Medicine in the Nineties Expectations, Priorities, and Realities John
L. Glover, MD
medicine the nineties, the is good and bad. The good is that the financing of medical For issue. has that become in
news
care
news
finally
a
recognized political
Sadly,
is also the bad news; and it is very bad. I use the word "recognized" deliberately because political analysts have only recently decided that it is an issue of sufficient strength to merit inclusion in political campaigns. It has obviously been a political issue since the passage of two important legislative acts: (1) the 1965 law that created Medicare, and (2) the 1963 law that provided federal funds to double the number of medical school graduates and increase the number of schools by 50%. Physicians enjoyed the benefits of this legislation almost as much as those whom it was intended to help. In fact, we used the Medicare legislation to accelerate progress on social and technological fronts: access to care and the implementation of new devices and procedures. On the social front, we had seminars about providing "one class care"—the best. And we advocated the right of all our citizens to the best health care available without regard to cost. On the technology front, we developed coronary artery surgery some¬ that could be done safely in community thing never considered when Medicare was created. We developed CT scanners that revolutionized the diagnosis and treatment of craniocerebral trauma. For a cancer that affects nearly 10% of American women, we developed systems for imaging it before it is palpable. Heart and liver transplantation became the treatments of choice for cer¬ tain conditions. It was a golden age for medicine. It was as though we were plowing a smooth new path with power to overcome the roughest and rockiest terrain. But in 1982, we lost power to one set of wheels. Congress, sensing that medical care was consuming about 10% of our gross national product and that taxes were paying 40% of that, made the arbitrary decision to place a limit on the amount it would pay for federal pro¬ grams by passing the Tax Equity and Fiscal Responsibil¬ ity Act of 1982. It was a major effort to insinuate expecta¬ tions and priorities into decisions about financing medical care. Until that time, the government had acted chiefly as a financing agent, attempting to exercise little control. "Expectation" is the act of expecting, and expecting means "to look forward to, to regard as likely to happen." It implies that one confidently believes, and usually for good reasons, that an event will occur. The government's
hospitals,
Accepted
publication January 25, 1992. Department of Surgery, William for
Beaumont Hospital, Mich. Presented as the Presidential Address at the 99th Scientific Session of the Western Surgical Association, Colorado Springs, Colo, November 18, 1991. Reprint requests to Surgical Services, William Beaumont Hospital, 3601 W Thirteen Mile Rd, Royal Oak, Ml 48073 (Dr Glover).
From the
Royal Oak,
John
L.
Clover,
MD
expectation was that costs could be reduced by legislative fiat.
"Priority" is the right to take precedence in obtaining supplies, services, or facilities, especially during a short¬ age. In this case, the shortage was money; everyone was in favor of reducing taxes, not raising them. The priority was reduction of medical costs, but no one was willing to say directly that those reductions should take precedence over
provision
never
of service. The
priority, therefore,
was
clearly established; and consequently, the expecta¬
tion was not fulfilled. Instead of a reduction in costs,
we had an increase. Medical costs, which were $248 billion in 1980 rose to $458 billion in 1986, and $523 billion in 1988. Medical inflation continues to rise faster than the consumer price index; and the government, still harboring its expectation to control costs, has brought its priority into sharper focus. It is now willing to say that limiting costs takes precedence over paying doctors and hospitals. The old system of costs and
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/09/2015
charges
was
scrapped,
and
hospitals began
to receive
payment on the basis of diagnosis only. More recently, government decided to pay physicians on the basis of a
resource-based relative value scale. To underscore their conviction, they even proposed a reduction in fees based on the presumption that physicians would make up for decreases in their income by performing more proce¬ dures. There could be no clearer sign that cost now has
priority over service. In this regard, a list of the health care priorities of the majority of our present government officials would in¬ clude (1) a limitation on expenditures and (2) provision of access to care for all patients who need it, but (3) not changing things very drastically. The latter has its roots both in people's general resistance to drastic change un¬ less they are in dire straits, and in the principle that rad¬ ical change is better suited to revolutions than elections. I do not think evidence supports the notion that patients in the United States have deficient medical care, and the rise of conservatism tempers calls for nationalizing any
system.
As the
government
has
strengthened
its
priorities,
however, business has become its welcome ally. The au¬ tomakers, for example, complain that health care costs are a major factor in keeping profits down; even Lee Iacocca,
champion of capitalism, has called for consideration of national health insurance (Detroit Free Press. April 17, 1989). A list of the health care priorities of industryincluding private insurers—might be: (1) to limit expen¬ ditures, but (2) to have medical care that keeps employ¬ ees healthy and satisfied. As a result of these priorities, we have seen the devel¬ opment of a coalition of government and industry which has brought about the most drastic changes in medicine since the widespread availability of health insurance. In addition to paying hospitals by diagnosis and setting up what amounts to a national fee schedule for physicians, there is discount pricing, bidding for services, require¬ ments to obtain "preauthorization" to admit a sick patient to the hospital, denial of payment for admission on the basis of retrospective chart review, and establishment of prepaid plans that paid participating physicians a bonus for not giving care. In Indiana, for example, one plan es¬ tablished a referral and hospital fund for each primary "gatekeeper" physician to cover costs of nonemergency referral and hospital services. ' If the funds were not spent during the year, half the surplus would be distributed to the physicians—the company kept the other half—but only to those who had surpluses in their individual accounts, and in proportion to their amounts of surplus. Those who ordered only a few consultations and hospitalizations got the biggest bonuses —clearly a reward for a
withholding care.
