ANNALS OF SURGERY Vol. 182
September 1975
No. 3
Presidential Address: United We Stand WILLIAM H. MULLER, JR., M.D.
jr Is WITH IMMENSE GRATITUDE that I stand here today
From the Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901
as President of this great organization. I am fully cognizant of the honor you accorded me at last year's meeting, and have tried to be aware of the responsibility and obligation which accompanies it. In preparing to address you, I, like most who have faced this duty, reviewed a number of previous Presidential addresses, and found them to be delightful and informative reading, but I believe I should have been somewhat like the student to whom the professor of engineering assigned the problem of designing a new device, advising him to ignore most published information concerning it, lest he be overly influenced by what had been written previously, because the subject of my comments today has been influenced by some of those before me, as well as by the current tenor of the national environment for health matters. During the last decade, and especially the last five or six years, the majority of addresses have adhered to a generally basic theme, each serving more or less as a sequel to the one before, and it is my intention to add yet another chapter. Owen Wangensteen regards this address as "an annual lectureship on the status, outlook and vistas of surgery," and while I shall not be so comprehensive, I do wish to focus on a number of problems currently facing the profession. If my comments do not Presented at the Annual Meeting of the American Surgical Association, Quebec City, Quebec, May 7-9, 1975.
seem to include our Canadian membership, it is only because they have experienced at least some of the possible transitions I shall discuss. One has only to observe the progression and complexities of government-medicine interrelationships, including Medicare, Medicaid, HRI, PSRO, and a host of other regulatory legislation exacted during recent years, to project the future course of medicine and surgery in the United States. One of the most imminent additions to these is some form of national health insurance. The great impetus for this legislation comes from the assumption by most citizens that health care is a right, and the recognition that some type of financial assistance is needed to provide it to the great mass of people not already included under one of the existing programs. Last summer, there were before the Congress no less than 12 bills supporting some type of a national health plan. The total estimated cost ranged from $103.6 billion to $116 billion a year, or more than 12% of the Gross National Product. Just as important, however, was the proposed source of funds to support comprehensive health care in each bill. These sources ranged from a high of more than 90% public funds in one bill to approximately 62% private funds in another, as developed in an comparison of the eight most prominent bills by the De-
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partment of Health, Education and Welfare in response to a request from the Congress. Therefore, even the bill with the greatest orientation toward the private sector depended heavily upon public-primarily federal-funds for financing. It was only because of problems related to funding of a last-ditch compromise bill that a national health program was not enacted by the last Congress. In his Inaugural Address, President Ford declared that a suitable health care plan assumed top priority in his administration. However, in his State of the Union message early this year, he announced that, except in the energy fields, he would veto all new spending programs, including National Health Insurance. Thus, it appears that there may be a moratorium on a national health plan for another year, and it is hoped that the medical profession can use this time to mobilize its forces to advise and consult more effectively for legislation which will provide financial assistance to the many uninsured citizens, while exerting the least regulatory limitations on the profes-
sion. It is of the utmost importance that responsible organized medicine seize this opportunity. The generally high quality of health-care currently delivered must be maintained, but freedom to render it must also remain. The assumption that a federally-regulated program will not only assure quality and quantity, but also control cost, is unfounded. In 1948, it was estimated that Britain's National Health Service would cost $400 million in the year 1974. The facts are, however, that it cost $7.2 billion in 1974, was in dire financial straits, and needed $1.1 billion to give it fiscal stability, according to the British Medical Association. This is only one example of the lack of cost-efficiency in a system administered totally by bureaucracy. The United States is one of the last of the developed countries in which professional freedom for medical practice prevails in spite of erosion by already implemented government health care programs. Thus far, many of these programs are administered through the private sector. Currently, however, new bills have been introduced into the Congress to provide comprehensive care and, in each, a federal agency of some type would be established for jurisdiction over its implementation. This jurisdiction would include such regulatory measures as control of expenditures, the establishment of national health benefit patterns, the setting of standards of participation, and the development of policy guidelines. In other words, these prerogatives would be removed from the private sector. It is my belief, and that of many others, that while we may accept the reality that we will have a national health insurance system, every effort should be made to encompass as much of it as possible in the private sector in order to preserve many of the desirable features of medical practice which we now have. William Anlyan has suggested that it should be a
Ann. Surg. * September 1975
private-public system, combining the advantages of a market economy through private insurance, with some subsidy from the government to underwrite the needed programs for the indigent, the medically indigent, and for catastrophic illness. For, as Harold Laski noted, "Most Americans have a deep sense of discomfort when they are asked to support the State. They tend to feel that what is done by government institution is bound to be less well done than if it were undertaken by individuals, whether alone or in the form of a private corporation." The variety and profusion of individual programs already established-some of which were short-lived, such as HSMHA-each with individual requirements for funding, eligibility and administration, are illustrative of the response by government to a health need. They conform to what John Gardner has called "the vending machine concept of social change. Put a coin in the machine and out comes a piece of candy. If there is a social problem, pass a law and out comes a solution." Senator Ribicoff has put it just as aptly, "Because we rely so heavily on a programmatic approach-passing a program when we discover a problem or a part of the problem-and rely so little on a comprehensive manner, our efforts are often marked by confusion, frustration and delay." However, pressures exerted upon the legislative and executive branches of government by large population segments during the past two decades have assured a response in the form of comprehensive healthcare legislation. The hope that it will come in an orderly, logical manner, conceived to provide high-quality care with minimal displacement of the practitioner, is questionable when one examines many of the programs already enacted and when one considers the experience in other countries. Only in April of 1974, 25 years after its initiation, did major reorganization and restructuring of the British National Health service occur in an effort to make it more effective. The chief aims were to introduce tighter management controls, to contain cost and increase efficiency, as well as improve the quality of patient care in areas neglected by main-stream medicine. These measures imply that rigid control is necessary to implement properly a totally nationalized medical plan. It can only be hoped that our political leaders will take some lessons from the 25-year British experience in comprehensive health-care, for the institution of a similar system would have an impact, both immediate and farreaching, on the practitioner, the consumer, and on teaching and research, greater than any other event in the history of medicine in the United States during peacetime. I prefer to believe it unlikely that a program totally controlled and financed from Washington would be thrust upon us. Representative Ullman, the new chairman of the House Ways and Means Committee, states that he believes a plan will evolve to mandate coverage by private health insurance companies and es-
