Michael Crichton - Five Patients

Sixth, lest private health insurance seem a financial panacea, one should note that private companies are often irrational in their payment procedures. For example, for many years one could not collect for certain treatments-such as the setting of fractures-unless one were admitted to the hospital, at least overnight. Thus a person who might easily receive therapy in the EW and be sent home had to be admitted in order to receive insurance coverage. This unnecessary admission raised the total cost of health care, and ultimately such increases are passed on to the consumer in the form of higher premiums. Some of these odd payment procedures have been changed, but not all.

Seventh, the American medical system in its full spectrum-from the private specialist's office to the municipal hospital wards-has never been able to structure the kind of competitive situation that encourages and rewards economies. Nor has American medicine tried. The American physician has been grossly irresponsible in nearly all matters relating to the cost of medical care. One can trace this irresponsibility quite directly to the American Medical Association.

For the past forty years, the American Medical Association has worked to the detriment of the patient in nearly every way imaginable; it is a peculiarity of this organization that it has worked to the detriment of physicians, as well. Dr. James Howard Means has said: "Its ideology is very like that of the big labor unions… it has now set up a continuing political action committee quite like those of the fighting labor unions. Every attempt that has been made by liberally minded groups to improve medical care and make it more accessible… the AMA has attacked with ever increasing trucu-lence… They forget perhaps that medicine is for the people, not for the doctors. They need some enlightenment on this point."

The truculence of the AMA has been expensive. In terms of the modern-day cost of medical care, we may cite the following points. Beginning in 1930, it opposed voluntary health insurance, such as Blue Cross. In 1932, it opposed prepaid group-practice clinics. In 1933, it began a successful campaign to block the construction of new medical schools and limit enrollment in those already in existence. We now have a shortage of doctors. More recently, the AMA spent millions-probably no one knows exactly how many millions-to fight Medicare, a program that resulted in health benefits to 10 per cent of the population and vastly increased income to physicians. (Indeed, a good gauge of the AMA's shortsightedness can be gained by imagining the outcry from private doctors should anyone now try to repeal Medicare.) Further, the AMA has failed to take any strong stand on prescription pharmaceutical prices in this country, which nearly every objective observer regards as grossly inflated. And more insidiously, the AMA has permitted what may politely be called blind spots in health care. The Journal of the American Medical Association refused to print a government study of combination-antibiotic drugs which concluded that many of these expensive medications are either worthless or dangerous; the AMA has still failed to condemn cigarette smoking despite overwhelming evidence that this habit, though profitable to certain industrial groups, is directly responsible for much disease, suffering, and medical expenses in this country.

One can only conclude that the American Medical Association has not considered the interests of patients for forty years, or perhaps longer. On the basis of its record, it is opposed to both better and cheaper medical care. Its only commitment is to the doctor's bank account-and even then, it makes astonishing errors in judgment.

In 1967, in his inaugural address, Milford O. Rouse, the incoming president of the AMA, deplored the growing sentiment in this country that medical care was a right, not a privilege. His opinion was not well received by an angry public, and later presidents have been more circumspect in voicing their views. Nonetheless, it is customary for AMA presidents to travel about, speaking to groups of doctors, applauding what they call "the phenomenal growth of the health industry."

That growth cannot be questioned. Personal consumption expenditures for medical care rose from $7.5 billion in 1948 to over $27 billion in 1965, and more than $50 billion in 1968. By 1975, it is expected to reach $100 billion or more. This is the sort of news to make a Wall Street broker squeal with delight. But medicine is a service, not an industry, and one really ought to look at it differently.

In fact, the United States spends more of its gross national product (6.2 per cent) on medical care than any other country in the world; it spends a larger absolute sum than any other country in the world. Yet by most objective standards of health- infant mortality, life expectancy, and so on-it is far from the leader.

Other countries are doing better, and most of them have some form of socialized medicine. The United States is extraordinarily backwards in this respect. However, many clear-headed American observers have looked at European socialized systems and have come away shaking their heads; and there is a widespread doubt whether any European system can be adapted to this country. Very likely, America will have to work out its own system. The combination of group insurance with a group-practice system (essentially the system at Kaiser and others) seems a feasible, economical, and practical method, acceptable both to doctors and patients.

Without question, the notion of the doctor as a legitimate fee-for-service entrepreneur, making his fortune from the misfortunes of his patients, is old-fashioned, distasteful, and doomed. It is only a question of time.

Ultimately, however, it is not useful to lay blame, whether on physicians, health-insurance administrators, politicians, or an apathetic public. For they all seem to share a common blindness-a total failure to understand why hospital costs are rising. In 1967, the average cost of a hospital room in America increased 15 per cent. What is happening?

The per-day room charge is the largest single item in the hospital bill. There are many ways to break down this charge-as many ways as there are accountants-but the clearest is the following.

In 1969, the cost of a semi-private room at the MGH was $70.00. Breaking this down, we find:

Per-Day Room Charge: $70.00

Utilities, housekeeping, maintenance,

plus business offices ("hotel expense") $ 6.96

Food and special diets 5.82

Nursing 18.42

Labs, records, house staff,

X rays, and pharmacy 28.80

Overcharge (to cover welfare debts) 10.00

Total $70.00

Now this breakdown contradicts one of the oldest complaints about hospitals, as quoted in a national magazine: "My work puts me in contact with hotels and hotel management and I know that a good hotel can give you a beautiful room for $30.00 a day, with three meals, and make a profit and pay taxes. And yet any hospital, which doesn't pay any taxes, operates in the red for $65.00 a day. I say it must be poor administration."

If the analogy were true, the conclusion would be correct. But the hospital is not a hotel-and in any case, its "hotel" costs are quite reasonable at $6.96 a day; this is approximately half the cost of a decent motel room in Boston. The charge of $5.82 for food, or approximately $1.95 a meal, is equally reasonable, especially when one considers that as a restaurant the hospital must provide an extraordinary range of services, including some eighty special diets.

The true hospital costs-the expenses incurred in a hospital but not in a hotel-are, on the other hand, very high. They account for 82 per cent of the total per-day room charge. And the question, really, is whether these charges are reducible. No sensible businessman would bother to try to get his hotel and food costs below thirteen dollars a day; if there is to be a decrease in costs, it must come from the non-hotel charges.