All these measures undermine what Bradford Gray2 calls "the fiduciary ethic," stated most succinctly by the American Medical Association's code of ethics: "... un¬ der no circumstances may the physician place his own fi¬ nancial interest above the welfare of his patients. "3 Arnold Relman of the New England Journal of Medicine put it another way, "The doctor-patient relationship [cannot] be adequately described in purely business terms. It is not that doctors are more ethical than businessmen. They aren't. It is simply that patients have to depend on doc¬ tors to take care of them, and this trust places legal and ethical obligations on doctors that do not apply to
businessmen ..." (Wall St Journal. July 2, 1986:27). In fact, this was one of the expectations of the general pub¬ lic; they believed that nearly all physicians were governed by this principle. As Gray says, "... the public's high expectations of health care providers had enough plausi¬ bility to support a largely private health care system that relied heavily on trust and self-regulating mechanisms."2 This, in turn, led to an expectation by physicians that nothing would change very drastically, that we could adapt to regulations and preserve the system we had be¬ come so comfortable with. I believe the majority of phy¬ sicians still hold this latter expectation, but the public has discarded trust in favor of accountability because their expectation collided with reality. A number of real factors contributed to changing pub¬ lic expectations, including a perception that medicine had done a poor job of self-regulation and the general aware¬ ness that physicians' incomes are among the highest in the country. Instances of greed and "conspicuous con¬ sumption" are real; and the rise of entrepreneurism among physicians has extended even to the resurgence of doctor-owned hospitals, relics of the pre-Flexner and pre-JCAH days. In addition, the dramatic increases in applications of technology were associated with a depersonalization of care. Patients are examined by physician's assistants; they are instructed by nurses; they review vid¬ eotapes edited by attorneys—all of which are fine, as long as they don't replace time to talk to the doctor. In the early eighties, technology was news; as the decade closed, all the talk was about money. With our aging population continuing to be the fastest growing segment, health care expenditures will continue to increase under our present systems of financing; and since government pays about half, the amount of public money is so great that its allo¬ cation has become a political issue which will figure sig¬ nificantly in campaigns in 1992 and beyond. And when any issue is elevated to campaign status, politicians assess it in terms of their highest priority: to be responsible pub¬ lic servants, responsibly overseeing social and fiscal issues, while fairly representing the welfare of their con¬ stituents. Translated cynically: get reelected. Conse¬ quently, they will be very concerned about the expecta¬ tions and priorities of those served by the health care systems, in other words, our patients who vote. I believe that most patients expect care to be available, that the care will be of good quality, and that they will have a good result from treatment. They also expect that they will not be denied the latest advances in technology if they are needed for diagnosis and treatment. Their pri¬ orities are consistent with their expectations in some re¬ spects. Getting well and being able to work are usually high on the list, as is receiving "state of the art" care. Per¬ sonalized care is still high on the list, and an emerging priority is that they don't want to hurt very much. They want "interventions" instead of surgery; and if an oper¬ ation is necessary, it should be done with a laser and through a tube instead of an incision. But another prior¬ ity relates to money: they don't want to pay "a balance" after insurance is paid; and while they believe in access to care for all, they don't want to subsidize it by increasing taxes. In light of these priorities, the politicians have a problem. The voters' expectations and priorities do not match, and they are at odds with reality. Where do doctors fit in this picture? We expect that medicine will continue to advance, helped by technology,
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so that we can provide better care. We also expect to be rewarded appropriately for what we do; we expect to be able to have some personal time; and we still expect that things won't change a lot. Except for doubting change, these expectations seem reasonable; and our priority is clear: to provide the best care for our patients in a personal and efficient manner. Reality, however, demands that changes be made; and the changes must be more than minor adaptations. One reality is that the voting public will not and should not stand for a system that has allowed the number of people without health insurance to continue to increase. Another reality is that continuation of our present system with the modifications now being implemented will lead to rationing of care, bankruptcy of additional hospi¬ tals, and demoralizing of physicians. The law is clear; federal spending has been capped, although the number of Medicare beneficiaries will continue to rise for three decades. Responses to this limitation of spending generated a spate of changes in the form of regulations which in¬ creased expenditures instead of reducing them, and the changes currently contemplated threaten to destroy the best features of a system that has flaws but is still the best health care system in the world. What can we do in this set of circumstances other than vote? Few of us have formal education in health care eco¬ nomics; some of us have worked with different kinds of systems, but have never designed new ones. Yet the bulk of our laws and regulations are written by congressional staff persons with less experience than we have, and with little or no background in the practice of medicine. To date, most of the activities of physicians have been directed at threats to income; and while that is appropri¬ ate, it generates no sympathy because we are well paid and are likely to continue to be. We are seen as protecting our personal status quo and as failing to offer solutions to prob¬ lems. The first thing we can do, then, is to stop complain¬ ing about our pocketbooks and use our energy for other activities. The landmark presentation we heard yesterday from Dr Maloney4 can hardly be described as complaining. It was a thoughtful analysis of a problem that has far worse implications than decreasing income. It threatens to dis¬ courage the best students from entering medicine. Those activities are legion; fundamentally, they mean developing an unprecedented level of political activism. But not political activism in the sense of campaigning—at least for most of us—but in the sense of participating in trying to solve specific medical problems at local, state, regional, and national levels. For example, look first at the problem of the uninsured and underinsured. Estimates of the number of uninsured range as high as 40 million, more than 15% of our popu¬ lation; and this number does not take into account those with inadequate insurance. In 1982, companies employing 100 or more people had 75% of them fully covered by health insurance; in 1989, it was only 48%. In the same pe¬ riod, the percentage of employees with family coverage fell from 50% to 31%. In addition, companies allowed the number of part-time employees to increase (to 55% in the case of Sears Roebuck) to avoid paying benefits, including health care. Finally, retirees are now seeing their health benefits challenged (Detroit Free Press. November 10,
1991).
