The Best Medicine for the Patient

by JAMES HOWARD MEANS, M.D.

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You are all right, until you get sick,” a woman who earns her own Jiving and supports an elderly mother said to me recently; “and then yo’re licked.” That sort of frank statement can be heard from an ever increasing number of people in the middle and lower income brackets. They indicate that all may not be as well, in this best of all possible medical worlds, as the spokesmen of the organized medical profession would have us believe. We hear a great deal about the kind of medicine the doctors want, but the question persists: What kind do patients want?

Organized medicine likes — and lights to retain — the medical status quo, private enterprise, individual medical practice. Patients often do not like it. Doctors and patients agree, however, that medical care should be of the best quality that medical scientific knowledge permits, and must be dispensed with skill and judgment on the part of the doctor. But the great controversial issue is: How shall medical care be equitably, efficiently, and economically distributed to all people, and how shall it be paid for?

We may have the best medicine in the world, as organized medicine claims, but it is very far from being universally available to our people. It would be more truthful to say we could have the best medicine if all our professional personnel, facilities, and resources were used to the best advantage of all concerned. The highly individualistic nature of medical practice in our country today is one of the major obstacles to the attainment of this objective. The medical profession sometimes loses sight of the fact that medical care is a service, and that, as with all services, there are those who provide and those who receive. Both have their rights, and neither must be permitted to trespass on the rights of the other.

Public discontent with the medical situation has been boiling up for more than a quarter century. Survey after survey has disclosed an appalling amount of unmet medical need in this, the most opulent nation on earth. The introduction of health bill after health bill is indication enough that our lawmakers are aware that the people want something done to give them belter medical care.

In the spring of 1951 President Truman challenged opponents of health legislation to come up with a better plan. None having been presented, on December 29 of that year he appointed a fifteenmember commission known as The President’s Commission on the Health Needs of the Nation. This commission has been actively engaged gathering the information ever since. It has worked through the medium of thirty panels of experts, and a preliminary report of findings and recommendations is expected soon. One of the members of the commission assures me that their studies confirm the existence of much unmet medical need, and that the problems resulting from the need are being identified, particularly under the headings of medical care in rural districts; care of the aged and of chronic invalids; integration of, and payment for, medical services; excessive infant mortality in certain areas; and the great problems of financing medical education, and of the relations between general practitioners and specialists.

The first requisite in the medical care of the individual patient is a good physician. The qualities which make the good physician are several. Of course adequate knowledge of medical science and the skill to apply it are indispensable, but there are other requirements. Plato puts it this way: “No physician, insofar as he is a physician, considers his own good in what he prescribes, but the good of his patient; for the true physician is also a ruler having the human body as subject, and not a mere money-maker.” These statements remain as true today as in Plato’s time; but our present-day society and our stock of medical knowledge being vastly different from Plato’s, the manner in which the physician fulfills his function is very different also. The complexity of what medicine has to offer the patient today transcends anything ever dreamed of fifty years ago, No longer can one physician meet all the requirements of medical care of patienls; nor can patienls meet, on a pay-as-you-go basis, the costs of all the professional services, involving both those of generalists and those of specialists, which their cases may require. Professional teamwork in the provision of medical care, and new ways of spreading its mounting costs, have become essential. The failure thus far of free-enterprise medicine to fmd solutions to these problems is the cause of all the present agitation about health legislation.

Under any system of medical practice, individual, group, private, or public, the accurate placement and acceptance of responsibility is imperative. The whole matter of the relation of generalist to specialist is a pressing one. Good medical care of the individual patient must be responsible medical care; hut in these days when a lot of specialists are involved, it may be very uncertain just who is responsible for what. It is my own deep conviction that for good medicine in every case, no matter under what circumstances medical service is being provided, some single physician must have final responsibility for ihe care of the patient. In other words, some one doctor must be in command, and remain so until he relinquishes the responsibility to another, at either his own wish or the patient’s. When a general practitioner is in charge of a patient, there need be no fuzziness about responsibility. He obviously is in charge of the whole situation. Tf he calls in consultants, then it is his responsibility 1 o decide whether to follow their advice. Two or more heads may be belter than one in arriving at a correct diagnosis, but one head has 1o make the decisions which lead to a course of action for the care of the patient.

