29
A LABOR PERSPECTIVE* BERNARD GREENBERG Assistant Director
Insurance, Pensions, and Employment Benefits Department United Steel Workers American Federation of Labor and Congress of Industrial Organizations Pittsburgh, Pa.
f HE revolution in medical science that has taken place in my own lifetime Ihas changed irrevocably the manner in which medicine is practiced and the relation between doctors and patients-or, at least, the relation between doctors and patients of small or moderate-sized incomes. When I grew up, how medical care was furnished was a function of my family's poverty, the state of medical science, and, more than anything else, the still-remaining tradition that required the family doctor to serve his patients as if his calling usually provided as much or more solace than it provided diagnosis, treatment, or cure. The contrast in medicine between 50 years ago and today is the substitution, by and large, of a new relation between doctor and patient. Where previously most medicine was provided close to home in a warm, intimate relation between family and doctor, today's medicine typically is provided by efficient, business-like, and expensive specialists whose relation to the patient is episodic and distant. The last continuing revolution in medical science began about the time of World War I, and has been accompanied by a revolution in the division of medical labor. Regrettably, unlike the broad changes in the characteristics of manual labor which resulted from the industrial revolution, the division of medical labor has not reached all levels of medical work. For example, it has not yet occurred at a significant rate at the level of medical care which would permit the substitution of what might be called semiskilled specialist labor assisted by technology and supervised by fully skilled professionals for professional labor trained to perform the full scope of diagnosis and drug-
prescribing
care.
The industrial revolution brought forth factory facilities which specialized *Presented in a panel, What is Primary Care? as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Vol. 53, No. 1, January-February 1977
30
30
B. B. GREENBERG
GREENBERG~~~~~~~~~~~~~~~~~~~~~~~~
in the high-technology production of unique commodities and which utilized unskilled, semiskilled, and skilled labor. The medical revolution, so far, in the main has succeeded in creating mostly specialized, skilled professional labor. The ancient, guildlike character of the organization of the medical profession by and large has continued unchanged, and the method of remunerating doctors for professional services so far has been affected little by the greatly changed character of medical care and its delivery. Indeed, the method of remuneration for doctors associated with hospitals-to the distress of many, but to the joy of hospital-based physicians-has been converted to the ancient fee-for-service basis, although this was originally foreign to hospital-based doctors. It has been suggested that it is not possible to create a division of labor among medical-care practitioners because medical science is extraordinarily complex. It seems to me that this argument has no more validity in medicine than it has in the physical sciences. No doubt the engineers who design aeroplanes and automobiles deal with complex problems of stress and propulsion which few professionals in these fields are competent to deal with in their entirety alone. However, few automobiles and aeroplanes would be produced if for that reason we had not recognized the possibilities of producing these vehicles with persons of varying degrees of skill ranging from little or none to highly skilled. Medical care is now big business-in some places the community's biggest business-and, like all big businesses, inevitably has become part of the nation' s politics. Those who long for the days of absolutely free and untrammeled medicine are as unrealistic as businessmen who decry the government's role in the business economy. Just as such developing economic problems as inflation, unemployment, protection of the environment, low wages, research, and development are inevitable concerns of government, so must such medical problems as the cost and availability of medical care, the building, financing, and administration of hospitals, research centers, and medical-education institutions, and the protection of public health be among the natural and inevitable concerns of government. When governmental participation or intervention in the affairs of people is inevitable, serious divisions are bound to arise. The first division, naturally, must be between many of those who previously operated without restraint or direction and those who would now impose restraint and direction. The response to governmental intervention in the affairs of medicine has been mixed. Although a small percentage of doctors accepted as inevitable the Bull. N.Y. Acad. Med.
