|
The Accession of this Beast!
6-27-09
The beast that has risen, wrapped in the words of the Hippocratic Oath, is complex and multi faced. And powerful, to the extent that the industry is capable of spending a cool 1.4 million a day to fight reform. While everyone seems to want healthcare reform to some degree, the problem is that our medical industry is not a monolithic industry, that in fact, it’s made up of physicians, nurses, surgeons, and that’s just to begin with. There is in addition to all the groups who practice some form of medicine, the Hospitals and Clinics, and those can be broken into different types of Hospitals and specialized clinics. Throw in the Insurance companies and the Pharmaceuticals, you’ve now got a mixed, foul tasting stew in a hot cauldron. Which ingredient do you remove or change to make the stew edible? Whatever part you change, the whole is changed. The first thing a sensible person does is look at the recipe, and in the case of our Healthcare system, it’s history. How did we get to where we are? You cannot fix anything, until you understand the history of how it broke.
And it’s a rather interesting history. Interesting in the sense that, for instance, the intent of Blue Cross was far different than it is today, interesting in that medical technology has been the cause for increased costs. Interesting too that power has shifted from the AMA to the Insurance, Pharmaceutical companies along with the Hospitals.
By and large, modern healthcare history has it’s roots in the mid 1850’s with Louis Pasteur, his theory of germs, and the advent of microbiology. You also have in the last half of the 19th century the invention of X rays and other tools such the ability to measure blood pressure. By 1900, medicine was on the road to being hi tech and a full fledged science. BY 1910 the AMA was a powerful force in the medical community because it was the only real force. Yet Hospitals were on the rise. The new medical technologies were available in urban areas and hospitals were built to accommodate them and doctors followed them.
With the rise of modern medicine, rural country doctors who sold their services for a chicken, were themselves on the chopping block. Doctors now, had to know something about diseases and germs and what medicines cures them. This lead to a significant change in stature and prestige. That change in stature led to a dramatic increase in what doctors charged, what hospitals charged and thus, medical costs in general. By 1920, the need for hospitals to be certified and accredited and Doctors licensed was well established.
By the end of the 1920’s people started worrying how a common worker could settle a simple medical debt. The concern was that a worker paying off even a short hospital visit would take a generation to pay the debt, at about a dime a month. Thus the advent of Hospital insurance programs, but understand that advent came from a group of Dallas teachers who contracted with Baylor Hospital to provide 21 days of hospitalization for $6.00. Understand, this was an agreement between a group of teachers and a Hospital. Doctors at the time wanted no part of the agreement because they believed it would affect their ability to charge whatever they wanted as well change the relationship between patient and Physician.
Yet, by the mid 1930s, it became clear to the AMA that first, during the depression, Hospitals had a stream of income due to the popularity of Blue Cross plans, second, due to the popularity, there was a fear that Hospitals would start offering insurance for physicians and third, there was serious political talk about compulsory medical insurance. The AMA had no choice but to enter the realm of insurance and they did so in 1934 with the intent to make sure Hospitals would not enter into the realm of offering insurance plans to cover doctor bills.
Up to the end of the 1930’s, Our healthcare system was comprised of Hospitals and Physicians. Insurance was basically not for profit, but rather for protection of debt.
Essentially, you can claim that the growth in medical technology lead to the current crisis and there’s truth to that. Yet the common belief that has been sold to the American public since day one, is that technology drives cost’s down. Compare it to the claim that the advent of computers would create a paperless society.
Anything but!
Consider this the first half of the equation. We haven’t even reached the point where medical insurance becomes commercialized.
Consider, that during the 30’s, the Blues who were a precursor to Blue Cross Blue Shield charged everyone the same premium, regardless of age, health or gender. They were basically non profit and simply wanted to offer limited protection for patient debt amid constantly growing medical costs. Commercial Insurance companies up to this time believed there was no profit to be made in insuring the sick. With the start of the Forties and the winds of war sweeping the Nation, our government issued price and wage controls, but failed to realize the need to control fringe benefits. Employers simply began to offer Health Insurance as a benefit to effectively compete in a stressed labor market during the war. Thus, the foundation for our employer based system we have today was born.
