Social Transformation of American Medicine

Book Two, Chapter Five: The Coming of the Corporation

2008-11-24T11:09:00.000-08:00

This chapter illustrates the unfortunately traditional tradeoff between efficiency and equity. While reading, I was continually struck by the perversion of patient care by the influx of possible profit. While I don't think that all consolidations are problematic and I understand the economics behind market-based health care, it remains disturbing to me that money has changed the way we provide care. The phrase "wallet biopsy" (page 436) is likely to haunt me forever. The government has worked strenuously to secure public health, first eradicating environmental reservoirs of disease, then acute individual conditions and now, individual chronic care conditions. While I agree that emergency rooms are often abused, transferring a patient to save money at the risk of the patient's life is unacceptable, for-profit hospital or not.

I also find it interesting to note that although a surplus has occurred, it has occurred unevenly. An article was recently released detailing the shortage of primary care physicians. As money was poured into specialties in the 1970s and 80s, a shortage of generalists slowly developed and persists today. Shortages also exist in certain communities. Unfortunately, market based tools are unlikely to adjust for these shortages.

Finally, the comment tying health care provision to a McDonald's hamburger is particularly revealing. On a macro level, we want health care that is effective and efficient. When it comes to health care for ourselves, our children or our parents, however, we want individualized health care, tailored carefully so as to address the individual needs of our loved ones. I am certainly guilty of this. I want health care that provides for all people, but when it comes to the needs of my sister, who is currently suffering from an enigmatic immune disorder, I want the best doctor available. One size fits all is simply not good enough for her. As we move forward and attempt to revitalize and redesign our system, we need to be pragmatic about stakeholder interests and realize that even individually, we hold conflicting values about what a health system should accomplish.

Book Two, Chapter Four: End of Mandate

2008-11-16T11:26:00.000-08:00

Crisis is a powerful motivator, whether a semantic conception or physical occurrence. As Chapter Four illustrates, the crisis of the 1970s surrounding healthcare led to an incredible amount of political activity, little of which can be argued to have moved us forward towards a better system. This is not to deny that there was an impending crisis, but merely to point out that from all the changes and new policies resulted little improvement.

I would argue that most of the crisis was political. While it was generally accepted that health care was an area government should be involved in, particularly because it doesn't get distributed equitably if only done on an ability to pay basis, by the 1970s, both conservatives and liberals were dissatisfied with the system. Costs were escalating far beyond that of inflation and yet, return on investment was flat. Health care, as we've discussed previously, had a significant case of the law of diminishing returns. In the early part of the 20th century, medicine had shifted from public health to acute individual disease care. Thus, improvements were readily observable. As we shifted to chronic care, however, improvements were less easily to observe because they were many improvements in quality of life. As Starr notes, life expectancy and death from chronic conditions were actually improving even in this time of acute criticism. However, people were so convinced of a low rate of return on investment that improvements were shrugged off.

Although I think the word crisis is often applied too soon, its effect is undeniable. I find it interesting that the plight of the uninsured and the poor persists today, along with the creeping sensation of a system in crisis. What will it take to enact true change? Why are the providers so resistant to lose profits? Does the Hippocratic oath not include cost and the barrier created by it as a source of harm? Why has the government resisted significant regulation on health care costs?

Book Two, Chapter Three: The Liberal Years

2008-11-14T19:41:00.000-08:00

This chapter begins to foreshadow many of the issues we still struggle with in health policy today and also shares some eerie similarities with today's political climate. What I found most interesting was the evolving federal role and the tie to leadership and the persistence of some inequities in health care provision that unfortunately persist today.

Starr notes, on page 349, that the Hill-Burton law "carefully limited political, particularly federal, discretion." This limitation of top-down authority is a trend we still observe today. For example, many economic development projects focus on similar geographic areas to the Hill-Burton act (at least in intent). Policy makers seem fervent that these projects should be bottom up efforts, or at the least, state to local, rather than federal-local. While some aspects of a centralized government are necessary in democracy, more than almost any other country, America has rejected the idea of paternalism from the federal government. In this light, it is particularly interesting to note the positive role the federal government has in driving the research agenda. It will be interesting to observe the changes, for example, in research with the Obama administration, as well as a Democratic Congress. Like the U.S. Congress of the liberal years, research grants are expected to rise.