A LABOR PERSPECTIVE
A
LABOR
PERSPECTIVE
31
participation of government in new areas of medical care and participated in constructive ways to help build the new relations, a larger percentage, by far, strongly opposes any further governmental intervention in medical affairs. The first refuge of anyone who is about to be made subject to and answerable to a higher authority is to assert as forcefully as possible that we live in the best of all possible worlds. The second line of attack is to demand positive proof that the newly-proposed-and, therefore, untried-system must demonstrate in advance that it will be superior to the system it seeks to replace. Additional attacks often consist of attributing to the proponents of change all sorts of devilish motives, unreasoned and unachievable goals, and base intentions. Inevitably, the dispassionate observer (if there is one) and the ordinary citizen initially are confused and unsure of the facts and the proposed changes. In my opinion, the uncertainties will disappear as the debate presses forward. The reason is that the demand for governmental intervention in medical care does not arise from the perverse or self-serving motives of its advocates. The demand for governmental intervention is a consequence of the magnitude of the health-care industry and the demonstrable fact that, left to the winds of caprice, the system grows so costly and wasteful that it can no longer be supported by voluntary, haphazard payments. Moreover, the medical-care system is in deep trouble and heading for more because in large parts of the nation the provision of primary care is inadequate or absent. In the absence of other means of initial access to medical care, millions of Americans enter the medical-care system through the outpatient departments of hospitals. In many ways this is the equivalent of using a cannon to eliminate flies. Not only is it extraordinarily expensive, but it is also inefficient and ineffective, though it may give the appearance of meeting the problem. This practice illustrates two problems: 1) Unmet essential medical-care needs cannot be dammed up and avoided. If the need is not met by one means it will be met by another. 2) Although there can be little doubt that hospitals and hospital care were expanded enormously because most health-care insurance in the United States always has been weighted heavily in favor of hospital care, the great expansion of the use of hospital outpatient departments took place even though almost all hospitalization insurance covered only hospital outpatient care in emergency accidents. The popular level of discussion is revealed in a speech delivered in Philadelphia at the opening session of the College of Physicians by Dr. Vol. 53, No. 1, January-February 1977
32 32
B. GREENBERG B.
GREENBERG
Robert G. Petersdorf, its president. He was reported in The New York Times to have said as follows: Challenging the concept that every hamlet needs a doctor, Dr. Petersdorf said that little evidence exists "that health in rural communities is in any way related to the presence of the physician." He added that there was no evidence that death and sickness rates in South Dakota, with 75 physicians per 100,000 population, for example, were any worse than in Massachusetts, with 200 doctors per 100,000 population. Dr. Petersdorf is described as a leader in the American Medical Association and the head of the Department of Medicine of the University of Washington in Seattle. He is opposed to recent health-care legislation proposed by Senator Edward Kennedy. Senator Kennedy's proposal would require 35% of new medical students to promise to serve for a specified period after their graduation in an area that lacks doctors. Dr. Petersdorf says that the senator's proposed legislation is misdirected. He is quoted as saying that correcting a number of other societal problems, "among them poverty, crime, alcoholism and drug abuse-would more effectively alleviate the geographic maldistribution of doctors than would the manpower bill." Having established that he is no foe of legislative action, Dr. Petersdorf then goes on to propose a specific remedy for the redistribution of medical specialists. The Times report continues: Dr. Petersdorf, who emphasized that he was speaking as a private citizen, said that if Congress wanted to change the specialty distribution of doctors, it would provide the proper incentives by bringing into appropriate balance the fees paid for a thorough history and physical examination, clinic and office visits and carefully personalized care, instead of emphasizing higher fees for laboratory and other tests of marginal value. Thus Dr. Petersdorf has attempted the type of feat that many another statesman before him has attempted, only to fail as miserably. It is simply not possible to mount a horse and drive it off in three different directions simultaneously. It cannot be argued 1) that there is no problem, 2) that the problem can be solved by abolishing mankind's frailties, 3) that Congress must endorse the presently prevalent mode of medical-care delivery by rewarding it more generously. On the day after the Times reported Dr. Petersdorf's criticism of Senator Bull. N.Y. Acad. Med.