And so too, modern and commercialized Health Insurance. With an increased demand and an eye to the fact that the Hospitals had not only survived the depression, but managed to prosper to some extent with their system of the ‘Blues’, mainstream Insurance companies entered the fray, recalculating premiums for those at higher risk. The 40’s also bought Roosevelt’s economic bill of rights which carried a provision for the right to adequate health care and Truman’s National Health Program, which proposed a universal plan for all Americans. In fact, any attempt by our Government to nationalize healthcare was called communistic, socialistic and just plain un-American by the American Medical Association. The AMA’s greatest fear was that the Government would intrude and limit what they could charge.
During the 40’s and into the 50’s, the debate on a national healthcare reform was also sidetracked by the second world war and then the Korean war. That is not to say there were no efforts made or concerns voiced. As Evidenced, both Roosevelt and Truman understood what a National Health system meant for our nation. Know too that during the 50’s, hospital care cost doubled, and moving into the early 60’s, the poor and the elderly struggled for access to healthcare, even in the face that by this time, there were over 700 companies selling medical insurance.
The truth is, proponents of a National Health system were on the losing end, against a profitable business and a public who had other concerns, so they simply changed tactics. Their belief turned to passing a national system bit by bit, and they started with the elderly. Thus, Medicare and Medicaid were passed buy Johnson and by this time, it was firmly established that those who had the ability to buy health insurance could, and would. All others, the poor and elderly, would be taken care of by our government.
One other interesting fact emerged during the 1960’s that laid an important trend for where we are today. The number of Doctors who claim that practiced a specialty, full time, rose from 55% n 1960 to 70% by the end of the decade.
By the mid 70’s, it was clear the system wasn’t working. While both costs and profits soared, middle class America was carrying the burden and the realization of a crisis of our own making was upon us. Due to inflation, the use of new technologies, new drugs, expenses and profits and the explosion of medicare, our system was headed toward a catastrophic collapse, or so it was believed. Hospitals, Doctors and Private Insurance companies were making good money on the backs of working Americans but it was unsustainable.
Enter the next great chapter, the birth of Government Intervention in HMO’s.
All those years ago, back in the mid seventies, when I went to a Doctor, I’d walk down to the corner of eight street where Dr. Fitzsimmons had a small office with a receptionist and a nurse. That was it. He, and other, older General Practitioners, had their offices scattered around town, their shingles proclaiming their trade hanging out from their front door. By the mid 80’s, they were gone, the last of their breed and when I needed to see a Doctor, I made my way to a small, red brick neighborhood clinic. Ironic, that in a time when physicians were beginning to share services, and started to maximize profits, that Healthcare was viewed as being in crisis. In crisis because of exorbitant medicare costs, economic inflation, rising hospital costs (and profits) due to a greater use of Pharmaceuticals and a lot of new technology.
In 1973, with Nixon’s support, the HMO act of 1973 was passed and the modern age of Health Maintenance Organizations was born. Understand, HMOs had been with us in several shapes and forms since early in the century, but the powerful AMA had fought against them, fearful of Government intrusion in the form of regulation. While the act talks about ‘qualifications’ and ‘dual choice’, of which no one really paid attention to, what Nixon’s HMO act did, was legitimize the concept of HMO’s and thus, turned the concept of HMOs from ‘non profit’ to ‘profit’. This legitimization came in the form of grants and loans to provide, start or expand HMOs, as well requiring all employers with over 25 employees, to offer one of these new HMO’s and by the late Seventies, the stock market was playing a major role. For instance, Blue Cross Blue Shield which was non profit, either started or partnered with new HMOs. The era of medical commercialization had arrived.
