AMERICA'S MEDICAL CRISIS
Chase, Edward T.
AMERICA'S MEDICAL CRISIS by EDWARD T. CHASE The erosion, crises, and sporadic breakdowns of the U.S. health-care system provide uniquely impressive evidence of an old wrong in American life:...
...His articles on social, economic, and cultural affairs have appeared in Harper's, The Atlantic, The Commonweal, Saturday Review, and other publications...
...This need cannot be met by the expected increase in doctors in this period—from the present total of 300,000 up to the anticipated 362,000...
...In Sweden, the comparable figure is ninety-five...
...Medical Education," sponsored by the Commonwealth Fund and the Carnegie Corporation, and in June of this year in the National Conference On Medical Costs, sponsored in Washington by the Department of Health, Education and Welfare...
...Economist Herman Somers of Princeton wrote recently in the New England Journal of Medicine that productivity has actually been declining in the health care field, "that the number of employe man days per patient used by general hospitals, now almost two-and-a-half, has been moving up steadily...
...It will be a major political issue for many years to come...
...It can instigate action by Secretary John Gardner and his able associates in the Department of Health, Education and Welfare, men like Assistant Secretary Dr...
...In The Doctor Shortage: An Economic Diagnosis, Fein demonstrates purely as an economist, not as a polemical ideologue, that whatever the depth of the doctor shortage, under the existing financing and distribution structure of American medicine, "the investment of resources in expanding supply is not likely to bring the desired medical care to those who need it...
...There is strong evidence for Federal underwriting of a floor of universal health insurance, that is, at least basic minimum Federal health insurance for all the population (regardless of age), to which more ambitious voluntary insurance protection can be added by the individual...
...15,000 X-ray technologists...
...The reason is that HIP's doctors are not full-time...
...In particular, "very large increases would probably be necessary before the number of physicians in rural areas and in poverty areas would significantly increase...
...At the heart of this inferior performance is the question of the productivity of the system, especially of physicians, and the matter of shortages and maldistribution...
...Public transportation and housing, like health care, are areas especially bedeviled by this conflict: in these sectors, inequitable allocation of resources is on a scale constituting a social crime...
...This may sound old hat, an echo of the 1930's...
...It has been demonstrated repeatedly that reducing hospitalization rates can best be accomplished if people are effectively treated at home or in outpatient clinics...
...As a result, the discrepancy between what might be done with available medical manpower for the health care of Americans, and what, in fact, obtains, is dismayingly more manifest day by day...
...No field requires the application of social cost-accounting more desperately than medicine...
...The conference pointed out the need to "bring the poor into the medical education system," and the need for more medical schools, financial support of all students, and new ways of compensating doctors so as to encourage comprehensive preventive care...
...it has the strongest lobby in the United States...
...The doctor shortage is not the cause that explains all of this, but it is a crucial factor in medical-care effectiveness and it is symptomatic of what is wrong with our medical structure...
...Fein's book is important because, while it supports the case for greatly increasing the supply of physicians, it exposes the myth that this expedient alone would substantially solve the problem of America's inferior health care services...
...Every act has reverberations upon innumerable other acts...
...New kinds of health workers are also necessary to supply the new demands...
...But comprehensive, planned, prepaid, group practice along the lines of Kaiser-Permanente will become central components of the tax-assisted health structure of the United States in the early years to come...
...AMERICA'S MEDICAL CRISIS by EDWARD T. CHASE The erosion, crises, and sporadic breakdowns of the U.S...
...fifteenth in available hospital beds—reveal that this country is well behind many other nations, most of them poorer than we are...
...There are shortages, maldistribution, and profound inequities in availability of services...
...The U.S...
...It has been clear for some time that under modern conditions the marketplace cannot be permitted to be the sole judge of policy issues...
...75,000 nurses...
...We will not adopt, on a national scale, Great Britain's health service...
...Medicaid, the greatest welfare measure in thirty years, may gradually change this significantly...
...It takes sophisticated procedures to trace cause and effect...