The situation is less clear when a patient, as often occurs nowadays, goes on his own initiative first to a specialist. What is the responsibility of the specialist under such circumstances? My philosophy would be dial the specialist, being the only doctor so far in ihe case, in spile of being a specialist — perhaps a rather narrow specialist —is still responsible for the patient’s total medical welfare uni il he 1 urns the case over to a not her doctor. \\ hat actually happens, I suspect, in most such instances is that the specialist goes along examining and caring for on I v part of t he pal lent tin less som’ sympt om or local sign suggests to him that more than the local disease exists; then he calls for help. Because hidden disease mav produce no sy mptoms, there is always risk in caring for a local disease without proper study of the whole patient.

The requirements for adequate medical care are best met when a physician capable of studying the patient in his entiret’ is consulted firsl and then does the necessary referring to specialists. When the role of a specialist, for example a surgeon, 1urns out to be the ma jor one, final responsibility should be turned oxer to him until his work is done. Then the generalist should again take charge.

In setting up professional teams or groups to provide integrated medical care, the placement of responsibility in some such way as I have indicated should be scrupulously carried out. Experience has shown that it is quite possible to do this. The responsible role of each member of a professional loam or group can be preserved within the group if there is the will to do so. Conversely, responsibility can be lost in individual practice if patients go shopping from specialist to specialist. Not infrequently in this confused society of ours they do just that, somet hues in order to compare the advice of one doctor with that of a nother, to make a selection of their own from among several opinions. Only the wealthy can a fiord such a procedure, and even they are likely to suffer from it, since the layman usually cannot judge accurately the value of a medical opinion.

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ANOTHER consideration is the effect which the palient’s illness has upon the community; because in addition to the patient’s direct interest, the doctor has the responsibility to minimize insofar as he can the burden which the patient’s illness may throw on others. In serving this function he can derive invaluable aid from the medical social worker, not only in cases from the lower and middle income brackets, but not infrequently from the upper also.

Heretofore medical care of communities has been thought of as somet liing apart from that of the individual. “Public health service" it has been called, and it has been generally regarded as a responsibility of government, national, state, or local; whereas medical care of the individual has been looked upon as purely a function of the medical profession to be carried out, in our country at least, by private competitive enterprise.

Abundant evidence is cropping up nowadays that such a separation is no longer tenable. It is significant, for example, that within recent years the American Public Health Association has set up a. section on “Medical Care.”The public health people are recognizing that the illness of any single member of the community is a concern of the whole community. By becoming sick the individual creates a social vacuum which affects others than his immediate family. For whatever he was doing that was useful, a substitute must be found when he becomes incapacitated. Certain other persons must spend some of their time caring for him. The costs of his illness and incapacity must be paid somehow, even though it be from taxation or charity. Consequently, illness of the individual, like fire, flood, or other destructive processes, is always a loss to the whole community.

The public interest, therefore, demands not only that water and food supplies be kept pure and that communicable diseases be controlled; it requires also that every individual receive such medical care, both preventive and curative, as will bold his days of incapacity to an irreducible minimum. The growth of rehabilitation clinics, which has received great impetus from the work of Dr. Howard A. Rusk at New York University and Bellevue Hospital, is an important effort in that direction. It is far better for the chronically ill or crippled person to be restored even to a fragment of useful activity than to remain in enforced idleness. Anything at all useful that he can do promotes his own peace of mind and thereby improves his health; it also lessens the burden he imposes on others.

