Health care system
The health care system provides professional (or professionally guided) services which preserve, restore, and improve your health. Let's consider variouselements of it as they have affected you in the past and may affect you in the future:
- You were probably born in a hospital, so let's look at hospitals first.
- You've had attention from various medical doctors, so let's look at the medical profession--medical training, where specialists fit into the pattern, and how to pick the best doctors available.
- Sooner orlater you'll have to pay the bills, so let's look at the economics of healthcare. We'll consider what's available to you as an individual and both present and possible future government programs.
- Some health care is rendered by other professionals. Let's consider those which work in conjunction with medical doctors first, then discuss some of the alternative non-medical care sources.
- Finally, let's consider your own part in the process. Because the "system" can't work without your informed cooperation.
Before medical care became intensely technical and scientific, most people cared for the sick in their own homes. Hospitals were founded primarily to carefor those who had no family members and couldn't afford to pay someone to care for them in their own homes. Hospitals were then usually operated by nunsor other volunteers, as an unpaid public service.
As care became more technical, sick people increasingly needed trained personnel and special equipment. It wasn't practical to provide those facilities inpeople's homes. Hospitals were the only facilities generally available to care for several sick people in one place, so that those patients could share trained personnel and special equipment. Thus hospitals became centers of scientific care. They began charging patients who could afford to pay in order tocontinue free care for those who could not. Almost all were operated by religious, nonprofit or governmental bodies.
With the advent of health insurance, many more people had ability to pay. Theearly policies paid a limited amount for basic room charges, but paid unlimited amounts for laboratory services, supplies, and operating room charges. Sohospitals commonly charged less for the room than it cost to provide it, andmade up for the loss by charging more for things the insurance policies covered. Some of these excessive charges remain today, with items like $2 for anaspirin tablet appearing on some hospital bills. At the time, with virtuallyall hospitals making no profit, such charges were a rational (if not truly fair) way of paying expenses.
Today the poor are covered by Medicaid, the elderly by Medicare, most workersand their families by employer-sponsored medical benefits. Although some people remain uncovered, most patients' bills are paid by either an insurance company or by the government. An increasing number of hospitals are operated byfor-profit private corporations. These hospitals generally check to be sureof insurance or government coverage before letting a patient in. Uninsured patients generally are sent elsewhere--these are not charitable institutions.
Another new element has entered the picture. As more and more people are covered by insurance or by HMOs (see p. 00), those bodies have negotiated an all-inclusive daily rate, covering all essential services. (You may still be billed for TV, telephone etc., but the daily rate covers both the room rate, those $2 aspirin, and special operating room or laboratory charges.) Then the insurance companies or HMOs have insisted on minimized hospital stays: You comein for an operation after midnight instead of the previous evening, for instance, and generally leave a day or two earlier than under previous rules.
Many of these changes create new problems. When hospitals were operating on anon- profit basis even their highest charges couldn't be deemed excessive--their total income was geared strictly to pay expenses. In a for-profit framework, some form of supervision and constant renegotiation is needed to avoid price gouging. As more services are crammed into less days, the hospital ratehas needed to reflect the additional costs. This has made it seem that costsare rising much faster than the general rate of inflation.
The fact remains that good care for the sick often involves the need for around-the-clock services, technical procedures performed by highly trained people, and use of expensive equipment. A century ago hospitals were places the poor went to die. Today they are places almost everyone must occasionally go regardless of cost if he wants to regain health and live.
The Medical Profession
Every physician has spent a lot of time in school. Most have four years of college and four years in medical school. At least one year is then spent working in a hospital as interns, rendering care under the supervision of established practitioners. Some general practitioners and all specialists spend further time working under supervision as hospital residents. Specialists who arelisted as "certified" have spent at least three years in this capacity and passed a rigorous set of examinations.
It takes substantially higher income to make up for years of expensive or low-paid training. Specialists, with longer training periods, virtually always charge more for their services than general practitioners. (Even so, a recentstudy showed that most specialists have a lower lifelong after-taxes income than G.P.'s.)
Probably the most efficient way to get medical services is to find and utilize a primary physician. Your primary physician can usually give sound preventive care and advice and care for 80-85% of your illnesses. When you have a problem which requires specialized attention your primary physician can send youto a doctor in the right specialty, and generally one selected as the best available.
