The American Urological Association and Medical Care Crisis

Vol. 104, Oct. Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1970 by The Williams & Wilkins Co.

THE AMERICAN UROLOGICAL ASSOCIATION AND lVIEDICAL CARE CRISIS DONALD J. JAFFAR

Eight years ago I stood on the same platform as moderator of a panel on Socio-Economic Problems Confronting Members of the American, Urological Association and said "It is an irony of fate that the first non-scientific pronouncement in the 60-year history of the American Urological Association should be made in Philadelphia, the city of brotherly love. It was here that the immortal Thomas Jefferson, the father of the Democratic Party, wrote in imperishable language the greatest document known to mankind-The Declaration of Independence-and later helped formulate the Constitution of the United States which was adopted in 1789. Jefferson would guarantee medical freedom as he would religious freedom and he would renounce the idea of state medicine along with state religion. With him natural freedom included medical freedom quite as it did political freedom. He wrote "happiness, liberty, life, health-these thrills can be only living conditions of a given individual not of the government". As foresighted as our forefathers were, they could not foretell that the impact of a social and economic revolution would produce a new breed, one that would challenge the Constitution and even ignore it. We were being bombarded on the subject of medical care for the aged. A great deal of heat and little light were being supplied by the advocates of the administration plan to provide medical care for the elderly through Social Security. I stated "no one knows how many of the aged actually need financial help with their medical bills and yet, to hear administration officials talk, you might think they were equipped with precise data, not only on the present problem but on all its future aspects. Private insurance programs for the elderly are multiplying rapidly and, by 1970, about 90 per cent of the people more than 65 years old are expected to be covered by private plans. But Government spokesmen claim they already can see that the private approach is 'clearly inadequate'. A federal-state medical care program is just getting under way, but Health, Accepted for publication June 25, 1970. President's address read at annual meeting of American Urological Association, Philadelphia, Pennsylvania, May 10-14, 1970.

Education and Welfare Secretary Ribicoff already has pronounced it a dismal failure. The only way to attack this unknown problem, the administration would have us believe, is to provide limited hospital care to everyone covered Social Security, whether they need financial or not. And anyone who says this isn't so, the government officials suggest, must be opposed to providing adequate medical care for our older citizens." Nobody wanted Medicare. It was fought from all sides but became an established fact. We pointed out that of the 17 ½ million elderly people, at most 2½ million needed help but that 15 million were better qualified to finance their health care than most young people in industry. Medicare has worked but too well. It has been highly successful because of the medical profession. Most of us despised it but when it became effective we all begrudgingly accepted and supported it, perhaps in some instances too well. In our civilization there are 2 basic professions: medicine and law. The one deals with the physical and mental condition of man while the other with his liberties, rights and obligations. I do not plan to compare the two or to attempt to rank them in order of importance. It is not my present concern whether life is worth living or preserving without liberty and the protection of the law or whether the rights and liberties of man are secondary to the preservation of health and life itself. Let it suffice to say that both are vital to the preservation of a society worth living in. Man can survive without any of the other professions. Not as well, certainly, nor as happily, nor as comfortably, but he can survive. Without medicine and law there can be almost literally no survival. Without medicine epidemics could decimate the populations of the world in short order. Without the restraints of law, modern scientific forces of destruction could wipe out the population over night. In my own professional life I have had what I regard as the good fortune to be rather allied with both professions. Because I have the most profound respect for both, I am extremely conscious of the dangerous consequences of permitting either to become subject to non-pro-

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fessional control. More particularly, I am concerned today with the medical profession and with some of the dangers that I see ahead if an indifferent or uninformed public allows itself the dubious luxury of complacence about the constantly continuing threats of encroachment on the freedom and independence of that profession. The chief threat is, of course, the ever greater socialization of medicine-the constant agitation for increasing governmental participation in the furnishing of medical care to the people through government financed, controlled and administered programs of all kinds. Sometimes boldly undisguised, often sugar-coated by being labeled temporary or supplemental or emergency, they nevertheless point to the same ultimate end-the loss of a free, independent and virile medical profession. If the time comes when that result shall have been attained, it will make little difference to you and to me or the ultimate consumers of medical care whether socialized medicine shall have resulted from the efforts of misguided idealists, the machinations of cheap politicians or the strategems of ambitious leaders of powerful minority groups who seek to alter the pattern of social and economic life to fit their own selfish ends. Whether socialized medicine shall have come about through big, bold socialistic programs-or through a series of more cunningly disguised and more disarming plans such as some that are now being proposed in the pre-payment medical care field-or through small erosionary processes such current local challenges of the right and duty of as the medical profession to regulate the practice of medicine in public and semi-public hospitals is of little real consequence. A nation cannot be strong and healthy and at the same time harbor an impotent medical profession. If an informed public wants and is satisfied with medical care strictly regulated from without the profession, that is what it will get and deserve. If it wants the highest and the best type of medical care that medical men are capable of giving, it will, in my judgment, get that kind of care, just as long and no longer as it entrusts to the medical profession the greatest latitude in self-control and self-regulation. Of course I do not mean self-control and selfregulation in the sense that the medical profession should be regarded as above or beyond the law of the land or that the profession, as a whole, or its members as individuals, ought to be free of the