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tablish health care corporations centered in hospitals as the focal point of the system. As regards national health insurance completely financed by taxes without private contributions, he said recently, "There is no way the economy could take this, and no way such a program could be managed efficiently from Washington." However, there is currently a liberal majority in the Congress and certain powerful, persuasive members have long attempted passage of bills for virtually total nationalization. The present economic crisis has caused the introduction of bills which would provide temporary emergency health insurance for the unemployed. All of the bills introduced, however, contain admitted inequalities and inequities. For instance, none of them would cover the working poor or the unemployed whose compensation had expired, and the same health benefits would apply to all regardless of how much or what type of coverage they had previously had. Congressional committee members as well as witnesses testifying before the committees pointed out that there would not be the necessity for this kind of legislation if a comprehensive program had already been passed. They believe it imperative, therefore, that the Congress pass a comprehensive bill as quickly as possible, because several years will be required for any national health insurance program to become fully operative. It is this environment of pressure under which national health insurance legislation finds itself today. The feeling that something must be done and done quickly could have Gardner's "vending machine" effect, giving rise to the belief that if a national health insurance bill is passed, any bill, the nation's health problems would be solved. Mr. Rostenkowksy, Chairman of the Ways and Means Health Subcommittee which has the responsibility for writing a comprehensive bill, has given assurances that one will be forthcoming by the end of the summer, but that a temporary bill for the unemployed should not be taken as a precedent for a comprehensive National Health Plan. He further states that the fact that we must do something about the immediate problem of unemployment health insurance illustrates clearly the need to fashion a sound, workable plan of comprehensive national health insurance for the long run. This latter statement is reassuring. Another problem represents the most immediate and devastating crisis upon us, the problem of professional liability. Malpractice claims, while nothing new, have increased both in number and magnitude to catastrophic proportions; the result has been that the cost of insurance premiums has risen geometrically throughout the country and in some specialties become virtually unaffordable. Even more alarming, the number of carriers has decreased and those remaining do not desire such business, so that some states or parts of states have been left or soon will be left without any coverage at all. Today
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malpractice insurance is a basic requirement for the physician and one would hardly think of clinical practice without it. Recently the President of the American Medical Association testified before the House Ways and Means Subcommittee on Health that physicians cannot practice medicine unless they have adequate insurance coverage, and injured patients cannot be compensated unless adequate funds are available. Insurance, therefore, must be available at reasonable premium costs in order for care to be delivered. Of equal importance, a workable system must be devised for the prompt and equitable resolution of personal injury claims resulting from medical treatment. Laws must be enacted, also, to control the level of payments to the plaintiff. Excessively large judgments, which are becoming more and more frequent, rather than compensating the patient objectively for his injury, reflect the sympathy and compassion of the court. The contingency fee creates another inequity in many cases. While the legal profession registers a disclaimer, this method of setting the legal fee undoubtedly encourages many unworth claims which otherwise would not be considered and frequently, especially in the case of very large judgments, provides payment to the attorney out of all proportion to his background and skill, and the time and effort expended. In 1973, the Federal Commisson on Medical Malpractice reported that it cost an average of $22,000 to bring a case through the courts. The attorney's argue, therefore, that without the contingency fee many patients with valid claims could not afford necessary legal fees for litigation and could not have any chance of being compensated. It has also been shown that the patient receives only about 16 to 24 cents of each premium dollar, and these fiscal inequities, along with the cost of insurance for hospitals, the total of which amounts to more than $1.5 billion per year, have become significant factors in che continuing rise in the cost of medical care. In addition to withdrawing coverage and increasing premium costs astronomically, insurance companies are changing from the traditional occurrence policies which insured physicians against claims filed at any time in the future as a result of incidents which happened during the policy period. They are substituting claims-made policies providing coverage only for those suits filed during each 12-month period the policy is in effect. Therefore, the physician who leaves one area of the country for another where he is covered by a different carrier, would be faced with the problem of carrying two policies at once, and the retired physician would be required to extend his policy for several years after he ceases to practice or until the statute of limitations on his last patient expires. The solution to the malpractice problem is indeed complex. Our primary task as surgeons and physicians is to reduce the number of preventable injuries; that is, elevate the quality of medical care. However, considera-
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tion should be given to revising the contingency fee principle, placing a ceiling on the dollar amount ofjudgments, eliminating collateral source benefits and payments for pain and suffering, revising the statute of limitations, maintaining occurrence-type policies or initiating affordable no-fault insurance, and possibly introducing binding arbitration, among many other approaches. The Secretary of HEW has steadfastly maintained that the solution of this problem should be left to the individual states and this appears desirable indeed when one considers the restrictions placed on physicians in the bills now under consideration by the Congress. Also, none of these bills would cope effectively with such intangibles as increasing claims consciousness among patients, larger awards, poor quality health-care delivery and the overaggressiveness of claims attorneys. However complex the solution, though, steps must be taken to rectify this malignant process. The recently passed laws in Idaho and Indiana are milestones indeed in this direction. That it can be controlled and the patient appropriately compensated is evidenced by the situation in Canada. Here, premiums are low and the patient is compensated more in keeping with the magnitude and the reasonable worth of the personal injury incurred. A third issue is a bill to control medical manpower, which was introduced into Congress this year by Congressman Paul Rogers, and is now being considered along with several others. This proposed legislation has many facets as regards both medical education and manpower distribution. It extends the National Health Service Corps and provides capitation support for medical schools. In addition, however, it fixes the number of first-year residency positions at a level of 155% of the estimated number of graduates from U.S. medical schools, with reduction by steps to 125% over a period of three years. It is aimed, among other objectives, at limiting the number of foreign medical graduates. This bill would appear also to fix ultimately the number of specialty residency programs and, eventually, the number of residency programs within each specialty. If this were done on a regional basis it is entirely possible that a relatively small area with a high population density and a large number of excellent programs might be required to eliminate some of them, whereas another region with fewer programs, many of poorer quality, might not be compelled to discontinue any. Another goal, of creating more first-contact physician residencies, is apparently already being met. In 1974, there was a 66% increase over 1973 in the number of family practice residency programs, and the figures show a continued upward trend in spite of the fact that the number of residency positions in the area of primary care has already reached a figure between 40 and 50%o. Vigorous congressional testimony from several organizations has tempered the stringency of the bill in a number of areas, enabling it more nearly to fulfill actual needs.