The typical "primary physician" is a general practitioner (especially in managed care structures or HMO's). But some women who need regular treatment or preventive care from a gynecologist (specialist in women's organ disorders) may use that specialist as their primary physician. Many people who can affordit use internists (specialists in internal medicine) as primary physicians. Internists can handle almost as high a proportion of illnesses as general practitioners, and have extra training in diagnosis and treatment of most non-surgical conditions. Children often use a pediatrician as their primary care source.
Many people feel that they can save money and time, and perhaps get better care more promptly, by going directly to a specialist. This is probably true ofwomen's organ problems, so even HMO's (which generally insist that you visita primary physician before seeing a specialist) permit patients to go directly to gynecologists. Some other problems clearly indicate which specialist would be appropriate, although your primary physician may be able to handle them adequately. Urinary problems, skin disorders and eye infections or inflammations fall into this group. Going directly to a specialist for these conditions may prove somewhat more expensive, but will not be grossly inappropriate or wasteful
In most other instances, going through your primary physician generally makessense. Symptoms often point toward an entirely different type of illness than is actually present. As one Johns Hopkins professor told his medical students: "If the patient says he has heart trouble it's probably his stomach. If he says stomach it's probably heart."
If you go to the wrong specialist, he feels obliged to be sure you don't haveany disorder in his sphere. Even if he strongly suspects that you belong elsewhere, he generally orders or performs exhaustive tests. It is very hard--also very expensive and often quite uncomfortable--to prove that absolutely nothing is wrong with your heart or your stomach.
The main key to getting good medical care is thus picking a good primary physician. He will then direct you to the best specialists available to you whenneeded.
So how can you pick a good doctor?
First check on his credentials. Almost every public library has on hand the American Medical Association Directory of Physicians, the Directory of the American Academy of General Practice and the Directory of Medical Specialists. Similar material is available on the Internet. Certification, membership in specialty societies, membership on hospital staffs, and teaching appointments at medical schools help you to evaluate various physicians.
Next check with friends or relatives who have gone to the physicians you areconsidering. But don't ask these people how satisfied they are--that is morelikely to tell you about his or her bedside manner than about skill and knowledge. Repeated studies have shown that all of a physician's key skills tend to correlate with one measurable quality: THOROUGHNESS! Ask your friends and relatives these questions about their doctors:
- Were they questioned thoroughly about their complaint, significant health history, and present medications?
- Did the doctors have them remove clothing before examining their heart and lungs?
- How many times did the doctors apply their stethoscope bells to the chests when checking heart or lungs?
- Did any annual or supposedly complete physicals include putting a finger into the rectum?Did women having a complete exam always have examination of the breasts and female organs?
- Did the doctors explain thoroughly exactly what medications their patients should take, what diet they should follow, what activities were permitted etc.?
You might need to keep notes to make comparisons valid. Of course circumstances alter cases: Someone being examined for chest pain should have more careful heart examination than someone who has no such complaints. But you may be able to find widely varying thoroughness in people being examined for the samereason. Everyone on your football team may have needed a physical for athletic participation, for instance. If one doctor just listened to one spot before declaring each heart healthy while another routinely applied the stethoscope five or six times, you know which was more thorough. If one checked for hernia, and the other didn't bother, you know which is more thorough.
The Money Side
Doctors have been paid in many different ways over the years. Doctors were paid only when they cured the patient in the Middle East about 900 years ago. One of the largest surgical fees in history (about $500,000 at the present cost of gold) was paid there for removal of a minor, non-life-threatening cyst from a Sultan's scalp. Of course the doctor would probably have been beheadedif anything went wrong. So under that system doctors never tried anything they weren't absolutely sure would work, and medical progress came to a screeching halt.
You'll hear a lot about the problems arising from the fee-for-service systemof payment, which generally prevails today. Under this system a doctor gets paid the same amount for an examination, procedure, or operation no matter what the result.
The main problem with this system is that the people who get the least benefit pay the most: The person with incurable diabetes, for instance, needs to beexamined over and over, with laboratory studies, special eye tests etc. He pays for each visit and each procedure, amounting to a great deal of money over the years. By contrast, the person with pneumonia, which doctors now can cure, needs much less care. He comes in once, gets the right antibiotic, and maybe needs one checkup later to be sure his cure is complete. He pays much less for total cure than the diabetic pays for mere maintenance.