I found it particularly of note that the inequities we struggle with today have been perpetual struggles, through various iterations of our health care system. Even with the best of intentions, the rural areas still end up with the fewest resources, the lowest paid (which likely translates into the least talented) staff and the most basic health care. Similarly, rural health centers face health problems far more complex than suburban health care institutions. Like the center in Mississippi, before providers could deal with sickness, they had to deal with the basic need of food. It is things like this that make working in a rural health center incredibly challenging and explains the high level of burnout.

Finally, the statement about Kennedy being a harbinger of change brings hope. Although we will never know what he would have done had he not been assassinated, his words ring remarkably close to that of President-elect Obama. The words of journalist Godfrey Hodgson offer a warning, however, that Americans "wanted change, but they did not want to be changed". (364) Thus, it is with that warning that we look forward to what Obama might change in health care.

Book Two, Chapter Two: The Triumph of Accommodation

2008-11-08T17:02:00.000-08:00

Since many of our conversations on the discussion forum have focused on the elements required to enact healthcare reform, this chapter was particularly interesting as it provides some history on what societal context gave rise to previous healthcare reforms. Starr talks about how the Great Depression was a huge impetus for the rise of insurance, particularly the rise of Blue Cross and Blue Shield, as well as a variety of indemnity plans. While we are not in a true Depression, we are in a recession and fears about the future are high. I wonder if the combination of economic insecurity and new leadership might be key ingredients to true reform.

I have also been struck throughout the book with the characterization of the AMA. While Starr fairly explains their intent, the effect of their policies seems to do harm, rather than avoid it. To claim total control over medicine is not only impractical, it fails to recognize the complex requirements of a healthcare system. While the relationships between the AMA and rest of the healthcare system appear to be less antagonistic now, traces of this former rift are still apparent. Healthcare providers complain that administrators don’t understand that of the floor staff while administrators hold that providers miss the big picture. If we seek to move towards reform, it is necessary that we move beyond turf battles to collaboration.

Finally, I thought it was interesting how the UMWA created an issue that John Kingdon would call “in-waiting” for a window of opportunity. Lewis carefully build stakeholder support and used various agenda setting opportunities to achieve his goal of insurance for miners. While he initially met opposition, he used the window of opportunity created by the 1947 Interior report to activate the miner’s funds. It is interesting to consider that many of our health policy issues are like the miner’s funds; they are formed and just floating along, waiting for the right opportunity.

The Mirage of Reform

2008-10-26T12:13:00.000-07:00

This chapter is eerily similar to the headlines in the paper this week. As McCain and Obama make their final pushes for the White House, we have heard socialism thrown around as an insult. We have heard about privatizing health care, about establishing national health insurance. It leaves one to wonder whether the efforts of either President-elect will come to fruition, or flounder like the efforts before them.

It seems that the greatest barriers to success are interest group politics and division of efforts. It is interesting to note that incrementalism, in this view, served to stratify and distract from a larger effort. As specialty hospitals weighed their options, they chose to go off individually and focus on their own agenda, rather than a group agenda. This is an oft-observed phenomenon. Tiny factional groups will work on their own piece of an issue, not because they are unable to see the larger picture, but because the resources required for collaboration, the high likelihood of failure and the sheer challenge of coordinating a large agenda overwhelm collective efforts. In local government, we are starting to use the term "collaborative governance." This replaces thirty vogue terms before it, but captures the challenge of change in an environment of significantly limited resources. We all have goals, individually and collectively and many of these goals actually have a high level of overlap. Collaborating in way that facilitates the achievement of these goals for more than the individual, however, requires sacrifices from all participants. In a group setting, sacrifice is political. Those who feel compelled to sacrifice sense a loss of power.

As we move towards election day and more importantly, into a new presidency, it will be interesting to observe the efforts towards health care and track them against this chapter and indeed this book. To watch? Interest groups, political compromise and scaling back of goals from the lofty to the achievable.