A LABOR PERSPECTIVE
A
LABOR
33
33
Kennedy's proposed legislation, an interesting letter appeared that challenges the notions of those who could direct affairs exclusively by financial incentives. It was written by Boris Pregel, a former president of the New York Academy of Sciences. The subject of the letter is not germane to our discussion, but one observation is: If energy is central to the security of the nation, then consideration of its policy priorities must go beyond our conventional dependence on the market mechanism and traditional economic forces. Energy security in terms of fuel supply, research and development and future planning must be given parity with other measures, both fiscal and political, which are seen to be essential to the security of the nation. Mr. Pregel's concern is that the market mechanism will result in not enough of America's resources being devoted to energy security. He says, "just as we do not balk at defense allocations of upwards of 100 billion dollars as an essential charge on the national budget, so should we be prepared to make comparable allocations to securing adequate energy." He concludes that "conventional economic pricing is, therefore, no real guide to the questions of energy and security." If we substitute the terms "health" for "energy" and "doctors and medical facilities" for "fuels" we have the essence of the current struggle between those who believe the United States is served inadequately by its present medical system and those who intend to use every means possible to thwart any fundamental change in the way medical care is delivered and paid for. Those of us who believe that the market mechanism neither organizes or delivers medical care adequately argue that an adequate primary-care system cannot be achieved without 1) authority to plan and to execute plans and 2) a change in the present system of financing and paying for medical care. Obviously, only the briefest sketch of these two requirements is possible in this essay. First, an adequate, efficient, and uniform system of initial entry into the medical-care system should be understood as easily and universally as our school system with its progressions of grade school, middle schools, academic or technical high schools, and college. Even though it was never announced that the hospital emergency room offered an appropriate initial access to the medical-care system, the spontaneous discovery of this entry and its extraordinary, widespread acceptance demonstrates how swiftly the levels of medical organization can be universally accepted. A new, rational system of delivering medical care should not be fettered by Vol. 53, No. 1, January-February 1977
34
34
B. GREENBERG
prejudice or by conventional thought which is based on past or present practices. The plan for an initial-entry and primary-care system must take into account the site where illness or accident strikes: home, work, or school, and urban or rural settings. The plan must recognize the need for new forms of facilities and for new kinds of professionals, paraprofessionals, and technicians. New kinds of personnel and skills require new types of education and training and new forms of organization. When I say that a new system should not be confined by present practices, I do not rule out a return to lost but valuable practices such as the reintroduction of home care-so long as home care is provided under optimum circumstances, including the use of known but now almost nonexistent home health-care disciplines. As to financing and the method of payment, we are all aware that the cost of services and the total allocation of resources to medical and health care have been multiplying. Much of this increase is attributable to the higher costs of supplies and wages, salaries, and fees caused by the inflation which presently affects the entire economy. Part of the increase is due to the costs of new procedures, new technology, and new means for fighting disease and disability. But some part of the increase undoubtedly is attributable to the inappropriate use of high-cost facilities and personnel, to unnecessary utilization of expensive procedures and facilities, and even to the increased costs of malpractice insurance-which includes both the direct costs of insurance and the indirect costs of additional procedures used in practicing defensive medicine. Most, if not all, labor unions presently have some form of health insurance included in their collective bargaining agreements, yet these same unions almost unanimously advocate federal health security. The reason for this advocacy lies not in the absence of coverage but in the recognition that the present system is simply an inflation-generating machine whose throttle has become stuck in the wide-open position. To be without insurance coverage today means instant medical pauperism. Millions of the unemployed and of other groups in our society are in this position. Private insurance and private payments can never generate nor support planning or create a system of controls and accountability. These are only possible through law and government. Finally, our present systems of remuneration for doctors may be appropriate as the exclusive method of payment for a system of medicine that is based on need and rational planning. Home care by physicians disappeared when its fee-for- service cost reached prohibitive levels. If such care is an essential part Bull. N.Y. Acad. Med.
