October/november 1984 | Volume 35, Issue 6
Americans have never been so healthy, thanks to advances in medical technology and research. Now we have to learn to deal with the staggering costs.
Our health is better than it has ever been before. There has been astonishing progress in just the past fifteen years. For a couple of decades before that, life expectancy had not increased much, but starting in 1968, the American death rate began to drop, and by 1980 the expectation of life at birth had grown by three and a half years. Infant and maternal death rates have plummeted, and death rates for black newborns have dropped an unbelievable 41 percent.
What brought this about?
It’s mainly the result, I think, of programs that were put into effect in the mid-1960s. Greatly expanded private health insurance programs coupled with Medicare, Medicaid, the neighborhood health centers, and the whole range of Great Society programs. Back then we realized that although we had some powerful technologies at our command, we were not delivering them to the American people on an equitable basis. Many people were badly underserved, especially the poor, the blacks, and the Hispanics. The programs worked. We’ve made remarkable progress in moving these people into the mainstream of American health care, so that now poor people are seeing doctors as often as others are, black people are seeing doctors as often as whites are, and people generally are healthier. Ten of the fifteen major killers of Americans are on the decrease, even in an aging population. The country has done a superb job. I only wish that our success was better known.
Because there is a danger that many of these programs will be dismantled, which could be tragic. To deal with our economic problems, we are cutting back sharply on social expenditures. In the medical care sector this could be tricky. For example, for several years we’ve been dropping people from the Medicaid rolls, which could be expensive in both human and economic terms. I think that’s penny wise and pound foolish.
But it’s easy to see why the politicians got worried about the expense. We’ve all been reading about how the cost of Medicare and Medicaid has escalated. What happened?
Something quite unanticipated took place. The way the legislation was originally structured, Medicaid was targeted primarily for younger people, poverty-level mothers with dependent children and the like. What the legislators did not foresee was the drain put on the system by oldsters, for whom Medicaid was a payment of last resort. Many older people who found themselves destitute because of health catastrophes ended up in nursing homes. Medicaid was the only program that could help them. In a number of states as much as half of all Medicaid funds are now going to support older people in nursing homes. Just the other day I was talking with someone whose primary concern is the welfare of children, and I asked him what he felt was the major problem for them. Without hesitation he said, “The elderly.” He meant that ‘many of the dollars that we had thought would be going for the nurture of our youngsters were being gobbled up in the care of the aged—and this could hurt the youngsters.
Sometimes it does indeed appear that we are being brought face to face with the repercussions of all the medical progress of recent decades; people are not dying the way they used to. They live a lot longer, and therefore we now have to spend money to care for them.
There’s no doubt that we are seeing an awful lot of hand-wringing about our aging population. Some gloomy souls tell us that chronic disabling conditions are going to be ever-increasing and that we are going to have to spend our whole gross national product caring for those eighty and over, who will be largely mindless and infirm. But I do not think there is cause for such despair. As others have pointed out, there’s a big misunderstanding here. When we say life expectancy is increasing, we don’t mean that we are extending life. In fact, the maximum duration of life for most humans probably has not changed much in a hundred thousand years: it averages somewhere around eighty-five years, maybe eighty-six or eighty-seven. Nothing medicine has done has moved that figure up one bit. What we have done is to protect different groups so that more and more people have a chance of reaching that classic age. And of staying healthy and vigorous almost to the end.
Are you saying not only that more people reach old age but also that fewer of them get senile?
Percentagewise, yes. What we are shooting for is a system in which we will have the answers to cancer, to the rotting of your arteries, to the aging of your brain, and to other mysteries, so that you have every chance of taking care of yourself and surviving soundly to eighty-five or so, at which point you can just take to your bed one day and be dead shortly thereafter. If this could be accomplished, the care of our elderly would not be such a disproportionate expense to society. And the point is, I believe we are getting closer and closer to that ideal.
But how are these elderly people going to support themselves?