The other problem with this system became apparent when third party payment (by insurance companies, Medicaid, Medicare etc.) became prevalent. In a sensethese seemed bottomless purses, and many medical fees went up at prodigiousrates. This precipitated public outcry and intense efforts to contain healthcare costs, which we'll discuss shortly.
There are two good things about the fee-for-service system, though, which youwon't hear much about. First, the fact that doctors get paid a lot more forcare of people they can't yet cure induces them to spend a great deal of timeand effort on today's unsolved problems. Doctors can afford to specialize indiabetes or treatment of cancer. Even non-specialists eagerly seek out and try new medications and methods for their incurable patients. This has tremendously aided finding and prompt application of new treatments. It has contributed greatly to the enormous progress made by the American health care systemin the past fifty years.
Second, fee-for-service encourages the types of care which make illness moretolerable when no cure is available. Probably over half of the medical care rendered in this country falls into that category. From relief of symptoms from a cold (which no doctor today can really cure) to giving terminal cancer patients extra months or years of reasonably pleasant life, amelioration of disease symptoms is hugely helpful. Fee-for-cure, or even compensation by salary(which usually means satisfying a supervisor with turnover) generally lead to virtual neglect of measures which give relief without achieving cure.
Still cost containment has become vital. In some years health care costs haveincreased four to six times the general inflation rate.
The public in the past has made two demands of the health care system: Firstthe best care available regardless of cost. Second keep the cost reasonable.It has become increasingly apparent that those demands are incompatible.
The main effort to contain costs has been through encouraging competition. For this purpose organizations were formed which offered total care. That provided a way of comparing the cost of various packages.
The readily available institutions for this purpose were the Health Maintenance Organizations. This name came from the assumption that preventive care andearly detection of illness through routine examinations would save money compared with wait-til-you're-ill attention. A few such organizations do stresspreventive care, but most simply offer a package deal providing all the medical and hospital care you need for a stated monthly charge. This is really Managed Care rather than Health Maintenance, and the HMO term is gradually beingreplaced with that more accurate phrase.
So if your health care is paid for by an employer or a government agency thechances are that you are now or soon will be involved with a managed care facility. If you can choose between several programs, consider these matters:
- Hospital affiliation
- Physicians affiliated
- Degree of choice of your primary physician, and degree to which that particular person will be available to you. In particular if you become ill will you see him, a different physician, or a nurse-practitioner?
- Away-from-home coverage
- Stability, with special reference to possibility of this group ceasingto cover people in your area
- Obviously, cost and convenience (but some of the other things are really more important)
Doctors would have a hard time functioning these days without the help of nurses, technicians and aides. You will never have to choose which of these people participates in your care, so you don't need to know much about them. Butyou might get along better with them if you realize how much they have had tolearn (and hopefully know). Here's a partial list of the ones you're likelyto encounter:
- Registered nurse. Trained in bedside care, administration of medications and injections, observation of patient status etc. Extent oftraining varies from three years hospital-centered training to 5 years or more, part in University classes and part at bedside.
- Practical nurse.Usually has one to two years hospital-based training in patient care.
- Technicians: people with training in specific tasks ordered and supervised by physicians. This includes physical therapists, occupational therapists, laboratory technicians, certified ocular technicians and many others. Training varies, but usually involves about four years of college.
It's more important for you to know as much as possible about the health professions and groups which some people use in place of physicians. All of theseinvolve choices which you must make for yourself, usually without help fromyour primary physician.
First, look at some professions which work with rather than compete with themedical profession:
- Dentist. Usually has four years college, four years dental school with D.D.S. degree (meaning Doctor of Dental Surgery). Some dentist take further training as specialists. They become orthodontists (toothstraighteners), endodontists (root canal specialists), periodontists (gum disease specialists), pedodontists (children's dentists), prosthodontists (specialists in replacing or reconstructing lost teeth), or oral surgeons (tooth removal, other mouth surgery -- these often have M.D. degree as well as D.D.S.)
- Pharmacist. Several years schooling beyond college. Dispenses medications. Needs to know appropriate dosages and applications of thousands of drugs.
- Clinical psychologist. Usually has Masters or PhD degree, several years study beyond college. Performs tests to aid diagnosis of mental conditions. In some instances counsels patients and gives psychotherapy.
