In writing this article I am reminded of the fabled three blindfolded wise
men describing the elephant. The results were not uniform, and far
off the mark.
I propose another viewpoint - that from within the elephant's belly and looking out at all the wise men.
This is what I see.
First, some personal definitions. This is about medical care, not "health care".
The latter would include a discussion of junk foods and healthfood stores, the use of jogging shoes and tennis rackets, the effective improvement of still scandalous occupational safety breaches in our profit-oriented corporate structure, the discontinuation of direct and indirect federal subsidies for alcohol and tobacco, and the promotion of transcendental meditation to counter life stresses.
Furthermore, I am not and do not wish to be called a health care professional. I am a physician, one of a group of persons whose philosophic bent, social outlook, liberal education and extensive scientific training have been carried through the furnace of intimate patient care.
All this and only this qualifies a person for the public trust of ultimate
responsibility and judgment for medical care as the ultimate advocate of
the patient. This is “where I am coming from".
Back to the elephant's belly. Around us I see patients, physicians, para-medical professionals, private third party payers, hospital corporations and, of course, the government. Orchestrating this cacophony of sound is the press. Let us probe each separately.
The patient should demand expert care and constant availability. This service should not be overused and requires a corresponding commitment by the patient to his own care. Convalescence and health are participatory sports.
The care should be sought at the most efficient and cost effective level, the doctor's offices - not at the most inefficient, the hospital. Physicians should not be expected to guarantee results or to insure the patient against "acts of God", as distinguished from bona fide negligence.
Furthermore, patients should end their evident commitment to self-destruction with cigarettes, alcohol, overstress, overeating and underexercise. For in the end, only God can put Humpty Dumpty together again.
Physicians are victims of a bum rap, To allege that the medical profession is the cause of a health care cost crisis is the wrong diagnosis, for which some suggested treatments would be lethal
Certainly physicians are more visible than some other components of the problem, and can be attacked with less risk than would he the case with massive corporations or big labor or big government.
But physicians have only partial control over what a patient demands and
no control over what he needs: They have been unsuccessful in reversing
the folly of third party coverage for care often paid only if the care
is provided in the hospital setting. They are also precluded from active
participation in hospital budgetary policy priorities.
Furthermore, "health care cost crisis" is often a euphemism for the idea that "doctors make too much money". The American physician has an average 60 to 70 hour work week in addition to a comparable period of on-call hours; and he accepts ultimate responsibility for decisions of life and death. In return, this average physician earns an average $60,000 to $70,000 yearly.
Computed at an hourly rate and including 20 per cent of on-call time, his average hourly rate of pay is $17.00. Fringe benefits include marital and family problems due to limited home-life, emotional fatigue while carrying his patients' burdens and a significantly reduced life expectancy.
Not an unfair price for a patient to pay for one of the few remaining sources of immediate and uncritical support, friendship, counsel and tangible benefit in an increasingly hostile and uncaring world.
Nursing and para-medical professions have always been of great importance
to the delivery of medical care. Their importance is increasing as
it should and so is the appetite in some quarters for an unwarranted incursion
into areas of ultimate responsibility and judgement – this often proposed
as a cost saving device. To pursue such an expedient apart from ultimate
physician responsibility would clearly reduce the quality of care now taken
The next two elements should be discussed together, since both historically and currently they have operated hand-in-glove. Originally, health insurance covered only surgical care and only in the hospital.
From that unrealistic beginning things got worse to the current ludicrous situation in which not only is much office medical care is not covered, but the third party pays the hospital a premium for rendering the care in the hospital at two or three times the otherwise available rate. The reader who does not already know this is in a fool’s paradise.
This costly and cozy arrangement between third party payers and hospitals,
is the main reason for bloated costs, wherein over 60 percent of "health
care crisis" costs go to hospitals, versus 14 percent to physicians.
Hospitals are great places if you are sick enough to need their special capabilities. They are wasteful and dangerous if you are not.
Incidentally, the 14 percent noted above constitutes about $20 billion annually versus more than $25 billion expended on alcohol annually.
The government correctly views the existing situation with alarm, but typically and sadly refuses to address the real problems. Whether related to the energy crisis, or the arms race crisis or the "health care crisis," our friendly politicians prefer to seek scapegoats and to place Band-Aids on cancer rather than to address real issues.
In their panic, they give only lip service to quality of medical care and prefer to discuss the relative worthiness of patients to receive needed care, a callous concept termed in appropriate bureaucratese, “quality adapted life expectancy.”
The issue is not greedy physicians, or patients dying in the streets without
care, or being maimed with too much care, three favorite themes of the
demigods and demagogues. The issue is that society has removed from medical
care quest and delivery the critical and inexpendable flywheel of supply
What is needed is less third party payment coverage, except for totally covered catastrophy health insurance; more co-payment; less hospital care; relatively ore in-office care; more patient judgment regarding whether a quantum of medical care is really needed; more patient information about the relative qualifications of physicians, since all physicians are not created equal.
What would be the reception for this proposal? It would be outrage by most of the public, some physicians, most unions and corporations (because of favorable tax treatment given to both for this fringe benefit,) and secondarily by politicians. Fat chance - but the only chance to maintain quality care at stable or reduced costs.
By contrasts, the expedients proposed to date - especially national compulsory
uniform health insurance would grossly reduce quality of care while grossly
increasing cost. The results for medicine would be similar to what
his resulted in two existing federalized professional areas - public education
and the dispensing of justice.
The role of the press in this national debate has often been not only that of honest broker but also as active, biased participant, thus making it part of the problem. Whether in my field or in journalism, the people should be given what they need, not necessarily what then want to hear.
There are some who maintain that there is no health care cost crisis, but merely a healthy growth industry that employs nearly seven million people in one capacity or another. I do not subscribe to that view. But neither will I sit by and allow my profession to be prostituted into accepting a treatment far worse than the disease itself.
The proper medicine is at hand, but it is the consuming public that must demand it rather than seeking an expedient and disastrous substitute offered by some of our timid leaders. Time will tell.