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A Search for Wisdom

Occasional Paper #7

February 1994



The deterioration and destruction of the best system of medical care in the world is the current medical crisis in the United States. True, medical care in the U.S. is not perfect. But then nothing is perfect.

The deterioration has been simply the result of third party payment and control of medical services. Ultimate destruction will come with a progressive loss of trust between patients and physicians.

As my professor of psychiatry said, medical care is built upon a system of trust between the patient and the physician. Where else would you bare your soul and everything else to a stranger? This basic relation of trust has been the foundation of medicine for thousands of years. Over those thousands of years the science of medicine has given the physician new tools. His pharmacopia has been expanded. But still the most powerful tool of medical care is the humanistic art of dealings between the physician and the patient.

The most important tool the physician has is the art of elliciting the pertinent medical history from the patient. The classical story of the patient who comes in with an ingrown toe nail and ends up in surgery with a bleeding gastric ulcer is an example of the application of the art of medicine. There is no doubt something is wrong which prompts the patient to come to the doctor but it is not always the immediate chief complaint.

The patient who goes to the doctor with the chief complaint that he is sick and refuses to elaborate, makes the doctor's job much more difficult. A physical examination and a panel of laboratory tests may reveal the problem, but again, it may not.

The relation between the patient and the physician is one of trust. This trust is a two way street. The patient trusts the physician to apply his best wisdom to address the problem at hand. The physician trusts the patient to accept the physician's wisdom as his best effort with confidence that he will seek further consultation for those problems beyond his skills and training. Associated with this relation of trust has been a system of fee for service. This economic relation is the same as exists between the home owner and the plumber.

To make this point more graphically, suppose that you could go to the grocery store and select all and everything you might want, the grocer could charge anything he wanted and someone else would pay for it. Reflecting on this a little in the field of medical services will illustrate why medical care services in the US are in a state of crisis.

For many years all patients were taken care of by the doctor. When there was a problem with the payment, the doctor usually provided the service with out charge. For many years the county hospital provided services for the indigent. This meant that everyone had access to a minimum level of medical care. That minimal level of medical care may not provide the ultimate in medical care such as renal dialysis or organ transplant surgery. But common medical problems were addressed. This was the state of medical care 50 years ago. Then a number of things happened.

One of the first was an explosion in the cost of many life saving treatments available. This began immediately after the second world war. The National Institutes of Health and many other organizations began a system of grant supported health research. For many years the total amount for medical research compounded at a rate of 20% and more. No other part of our social system ever grew at that compounded rate for decades at a time. This distorted the allocation of our social resources.

The result of this distorted rate of growth of medical research, increased the tools available for patient care. The new tools were expensive. Renal dialysis techniques have not only treated the problems of acute renal failure, but can now provide many years of additional life for those with chronic renal failure, at a cost of as much as $50,000 per year per patient. That cost is more than most patients could afford on their own, so a social system of providing that cost for patients through a government program from tax dollars was started. This is but one of many tools now available for patient care.

In this country, the tools available have become greater than in any other country in the world. As a result, patients from the rest of the world who could profit from our new medical tools and could afford the costs would come to this country for their care. True they have had to pay their full cost, but never enough to cover those who could not afford to pay too.

As a matter of fact, the cost of many of the tools developed by medical research is more than an individual can afford to pay. A system of medical insurance was developed. Like other types of insurance, the premiums were at first based upon the statistical risk before the fact. Fire insurance is hard to buy after your house has burned. But to deny a person medical care after he has the condition seems to be inhumane. After all it is a human life and the tools to treat the condition are available. So various schemes of medical insurance have been developed to pay the medical fees for those who are poor risks or already requiring the medical care.

Other countries have addressed the problem with various national medical health care plans. They all work, but still foreigners come to the US for medical care not available at home. One example is the Canadian stevador who developed a hernia. He was put on an 18 to 24 month waiting list for local treatment. Without treatment he was unable to perform in his occupation. He would have had to be unemployed for that time of waiting. With a fee for service in this country, he had his hernia repaired in a short time and was back at work. This is only one example of many we have heard about.

An evaluation of the many foreign national medical care programs suggests that they all provide a level of medical care available in this country to all through the system of county hospital and the many physician providing care to the poor. Only in the US has the level of medical care beyond this basic level become available to some -- those who could afford the additional fees.

The governmental mandate that insurance for all conditions be provided to all without consideration of risk has been a driving force in the increasing cost of medical insurance. This has been done as the only humane way to provide the more expensive tools of medical care.

Another factor has led to a major increase in the cost of medical care. There has been a progressive break down in the trust relationship between the patient and the physician. The physician has had many years of training, which itself is expensive, and usually a number of years of experience. Especially with specialization, the contact between the patient and his highly specialized physician is minimal. Little opportunity to develop that feeling of trust is available.

As in any profession, some members are more capable than other and some are even incompetent. Lacking trust in our litigious society, the lawyers have gotten into the act with malpractice suits. Now the physician is not only burdened with high and increasing rates of malpractice insurance but is forced to consider the medical care he provides in a defensive way. He must cover himself by using all possible tests and examinations just because he knows he may not be correct and could be brought into court to defend himself. He just does not trust the patient to accept his best efforts. The limits of negligence have been extended.

Few doctors can afford private practice. The cost of necessary insurance protection must be added to his fees. The collecting of his fee for service through third party payment has increased the paper work required. Furthermore, the third party making the payments may decide what an appropriate fee for a given service might be. Too often a representative of the third party carrier is actually in the practice of medicine making important medical decisions without medical training.