Chapter 6: Escape from the Corporation

2008-10-03T15:13:00.001-07:00

Chapter 6 hints at struggles within the medical profession that pervade today. Even within the elevated rank of physician are strata that separate the "regular" doctor from the specialist. Some of this is attributable to popular television, which is an information source for many people. On shows such as Grey's Anatomy, House or E.R., the doctors who get the most attention are not the General Practitioners, but the specialists, the renowned plastic surgeon or neurosurgeon or the doctor who only takes the most complicated cases. This is further propagated by the online informational sites that many people consult daily to supplant the need for a doctor for every ache and pain. Often, these sites contain a recommendation to seek further help from a doctor specializing in the field. While a specialist is certainly an expert, general practitioners are also highly knowledgeable and in many cases, can treat a variety of common afflictions.

The chapter also hints at the division between physician and other medical professions, one which also persists today. Indeed, although they often work together seamlessly, the division between nurses and physicians is not only significantly separated by gender, but by authority as well. Like the specialists of the early 20th century who were highly qualified for X-ray or radiology, the level of training for associated medical professionals seems to be continually on the rise, no doubt in an attempt to secure some of the authority physicians fought for in the early decades of organized medicine. Physical therapists, for example, are now required to have a PhD to practice. Although the PTs who were certified when it was a B.S. or M.S., the continued rising bar to practice is becoming a barrier to entry for some people. Similarly, nurse practitioners currently require only a masters. However, people within the industry estimate that within a decade, NPs will be required to hold a PhD. The legitimacy we associate with education is forcing many specialists, who are highly qualified with current qualifications, to receive higher and higher degrees to remain competitive and ensure authority.

Chapter 5: The Boundaries of Public Health

2008-10-03T15:10:00.000-07:00

Much like public health at the turn of the 20th century, public health at the turn of the 21st retains much of the negative publicity of a century ago. While the practice of public health is becoming “cool” again, at least according to a New York Times article last week, the idea of the County Public Health Department is wrought with stereotype. Be it the commonly served population, who is often poor or minority, or the basic buildings in which care is provided, most people would rather not use public health, given the choice.

However, after our discussions about how to fix health care in this country for the 47 million uninsured, it occurs to me that public health might be the cure. Public health cannot provide everything for everyone. It can provide, however, the basic care that we as a group agreed should be a right. Vaccines to prevent the diseases we thought formerly eradicated, basic check-ups, neonatal care for poor mothers, eye and ear screens for children (although schools continue this practice, early detection is largely held as key to resolving and dealing with these issues), and nutrition information can all be disseminated by a public health department. Furthermore, for many people, the services provided by government are a mystery. For example, people know that food stamps are available, but the process of applying for them seems too laborious. Public health departments can also serve as a hub for more general community health.

But of course the question emerges, how do we pay for this? We pay for this the same way we provide a free, basic education for everyone- through taxes and grants and some in-kind donations. Paying for public health will cost money, but in many ways, we are already paying it. People who use Emergency Room services who have the ability to pay are already absorbing some of the costs of those who cannot pay. People who are not healthy enough to go to work impact our workforce and our productivity. Children who do not have adequate healthcare spread illness to children who do. There are so many discriminatory elements of life in this country, particularly along socio-economic lines. Although paying for public health may have a more direct cost, I believe a full cost-benefit analysis would reveal that the benefits outweigh the costs.

Chapter 4: The Reconstitution of the Hospital

2008-10-03T15:09:00.000-07:00

As with many institutions, the history of the hospital can be explained through the view of social science disciplines. As Starr notes at the end of Chapter 4, however, the hospital is an anomaly from almost all of these perspectives. While the early hospital did not maximize profit, which goes against the economic theory that states that firms will always seek to balance marginal revenue with marginal cost, I would argue that hospitals today seek to maximize profit for a number of reasons.

First, competition has increased again. In the last few years, we have witnessed the proliferation of private clinics, often in strip malls or free-standing buildings. While these clinics first handled only minor illnesses, like the common cold or flu, many are now able to deal with more acute issues like broken bones. These clinics have set fee schedules, due upon service. For people without health insurance, however, they may be less expensive than a trip to the Emergency Room.