Ann.
Surg. September 1975
Nor is the health-care industry immune from restrictive legislation by the individual states. This year in my own state of Virginia, a bill was introduced into the General Assembly which would allow each senator the prerogative of designating two students for the entering class of the two state medical schools. Fortunately, it was roundly defeated in committee before reaching the floor. One senator commented later that he had calculated the number of votes he would have lost if 50 premedical students requested admission and he could admit only two. The families, relatives, friends and sympathetic acquaintances of the other 48 might constitute a block of votes large enough to prevent his re-election. He was therefore very much against the bill. A host of other health legislation is being introduced into or considered by Congress at the present time. I have discussed briefly three areas of concern, which I believe include some of the most important health issues. The outcome of this and other legislation will have a tremendous influence on the practice of medicine in the immediate and long-range future. Since next year is an election year and since health issues make popular political footballs during those times, it is of the greatest importance that we continue, and in fact increase, the vigorous efforts now being made. Equally so, organized medicine must have, insofar as possible, a unified voice or spokesman. This may be impossible, however, in view of the paradoxical philosophical heterogeneity of this profession with a generally homogeneous educational background. It is doubtful that the. average practitioner prior to World War II ever considered or cared whether or not his profession had a spokesman, for there was little need for one. At the turn of the century, specialization had just begun and the Flexner Report was in the immediate future. Concerns lay primarily in developing the science and art of medicine, higher quality medical schools and better health-care facilities. The government and medicine had only loose liaisons. Regulation was applied chiefly to the use of narcotics and the U.S. Public Health Service was the primary medical arm of government. The Veterans Administration rendered care to a large segment of the population, which became even larger after World War II, and through Public Law 293, many of its hospitals became closely affiliated with adjacent medical schools. The establishment of the National Institutes of Health in the late 1940s with its peer review systems and direct access to Congress for its fiscal and other needs, seemed to most a great step forward, although some believed it was a step toward government control of medicine, and refused to accept NIH grants. The NIH seemed a never-ending, ever-increasing cornucopia to support basic and applied research, certain types of medical care, and medical education. The Hill-Burton Act likewise provided untold amounts of money for hospital construction. The creation of the Department of Health,
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Education and Welfare during the Eisenhower administration commanded a broader base and larger budget. Research productivity and clinical application never before equalled in such a short period in medical history evolved. Categorical programs, such as that for heart, stroke and cancer, were created and there seemed to be no end to the possibilities for elucidating more and more of what Lewis Thomas has described as "true science." And yet, in the early 1960s, the bubble was beginning to burst. Rumblings of physician shortage, unavailability and poor physician access could be heard from many public sources. The media in virtually every form responded to demean the physician and the entire health industry as inadequate, inefficient, extravagant and, indeed, even chaotic. The implication or direct statement was frequently made that the majority of U.S. citizens received poor medical care. Scarcely a week passed that inflammatory, often inaccurate, articles did not appear in lay publications. On television, so-called documentary programs appeared not infrequently and at least one blunty warned its audience not to get sick in America. In his book entitled "The Case for American Medicine," Harry Schwartz refers to this media blitz as "rhetorical overkill" and describes it as "reminiscent of the simplistic anti-Soviet and anti-Chinese propaganda of the worst cold war days." In a very objective manner, he proceeds further to demonstrate that "health-care crises, or health crises in terms the propagandists usually present the matter, do not exist." He focuses, moreover, on the many positive features of American medicine not mentioned by the critics. This brief outline, step-by-step, of the progression of government-medicine interrelationships and the negative propagandizement of the media, serves to emphasize that never before has the need been so paramount as it is today for a unified voice, in order for American medicine to make itself heard during these critical times. If we were asked who speaks for the medical profession, I doubt that there would be unanimity on any one organization or individual. I believe it is fair to assume that the lay public looks to the American Medical Association as the voice of organized medicine in the United States, but it is equally true that the AMA does not serve as such for the entire profession, for there are other strong, vocal organizations in positions to take a stand. These include the large organizations such as the Association of American Medical Colleges, the American Hospital Association, the American College of Surgeons, and the American College of Physicians, plus small, broadly representative committees such as the Coordinating Council on Medical Education, the Council of Medical Specialty Societies, The American Board of Medical Specialties, and a host of others. The AAMC, an old organization initially constituted primarily of deans, until a few years ago was relatively inactive and involved chiefly. with mundane problems.