The honest answer is, I simply don’t know. Perhaps they’ll work longer. Already the retirement age of sixty-five is being pushed up, although many people are electing to retire as early as sixty-two. According to legend, retirement age was set generations ago by Bismarck of Germany, at a time when very few people lived to sixty-five. It doesn’t seem very logical anymore. Many people can work well into their seventies. For those who cannot, clearly we must design a system to care for them with respect and dignity.
But what of the cost of medical care? It is punishingly expensive now and getting more so. It is everyone’s major worry, or at hast every patient’s.
I have to take issue with you on that last point. Most patients, if they are really sick, don’t care about the cost. “Doc, I don’t care what it costs,” they say. “I want the very best. ” What we have here is a massive public concern about total cost, and appropriately so. Society, or more accurately our public officials, are looking at the enormous amount of the gross national product that health care is taking and saying it’s too much. However, the public views here are schizophrenic. While they feel medical care is too expensive for them personally, polls show that most Americans would actually like to see the nation spend more, not less, on health care.
How did it happen that the cost went up so steeply?
The root cause is the technological revolution that has transformed medicine in the last fifty years. The revolution not only helped improve everyone’s health but changed for all time the ways you are treated, the kinds of doctors you see, and the nature of what has become the central institution in the system, the hospital. Historically medicine was a modestly paid, profession. Doctors made about what teachers did and certainly less than lawyers. That was partly because they couldn’t do much. As late as the 1920s there wasn’t an awful lot a doctor could do to influence the course of many diseases other than providing reassurance and hand holding.
Which everyone now misses.
Which everyone misses, and for good and proper reasons: but, back then, we were only beginning to get some of the incredible advances that changed everything. We had insulin, so that we could take one dreadful disease, diabetes, and prevent death from it; we could treat pernicious anemia with liver extract and malaria with quinine, and we could give heart patients digitalis; but that was about it. Tuberculosis was our number one killer, and hospitals were full of people with other diseases that really couldn’t be treated. Starting in the 1930s, with the discovery of the sulfanilamides and subsequently penicillin and other antimicrobials—what people refer to generally as antibiotics—doctors found that they had the weapons with which they could actually cure an impressive number of human illnesses. The changes were accelerated by our experience in World War II when we found that if you apply a lot of money to a problem, you get substantial results. So the American people turned to the medical profession and said, “Find the answers to those things that are troubling us.” The result was the march of science-based medicine, which is continuing at an accelerating pace.
And this was happening even before the Russians’ launch of Sputnik focused our attention on the need for greater funding of scientific research?
Yes. One of the new drugs—isoniazid, discovered in 1950—virtually overnight made tuberculosis a readily curable disease. Research was really paying off. But it cost big bucks. We began putting together big hospital complexes and groups to do the research, all very expensive. Out of this, furthermore, came two related developments. One was that we decided that people who worked in hospitals, who had in the past been very poorly paid, should get living wages just like everybody else. And because it is a very labor-intensive industry, when we began to pay decent wages to orderlies, people who swept the floor, nurses and nurses aides, and the rest, that shot the price up enormously. The second outcome had to do with the new scientific knowledge we were acquiring. In the old days there was just so much the doctor could do; now he can do far more—but it costs money.
You mean because there is more the doctor can do, he must do it all, touch all bases?
In many instances, yes. When I was in my residency at New York Hospital back around 1950, if you came in with high blood pressure, there were only a couple of tests I could give you to make sure that was indeed what you had, and they would take only an hour. Assuming they were negative, I would announce that you had high blood pressure and tell you to lose weight, avoid stress, and take phenobarbital. Period. But my God, if you come in today with hypertension, I know there are over thirty different potentially remediable causes. Testing you to find whether any of them is involved is expensive, but I have to go that route because the payoff is so high if I find any of them. Even if I don’t, I’ll end up prescribing drugs for you that are much better than phenobarbital—but they cost more. Furthermore, I would have to charge much more than in the old days because it has taken me so much longer to get the answers I must have. Back in my time a resident used to be able to work up ten high-blood-pressure patients in one day; now he’s got a tough time finishing just one. So the human cost has multiplied too.
Don’t doctors often give more tests than they really have to, though?