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THE methods of paying doctors for supplying medical care have a direct bearing on the quality of care. There are four main sources from which they can be paid — private pocket books, tax money, employers’ money, and charity — and there are three main methods of paying them —the time-honored fee-for-service method, capitation, and salary.

Tee for service is what organized medicine clings to. It has somewhat grudgingly approved the other methods in situations in which complete doctor control is maintained. The trouble with fee for service is that it makes little if any provision for preventive medicine and it may make the patient postpone going to the doctor — a delay that could have serious consequences. When consultations with specialists are required, it means a multiplicity of charges which may add up to distressing proportions. Under fee for service the more patients the doctor sees, the more money he makes, and this leads to the risky situation where he is templed to overload himself. A doctor must be unhurried to practice good medicine.

One of the worst features of fee for service is that it is a downright invitation to fee splitting, the evils of which were publicized last September by the American College of Surgeons. The best form of the fee-for-service method is found when the fees are determined by a neutral party — for example a hospital administrator or the business office of a practice group — in accordance with an accepted schedule of fees. Such a procedure has been in successful operation in the Baker Memorial of the Massachusetts General Hospital for the last twentytwo years.

Capitation is the method which is now used in Great Britain for paying general practitioners under the National Health Service. It means that a doctor has a panel of patient s, for each one of whom he gels a fixed fee each year, in return for which he is to render such complete general medical service as the patient requires. Under the unrestricted fee-for-service method of payment the doctor can exploit the patient, by requiring him to come too often, while under the capitation method the patient can exploit the doctor by demanding attention when he doesn’t need it. Overloading of the doctor under capitation can be checked by limiting the size of his panel to a number of patients which he can handle unhurriedly.

Altogether it is my belief that the best method of paying the doctor is by salary — best for him and best for his patients, provided at least that some safeguards against overloading are included. Of course paying doctors by salary presupposes the existence of some agency, an organization for medical care, to which payments lor care are made and by which they are redistributed to meet the costs.

The patient can pay the doctor in one of three ways: irom his own pocket book or from funds derived from indemnity insurance; by participating in some form of prepayment plan which provides services directly; or by getting the government, his employer, or a charitable organization to meet the costs for him.

Of nonprofit sickness insurance plans, Blue Gross for hospital charges and Blue Shield for doctor’ bills are at present the most nearly nation-wide in scope. Blue Cross is the older, the larger, and by far the more complete in serving its purpose, which originally was to provide for its subscribers, in return for an annual lived premium, as complete security as possible against all hospitalization costs. Benefits included not merely bed, board, and nursing, but special services such as laboratory examinations, X rays, and anesthesia. Unforlunately under the pressure of mounting costs the special benefits have been somewhat pared down.

Blue Shield was set up to help patients meet the costs of doctors’ services. The idea is fine, but actually Blue Shield is a poor thing in contrast to Blue Cross. Sponsored usually by state medical societies, it differs from commercial medical expense indemnity insurance only in that doctors have agreed to accept fees lived according to a fee scale for persons in lower income brackets. For persons with higher incomes, doctors are free to increase their fees as they wish. For the most part, Blue Shield pays doctors’ fees only when the patient is hospitalized. Care outside of hospital is included in the benefits in a very restricted manner. Thus Blue Shield added to Blue Cross does not really constitute a comprehensive health plan; and most important, the two together make no provision for preventive medicine, as do some other enterprises.

All people want, need, and deserve comprehensive medical care. This may be defined as all services necessary to keep them well or get them well if they become sick. It includes not only the services of physicians, surgeons, and public health officers, but of all the auxiliary professions — nursing, social work, and so forth — as well. These services must be available in office, in clinic, in the home, or in the hospital, as the case requires. Preventive medicine must be included no less than curative medicine. Many attempts to move toward this ideal are being made in our country today, both by government and by private enterprise. Only the private plans fall within the scope of the present article; the role of government will be considered in a future paper.