...Five years ago there were only some 250 home health service agencies (physician-directed nursing care and physical therapy) in the nation...
...death rate is double the Swedish rate: of every one hundred American males who reach the age of forty-five, only ninety will live to fifty-five...
...These are not destined for implementation through legislation in the current Congress, but they are long-needed and their need is so strongly substantiated that action on them may not be far off...
...they may require raising the individual's Medicare premiums from $3 to $4 a month...
...The historic evidence is now incontrovertible that this type of practice greatly lowers hospitalization rates...
...The massive new programs—Medicare to provide hospital care for the aged under the Federal Social Security system, and Medicaid, a Federal-state-county financing of medical costs for indigent Americans—are exposing the financial and social costs, the wastes and abuses, of present entrepreneurial, private voluntary systems of medical care...
...The success of these programs will depend on the degree to which they can operate outside the marketplace...
...The ultimate nightmare for the medical-establishment leadership would be some national system of health-manpower allocations involving nurses and doctors...
...They are designed to reduce the necessity for in-hospital care—a powerful booster in the upward-cost spiral...
...The leaders of the politically oriented medical establishment, "organized medicine," have acted to control the supply of doctors for generations...
...Medicare has already begun to improve matters for the aged...
...Fein uses detailed studies to show that by 1975 our present supply of 300,000 physicians will grow to 362,000 but that, at best, we will be from three per cent to ten per cent short in maintaining even our present inadequate level of services...
...Seven nations have a higher proportion of doctors to population than the United States...
...Area planning of health resources was urged, as was the development of a National Center For Health Services, Research and Development...
...The shortages of doctors and other health personnel is exacerbated by a crazy maldistribution of services...
...16,000 occupational therapists...
...overall commitments to the growth and stability of such countries...
...In a number of rural states, there are fewer than eighty doctors for each 100,000 of population...
...Fein carefully reviews the pros and cons of group practice versus solo practice and comes out strongly for group practice on the evidence of improved overall productivity...
...As an economist, Fein emphasizes that our medical system operates as a private entrepreneurial affair, with prices and allocations of resources determined by the mechanism of the market...
...It consumes six per cent of the Gross National Product, nearly $41 billion in 1965 and an estimated $50 billion today...
...The ratio of doctors to population in this country has fluctuated from 130 to 140 per 100,000 persons in recent years...
...For if such consumer demand is not backed up by actual purchasing power, the needs remain buried...
...Such public crises will be identified through increasing use of systematic social cost-benefit accounting...
...As the insurance companies, acting as financial intermediaries in the handling of Medicare bills, audit the fees, patient overcharges and other exploitation are uncovered...
...But, to quote Fein, "Creating physicians because Appalachia or Harlem are without sufficient services is not likely to bring those physicians and their services to Appalachia or Harlem...
...But with an increased drain of doctors out of private practice into research, teaching, and administration, the actual ratio of practicing doctors to population is ninety per 100,000, or fifty-one fewer than the minimum deemed acceptable by the Surgeon General's Consultant Group on Medical Education...
...Many authorities feel that HIP's deficiencies, accompanied by publicity about them, have set back the cause of group practice more than any other single factor, with the exception of the continuing hostility of the medical establishment leadership...
...Should the cost-maldistribution-shortage-waste crisis in health deepen, this is not an unthinkable possibility, though it is highly unlikely...
...These fee increases, Gardner has said, are a major factor...
...He is particularly concerned with increasing productivity as well as with speculating upon ways to distribute medical services more equitably...
...In a complex, technologically-sophisticated, over-populated society, interdependence is the dominating fact...
...These quiet statements are devastating: they say that the American health care system, the world's most expensive, is out of kilter, that supply of services bears no relationship to need...
...Productivity" means the amount of services produced in relation to the resources utilized or consumed...
...The health care problem is not confined to direct health care alone...
...Substantial government funding to establish such agencies could counter some of the heavy pressure on hospitals...
...Medicare treated 3.5 million persons, aged sixty-five and over, in its first year...
