...The forward march of science inevitably means that hospital and medical costs will keep on going up...
...There was general agreement that not only are existing mechanisms for accomplishing this grossly inadequate but that action also is needed to raise the standards for internship and residency training...
...Restrictive laws and codes will be amended...
...While the Medicare law gives the HEW Department considerable leeway in the imposition of controls, it also provides opportunity for serious abuses by the purveyors of medical and hospital services...
...The major points brought out at the conference were that the amount of medical care now available in many areas is grossly inadequate, that a solution will require basic changes in the organizational structure of our health care system as well as further legislation, and that the crux of the problem in the immediate future is the pressing need for expanding the supply of medical manpower and facilities...
...Under supervision of the future physician, public health nurses will probably take over the bulk of home visits...
...Reliable estimates are that the basic and supplemental Medicare programs will cover only about sixty per cent of the average medical costs of the aged, taking into consideration the various deductibles and the services still left uncovered...
...Ordinarily, any sign of relaxation in the AMA's posture of unregenerate reaction would be welcome...
...Pediatric nurses will give injections and do most routine child health maintenance...
...And physicians will have to overcome their professional superiority complex and learn to assume more effectively their role as leaders of teams of health workers...
...For it will mark the full start of the truly gargantuan job of implementing Medicare and other health care programs written into law by the current Congress...
...The homes now unable to do so will have considerable difficulties recruiting the nurses necessary to meet the standards...
...Because of the grave shortage of nursing-home beds, the benefits for this form of care will not go into effect until January 1, 1967, six months later than the other provisions of the Medicare law...
...It still remains to be seen how tough-minded the new top-level team in the Department of Health, Education and Welfare, headed by Secretary John W. Gardner, will be in resisting the pressures of the powerful vested interests involved to make sure that the best possible hospital and medical care is provided at a reasonable cost in tax dollars...
...In the long run, some authorities feel, many of the proprietary nursing homes, which now constitute the great bulk of such facilities, will be absorbed by the nonprofit hospitals, just as most proprietary hospitals have been gradually so absorbed...
...Negotiations for establishing the administrative ground rules are now under way between Federal officials and representatives of the various sectors of the hospital and medical establishments and the insurance industry...
...Occupations will be redefined...
...But coming at a time when the administrative policies that will shape the future of Medicare and other government-sponsored health programs are in the process of development, it is not an unmixed blessing...
...The act specifically prohibits government interference with the practice of medicine or with the operation of hospitals...
...While most doctors continue to cling to an archaic form of piecework remuneration, specialization and the emergence of the hospital as the central focus of care make imperative a far greater coordination of the various disciplines within the medical profession and the auxiliary health occupations...
...It makes it imperative instead that we exercise the leverage of our governmental power to insist on the streamlining of the antiquated organizational structure of our health care economy so that we may get full value at the lowest price consistent with high quality care...
...Do we have educational programs that will prepare people to meet the needs of Appalachia, of Harlem, or even of Westchester County, New York...
...The new law requires every nursing home to have twenty-four-hour nursing services, with at least one registered nurse on duty at all times...
...That most eager and obedient of all aides, the computer, will help with many diagnostic tests and patient monitoring...
...A highlight of the White House Conference was the notice served by Dr...
...the law to demand adequate standards of care and economy of operation, including curbs on excessive utilization of costly hospital beds...
...The U.S...
...Much concern has been expressed by knowledgeable observers in recent years over the quality of internship and residency training in the poorer hospitals...
...The sweeping amendments to the Social Security law enacted last year provide for government-financed medical services not only for the aged but for millions of the medically indigent of all ages...
...Mrs...
...Mid-wives, [perhaps operating under] some more acceptable euphemism, will deliver most babies...
...The developments of the recent past," he said, "have produced a medical culture which has been characterized as 'islands of excellence in a sea of mediocrity.' Are we, in our professional schools, so preoccupied with the purity of clinical excellence—as exemplified in our super-equipped and super-staffed teaching hospitals—that there is nothing left over for raising the base of medical care in the broader community...
...In the light of the history of the Social Security program, there appears to be little doubt that the Medicare law will be progressively liberalized and that the age limit for eligibility will ultimately be lowered...
...Translated into plain English, this gobbledygook means that the AMA has finally discovered that it can probably protect the economic interests of its members far more effectively by wirepulling than by trying to slug it out in Congress...
...Several speakers at the Washington conference drew attention to the fact that the Scandinavian countries have an excellent health record with a lower ratio of physicians to population than in the United States...
...The number of available candidates for training in nursing fall far short of need, and the same situation prevails in the other health occupations...