AA LABOR PERSPECTIVE LABOR PERSPECTIVE
35 35~~~~~~~~
of a rational health-delivery system, to have it return we must recognize that practitioners never will be attracted to it unless they are remunerated properly. Home care can never be expected to return if the remuneration of home-care physicians is to be based on a fee-for-service system which is paid by the patient out of pocket or by a private insurance plan. Similarly, such other aspects of medical care as industrial medicine, school medicine, and emergency care-by their nature consisting of only intermittent, normally low-volume care-can only be provided adequately by doctors who are remunerated on other than a fee-for-service basis such as salary, per diem, or per capita. Payment practices for professional medical service should be suitable in method as well as in amount in accordance with each professional's functions. The medieval fee-for-service system of payment may continue to be appropriate for the remuneration of such services as those provided by barbers. Today, however, it may be as inappropriate for most medical services as it is for the payment of such other public services as fire, police protection, and education. After all, is it not a basic premise of fee-for-service payment that he who lacks the fee is not entitled to the service? Is this not an anomaly where medical care is accepted as a universal human right?
CONCLUSION The pressures for the reform of the system of medical-care delivery will not go away by being disregarded or attacked. The pressures for change come from millions of people who feel unmet needs, are deprived, or are outraged by what they consider unreasonable costs. As we anticipate that an unemployed person will resent his inability to provide his family with what he perceives to be the requirements of the American standard of living, so we should anticipate that many people resent their inability to participate in what they perceive as the standard of medical care that the United States is capable of providing. The stakes in this confused situation are high. It is not so much a matter of whether the reformers or those who wish to stand pat will win. The widespread mood of dissatisfaction will compel a decision; that cannot be prevented by rhetoric. What is more important is the shape that the newly emerging system will assume. Our experience with Medicaid and Medicare clearly indicates that while change is inevitable, its form is not. The choice lies between a reformed system which boldly recognizes and modifies the deficiencies of the present system or a system which is a papered-over Vol. 53, No. 1, January-February 1977
36
36
B. GREENBERG
affirmation of the status quo. Should the current struggle in Congress merely result in the enactment of something like the anemic and dehydrated "catastrophic" insurance bill advocated by the present administration, the struggle may be temporarily diverted, but it certainly will be revived in more radical form as problems of medical care become more serious and more difficult to resolve with the passage of time.
Bull. N.Y. Acad. Med.
A LABOR PERSPECTIVE* BERNARD GREENBERG Assistant Director
Insurance, Pensions, and Employment Benefits Department United Steel Workers American Federation of Labor and Congress of Industrial Organizations Pittsburgh, Pa.
f HE revolution in medical science that has taken place in my own lifetime Ihas changed irrevocably the manner in which medicine is practiced and the relation between doctors and patients-or, at least, the relation between doctors and patients of small or moderate-sized incomes. When I grew up, how medical care was furnished was a function of my family's poverty, the state of medical science, and, more than anything else, the still-remaining tradition that required the family doctor to serve his patients as if his calling usually provided as much or more solace than it provided diagnosis, treatment, or cure. The contrast in medicine between 50 years ago and today is the substitution, by and large, of a new relation between doctor and patient. Where previously most medicine was provided close to home in a warm, intimate relation between family and doctor, today's medicine typically is provided by efficient, business-like, and expensive specialists whose relation to the patient is episodic and distant. The last continuing revolution in medical science began about the time of World War I, and has been accompanied by a revolution in the division of medical labor. Regrettably, unlike the broad changes in the characteristics of manual labor which resulted from the industrial revolution, the division of medical labor has not reached all levels of medical work. For example, it has not yet occurred at a significant rate at the level of medical care which would permit the substitution of what might be called semiskilled specialist labor assisted by technology and supervised by fully skilled professionals for professional labor trained to perform the full scope of diagnosis and drug-
prescribing
care.