...Counties, and even states (New York, California, and Michigan), are forced to forestall bankruptcy from skyrocketing medical costs by cutting back Medicare and Medicaid programs—as doctors' fees and incomes soar...
...And for decades organized medicine has kept the supply smaller than impartial, expert analysis has deemed tolerable...
...Productivity is low...
...Encouragingly, there is a growing popular or quasi-popular literature of protest that is beginning to accomplish this end...
...Yet, of all areas, incredibly enough, the market has been calling the shots in health care, the system that deals with life and death and with the causes of dependency...
...As the HEW conference revealed, the most probable direction will be toward the development of systems of incentives and sanctions, applying in the first instance to medical students and ancillary health workers, to motivate them to serve where most needed...
...By 1975, the U.S...
...It explains, in large part, why the United States' ranking in health has dropped alarmingly in the past decade...
...It now provides high-quality preventive, diagnostic, therapeutic, and rehabilitative services on a prepaid basis in the home, the doctor's office, and in the hospital for a membership of 1,565,000...
...This is especially true when monopoly conditions characterize the supplier, as they do in medicine...
...Medicaid, which focuses on the indigent and medically indigent (not impoverished but unable to pay their medical bills), will have treated some 6.5 million persons by the end of 1967...
...Most important and most threatening to the old order are new Federal grants designed to encourage the formation of group practice, especially those groups that are hospital-based and organized on a prepayment basis...
...George Silver, formerly director of social medicine at famed Montefiore Hospital in New York City...
...If reforms in the present piecework, fee-for-service entrepreneurial solo practice system are not forthcoming soon, the government finally will have to establish the public's interest in more equitable and productive health care systems, "Systems" is the word because reform will come on a pluralistic basis...
...medicine constitutes— absolutely and relatively—the world's most expensive health-care system...
...In ghetto areas in major cities there are often no accessible private doctors whatsoever...
...Light was thrown on this subject in February, 1966, in a notable conference, "The Crisis in Medical Services and...
...These programs are dramatizing the desperate shortage of doctors...
...These recommendations, if brought to fruition, would radically challenge the present system of American health care...
...He observes that if the proposed "International Health Act" goes through, which would act to inhibit such immigration of foreign doctors, our physician supply would worsen severely...
...The medical profession is the most affluent of any...
...and many others...
...Department of Labor estimates the personnel shortages in health at 500,000—at least 100,000 doctors too few...
...Furthermore, the average patient-day cost is fifty-six dollars under the Plan compared to sixty-three dollars for other hospitalized patients in California...
...It is linked to welfare needs, for behind many welfare cases there are medical problems...
...its members enjoy a uniquely powerful role in society as charismatic father-figures privy to sacred knowledge and in contact with us when we are most dependent— either ill or dying...
...Brookings Institution economist Rashi Fein has written a book about the findings and deliberation of the first conference, and he played a starring role in the second...
...The Kaiser-Permanente Plan on the West Coast is the most outstanding program of this kind...
...It is small wonder that the U.S...
...Meany called for immediate control of physicians' fees paid under Medicare...
...too often they are diverted from concentrating on their HIP duties by their supplemental private practice...
...30,000 medical technologists...
...Comparative statistics—the United States ranks eighteenth in infant mortality...
...Generalized demand (but not effective demand) is accordingly at a high pitch...
...The first step, as always, must be public awareness of the realities...
...Because they lack funds to pay for medical care, the poor in urban slums and in Appalachia, while known to have the highest morbidity rates, have by far the most limited access to doctors' services...
...Nor are future prospects encouraging...
...Among males over forty-five, to cite perhaps the most significant statistic, the U.S...
...for instance, a ratio of 217 doctors per 100,000 population in New York City with a density double this on Park Avenue...
...health-care system provide uniquely impressive evidence of an old wrong in American life: the incompatibility of market economics and distributive justice...
...Lester E. Wolcott and Paul C. Wheeler shows that such supervised home health care is at least the equal of, and probably superior to, institutional care...