While that is a national problem, it might be better dealt
with at
local level. And while it crosses all dis¬ ciplines, surgeons could take the lead by suggesting so¬ lutions for surgical care. As Claude Organ5 wrote recently, "We have sat on the sidelines too long watching this rev¬ olution and hoping that some one else will take care of the problem." Surely a coalition of surgical leaders from all aspects of practice and education, perhaps through chap¬ ters of the American College of Surgeons, could develop methods for providing surgical care for the uninsured in a
a
county,
state
a
or
region,
We could use the
state. approach to
or even a same
suggest methods of
handling surgical patients with Medicaid, a program al¬ most universally regarded as a disaster, and rightly so. It cost $1.6 billion in
1966, $12.6 billion in 1975, $52 billion in 1988, and is projected to cost $105 billion in 1992, in spite
of the fact that only about half the poor are covered. Most physicians avoid the program, and not surprisingly, as the reimbursement for physicians is less than 40% of that of Medicare in some states. We must, however, look for a so¬ lution to the problem, not an increase in reimbursement; and the problem is best shown by the program's require¬ ments for eligibility. In Alabama, for example, a family of three must earn less than $1416 a year to qualify for benefits (The New York Times. September 4, 1991). Another area we can deal with specifically is the $300 million bureaucracy known as the Professional Review Or¬ ganization (PRO) Program, which was foisted on us by Congress under the pseudonym of quality assurance. There are 54 PRO organizations, all under contracts let by competitive bidding, and all with the mission to find prob¬ lems or lose their contracts. As a result, they sometimes invent new science. In Michigan, for example, a reviewer recently designated failure to take a temperature within 15 minutes of an outpatient esophagogastroduodenoscopy as a level two quality problem, meaning that there was a sig¬ nificant chance the patient might have sustained adverse effects from this omission. The reasoning of this anony¬ mous (though legally protected) reviewer was as follows: "Since the procedure performed increases the risk of bac¬ teremia, if the patient was found to be febrile prior to the procedure further evaluation would have been necessary to determine whether it would have been safe to risk per¬ forming the procedure ..." (peer review confidential data, William Beaumont Hospital, Royal Oak, Mich, March 1991). The logic eludes me (as does the grammar), but the cost does not. The $300 million does not include costs for doctors and hospitals to respond. For example, our hospital employs an experienced nurse who works full-time to respond to such nonsense. I do not doubt the existence of variations in the quality of care; but as long as these organizations focus on large hospitals with already established programs to monitor quality, the return on the taxpayer's investment is minuscule. And as with any pro¬ gram giving away money there is fraud. For example, Cal¬ ifornia Medical Review recently paid $1.2 million in a pleabargain agreement; and the Florida PRO pleaded guilty to one count of an indictment for fraud (AM News. June 24,
1991).
