The Cost of Illness
I
IN discussing doctors’ fees, in dealing with questions of medical and hospital service, we are treating of some of the most fundamental problems of social organization.
It is estimated by the most careful and reliable authorities that about two per cent of the population of the United States are ill all the time — ill enough to be unable to attend to their daily tasks. This means that every day there are over 2,300,000 people sick in the United States. In New York City fifteen per cent of the sick go to hospitals. In other communities this proportion is sometimes larger, sometimes smaller.
At a recent convention of the American Hospital Association the presiding officer called attention to the fact that the hospitals of North America are among the billion-dollar enterprises. Annually the hospitals of this country are spending a sum equal to about onethird of the expenditures of the United States Government. No wonder that public opinion is becoming more and more insistent in its demand for an adequate accounting of the stupendous sum expended for the care of the sick.
Every year the demand for hospital accommodations is increasing. The housing conditions in the large cities are growing worse in the sense that private homes are rapidly giving way to apartments of small rooms in multistoried structures. The rents per family are increasing and the space is decreasing. This, coupled with the difficulty of obtaining domestic help, makes the problem of sickness at home still more perplexing.
Then comes the question of getting nurses. In spite of the high — we might better say the prohibitive — prices paid, nurses do not want to work in private homes. They are now on two shifts a day ($7 or $8 or more per shift), but they find so many opportunities in the public-health field, with regular hours of work, good pay, and a month’s vacation on pay, that privateduty nursing becomes unattractive.
People realize also that surgery cannot be done satisfactorily at home, and almost two-thirds of our hospital work is surgical. Modern medicine requires so many ancillary departments, such as laboratories and X-ray equipments, that the best diagnostic and therapeutic work can be done only in hospitals. Women are using the hospitals during parturition in greater numbers every year. In some cities as many as sixty per cent of the births are in hospitals.
Some of us have forgotten that hospitals were built originally for the poor. They were charitable organizations. The poor are still there, crowding the clinics and wards; the rich have usurped the remaining space — the limited number of private and semiprivate rooms; and the middle class are almost completely crowded out.
Formerly, when the hospitals were built for and used by the poor, a rich woman prepared a room or rooms in her home for an operation or for parturition. This was done with painstaking care, according to her physician’s instructions. Often walls were painted or frequently they were hung with clean white sheets. The surgeon came with assistant and nurse, expecting the entire household, including servants, to wait in attendance. When the woman of means found it more convenient to go to the hospital for childbirth, operations, or any other kind of medical care, she carried her demand for luxury with her. She must have nurses night and day; she must receive every sort of attention and consideration.
Little by little this quality and quantity of service have become standard, and the middle-class man, desirous of giving nothing but the best to his family, has aped the rich, with the result that insidiously there has come about this condition: the best medical service is available only for the very rich and the very poor. The great middle class is not rich enough to buy the best service and not poor enough to accept charity.
A professor in one of our large universities came up against the necessity of having his tonsils removed. After careful consideration and investigation of doctors’ fees he went to a local man who hacked at his throat for something like forty minutes. Returning home after one night in the hospital, he was a very sick man. His dean expressed indignation that he should jeopardize his throat (the use of his voice as a lecturer being his only means of support) by allowing any but an expert to operate on it. Why did he? Because he had found that an expert who operated in four or five minutes charged $150 and his local doctor asked $25. With a salary of $4000, and a wife, two children, and an elderly relative to support, the expert’s fee was not to be thought of. This year he is taking his boy to the local man to have his tonsils removed.
His wife, a cultured woman, is in need of an operation. She will not have it. She will ‘get along.’ She may go through life without experiencing the joy of positive health. She is giving unstintingly to the riches of the nation — a beautiful home, well-disciplined children, public service on charity boards, even service of a civic nature, but she cannot afford for herself the luxury of sanitariums, rest, or hospital service.
II
Perhaps considering authentic specific cases will give us a keener perception of the appalling changes that have taken place in the hospital world.