Sometimes. But the catch is that they often get a tremendous windfall of information from these new, automated machines that analyze samples even if not requested to. The way the modern lab works, it doesn’t really cost all that much more to add the extra tests—it’s all done on the same blood sample or whatever. Trouble is, the outcome of one test may be suspicious enough to require another test. If I’ve requested your blood calcium, the report may show that your calcium is indeed up—but it may also tell me that your uric acid is way up too. So I must ask myself, Does this fellow have gout? Answering that one will cost you another fifty dollars or more.
You once wrote about a family physician who kept track not long ago of what the actual cost was of all the treatment, tests, and medication that he had authorized just in one day—and it came to $13,400.
He was amazed and upset by that figure. But he felt it was inevitable. He felt he’d had no choice in virtually every case. On the other hand, I do believe that we can educate physicians to be more selective in the tests and treatments they generate. A group of us did a study recently of the costs of tests, to see if those big expensive gadgets like the CT scanner—which provides a particularly revealing kind of internal body image—were really responsible for the increases. We concluded they were not. It’s the smaller tests being given in such profusion that really hurt your pocketbook. We must try to get doctors to cut down on them. I think we are using some technologies unwisely, and perhaps using too many of them sometimes. But I must add one point here. Often the reassurance you get when all those tests come back negative is worth every penny to you. Let’s say you come to me with a terrible cough and tell me you think you may have cancer of the lung.
I’ll surely want all the tests.
You will indeed. So maybe I’ll come back to you in four days and say I have good news: You have no cancer, it’s an old calcific lesion you’ve had for twenty years, and you can forget about it. It may cost several thousand dollars to tell you that. But it’s a pretty important piece of knowledge for you to have.
And another point is that my insurance will pay for most of it anyway.
Yes—and that’s an inflationary pressure too. Since your insurance pays for the tests, the tendency is to think they are free. So let’s do them even if they are not absolutely necessary. But one way or another you end up paying. You pay for your insurance—directly or via your employer. Worse yet, the insurance is so designed that it often pays for costs while you are in the hospital but not for outpatient care. So people are admitted to hospitals for work that could just as easily be done on an ambulatory basis where it would be cheaper. Insurance that pushes us toward hospitals is helping to drive costs through the roof. We’ve got to change the way medical care is reimbursed. The money often goes for the wrong things. That reminds me of the story of a friend of mine, a medical school dean who decided to take his sabbatical by practicing in a small town in Maine. After it was over, he said to me: “Dave, I learned a lot from it. I worked my butt off for ten hours every day, spending time with patients, talking with them, working with them, and I really enjoyed it. But one thing bothered me. Because I was the only really knowledgeable physician in the area, the other doctors began asking me to read all the electrocardiograms. So in the evening I would take twenty minutes and read them. No problem. But would you believe that that twenty minutes generated much more income for me than all the hours I had spent with patients?” That’s a shame, and we have got to do something about it.
Your friend the dean was really acting as a specialist when he read the EKGs, wasn’t he? And isn’t such specialization exactly what is responsible for a big hunk of the increase in costs?
Yes, it’s another expensive by-product of the technological revolution. As we’ve acquired new machines, new drugs, and new techniques over the past few decades, and as science-based medicine took over, we required new kinds of people to operate the system. There was much too much for any one person to know. So we trained the specialists, the subspecialists and superspecialists, and they all charge more than the family practitioner or generalist. Our dilemma as a country has been that we have no national monitoring system to specify what kinds of doctors will be trained. We have 127 medical schools, none of which has any responsibility for what the total system looks like, plus an American ethos that says that if you get into medical school, it is your right to choose what you are going to do. If you want to be an anesthesiologist or neurosurgeon, that’s what America is all about. And those are very attractive, fascinating callings.
I gather that many of the students enter medical school not expecting to specialize, but while they are in training they find that specialization is where the action is, where the romance is, and coincidentally where the money is.
