A Continuing Series on the Report of the Committee on the Costs of Medical Care, 1932.
In Chapter Two the CCMC outlined six essential elements or criteria to judge the completeness of a health care system:
1. “The plan must safeguard the quality of medical service and preserve the essential personal relation between patient and physician.
2. It must provide for the future development of preventive and therapeutic services in such kinds and amounts as will meet the needs of substantially all the people and not merely their present effective demands.
3. It must provide services on financial terms which the people can and will meet, without undue hardship, either through individual or collective resources.
4. There should be a full application of existing knowledge to the prevention of disease, so that all medical practice will be permeated with the concept of prevention. The program must include, therefore, not only medical care of the individual and the family, but also a well organized and adequately-supported public health system.*
5. The basic plan should include provisions for assisting and guiding patients in the selection of competent practitioners and suitable facilities for medical care.
6. Adequate and assured payment must be provided to the individuals and agencies which furnish the care.
When, hereafter, the Committee speaks of a ‘satisfactory medical service,’ it means a service which meets these six criteria.
“The term ‘public health program’ is meant to include the work of the official public health department and of voluntary health agencies.” (CCMC op.cit. pg 38).
The Committee elaborated on these points:
1. Quality was the highest criteria. Quality had to promote the physican’s time to be up-to-date on post graduate studies, time with their colleagues and patients and avoids “….setting up any conflict that put the practitioner’s economic interest and his professional interests in conflict, or if it isolates certain practitioners from necessary association with others, these defects must be corrected or the plan condemned.” (CCMC op.cit. pg 39).
The personal relation between the patient and the physician was sacrosanct. “….not only the privileged confidential communications of patient to physician which are recognized as inviolate by law, but also the relation in the communication of his medical history to any physician chosen by the patient and the continuing mutual responsibility between patient and physician. (emphasis theirs)….The business relation between physician and patient is not considered a necessary part of the personal relation as defined above nor does the definition carry a commitment for or against any scheme of organization of medicine.” (CCMC op. cit.)
The Report went on to say: “….The physician needs continued contacts and study to enable him to treat the patient as a human being in a family and a social environment and not merely as a complex of symptoms….the physician must have the opportunity to establish himself as the trusted adviser and confidant of the patient on all matters affecting health. Confidence is frequently more important than drugs.” (CCMC op.cit. pg 41).
2. Meeting the People’s Real Needs. The Committee wanted to provide good medical services for all the people. It recognized, however, that this might not be possible to do all at once and asked instead that a plan be made that would eventually lead to coverage for all.
3. Service on Acceptable Terms. The Committee felt strongly that hospitals and physicians should not bear the burden of charity care, as they did at that time. It also thought the patient should not have to choose between expensive care or no care. “A satisfactory program should make it possible for a large proportion of the total population to pay in full whatever may be charged for needed medical service, on terms which are reasonable and which fully preserve self-respect. The cost of care of those who cannot pay should be distributed, according to ability to pay, over the rest of the community.” (CCMC op.cit.pg 42).
4. Prevention. The only issue as important to the Committee as quality was prevention. “Medical service should include systematic and intensive use of preventive measures in private practice and in public health work….Through the prevention of disease further increases in the total cost of medical care can best be avoided….any program for the provision of medical service should have as its paramount aim the prevention of disease.” (emphasis theirs) (CCMC op.cit.).
The physician was seen as being the person responsible for teaching preventive health measures to his patients. Public health services should be adequately supported and include: “…. a) collection of vital statistics; b) the control of water, milk and food supplies; c) the control of sanitation; d) the control of communicable diseases, especially tuberculosis and venereal disease; e) the provision of laboratory services; f) popular health instruction; g) the provision of maternal, infant and child hygiene, including school health service; and h) the organization of other special services as needed for the prevention and treatment of malaria, hookworm or other diseases which constitute special health problems.” (CCMC op.cit., pg 43).
5. Competent Practitioners. Because the physician is the only person who understands the medical arts, and because medical services are a ‘commodity’ that the public cannot evaluate, the Committee believed the patient must be assisted by physicians to select the best practitioner.
6. Adequate Payment. The Report stressed the importance of paying hospitals and physicians for their education, services and facilities. They felt such funds must come from the patients and “….from some central fund to which he has contributed all or part of the amount needed for his care.” (CCMC op.cit. pg44).
In what was sure to be controversial, the Committee recommended three major approaches:
a) “The development of types of organized or group practice that will effectively and economically meet the community’s medical needs;
b) The distribution, over a period of time and over a group of families or individuals, of the costs of the services;
c) Provision for the planning and coordination, on a local and regional basis, of all health and medical services.” (CCMC op.cit.).
These recommendations were truly radical in the 1930’s when the majority of physicians were in private practice. Planning for medical services on a local and regional services was probably equally radical and probably seen as an intrusion on a physician’s right to chose his medical specialty.
Coming Next Week: How health care services could be delivered and funded in a group practice model. The O’ConnorReport will be published on Monday, November 22 because of the short Thanksgiving week and resumed on Thursday, December 2nd.