Minority Report Number Two*

Minority Report Number Two*

M IN O R IT Y REPORT N U M B E R TWO* H E undersigned are in accord w ith the main position of the m ajority of the Committee, in that we recog­ nize ...

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M IN O R IT Y REPORT N U M B E R TWO* H E undersigned are in accord w ith the main position of the m ajority of the Committee, in that we recog­ nize existing professional and social trends in medical care as brought out by the Comm ittee’s studies and believe th at these trends necessitate substantial changes in the manner in which medical service is rendered and paid for. T here is no doubt in our minds that an in­ creased amount of medical service should and w ill be rendered through pro­ fessional organizations rather than by individual practitioners working inde­ pendently. W e also believe that pay­ ment for medical service by distributing the costs over groups rather than having it fall upon individuals is a sound prin­ ciple w hen applied in such ways as maintain professional standards of serv­ ice. W e are in accord, therefore, with the general recommendations of the ma­ jority in favor of group practice and group payment, although we must reg­ ister dissent from certain specific pro­ posals and certain implications of the m ajority report which we do not consider justified. W e are, however, in accord w ith those who signed M inority Report No. 1 in strongly emphasizing the necessity of maintaining professional standards and the position of the general practitioner, and we recognize, as they do, that grave dangers to these standards have developed in the past and w ill exist particularly during a period of rapid changes in med­

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*From the Report of the Committee on the Costs of M edical Care. Jour. A . D . A ,, January, 1933

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ical service such as we are undoubtedly facing. In our opinion, the most impor­ tant influence for the maintenance of professional standards is vigorous initia­ tive on the part of the professions them ­ selves. T h ey should, as individuals, and through their professional organizations, recognize frankly the existence of the problems and needs which are brought out by the studies of this Committee and should themselves take steps to deal w ith them, through initiating or par­ ticipating in experiments in group prac­ tice and group payment. W e realize that needs are more acute in some localities than in others and therefore early rec­ ognition of these needs should be made. Nothing, in our opinion, would be more detrim ental not only to the medical service of the public, but to the welfare of the professions, than an attitude of opposition or mere aloofness on the part of the professions. W e recognize that certain evils th at have developed in group practice and in sickness insurance in the past have been chiefly due to lack of pro­ fessional initiative and control and that w ith the assumption of initiative and control by the professions at this time these evils w ill be minimized in the fu­ ture. W e feel w ith those signing M inority R eport N o. 1 that the attitude of the m ajority is unduly critical of the pro­ fessions, and that this attitude has de­ veloped a bias in some of the statements in their report. W e agree also that the investigation of industrial schemes by the Committee almost entirely over­

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T h e Journal of the American D ental Association

looked their defects, and only the least objectionable and most successful were chosen for study. W e agree w ith M inority Report No. 1 that the description of the community medical center, which is set forth in the third chapter of the M ajority Report as the ultim ate goal of development, is Utopian in concept, and involves many details which are too visionary or prob­ lematical to justify inclusion in an au­ thoritative report of this kind. I t is to be regretted th at the Com­ mittee’s studies did not include any study of dental group practice. Studies of such groups should have been made both as regards their organization and the quality of their service. T h e dental pro­ fession should initiate experimentation in dental group practice and should en­ courage cooperative experiments involv­ ing physicians and hospital service. Stud­ ies of the American D ental Association show th at such cooperative participation is on the increase. A ll such experiments would provide valuable facts as a basis for future development. W e do not consider that voluntary and compulsory sickness insurance should be regarded as in opposition to each other or as unrelated proposals, as seems to be implied in the M ajority Report. E uro­ pean experience indicates that methods developed under voluntary insurance have indicated the pattern for compul­ sory insurance later, and should furnish necessary experience for the United States. Experience thus gained in volun­ tary insurance, both by the public and the professions, would be an asset if and when certain states contemplate com­ pulsory systems. In certain sections of the U nited States, voluntary insurance has already developed to a considerable degree. I t is true th at in these sections certain evils have developed but it is

