A business perspective on industry and health care

Sm. Sm & Mrrl.Vol. 13D.Pp. 135 10 139 Perp;~mon PrerrLid 1979.Prmed in Great Britam

BOOK

REVIEWS

Paver, Provider. Consumer: Industry Confronts Health C&e Costs, by DIANA CHAPMAN WAUH and RICHARD H. EGDAHL. Soringer Series on Industry and Health Care No.

1. Springe; Purblishing., N.Y.. 1977.- 1I7 pp. $7.80. A Business Perspective on hubtry and Health Care, by WILLIS B. GOLDBECK. Springer Series on Industry and Health Care No. 2. Springer Publishing, N.Y.. 1978. 70 pp. 57.80. Background Papers on lodustry’s Chogiog Role in Health Ore Delivery, Edited by RICHARD H. EGDAHL. Springer Series on Industry and Health Care No. 3, Springer Publishing. N.Y.. 1977. 198 pp. 529.80 (cloth) The burgeoning costs of medical care-especially to corporate employers-has created a flurry of activity on the part of corporate strategists. The corporate response includes lobbying pressure for National Health Insurance; the active creation of in-house medical facilities to render medical care for employees and their families; and corporate presence in secular health institutions with planning bodies to make them more directly responsive to the corporate perspective. A new series has been published with the promise of four monographs per year by the Springer Publishing Company of America in collaboration with the Boston University Institute for Industry and Health Care. In order to understand the necessity for these books and to get some sense of the strategy they propose, it is necessary to relate how industry became such a major factor in American health care. Unable to give major pay rises to employees during the wage and mice restrictions of World War II, many of the la&&&~rations opted to give health insurance as a non-taxable fringe benefit instead. Most employers used Blue Cross (hospital) and Blue Shield (physicians’ services) plans, which mushroomed in size during the depression. Early pushes for the passage of a national health insurance were rebuffed in Congress, but continued’ pressure prompted the Eisenhower administration to press for the growth of voluntary health insurance instead. This brought the large commercial (primarily life) insurance companies into the picture. The %asic mode of reimbursement was that of “cost-olus”. As Blue Cross was formally affiliated with the American Hospital Association and Blue Shield with the American Medical Association, these companies did little to alter the reimbursement scheme for their friends. Since expansions of medical facilities and more treatment would almost automatically be reimbursed by these payers, and since spreading the risk over a relatively large population made their increases seem minor, there was little reason for anyone to complain. As the commercial insurance companies came into the picture, they simply raised their premiums in order to maintain the rate of return they wanted to make. With state insurance departments in a quiescent mood, no aggressive challenging action was taken. As the sixties progressed, however, the costs began to increase to a more noticeable extent. The government became a major financer of health care with the passage of Medicare and Medicaid. and also used a cost-plus reimbursement mechanism. As medical care providers (doctors. hospitals, nursing homes. etc.) raised fees and charges to cover the costs of expansion and to increase profits, the inflation rate in the medical care sector soon surpassed and then doubled the national rate. As more and more employers added health insurance to their wage and fringe

package, the costs to them began to rise dramatically. Coupled with the worldwide recession of 1973-1975 and the continued economic difficulties in the U.S., business has begun to look for ways of lowering its expenses in this area through the rationalization of the medical care sector. It is often noted in this regard that Genera1 Motors makes larger payments to Blue Cross than it does to U.S. Steel. its major structural supplier. Corpora& think-tanks and policy groups such as the Conference Board, the Business Roundtable and the COF.. mittee for Economic Development have been discussing the health system for the last few years. Only recently a new group, the Washington Business Group on Health. has been set up to specifically focus on the area. This, then, forms the background that inspires these and the forthcoming volumes put out under the auspices of the Center for Industry and Health Care at Boston University, a center set up by corporate grants. To date three volumes have been published. The first is a general introductory monograph entitled

135

Payer Provider Consumer: Industry Cosrs. It views the different ways

Confronts

Health

Care

that corporations relate to the health care system: as a major payer for health insurance plans and medical costs of its employees; as a provider of medical care services to its employees through in-house medical and occupational health clinics; as a consumer of medical care interested in health planning and consumer health education. We are told that in the interests of keeping costs and unnecessary utilization of medical services down, corporations are increasingly shifting to creation of their own medical departments because they feel that in this manner they have greater control over costs and utilization. Moreover. corporations are seeking a greater presence on planning bodies in order to better put across their position on rationalizing the system. The second volume, entitled A Business Perspective on Industry and Health Care, by Willis Goldbeck, the executive director of the Washington Business Group of Health, is an extremely short (under 60 pages) monograph that presents the group’s perspective. Its chief value lies in its discussion of concrete examples of the various corporate activities to further cost control and keep utilization down. The third volume, entitled Backwound Papers on In.. dustry’s Changing Role in Health C&e Delivery, edited by Richard Eadahl. is a collection of DaDers presented at co”ferences; tie Sloan Institute of H’os$tal’and Health Services Administration at Cornell University, and the Boston University Health Policy Institute. These papers present in-depth and substantive comments from corporate medical directors regarding the problems they face and their prospects and means of resolution. The books clearly show the increased corporate role in trying to stem the rising costs of health care, and go so far as to admit that this is in the interest of increasing profits and reducing absenteeism and low worker productivity. While the candor is admirable, one must ultimately question the value of a health system in which showing up and working to some expected norm becomes defined as health. There is no mention in these books of health being anything more than “showing up” at work on time. and it is this that reminds us of the fact that in an economy based on profit, corporate actions are not always benign. While it is in the interest of us all to lower health care costs, it is important to remember that health is more than mere productivity and maintainence. We must remain alert so that increased corporate activity does not go beyond I..