Yes, but it’s a little more than that. Almost all the medical schools are based in the very high-technology hospitals, and virtually all the faculty are superspecialists. A young person cannot help being impressed by the hospital drama of a superspecialist coming into a situation that is one of utter chaos and dealing with it calmly and effectively. You see this guy come in and save the patient’s bacon, and you say to yourself, “I’d sort of like to be that doctor. ” Just being a kindly, thoughtful physician with only a smattering of the technological know-how may well help lots of people, but you know that when you become a doctor, you’re going to have this sacred responsibility for humans, and some people are going to come to you bad sick and you’re going to kill them if you do wrong. Doctors tend to be high achievers, and after thinking about it, many of them are going to head toward a specialty.
Where does this leave the family practitioner or general practitioner? Are they a vanishing breed?
No, but there aren’t enough of them, and we are trying to do something about that here at the foundation. One thing we’re working on is the reward or reimbursement system. What can we do about it? Specialists earn more than generalists. Part of that is because they have gotten more training: it costs a lot more to train a neurosurgeon than a family practitioner. But we’ve got to narrow the gap. Then there’s the prestige factor. The public regards the advanced hospital institutions as if they were space centers manned by astronauts. Meanwhile, community-oriented physicians are viewed as those who drive the buses and the subway trains. The paradox is that the generalists have, in many ways, the tougher job. They’re right out there on the front lines, dealing with uncertainty all the time and without this enormous professional support system all around them. They don’t have fifty well-trained people around to make them look smart and keep them up to date. I think if I went back into practice today I would do it as a general practitioner. Because I think that after a doctor gets the technologies very well in hand, the satisfactions come from real interaction with individuals. After treating a patient with pneumonia, the doctor wants to know more about that person—what’s he really like? The generalist is dealing with the whole person, not just a part.
If we don’t have enough GPs, what about the total supply of doctors?Are there enough of them?
A great push was made in the 1960s to expand medical training, and the schools were persuaded to enlarge the size of their classes. However, we overshot the mark. I think there is everything to suggest that we are well on the way to a surplus of doctors. This is likely to bring about many changes in medicine—some good, some bad. It may help to right the specialist-GP imbalance. It may get more doctors moving to places where they are urgently needed. We’ve greatly improved the reach of medical care in this country, but there are still pockets of people who, by virtue of culture, language, or location, are still having a tough time getting into the medical care system. Now it turns out that doctors are moving out into the hinterland and into smaller communities because there’s no more room at the inn in suburbia. That’s good. Another result—although it may only be a coincidence—is that doctors’ incomes have reached a plateau. That’s very good news.
Will the house call come back?
I hope so. It was the new technologies, plus the doctor shortage we had for a while, that drove out the house call. Most doctors genuinely felt that while the house call was comforting, there was so much more they could do for you in the office or in the hospital that it made sense to get you there; and they could treat a lot more patients that way too. But a number of thoughtful physicians today are saying that for the crippled, lonely old lady with arthritis, there is only a modest amount that can be done for her in the hospital, but in terms of her ability to function as a human being and to feel good about herself, yes, it does pay off to see her at home.
What is the role of the physician’s assistant or nurse practitioner in all of this?
That was another outgrowth of the doctor shortage as well as the advance of technologies. It was a very important development and remains so: certainly there were many things that could very properly be delegated, freeing physicians for the work that they were most needed for. The convenient term for these people was physician extenders , which I always felt was a denigrating term. It sounded like putting bread into hamburger mix. But these new health professionals are extremely valuable, and many, I’m convinced, will continue in certain specialty areas. Intensive care nurses, for example: they are more proficient than most doctors in dealing with critically ill patients. In certain instances the same goes for pediatric nurse practitioners and surgical nurse clinicians, not to mention the nurse-midwife. But with more doctors around, the trend seems to have leveled off. With doctors’ incomes static or even declining, they are more likely to say, “I’ll do it myself.” Also, with fewer patients per doctor, doctors are going to spend more time with those they have. At least, it is my fond hope that this will happen. But it does mean that the physician will be less willing to delegate patient care to others.
What has happened to the typical doctor? Is he still the totally dedicated, almost driven person who seems to have to work around the clock?
