Continuing on our series of the 1932 Report of the Committee on the Costs of Medical Care, this section examines the organization and of the health care system, critiques practices that sound much like current hospitalists, and how to organize health care more economically and efficiently. This analysis and subsequent recommendations were probably what doomed the final Report. Especially the final part of this section on the Costs of Complete Medical Care and the medical needs that must be met. Read on!
Complexity of Medical Practice: One driver of health care costs was the complexity of the health care system. The Report listed the increasing complexity of medical facilities and practices, except in small communities. “A considerable proportion of physicians, amounting in some communities to 30 per cent, limit their practice to a specialty, and almost as many more tend toward specialization. Some twenty-five different specialties of medicine are now recognized.” (CMCC op.cit. pg. 29)
A major concern at the time was the shift from rural living to urban living, modern transportation, and increased mobility of the population, which the Report said contributed to the decrease in the frequency “of continuous personal contact between individual families and physicians. Many individual families, particularly in urban areas, find it difficult to discover a satisfactory family physician, and often unwisely choose specialists without the guidance of a general practitioner.” (CCMC op.cit.)
The Report also noted: “There is a wide-spread public demand for useable information. The increased proportion of illnesses cared for in hospitals forces many patients to choose between home and hospital, a choice which they are not always in a position to make wisely. Many persons are confused by these and other complexities of medical practice.” (CCMC op.cit.)
Organization of Medical Service: The Report also examined how health care services were organized and delivered. It observed that medical professions were very well organized in professional associations at the national, state and county levels, and they “exercise an immense and wholesome influence upon standards of training and practice. Many local and national organizations of specialists stimulate both scientific and practical advances. About two-thirds of the 142,000 physicians of the United States are members of their county medical societies and thus of the state associations and the American Medical Association. These organized medical groups are of the first importance as expressing professional standards and opinion, and they play major parts in representing the profession in its relations with educational, industrial, philanthropic, public health, and governmental bodies.” (CCMC op.cit. pg. 30).
However, the Report noted that there was a new type of organization developing: about two-thirds of all physicians were then associated with hospitals and clinics. National professional organizations were working on how to make the hospital staff organization work effectively with other physicians to create efficient patient care and “effective relationships among staff physicians.” (CCMC op.cit.)
The Report, however, went on to say: “On the other hand, in many ways the growing complexity of medical services has outrun the development of its organization. The fact that medical care may now be obtained through an increasing variety of practitioners and agencies tends to create a lack of continuity in the medical care of the individual. During the course of a single year, he may receive from several different specialists services which are not coordinated by a family physician. If he goes to the hospital, he may pass under the care of a physician who was not previously acquainted with his case; and on his discharge from the hospital, the information concerning his hospital diagnosis and treatment may not be available for the physician or clinic which becomes responsible for his subsequent care.” (CCMC op.cit.)
Health care, the Report noted, is also unorganized from a community perspective: “The educational facilities of a community, on the contrary, are planned and distributed on the basis of the number of children of various ages. The community’s expenditures for education are budgeted, and the relative merits of expenditures for buildings, for equipment, and for teaching staff are discussed and agreed upon. A definite attempt is made to eliminate waste and to maintain standards. Increasingly, building programs for public schools are planned for five, ten and fifteen years in the future, and this is true not only in metropolitan areas, but also in smaller cities and rural areas. The various persons and agencies concerned—school boards, superintendents, teachers, special consultants—are organized to promote effectively their common efforts in a common task.” (CCMC op,cit. pg 30-31).
Noting there are differences between education and medical service, the Report went on to say: “The analogy is useful, however, to show that, although medical service is as essential to the national welfare as public education, the task of providing it to all the people has not yet been tackled in an organized and coordinated way.” (CCMC, op.cit. pg. 31).
Cost of Complete Medical Care: “If services were organized economically and efficiently and were sold to representative groups of the population, among whom there is not an abnormally high rate of sickness, all needed medical care of the kind which people customarily purchase individually could be provided, in urban areas at least, at a cost, excluding capital charges, of $20 to $40 per capita per annum. Included in this care would be the services of physicians, dentists and other personnel and the provision of hospitalization, laboratory service, x-ray, drugs, eyeglasses, appliances and other items.” (CCMC op,cit.)
