Rise Fall of Healthcare in America available in Paperback
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The Rise and Fall of Health Care in America
By Ted Nolan Thompson
SAVANT INFORMATION PUBLISHINGCopyright © 2003 Ted Nolan Thompson, M.D.
All right reserved.
Chapter One"THE FREE ENTERPRISE SYSTEM AND HEALTH CARE IN AMERICA"
By 1938, during the latter part of the Great Depression, fee for service delivery of medical care had had its' shortcomings for several years. It was well known physicians at times performed their services for no pay. Moreover physicians were willing to do so. Once in awhile it was a pleasure. Physician-sons' of physicians remembered their doctor-father staying all night at a patients' home. He administered morphine periodically until daybreak to help alleviate agony, with such appropriate medications and moral support, until at last the patient passed that kidney stone.
Soon after sun-up it was time for breakfast. Following handshakes, along with hugs and tears of gratitude, "Doc" went ahead and joined the family for several cups of coffee and some breakfast. It was understood from the very start there simply was no means whereby the physician would be paid in money. For all too many there was very little money. In those days a cup of coffee in an "FBI cup" cost a nickel. A loaf of bread was hardly more than ten cents. A good hair cut cost a quarter.
Doc left directly for his office. Having had just a few short naps he was a little surprised not having too much trouble staying awake for the day's patient load. That great feeling, you helped someone in need, kept you going for a while at least. Furthermore times were tough for so many. Arriving home 33 hours after being away was wonderful. No one complained. Only good things were said, but there were private thoughts before dad at last went to bed. No matter how you reasoned, it was thought better all around if the doctor could have skipped the breakfast and simply gotten paid.
Henry John Kaiser, American industrialist, thought exactly that; that physicians ought to get paid. In 1938 the energetic, colorful, very successful road, dam and bridge builder, soon to become a civilian hero of World War II, set up a prepaid medical care plan for his employees, the very first health maintenance organization (HMO), in Oakland, California. It was given a name: "Kaiser-Permanente."
After World War II membership in Kaiser-Permanente was open to everyone. The idea of a prepaid medical plan had caught on. In fact a very good natured Sicilian, who genuinely cared about "the little people," and who once raced a produce truck over Southern California's very hazardous "grape-vine highway," felt it was a noble idea. By 1952, labor leader, Joseph T. DeSilva, of Retail Clerks 770, raised $100,000 to establish Kaiser-Permanente in Los Angeles, California.
Physicians, however, by and large favored the system of "fee for service." Blue Cross and similar insurance plans for medical care were put in place. In the fifties a medical consultation costing $25 was considered robbery! $25 paid for 24 hours in a hospital! By the mid-sixties Blue Cross of New York cost slightly less than Blue Cross of California. For New York it took just $32, paid quarterly, for a family of two adults with four children to have just a hospitalization plan. With fee for service, the physician was on his own to serve in his chosen community. After four years of medical school and one year of internship, that commonly included experience in surgery, surgical specialties, internal medicine, obstetrics and pediatrics, one went into general practice, or, went on to try to qualify and be accepted for more training. This usually meant three years of general surgery, and then a year or more training in a surgical specialty. A similar amount of time needed to be invested in internal medicine and then a specialty (e.g. infectious diseases), or, one year of internal medicine and then three years of neurology. Pediatric residency required two consecutive years, with more time in a pediatric specialty. Psychiatric medicine consisted of three consecutive years of psychiatry. Just medical school and a good internship, however, meant the physician could "write his or her own ticket." Parents of "fee for service physicians," just starting out, were boastful. People looked up to their physician, and it wasn't necessary at all to be a specialist as far as the public was concerned. It seemed to everyone that practicing medicine was the ideal profession. Medical practitioners, however, were not businessmen. Being "disease smart" wasn't the same as being "street smart." Doctors were "doctors" and that was just what they were meant to be.
Unfortunately some doctors were unable to fashion themselves that way. They became more business oriented. During the fifties all too many patients, who bought medical insurance, determined also to spoil a good thing. Most often it was the type of patient who wanted to be "screened" for everything! Certain folk chose the "high option." Hearing of laboratory tests they felt they ought to have, they somehow felt "entitled" to these tests. Overlooking the "principle of insurance," they felt since they paid for it, why shouldn't they get tested? Physicians, especially those with good clinical acumen, resisted such patient pressures put upon them and tried to reassure patients without so much lab work, but eventually many doctors simply caved in. Financially focused physicians already offered their patients "lab test menus!" Insurance lobbyist very annoyed with this rising trend complained privately to legislators as well as those of organized medicine. "There were doctors practicing who should not be practicing," they said. They were correct but reasonably it was too late to do anything about it.