Individually, or through local organizations, we need to insist that the budgets of these organizations be published so that taxpayers can understand their investment. Also, at regular intervals, there should be a review of the number of proposed sanctions and the number upheld, with comments from the physicians or hospitals; a publicly funded pro¬ cess demands public accountability. In addition, each
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physician who receives a letter accusing him of providing poor quality care should notify the hospital, formulate an appropriate reply, and send copies to his congressmen. Finally, we should insist on local methods ofadjudicating disputes; as it stands, the PROs make the charges, hear the appeals, and render final judgments. To allow a PRO to act as ac¬ cuser, judge, and jury is to sanction a conflict of interest,
since it is clear that PROs with too few sanctions will lose their contracts. In contrast to disputes about quality, dis¬ putes about necessity of admission can be taken to an ad¬ ministrative law judge; we need such a local solution for appealing decisions about quality also. If these comments fit your PRO, you need to become vig¬ orously active as an individual and asa member of the local organizations in its jurisdiction. Even health economist Al¬ fred Enthoven believes, "The indications for care are too numerous, too uncertain, and too changeable for a police force of reasonable size to keep up."6 If we can't topple the bureaucracy, we must insist on publicizing its work and let the taxpayers be the judge of its worth. Although the PRO is an example of "negative restraints in the face of inap¬ propriate incentives," to use Enthoven's phrase, we must establish systems that truly monitor quality, for our hospitals and for our individual practices. As long as we do not have the ongoing statistics for such things as wound infections, wound dehiscence, graft occlusion, and anastomotic leak, we cannot protest mechanisms that try to assess our re¬ sults objectively. After all, we are paid with public money to a great extent. If surgeons, who are accustomed to scru¬ tinizing results at morbidity and mortality conferences, will take the next step by assisting in implementing mean¬ ingful monitors of quality in our hospitals and individual practices, there will be no need for others to do the job. The idea is not show and tell; it is to identify medical problems that require thoughtful solutions. It serves no purpose, for example, to generate a report that minimizes numbers of infections in leg wounds after coronary artery surgery; it is poor practice not to know the real number; and it is ir¬ responsible not to try to decrease it. A fifth thing we must do is to continue our efforts to bring sense to the problem of professional liability. It is madness to continue a system in which 80% of the costs are overhead, a system that equates a bad result with negligence, and a system that makes patients our adver¬ saries. Concerted efforts by physicians have brought ac¬ tions in times of crisis before, as in a passage of a reason¬ able law in Indiana in 1975. And when costs of liability amount to at least 10% of all medical expenditures, a cri¬ sis certainly still exists. The problem with this piecemeal list of "solutions" is that it requires action in many arenas—actions that are not on most physician's lists of priorities. I say that because of an experience that Scott Woods, George Block, and I (and undoubtedly others) shared, when we served as Gover¬ nors of the American College of Surgeons representing re¬ gional surgical societies. Every year we asked our mem¬ bers (at meetings and through newsletters) to write us with their concerns, so that we could include them in our reports and bring them to the attention of other governors and ultimately, the regents. No one wrote! These kinds of actions were not on our members' lists of priorities. Are we too comfortable? Is it that we don't feel a shortage and therefore, don't need to make priorities? If so, we are in no position to argue with the public about theirs. Public priorities are probably best judged by the way we
spend our money. In 1987, we spent $500 billion for health we made some other interesting purchases too: (1) $20.5 billion for pets, toys, and playground equipment; (2) $21.8 billion for tobacco products and smoking sup¬ plies; (3) $27.2 billion for beer, wine, and whiskey; and (4) $34.7 billion for cosmetics, jewelry, and personal care products.7 These expenditures, totaling $104.2 billion, were not quite as high as the $106.9 billion paid for health care "out of pocket" by consumers (including insurance); care; but
but it was somewhat less than the $112.3 billion spent for entertainment. Note that the latter does not include the amount spent on lotteries—over 11 billion. Not surpris¬ ingly, we spent $433 billion for motor vehicles, parts, gas, oil, and auto insurance. These figures make me ask, "whose crisis is this, any¬ way?" Does it really belong to the patient if the average household spends about the same for entertainment as for health care, and four times as much for transportation? Does it belong to businesses which would like to use those funds for profits and a government searching for a new domestic platform? Both spend more on medical care than consumers; and their calls for change are definitely louder than those of our patients. In reality, the crisis belongs to all of them; but more importantly, it belongs to you and me, because we are the patients' advocates and their only hope for avoiding the dismantling of critically important features of our health care system. We might as well rec¬ ognize that our unregulated private system of health care is a thing of the past. John Donne's words now fit our profession: "No man is an island, to himself alone. Each man is a part of the continent, a piece of the main. There¬ fore, never send to know for whom the bell tolls; it tolls for thee."8 Donne was talking about a funeral bell; with luck, we may have a warning bell instead. In this time when the world is ravaged by the AIDS ep¬ idemic, we must continue to promote medical education and research, the only true preventive medicine mea¬ sures. The warning is that funds for these purposes are in danger of being lost because of the cost of patient care. To preserve the one and provide the other will take unprec¬ edented medical leadership and activity from all of us. Those of us who have used the cloak of science as a hiding place from social action must begin to educate our patients and to challenge ourselves and our organizations to speak out against all the nonsense we'll soon be hearing, and to help preserve the features that made our system great. The only way to continue to provide the best care is to partic¬ ipate in the debate, holding steadfastly to the features that foster quality and humane care, and rejecting others. We must make such actions our highest priority. References 1.
1984;15:5-6.
GloverJL. Muddled
logic.
Bull Marion
County
Med Soc.
2. Gray BH. The Profit Motive and Patient Care. Boston, Mass: Harvard University Press; 1991:167. 3. American Medical Association. Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association. American Medical Association. 1986:16. 4. Maloney JV. A critical analysis of the resource-based relative value scale. JAMA. 1991;266:3453-3458. 5. Organ C. Surgical care for the uninsured and underinsured. Arch
Surg. 1991;126:549-550.
