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| By Charles William Bailey, Jr., M.D., J.D. |
As we survey
the medical environment today, searching for solutions for tomorrow, it may be
helpful to consider the evolution of this complex system.
As a third generation physician who
was raised in a medical family, I have observed first hand many of these
changes.
My
grandfather and father practiced during a period when medicine was not a big
business. There were no stockholders benefiting from the misfortunes of the
sick and injured. Almost all physicians had a significant number of patients
who could not pay for their care. Many of them reciprocated with small
kindnesses, which dwarfed any financial reward.
There was no Medicare or Medicaid and
hospitals were predominately operated by municipalities or churches. Efficiency
and cost control were essential. The number of hospitals in a community was
based on need and not the prospect of profits.
In short, medicine and hospitals did
not spark an interest with Corporate America.
With the passage of Medicare and the
advent of Medicaid the economic picture changed. Hospitals and doctors were
paid for services, which formerly were free or significantly
discounted.
Suddenly Corporate America saw possibilities for profit in the
healthcare market. Corporations were created which established for profit
hospitals throughout the country. Others providing ancillary products and
services were also created. Enter the stockholder.
Now, not only must the physician and
the hospital be paid for services, but also the patient must pay more to
benefit the stockholders. This is perhaps the largest defect in the healthcare
system.
The sick
are not consumers who chose a disease or injury that fits their budget. They
cannot save their money and choose a time or place to be ill which they have
anticipated in advance.
In short, a patient is a very different consumer than one
purchasing a car or refrigerator when they are financially able, and the time
is convenient.
As
important as free enterprise is, there may be no place for a non-provider who
benefits from another's misfortune.
As years have passed other events have exacerbated
our problems with cost control. The "sun setting" of the Certificate of Need
required of those wishing to build a hospital allowed an oversupply to result.
Many hospitals once 90-100% occupied suddenly were only half full or less.
Fixed costs remained the same and hospital bills increased rapidly. Hospitals
had to begin marketing to compete for the limited pool of patients in the
community, further increasing their costs.
The lack of requirement for the Certificate of Need
also allowed duplication in the area of technology and resulted in pressure on
investors to utilize certain services to excess.
Over utilization of technology and
laboratory services has been exacerbated by a legal system, which has caused
physicians to order unnecessary tests solely for defensive
purposes.
In the
70's, Nixon's brief imposition of wage and price controls, once lifted, caused
all services to be priced higher fearing a similar act in the
future.
Fee
profiling by payers eliminated ranges of fees for the same procedure or service
based on time spent or difficulty. All such procedures and services were priced
at the maximum level.
This upward spiral in cost set the stage for proposed
government plans for quasi-socialistic approaches to healthcare, and the advent
of the Managed Care concept.
Now physicians are struggling with decreasing
reimbursement, increasing costs, and administrative hassles to the point that
it is affecting patients.
Adding to these financial pressures are ever-increasing
liability insurance premiums.
Managed care has resulted in most physicians not having the
long-term relationships with patients and families, which result in comfort and
trust. Continuity of care is interrupted with the need to establish new
relationships every few years.
We also see over utilization of healthcare by patients. In
years past, with traditional health insurance, there were significant
deductibles, which applied to office visits as well as hospital services.
Patients were more responsible consumers of healthcare. They did not see
doctors for minor afflictions or injuries they could deal with
themselves.
Today
with small co-pays and small deductibles, the trend is not to hesitate to see a
physician even for minor problems. This creates an increased workload on
physicians and their staff with insufficient reimbursement to cover
administrative expenses.
Low deductibles also lead to overuse of emergency rooms as a
convenience rather than necessity further increasing the cost of
insurance.
Where
does this end? What can we look to, to predict the future of
medicine?
An
ominous example is the plight of our public school system.
We as Americans have enjoyed
prosperity and a level of healthcare as no other society in history. The
present generation has had access to the most advanced technology, abundant
services, and has enjoyed resources apparently without end.
In short, we have been privileged for
so long that the American public is hopelessly "spoiled".
This mind set has resulted in a degree
of short-sightedness or unwillingness on our part as a society to look
critically at the long-term effects of our actions. This is exemplified by the
national debt. A problem has to reach the magnitude of the oil embargo during
which Americans sat in long lines waiting for gasoline for their predominately
gas-guzzling automobiles.