probable that the introduction of com­ pulsory insurance under professional con­ trol w ill eliminate the objectional features. T h e more the difficulties are eliminated or controlled in the voluntary plan, the less risk of having objectionable features in the subsequent compulsory insurance. W e do not feel that this method of payment need interfere with the highest professional standards nor w ith the close personal relationship between practi­ tioner and patient. T h e studies of the Committee indicate th at a large proportion of the population receive incomes, even during prosperous times, so low as to preclude the purchase, under any form of payment, of adequate medical service. T his is emphasized by the following quotation from Summary Volume, Chapter X X X IV : T he significance of the economic barrier between the true need and the current re ­ ceipt of medical care is especially evidenced by the finding that fa r g reater inadequacies obtain for those of small than those of large means. Just as some people go hungry though the country produces more food than the people can consume; many are inade­ quately clothed though we manufacture more clothing than we can use; even so millions are sick, hundreds of thousands suffer pain and anguish, and tens of thousands die pre­ maturely for lack of medical care which available personnel and facilities could sup­ ply. T he tragedy concealed in this conclusion is the more poignant because medical practi­ tioners and institutions are used to only p art of th eir capacity—not because their services are not needed, nor because they are unwilling to serve.

W e add to these reasons because fun­ damentally, as the studies of the com­ mittee reveal, the problem of providing medical care is a question of low incomes and the solution depends at least as much upon increasing incomes to a satisfactory standard of living, as upon methods of organizing medical care. W e recognize,

M inority Report N um ber T w o however, that the ability to purchase medical care on an insurance basis is greater than when the cost falls upon the individual family. W e are in accord w ith and strongly recommend medical society plans of sick­ ness insurance such as those referred to in M inority Report No. 1, page 179. These would place responsibility on the professions for the maintenance of stand­ ards of service and would set up, for a state or a community, agreed rates of payment so that competition between different professional groups furnishing service or between individual practi­ tioners would be on a basis of quality of care and not on a basis of charges. I t is destructive to standards of medical care, in which both the public and the pro­ fessions have a common interest, if com­ petition exists in such form as to bring about price-cutting and underbidding for service. W e strongly endorse the initiative of such professional bodies as the M ilw aukee M edical Society* or the State M edical Society of California in endeavoring to meet their obligations to the public by developing plans of group payment. Such a form of organi­ zation of medical service under profes­ sional control w ill set a pattern which will determine the direction of any fu­ ture development of organized medical care in voluntary or compulsory in­ surance. Such an opportunity typifies the attitude of the British M edical Associa­ tion referred to in the quotation on page 118 of the m ajority report as follows: *See p. 75 of the Committee’s report for a description of the Milwaukee plan.

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Such a scheme may be compared to a plan submitted by an architect to a house­ holder who wants to extend the house in which he lives, and to introduce all modern improvements. T h e householder may, on seeing the plan, decide that it would cost too much and that he must put up with his house as it is ; or he may make suggestions for the modification of the plan. But the householder knows th at if he wants to ex­ tend his house he is, as regards essentials, in the hands of the architects and builders.

W e fully agree w ith the statement concerning coordination of medical serv­ ice contained in M inority Report No. 1, page 172, as quoted from the Com­ m ittee’s report, page 134. W ith a full knowledge of the inherent evils of the early competitive systems of medical and dental education, we believe it would be of great value if a national organization were to be formed to study group practice and to define its stand­ ards, and suggest that such a plan be sponsored by those bodies that have sup­ ported studies of medical and dental education. D uring rapid social changes group practice and individual practice are de­ veloping side by side, and should develop in cooperation. Conflicts between those dealing in medical care under any aus­ pices w ill have a disturbing effect on practitioners and a detrimental effect on the public, whom they serve. A ll of this is against professional traditions of medical care. These methods must meet in service, adjustment must be made so th at conflicts may be eliminated, and codes m ust be adapted to meet changing conditions. H e r b e r t E. P h i l l i p s , C. E. R u d o l p h .