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Ignited by the Coggeshall Report in 1965, aided by the AMA's less than effective involvement with Medicare and Medicaid, and expertly led by a small group of skillful, dedicated, informed physicians, it has skyrocketed into a position of political eminence. Operating from a Washington office with an adequate budget and an experienced, skilled staff, the AAMC undoubtedly speaks for academia and is believed by many to have had the greatest influence in shaping health policy in the United States during recent years. Oriented toward educational issues, its shadow nevertheless touches many other areas in the broad health-care field. But, in spite of its power and influence, it is little known outside the academic circle of the profession and can hardly be described as broadly representative. The American College of Surgeons, a large organization, embraces as members nearly two-thirds of the qualified surgeons in the United States and virtually every one in the ASA. For many reasons electing not to become an official lobbying organization, it nevertheless serves as an effective voice for surgery. At what level do, or should, the American Surgical Association and similar specialty organizations function as spokesmen? The ASA has always been an organization of limited membership achieved through recognized contributions to surgery. Its leadership role has undergone self-examination from time to time, and until an exhaustive assessment in 1938 by a distinguished committee appointed by Dr. Evarts Graham, considered itself an honor society only. This committee recommended that it be a working organization as well as an honor society, and, about this time, although not as a result of this committee's report, from the Association was born the American Board of Surgery. The next major undertaking, however, did not occur until more than 30 years later, when the Committee on Issues was appointed, spawning SOSSUS. While the ASA comprises one of the most outstanding groups of surgeons in the United States and Canada and, indeed, the world, it is not constituted in its present form to undertake major projects on its own. It has no permanent staff or officers, with the exception of the Secretary, Treasurer and Recorder, who serve for five-year terms. It has a budget which barely covers its minimal operating expenses, and no permanent headquarters. It meets as a whole only once a year, and the Council only twice. The ASA undertook the SOSSUS study by joining with the American College of Surgeons and other organizations, and the joint executive committee so formed set up permanent headquarters, acquired staff and served as an agent to procure funds. Even so, multiple yearly assessments of the membership were required. Since our last meeting, the Association has acquired 501C6 Internal Revenue Status, which allows active political involvement. In his presidential address last year, Dr. Scott recommended reactivation of the Conm-
Ann. Surg. September 1975 MULLER 182 In a recent article, Dr. Charles Edwards, who served mittee on Issues and the establishment of a Committee on
Government. Both have been accomplished, the former under the chairmanship of Dr. Francis D. Moore and the latter under Dr. William P. Longmire, and these committees will report to the Association this year. The Association is in a position, theoretically at least, to serve as an active lobbying organization and to request the opportunity to testify before congressional committees. In order to function in this capacity to a significantly effective degree, however, an office and probably minimal staffing would be desirable, and this would require more funding than I believe the Association may be willing to provide through the dues or assessment mechanism. For instance, a single meeting of one of the two recently established committees could cost in the thousands of dollars, and this would strain the treasury. With the newly formed 501-C3 Foundation, it is possible that members might procure donations from individuals or agencies to support these functions, but it is unlikely that this would be done on a continuing basis. It seems to me that a wiser and more effective course for this Association as well as for other, similar specialty organizations with limited membership, might be that of operating in a consulting capacity with their committees serving as groups of particular expertise, or "think-tanks," for input into a small group of appropriate organizations, who could then present a consensus, although on occasion the Association may wish to act directly. A council or consortium, possibly composed of the chief executive officers or representatives of these selected organizations, would thus be formed, which would provide unified representation. For, while the image of the medical profession is still relatively favorable in the eyes of the public, as indicated from a number of sources, it is not generally considered in the same light before the various branches of the government, and one major reason is that we speak through many channels oftimes presenting conflicting views. As I stated earlier, it may be virtually impossible to achieve even a near consensus, but this should in no way dampen our efforts. I feel fortunate to have been a part of this profession during what I consider a golden age for the medical practitioner. There are admitted deficiences during this period which should be corrected insofar as possible. Attempts to rectify these inadequacies and inequities are being made by the profession as well as through some of the legislation under consideration. It falls on the shoulders of the profession to assume a truly aggressive leadership role and to resolve our major health problems before this is done by others in what might be an unpalatable manner. I believe that the profession has rallied to a great degree, especially during the past five years or so, in an effort to accomplish this, but it may well be too little and too late.
five years in top government health positions, the last two as Assistant Secretary of HEW for Health, states forcefully that the highest health office within the government today has inadequate authority. He further indicates that certain management logic within the Department of HEW began to deteriorate with the enactment of Medicare and Medicaid, so that toward the end of the sixties most of the health system was being administered by welfare and social security agencies rather than by health offices. In addition, although the authority to do so exists on paper, the highest health office has very limited ability to influence Medicare and Medicaid policies. If this allocation of authority persists and the trend continues, the administration of a national health insurance plan, in either the public or the private sector, could be greatly jeopardized. Dr. Edwards believes that a Department of Health must be established within the Executive Branch, headed by an individual with cabinet status, and this seems logical when one considers the magnitude of the health industry from the monetary, manpower and other standpoints. On the other hand, I would point out that there has been a certain lack of stability in the executive branch during recent years. He also argues that the pluralistic health-care system as we know it today in the United States is headed toward its own self-destruction by default, because of our failure to accept leadership responsibility in several important areas, including the allocation of health resources, cost control and utilization of health services, and the lack of quality control. Many in the profession share this view. He further asserts that the federal government is not now, nor will it ever be, capable of managing the American health-care industry, and he states pessimistically, and I quote, "Unless the industry demonstrates that it is its own best manager and that the American people are better served by privatepublic partnership in health, that partnership, such as it is, will be dissolved in favor of public ownership, and the health industry like the railroads will have had a glorious past with no future." I hope that this is not and will never be the case, and it is our challenge to prevent its occurring. For the last 215 years of American history, longitudinal stability has resided consistently in the private sector and it is here that our hope for the future lies. We must therefore assume the leadership of our health-care system and speak with a forceful, unified voice in the arena of public debate to make the greatest impact possible. Otherwise, we may well fall to a system which few if any of us would deem desirable. If some of my comments seem overly altruistic and impossible to effect, one point stands clear and that is that only united can we stand.
