Dollars, Doctors, and Disease

"Society must look forward to providing for health on the same basis as education, or else leave the medical profession in its present unfortunate plight."
IV

The reports of the committee show, with an almost incredible range of dependable facts, that failure to use our available knowledge and services causes a vast amount of preventable physical pain and mental anguish, needless deaths, and economic wastes. Present conditions call, not merely for a little improvement here and there, but for far-reaching changes.

The recent progress of the science of medicine has been little short of miraculous. Physicians and other men of science have shown an almost unparalleled professional spirit in making available, for the benefit of mankind, the results of their research in aseptic surgery, anesthesia, bacteriology, physiology, and radiography. Physicians as a body, especially family doctors, have shown a willingness to risk their lives and to serve suffering mankind without regard to money reward—a record which is scarcely equaled by any business, or even by any other profession. Yet in the distribution of benefits, medicine has made intolerably slow progress.

Under the prevailing form of medical service—private individual practice—more than 80,000,000 persons in the United States either do not receive the care which they need and which could readily be provided, or are heavily burdened by its costs. At the same time, many of the competent practitioner and agencies are underemployed and poorly paid. A barrier, mainly economic, stands between the doctors, dentists, and nurses who are able and eager to serve and the patients who are sorely in need of services. This is the conclusion reached by the committee after five years of research.

About 1,000,000 persons in this country provide medical care and depend upon it for their livelihood. There are nearly 7000 hospitals, with a total capacity of about 1,000,000 beds; 8000 clinics and out-patient departments of hospitals; 60,000 drug stores; and many state, county, and municipal health departments. These extensive facilities, however, are not distributed according to need: many communities are undersupplied, while many others have a surplus. For example, there is one physician to every 1431 persons in South Carolina, but one to every 484 in California. There are 19 dentists per 1000 of the population in Mississippi, but 101 in Oregon. Only half the counties in the United States have hospitals for general community use. There is also maldistribution as to type. For example, about 45 per cent of the physicians completely or partially limit their practice to a specialty, although the needs of patients might be met if only 18 per cent of the physicians were specialists.

Moreover, even in places where adequate medical care can be purchased, most of the persons in the lowest income groups do not get it. In spite of the large volume of free work done by hospitals, health departments, and individual practitioners, and in spite of the sliding scale of charges, it appears that each year nearly one half of the individuals in the lowest income group receive no professional medical or dental attention of any kind, curative or preventive.

Even more extensive is the failure of the people to benefit by preventive medicine. In any one year, fewer than 7 per cent of the population have a complete or even a partial physical examination. Public health services are also grossly inadequate. Less than 25 cents per capita is now spent for county and rural health work whereas the committee estimates that adequate services would cost not less than $2.50 per capita.

Then, too, much of the money that is now spent for medical care is spent to poor purpose. Of the $3,647,000,000 that is paid out each year, $125,000,000 is spent for the services of naturopaths, faith healers, and similar groups, and $360,000,000 for patent medicines. In the opinion of the committee, much of the $125,000,000 and virtually all of the $360,000,000 are wasted.

Another difficulty is that the patient does not know what he wants. How can he know? And even when he does know, he cannot tell where to find it. He may drift around or be sent around for weeks, from one specialist to another, all the while with decreasing funds and increasing pain.

‘Everyone,’ says Professor Walton H. Hamilton, a member of the committee, ‘has learned the knack of buying bread and shoes and houses. If he wants candy, coffee, or cigars; if his heart yearns for dancing, preaching, or faking, he gets just about what he asks for.’ Not so with medical care. The market for that is unique. The demand is for a necessity; failure in supply often means death; yet the patient who buys medical care in the open market runs serious risks. It does not come in standardized packages: there is no simple test of worth which the buyer can apply. As a result, medical care is now bought with little knowledge of its quality—often, too, with little knowledge of its price. The patient commits himself to an unknown course, in which one bill may merely breed others. The price does not behave the way prices behave in textbooks on economics.

Worse still, under the present ‘fee-for-service’ basis of private practice, the patient may fall into the hands of fee-splitting doctors, and thus be misled when he thinks he is getting honest advice. The objections to fee-splitting are that physicians thereby gain income without regard to their qualifications; patients are diverted by misinformation from the best specialists; the fee is usually exorbitant; men who thus buy and sell patients often perform unnecessary operations; and the fee-splitting surgeon is surrounded by paid solicitors, all greedy for money profit. The committee declares that fee-splitting ‘increases the cost of professional care, degrades the profession, and, in effect, puts the patient in the hands of the highest bidder.’

What every sick person needs, evidently, is a single agency, in one place, freed from every taint of commercialism, which will furnish him all the necessary information.

V

Even in the face of all these facts, however, the committee believes that the chief reason why the costs of medical care lie at the root of the problem is that the costs are uneven and unpredictable. The average cost per family means nothing as a practical matter. In one group of 9000 white families, the committee found that the collective expenses of 4 per cent of the families were as large as the collective expenses of 80 per cent. Of the low-income families, the expenses of 80 per cent were less than $60 per family per annum, while the expenses of 3 per cent were above $50. These high-expense, low-income families did not find their burdens bearable, merely because the average costs of medical care are not excessive for families with average incomes.2

The budgeting of family income, which has been encouraged of late years and has been facilitated by the use of installment payments, may assist families in planning for expenditures which can be determined in advance. But the unpredictable nature of sickness, and the wide range of professional charges for nominally similar services, render budgeting for medical care on an individual family basis impracticable. On the present fee-for-service basis, it is impossible for 99 per cent of the families to set aside any reasonable sum of money, with positive assurance that no more will be needed for medical care.

Another objection is that medical costs which are too high for many families to pay nevertheless do not guarantee high incomes to most of the practitioners. The total income of physicians in private practice is much less evenly distributed than the income of several comparable professions: actual net incomes are inadequate for large numbers of practitioners and more than adequate for others. For every physician who, in 1929, received a professional net income above $10,000, there were two who received less than $2500. The contrast is especially great, as everybody knows, between the incomes of general practitioners and the incomes of specialists. The committee concludes that no solution to the problem of medical costs can be reached through a reduction in the average of professional incomes.

Another difficulty in providing medical care is that the per capita income, even in prosperous 1929, was less than $700, and the income of half the families was less than $1800. Furthermore, the 123,000,000 human beings who need doctors and dentists and nurses are scattered over 3,000,000 square miles of territory. There are 20,000 persons to the square mile in Manhattan, and only one to the square mile in Nevada. Then, again, 10 per cent of those who need care are Negroes, and of these 23 per cent are illiterate. Still further to complicate the problem is a climate notoriously fickle, and a temperature which ranges from 119 degrees above zero to 45 degrees below zero. These difficulties are slight, however, compared with the fact that millions still believe in incantations as a cure for smallpox, or in other remedies of the same fascinating nature.

These, then, are some of the conditions which the committee had to take into account in formulating a plan for the satisfactory medical care of all the people and adequate means of payment for all the services. These conditions are the outcome of social evolution; they are not the fault of the medical profession or of any other group; they must, nevertheless, be faced.

The crux of the problem, evidently, is to bring Doctors, Dollars, and Diseases into such helpful and continuous contact with each other that the practice of medicine can keep pace with the science of medicine.

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