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End of the golden age?
Surg Neurol 1986;26:417-8
417
Editorial End of the Golden Age?
"We have been privileged to live through one of the golden ages of medicine," begins J o h n Cooper, the first speaker for the annual J o h n A. D. C o o p e r Lecture (J Med Educ 1986;61:112-8). Recalling World War II and the following era, he reminds his audience of the tremendous strides made toward a national c o m m i t m e n t to medical research and to greater availability of health care for all citizens, especially the p o o r and the elderly. In a wave of altruism and liberalism encouraged by such works as J o h n Galbraith's The Affluent Society, C o o p e r says that "we had great hopes that we could soon provide a single class of medicine for all socioeconomic levels in our nation." These hopes, however, increasingly appear to be a mere illusion, as important and radical changes take place in the national attitude--changes evident in government, labor, and business. C o o p e r believes that a surge of capitalistic interest and, indeed, self-interest, is establishing the "market" as the new impetus of medical care. Government, business, labor, and insurance companies are calling stridently for a reduction in medical care costs in their efforts to change the way in which we use our national wealth... Mixtures of governmental regulation and promoting competition have been employed to slow the rate of increase in medical care costs. Federal payments for Medicare have been leveled off by freezing physican fees and the direct costs of graduate medical education, controlling increases in prospective payments for hospital care, and contracting with professional review organizations to establish goals for reducing hospitalization. Increases in federal matching funds for Medicaid have been restrained, and states are now permitted to reduce eligibility and benefits and, through fixed-price contracts, eliminate the freedom of beneficiaries to choose their physicians and hospitals. All payers, government, business, and insurance companies, require that a greater share of personal care costs be paid by patients through increases in coinsurance and deductibles. Payers are also negotiating lower physician fees and hospital payments for their beneficiaries, and are promoting care avoidance plans such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and independent practice associations. What will this new mercantilized medicine mean for our society? According to Cooper, it heralds the end of © 1986 by Elsevier Science Publishing Co., Inc.
a tradition of personalized medicine. Instead of seeing the regular family physician, it is predicted that the majority of people will use "managed fee-for-service" operations, in which physicians are employed by insurance companies or other organizations, and hospitals are owned by stockholders interested only in quarterly dividends. In this new convenience store medicine, C o o p e r says, "you can combine medical care with the search for a new pair of shoes." T h e changes also will bring to an end the dream of equitable medical care. Medicine will become a commodity, with the wealthy receiving the very best care possible and the p o o r receiving only the care they can afford, if any at all. C o o p e r admits that Perhaps the prevailing reimbursement policies for medical care led us into bad habits in the use of expensive, new technology and in the charges made by physicians. We probably hospitalized too many patients for too long when they could have been treated just as effectively and less expensively in other settings. But, he asserts, equity dictates that corrections of any excesses not press those with the greatest needs back to the lowest and thinnest rung of a multitiered medical care system, a system that seems destined to return after 30 years of efforts to abolish it. A nation as blessed as ours should not deny patients the fruits of modern medicine to restore to them their most precious possession, their health. N o t only do g o v e r n m e n t cutbacks and market pressures threaten equitable care and personalized medicine, they also constitute a major threat to academic medicine. While there is an influx of insufficiently prepared foreign graduates, American medical school classes will shrink because there are fewer 22-year-old students available, and many look at medicine as an increasingly competitive and unattractive profession. T h e training of specialists, an expensive proposition, will certainly suffer. Fear o f competition from one's own students may encourage "noncompetitive contracts and golden handcuffs . . . to keep those given advanced training from leaving the institution." Furthermore, the expense of medical education may make medicine prohibitive for minority and other economically disadvantaged students. 0090-3019/86/$3.50
418
Surg Neurol 1986;26:417-8
Medical education itself may undergo significant changes as hospitals, in an effort to compete for patients, cut all inefficient programs to the bone. As the tertiary care institutions are increasingly filled with patients "receiving 'cutting edge' medical care," they will not be "a very satisfactory resource for the general professional education of p h y s i c i a n s . . . " The rising tide o f marketplace mentality poses serious questions for the medical profession. Cooper concludes by asking, Can we find ways for learning and scholarship to flourish in an environment where business principles and economics are the overarching dogma for all human activities; where the freedoms, inconsistencies, and inefficiencies of the academic cloister.., are under attack by those who would still the unique contributions of the unversity by inappropriately imposing on it the dead-
Editorial
ening hand of business organization and its short-term goals? Can we instill in our students the values and attitudes to ensure that their personal responsibility for the health and welfare of each patient they serve is not suborned by the financial goals of those who employ them? I hope that these concerns may stimulate more of you to increase your efforts to try to prevent the loss of the fundamental attributes of a great medical care system and a preeminent medical education and biomedical research enterprise. I earnestly hope that we are successful and that 30 years hence some now-young medical educator and scholar can declare: "We have lived through one of the golden ages of medicine." JANICE M. LEWIS, Editorial Assistant
417
Editorial End of the Golden Age?