Second, hospitals have become “big business.” Because the demand for hospital care is relatively inelastic, it can be assumed that consumers are essentially price takers, particularly when critically ill. For some items, patients pay a user fee. Durable medical goods are an example of this. A patient will lay on a hospital bed and have his blood pressure and pulse monitored. When he leaves, the bed can be used again. Because this is an exhaustible good, the fee for use is prorated. For laboratory procedures, economies of scale apply. While a laboratory technician can run one urinalysis at a time, she can also run 8, decreasing the cost per urinalysis. Each patient, however, will pay a cost that reflects the marginal cost of ONE urinalysis. Thus, internal efficiency can increase profit without the knowledge of the patient.

Finally, many insurance plans reimburse by diagnosis. That is, all people who are diagnosed with a disease are estimated to “cost” the same amount, regardless of actual treatment received. It is in the best interest of the hospital, then, to try to come in under the reimbursed cost.

None of these elements of profit maximizing are inherently bad, but the risk of poor patient care does exist. As hospitals struggle with other industries to stay in the black even with rising costs, a loss is inevitable. The question is, however, does this loss represent a loss to consumers (patients) or to hospitals. Both choices have consequences we will continue to affront through the next century.

Chapter 3: The Consolidation of Authority 1850-1930

2008-09-15T11:10:00.000-07:00

As Starr recounts the history of medicine in America, I am continually stuck with the relative role of timing. Rather than a focused movement, the consolidation of authority for physicians seems almost accidental. A few legislative priorities, a scathing report of medical schools and the influence of societal factors such as transportation and urbanization better explain the consolidation of authority than any efforts from within the profession. The comment that sticks in my mind is that which stated that the biggest enemy of physicians were the physicians themselves.

Hindsight is always 20/20 and I imagine the physicians who worked in both the late 19th century and early 20th century would agree that had they known the benefits of consolidation and cooperation, they would have advocated for them earlier. Instead it took the donation of a huge endowment from Johns Hopkins, the leadership of Harvard's president and eventual acceptance of sectarian physicians into the mainstream to march forward towards true professionalism.

It is interesting to me to observe the backswing of the pendulum towards homeopathy. Although generally considered alternative, it seems that alternative medicines enjoy regular spurts of popularity in response to concerns in the medical community. For example, when a report was released that stated that hormone replacement therapy (HRT) was dangerous to menopausal women seeking relief, we saw a rise in alternative solutions such as black cohosh. While I personally dispute the findings on HRT, it is interesting that as consumers, we often view homeopathy as a safer alternative to "drugs." Another example is "Airborne," the miracle tablet marketed by a teacher that alleged great effectiveness against colds with natural ingredients. In clinical studies, Airborne has not outperformed placebos, but for many consumers, the idea of fighting colds naturally is still highly attractive. In recent months, I have observed another backswing as the economy has fallen. Unwilling or unable to bear the cost of doctor's visits, people seem to again be turning to natural remedies for an economical solution. Although I do not discount the benefits of natural remedies, I am always concerned when people assume that because it is directly from the earth (as opposed to derived from, like many "drugs"), there are no side effects, no risks.

Finally, it is interesting to hear about the AMA in its nascency. In a recent economics class, a professor remarked that the AMA is a cartel. I disagreed, stating that although it may be a cartel by definition (controlling the market via medical schools), it is not a cartel in intent or even effect. The plethora of reimbursement structures themselves mean that increasingly, physicians individually and the AMA collectively, lose control over the market. While I don't anticipate a return to the AMA in its diffuse, powerless state, I wonder if the AMA percieves shifts in the health care market to be chipping away at its authority.

The Expansion of the Market

2008-09-04T11:48:00.000-07:00

As Starr chronicles, the rise of American medicine was slower than the rise of medicine in other industrialized nations. During the 19th century, however, wheels began to turn that would help medicine begin to morph into a profession. The two that stood out most to me was the development of economies of scale and emergence of a critical mass of patients.