- Podiatrist. College degree or better. Takes care of feet--fallen arches, corns, callouses etc.
- Midwife. Trained to assist in normal births, often in the home.
Next let's look at some professions or groups which you might choose insteadof a physician:
- Optometrist. Trained in determining which lenses willbest correct your vision. In competition with oculist (also called "ophthalmologist"), a physician with specialist training in eye disorders. If you havenearsightedness, farsightedness and/or astigmatism with no other varieties ofeye disease, an optometrist can fit glasses which will correct your vision.The advantage is that his services are less expensive. One disadvantage is that he may not diagnose any other eye condition present. That may be very important if you get a condition for which early treatment is necessary to preserve vision. In some instances there is another disadvantage: if the optometrist is associated with an optician (who actually makes and sells you the glasses) he may be inclined to prescribe glasses you don't need, or new lenses whenthe old ones would still be good. The author knows of several instances in which glasses were prescribed with 1/4 diopter correction, for instance. You would have a hard time telling them from window glass. Of course, the author also knows of many optometrists who have never done such a thing, and does notintend this as condemnation of the entire profession.
- Osteopathic physician. The original tenet of osteopathy was that virtually all disease wascaused by misalignment of bones and could be cured by manipulation. This theory has gradually been displaced. At this time osteopathic schools teach almost exactly the same courses as medical schools, perhaps with one or two extracourses on manipulation. (And standard medical schools now teach manipulationfor appropriate conditions.) Medical schools get to choose from many applicants (there are usually about five times as many applicants as there are berths) and osteopathic schools can't be quite as selective. That's about the onlydifference between the two disciplines these days.
- Chiropractor. Thebasic theory of chiropractic is that virtually all disease is caused by misalignment of vertebrae. Virtually all treatment is based on manipulation of the spine. Medical scientists consider this theory to be totally false. However, many people seem to get relief from chiropractic treatment, especially if they have back trouble or muscular aches. Chiropractors spend time with theirpatients, listen to their complaints, and perform massage. (Most chiropractors stick to this role and probably do more good than harm. A few use chiropractic treatment inappropriately for conditions like cancer, often fatally delaying medical treatment which could have been curative if applied promptly.)
- Naturopath. Stresses natural cures, emphasizing dietary supplements andherbs.
- Christian Science reader. Offers prayer and rituals aimed atgaining divine intervention.
Remember that we started by saying that the health care system "provides professional (or professionally guided) services which preserve, restore, and improve your health." That doesn't stop at your front door! A lot of the "professionally guided" services are up to you!
For one thing, pills don't do any good if you leave them in the bottle. Whendoctors have prescribed medications to be taken three or four times a day, studies show that the patients skip about two out of every five doses. Averagecompliance is even worse with other instructions, like diet, specific exercises, or limited activity.
You can get much more out of the health care system if you really follow themedical advice you've paid for.
Finally, future progress in health improvement almost has to come through adoption of healthier lifestyles. Medical progress against mortal illness mightgo a little farther, but is reaching the point of diminishing returns. Meanwhile, traffic and other accidents, cigarette smoking, and overweight lead to more shortening of life than almost all other problems combined. Everybody knows what to do about these things. They just don't follow through.
Two things make it easy to ignore advice you know makes sense:
- The usual way of expressing health risks is to talk about life expectancy. That makes the hazard seem very remote. You don't care much whether you live to 75 orto 80, at least until you're pushing up near there. But the years lost by diminished life expectancy aren't really the terminal years. Cigarette smoking and obesity each cause victims to have about ten times as many heart attacks as normal in their thirties, about four times as many in their forties: Stillnot totally immediate, but a long way from remote! Automobile and other accidents always rank in the top three causes of teenage death and death in the twenties. Getting immediate enough to affect your behavior?
- Then there's the "personal immunity factor". That's the psychologic barrier your brain puts up to protect you from unbearable anxiety. You just can't be comfortableif you think you might be headed for fiery death in a crash every time you get into an automobile. So your brain ignores that risk, saying "it can't happen to me."
You need that "personal immunity factor" to survive in our fast-moving society. But you don't need to let it dominate all your actions. You don't need tosay "early heart attacks can't happen to me" as you light up that cigarette.You don't need to say "accidents only happen to other people" as you push thespeedometer up past 80.
You can become the most important part of your own health care system: Get the best advice that's available, then put it to work in your own life!