6. Enthoven A. What can Europeans Learn From Americans? Health Care Systems in Transition. Paris, France: OECD Social Policy; 1990. 7. US Dept of Labor. Consumer Expenditure Survey, 1987. Washington, DC: US Dept of Labor, Bureau of Labor Statistics. 1990:2354. 8. Donne J. Devotions upon emergent occasions. In: Collection of Sermons. Verse 6.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/09/2015
L. Glover, MD
medicine the nineties, the is good and bad. The good is that the financing of medical For issue. has that become in
news
care
news
finally
a
recognized political
Sadly,
is also the bad news; and it is very bad. I use the word "recognized" deliberately because political analysts have only recently decided that it is an issue of sufficient strength to merit inclusion in political campaigns. It has obviously been a political issue since the passage of two important legislative acts: (1) the 1965 law that created Medicare, and (2) the 1963 law that provided federal funds to double the number of medical school graduates and increase the number of schools by 50%. Physicians enjoyed the benefits of this legislation almost as much as those whom it was intended to help. In fact, we used the Medicare legislation to accelerate progress on social and technological fronts: access to care and the implementation of new devices and procedures. On the social front, we had seminars about providing "one class care"—the best. And we advocated the right of all our citizens to the best health care available without regard to cost. On the technology front, we developed coronary artery surgery some¬ that could be done safely in community thing never considered when Medicare was created. We developed CT scanners that revolutionized the diagnosis and treatment of craniocerebral trauma. For a cancer that affects nearly 10% of American women, we developed systems for imaging it before it is palpable. Heart and liver transplantation became the treatments of choice for cer¬ tain conditions. It was a golden age for medicine. It was as though we were plowing a smooth new path with power to overcome the roughest and rockiest terrain. But in 1982, we lost power to one set of wheels. Congress, sensing that medical care was consuming about 10% of our gross national product and that taxes were paying 40% of that, made the arbitrary decision to place a limit on the amount it would pay for federal pro¬ grams by passing the Tax Equity and Fiscal Responsibil¬ ity Act of 1982. It was a major effort to insinuate expecta¬ tions and priorities into decisions about financing medical care. Until that time, the government had acted chiefly as a financing agent, attempting to exercise little control. "Expectation" is the act of expecting, and expecting means "to look forward to, to regard as likely to happen." It implies that one confidently believes, and usually for good reasons, that an event will occur. The government's
hospitals,
Accepted
publication January 25, 1992. Department of Surgery, William for
Beaumont Hospital, Mich. Presented as the Presidential Address at the 99th Scientific Session of the Western Surgical Association, Colorado Springs, Colo, November 18, 1991. Reprint requests to Surgical Services, William Beaumont Hospital, 3601 W Thirteen Mile Rd, Royal Oak, Ml 48073 (Dr Glover).
From the
Royal Oak,
John
L.
Clover,
MD
expectation was that costs could be reduced by legislative fiat.
"Priority" is the right to take precedence in obtaining supplies, services, or facilities, especially during a short¬ age. In this case, the shortage was money; everyone was in favor of reducing taxes, not raising them. The priority was reduction of medical costs, but no one was willing to say directly that those reductions should take precedence over
provision
never
of service. The
priority, therefore,
was
clearly established; and consequently, the expecta¬
tion was not fulfilled. Instead of a reduction in costs,
we had an increase. Medical costs, which were $248 billion in 1980 rose to $458 billion in 1986, and $523 billion in 1988. Medical inflation continues to rise faster than the consumer price index; and the government, still harboring its expectation to control costs, has brought its priority into sharper focus. It is now willing to say that limiting costs takes precedence over paying doctors and hospitals. The old system of costs and
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/09/2015
charges
was
scrapped,
and
hospitals began
to receive
payment on the basis of diagnosis only. More recently, government decided to pay physicians on the basis of a
resource-based relative value scale. To underscore their conviction, they even proposed a reduction in fees based on the presumption that physicians would make up for decreases in their income by performing more proce¬ dures. There could be no clearer sign that cost now has
priority over service. In this regard, a list of the health care priorities of the majority of our present government officials would in¬ clude (1) a limitation on expenditures and (2) provision of access to care for all patients who need it, but (3) not changing things very drastically. The latter has its roots both in people's general resistance to drastic change un¬ less they are in dire straits, and in the principle that rad¬ ical change is better suited to revolutions than elections. I do not think evidence supports the notion that patients in the United States have deficient medical care, and the rise of conservatism tempers calls for nationalizing any
system.
As the
government
has
strengthened
its
priorities,
however, business has become its welcome ally. The au¬ tomakers, for example, complain that health care costs are a major factor in keeping profits down; even Lee Iacocca,
champion of capitalism, has called for consideration of national health insurance (Detroit Free Press. April 17, 1989). A list of the health care priorities of industryincluding private insurers—might be: (1) to limit expen¬ ditures, but (2) to have medical care that keeps employ¬ ees healthy and satisfied. As a result of these priorities, we have seen the devel¬ opment of a coalition of government and industry which has brought about the most drastic changes in medicine since the widespread availability of health insurance. In addition to paying hospitals by diagnosis and setting up what amounts to a national fee schedule for physicians, there is discount pricing, bidding for services, require¬ ments to obtain "preauthorization" to admit a sick patient to the hospital, denial of payment for admission on the basis of retrospective chart review, and establishment of prepaid plans that paid participating physicians a bonus for not giving care. In Indiana, for example, one plan es¬ tablished a referral and hospital fund for each primary "gatekeeper" physician to cover costs of nonemergency referral and hospital services. ' If the funds were not spent during the year, half the surplus would be distributed to the physicians—the company kept the other half—but only to those who had surpluses in their individual accounts, and in proportion to their amounts of surplus. Those who ordered only a few consultations and hospitalizations got the biggest bonuses —clearly a reward for a
withholding care.