The industrial revolution brought forth factory facilities which specialized *Presented in a panel, What is Primary Care? as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Vol. 53, No. 1, January-February 1977
30
30
B. B. GREENBERG
GREENBERG~~~~~~~~~~~~~~~~~~~~~~~~
in the high-technology production of unique commodities and which utilized unskilled, semiskilled, and skilled labor. The medical revolution, so far, in the main has succeeded in creating mostly specialized, skilled professional labor. The ancient, guildlike character of the organization of the medical profession by and large has continued unchanged, and the method of remunerating doctors for professional services so far has been affected little by the greatly changed character of medical care and its delivery. Indeed, the method of remuneration for doctors associated with hospitals-to the distress of many, but to the joy of hospital-based physicians-has been converted to the ancient fee-for-service basis, although this was originally foreign to hospital-based doctors. It has been suggested that it is not possible to create a division of labor among medical-care practitioners because medical science is extraordinarily complex. It seems to me that this argument has no more validity in medicine than it has in the physical sciences. No doubt the engineers who design aeroplanes and automobiles deal with complex problems of stress and propulsion which few professionals in these fields are competent to deal with in their entirety alone. However, few automobiles and aeroplanes would be produced if for that reason we had not recognized the possibilities of producing these vehicles with persons of varying degrees of skill ranging from little or none to highly skilled. Medical care is now big business-in some places the community's biggest business-and, like all big businesses, inevitably has become part of the nation' s politics. Those who long for the days of absolutely free and untrammeled medicine are as unrealistic as businessmen who decry the government's role in the business economy. Just as such developing economic problems as inflation, unemployment, protection of the environment, low wages, research, and development are inevitable concerns of government, so must such medical problems as the cost and availability of medical care, the building, financing, and administration of hospitals, research centers, and medical-education institutions, and the protection of public health be among the natural and inevitable concerns of government. When governmental participation or intervention in the affairs of people is inevitable, serious divisions are bound to arise. The first division, naturally, must be between many of those who previously operated without restraint or direction and those who would now impose restraint and direction. The response to governmental intervention in the affairs of medicine has been mixed. Although a small percentage of doctors accepted as inevitable the Bull. N.Y. Acad. Med.
A LABOR PERSPECTIVE
A
LABOR
PERSPECTIVE
31
participation of government in new areas of medical care and participated in constructive ways to help build the new relations, a larger percentage, by far, strongly opposes any further governmental intervention in medical affairs. The first refuge of anyone who is about to be made subject to and answerable to a higher authority is to assert as forcefully as possible that we live in the best of all possible worlds. The second line of attack is to demand positive proof that the newly-proposed-and, therefore, untried-system must demonstrate in advance that it will be superior to the system it seeks to replace. Additional attacks often consist of attributing to the proponents of change all sorts of devilish motives, unreasoned and unachievable goals, and base intentions. Inevitably, the dispassionate observer (if there is one) and the ordinary citizen initially are confused and unsure of the facts and the proposed changes. In my opinion, the uncertainties will disappear as the debate presses forward. The reason is that the demand for governmental intervention in medical care does not arise from the perverse or self-serving motives of its advocates. The demand for governmental intervention is a consequence of the magnitude of the health-care industry and the demonstrable fact that, left to the winds of caprice, the system grows so costly and wasteful that it can no longer be supported by voluntary, haphazard payments. Moreover, the medical-care system is in deep trouble and heading for more because in large parts of the nation the provision of primary care is inadequate or absent. In the absence of other means of initial access to medical care, millions of Americans enter the medical-care system through the outpatient departments of hospitals. In many ways this is the equivalent of using a cannon to eliminate flies. Not only is it extraordinarily expensive, but it is also inefficient and ineffective, though it may give the appearance of meeting the problem. This practice illustrates two problems: 1) Unmet essential medical-care needs cannot be dammed up and avoided. If the need is not met by one means it will be met by another. 2) Although there can be little doubt that hospitals and hospital care were expanded enormously because most health-care insurance in the United States always has been weighted heavily in favor of hospital care, the great expansion of the use of hospital outpatient departments took place even though almost all hospitalization insurance covered only hospital outpatient care in emergency accidents. The popular level of discussion is revealed in a speech delivered in Philadelphia at the opening session of the College of Physicians by Dr. Vol. 53, No. 1, January-February 1977