In 1902 a young woman was teaching in one of the best-known private schools in New York City. Her salary was $800 and that was rather good, considering the four months’ vacation. She was injured in gymnasium work. A disagreeable hernia resulted. She was sent by her family physician to Dr. Robert Abbey, who promptly arranged that she should go to St. Luke’s Hospital and be operated on.
In St. Luke’s Hospital, in the year 1902, she occupied a private corner room with windows on two sides, paying $23 a week. She had as nearly perfect care as one could wish for. Such an idea as having a private nurse was never mentioned to her. The day nurses came in and out, attending to every duty, answering the bell when especially needed, going from room to room, from patient to patient, calling the interne if necessary.
At night a magnificent type of young Canadian woman came in like an evening benediction. The patient, being addicted to insomnia, followed the sounds of her footsteps through much of the night — up and down the halls, in and out of rooms in answer to the buzzing of the bell calls. How many rooms, how many patients, were under her care it would be difficult now to report, but there were many, and she gave unstintingly of care and cheer to all.
The hospital bill, including the small charges for the operating room, was about $50. When it came to paying Dr. Abbey, he asked the patient’s salary, her other means of income, and set the price at $25. The entire illness cost her about ten per cent of her income. She knew at that time that Dr. Abbey frequently received $5000 for performing operations, — remuneration his great skill deserved, — a sum which might have been much less than ten per cent of another’s income.
Notice especially the nursing service that accompanied this operation.
On October 24, 1909, the New York Herald published the following table compiled by two prominent New York physicians.
In setting the charges for a major surgical operation one of the most noted surgeons in the country maintained that ten per cent of a man’s income was a fair charge.
At this time a competent nurse came into the home, taking entire care of the patient, arranging with the family about her hours of rest and recreation, for $25 a week. Of course, added to this were her room and board.
An authoritative book on medical finance published in 1912 gives the following schedule of operating fees.
| Appendicitis | $100 |
| Removal of kidney | 100 |
| Tapping of abdomen or bladder | 25 |
| Operation for fistula | 25 |
| Bronchotomy, thyrotomy | 25 |
| Incision of abscess, boil, felon, carbuncle | 5 |
| Minor operation on nose, ear, or throat | 10 |
| Malignant tumor | 50 |
| Skull trepanning | 100 |
| Operation for mastoiditis | 50 |
| Amputation of hand or foot | 25 |
| Suturing wounds | 5 |
In 1912 this was written to doctors: —
‘You have invested a capital of $10,000 at the very least. Your returns from this will vary. In the large city $500 is a fair return for the first year. This should show about $800 better each year until $5000 or $6000 is reached. The number of men making more than this is not great and they are well known. If at the end of ten years your returns are $9000 you are the exceptionally successful practitioner.’
Now let us consider conditions in 1927.
Recently a physician was called in to see a young woman who was suffering from what appeared to be an acute attack of intestinal indigestion. He found her vomiting and in great pain. He examined her and feared appendicitis. He had reason to suspect it might be a ruptured appendix. He wanted another doctor called in consultation. He asked the family if there was any particular doctor they preferred. No, he should use his own judgment. He immediately telephoned for a specialist, a surgeon.
| CASE | LABORERS | CLERKS | BUSINESS MEN | WEALTHY PATIENTS |
|---|---|---|---|---|
| Abscess | $2 | $3 | $5 | $10 |
| Amputations (easy) | 20 | 40 | 60 | 100 |
| Anaasthesia | 5 | 5 | 10 | 50 |
| Empyema | 15 | 25 | 100 | 200 |
| Tracheotomy | 30 | 50 | 100 | 500 |
| Trepanning (simple) | 25 | 50 | 200 | 500 |
| Visits from 7 to 10 P.M. | 3 | 5 | 10 | 25 |
| Vaccination | 2 | 2 | 10 | 25 |
| Appendicitis | 25 | 100 | 250 | 500 to 10,000 |
| Maternity cases | 10 | 25 | 100 | 500 to 10,000 |
As it is customary to pay this specialist at the time of his visit, the doctor consulted with the father, telling him the fee ranged from $25 to $100. The father produced the money. The specialist was moderate, charging $50.