Even if a doctor called a case of hemorrhoids "strep throat," if such were agreeable to his patient and the patient didn't complain how would anyone find out? Reportedly a Santa Clara California physician, who owned the pharmacy nearest his office, called virtually all his cases "strep throat!" He had a Spanish speaking practice, was pushing penicillin billing also from his pharmacy to MediCal, California's social welfare plan. The physician, who spoke fluent Spanish was dedicated to "preventing rheumatic heart disease" from striking any patient within his sphere of medical influence. Presumably this was accomplished. Academically such practice redefined absurdity in therapeutics, however, none of his patients complained. He was worshipped instead as a "penicillin god." Taking advantage of the up and coming computer age each case was registered separately as "appropriate treatment for an appropriate condition." His income in the late nineteen sixties was about $70,000 per year, virtually all Medi-Cal (Medicaid). You can be certain the obsessed physician had a lawyer who was in very close touch with a judge who also spoke Spanish.
The Department of Vocational Standards (DVS) received many complaints in California. They ranged from the bewildering to the bizarre. Virtually anything and everything you can imagine became at face value a legitimate request for an investigation! There was no way for such a department to respond to all requests. Having lunch at Posey's restaurant in Sacramento, with Earl Waters, then head of the DVS, some very weird complaints were occasionally related. There was nothing to do but have a chuckle and say, "It's a sick world, and how to 'healers and their patients' get involved in such goings on?" What really was the DVS supposed to do about it?
Nearly all America approved of physicians having a nice home and driving a new car and being able to collect sufficient money to send their children to college. By 1955 certain doctors had already focused on the almighty dollar. A few had "tunnel vision" as they used to say. They were too "focused on the nickel" and nothing else.
In 1960, a professor and chairman of a medical or surgical department in a university teaching center was for the most part delighted to make about $30,000 per year. There was additional income from billings from private practice representing about ten percent of time away from seeing "teaching cases." Sops from pharmaceutical firms were just beginning. The hope was to encourage a less that objective university clinic evaluation of some new drug. It was fortunately a rare professor who went for the money. If he did he was sort of "out of the loop of respect" by medical students that got wind of it.
So called "town and gown battles" became very evident in certain areas. A classic example, when UCLA developed their "ivory tower teaching center," physicians in Beverly Hills were so upset (financially threatened), teaching case material became impeded. Those serving internships in 1958 at UCLA were required to work-up the same clinical teaching case twice for experience while hospitalized ill patients gladly cooperated but suffered deja vu.
As newly appointed department heads from UCLA swooped into the County Hospital in Torrance California, known then and now as Harbor General Hospital, to assume control of a specialty division exceptional teachers of medicine and pediatrics were brushed aside like Mel Kaplan, MD, internal medicine and Kenneth Zike, MD, pediatrics. In some cases it smacked of arrogant personalities replacing nice people who were also enthusiastic teachers. It seemed sort of obvious the "image of the newly formed institution" was more important than the actual teaching program, or, going further yet whether patients were cared for in the most decent efficient way.
While costs from 1958 to 1961 were "nothing" compared to medical-surgical costs today, even in 1958 emphasis on finance clearly overshadowed medical care. Having just admitted a case of heart failure via the emergency room, the very next morning anxious to check your patient on "dig and mere" you, the "doctor," were surprisingly upstaged! Your patient was being interviewed by a social worker over "property ownership status" should it be necessary to attach a lien. As ordered the nurses had done a good job of propping the struggling patient up to assist his breathing. Valuable information on how much of a diuretic effect had thus far taken place along with quizzing the patient to critically adjust digitalis dosage logically took precedence but never did! Without exception each case was treated as a Los Angeles County "financial emergency!" There's no personal recollection of any exception. More bizarre yet, the patient could not possibly have walked out of the hospital; the rush based on economic fears the patient might have died before the social worker got there to document the information!
