Changes in Health Care over time
An article in Saturday’s Boston Globe (8/21/10) recalling the 200th anniversary of two physicians starting the first hospital in the United States evoked many memories of the way changes in health care innovation have evolved since then; many wonderful and some not so wonderful. Great contributions like the development of penicillin by Dr. Fleming in the late 1920s and cardiac catheterization by Dr. Lewis Dexter at the Brigham in the 1960s led to great advances.
Physicians in the 60s and 70s recognized the need for specialized technology to further advance their ideas which led to collaboration with bright engineers like Herb Karsh at MIT’s Lincoln labs which led to the development of an early computer to facilitate physiologic study of the heart.
Paralleling these medical innovations were health insurance programs. Initially there were indemnity programs which set “reasonable” (less than charged) fees. In the 80s HMOs made their appearance with moderately discounted fees which physicians, hospitals and other medical personnel either accepted or were unable to care for patients who joined those HMOs. That was probably the beginning of the end of the strong bond of the physician/patient relationship. Patients from one community could not continue to see specialists from another as they were not in the same circle or network. Significant reductions in reimbursement led physicians to reduce their time spent with patients further eroding that relationship. Independently, technology exploded with bright engineers developing solutions to medical problems before physicians recognized their potential usefulness. Health care costs exploded. HMOs discounted more. Medicare, facing depletion of its trust funds, encouraged patients to shift to HMO Medicare plans which costs the government less than traditional Medicare.
Cost containment became more important than how medical care was delivered. All those payers – government, insurance companies, and HMOs focused all their attention on that goal. Hospitals became more concerned with garnering your insurance information to ensure payment then to addressing your care. Rising care costs have been attributed to variations in care, too great a use of technology, excessive pharmaceutical costs, defensive medicine etc. Each attempt to rein in costs has, not surprisingly, led to rapid escalation in costs. The “system” has not yet figured out then when two parties ( doctor and patient) decide on what is done for a patient AND someone else pays for it (insurance company), there will be excessive spending. Every patient will tell you to spare no expense. “I’ve got insurance”. Go to a cocktail party where there is an open bar and see how much liquor is consumed in comparison to a similar party with a cash bar.
So now we have health care reform which will add 30 – 40 million people to the insured pool and we are told it will save money. How are they going to do it? Standards of care are being developed which stipulate what care is appropriate for a given diagnosis and equally important, what care is inappropriate (unnecessary or redundant). Interestingly, there are few if any physicians in clinical practice developing these standards. The newly enacted Health Care Reform Act has hundreds of parts. Another one of these is mandatory computerized medical records for physicians and hospitals. Using the standards of care and the medical record will make it easy for any insurance company to control the practice of medicine. Just print out the guidelines and pay for those things that are recommended and debit the provider for those not recommended.
We’ve come a long way from those two physicians who started a hospital 200 years ago. Unfortunately it may not be such a good direction.
Gerald L. Evans, M.D.