All these measures undermine what Bradford Gray2 calls "the fiduciary ethic," stated most succinctly by the American Medical Association's code of ethics: "... un¬ der no circumstances may the physician place his own fi¬ nancial interest above the welfare of his patients. "3 Arnold Relman of the New England Journal of Medicine put it another way, "The doctor-patient relationship [cannot] be adequately described in purely business terms. It is not that doctors are more ethical than businessmen. They aren't. It is simply that patients have to depend on doc¬ tors to take care of them, and this trust places legal and ethical obligations on doctors that do not apply to
businessmen ..." (Wall St Journal. July 2, 1986:27). In fact, this was one of the expectations of the general pub¬ lic; they believed that nearly all physicians were governed by this principle. As Gray says, "... the public's high expectations of health care providers had enough plausi¬ bility to support a largely private health care system that relied heavily on trust and self-regulating mechanisms."2 This, in turn, led to an expectation by physicians that nothing would change very drastically, that we could adapt to regulations and preserve the system we had be¬ come so comfortable with. I believe the majority of phy¬ sicians still hold this latter expectation, but the public has discarded trust in favor of accountability because their expectation collided with reality. A number of real factors contributed to changing pub¬ lic expectations, including a perception that medicine had done a poor job of self-regulation and the general aware¬ ness that physicians' incomes are among the highest in the country. Instances of greed and "conspicuous con¬ sumption" are real; and the rise of entrepreneurism among physicians has extended even to the resurgence of doctor-owned hospitals, relics of the pre-Flexner and pre-JCAH days. In addition, the dramatic increases in applications of technology were associated with a depersonalization of care. Patients are examined by physician's assistants; they are instructed by nurses; they review vid¬ eotapes edited by attorneys—all of which are fine, as long as they don't replace time to talk to the doctor. In the early eighties, technology was news; as the decade closed, all the talk was about money. With our aging population continuing to be the fastest growing segment, health care expenditures will continue to increase under our present systems of financing; and since government pays about half, the amount of public money is so great that its allo¬ cation has become a political issue which will figure sig¬ nificantly in campaigns in 1992 and beyond. And when any issue is elevated to campaign status, politicians assess it in terms of their highest priority: to be responsible pub¬ lic servants, responsibly overseeing social and fiscal issues, while fairly representing the welfare of their con¬ stituents. Translated cynically: get reelected. Conse¬ quently, they will be very concerned about the expecta¬ tions and priorities of those served by the health care systems, in other words, our patients who vote. I believe that most patients expect care to be available, that the care will be of good quality, and that they will have a good result from treatment. They also expect that they will not be denied the latest advances in technology if they are needed for diagnosis and treatment. Their pri¬ orities are consistent with their expectations in some re¬ spects. Getting well and being able to work are usually high on the list, as is receiving "state of the art" care. Per¬ sonalized care is still high on the list, and an emerging priority is that they don't want to hurt very much. They want "interventions" instead of surgery; and if an oper¬ ation is necessary, it should be done with a laser and through a tube instead of an incision. But another prior¬ ity relates to money: they don't want to pay "a balance" after insurance is paid; and while they believe in access to care for all, they don't want to subsidize it by increasing taxes. In light of these priorities, the politicians have a problem. The voters' expectations and priorities do not match, and they are at odds with reality. Where do doctors fit in this picture? We expect that medicine will continue to advance, helped by technology,
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so that we can provide better care. We also expect to be rewarded appropriately for what we do; we expect to be able to have some personal time; and we still expect that things won't change a lot. Except for doubting change, these expectations seem reasonable; and our priority is clear: to provide the best care for our patients in a personal and efficient manner. Reality, however, demands that changes be made; and the changes must be more than minor adaptations. One reality is that the voting public will not and should not stand for a system that has allowed the number of people without health insurance to continue to increase. Another reality is that continuation of our present system with the modifications now being implemented will lead to rationing of care, bankruptcy of additional hospi¬ tals, and demoralizing of physicians. The law is clear; federal spending has been capped, although the number of Medicare beneficiaries will continue to rise for three decades. Responses to this limitation of spending generated a spate of changes in the form of regulations which in¬ creased expenditures instead of reducing them, and the changes currently contemplated threaten to destroy the best features of a system that has flaws but is still the best health care system in the world. What can we do in this set of circumstances other than vote? Few of us have formal education in health care eco¬ nomics; some of us have worked with different kinds of systems, but have never designed new ones. Yet the bulk of our laws and regulations are written by congressional staff persons with less experience than we have, and with little or no background in the practice of medicine. To date, most of the activities of physicians have been directed at threats to income; and while that is appropri¬ ate, it generates no sympathy because we are well paid and are likely to continue to be. We are seen as protecting our personal status quo and as failing to offer solutions to prob¬ lems. The first thing we can do, then, is to stop complain¬ ing about our pocketbooks and use our energy for other activities. The landmark presentation we heard yesterday from Dr Maloney4 can hardly be described as complaining. It was a thoughtful analysis of a problem that has far worse implications than decreasing income. It threatens to dis¬ courage the best students from entering medicine. Those activities are legion; fundamentally, they mean developing an unprecedented level of political activism. But not political activism in the sense of campaigning—at least for most of us—but in the sense of participating in trying to solve specific medical problems at local, state, regional, and national levels. For example, look first at the problem of the uninsured and underinsured. Estimates of the number of uninsured range as high as 40 million, more than 15% of our popu¬ lation; and this number does not take into account those with inadequate insurance. In 1982, companies employing 100 or more people had 75% of them fully covered by health insurance; in 1989, it was only 48%. In the same pe¬ riod, the percentage of employees with family coverage fell from 50% to 31%. In addition, companies allowed the number of part-time employees to increase (to 55% in the case of Sears Roebuck) to avoid paying benefits, including health care. Finally, retirees are now seeing their health benefits challenged (Detroit Free Press. November 10,
1991).
