Where It All Began

Their stories begin in the 1980s, but by then the die was cast. How and why did the crap shoot begin?

During World War II we invoked wage and price controls to manage an economy confronting shortages of workers and goods. The civilian sector competed with war industries, with cost plus contracts for the few workers on hand. Both offered the one inducement exempt from wage controls - health benefits.

Employers and unions vied for the right to negotiate such benefit contracts for their employees and members. The first packages were based on indemnity plans insuring a large pool of low risk, healthy and active beneficiaries. Later, employers and unions turned to capitation and closed provider panels to improve access and control costs.

Post-war "baby-boomers" saw themselves as healthy workers, not patients. All they wanted was coverage for pregnancies, for their children, and for that rare, unexpected, costly medical event. They still enjoyed a personal relationship with their treating physician and had little use for specialists. Primary care doctors were the norm; specialists were rare; hospitalization - auguries of a grim outcome - nearly as rare.

Physicians who had given or bartered their services away during the Great Depression, enjoyed having patients with cash in their pockets or an indemnity policy that asked no questions. Medicine was changing, but was still more the art of healing than the science of treating.

As diagnosis and treatment became more potent and procedures more specific and complex, costs and fees soared. Patients learned to want specialists, symbols of the new magic, and came to expect more magic than tenderness from their physicians.

Benefits inevitably become entitlements - whether distributed by government, employers or unions. In the boom years after World War II, new families blossomed. They became materialistic "consumers" - the new name for "patients" - and felt "entitled" to seamless care from cradle to grave, from prevention to terminal treatment.

Large not-for-profit "health maintenance organizations" developed, especially in New York, California and Washington States. "Closed panels" or "physician cooperatives" under contract to employers or unions, they promised access to quality care and cost containment through prevention and early intervention.

As former wage-earners grew older, left their jobs and lost their insurance benefits, they became "worthy" but high-risk elderly. Many had to turn to the parallel, but not equal, eleemosynary systems of care. Underfunded and over-burdened county facilities and teaching and church-operated facilities in the disjointed health care system united in fear behind a single-payer system, "Medicare."

Never before had the U.S. public bought a single-payer, government-operated, universal coverage health care system. Elderly "consumers" wanted it. Providers wanted it. Society wanted it. Medicare would end the discriminatory two-track non-system that separated medical care for the "haves" from that for the "have-nots." Medicare would rely on mainstream medicine to serve the elderly poor.

No one seemed to anticipate the impact of such a large infusion of money into the healthcare market place. Prices soared. Physicians and hospitals charged what the traffic would bear - and high expectations made for heavy traffic. Squeezed middle class "consumers" and their insurers, including government, exerted pressure to institute voluntary fee schedules and slow the rise of hospital charges. Government regulations tried to reduce duplication of facilities and resources and introduced peer review to limit "unnecessary" care - letting physicians define "unnecessary."

Nothing stopped the inflationary rise. Employers were in the driver's seat, whipping the team of insurers and managers into reducing health care costs. Physicians had increasing medical responsibility and decreasing authority. High costs and high expectations soured patient-physician relationships. Access dropped, malpractice claims rose, management costs rose, and care became more, not less, fragmented. Reciprocal suspicions replaced the old physician-patient alliances; patients and physicians became intrusive strangers to each other.

Some, but not all, physicians knew how much hospitalization and outpatient procedures cost, but were reluctant to talk about that with patients, nor did patients want to hear about it - until after the services were rendered, or withheld, when they could complain with impunity.

That's where Drs. Gibson and Pan begin their story, but first let's look at two recent findings.

The California Health Foundation report, "The Quality Initiative,"¹ compares how "consumers" and "experts" define quality of health care.

"Consumers," it says, "judge quality by personal interactions with providers and organizations." Consumers frame quality as access to care when and where they need (want) it and provided by people who answer their questions, seem knowledgeable and treat them "with respect, consideration and empathy." Consumers also wonder "whether managed care is inappropriately denying access to expensive specialists or procedures" - as they used to wonder whether physicians were doing "acute remunerative" procedures.

The Foundation turns to the Institute of Medicine for its "expert" definition: "Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

"Experts" look for how well patients function in daily life, including how much emotional and informational support patients receive. Experts compare health care outcomes for treated and ignored patients and local standards with universal best practices. Outcome is what matters to experts.

The other relevant finding concerns physician attitudes. Ginsburg, Kravitz and Sandberg (our very own) surveyed 1000 physicians in clinical practice in El Dorado, Nevada, Placer, Sacramento and Yolo Counties and published their results in the December 2000 Western Journal.² They found that 92 percent of physicians considered cost containment a legitimate need in today's health environment and 95 percent said individual clinicians should play a role in that containment.

Although about equally divided on whether the physician had a duty to offer a medical intervention regardless of its cost, 88 percent said it was appropriate for physicians to consider cost-effectiveness when weighing medical interventions.

These physicians identified the following barriers to cost-effective care:

o Patients with "unrealistic expectations" (93 percent of surveyed physicians).

o Patients not directly sharing health care costs (85 percent).

o A short term view of coverage decisions (86 percent).

o Society's unwillingness to acknowledge health resource limits (93 percent).

The survey did not ask physicians about their responsibility to discuss cost and cost-effectiveness as part of consent discussions or their responsibility to inform and educate coverage decision-makers and public policy makers about the importance of direct patient payment and long-term costs of short term benefits.

Until physicians bring their expectations and the public's expectations closer together, the health care system will be in turmoil, and medicine, which used to be a way of life for physicians, will remain a device for making money for CEOs and stockholders.

Ed_Rudin@macnexus.org

1. The report may be downloaded in PDF format at www.chcf.org.
   2 Ginsberg M.E., Kravitz R., Sandberg W.A. "A survey of physician attitudes and practices concerning cost-effectiveness in patient care." WJM 2000; 173: 390-94.