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THE initiative may come cither from the medical profession or from the side of the consumers. Doctors may organize to provide medical care more effectively, or people may organize to obtain it. Two or three doctors in partnership, so that each may be off call at certain stated times, is the rudiment of organization. But there are now a considerable number of organizations for medical care, throughout the country, of much larger proportions than that.

The doctor-run private-practice group is a very familiar one. Generally called Clinics" with a designating adjective ahead, they vary greatly in size, in the number of doctors participating, and in the extent of services offered. Few if any offer what can truly be called comprehensive medical care, but some approximate it. Within such groups there should be general practitioners, as well as specialists, who establish the responsible doctorpatient relationship and steer the patient through the maze of the remainder of the clinic. Such private-practice, doctor-controlled groups are often dominated by a single member. He may even own the enterprise, hiring his staff as professional employees, paying them straight salaries or salary plus a share of the profits at the end of the year, and having the right to discharge them as he pleases. Patients in this type of clinic, however, usually are charged on the fee-for-service basis, which mav at times be as high as the traffic will bear. Such an autocracy is entirely acceptable to organized medicine so long as it is completely doctor-controlled; but if any element of lay control should creep into a group, it would become thoroughly distasteful to them. When such a situation exists, one generally finds that the boss is a surgeon. Olten the clinic bears his name. This, to my way of thinking, is unfortunate. A clinic headed by a surgeon tends to be overweighted in favor of surgical trealment.

The most famous of private-group clinics in the United States is the Mayo Clinic. Starting in the individual private practices of the Mayo brothers, this enterprise has grown over a period of many years during which it has passed through stages of autocratic, oligarchic, and now of limited democratic control, to truly huge proportions. Its doctors are on salary, but its patients are on lee for service. It offers, with its affiliated chain of hospitals, comprehensive medical and hospital care for as long as its patients remain in the town of Rochester, Minnesota, to which some of them come from very long distances. Correspondence and return visits to the clinic furnish some degree of follow-up care, but a clinic in Rochester, Minnesota, no matter how comprehensive its services, cannot provide continuous comprehensive medical care for persons living in Bath, Maine, or Phoenix, Arizona. The great cost of travel of huge numbers of patients from all over the country to and from the Mayo Clinic and other similar centers is an item in the total medical bill of the American people which must be classified as a luxury. Usually it is possible to get adequate service nearer home.

In the case of organizations for medical care, or health plans initiated by consumers, we again find a variety of types. There are those set up by labor organizations for their members, or by industry or employer groups for their employees, or by groups of people in a community for themselves.

The Sidney Hillman Health Center in New York may be taken as an example of the first. This organization represents the laudable effort of a great labor union to obtain “ Radiant Health,”as it is put, for all its members. Established through joint action of the Amalgamated Clothing Workers of America and the New York Clothing Manufacturers Exchange, this plan, for an annual ten-dollar fee paid by members of the union to the Center, furnishes all the diagnostic serv ices and treatment that it is possible to provide to ambulatory patients in a thoroughly well staffed and equipped clinic building. Preventive medicine is stressed, and “comprehensive health inventories” as well as day-to-day medical service are included. Domiciliary care and hospitalization when needed have to be arranged outside the plan, but the Center cooperates freely with outside doctors who have been called by its members, by furnishing full informal ion about all relevant services within the Center. The whole objective is to reduce to the absolute minimum the need for domiciliary or hospital care by promoting health and preventing disease at the Center. By any modern philosophy of medicine this objective must be regarded as thoroughly sound.

As an example of an employer-run health plan we may take that offered by the Endicott-Johnson Company in “Three Cities,”New York. Gradually built up by the company as “a means of general health promotion,”this plan now has a staff of about forty-five doctors (the majority engaged for only part of their time) and operates two excellently equipped clinics, one at each end of the area served. In these clinics office type of service is provided, and domiciliary care can be given when needed. There are abundant good hospital facilities in the neighborhood. Complete medical care of high quality is provided entirely free by the company for all employees who have been employed six months or more and their dependents, and all hospital bills are paid by the company. Approximately 18,000 employees are eligible and they and their families make a total of about 50,000 people covered. The cost to the company of this complete health service for the year 1950 was about $42 per employee. The plan is financed entirely by the company. The management believe that it is money well spent, promoting both the health and the morale of their people.