"We have been privileged to live through one of the golden ages of medicine," begins J o h n Cooper, the first speaker for the annual J o h n A. D. C o o p e r Lecture (J Med Educ 1986;61:112-8). Recalling World War II and the following era, he reminds his audience of the tremendous strides made toward a national c o m m i t m e n t to medical research and to greater availability of health care for all citizens, especially the p o o r and the elderly. In a wave of altruism and liberalism encouraged by such works as J o h n Galbraith's The Affluent Society, C o o p e r says that "we had great hopes that we could soon provide a single class of medicine for all socioeconomic levels in our nation." These hopes, however, increasingly appear to be a mere illusion, as important and radical changes take place in the national attitude--changes evident in government, labor, and business. C o o p e r believes that a surge of capitalistic interest and, indeed, self-interest, is establishing the "market" as the new impetus of medical care. Government, business, labor, and insurance companies are calling stridently for a reduction in medical care costs in their efforts to change the way in which we use our national wealth... Mixtures of governmental regulation and promoting competition have been employed to slow the rate of increase in medical care costs. Federal payments for Medicare have been leveled off by freezing physican fees and the direct costs of graduate medical education, controlling increases in prospective payments for hospital care, and contracting with professional review organizations to establish goals for reducing hospitalization. Increases in federal matching funds for Medicaid have been restrained, and states are now permitted to reduce eligibility and benefits and, through fixed-price contracts, eliminate the freedom of beneficiaries to choose their physicians and hospitals. All payers, government, business, and insurance companies, require that a greater share of personal care costs be paid by patients through increases in coinsurance and deductibles. Payers are also negotiating lower physician fees and hospital payments for their beneficiaries, and are promoting care avoidance plans such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and independent practice associations. What will this new mercantilized medicine mean for our society? According to Cooper, it heralds the end of © 1986 by Elsevier Science Publishing Co., Inc.
a tradition of personalized medicine. Instead of seeing the regular family physician, it is predicted that the majority of people will use "managed fee-for-service" operations, in which physicians are employed by insurance companies or other organizations, and hospitals are owned by stockholders interested only in quarterly dividends. In this new convenience store medicine, C o o p e r says, "you can combine medical care with the search for a new pair of shoes." T h e changes also will bring to an end the dream of equitable medical care. Medicine will become a commodity, with the wealthy receiving the very best care possible and the p o o r receiving only the care they can afford, if any at all. C o o p e r admits that Perhaps the prevailing reimbursement policies for medical care led us into bad habits in the use of expensive, new technology and in the charges made by physicians. We probably hospitalized too many patients for too long when they could have been treated just as effectively and less expensively in other settings. But, he asserts, equity dictates that corrections of any excesses not press those with the greatest needs back to the lowest and thinnest rung of a multitiered medical care system, a system that seems destined to return after 30 years of efforts to abolish it. A nation as blessed as ours should not deny patients the fruits of modern medicine to restore to them their most precious possession, their health. N o t only do g o v e r n m e n t cutbacks and market pressures threaten equitable care and personalized medicine, they also constitute a major threat to academic medicine. While there is an influx of insufficiently prepared foreign graduates, American medical school classes will shrink because there are fewer 22-year-old students available, and many look at medicine as an increasingly competitive and unattractive profession. T h e training of specialists, an expensive proposition, will certainly suffer. Fear o f competition from one's own students may encourage "noncompetitive contracts and golden handcuffs . . . to keep those given advanced training from leaving the institution." Furthermore, the expense of medical education may make medicine prohibitive for minority and other economically disadvantaged students. 0090-3019/86/$3.50
418
Surg Neurol 1986;26:417-8
Medical education itself may undergo significant changes as hospitals, in an effort to compete for patients, cut all inefficient programs to the bone. As the tertiary care institutions are increasingly filled with patients "receiving 'cutting edge' medical care," they will not be "a very satisfactory resource for the general professional education of p h y s i c i a n s . . . " The rising tide o f marketplace mentality poses serious questions for the medical profession. Cooper concludes by asking, Can we find ways for learning and scholarship to flourish in an environment where business principles and economics are the overarching dogma for all human activities; where the freedoms, inconsistencies, and inefficiencies of the academic cloister.., are under attack by those who would still the unique contributions of the unversity by inappropriately imposing on it the dead-
Editorial
ening hand of business organization and its short-term goals? Can we instill in our students the values and attitudes to ensure that their personal responsibility for the health and welfare of each patient they serve is not suborned by the financial goals of those who employ them? I hope that these concerns may stimulate more of you to increase your efforts to try to prevent the loss of the fundamental attributes of a great medical care system and a preeminent medical education and biomedical research enterprise. I earnestly hope that we are successful and that 30 years hence some now-young medical educator and scholar can declare: "We have lived through one of the golden ages of medicine." JANICE M. LEWIS, Editorial Assistant