136

Book reviews

the active reduction of costs to the detriment of our collective health. These books present a current perspective on the attempts of big business to effect control over the American health care system. They provide policy researchers and health workers with an insight into a potential health care system of the future. Their prime value lies in their giving a clear indication of the motivations behind this corporate involvement and thus a chance to prevent these plans from coming to full fruition. The books are well written. though their brevity does not justify their price.

subject. both parents and adolescents desired more detailed birth control lessons at school. Although teenagers who had birth control information at school were more knowledgeable than peers without such lessons. use of birth control. unfortunately. was the same in both groups. For those familiar with Sorensen’s book, My Morher Said is shorter but somewhat more difficult to wade through because of the numerous tables and comparisons of working class and middle class adolescents. Nevertheless, if one accepts the need to read this book in daylight hours rather than at bedtime, the sheer number of adolescents interviewed make the data important to those interUniwrsit~ ofMas.wchrrserts HOWARDS. BIXLINI:R ested in adolescent sexuality. Although the scope of sex Amherst. MA. U.S. A. education is narrow in the study. I’m sure the authors with the bias toward lessons at school would support a broader concept of teaching about human relations. For those embarking on studying this book, J suggest reading the technique and conclusions in Chapter 1. 13 and 14 My Motber Said.. . the way young people learned about sex first and then going back to the detailed information in and birth control by CHRISTINE FARRELL. Routledge & Chapters 2-12. Kegan Paul. London, 1978. 274~~. f5.95. As parents, doctors and school personnel grapple with the epidemic of unwanted teenage pregnancies, surveys looking at adolescent sexual behavior and sources of learning will hopefully give us a starting point for understanding some of the issues involved. Christine FarrellS book My Morher Said is such a start. It is a compilation of data gathered about sources of sexual information during interviews of over 1500 British adolescents 16-19 years-old and 300 parents; specifically (I1 where babies come from (2) sexual intercourse and (3) birth confrof. Although attitudes and behavior of parents toward physical contact (hugging, kissing. masturbation. nudity, etc.) as well as the quality of the relationship between parents have a profound impact on a child’s developing sexuality. these issues are clearly more difEcult to quantitate. This is undoubtedly why the authors chose to restrict the scope of their questioning to the three topics mentioned. As a British study. the participants were divided by sex and class (working class or middle class). Half of the teenagers were sexually experienced, and most felt that premarital sexual intercourse was acceptable within the context of a loving stable relationship. In agreement with Sorensen’s Adolescrr~t’S~~.uualit)~ itr Contemporar.v America. this study showed little evidence of casual sexual relationships among teenagers. However. although Farrell’s statistics showed many teenagers using intermittent birth control or less effective measures such as withdrawal. her interpretation of the data varies from SorensenS study. She characterizes the teenager with the unwanted pregnancy as “unlucky”. In this country. interviews with pregnant teenagers have demonstrated many other issues besides bad luck involved in the large numbers of unwanted pregnancies. Of interest to educators wishing to support the virtues of sex education in the schools. teenagers who learned about sex from peers were more apt to be sexually active than those who learned at school. Such data, as the author herself points out. may not be causal because working class adolescents are more apt to learn from peers and be sexually active. Teenagers were also apt to express dissatisfaction with sexual learning if the first knowledge of intercourse came from peers rather than parents, athough peers were felt to be a valuable source of discussion once the basic facts had been acquired. Adolescents expressed a desire to learn more at school and from parents. Although parents felt that they should be taking an active role in imparting information. they unfortunately rarely lived up to their own expectations. Mothers tended to play an active role, especially in education of daughters: fathers tended to avoid discussions both with daughters and’ sons. Since parents often lacked specific knowledge about birth control measures and felt ambivalence about discussing the

Adoiescenrs’ Unit Children’s Hospital Medical Harvard Medical School Boston. MA. U.S.A.

Abortion National

S. JEAN EMANS Center

In America, The Origins and Evolution of Policy, WO-1900, by JAMESC. MOHR. Oxford

Univ. Press, New York, 1978. 331 pp. $6.75 For those of us who are either providers or students of women’s health, there is a tendency to be caught up in the rapidly changing politics and legislations of this last decade. It is also far too easy for us to be shortsighted and to believe that we wage our own particular contraceptive and abortion wars in the present only and to be unaware, of the historical antecedents in the field. Given this propensity, James Mohr’s book is extremely welcome and useful. Abortion In America is a complete and analytical pr~entation of the history of attitudes both pro- and antiabortion. Mohr points out how, in the 19th century, what was initial liberal and laissez faire attitudes toward abortion were changed, resulting in negative public opinion and restrictive legislation. He indicates how social and legisfative poiicy emerged mainly from a move toward professionalization for the medical profession and how these pressures combined with feminist groups, the media and the politicians. For those of us who have believed that abortion is a moral dilemma. Mohr’s material is extremely interesting. From the data presented it is clear that pregnancy and termination thereof is far from either a personal or a religious issue, but is rather a social reality explicable in terms of social movements, ideologies, economics and the like. A women’s body was then, as it is now, an arena or setting for philosophical, ethical, moral. medical and economic struggles. The latter is my conclusion. Mohr is not political nor does he draw many conclusions from his material. His comment that perhaps the late 19th century is more an aberration in terms of abortion policy and that we have returnrd to a liberalized position is. I believe. premature given the last few years. The comment that it is ironic that physicians today who are working to liberalize abortion are undoing that which their predecessors worked so hard to accomplish is very interesting. However, Mohr

does not continue to explore or comment on the role of the male physician in defining women’s health care, be it for economic, status, paternalistic reasons. The fact that Mohr does not

or

professional

theorize is disappointing to me. but perhaps that is more a result of the differences between historians and sociologists.