September 1975
No. 3
Presidential Address: United We Stand WILLIAM H. MULLER, JR., M.D.
jr Is WITH IMMENSE GRATITUDE that I stand here today
From the Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901
as President of this great organization. I am fully cognizant of the honor you accorded me at last year's meeting, and have tried to be aware of the responsibility and obligation which accompanies it. In preparing to address you, I, like most who have faced this duty, reviewed a number of previous Presidential addresses, and found them to be delightful and informative reading, but I believe I should have been somewhat like the student to whom the professor of engineering assigned the problem of designing a new device, advising him to ignore most published information concerning it, lest he be overly influenced by what had been written previously, because the subject of my comments today has been influenced by some of those before me, as well as by the current tenor of the national environment for health matters. During the last decade, and especially the last five or six years, the majority of addresses have adhered to a generally basic theme, each serving more or less as a sequel to the one before, and it is my intention to add yet another chapter. Owen Wangensteen regards this address as "an annual lectureship on the status, outlook and vistas of surgery," and while I shall not be so comprehensive, I do wish to focus on a number of problems currently facing the profession. If my comments do not Presented at the Annual Meeting of the American Surgical Association, Quebec City, Quebec, May 7-9, 1975.
seem to include our Canadian membership, it is only because they have experienced at least some of the possible transitions I shall discuss. One has only to observe the progression and complexities of government-medicine interrelationships, including Medicare, Medicaid, HRI, PSRO, and a host of other regulatory legislation exacted during recent years, to project the future course of medicine and surgery in the United States. One of the most imminent additions to these is some form of national health insurance. The great impetus for this legislation comes from the assumption by most citizens that health care is a right, and the recognition that some type of financial assistance is needed to provide it to the great mass of people not already included under one of the existing programs. Last summer, there were before the Congress no less than 12 bills supporting some type of a national health plan. The total estimated cost ranged from $103.6 billion to $116 billion a year, or more than 12% of the Gross National Product. Just as important, however, was the proposed source of funds to support comprehensive health care in each bill. These sources ranged from a high of more than 90% public funds in one bill to approximately 62% private funds in another, as developed in an comparison of the eight most prominent bills by the De-
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partment of Health, Education and Welfare in response to a request from the Congress. Therefore, even the bill with the greatest orientation toward the private sector depended heavily upon public-primarily federal-funds for financing. It was only because of problems related to funding of a last-ditch compromise bill that a national health program was not enacted by the last Congress. In his Inaugural Address, President Ford declared that a suitable health care plan assumed top priority in his administration. However, in his State of the Union message early this year, he announced that, except in the energy fields, he would veto all new spending programs, including National Health Insurance. Thus, it appears that there may be a moratorium on a national health plan for another year, and it is hoped that the medical profession can use this time to mobilize its forces to advise and consult more effectively for legislation which will provide financial assistance to the many uninsured citizens, while exerting the least regulatory limitations on the profes-
sion. It is of the utmost importance that responsible organized medicine seize this opportunity. The generally high quality of health-care currently delivered must be maintained, but freedom to render it must also remain. The assumption that a federally-regulated program will not only assure quality and quantity, but also control cost, is unfounded. In 1948, it was estimated that Britain's National Health Service would cost $400 million in the year 1974. The facts are, however, that it cost $7.2 billion in 1974, was in dire financial straits, and needed $1.1 billion to give it fiscal stability, according to the British Medical Association. This is only one example of the lack of cost-efficiency in a system administered totally by bureaucracy. The United States is one of the last of the developed countries in which professional freedom for medical practice prevails in spite of erosion by already implemented government health care programs. Thus far, many of these programs are administered through the private sector. Currently, however, new bills have been introduced into the Congress to provide comprehensive care and, in each, a federal agency of some type would be established for jurisdiction over its implementation. This jurisdiction would include such regulatory measures as control of expenditures, the establishment of national health benefit patterns, the setting of standards of participation, and the development of policy guidelines. In other words, these prerogatives would be removed from the private sector. It is my belief, and that of many others, that while we may accept the reality that we will have a national health insurance system, every effort should be made to encompass as much of it as possible in the private sector in order to preserve many of the desirable features of medical practice which we now have. William Anlyan has suggested that it should be a
Ann. Surg. * September 1975
private-public system, combining the advantages of a market economy through private insurance, with some subsidy from the government to underwrite the needed programs for the indigent, the medically indigent, and for catastrophic illness. For, as Harold Laski noted, "Most Americans have a deep sense of discomfort when they are asked to support the State. They tend to feel that what is done by government institution is bound to be less well done than if it were undertaken by individuals, whether alone or in the form of a private corporation." The variety and profusion of individual programs already established-some of which were short-lived, such as HSMHA-each with individual requirements for funding, eligibility and administration, are illustrative of the response by government to a health need. They conform to what John Gardner has called "the vending machine concept of social change. Put a coin in the machine and out comes a piece of candy. If there is a social problem, pass a law and out comes a solution." Senator Ribicoff has put it just as aptly, "Because we rely so heavily on a programmatic approach-passing a program when we discover a problem or a part of the problem-and rely so little on a comprehensive manner, our efforts are often marked by confusion, frustration and delay." However, pressures exerted upon the legislative and executive branches of government by large population segments during the past two decades have assured a response in the form of comprehensive healthcare legislation. The hope that it will come in an orderly, logical manner, conceived to provide high-quality care with minimal displacement of the practitioner, is questionable when one examines many of the programs already enacted and when one considers the experience in other countries. Only in April of 1974, 25 years after its initiation, did major reorganization and restructuring of the British National Health service occur in an effort to make it more effective. The chief aims were to introduce tighter management controls, to contain cost and increase efficiency, as well as improve the quality of patient care in areas neglected by main-stream medicine. These measures imply that rigid control is necessary to implement properly a totally nationalized medical plan. It can only be hoped that our political leaders will take some lessons from the 25-year British experience in comprehensive health-care, for the institution of a similar system would have an impact, both immediate and farreaching, on the practitioner, the consumer, and on teaching and research, greater than any other event in the history of medicine in the United States during peacetime. I prefer to believe it unlikely that a program totally controlled and financed from Washington would be thrust upon us. Representative Ullman, the new chairman of the House Ways and Means Committee, states that he believes a plan will evolve to mandate coverage by private health insurance companies and es-