legal obligations and restraints applicable to all society. However, I do mean that the medical profession should not be regarded as fair game for the sniping of those who would make it a servant of bureaucracy rather than a servant of mankind-nor should it be regulated, with the public's blessing, to the status of the supplier of a fringe benefit to be bartered for at the bargaining table of labor and industry. The great strength of the medical profession lies in the unselfishness and dedicated purpose of the overwhelming majority of the individuals of which it is composed. I know of no other profession or business which can make the proud boast that it has no professional secrets except those between doctor and patient. A new discovery, a new technique or a new method of treatment belongs to the profession not the individual. Each is dedicated to the common good, not to the profit of the discoverer or developer. The ingenious devices used to check the body's functions, the complex machinery of modern surgery and the building of banks of spare parts of the human body, all adding up to a tremendously impressive record of achievement by the medical profession, cost money. Sixty-eight years ago who could have dreamed that in the 1950's we would witness the preservation of life by means of renal transplantation and the even more impressive miracle of the transplantation of human hearts. These remarkable achievements are not those of men who regard the practice of medicine as a right. These miracles are not performed by amateurs. In large measure they are not the achievement of individuals at all but of a unified profession. They are the result of the unselfish exercise by dedicated men of the priceless privilege of practicing medicine. Under modern medical organization, not only has the art and science of medicine advanced with tremendous strides but, of equal importance, adequate medical care has been made available to a far greater proportion of the people. This has been accomplished through the development of prepaid medical care plans which have been conceived, organized, implemented and operated by the medical profession itself. Michigan's own Michigan Medical Service, commonly known as Blue Shield, was the first to be conceived anywhere. It was organized by the Michigan State Medical Society following the depression days of the 1930's. It was developed out of a recognition

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of a crying need for the extension of medical care argued that a national insurance plan and "reto more people who could not afford it. It was not structuring" of the present American system of developed by persons in insurance companies who providing medical care is needed to meet the were afraid of it, not by politicians or labor union rising cost of medical care. The existing system leaders (who now seek to adopt it and turn it to he charged is providing "unacceptable, unsatistheir own ends) but by the doctors themselves factory and second-rate health care services". Reuther's Committee on National Health Inout of the sense of public duty. It has worked not with absolute perfection but tremendously well. surance proposed universal health insurance It has supplied a pressing need and, of vital covering all Americans, operated by the Federal importance to us all, has supplied it not at gov- Government and financed by payroll and general ernment expense or under governmental or po- taxes. The 3 vice chairmen of the Committee are litical control but under the principle of a free the famed heart surgeon, Dr. Michael E. DeBakey, President of Baylor College of Medienterprise system and a free profession. Despite the fact that the medical profession cine; medical philanthropist Mrs. Albert D. pioneered and developed this type of service Lasker and executive director of the National when practically no one else thought it could be Urban League, Whitney M. Young. Other memdone, there is agitation in some quarters for bers include the Reverend Ralph D. Abernathy adoption of the theory that others can do it of the Southern Christian Leadership Conference; better. From some sources the agitation is for Harvard economist John Kenneth Galbraith; governmental control and from others it is for Senator John Sherman Cooper (R., Ky.); former labor union control. In my judgment we need Illinois Senator Paul Douglas; Mayor Carl B. look only to the record of organized medicine in Stokes of Cleveland; Senator Ralph W. Yarthis country on the one hand and on the other to borough (D., Texas), just defeated in the primary the socialistic experiences of other countries to for re-election and Senator Edward M. Kennedy convince ourselves that we had best leave medical (D., Mass.), the man who does not know the care in the hands of a free and independent medi- difference between a right-hand turn and a leftcal profession. Any program of medical care hand turn but considers himself eminently qualigovernmentally and politically controlled or fied to discuss medical care. "The cost of hospital care and medical care sponsored and controlled by lay interests necessarily means, in my judgment, inferior medical exceeds the already alarming inflationary trends care. The incentive to reach for new medical in our economy .... Workers are terrorized by horizons will have been weakened. Eventually, these awesome statistics.... Most workers will but inevitably, a noble profession will have been become medically indigent .... Hospitals are not operating at their fullest capacity .... They reduced to a sordid routine business. It seems that the physicians in this country work a 5-day bankers' week .... There needs to have little or no right to influence the decision as be a most responsible and careful medical review to which physician will best represent and meet of x-ray and laboratory utilization." This was the needs of patients and medicine in our govern- not Don Jaffar speaking; it was the testimony of ment. However, when a former plumber, elec- Harry Boyer, President of the Pennsylvania trician or bricklayer becomes head of a union, he AFL-CIO, before the House Consumer Proautomatically becomes a paragon on foreign tection Committee. Boyer, of course, talked out policy, medical matters, the appointment to the of the other side of his mouth when he urged insupreme court and any other governmental creasing hospital costs by doing something about matter in addition to his being head of the union. "wages for non-professional personnel in hospitals The late Walter Reuther, the sage of Solidarity that lag behind earning in the private sector". He House, stated in October 1969 that the nation urged that utilization of nurses services be imspends some $60 billion annually on medical ex- proved, pointing out that 30 per cent of their penses and 80 per cent of this is siphoned off by time is spent in non-productive paper work. Howinflation and inefficiency. Consumers have a right ever, Boyer did not point out that most of this to "insist on a dollar's value for a dollar spent". is the product of "the criminal and rapidly spreadIt appears that some of this statement was ab- ing malpractice racket," edicts from government sorbed over a bargaining table. The rest is pure agencies, legislative bodies and irresponsible legal hokum. This is demagoguery at its finest. Reuther and court decisions. He concluded that there "is

