JAMA Revisited January 11, 1930
The Cost of Medical Care The interest of the public in the cost of medical care, apparently for many years dormant, seems now to be the topic of the hour. True, one may visit innumerable villages, cities and hamlets of the Middle West, the South, and even the New England states and find both the physicians and the general public little concerned in the current agitation; but in other communities it arouses burning argument and intense feeling. Much of this emotionalism is, of course, the result of propaganda and of personal issues which have little or nothing to do with the purely economic aspects of the question. Nevertheless, the work of the Committee on the Cost of Medical Care and the numerous investigations now being carried on under various auspices in new methods of medical practice make the situation one which the medical profession must consider. As has been said previously in these columns, regardless of the nature of medical practice in the future, physicians will have to do the practicing; and the success or failure of any experiment will depend on the extent to which physicians deliver what the public has been accustomed to expect from them in the way of prevention and cure of disease. The most recent publication of the Committee on the Cost of Medical Care concerns hospital service for patients of moderate means. Mr. Carpenter introduces his consideration with a realization of the fact that hospitals were first constructed for the poor and then provided rooms for the rich, and that only recently have institutions begun to adapt both structure and administration to the care of the middle class. The survey revealed that 121 hospitals out of 132 whose letters tell of future plans include the provision of special facilities for patients of moderate means. One of the greatest difficulties in adaptation of the present hospital construction and management to the problem of the middle class is the fact that various classes of service are provided under one roof, much as occurs on board ship. Here enter in all the problems of pride, comparisons in food and dishes and linens and decoration, and all those other psychologic and esthetic factors on which scientists and economists are likely to lay little stress but which play such a large part in human life. Already buildings are being developed wholly devoted to one type of hospital service. Hospital rooms with service can now be had at prices varying from six dollars a day to as much as the patient cares to pay,
Editor’s Note: JAMA Revisited is transcribed verbatim from articles published previously, unless otherwise noted.
these rates being after all about the same as for the hotels; and the latter do not provide food. Nevertheless, a person who selects a middle class or low middle class hotel when he travels is likely to want the best of hospital accommodations when he is sick. Ward beds and semiprivate beds in rooms for two or four may be had for much smaller charges than single private rooms. However, associated with the charge for the room are such charges as laboratory, anesthetic, roentgen-ray, special nursing and operating room fees, for which the patient is usually not prepared and which serve not infrequently to bring his total bill to a sum that arouses consternation. Suggestions have been made for elimination or redistribution of such fees, charging them to the room charge or to the flat-rate operation or obstetric fee; but the whole matter of administration is still in an experimental stage. It is argued that the patient may be able to pay the hospital and special fees and not be able to pay the physician, and vice versa. Of the former state of affairs, physicians are unfortunately too fully cognizant. Hospitals, nurses, ambulances and all the other services are likely to collect before the physician renders and secures payment for his bill. Some institutions are planning to submit one bill covering all fees, and others to establish maximum charges for certain types of medical, surgical or obstetric care. Here are experiments which will be full of grief and grievances before their answers can be known. Mr. Niles Carpenter, who submits this report for the Committee on the Cost of Medical Care, in his concluding paragraphs arrives at a question which physicians, through their experience, have been asking for several years. “Would the patient of moderate means be able to pay for his hospital care even if the entire hospital world should adopt every one of the new policies outlined in this study?” The advances of modern medicine are amazing and costly. The problems of medical care cannot be separated from all the other economic situations of modern civilization. It is true that far more patients are going to hospitals for medical care than actually require hospitalization from the medical point of view; but the home has disappeared and the helpmate who used to nurse the sick is now a clerk, a secretary or an advertising copy writer, whose income must not be disturbed. The only possible place for the care of the ailing member of the family is the hospital. If the hospital is too expensive, somebody will have to wait for his money; and it requires no Ph.D. to guess who that somebody is going to be. JAMA. 1930;94(2):106.