For the sociologically complex measurement of costs of medical care from the fifties to just before the "ax" fell during the nineties for instituting managed care, one needs to address units of effort as well as time spent per each task at hand. One wonders too if some narcissistic entitlement syndrome, like "a virus," had previously overcome the entire medical profession! Increasing propaganda designed to convince the American public "over utilization" of high technology instrumentation is necessary, or else you are not receiving the "'best medical care," continues on its way to becoming even more of a smashing commercial success.
Public acceptance of "over utilization of medical testing" continues into the 21st century. The trend fails to slow in spite of physician awareness hi-tech instrumentation, thrust upon them through the system, fails to help patients all things considered. Furthermore over utilization comes about not by one doctor's decision but through committee decisions by momes, or greedy business oriented administrators, in concert with insurance providers who never fully understood what physicians are taught to do if those who taught those committee oriented types ever knew in the first place. It's simply a business of making as many bucks as possible on sick patients. How else do you make the hospital payroll? That is a problem.
In spite of amazing medical and surgical accomplishments medical care for the masses worsens for three clear-cut reasons. First physicians are being trained more and more like molecular biologists as if lost in some futuristic dream world that cannot yet be taught. Second is a fixation on "business" in spite of the cost of technology-driven-medical-care exceeding the financial capabilities that man on earth can allow! Third, more patients are being seen in some emergency care center (ER) where stab wounds, bullet wounds and "raving or tripping on various street drugs" are their areas of expertise when such patients "should be seen in the quiet of an appropriate physician's office or via a house call."
As a senior medical student professors encouraged me to become a surgeon, that I was good at it. To this day I've no idea why though some people can remove a sliver from a finger better than someone else. My fascination, however, was about the function of the nervous system particularly the brain or the "mind" (After 40 years I'm still working on it). In America you have the freedom of choice and hopefully the chance to enjoy yourself. Had I been a Soviet medical student at the time of Stalin's dictatorship surgery would have been my profession. Who knows, having skillfully performed some unusual procedure successfully on a celebrity and receiving all kinds of favorable publicity, maybe then one begins to enjoy surgery and thinks, "Uncle Joe was right! On the other hand in the United States you have choice, albeit perhaps not the wisdom to make the best choice. Like your lawyer said, "You married her!" You picked her and she picked you and the marriage turns into a disaster! You then wish you had relied on the wisdom of others with more experience, thinking everything might have worked out, but who on someone else's advice is willing to take such a chance?
Doing some surgery during internship whether enjoying it or not, the first tonsillectomy took only twenty minutes with the patient seated on a chair. Huge tonsils called "'kissing tonsils" made the job all the easier. One had to be 15 years or older to have the procedure done in this manner utilizing a local anesthetic. You were instructed Not To Bother The Patient's Carotid Arteries and I meticulously obeyed those instructions! Having practiced this "art" over the years imagining time involved, the procedure, "Tonsils in; Tonsils out," should by this time take about six minutes!
Why is it then a whole hour is scheduled for a simple tonsillectomy in an outpatient wing of any major medical center or hospital? Why not 30 minutes? Why not do four patients in that hour?
As an intern it was fun to order a "tray" and fix an umbilical hernia in a few minutes for merely a "thanks Doc." Why during the nineteen nineties did an insurance carrier have to pay just the surgeon's fee of $2500 (!) for fixing an umbilical hernia for a close friend of mine in Los Altos Hills, California? With that "tray" I'd have fixed it for $100 right in his home! That way, had there been an unlikely post-op infection, a few dollars worth of penicillin would have taken care of it! There was no risk in someone's home of a "hospital environment penicillin resistant staphaureus." Such a "hospital related complication;" the treatment cost alone for I.V. antibiotics has in my own experience been as high as $20,000!
As for "cataract removal," it was a dead animal's eye for practice in a lab. It wasn't easy. On the other hand I've been told that graduates of the "cataract school of India" go village to village removing cataracts at the proper time needing about 20 minutes for each case.
By the late fifties cataract removal cost $300 in San Francisco California. In 1962, during my residency at UCSF I dash across town to see a cataract patient (my dad). He tells me the charge is $700! He's visibly upset about the charge. Looking at the surgery schedule board it's shows his Stanford eye-surgeon has several cataract cases scheduled for that morning.
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