...It is unrealistic, they noted, to train physicians at great cost only to have them perform jobs which can be done just as well and at substantially lower cost by less thoroughly trained people...
...Wrapped into the problem of expanding the nation's supply of medical and paramedical personnel are a number of challenging issues, all of which run into the obstacles of institutional inertia and the economic self-interest of many of the physicians now in practice...
...This goes a long way toward undoing what the medical schools are trying to accomplish and to defeat what is perhaps the most critical phase of the whole educational process for the young doctor...
...Appel said recently that the AMA had decided to participate in the discussions on the administrative setup for Medicare "because we must take every action possible to preserve and strengthen the freedom of decision-making by physicians and to insure that the blame for the harmful effects of Medicare will not be placed upon our shoulders...
...But this brief period of grace will hardly be sufficient to remedy the situation...
...See "LBJ Yields to the AMA," The Progressive, December 1965...
...But raising the standards of care will further aggravate the staffing problem...
...Authoritative opinion is that hospital costs will continue rising and will probably reach an average of about $60 a day by 1970...
...The framers of the Medicare bill wisely provided for alternatives to costly hospital care in the form of nursing-home and home-care services...
...For the plain truth is that we may have bitten off more than we can chew and will certainly have our hands full in the next few years trying to provide the trained medical and paramedical personnel and the facilities required for carrying out the legislation already placed on the statute books...
...Perhaps more than in some other areas of regulatory activity, the tool-ing-up process for Medicare is full of pitfalls...
...Individuals will be upgraded...
...But the most meaningful conclusion to emerge from the crowded conference agenda was that we face a formidable job in seeking to realize our commitment to provide the best possible medical care to all those who need it and cannot afford to pay for it...
...But 1966 is certain to be fully as crucial in laying the groundwork for far-reaching changes in the character of our hospital and medical services...
...There are severe shortages of teachers for medical and other professional schools...
...This would obviously be a step in the right direction...
...It does not mean, however, that we must resign ourselves to an uncontrolled inflationary spiral by agreeing supinely to reimburse the suppliers of hospital and medical services for whatever they themselves regard as their "reasonable charges...
...But the bill in its final form authorizes only $340 million for three years and has been weakened in some other vital areas under pressure by the lobbyists for organized medicine...
...Furthermore, only $25 million was appropriated for the first year...
...The conference, which was attended by about 850 persons, revealed a muting, on the surface at any rate, of differences of opinion on some of the highly-controversial issues of medical care...
...James Z. Appel, the current AMA president, and some other moderates who joined with him in heading off a threatened strike of doctors against Medicare, appear to have convinced the rest of the leadership of the advantages of the soft-sell technique...
...Their efficiency must be further extended through greater resort to group practice with its pooling of skills and equipment for providing more balanced and economical services...
...But he is a newcomer to government and has yet to prove his mettle as an aggressive administrator able to hack his way through the thicket of medical economics and the fog of propaganda enshrouding it...
...To remedy this situation, a number of authorities have proposed that control of postgraduate education, now in the hands of the AMA Council on Medical Education, be vested in the medical schools...
...Hospital planners will help to avoid duplication of facilities...
...It authorizes HEW to designate Blue Cross, Blue Shield, or commercial insurance carriers as fiscal agents for the operation of the Medicare program with the power to determine the level of "reasonable charges...
...The gutting of the regional center measure is deplorable not only because it impairs a crucial project but perhaps even more because it underlines the wide gap which exists in certain areas between the Johnson Administration's evangelical fervor and its readiness to go to bat for the public interest...
...To raise the quality of nursing-home care, the Medicare act requires such homes to be affiliated with general hospitals through transfer agreements and an exchange of medical records...
...President Johnson watered this down by proposing a five-year program costing $1.1 billion...
...Much of the same thing holds true of some of the residency training...
...It is reported that only about half of the existing nursing homes can meet this qualification...
...The AMA spokesmen were mostly on the defensive and did not contest some of the reformist views expressed by their colleagues on the medical school faculties who have long been at odds with the organized profession's party line...
...Gardner, a Republican, made a distinguished record as president of the Carnegie Foundation by promoting important new departures in the field of education...
...Their range of effectiveness can be extended, first of all, by having them delegate the relatively simpler tasks to machines and to nurses and other technicians to a far greater extent than is now being done...
...Management engineers and systems experts will seek to restructure the delivery of services...
...They emphasized that we will never be able to train all the doctors we would like to have under our present medical care system...
...Steps are long overdue to utilize more efficiently our limited supply of physicians...
Vol. 30 • January 1966 • No. 1