After consultation it was decided that an operation was imperative. The entire family was seized with alarm — panic. Fear clutched them. They told the doctor to call up the hospital and make the necessary arrangements. When this was done, an ambulance was called. The doctor again explained that, it is customary to pay this expense immediately, so the father paid $20 for the use of the ambulance.
Arriving at the hospital, the patient was taken directly to a room, while the father was asked to step to the office. It was explained to him that the rule of the hospital requires payment two weeks in advance. Sometimes payment for one week only could be accepted, but in a case of this kind payment for two weeks was the rule. (A man has to experience this in order to appreciate the sickening sensations.)
There ensued a frantic, hurried family consultation. A private room would be cheap at $10a day. They considered the ward. No, they could not see her put there. She must have a private room if only for a few days. Perhaps later, when she was recovering, the change to the ward could be made. The hospital explained that the money would be refunded if they wanted to make the change later.
The father paid $140 for the room. The frightened family explained their straitened circumstances. They said they must do everything as economically as possible. Everyone understood, of course, but there is no getting away from rules.
The use of the operating room, setting up, and supplies would be $35. They engaged the hospital anæsthetist at $25, for a special anæsthetist would have cost $100.
The case proved to be a ruptured appendix — a difficult operation. The hours of suspense were somehow lived through. By this time, in their fear and anguish, the members of that family would have sold their souls to save the girl’s life. They would have shouldered any debt.
Now they were to understand about the nurses. They were obliged to have two nurses: $18 for every twenty-four hours of nursing for two weeks at least — $252. (Those competent young women of the past are merely a tender memory, inhabiting the land of ‘long ago’ with Florence Nightingale.)
They had two nurses for the first two weeks and after that one nurse for four weeks more because it was a pus case which kept the girl six weeks in the hospital.
The drainings, dressings, and changes cost $12.
When the bill was paid there was the usual item, ‘Laboratory fees.’ This means simple things like urine examination, blood count. It seemed an outrage to charge $10 for this, but they were told it was the usual hospital price.
So far the total is $1076.
This was without the surgeon’s fees or the medical fees both before and after the operation. The surgeon stated that his fee was $1000, but after a humiliating scene and a complete public exhibition of the barrenness of the family’s resources he cut it to $500 and allowed them to pay it in installments over a period of time. Heartsick and burdened with debt the girl began her convalescence.
III
Someone has said the sick poor are doubly unfortunate: they are sick and poor. But the sick middle class are likewise unfortunate; they are sick and they will be poor when the bills are paid.
Right here there could be inserted half a dozen stories told by reputable doctors illustrating the diabolical cleverness with which impostors have cheated surgeons, posing as poor when they could well afford to pay. I know of a throat specialist who operated on a poorly dressed woman who whimpered and groaned about her poverty until the surgeon did not have the heart to charge her even costs. A year later he discovered through another patient that the woman owned an apartment house, was wealthy, and boasted of her cleverness. He sued her and the court allowed him an amazing sum, which in this case was his right.
There is the impostor. There is also the doctor whose hardness and mercenary impulses lead him to extract the pound of flesh and bleed his patients of their bank notes if not of their blood. With these we are not here concerned.
Neither are we concerned with the man who will not pay his bills. As a matter of fact he is well and harshly taken care of at the present day. A surgeon with a large practice stated recently that she sends out her bills every six months — in some cases once a year — and within a month after the bills are mailed ninety per cent of the money is in.
The great majority of men are honest and wish to deal justly. The big business and the small business of the nation are based on credit. Ask the credit manager of some million-dollar concern what he thinks of the general honesty of mankind. You may be surprised to find that he who is giving large and small amounts of credit every day has a much higher opinion of the fundamental honesty of people than has the small man in the street.