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a need to bring the entire practice of hospital care delivery under permanent scrutiny by state government". The AFL-CIO believes that something can and must be done. Dr. Simon Beisler reported on changes in a New York Hospital to a full-time status, with the administrator becoming a very powerful individual in all phases of hospital operation. One 600-bed hospital, following World War II, had an annual budget of $500,000. The budget changed to $4,000,000 with the full-time staff, and this year it is 28 million. The building program requires $5,000,000 a year. Most hospital administrators are lay people. They are most honorable and their intentions may be well meaning; however, "the road to hell is paved with good intentions". Hospital administration almost completely controls the destiny of the physician and patient-the very foundations of medicine. It is imperative that at least 25 per cent of the Boards of Trustees and/or Governors be elected from the actively practicing physicians of the hospital staff. This drastic change can most effectively be accomplished through the Joint Commission on Accreditation of Hospitals. A hospital that does not comply should not be accredited. In recent years crises have been the prime motivating force of our nation. Anything less than a crisis seems unworthy of attention by our political leaders. Whether right or wrong, the problems of health care have had to assume such a designation. The label may be inappropriate but truth in labeling has never applied to political issues. This has created a charged atmosphere in which many claims are made, few are substantiated. The claim is often made that, through avarice, physicians are increasing the cost of federal health programs to the point of insolvency. Such emotional outbursts ignore the simple mathematics of these programs. Physicians' fees account for approximately 12 per cent of Medicaid costs and about 20 per cent of Medicare expenditures. Thus, if physicians' fees were increased by a remarkable 50 per cent, the net effect would be to increase total cost of these programs by from 6 to 10 per cent. This is well within the limits of error for budget estimates on such programs at their inception. Claims that physicians are responsible for increases in the length of patients' hospital stay are equally invalid. Figures clearly indicate that

during the past few years there has been no significant change in the length of the hospital stay for patients less than 65 years old. During that same period, however, the average stay for patients more than 65 has increased by approximately 2 days. Much of this increase can be attributed to federally imposed policies which require a 4-day admission to a general hospital before an elderly patient can be admitted to a skilled care nursing home under Medicare. How many hospital days are consumed while waiting for a transfer to an approved facility? Dr. Jacob H. Fine, President of the Massachusetts Medical Society, in a wire to Senator Edward M. Kennedy on February 12, 1970 stated, "The physicians of the Massachusetts Medical Society urgently request that you exert your influence to put into proper focus the role of the physician in the implementation of the Medicare and Medicaid Programs and to determine whether or not there is a deliberate attempt to disparage physicians on a national level by continuous attacks on their integrity and dedication. The publicity resulting from the release of the Report of the Senate Finance Committee on Medicare and Medicaid is the most recent case in point. We resent being singled out as being responsible for the financial faults of Medicare and Medicaid. We resent the implication that fraud by physicians is rife in these programs when in fact evidence of fraud by physicians is demonstrably small and insignificant in relation to the cost of the over-all program. The evidence is that the great majority of physicians do not overcharge, are not abusing the program and are dedicated to making Medicare and Medicaid work. We are discouraged. We dislike being scapegoats. We look to our statesmen in Congress to set the record straight, to let it be known that they have faith in the medical profession and that the vast majority of physicians are honest and dedicated to providing high quality medical care to all persons. Labor has learned that in unity there is strength. The concept of unionism and collective bargaining has spread far beyond the coal mines and automobile factories to include such professional groups as school teachers, nurses, firemen and policemen. The idea is not new. It has been discussed for decades only to be rejected by

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conservatives in the profession who consider it beneath our professional dignity to be unionized. Today's explosive anti-doctor sentiment forces a reappraisal of our ideals if we are to survive and remain free. The word union and unionism strikes horror in the minds of most of us. I believe that a more acceptable term would be to call it a guild. It is high time that all persons dedicated to the

health professions join together and form a professional guild for all physicians. Let me close by quoting Abraham Lincoln: "Let us have faith that right makes might, and in that faith let us, to the end, dare to do our duty as we understand it". 16901 West Nine Mile Road, Southfield, Michigan