While that is a national problem, it might be better dealt
with at
local level. And while it crosses all dis¬ ciplines, surgeons could take the lead by suggesting so¬ lutions for surgical care. As Claude Organ5 wrote recently, "We have sat on the sidelines too long watching this rev¬ olution and hoping that some one else will take care of the problem." Surely a coalition of surgical leaders from all aspects of practice and education, perhaps through chap¬ ters of the American College of Surgeons, could develop methods for providing surgical care for the uninsured in a
a
county,
state
a
or
region,
We could use the
state. approach to
or even a same
suggest methods of
handling surgical patients with Medicaid, a program al¬ most universally regarded as a disaster, and rightly so. It cost $1.6 billion in
1966, $12.6 billion in 1975, $52 billion in 1988, and is projected to cost $105 billion in 1992, in spite
of the fact that only about half the poor are covered. Most physicians avoid the program, and not surprisingly, as the reimbursement for physicians is less than 40% of that of Medicare in some states. We must, however, look for a so¬ lution to the problem, not an increase in reimbursement; and the problem is best shown by the program's require¬ ments for eligibility. In Alabama, for example, a family of three must earn less than $1416 a year to qualify for benefits (The New York Times. September 4, 1991). Another area we can deal with specifically is the $300 million bureaucracy known as the Professional Review Or¬ ganization (PRO) Program, which was foisted on us by Congress under the pseudonym of quality assurance. There are 54 PRO organizations, all under contracts let by competitive bidding, and all with the mission to find prob¬ lems or lose their contracts. As a result, they sometimes invent new science. In Michigan, for example, a reviewer recently designated failure to take a temperature within 15 minutes of an outpatient esophagogastroduodenoscopy as a level two quality problem, meaning that there was a sig¬ nificant chance the patient might have sustained adverse effects from this omission. The reasoning of this anony¬ mous (though legally protected) reviewer was as follows: "Since the procedure performed increases the risk of bac¬ teremia, if the patient was found to be febrile prior to the procedure further evaluation would have been necessary to determine whether it would have been safe to risk per¬ forming the procedure ..." (peer review confidential data, William Beaumont Hospital, Royal Oak, Mich, March 1991). The logic eludes me (as does the grammar), but the cost does not. The $300 million does not include costs for doctors and hospitals to respond. For example, our hospital employs an experienced nurse who works full-time to respond to such nonsense. I do not doubt the existence of variations in the quality of care; but as long as these organizations focus on large hospitals with already established programs to monitor quality, the return on the taxpayer's investment is minuscule. And as with any pro¬ gram giving away money there is fraud. For example, Cal¬ ifornia Medical Review recently paid $1.2 million in a pleabargain agreement; and the Florida PRO pleaded guilty to one count of an indictment for fraud (AM News. June 24,
1991).