We have not yet touched upon the drug companies. Developing new drug treatments is expensive business. The necessary research requires funding. Not all new drugs work. New laboratory tools and the extensive animal experimentation necessary are expensive. It is better that the drugs are developed on animals rather than humans in the first place. Once an effective drug is identified, the costs of bringing that drug to market have just begun. The number of years of reports and testing required by the Federal Drug Administration is extensive. It has been said that it takes ten years for a new drug in the laboratory to get to the market. In addition the costs of trying to develop a drug that does not make it to market must be added to the expenses of the drug companies.

Some drugs, once approved are easy and inexpensive to manufacture while others are difficult and expensive to manufacture. The costs of the false starts and the extensive FDA requirements must be recovered from the fee for those drugs which do get to market.

The government is supporting a major effort of billions of dollars to define the human geneome. The techniques of genetic manipulations including hybridization are contributing to the tools becoming available to medical practitioners. These developments are expensive. A number of startup companies are working to identify and bring these tools to market. Some of these companies have already fallen by the wayside and other are looking to their first returns from products in a time span of years. The cost of existing and doing their work for years must be added into the cost of the final product.

With this overview of what has been leading to the current deterioration of medical care in the U.S., the immediate crisis is the threatened distruction of our current quality of medical care. Future developments will be restricted. Those capable of earning higher wages will turn to other professions.

In the name of humane values, the politicians have promoted the concept that the costs of modern medical care leaves too many people who can not afford it. How could one deny a patient renal dialysis?

It has been estimated that medical services now consume one seventh of our GDP. If everyone were entitled to the latest and greatest from the existing medical tools, that amount would be substantially more. The argument is made that the country is rich enough that no one should be denied access to the latest tools regardless of cost.

There are many things which would be nice like two cars in every garage (if you remember that far back.) Most people can think of other things that they might like. Things that would be nice. But some things most of us just can not afford. Some things we must just do without.

On the wave of this emotional appeal of the politicians to provide everyone everything they need, there are at present many variations on the plans to provide medical care to all. If the payment of the bill is to be passed on to the goose that lays the golden egg, we will destroy our high level of patient care. Not only will the bill be an overwhelming burden on our society, but everything the government tries to manage, it makes a mess of.

In an effort to curtail costs, many limitations on the availability of medical care will have to be imposed. There will be some scheme of rationing. Those over 65 will not be eligible for some services at all. Others will have to wait months or years before they come to the top of the waiting lists. A look at other countries with national health insurance will illustrate the types of limitations which could be imposed. Some countries with national health plans are now finding that they will have to further limit the benefits they provide. In some places, the best of medical care is not available at any price and private treatment is not allowed.

Given that something needs to be done about the deterioration and destruction of medical care in the US, what might be accomplished without further deterioration and ultimate destruction of the best medical available in the world?

The most important step is to focus on the basic role of trust between the patient and the physician. The patient needs to assume an active role in his health care. Through education and experience we know that regular healthful meals and regular sleep will do more for our general health than anything else. A second factor which will improve our general health is learning to control and live with the stresses and strains in daily life. Finally, and perhaps the most important therapy for a good life and many if not most medical condition is to be sure to have at least one good belly laugh every day.

The patient should find a doctor he trusts. There must also be a significant problem before consulting the doctor.

Medicare and deductible insurance premiums as part of wage benefits distort the patients ability to make intelligent decisions. This came about because of government controls. At a time when wage ceilings were in effect, employers competing for employees needed to find other ways of paying a better wage. Thus came into creation a variety of employee benefits not subject to personal income tax. One way to increase the tax coffers would be to make all employee benefits taxable. Perhaps the employee benefits should be paid directly to the employee and he be allowed to allocate the fruits of his labors as he sees fit. If he wants insurance let him buy it. Group rates for insurance not actuarily sound, are just a way of distorting the meaning of insurance.

With the employee receiving the health benefits directly, he will have the funds to contract with the physician as he contracts with his plumber. In all of history there has been a safety net through the county hospitals or their equivalent. The patient can decide when he really needs to go to the doctor and decide which doctor he can best trust.

The doctor must be free to select his patients. Presumably he will select patients that he trusts. He will build a relationship of trust by providing care to the best of his ability. With mutual trust, the threat of the lawyer hanging over every transaction will be reduced. The patient and the doctor must share in the responsibility for the best choice of treatment. There are some doctors who are reluctant to do this, but most competent physicians are not only willing to share that responsibility but are anxious to do it. When the responsibility is shared, the problems of estimating the patient's compliance with any course of therapy will be easier.

A patient who wants to share his medical risks through insurance must be willing to pay a premium according to risk. It might be worth remembering the problem stories from people with fire insurance. The patient must read and understand the fine print in the insurance policy. Not all insurance companies are equal. If the patient prefers the use of an HMO to dealing with a personal physician of his choice, that is an option open to him. This country has developed because we have a society freer than any known before. By working toward a free society in medical care we will be able to continue to grow. The concept of managed competition in the name of a free society is a contradiction in terms.

Unfortunately, the medical crisis in the U.S. is not the only crisis facing the American people. But it does involve a major portion of our GDP. It probably follows only food and shelter. Think again about what would happen if a third party were to pay your grocery bill.

Trust between the patient and the physician is a personal matter and is at the root of all medical care.

Glen B. Haydon, M.D.
Route 2, Box 429
La Honda, CA 94020
HINDSIGHT is decicated to examining the past in a search for wisdom coping present. After all, hindsight is always 20/20. Extrapolations into the future are left to the reader.