32 32
B. GREENBERG B.
GREENBERG
Robert G. Petersdorf, its president. He was reported in The New York Times to have said as follows: Challenging the concept that every hamlet needs a doctor, Dr. Petersdorf said that little evidence exists "that health in rural communities is in any way related to the presence of the physician." He added that there was no evidence that death and sickness rates in South Dakota, with 75 physicians per 100,000 population, for example, were any worse than in Massachusetts, with 200 doctors per 100,000 population. Dr. Petersdorf is described as a leader in the American Medical Association and the head of the Department of Medicine of the University of Washington in Seattle. He is opposed to recent health-care legislation proposed by Senator Edward Kennedy. Senator Kennedy's proposal would require 35% of new medical students to promise to serve for a specified period after their graduation in an area that lacks doctors. Dr. Petersdorf says that the senator's proposed legislation is misdirected. He is quoted as saying that correcting a number of other societal problems, "among them poverty, crime, alcoholism and drug abuse-would more effectively alleviate the geographic maldistribution of doctors than would the manpower bill." Having established that he is no foe of legislative action, Dr. Petersdorf then goes on to propose a specific remedy for the redistribution of medical specialists. The Times report continues: Dr. Petersdorf, who emphasized that he was speaking as a private citizen, said that if Congress wanted to change the specialty distribution of doctors, it would provide the proper incentives by bringing into appropriate balance the fees paid for a thorough history and physical examination, clinic and office visits and carefully personalized care, instead of emphasizing higher fees for laboratory and other tests of marginal value. Thus Dr. Petersdorf has attempted the type of feat that many another statesman before him has attempted, only to fail as miserably. It is simply not possible to mount a horse and drive it off in three different directions simultaneously. It cannot be argued 1) that there is no problem, 2) that the problem can be solved by abolishing mankind's frailties, 3) that Congress must endorse the presently prevalent mode of medical-care delivery by rewarding it more generously. On the day after the Times reported Dr. Petersdorf's criticism of Senator Bull. N.Y. Acad. Med.
A LABOR PERSPECTIVE
A
LABOR
33
33
Kennedy's proposed legislation, an interesting letter appeared that challenges the notions of those who could direct affairs exclusively by financial incentives. It was written by Boris Pregel, a former president of the New York Academy of Sciences. The subject of the letter is not germane to our discussion, but one observation is: If energy is central to the security of the nation, then consideration of its policy priorities must go beyond our conventional dependence on the market mechanism and traditional economic forces. Energy security in terms of fuel supply, research and development and future planning must be given parity with other measures, both fiscal and political, which are seen to be essential to the security of the nation. Mr. Pregel's concern is that the market mechanism will result in not enough of America's resources being devoted to energy security. He says, "just as we do not balk at defense allocations of upwards of 100 billion dollars as an essential charge on the national budget, so should we be prepared to make comparable allocations to securing adequate energy." He concludes that "conventional economic pricing is, therefore, no real guide to the questions of energy and security." If we substitute the terms "health" for "energy" and "doctors and medical facilities" for "fuels" we have the essence of the current struggle between those who believe the United States is served inadequately by its present medical system and those who intend to use every means possible to thwart any fundamental change in the way medical care is delivered and paid for. Those of us who believe that the market mechanism neither organizes or delivers medical care adequately argue that an adequate primary-care system cannot be achieved without 1) authority to plan and to execute plans and 2) a change in the present system of financing and paying for medical care. Obviously, only the briefest sketch of these two requirements is possible in this essay. First, an adequate, efficient, and uniform system of initial entry into the medical-care system should be understood as easily and universally as our school system with its progressions of grade school, middle schools, academic or technical high schools, and college. Even though it was never announced that the hospital emergency room offered an appropriate initial access to the medical-care system, the spontaneous discovery of this entry and its extraordinary, widespread acceptance demonstrates how swiftly the levels of medical organization can be universally accepted. A new, rational system of delivering medical care should not be fettered by Vol. 53, No. 1, January-February 1977
34
34
B. GREENBERG