Individually, or through local organizations, we need to insist that the budgets of these organizations be published so that taxpayers can understand their investment. Also, at regular intervals, there should be a review of the number of proposed sanctions and the number upheld, with comments from the physicians or hospitals; a publicly funded pro¬ cess demands public accountability. In addition, each
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physician who receives a letter accusing him of providing poor quality care should notify the hospital, formulate an appropriate reply, and send copies to his congressmen. Finally, we should insist on local methods ofadjudicating disputes; as it stands, the PROs make the charges, hear the appeals, and render final judgments. To allow a PRO to act as ac¬ cuser, judge, and jury is to sanction a conflict of interest,
since it is clear that PROs with too few sanctions will lose their contracts. In contrast to disputes about quality, dis¬ putes about necessity of admission can be taken to an ad¬ ministrative law judge; we need such a local solution for appealing decisions about quality also. If these comments fit your PRO, you need to become vig¬ orously active as an individual and asa member of the local organizations in its jurisdiction. Even health economist Al¬ fred Enthoven believes, "The indications for care are too numerous, too uncertain, and too changeable for a police force of reasonable size to keep up."6 If we can't topple the bureaucracy, we must insist on publicizing its work and let the taxpayers be the judge of its worth. Although the PRO is an example of "negative restraints in the face of inap¬ propriate incentives," to use Enthoven's phrase, we must establish systems that truly monitor quality, for our hospitals and for our individual practices. As long as we do not have the ongoing statistics for such things as wound infections, wound dehiscence, graft occlusion, and anastomotic leak, we cannot protest mechanisms that try to assess our re¬ sults objectively. After all, we are paid with public money to a great extent. If surgeons, who are accustomed to scru¬ tinizing results at morbidity and mortality conferences, will take the next step by assisting in implementing mean¬ ingful monitors of quality in our hospitals and individual practices, there will be no need for others to do the job. The idea is not show and tell; it is to identify medical problems that require thoughtful solutions. It serves no purpose, for example, to generate a report that minimizes numbers of infections in leg wounds after coronary artery surgery; it is poor practice not to know the real number; and it is ir¬ responsible not to try to decrease it. A fifth thing we must do is to continue our efforts to bring sense to the problem of professional liability. It is madness to continue a system in which 80% of the costs are overhead, a system that equates a bad result with negligence, and a system that makes patients our adver¬ saries. Concerted efforts by physicians have brought ac¬ tions in times of crisis before, as in a passage of a reason¬ able law in Indiana in 1975. And when costs of liability amount to at least 10% of all medical expenditures, a cri¬ sis certainly still exists. The problem with this piecemeal list of "solutions" is that it requires action in many arenas—actions that are not on most physician's lists of priorities. I say that because of an experience that Scott Woods, George Block, and I (and undoubtedly others) shared, when we served as Gover¬ nors of the American College of Surgeons representing re¬ gional surgical societies. Every year we asked our mem¬ bers (at meetings and through newsletters) to write us with their concerns, so that we could include them in our reports and bring them to the attention of other governors and ultimately, the regents. No one wrote! These kinds of actions were not on our members' lists of priorities. Are we too comfortable? Is it that we don't feel a shortage and therefore, don't need to make priorities? If so, we are in no position to argue with the public about theirs. Public priorities are probably best judged by the way we
spend our money. In 1987, we spent $500 billion for health we made some other interesting purchases too: (1) $20.5 billion for pets, toys, and playground equipment; (2) $21.8 billion for tobacco products and smoking sup¬ plies; (3) $27.2 billion for beer, wine, and whiskey; and (4) $34.7 billion for cosmetics, jewelry, and personal care products.7 These expenditures, totaling $104.2 billion, were not quite as high as the $106.9 billion paid for health care "out of pocket" by consumers (including insurance); care; but
but it was somewhat less than the $112.3 billion spent for entertainment. Note that the latter does not include the amount spent on lotteries—over 11 billion. Not surpris¬ ingly, we spent $433 billion for motor vehicles, parts, gas, oil, and auto insurance. These figures make me ask, "whose crisis is this, any¬ way?" Does it really belong to the patient if the average household spends about the same for entertainment as for health care, and four times as much for transportation? Does it belong to businesses which would like to use those funds for profits and a government searching for a new domestic platform? Both spend more on medical care than consumers; and their calls for change are definitely louder than those of our patients. In reality, the crisis belongs to all of them; but more importantly, it belongs to you and me, because we are the patients' advocates and their only hope for avoiding the dismantling of critically important features of our health care system. We might as well rec¬ ognize that our unregulated private system of health care is a thing of the past. John Donne's words now fit our profession: "No man is an island, to himself alone. Each man is a part of the continent, a piece of the main. There¬ fore, never send to know for whom the bell tolls; it tolls for thee."8 Donne was talking about a funeral bell; with luck, we may have a warning bell instead. In this time when the world is ravaged by the AIDS ep¬ idemic, we must continue to promote medical education and research, the only true preventive medicine mea¬ sures. The warning is that funds for these purposes are in danger of being lost because of the cost of patient care. To preserve the one and provide the other will take unprec¬ edented medical leadership and activity from all of us. Those of us who have used the cloak of science as a hiding place from social action must begin to educate our patients and to challenge ourselves and our organizations to speak out against all the nonsense we'll soon be hearing, and to help preserve the features that made our system great. The only way to continue to provide the best care is to partic¬ ipate in the debate, holding steadfastly to the features that foster quality and humane care, and rejecting others. We must make such actions our highest priority. References 1.
1984;15:5-6.
GloverJL. Muddled
logic.
Bull Marion
County
Med Soc.
2. Gray BH. The Profit Motive and Patient Care. Boston, Mass: Harvard University Press; 1991:167. 3. American Medical Association. Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association. American Medical Association. 1986:16. 4. Maloney JV. A critical analysis of the resource-based relative value scale. JAMA. 1991;266:3453-3458. 5. Organ C. Surgical care for the uninsured and underinsured. Arch
Surg. 1991;126:549-550.
6. Enthoven A. What can Europeans Learn From Americans? Health Care Systems in Transition. Paris, France: OECD Social Policy; 1990. 7. US Dept of Labor. Consumer Expenditure Survey, 1987. Washington, DC: US Dept of Labor, Bureau of Labor Statistics. 1990:2354. 8. Donne J. Devotions upon emergent occasions. In: Collection of Sermons. Verse 6.
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