Your Life is Their Toy - Emanuel Josephson |
JJefoke embarking on a discussion of medical care it should be reiterated that good health docs not depend primarily on medical care. Proper food, clothing and shelter are more fundamental requisites for good health than the best medicines. Conversely, thanks to the power of self-repair with which Nature has endowed Man, he often survives the vilest abuse and the most incompetent medical treatment. The history of medicine attests that it is fortunate for human survival that "a good man is hard to kill."
It is a foregone conclusion that a solution of the question of medical care will not be found in the proposals of either the Medical or Social Service Rackets. Both merely seek their own advantage and profit and are Largely responsible for aggravating the situation. In fact, without their elimination no solution is possible; for their use as political devices has not only impaired the caliber of medical services but has also dangerously cheapened human life. Any solution must correct these evils.
ESSENTIAL FEATURES OF SOLUTION
The public certainly should not entrust the solution to the politician. It should effect an arrangement directly with the medical profession that would eliminate all middlemen or political bosses. Any adopted plan must have certain essential features, among which are the following:
This implies an elimination of rivalry for fees. All physicians in the group should work and earn equally. A basic drawing account should be supplemented by bonuses the size of which would depend upon the good health of their patients and the consequent accrued surplus. It is a curious fact that it is the medical merchants who most loudly mouth the priestly character of the medical profession who are most insistent upon the right to fleece their patient-public, and who most strenuously object to a reorganization of medicine that will provide merely a good income for the physician.
NEW YORK MEDICAL GUILD PLAN
An ideal plan that is entirely feasible and combines every feature that is desirable to all parties involved is one that I drew up and was offered to the public in 1930 by the New York Medical Guild.
For the medical profession the plan provides group medical practice; a minimal income of eight to ten thousand a year net; an eight hour day; vacations with pay; compulsory study for keeping abreast of medical advance; a pension and retirement plan; reward and bonus for preventive medicine based on continued good health of the clientele which serve to shift the profit motive to coincide with the interests of the public; and finally a uniform income for all professional members to eliminate commercial rivalry.
For the public the plan provides a higher grade of medical care than is available today at any price, at a cost that corresponds with the charges of the average clinic. For about eight cents a day, the public would receive all types of medical, preventive, surgical and specialty care, with periodic health examinations at the hands of cooperating groups of physicians. For an additional sum of less than seven cents a day hospital and nursing care would be provided.
The poor would join in the plan at the expense of the community. The millions of dollars which Organized Social Service now converts to its own uses would help defray the cost. The cost of the plan to the public could be further materially reduced if municipal hospitals were made available to the members of the Guild for the care of their patients. In any event the plan would represent a saving to the municipality and a material improvement in the medical care of the poor.
DOCTORS' BONUS FOR HEALTHY CLIENTELE
Under this plan a member would be the patient of a physician of his own choice working in cooperation with a group of associate physicians. The in Instead of giving rise to hurried, careless slovenly "mass production" methods which inevitably result from State Medicine and Compulsory Health come of the physicians of the group would be supplemented by bonuses, the size of which would depend upon the good health and freedom from illness of their group of patients. Consequently, each and every member of the group would have a real, sincere, and vital interest in the good health of clientele rather than in the number of operations and treatments that might befall or be inflicted upon them.
It can be expected that when the income of the doctors of the group depends upon protecting the health and life of their clientele they will very critically observe and control the work of their colleagues. They will demand of their colleagues the highest obtainable competence and the maximal development of ability. The highly critical check on the work of each member of the group by his colleagues prompted by the desire to increase their incomes by good work, would be certain to have a salutary effect on the quality of the services rendered the public.
SUPERIOR PHYSICIANS AND SERVICES INSURED
The plan provides an adequate income for the physicians coupled with leisure and an insistence on compulsory study to keep abreast of medical advances. This would be certain to improve the caliber of medical care and to stimulate medical research and discovery in the direction of protecting health and life.
Instead of giving rise to hurried, careless, slovenly "mass production" methods which inevitably result from State Medicine and Compulsory Health Insurance, the Guild plan of group medicine would affect highly individualized and careful medical care by groups of physicians keenly interested in the patient's well-being.
The plan also provides for a progressive reduction of the cost to the public when its reserves and surpluses had been built up. It also makes provision for "carrying" patients who were temporarily unable to pay due to unemployment or other causes. If the plan were launched with adequate financing or endowment, the cost could be set at a lower level from the start. Present price levels also permit a reduction in the rate,
DOCTORS' INTEREST BELIES PROPAGANDA
The interest of the rank and file of the medical profession in the provision of adequate medical care of the average man is borne out by the fact that in a short period of time the New York Medical Guild built up a membership of several hundred physicians intent upon joining the plan.
The Guild came into being at the time that the social-service-dominated, and Metropolitan Life Insurance Company and Milbank Fund subsidized, Committee for the Study of the Cost of Medical Care was indulging in propaganda designed to lead the public to believe that the medical profession was not interested in the provision of adequate medical care for the average man at a fee that he could afford. The willingness of the medical profession of New York City to join such a plan forced the Committee to reconsider and retract its false propaganda; and forced it to accept in principle the idea, of group medical services at fixed annual fees advocated by the Guild. For although similar plans had been adopted in various sections of the country, the Guild plan was the most acceptable to the rank and file of the profession.
