Medicine: Crisis of Organization

NATIONAL HEALTH

Crisis of Organization

The “health industry” is already the nation’s third biggest employer. By 1975, it may well be the biggest. Costs for its services are rising twice as fast as the general cost of living, and are expected to keep on soaring, hospital costs to the tune of 250% by 1975, physicians’ services by 160% and dental care by 100%. Yet the industry is ill-organized and inefficient, and much of the care given in hospitals is of poor quality. That is what the National Advisory Commission on Health Manpower reported to President Johnson last week. It recommended a variety of remedies, and some preventive medicine.

Appointed 18 months ago, with Engine Manufacturer J. Irwin Miller of Columbus, Ind., as chairman, the 15-member commission included five physicians. Two of the best known: San Francisco’s Dr. Dwight L. Wilbur, president-elect of the American Medical Association,* and the Mayo Clinic’s Dr. James C. Cain, the President’s old friend and personal physician. In its proposals for wide and deep reforms the commission showed remarkable unanimity; there were only half a dozen footnotes of individual dissent in its 86 pages of review and recommendations.

More than Numbers. At the outset, the commission was faced with an apparent paradox. In proportion to population, the numbers of physicians, hospital beds and other health facilities are equal to or greater than they were 30 years ago; research has vastly expanded medical knowledge, and insurance and Government funds have “reduced financial barriers to care.” Yet there is a “health crisis” in the country, marked by long delays in getting to see a doctor for routine care, hurried and sometimes impersonal attention, difficulty in getting care at night and on weekends, unavailability of beds in one hospital while beds are empty in another near by, uneven distribution of care hurting both urban and rural poor, and obsolete hospitals in many of the major cities.

The crisis, the commission quickly concluded, is not one of numbers alone, though they are important. It involves the organization of care and the system by which it is provided. Unhappily, the commission found, the so-called system in the U.S. is not a system at all but “is more a collection of bits and pieces, with overlapping, duplication, great gaps, high costs and wasted effort.” Recommended corrections:

∙ MANPOWER. Though the number of new doctors will increase between now and 1975 at a faster rate than the population, and each doctor will be able to give 50% more services, those increases will not be enough because the demand for services will rise still faster. Medical schools should increase the size of their classes, with federal funds as a stimulus; new schools also should be helped in getting started. The length of medical and specialty education should be shortened so that doctors can begin earning a living earlier. Use of foreign medical graduates, who now make up 28% of doctors in training programs, should be gradually phased out. Training of more dentists should be subsidized by the Government. Since a shortage of nurses persists despite currently adequate training facilities, “nursing should be made a more attractive profession” by providing increased professional responsibilities, improved salaries, more flexible hours for married women, and better retirement provisions for nurses of every sort.

∙ FINANCING EDUCATION. The Federal Government should “carefully explore” ways to provide funds directly for medical education (something that the A.M.A. had opposed until last summer). To help individual students, the commission recommended a greatly expanded federal program of loans to be repaid after graduation. Radcliffe College’s president, Mary Bunting, went along with this grudgingly, “until such time as free medical education becomes available.” Dr. Wilbur dissented emphatically, declaring the idea unsound and impractical and “largely unacceptable to most students.”

∙ RE-EXAMINATION. Licensing of the health professionals, now subject to wide variation among the states, should at least set minimum requirements that “would assure citizens a basic standard of quality wherever they might be when illness occurs.” After that, doctors especially should be induced to keep their knowledge up to date by being subjected to periodic re-examinations, and then performance should be continuously monitored by local “peer groups.”

∙ IMPROVING HOSPITALS. Variations in costs between top-quality hospitals are enormous: in New York City, the average daily cost of treating a patient ranges from $50 to $87; across the nation, from $46 to $96. The disparity among community hospitals is as great or greater. The Federal Government and private insurers should experiment with new methods of paying hospitals, to reward them for efficiency and high-quality care. It should be made unprofitable for a hospital to reduce quality and community service in order to lower its costs. Then the better hospitals would expand, and the poorer would wither away.

∙ INSURANCE COVERAGE. Health-insurance organizations should develop plans to cover outpatient as well as in-patient services. This would cut down the unnecessary admissions to hospitals that are now engineered to get insurance reimbursement. Committees of physicians should review the laboratory tests and other procedures ordered by their colleagues, to make sure that they are necessary and not overly expensive.

One way to improve medical care is to have the patient pay for it in advance and to have the doctors who provide it practice in groups, said the Wilbur Committee’s report in 1932. This year’s commission, though favoring prepayment, gives no such strong endorsement to group practice. Joseph A. Beirne, president of the Communications Workers of America, argued in vain that the commission should have taken a forthright stand in favor of pre-paid group-practice plans, in the light of “compelling evidence” that they bring about the most economical delivery of medical services. Even without that, the commission gave most of the planners among the nation’s health professionals plenty to think about. Said President Johnson: The report is “required reading for members of the Cabinet.”

* And son of Dr. Ray Lyman Wilbur, who was Herbert Hoover’s Secretary of the Interior and headed a similar presidential commission on health costs in 1927-1932.