Consider, from 1970 to 1999, enrollment climbed from 3 million to over 80 million, even with the shakeout (when poorly run HMO’s went bust) of the late 80’s. Most of this explosion was driven by employers who switched to HMO’s simply because they could not continue to offer independent Health Insurance because of the escalating costs. Indeed, the old system of paying for a doctors service, or fee for service, was dead. You now paid, upfront, before you needed the service and that service, you bought from your employer, and your choices were limited.
Over the course of the last 30 years, costs and profits have continued, technology continues to improve, new drugs arrive on the market daily, specialized clinics sprout like weeds, hospitals continue to be in a state of perpetual reconstruction and premiums skyrocket and benefits fall.
Nothing has essentially changed since the early 20th century, or in the last hundred years since the modern era of medicine began. From day one, costs have escalated due to new technology, research, new medicines, ongoing construction, specialized services, and from the need to turn a profit. This is the nature of the healthcare beast and it will continue to grow and suck the life out of many Americans.
The question is why? Usually, the thought is that technology eventually lowers cost. Usually, competition controls cost, or that’s another common thought. In most other industry’s, both technology and competition have successfully controlled market costs, not so in the health industry, and in fact, have driven the costs skyward.
Why?Looking back at what I’ve wrote in the last month regarding the history of health care, it’s evident that fear and power both play a part, as does business and technology and it’s clear that we are in the midst of a perfect storm of our own creation. The single problem today is that the storm is not subsiding, but continuing to grow, gaining strength and it’s bearing down on all of us.
If all we had to deal with in today’s modern age, were the American Medical Association and Joint Commission to accredit Hospitals, the problem might be a lot easier to solve. Then again, maybe not, as we had our chance in the last century and the AMA fought tooth and nail for the Government to stay out of their business. While the AMA has waned in power, Insurance and Pharmaceutical companies have managed to supplant them. Hospitals too have waned in power but still carry enormous prestige and weight in their communities and they use that advantage to grow and prosper. Yet Hospitals, whether private or for profit, are keenly aware of the need to compete against outpatient surgical centers and specialized clinics.
Indeed, the Healthcare industry can be equated to a single cell that suddenly started multiplying, and simply refuses to stop. So much so, that the original cell has been lost. That is to say, the days of the General Practitioner are near over. The industry now is comprised of thousands of specialized professions. Even the role of Nurses has changed over the years with the advent of Physicians Assistants and R.N.s moving toward more managerial duties.
This storm, this cell, will not stop by it’s own accord as there are simply too many factors involved. The first and most important factor is that the industry drives local communities and entire regions. It’s a well kept secret that a step in the right direction to solving the ills of our healthcare problems is simple for city councils across the Nation to say ‘No’ to hospital remodels, replication of services, new clinics, surgical centers and the like. The second factor is simply that Doctors and Hospitals need to start adhering to a mindset that they do not need the latest technologies to administer appropriate healthcare. These first two factors are a spend, spend, spend mentality that are used to stay competitive.
A third factor is two fold, and that is to eliminate Health Insurers in the decision making process of treatment, and to eliminate their ability to control what a Physician or Hospital charges for that service. Let them charge what they will for a policy, but keep them out of the business of being a doctor.
Fourth, Pharmaceutical companies simply need to be heavily regulated and forbidden from contributing to our political process in the form of Lobbyists. Their market should be those in the medical field, not the American public.
What a wonderful world we would live in if each of us were not concerned with ourselves, but with the welfare of others. What a world if we as individuals and collected groups were able to consider the larger picture as opposed to our narrow vision.
But we do not! In fact, the industry has proven time and time again, it has an inheriant refusal to administer the needed medicine for a variety of reasons, and those reasons have always been and always will be, self serving. Unfortunetely, the solution has to now come from Government, right or wrong.
If it does not, the Industry will fail and adaquate healthcare will be available only to the wealthy, our Hospitals will close their doors, communities will suffer and the American way of life will be diminished in ways that are unfathomable.
|