They noted that this estimate was based not only on theoretical computations, but on the experience of real organizations “now providing complete or nearly complete service for weekly or monthly fees or without direct charge to the beneficiary.” (CCMC op.cit.)
The Report then cited the actual costs from groups that offered complete medical care: Family population of Ft. Benning, Georgia; Endicott-Johnson Employees; Roanoke Rapids employees; University of California students; Employees of Homestake Mining; Families subscribing to Rose-Loos medical service.
The Report noted: “Each of these organizations provides its patients with a substantially larger volume of services that most persons receive for approximately the same expenditures. This is made possible: (1) by the organization of the services so that the time of practitioners is conserved and the medical facilities are used efficiently; and (2) by the provision of service on such financial terms that patients are encouraged to obtain care in the early stages of disease, thus reducing somewhat the number of difficult cases.” (CCMC op.cit. pg. 32).
The Report concludes it’s first chapter with a list of the medical needs that should be met:
a) The people need a substantially larger volume of scientific medical service than they now utilize.
b) Modern public health services need to be extended to a far greater percentage of the people, particularly in rural areas, towns and small cities.
c) There is need for geographical distribution of practitioners and agencies which more closely approximate the medical requirements of the people.
d) In the rural and semi-rural areas, the current expenditures for medical care are insufficient to insure even approximately adequate service, to support necessary facilities, or to provide satisfactory remuneration to the practitioners.
e) There should be an opportunity for many practitioners to earn larger net incomes than they now receive. ….The incomes of general practitioners and of specialists should be more nearly equal than at present, and the opportunity and incentive for ‘fee-splitting’ should be removed.
f) There needs to be better control over the quality of medical service, and opportunities should be provided for improving quality as rapidly in the future as it is has been improved in the past. Practice by unqualified ‘cult’ practitioners should be eliminated, and control should be exercised over the practice of secondary practitioners, such as midwives, chiropodists, and optometrists. The practice of specialties should be restricted to those with special training and ability; more opportunity for postgraduate study should be available for physicians, particularly rural practitioners; and there should be constant chances for physicians to exchange experiences and assist each other. ….
g) There should be more effective control over the number and type of practitioners trained, and their training should be adjusted so that it will prepare them to serve the true needs of the people.
h) There is a need for reduction of waste in many different directions. Substantial sums are wasted on unnecessary medication, on the services of poorly qualified or utterly unqualified ‘cultists,’ in the idle time of physicians, dentists, nurses, and other practitioners, in the high ‘overhead’ of private medical and dental practices, in unused hospital accommodations, and in the time of patients who go from place to place seeking medical services.
i) The prevailing methods of purchasing medical care have unsatisfactory consequences. They lead to unwise and undirected expenditures, to unequal and unpredictable financial burdens for the individual and the family, to neglect of health and of illness, to inadequate remuneration of practitioners. There needs to be some plan whereby the unequal and sometimes crushing burden of medical expenses can be distributed. …
“…it is amazing so much is done. Physical facilities are duplicated between hospitals and the offices of practitioners and are insufficiently utilized in both. Hospital beds are empty and much of the physician’s, dentist’s and nurses’ time is idle while persons suffer and many die for lack of medical attendance. Misdirected expenditures, competition and excessive specialization among practitioners, and the absence of community planning and the integration of services and facilities contributes to excessive waste.” (CCMC op.cit. pg. 33-34).
Responsibility for Present Situation: Despite this indictment of the health care system, the Report pointed no fingers of blame. “….medicine is to a considerable extent dependent upon the whole social fabric into which it is woven. The social attitudes, the habits of mind, the cultural standards, the economic activities, the monetary returns, and the spending habits of the people all affect the practice of medicine.” (CMCC op.cit, pg. 34).
All this work led the CCMC to one conclusion: “None of the major problems of medical care can be solved by any one group alone. Those who furnish the services on the one side and those who receive and pay for them on the other, must cooperate if either is the meet the needs which they perceive or to attain the benefits which they desire.” (CCMC op.cit., pg.35).
Coming Next Week: The Essentials of a Satisfactory Medical Program. In this Chapter, the Report outlines the six essentials for a health care system, how care could be offered through organized groups and how costs could be distributed. This maybe what triggered the intense opposition from the AMA.