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tablish health care corporations centered in hospitals as the focal point of the system. As regards national health insurance completely financed by taxes without private contributions, he said recently, "There is no way the economy could take this, and no way such a program could be managed efficiently from Washington." However, there is currently a liberal majority in the Congress and certain powerful, persuasive members have long attempted passage of bills for virtually total nationalization. The present economic crisis has caused the introduction of bills which would provide temporary emergency health insurance for the unemployed. All of the bills introduced, however, contain admitted inequalities and inequities. For instance, none of them would cover the working poor or the unemployed whose compensation had expired, and the same health benefits would apply to all regardless of how much or what type of coverage they had previously had. Congressional committee members as well as witnesses testifying before the committees pointed out that there would not be the necessity for this kind of legislation if a comprehensive program had already been passed. They believe it imperative, therefore, that the Congress pass a comprehensive bill as quickly as possible, because several years will be required for any national health insurance program to become fully operative. It is this environment of pressure under which national health insurance legislation finds itself today. The feeling that something must be done and done quickly could have Gardner's "vending machine" effect, giving rise to the belief that if a national health insurance bill is passed, any bill, the nation's health problems would be solved. Mr. Rostenkowksy, Chairman of the Ways and Means Health Subcommittee which has the responsibility for writing a comprehensive bill, has given assurances that one will be forthcoming by the end of the summer, but that a temporary bill for the unemployed should not be taken as a precedent for a comprehensive National Health Plan. He further states that the fact that we must do something about the immediate problem of unemployment health insurance illustrates clearly the need to fashion a sound, workable plan of comprehensive national health insurance for the long run. This latter statement is reassuring. Another problem represents the most immediate and devastating crisis upon us, the problem of professional liability. Malpractice claims, while nothing new, have increased both in number and magnitude to catastrophic proportions; the result has been that the cost of insurance premiums has risen geometrically throughout the country and in some specialties become virtually unaffordable. Even more alarming, the number of carriers has decreased and those remaining do not desire such business, so that some states or parts of states have been left or soon will be left without any coverage at all. Today
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malpractice insurance is a basic requirement for the physician and one would hardly think of clinical practice without it. Recently the President of the American Medical Association testified before the House Ways and Means Subcommittee on Health that physicians cannot practice medicine unless they have adequate insurance coverage, and injured patients cannot be compensated unless adequate funds are available. Insurance, therefore, must be available at reasonable premium costs in order for care to be delivered. Of equal importance, a workable system must be devised for the prompt and equitable resolution of personal injury claims resulting from medical treatment. Laws must be enacted, also, to control the level of payments to the plaintiff. Excessively large judgments, which are becoming more and more frequent, rather than compensating the patient objectively for his injury, reflect the sympathy and compassion of the court. The contingency fee creates another inequity in many cases. While the legal profession registers a disclaimer, this method of setting the legal fee undoubtedly encourages many unworth claims which otherwise would not be considered and frequently, especially in the case of very large judgments, provides payment to the attorney out of all proportion to his background and skill, and the time and effort expended. In 1973, the Federal Commisson on Medical Malpractice reported that it cost an average of $22,000 to bring a case through the courts. The attorney's argue, therefore, that without the contingency fee many patients with valid claims could not afford necessary legal fees for litigation and could not have any chance of being compensated. It has also been shown that the patient receives only about 16 to 24 cents of each premium dollar, and these fiscal inequities, along with the cost of insurance for hospitals, the total of which amounts to more than $1.5 billion per year, have become significant factors in che continuing rise in the cost of medical care. In addition to withdrawing coverage and increasing premium costs astronomically, insurance companies are changing from the traditional occurrence policies which insured physicians against claims filed at any time in the future as a result of incidents which happened during the policy period. They are substituting claims-made policies providing coverage only for those suits filed during each 12-month period the policy is in effect. Therefore, the physician who leaves one area of the country for another where he is covered by a different carrier, would be faced with the problem of carrying two policies at once, and the retired physician would be required to extend his policy for several years after he ceases to practice or until the statute of limitations on his last patient expires. The solution to the malpractice problem is indeed complex. Our primary task as surgeons and physicians is to reduce the number of preventable injuries; that is, elevate the quality of medical care. However, considera-
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tion should be given to revising the contingency fee principle, placing a ceiling on the dollar amount ofjudgments, eliminating collateral source benefits and payments for pain and suffering, revising the statute of limitations, maintaining occurrence-type policies or initiating affordable no-fault insurance, and possibly introducing binding arbitration, among many other approaches. The Secretary of HEW has steadfastly maintained that the solution of this problem should be left to the individual states and this appears desirable indeed when one considers the restrictions placed on physicians in the bills now under consideration by the Congress. Also, none of these bills would cope effectively with such intangibles as increasing claims consciousness among patients, larger awards, poor quality health-care delivery and the overaggressiveness of claims attorneys. However complex the solution, though, steps must be taken to rectify this malignant process. The recently passed laws in Idaho and Indiana are milestones indeed in this direction. That it can be controlled and the patient appropriately compensated is evidenced by the situation in Canada. Here, premiums are low and the patient is compensated more in keeping with the magnitude and the reasonable worth of the personal injury incurred. A third issue is a bill to control medical manpower, which was introduced into Congress this year by Congressman Paul Rogers, and is now being considered along with several others. This proposed legislation has many facets as regards both medical education and manpower distribution. It extends the National Health Service Corps and provides capitation support for medical schools. In addition, however, it fixes the number of first-year residency positions at a level of 155% of the estimated number of graduates from U.S. medical schools, with reduction by steps to 125% over a period of three years. It is aimed, among other objectives, at limiting the number of foreign medical graduates. This bill would appear also to fix ultimately the number of specialty residency programs and, eventually, the number of residency programs within each specialty. If this were done on a regional basis it is entirely possible that a relatively small area with a high population density and a large number of excellent programs might be required to eliminate some of them, whereas another region with fewer programs, many of poorer quality, might not be compelled to discontinue any. Another goal, of creating more first-contact physician residencies, is apparently already being met. In 1974, there was a 66% increase over 1973 in the number of family practice residency programs, and the figures show a continued upward trend in spite of the fact that the number of residency positions in the area of primary care has already reached a figure between 40 and 50%o. Vigorous congressional testimony from several organizations has tempered the stringency of the bill in a number of areas, enabling it more nearly to fulfill actual needs.