The ethics of the public in regard to paying for medical care are generally sound and the ethics of the medical profession are generally sound. Doctors are generally competent in their respective fields; they dislike to divide a fee for medical advice or to suggest treatment unless the patient is fully informed as to the terms of the transaction. They are mostly decent, competent men and women, but it is a fact that the time has come when the likewise decent, competent man, woman, or child of the middle class cannot afford to avail himself of their skill.
Some who have studied the problem believe it can be solved through social insurance. For the laboring class this may be true.
It is a very interesting fact of American social history that from both the point of actual achievements and that of intelligent consideration much more has been accomplished in the way of pensions for old age and superannuation than in the way of sickness insurance.
It is difficult to refrain right here from discussing this question of social insurance against sickness. It is profitable to study what is being done by the sickness societies throughout Germany and Denmark. In no other country has the experiment been tried so thoroughly as in Germany, where there has been insurance against sickness since 1884. Denmark has had it since 1893. In both countries sufficient time has elapsed for definite results to crystallize. It is interesting to note that in Germany the insurance is compulsory, while in Denmark it is voluntary. In both countries the greatest blessings resulting are the systematic measures adopted for educating the insured public in matters of health and medical treatment. In Germany, should an insured person become incapacitated, the usual pension may for a time be refused if he has without justification declined to submit to examination and medical treatment. Think what this means in inculcating the idea of positive health in a nation!
Most of us middle-class people have the idea of positive health thoroughly inculcated in us without the means of availing ourselves of medical care when we know the need of it.
The next ten years will doubtless see forward strides taken in the direction of both educational and remedial work for the laboring classes, but the great middle class may be still uncared for. This is not because of indifference. It is not apathy or ignorance that is causing the problem to continue undiscussed and unsolved.
Perhaps it is partly the peculiar personal quality inherent in illness. A man has a child ill with mastoiditis, a mother ill with pneumonia. Both illnesses are necessarily taken care of in the hospital, where the expense leaves him burdened with debt. He thinks of this as a misfortune peculiar to himself—forgetting that his neighbor in the next block, his neighbors all through the city and country, are undergoing the same worry and impoverishment. When he thinks of his every ill in terms of community illness, community problems, he will rouse himself to band together with his neighbors and do something about it.
The latest available statistics of the National Bureau of Economic Research show that 96.8 of the population of New York State have incomes of less than $5000 a year. These figures become significant and thought-provoking when studied in connection with the cost of illness to-day.
It is gratifying to see that the recognition of the appalling conditions that prevail, both as to doctors’ fees and as to hospital expenses, is coming from the medical world. Some of its finest minds are alive to the seriousness of the situation. Some doctors suggest a modern and much improved method of applying the old Chinese idea of paying the doctor to keep us well and stopping payment when we are ill. The solution will come with free public expression of opinion and a frank disclosure of the tragedy that illness is at present to the man of moderate means.
Looking toward this end, a group of women doctors in New York City are planning to build in the near future a hospital so equipped and managed, organized and endowed, that patients will be charged in accordance with their incomes. One hundred and fifty beds — out of two hundred — are to be set aside for the use of people of moderate means; and the income of a special endowment will be used to reimburse the hospital for the loss sustained for caring for such patients at a price based on the individual’s income. A price charged to cover all extras will include the use of operating and delivery rooms, anæsthesia, laboratory examinations, special drugs and special dressings. There will be fixed fees for the services of physicians and surgeons attending patients receiving the benefit of the endowment.
Not long ago a man who is an authority on civic health conditions and hospitals expressed himself as believing that the time must soon come when society in general must shoulder the burden of caring adequately for its sick. Hospitals must be maintained, medical and surgical care furnished, according to the man’s income.
The endowment of education has long been considered essential. For instance, we know that no Yales student pays the full cost of his tuition. Boys and girls go to college and never for one instant feel they are objects of charity. And they are not. Their added education enables them to give back to their communities a hundredfold more than has been expended on them.
Is not this even more true of health? Is not the health that makes men and women efficient, happy, active, independent, one of the choicest assets of the nation?