Section Editor: Jennifer Reiling, Assistant Editor.
jama.com
JAMA October 22/29, 2014 Volume 312, Number 16
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/02/2015
1699
The Cost of Medical Care The interest of the public in the cost of medical care, apparently for many years dormant, seems now to be the topic of the hour. True, one may visit innumerable villages, cities and hamlets of the Middle West, the South, and even the New England states and find both the physicians and the general public little concerned in the current agitation; but in other communities it arouses burning argument and intense feeling. Much of this emotionalism is, of course, the result of propaganda and of personal issues which have little or nothing to do with the purely economic aspects of the question. Nevertheless, the work of the Committee on the Cost of Medical Care and the numerous investigations now being carried on under various auspices in new methods of medical practice make the situation one which the medical profession must consider. As has been said previously in these columns, regardless of the nature of medical practice in the future, physicians will have to do the practicing; and the success or failure of any experiment will depend on the extent to which physicians deliver what the public has been accustomed to expect from them in the way of prevention and cure of disease. The most recent publication of the Committee on the Cost of Medical Care concerns hospital service for patients of moderate means. Mr. Carpenter introduces his consideration with a realization of the fact that hospitals were first constructed for the poor and then provided rooms for the rich, and that only recently have institutions begun to adapt both structure and administration to the care of the middle class. The survey revealed that 121 hospitals out of 132 whose letters tell of future plans include the provision of special facilities for patients of moderate means. One of the greatest difficulties in adaptation of the present hospital construction and management to the problem of the middle class is the fact that various classes of service are provided under one roof, much as occurs on board ship. Here enter in all the problems of pride, comparisons in food and dishes and linens and decoration, and all those other psychologic and esthetic factors on which scientists and economists are likely to lay little stress but which play such a large part in human life. Already buildings are being developed wholly devoted to one type of hospital service. Hospital rooms with service can now be had at prices varying from six dollars a day to as much as the patient cares to pay,
Editor’s Note: JAMA Revisited is transcribed verbatim from articles published previously, unless otherwise noted.
these rates being after all about the same as for the hotels; and the latter do not provide food. Nevertheless, a person who selects a middle class or low middle class hotel when he travels is likely to want the best of hospital accommodations when he is sick. Ward beds and semiprivate beds in rooms for two or four may be had for much smaller charges than single private rooms. However, associated with the charge for the room are such charges as laboratory, anesthetic, roentgen-ray, special nursing and operating room fees, for which the patient is usually not prepared and which serve not infrequently to bring his total bill to a sum that arouses consternation. Suggestions have been made for elimination or redistribution of such fees, charging them to the room charge or to the flat-rate operation or obstetric fee; but the whole matter of administration is still in an experimental stage. It is argued that the patient may be able to pay the hospital and special fees and not be able to pay the physician, and vice versa. Of the former state of affairs, physicians are unfortunately too fully cognizant. Hospitals, nurses, ambulances and all the other services are likely to collect before the physician renders and secures payment for his bill. Some institutions are planning to submit one bill covering all fees, and others to establish maximum charges for certain types of medical, surgical or obstetric care. Here are experiments which will be full of grief and grievances before their answers can be known. Mr. Niles Carpenter, who submits this report for the Committee on the Cost of Medical Care, in his concluding paragraphs arrives at a question which physicians, through their experience, have been asking for several years. “Would the patient of moderate means be able to pay for his hospital care even if the entire hospital world should adopt every one of the new policies outlined in this study?” The advances of modern medicine are amazing and costly. The problems of medical care cannot be separated from all the other economic situations of modern civilization. It is true that far more patients are going to hospitals for medical care than actually require hospitalization from the medical point of view; but the home has disappeared and the helpmate who used to nurse the sick is now a clerk, a secretary or an advertising copy writer, whose income must not be disturbed. The only possible place for the care of the ailing member of the family is the hospital. If the hospital is too expensive, somebody will have to wait for his money; and it requires no Ph.D. to guess who that somebody is going to be. JAMA. 1930;94(2):106.
Section Editor: Jennifer Reiling, Assistant Editor.
jama.com
JAMA October 22/29, 2014 Volume 312, Number 16
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/02/2015
1699