At the turn of the nineteenth century, physicians had to travel to their patients. This was costly both for the physician, who sacrificed time, and for patients, who called a doctor only when absolutely necessary. This distance, however, would shorten both physically and figuratively by the middle of the century because of improvements in transportation and the invention of the telephone. This meant that physicians could see more patients a day, increasing their profit and decreasing the cost passed on to patients. As Starr astutely notes, more availability bred more dependency on physicians, creating a mutually reinforcing cycle. We can observe a similar, but reversed corollary today. As people's schedules become more crowded and the costs of insurance and in-office visits rise, we are beginning to see the rise of "phone in" nurses and other medical services. Like the patients of the nineteenth century, the cost of traveling to the doctor's office, both from time lost and co-pays, has forced possible patients out of the market. Of course, this type of service is evidence of the high level of professionalism we now associate with doctors and nurses; we trust their expertise to the extent that we will accept consultation over the phone.

The other interesting by-product of urbanization that Starr points out is the development of a critical mass of patients. When people were diffuse, doctors had to search for patients and build and maintain relationships. As people migrated to urban areas, a more "automatic" mass of patients emerged. This was accompanied by a shift in family structure that tended more towards care OUTSIDE the home as opposed to within the home. This concentration of people served to increase the professionalism of doctors by exposing more people to the benefits of using a physician. It can also be assumed that at least in some part, word-of-mouth also benefited the profession. Whereas when population was diffuse, interaction between families was limited. As population became more concentrated, social interaction increased between families and people were more likely to know someone who had visited a doctor for more than just a dire situation.

The other issue of note that this chapter raised for me was the beginning of the mental health system. While so many other aspects of the health system have evolved, the mental health system seems to have clung to its original auspices. We still institutionalize those who are insane in many cases and choose to isolate, rather that include. Treatment at these institutions has improved, although in some cases, not markedly. Just this past month, allegations of severe mistreatment resulting in death emerged from a North Carolina mental health institution. Even without this incident, mental health in North Carolina and elsewhere continues to be an Achilles heel politically and emotionally.

Introduction/ Chapter One

2008-08-31T16:52:00.000-07:00

I was struck throughout the preface with how familiar the struggle for professionalism in the physician community echoes the current struggle of a number of professions, public administration being the one with which I am most familiar. In our field, we speak often about becoming more professional. Unlike the physicians of the early 20th century, we in PA often possess a significant amount of social authority. We struggle, however, to respond to claims that this authority should not be vested in us. "Good enough for government" and "bloated bureaucracy" are just two examples of barbs regularly hurled at us. What would be the impact of following the example of the physicians, then? Should we institute a certification test to be a public administrator? One governing body, the International City and County Managers Association (ICMA), has started giving out certifications indicating that certain City and County Managers are considered the "best of the best." Similarly, the Masters of Public Administration (MPA) has become the rubber stamp without which you cannot get a job.

A similar transformation has occurred in the physical therapy community. As recently as ten years ago, a BS plus clinical was sufficient to practice. It then required a masters. In the last two years, it shifted to requiring a PhD. This incredible amping up of education requirements can be construed as an attempt to infuse more professionalism into PT and also a declaration of deserved authority.

I also found it interesting to trace the evolution of medicine along major societal shifts. Much like other aspects of American life, the end of the agrarian lifestyle for many people served as the impetus for many large scale societal shifts. As people moved away from the family-centric farms, where self-sufficiency was paramount, to urban centers, where specialization abounded. As we think about some of the qualities of the Industrial Revolution and concommitent rise of Taylorism, it is unsuprising then, that while the medical profession was creating societies and entrance exams, there was also a rise in the number of specialties for physicians. As we would find out later in the century, these specializations would become a complicated calculus with the rise of managed health care.

Overall, the chapter was fascinating because I had previously assumed that physicians always enjoyed the prestige that they do now. The connection between education and organization is also fascinating. If I were to list the professions that immediately come to mind as prestigious, all share similar processes to medicine: extensive education, certification, professional organizations, tightly controlled information etc...It will be interesting to watch which professions join medicine and law over the next century.