ORGANIZED MEDICINE OPPOSES PLAN
The medical merchants of the New York County Medical Society and the New York Academy of Medicine feared that their incomes would be reduced by such a plan, and on resounding "ethical" grounds they rejected it and brought the pressure of their power to bear against it. Dr. Bernard Sachs alone among the officers of the New York Academy of Medicine showed sincere and honest interest in the problem; he openly advocated and endorsed the provision of medical care for fixed annual fees by medical groups—the fundamental principles of the Guild plan.
Curiously enough, however, the Economic Committee of the New York County Medical Society approved of the Guild plan for adoption by the hospitals. The implications of their report were that the society desired to protect the incomes of the hospitals in preference to protecting the interests of the medical profession and its' membership. The adoption of the Associated Hospital Service of New York plan for provision of incomes for the hospitals and of hospitalization of the public for limited periods of time at a fixed annual fee of ten dollars per year was a direct outgrowth of the Guild Plan.
ORGANIZED SOCIAL SERVICE OPPOSED PLAN
Most interesting and illuminating was the attitude of Organized Social Service toward the Guild's plan of provision of medical care for the public at fixed annual fees. Though the Guild approached the various social service organizations and philanthropies that pretended to be interested in such plans the responses varied from flat rejections of the invitation to cooperate, and antagonism, as in the case of E. A. Filene, Evans Clark, and the Twentieth Century Fund; to utter apathy on the part of Mr. Michael M. Davis, Director for Medical Services of the Julius Rosenwald Fund. They made it clear that they were not interested in any plan which did not give the social workers complete control and provide for them munificient salaries. The same groups have been actively pushing Wagner's Socialized Medicine Bill which provides munificently for social workers.
Many similar plans have been publicized and launched. None of them, however, permits of the possibility of superior medical care because they do not provide for an adequate charge or sufficient income for the physicians to enable them to develop their capacities. In most of them the physician is merely an employee rather than a free agent, and thus the incentive to superior services is absent. They also have not a democratic organization within the medical group or the bonus and other incentives.
PUBLIC UNINTERESTED IN MEDICAL COSTS
Though tremendous volume of publicity was given the Guild plan there was little public response. The public apparently was unwilling to pay anything for medical services so long as they knew it was obtainable free or at nominal cost from the clinics of the city. The inference was clearly that the public do not desire to pay for something that they can get for nothing; that they are not aware of any deficiencies in the quality of medical care which they receive; and that they do not recognize the existence of any problem in medical care.
The experience of a group of 5,000 doctors organized in the California Physician's Service in 1939 for voluntary health insurance has been identical. They have found that the public is little concerned about the cost of medical care and still less interested in health insurance. In four months of intensive drive they were able to secure only 3,000 members.
It is doubtful that years of propaganda by Organized Social Service has materially changed the picture; which may explain why it is attempting to gain its objectives by making health insurance compulsory. That would solve the problem of the social worker, but would merely aggravate those of the medical profession and of the public.
NEW YORK PLAN DOOMED TO FAILURE
It is idle to dream that any compulsory plan or bureaucratic system will improve medical care. For the life of the patient often depends on such intangibles as the physician's good will and solicitude. These can not be commanded or demanded. They can only be elicited by a rational system of rewards. It is only through voluntary, collaborative plans that the highest grade of medical care can be expected to develop.
Equally ineffective and doomed to failure in advance, are plans advocated by Organized Medicine for insuring medical costs up to a certain amount. Laws permitting the issuance of such insurance have been passed in several states, including New York. It can be predicted with certainty that the result will be padded medical and surgical bills aimed at absorbing the entire sum insured?
The cost of medical care at the hands of medical merchants will be materially increased by the plan and additional costs over and above the insured limit will be imposed on patients up to the limit of their capacity to pay. It will work out in much the same manner as has the amended Workmen's Compensation Bill. The gravest defect of the plan,, however, is that the doctor's profit and interest lies in the patient's ill health and in operations and treatments; and the patient's purse is as seriously endangered thereby as ever . It is no solution of the problem.
FORMS THAT SOLUTION MUST NOT TAKE
It should be obvious to a tyro that there are some forms that attempts at solution of the problem of medical care should not take. Any attempt to solve the problem that jeopardizes the livelihood of the public and thereby threatens their ability to provide for themselves the necessities of life, is doomed to failure. For this reason plans that compel the employer to pay part of the costs and penalize him for giving employment are utterly unsound.
To intelligent persons these plans should appear objectionable for other reasons. They are a reversion to medievalism and feudalism, the essence of totalitarianism. They constitute in principle a reassertion of the property right of the employer in his employee. For only on the ground of self-interest can the employer be called upon justly to pay any part of the cost of medical care of his employees, in any case other than illness or injury arising directly out of employment. Such payment implies the surrender of his privacy by the worker; for when the employer pays for the services, he is entitled to know its nature and significance.
Such plans imply the surrender of concepts of independence and freedom. That was precisely Bismarck's objective when he introduced his program. It appears inconceivable that a people who have enjoyed the blessings of freedom should in this manner consent to being shackled.
THE ONLY ULTIMATE SOLUTION OF THE COST OF MEDICAL CARE IS A SOLUTION OF THE PROBLEM OF THE ECONOMIC ORGANIZATION OF SOCIETY.