This need for a full-blown crisis before we as a society
recognize and act on a major societal problem may well be our ultimate downfall
as a world economic power. The most glaring example of this phenomenon is the
state of our public school systems. Our public schools and institutions of
learning are without a doubt the very foundation of everything positive in our
society, and our young people are our lifeblood. Yet, it is obvious that for
the past several decades we have neglected this precious resource by allowing
our public school systems to be under funded, resulting in decreasing numbers
of gifted individuals willing to enter that most honorable of professions:
teaching. Our teachers traditionally have been unselfish individuals reaping
the intangible rewards of educating young people. However, the disparities of
teachers' salaries, their increasing financial burdens, administrative hassles,
and family obligations have diverted many of these special individuals from
careers in public schools.
Without a doubt, almost every problem with which this country
is struggling today is in some way related to the inadequacy of our educational
system, either in its ability to deliver a quality education or in its capacity
to mold the character of our young people as responsible
citizens.
What we
presently see in our public schools systems offers insight into what medicine
may become if we do not proceed with great care and foresight in our attempts
to improve the system. We must realize as we proceed, that it would take 15 to
20 years to rebuild our school systems, as they once were if we were to
adequately fund them tomorrow.
Let us look at medical care in the U.S. today. There is no
doubt it is the best in the world. It is expensive and not all have access to
the same quality of care for many different reasons. We must work to minimize
expense and increase accessibility, but we must not do this in such a way that
twenty years from now we have created another "public school"
system.
The
ultimate source of medical care is the physician. Traditionally, as was the
case with our teachers, those seeking a medical education are superior students
who want to serve mankind. The financial incentives associated with being a
physician can be found in many other professions, which individuals of this
caliber could pursue with equal success, as apparently have many of our
prospective teachers. Individuals of this type have brought the field of
medicine to where it is today, as our school systems once were - the best in
the world.
Physicians' rewards begin after one-third of their life is
over, usually in their 30s. The rewards are directly proportional to the amount
of work and effort they are willing to put forth.
In any profession, including medicine,
there will always be those entrepreneurs who make obscene amounts of money - an
inevitable by-product of the free enterprise system, which has made our country
great.
Whatever
plan is created for medicine; we must preserve the incentives to attract the
individuals who will maintain the quality of care we presently enjoy. We have
seen our school systems reach the point that the incredible reward of
influencing a young person's life in a positive way has been offset by our
apparent lack of appreciation for the role our teachers play in society.
Americans and our representatives in government have let our teachers and our
children down.
The
rewards of practicing medicine, tangible and intangible, can also be offset and
thus discourage those who would pursue medicine as a career. Offset by the
practices of managed care, which push physicians into assembly line mode to
survive on volume, rewards those willing to spend less time and money in the
care of the patient. Such practices offering no incentive to expend more than
minimal time and effort will rob patients of the caring physicians of the
past.
Who will
replace our physicians? There will always be a few of the gifted, but most
likely a second tier of individuals will come forth. They will not be "bad"
individuals, but they will be those who want primarily a 9 to 5 job. They will
be individuals who realize and accept that they must follow protocols and
guidelines rather than stand firm as an advocate for diagnostic tests or
treatment, which fall outside such guidelines. Each physician will take his
assigned time on-call or in the office, and at other times will be largely
unavailable. The dynamic, exciting and gratifying world of medicine as
physicians have known it will become dull and less attractive to those
selecting their life's work.
There are many areas where costs can be decreased
especially through tort reform and in the administrative and regulatory costs.
Hopefully the Human Genome Project will eliminate or control genetic diseases
such as diabetes, cystic fibrosis and some cancers. This could result in
significant positive economic impact. Healthcare should not serve as a full
employment scheme for administrators and bureaucrats who contribute nothing to
care of patients.
Whatever measures we pursue must be methodically projected into
the future. We must reflect on the changes that have brought us to this point
and remember the dismal plight of our public school system. We must avoid
drastic overreaction, which so often happens as these multifaceted problems are
politicized through our system of government.
In the end, we are all patients. Every
single member of our family at some time will be a patient. We must look
critically at our healthcare system - past, present, and future - with this in
mind.
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