I think the days of “iron men in wooden ships” are mostly over in medicine, as they are in many other areas. Maybe it’s an outgrowth of the feeling that became widespread in the 1960s, when young men and women were saying, “Work is important to me but I do want to raise a family and I’m going to put that in my priority of things.” So the total dedication to medicine that typified people of my generation is not so evident. Particularly in the case of the children of old-time doctors, there was the feeling that “I watched the old man killing himself, I never knew him, and toward the end he was embittered about it. He didn’t even like his patients because he was so overworked, and I don’t want to be like that—there are some other things to life as well.”
Is there also a feeling that they may be better physicians if they don’t overwork themselves?
Yes, I think that’s true. You get enormous arguments between the generations on this. The old guard says: “What is medicine coming to? When I started, I couldn’t get married till I was thirty-five, I never made over five thousand dollars a year, and I got up anytime in the middle of the night when I had to. What’s the matter with these kids who gripe about working every other night? I worked every night. To want to have every other weekend off is a disgrace—it’s ruining the profession.” I think the answer to that has to come from knowing how long you can stay up and still make sensible decisions. Young doctors make many more critical life-or-death decisions nowadays. Without a doubt, overwork can have its unfortunate effects. Of course, it is a basic part of the training of physicians to be capable of making decisions on the basis of considerable uncertainty about every fifteen minutes all day long, some of them with rather profound implications. When you are terribly tired, there is probably too big a chance that you might not make the right one.
And I suppose you could say that with all the new technologies around and so much recently discovered knowledge, the job of being a good doctor is tougher now and the clear-cut decisions even harder to come by.
Much, much tougher—and the decisions are often more important. But with our advances has come yet another tricky problem. We have largely lost the ability to prognosticate—to tell you what is going to happen to you. That was not so difficult when the physician’s world was dominated by all the infectious diseases that were both acute and self-limiting. If you came to me with pneumococcal pneumonia in the old days, I could say, “You’ve got a Type 3 pneumococcus infection, and your chance of dying is 30 percent. If you do die, you’ll do so in a week, but if not you will recover completely and have no lasting effects. ” But now we’ve skimmed off all those diseases and are left with a huge burden of chronic diseases that have such infuriatingly variable courses. Take hypertension, which we mentioned earlier. If you are sixty and have hypertension, I know that for every hundred of you with high blood pressure, fourteen will get into trouble. But eighty-six will not. So how do I know whether to treat you? I have to make an educated guess—and it’s a very tough one. It is also likely to be an expensive one: the tests are costly, but so is the medication if you end up getting it. So there is an enormous amount of time and money going into the management of problems where we’re almost flying blind.
On top of that, I gather from what you have written in the past that you feel doctors often don’t follow up with their patients to make sure the patient returns to leading an effective life.
I call it paying more attention to the functional outcome of an illness. Say you’ve had a heart attack and it’s a minor one. We treat you and you go home and then we tend to let you go it alone. That’s not acceptable, to my mind. Because months later you may be still sitting at home, scared to go out on the golf course, even scared to have intercourse. You are a functional cripple, because of our not having followed up fully and satisfactorily. We’ve got to get you back to work so that you are not a loss to society. Which leads to another point: One of medicine’s problems is that it legitimizes a lot of illness that perhaps should not be legitimized.
What do you mean by that?
Well, let’s say you and I each have a cold. We both know what it is. You are a highly motivated person and you decide to live right through it, so you keep on working. But I go to the doctor and tell him I feel awful. He says, “You’d better take three days off, stay home, drink lots of fluids, and take aspirin.” He has legitimized my being disabled with something that really is not a disabling illness at all. A related problem, while we’re on that subject, and an extremely serious matter, is that we are an overbedded nation.
You mean our hospital capacity is too great?
Yes, And it is very hard to close a hospital. Now there is no question that we built all those hospitals for the right reasons. After World War II we had a serious need for them. So the government passed the Hill-Burton Act, which made it possible for communities to get matching funds for new hospitals. Then two things happened. One, we overshot the mark and built too many. Two, technological developments reduced the need for such capacity. For example, we had all those beds for tuberculosis patients, but isoniazid came along and knocked all the projections out of the ball park. Similarly, we had perfectly reasonable projections of the need for mental hospitals, whereupon along came the psychoactive drugs, and instantly there were too many mental hospitals. Today the estimate is that we have a hundred and fifty thousand too many hospital beds in this country. But trying to close down a hospital generates a raft of political and social problems.