...The hospital utilization rates of the Plan's members run forty per cent lower than that of other Californians...
...In contrast, the Kaiser-Permanente Plan is proving to be a powerful example of the effectiveness of prepaid group practice...
...Costs have climbed beyond the private means of millions of Americans well above the poverty class, with hospital charges of nearly $100 a day, and doctors' fees rising more in 1966 than in any of the past forty years...
...The root reason is that market prices do not reflect social costs and needs, though Americans persist in pretending that they do...
...Hence, there is mounting pressure for Federal financing of home health services, of hospital-based group practice units, and of relatively inexpensive convalescent facilities for those not acutely ill...
...How, then, can the profession be made to reorganize its system...
...On the East Coast the biggest plan is HIP (Health Insurance Plan of New York), which, for all its solid successes, is in bad odor in health-care circles...
...Federal aid in the funding of group-practice plans of all kinds was proposed, along with "the development of ancillary care specialists to render more of the services now rendered by physicians alone...
...The health-care crisis—as are so many major national problems —is caused by the conflict between the uncoordinated private profit-seekers and the rational use of scarce resources in the public interest...
...Even the man in the street is becoming aware, in a general way, of this oft-publicized fact...
...Unhappily, this is a truth of the late 1960's...
...A recently completed study in Missouri by Drs...
...Medicare funds have already begun to underwrite some of these services...
...Yet it ranks down the scale among the leading nations in effectiveness...
...Among those protesting high medical costs is AFL-CIO President George Meany, who has informed Gardner that doctors' fees have gone up "nearly three times the rise in the over-all "Pressure's Up" consumer price index" during the year ended last June...
...Gardner's widely publicized June conference on medical costs came up with a number of sound recommendations...
...Today there are 1,780 such agencies certified for Medicare participation...
...25,000 practical nurses...
...This applies equally to private non-profit hospitals because their location is usually determined by the relative affluence of the area...
...Social cost accounting is increasingly essential to make public policy decisions: for example, measuring, aside from the dollar cost, the total consequences to a community's "liva-bility" of an elevated superhighway being built through it as compared with an underground highway or a rapid-rail transit system...
...The medical profession itself, however, and its friends in the private health insurance industry, are violently opposed to any change...
...The recommendations included the proposal for a detailed system of incentives and sanctions to control the cost of hospital care...
...Furthermore, the context of health care today is one of miraculous technological advances, amazing new surgical techniques, and wonder drugs, terribly expensive, to be sure, but holding forth to all the expectation that almost no illness is unconquerable...
...The evidence is compelling that radical reorganization of the traditional individual practice toward group practice is needed...
...It is clear that something has to give...
...No wonder the Plan is booming...
...He also speculates on the value of creating new categories of physician assistants—medical specialists relating to M.D.'s as Bachelor's and Master's degree holders relate to Ph.D's Fein questions the equity and rationality of the United States importing doctors from developing nations—about 1,500 a year—in the light of U.S...
...The fact is that medical doctors are in extremely short supply—there are more than 5,000 communities in the United States without a single doctor—and everywhere the demand for their services is on the increase...
...The country's health picture looks like this: There is accelerating inflation in costs...
...This literature, in combination with public revelations about the health-care systems that have come to light because of the experience with Medicare and Medicaid, can be expected, in time, to trigger Congressional action...
...The health-care crisis will be one of the great domestic crises of the welfare state of the 1970's...
...Health care needs do not necessarily translate into effective consumer demand...
...25 EDWARD T. CHASE is an editorial vice president of the New American Library publishing house...
...population will have increased from 195 million people to about 223 million...
...The need for medical services will increase by some twenty-six per cent, according to a new Brookings Institution study...
...twenty-second in life expectancy for males, tenth for females...
...This latter figure, incidentally, assumes success in attracting some 16,000 foreign doctors to practice in the United States...
...example is not universally appealing to the new nations of "the third world...
Vol. 31 • December 1967 • No. 12