The Endicott-Johnson plan operates, of course, for a very specialized community; nevertheless it is worth study from the organizational and actuarial points of view, it demonstrates one way in which a population of 50,000 can be given good, comprehensive medical service at low cost. Somewhat analogous to it are certain university and college health plans, together with other industrial plans, operated sometimes by management, sometimes by labor, sometimes jointly. Personally I believe that the Sidney Hillman type in which members take great pride, because they originated it — it ‘s their baby —is sociologically sounder than the free-gift-from-the-employer type, which is essentially paternalistic.

One of the most promising types of endeavor on the part of members of a community to secure comprehensive medical care for themselves falls in a category which can genericully be called the “consumer-sponsored cooperative health plan.”There are over twenty of these now, fairly well scattered over the country. They have become linked together loosely on a national basis through the Cooperative Health Federation of America, which has headquarters in Chicago. Under this plan a group of people organize themselves into a cooperative and engage a staff of doctors to provide medical care, and to obtain clinic and hospital facilities as needed.

Organized medicine hates these coöperatives and does its best to put them out of business; nevertheless they have continued to grow and flourish — which proves that they meet a public need. In trials of strength in the courts, the coöperatives have won at least three important victories. The first was the famous Supreme Court of the United States decision of 1943, in which the American Medical Association and the Medical Society of the District of Columbia were found guilty of conspiracy in relation to their attempts to put Group Health Association out of business. Group Health is a coöperative of the type which I have described.

A more recent example is the decision of the Supreme Court, of the State of Washington, handed down November 28, 1951, enjoining the county medical society from making similar attempts against Group Health Coöperative of Puget Sound. In California the San Diego County Medical Society brought a suit against a similar cooperative, d he society had alleged that the coöperative was practicing medicine illegally, but the trial judge on April 22, 1952, found no evidence of this and rebuked the society. Finally, in May, 1952, probably as a result of these several decisions, a case concerning a cooperative in Elk City, Oklahoma, emerging from twenty years of struggle, was settled out of court in what was clearly a victory for the cooperative.

I am not suggesting that the cooperative type of health plan is the ideal solution to the over-all problem of organizing for medical care. However, it is one way, and its possibilities and limitations should be determined by experiment, as is in fact being done. Organized medicine should give full support to such research.

In my article in the Atlantic for October, 1950, the Health Insurance Plan of Greater New York was briefly considered. It describes itself as a community enterprise. Through a chain of practice groups scattered over Greater New York it offers highgrade comprehensive medical care on a prepayment basis to nearly 400,000 subscribers. Hospital costs arc met from Blue Cross subscription (or its equivalent) which is required of HIP members. I also discussed two doctor-controlled prepayment plans, Permanente and Ross-Loos in California. HIP particularly seems to be highly promising, and to meet a widespread demand. It pays its medical groups on a capitation system. The group then takes these fees and redistributes them, paying the doctors by salary, a somewhat novel use of the capitation system which is working very well.

If by best medicine for the patient we mean best for every potential patient, which means everybody, then it becomes evident that organization for medical care must be on a nation-wide basis. If we are to develop a national health plan by private endeavor, it will have to be derived from voluntary plans of the kinds just mentioned. It is conceivable that private health plans might enlarge and coalesce throughout the country in a manner finally to include all people not already covered by government, but such a consummation would require medical statesmanship of a type not yet in sight, at least among the controlling echelons of organized medicine. It is because they see no likelihood of achieving a national health plan by private enterprise that a number of highly intelligent persons have swung to compulsory health insurance as the only means which can maintain health fairly for all our people.