Is that because community leaders, congressmen, and so on, get into the act?
Yes, it’s worse than trying to move a cemetery. Even though your community is ten minutes from another hospital, your particular hospital is a great source of community pride, the local doctors are all connected with it, the annual fund-raising drive is a neighborhood fixture—it’s like having your own fire department. On top of that, and sometimes most importantly, it’s a matter of losing jobs. But there’s no doubt we’ve got lots of excess hospital-bed capacity.
Isn’t there any recourse other than closing them?
As I see it, our great need now is not for acute-care beds but for more humane, effective, well-monitored nursing homes or chronic-care beds. Some communities have already converted portions of their hospitals into special sections in which people can take care of themselves—where they have their own dining room and other facilities—and sometimes the funding can be arranged to make it pay. This is welcome news, because most nursing homes are out of the mainstream of national supervision. Right now we are just warehousing too many of our older population, and it’s a national scandal. The frail or dependent elderly need to be in places where qualified doctors can watch over them.
Is this excess capacity true in the case of the great urban medical centers, the teaching hospitals?
Not so much, but they themselves face a severe crisis today for other reasons, and this has troubled me for some time. The teaching hospitals occupy an odd position. They are the major producers of doctors, but they are also the court of last appeal for very sick people, the providers of the most expert care and treatment. And they have a third responsibility: To care for the sick poor. This close tie with the public is something you don’t find in the law schools or engineering schools—all they do is train professionals. Now the three-part responsibility was perfectly all right in the old days. The fledgling doctors could learn their craft by taking care of the sick poor and they also could observe extremely complex medical cases at firsthand. But the teaching hospitals took on a greatly expanded role when the technological revolution came along: they were asked to be the centers of biomedical research. This made them quite expensive. On top of that, in recent decades they were asked to expand their community services tremendously. More than a quarter of these magnificent institutions sit squarely in the midst of our largest and most troubled inner cities. So they found themselves running all sorts of drug abuse centers, alcohol programs, outreach clinics, and the like, largely for the poorer segments of our society. Most of this was paid for by the public through government funding. I’m not sure that it was wise to ask all this of teaching medical centers: perhaps the private medical profession could have shared in the responsibility for taking care of the have-nots. But the government and organized medicine simply have never been able to settle that question. As a result, many of the problems came to rest on the academic centers. Now comes the crunch: The government is beginning to cut back on its funding, but meanwhile the teaching hospitals have lost not only many of their biggest sources of private money—middleclass patients—but also many of their most competent doctors to the suburbs. They are in a terrible bind. They are still being asked to do everything they did before, but the money is simply drying up.
What are they going to do about it?
I’m afraid they will have to cut back on many of those new services, and simply do less. The one thing they cannot give up is their traditional mission of providing care for poor people, who have the toughest time getting it. If they back away from that, I believe they will forfeit much of their legitimate call on public support.
All this adds up to a formidable lot of changes that have come over the U.S. medical community in the past half-century. Sometimes it almost looks as though doctors have to keep scrambling just to stay abreast of all the shifts and crosscurrents.
I would agree. Once society has acquired technology with such great potential, you ask yourself, What do we want of the medical profession? You want your doctors to fulfill their sacred vows to take care of you as an individual, on a one-on-one basis, without regard to any political beliefs, yours or theirs. You surely do not want your physician to make value judgments as to whether you do or do not deserve good care because of your age or social status. But you probably hope that he or she will be aware of the changes that are going on in society and in the profession and will be ready to adapt. I think they are. I’ve watched my colleagues and believe that an encouraging number of them are saying: “The practice of medicine has changed profoundly, but I’m changing too. I admit patients to the hospital much less often than I used to when appropriate, and I do virtually all my work-ups on the outside. Many of my dying patients die at home. The system is too expensive. We don’t have to fill all those hospital beds. The support system is there when I need it, but I don’t need it that often. I’ve got to do everything I can to cut down on those costs. I think my patients are better off—and happier—that way.”