A Cure for Doctors' Bills

The medical profession sees the writing on the wall.

The second item of the medical programme we are proposing is the periodic medical examination. No doctor will deny the value of a thorough physical examination at least once a year for every man and woman. Like fire, many diseases are controllable in direct ratio to the time at which they are discovered. It is astonishing that so many people neglect to give their own bodies the kind of watchful inspection to which they subject their automobiles. It is obvious that the regular physical examination would be made much easier, and the whole cause of preventive medicine advanced, if doctors were associated in groups, each equipped with its comprehensive records and plant.

The third item has more directly to do with the cost of medical service to the patient. Why the principle of insurance has not long since been generally applied to medical care is a mystery to those laymen who have stopped to consider it. The essence of insurance is cooperative protection through small regular premium payments by a group sufficiently large so that the sum total of contributions is enough to cover the future losses of any one member. Perhaps none of us will ever suffer loss by fire or run down a pedestrian, but we are willing to drop enough money into a common insurance box every year to relieve ourselves of the necessity of meeting such a crisis with a lump-sum payment. Only in this way can we budget life—can we discount the future in terms of our present resources.

Insurance against the expenses of illness is no more difficult of application in principle than insurance against fire or burglary or flood or earthquake. Every form of insurance rests upon future expectancies reduced to a mathematical formula on the basis of past experience. Were accurate records available of the amount of medical care required per person per year by a large enough segment of human experience, it would he possible to calculate the size of the insurance pool necessary to pay for such care in the future.

A straightforward mathematical process would then reduce this amount to the dollars and cents which each individual would have to contribute each year to make up such a sum. As in the case of fire or burglary insurance, this amount would be far less than the individual would have to pay to foot the bill of a sudden illness—would be small enough, indeed, to be easily encompassed in a modest family budget.

Group practice, periodic examinations, and insurance—each is a valuable contribution to the cause of health. A whole, however, is often of greater value than the sum of all its parts. So would an institution be that fused these three elements into a complete service to the public. The medical guild which we propose would combine the efficiencies and economies gained by organizing doctors in well-staffed groups with a cooperative sharing of the costs of illness by patients and with the advantages of regular medical examinations.

Let us set down more in detail the specifications for such a guild. Its owners would be a group of doctors—or of laymen, if the doctors do not see its possibilities. Perhaps a judicious mixture of both would produce the best results; possibly the most fruitful arrangement would be a group composed two thirds of doctors and one third of experienced business executives, with perhaps an economist or two. Or an existing institution might be converted into a guild, a medical centre or school or hospital, a pay clinic, or an already established group-practice organization.

But to be a guild the group would have to offer a representative selection of specialized professional services at fixed annual fees. Whether these services are rendered by the members or owners of the guild, or by a professional staff employed by them, is a relatively unimportant detail. Each guild would, of necessity, have two or more general diagnosticians. These doctors would form the keystone of the arch, for they would be in closest contact with the lay public, and through them cases would be referred to the specialists of the guild as their services were required. Upon the personality and professional standing of the diagnosticians would the success of the guild largely depend.

The rest of the professional staff would comprise at least one specialist in every major field of practice. In some, such as dentistry and oral surgery, the prevalence of defects would probably require two or more. The roster might include, for example, the following: four general diagnosticians, three dentists, two gynecologists, two pediatricians, two oculists, two nose and throat specialists, two psychiatrists, and one specialist each in diseases of the heart, lungs, digestive tract, bones, with possibly other fields represented.

The guild would own or rent a building to house the offices of all the professional staff. In it would be included the necessary auxiliary equipment of X-ray and other laboratories, also a hospital with a complete equipment of operating rooms and offices for the administrative and nursing staff.

The owners of the guild would employ the non-professional force, from the administrative head to the orderlies and cleaning women. Purely business matters—the purchase of supplies, the keeping of accounts and records, the management and care of the building—would be in the hands of an administrator of wide experience. They would be conducted on principles of scientific management and modern business efficiency.

Membership in the guild would be open to the general public on condition that each member agree on behalf of himself and his family to submit to a thorough physical examination at least once in every year. The guild would guarantee to provide medical care and hospital service when necessary for its members and their families for the period covered by the dues—preferably a year. As in the case of insurance premiums, the dues would have to be paid whether services were actually rendered or not, and preferably in advance.

What the dues of such a guild would be and how they might vary is an interesting speculation. Its managers would be faced at the start with several problems. Should a rate be charged for each individual covered by the service or should there be a family rate regardless of the size of the family? Should the rate be graduated according to risks in each individual case or should a flat rate be established no matter what the age and physical condition of the member? But these are all questions of policy and not of principle. Dues would necessarily have to be set at a figure sufficient to pay the costs of operation of the guild, including salaries, and to amortize the loans by which it was financed. And these costs in turn could only be determined by a thorough actuarial study of sickness and by the number of members which the guild could enroll.

It is obvious that a certain amount of flexibility of operation should be allowed. For example, the lay members should have a free choice of physicians. If they should want to call in some doctor outside the guild staff or go to some other hospital they should obviously be free to do so—at their own expense. Some flexibility might also be allowed to the professional staff in serving patients other than members provided, of course, that such outside practice did not interfere with their obligations to the guild.

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