Ann.
Surg. September 1975
Nor is the health-care industry immune from restrictive legislation by the individual states. This year in my own state of Virginia, a bill was introduced into the General Assembly which would allow each senator the prerogative of designating two students for the entering class of the two state medical schools. Fortunately, it was roundly defeated in committee before reaching the floor. One senator commented later that he had calculated the number of votes he would have lost if 50 premedical students requested admission and he could admit only two. The families, relatives, friends and sympathetic acquaintances of the other 48 might constitute a block of votes large enough to prevent his re-election. He was therefore very much against the bill. A host of other health legislation is being introduced into or considered by Congress at the present time. I have discussed briefly three areas of concern, which I believe include some of the most important health issues. The outcome of this and other legislation will have a tremendous influence on the practice of medicine in the immediate and long-range future. Since next year is an election year and since health issues make popular political footballs during those times, it is of the greatest importance that we continue, and in fact increase, the vigorous efforts now being made. Equally so, organized medicine must have, insofar as possible, a unified voice or spokesman. This may be impossible, however, in view of the paradoxical philosophical heterogeneity of this profession with a generally homogeneous educational background. It is doubtful that the. average practitioner prior to World War II ever considered or cared whether or not his profession had a spokesman, for there was little need for one. At the turn of the century, specialization had just begun and the Flexner Report was in the immediate future. Concerns lay primarily in developing the science and art of medicine, higher quality medical schools and better health-care facilities. The government and medicine had only loose liaisons. Regulation was applied chiefly to the use of narcotics and the U.S. Public Health Service was the primary medical arm of government. The Veterans Administration rendered care to a large segment of the population, which became even larger after World War II, and through Public Law 293, many of its hospitals became closely affiliated with adjacent medical schools. The establishment of the National Institutes of Health in the late 1940s with its peer review systems and direct access to Congress for its fiscal and other needs, seemed to most a great step forward, although some believed it was a step toward government control of medicine, and refused to accept NIH grants. The NIH seemed a never-ending, ever-increasing cornucopia to support basic and applied research, certain types of medical care, and medical education. The Hill-Burton Act likewise provided untold amounts of money for hospital construction. The creation of the Department of Health,
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Education and Welfare during the Eisenhower administration commanded a broader base and larger budget. Research productivity and clinical application never before equalled in such a short period in medical history evolved. Categorical programs, such as that for heart, stroke and cancer, were created and there seemed to be no end to the possibilities for elucidating more and more of what Lewis Thomas has described as "true science." And yet, in the early 1960s, the bubble was beginning to burst. Rumblings of physician shortage, unavailability and poor physician access could be heard from many public sources. The media in virtually every form responded to demean the physician and the entire health industry as inadequate, inefficient, extravagant and, indeed, even chaotic. The implication or direct statement was frequently made that the majority of U.S. citizens received poor medical care. Scarcely a week passed that inflammatory, often inaccurate, articles did not appear in lay publications. On television, so-called documentary programs appeared not infrequently and at least one blunty warned its audience not to get sick in America. In his book entitled "The Case for American Medicine," Harry Schwartz refers to this media blitz as "rhetorical overkill" and describes it as "reminiscent of the simplistic anti-Soviet and anti-Chinese propaganda of the worst cold war days." In a very objective manner, he proceeds further to demonstrate that "health-care crises, or health crises in terms the propagandists usually present the matter, do not exist." He focuses, moreover, on the many positive features of American medicine not mentioned by the critics. This brief outline, step-by-step, of the progression of government-medicine interrelationships and the negative propagandizement of the media, serves to emphasize that never before has the need been so paramount as it is today for a unified voice, in order for American medicine to make itself heard during these critical times. If we were asked who speaks for the medical profession, I doubt that there would be unanimity on any one organization or individual. I believe it is fair to assume that the lay public looks to the American Medical Association as the voice of organized medicine in the United States, but it is equally true that the AMA does not serve as such for the entire profession, for there are other strong, vocal organizations in positions to take a stand. These include the large organizations such as the Association of American Medical Colleges, the American Hospital Association, the American College of Surgeons, and the American College of Physicians, plus small, broadly representative committees such as the Coordinating Council on Medical Education, the Council of Medical Specialty Societies, The American Board of Medical Specialties, and a host of others. The AAMC, an old organization initially constituted primarily of deans, until a few years ago was relatively inactive and involved chiefly. with mundane problems.