prejudice or by conventional thought which is based on past or present practices. The plan for an initial-entry and primary-care system must take into account the site where illness or accident strikes: home, work, or school, and urban or rural settings. The plan must recognize the need for new forms of facilities and for new kinds of professionals, paraprofessionals, and technicians. New kinds of personnel and skills require new types of education and training and new forms of organization. When I say that a new system should not be confined by present practices, I do not rule out a return to lost but valuable practices such as the reintroduction of home care-so long as home care is provided under optimum circumstances, including the use of known but now almost nonexistent home health-care disciplines. As to financing and the method of payment, we are all aware that the cost of services and the total allocation of resources to medical and health care have been multiplying. Much of this increase is attributable to the higher costs of supplies and wages, salaries, and fees caused by the inflation which presently affects the entire economy. Part of the increase is due to the costs of new procedures, new technology, and new means for fighting disease and disability. But some part of the increase undoubtedly is attributable to the inappropriate use of high-cost facilities and personnel, to unnecessary utilization of expensive procedures and facilities, and even to the increased costs of malpractice insurance-which includes both the direct costs of insurance and the indirect costs of additional procedures used in practicing defensive medicine. Most, if not all, labor unions presently have some form of health insurance included in their collective bargaining agreements, yet these same unions almost unanimously advocate federal health security. The reason for this advocacy lies not in the absence of coverage but in the recognition that the present system is simply an inflation-generating machine whose throttle has become stuck in the wide-open position. To be without insurance coverage today means instant medical pauperism. Millions of the unemployed and of other groups in our society are in this position. Private insurance and private payments can never generate nor support planning or create a system of controls and accountability. These are only possible through law and government. Finally, our present systems of remuneration for doctors may be appropriate as the exclusive method of payment for a system of medicine that is based on need and rational planning. Home care by physicians disappeared when its fee-for- service cost reached prohibitive levels. If such care is an essential part Bull. N.Y. Acad. Med.
AA LABOR PERSPECTIVE LABOR PERSPECTIVE
35 35~~~~~~~~
of a rational health-delivery system, to have it return we must recognize that practitioners never will be attracted to it unless they are remunerated properly. Home care can never be expected to return if the remuneration of home-care physicians is to be based on a fee-for-service system which is paid by the patient out of pocket or by a private insurance plan. Similarly, such other aspects of medical care as industrial medicine, school medicine, and emergency care-by their nature consisting of only intermittent, normally low-volume care-can only be provided adequately by doctors who are remunerated on other than a fee-for-service basis such as salary, per diem, or per capita. Payment practices for professional medical service should be suitable in method as well as in amount in accordance with each professional's functions. The medieval fee-for-service system of payment may continue to be appropriate for the remuneration of such services as those provided by barbers. Today, however, it may be as inappropriate for most medical services as it is for the payment of such other public services as fire, police protection, and education. After all, is it not a basic premise of fee-for-service payment that he who lacks the fee is not entitled to the service? Is this not an anomaly where medical care is accepted as a universal human right?
CONCLUSION The pressures for the reform of the system of medical-care delivery will not go away by being disregarded or attacked. The pressures for change come from millions of people who feel unmet needs, are deprived, or are outraged by what they consider unreasonable costs. As we anticipate that an unemployed person will resent his inability to provide his family with what he perceives to be the requirements of the American standard of living, so we should anticipate that many people resent their inability to participate in what they perceive as the standard of medical care that the United States is capable of providing. The stakes in this confused situation are high. It is not so much a matter of whether the reformers or those who wish to stand pat will win. The widespread mood of dissatisfaction will compel a decision; that cannot be prevented by rhetoric. What is more important is the shape that the newly emerging system will assume. Our experience with Medicaid and Medicare clearly indicates that while change is inevitable, its form is not. The choice lies between a reformed system which boldly recognizes and modifies the deficiencies of the present system or a system which is a papered-over Vol. 53, No. 1, January-February 1977
36
36
B. GREENBERG
affirmation of the status quo. Should the current struggle in Congress merely result in the enactment of something like the anemic and dehydrated "catastrophic" insurance bill advocated by the present administration, the struggle may be temporarily diverted, but it certainly will be revived in more radical form as problems of medical care become more serious and more difficult to resolve with the passage of time.
Bull. N.Y. Acad. Med.