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Ignited by the Coggeshall Report in 1965, aided by the AMA's less than effective involvement with Medicare and Medicaid, and expertly led by a small group of skillful, dedicated, informed physicians, it has skyrocketed into a position of political eminence. Operating from a Washington office with an adequate budget and an experienced, skilled staff, the AAMC undoubtedly speaks for academia and is believed by many to have had the greatest influence in shaping health policy in the United States during recent years. Oriented toward educational issues, its shadow nevertheless touches many other areas in the broad health-care field. But, in spite of its power and influence, it is little known outside the academic circle of the profession and can hardly be described as broadly representative. The American College of Surgeons, a large organization, embraces as members nearly two-thirds of the qualified surgeons in the United States and virtually every one in the ASA. For many reasons electing not to become an official lobbying organization, it nevertheless serves as an effective voice for surgery. At what level do, or should, the American Surgical Association and similar specialty organizations function as spokesmen? The ASA has always been an organization of limited membership achieved through recognized contributions to surgery. Its leadership role has undergone self-examination from time to time, and until an exhaustive assessment in 1938 by a distinguished committee appointed by Dr. Evarts Graham, considered itself an honor society only. This committee recommended that it be a working organization as well as an honor society, and, about this time, although not as a result of this committee's report, from the Association was born the American Board of Surgery. The next major undertaking, however, did not occur until more than 30 years later, when the Committee on Issues was appointed, spawning SOSSUS. While the ASA comprises one of the most outstanding groups of surgeons in the United States and Canada and, indeed, the world, it is not constituted in its present form to undertake major projects on its own. It has no permanent staff or officers, with the exception of the Secretary, Treasurer and Recorder, who serve for five-year terms. It has a budget which barely covers its minimal operating expenses, and no permanent headquarters. It meets as a whole only once a year, and the Council only twice. The ASA undertook the SOSSUS study by joining with the American College of Surgeons and other organizations, and the joint executive committee so formed set up permanent headquarters, acquired staff and served as an agent to procure funds. Even so, multiple yearly assessments of the membership were required. Since our last meeting, the Association has acquired 501C6 Internal Revenue Status, which allows active political involvement. In his presidential address last year, Dr. Scott recommended reactivation of the Conm-
Ann. Surg. September 1975 MULLER 182 In a recent article, Dr. Charles Edwards, who served mittee on Issues and the establishment of a Committee on
Government. Both have been accomplished, the former under the chairmanship of Dr. Francis D. Moore and the latter under Dr. William P. Longmire, and these committees will report to the Association this year. The Association is in a position, theoretically at least, to serve as an active lobbying organization and to request the opportunity to testify before congressional committees. In order to function in this capacity to a significantly effective degree, however, an office and probably minimal staffing would be desirable, and this would require more funding than I believe the Association may be willing to provide through the dues or assessment mechanism. For instance, a single meeting of one of the two recently established committees could cost in the thousands of dollars, and this would strain the treasury. With the newly formed 501-C3 Foundation, it is possible that members might procure donations from individuals or agencies to support these functions, but it is unlikely that this would be done on a continuing basis. It seems to me that a wiser and more effective course for this Association as well as for other, similar specialty organizations with limited membership, might be that of operating in a consulting capacity with their committees serving as groups of particular expertise, or "think-tanks," for input into a small group of appropriate organizations, who could then present a consensus, although on occasion the Association may wish to act directly. A council or consortium, possibly composed of the chief executive officers or representatives of these selected organizations, would thus be formed, which would provide unified representation. For, while the image of the medical profession is still relatively favorable in the eyes of the public, as indicated from a number of sources, it is not generally considered in the same light before the various branches of the government, and one major reason is that we speak through many channels oftimes presenting conflicting views. As I stated earlier, it may be virtually impossible to achieve even a near consensus, but this should in no way dampen our efforts. I feel fortunate to have been a part of this profession during what I consider a golden age for the medical practitioner. There are admitted deficiences during this period which should be corrected insofar as possible. Attempts to rectify these inadequacies and inequities are being made by the profession as well as through some of the legislation under consideration. It falls on the shoulders of the profession to assume a truly aggressive leadership role and to resolve our major health problems before this is done by others in what might be an unpalatable manner. I believe that the profession has rallied to a great degree, especially during the past five years or so, in an effort to accomplish this, but it may well be too little and too late.
five years in top government health positions, the last two as Assistant Secretary of HEW for Health, states forcefully that the highest health office within the government today has inadequate authority. He further indicates that certain management logic within the Department of HEW began to deteriorate with the enactment of Medicare and Medicaid, so that toward the end of the sixties most of the health system was being administered by welfare and social security agencies rather than by health offices. In addition, although the authority to do so exists on paper, the highest health office has very limited ability to influence Medicare and Medicaid policies. If this allocation of authority persists and the trend continues, the administration of a national health insurance plan, in either the public or the private sector, could be greatly jeopardized. Dr. Edwards believes that a Department of Health must be established within the Executive Branch, headed by an individual with cabinet status, and this seems logical when one considers the magnitude of the health industry from the monetary, manpower and other standpoints. On the other hand, I would point out that there has been a certain lack of stability in the executive branch during recent years. He also argues that the pluralistic health-care system as we know it today in the United States is headed toward its own self-destruction by default, because of our failure to accept leadership responsibility in several important areas, including the allocation of health resources, cost control and utilization of health services, and the lack of quality control. Many in the profession share this view. He further asserts that the federal government is not now, nor will it ever be, capable of managing the American health-care industry, and he states pessimistically, and I quote, "Unless the industry demonstrates that it is its own best manager and that the American people are better served by privatepublic partnership in health, that partnership, such as it is, will be dissolved in favor of public ownership, and the health industry like the railroads will have had a glorious past with no future." I hope that this is not and will never be the case, and it is our challenge to prevent its occurring. For the last 215 years of American history, longitudinal stability has resided consistently in the private sector and it is here that our hope for the future lies. We must therefore assume the leadership of our health-care system and speak with a forceful, unified voice in the arena of public debate to make the greatest impact possible. Otherwise, we may well fall to a system which few if any of us would deem desirable. If some of my comments seem overly altruistic and impossible to effect, one point stands clear and that is that only united can we stand.
