Issue and inquiry; 6; Public Medicine: New Prescription for the Nation's Health

From Northeastern University the national information that we're presenting issue and inquiring. I would hope that the private voluntary hospitals and private doctors could solve these problems. But in fact many of the problems they have not solved and the public at large has got to have prepaid medical insurance for comprehensive health service and I would hope that central government somehow would reorganize itself and confine itself to financing and questions of policy. For example the policy should be that all Americans in all states should have comprehensive prepaid health insurance number one. Number two those people who are unemployed or on employable and can't afford it it should be paid for out of tax money in fact that's what's happening right now. Number three once the policy in the financing is set the control and evolution and development of such plans should be left to the private regional sector in combination with public representatives in that area we've got to somehow

de-centralized the power of federal government back to local states cities and regions. The price of freedom from central control is local responsibility to the public interest and this is what doctors and hospitals have got to do to maintain their precious autonomy and freedom from central control. This week on issue an inquiry Dr. John Noble director of the Massachusetts General Hospital discussing public medicine a new prescription for the nation's health. Here is your host Joseph R. major. The United States has the best system of medical treatment in the world. Or so Americans like to believe. Yet every day in this nation that boast is more open to question in a country that performs the miracle of the heart transplant some 30 million people receive insufficient care or no medical care at all. We rank

15 among other nations in infant mortality treatment costs are skyrocketing and there is a critical shortage of doctors and adequate medical facilities. Dr. No if you're a director of one of America's most prestigious hospitals on those facts and figures work and no news to you how do you as director of this huge hospital size up the state of the nation's health. In this year we will spend over 60 billion dollars on health which is six point seven percent of our gross national product. Both of that figure plus the per capita expenditures for health by all Americans in this country is the largest expenditure by any country in the world on health and yet our health statistics and the State of the nation's health would belie those figures and whether we're talking about infant mortality whether we're talking about the virtually destitute condition of those 30 million poor people when it comes to health services. One can logically

ask the question when we spend more money than any other country in the world why don't we have better health than any country in the world. The fact is that we don't. 30 million medically indigent people or what the Social Security Agency cost 45 million poor people defined as families of four with an income of forty three hundred dollars or less of whom by the way 25 million are in the inner city ghetto areas and the other 20 million are in rural areas like Appalachian southwestern United States the border land of Texas and Mexico and so on. These people ahead do not know that they need health services and when they do they're unable to get to them. And once they get to them they suffer incredible waits and ordinarily for the mentally have to be hospitalized in high cost facilities. Dr. KNOWLES I know you're aware of this next to to stick. Daily hospital treatment has skyrocketed some one hundred twenty two percent in the

last decade. The question what are the reasons for this rise. Well there are several in number first of all about 70 percent of our costs go into the wages and fringe benefits of our employees. And until several years ago we didn't even pay overtime or give any fringe benefits to hospital employees. Most of the hospitals in this country hadn't even reached the minimum wage because they were exempted by federal law from minimum wage requirements. This exemption by the way was removed in 1970. So the first and biggest cause of this is in increased wages and fringe benefits and finally in the hospitals of this country we are competitive with industry at large for crucial health workers. A second issue is that we have all required more employees per bed as our technology expands we do open heart surgery we do more complicated X-ray procedures. We do many more types of chemistry test which make accurate

diagnosis and treatment possible. We've had to add more people the average in the country was maybe two employees per bed ten years ago and it's now three or more employees per bed to carry out all the technology which improves the care. There are other causes in addition our cost for supplies for example our food costs have doubled. Just like the general consumer our cost of everything from bandages to drugs 10 years ago at the Masters General Hospital we spent one million dollars on drugs this year will spend two and a half million dollars which is almost $400000 more than we spent last year on the drugs that our patients need. So all these things have compound it to give the large rise in hospital costs I would expect them to now level off from the 12 to 15 percent increase that has occurred each year for the last three years and settle down to 6 or 7 percent.

Can you really expect the average American hospital patient to be able to pay your rising costs pay the bill. No I don't think there's any question that they can't. Medicare for example now covers about 40 percent of the total medical care costs of those people over 65 Medicaid covers another 13 percent for people over 65 which leaves greater than 40 percent. To the pocketbooks of the elderly people themselves and income under Social Security benefits has withered under inflationary forces. And so it's becoming increasingly difficult for people over 65 with the advantages of Medicare to afford these costs. I think there's going to have to inevitably be an expansion of Medicare coverage for people over 65 to cover such things as drug costs a greater percentage of physician fees nursing homes and so on. And I think furthermore that the sooner we reach a state of comprehensive prepaid health insurance for all Americans the better we're going to be. We've

almost achieved that now. There are many blind spots in our insurance coverage in this country today. It occurs to me as I listen to you talk that you're really talking about socialized medicine. That's really a scare word and historic streets that worst words you could conceivably used as I've said many times however it was decided at one time in the history of this country that education for all our people was an important issue and that the private sector could not or would not support the development of educational facilities in fact at least for all our children in this country so therefore we develop the finest system of public education. In the world we do not call that socialized education but in fact it is socialized education we're all taxed and the tax money is used to build the schools which all our children can then go to. What you're essentially run by local state and federal government. So let's call it public medicine.

Public medical care for people. And yes there should be. Bear in mind in our educational system we do have room for both public education and private education. I would hope that we could develop similar patterns in medical care which in fact we have however imperfectly. We do have public and private medicine today and I think there are virtues to both. You know it's a little odd though to see talk of the public. Medicine come out of your mouth you're an establishment figure in the city. You would the finding of some people be the last person to know about a revolutionary change oh absolutely here I am the director of a voluntary hospital and I've raised the flag of volunteerism and local initiative and private medicine and private voluntary system of medical care and I will continue to do so because I do believe that the more you ask the central government the more you're subjected to the tyranny of absentee ownership in Washington. And I think we've seen one example of this after another do you really think that the Massachusetts General Hospital under voluntary private

control has failed where municipal hospitals in this country state mental institutions and federal hospitals have succeeded because they've been socialized and under governmental control. Well the answer is Alex or sued. They certainly have not succeeded in this hospital as a private voluntary hospital with a private staff of private practicing physicians is as fine a development of medical responsibility and medical care as you could find any place in the western world if not the entire world. So I most certainly am part of the establishment and that way I do would I would hope that the private voluntary hospitals and private doctors could solve these problems. But in fact many of the problems they have not solved and the public at large has got to have prepaid medical insurance for comprehensive health service and I would hope that central government somehow would reorganize itself and confine itself to financing and questions of policy. For example the policy should be that all

Americans in all states should have comprehensive prepaid health insurance number one. Number two those people who are unemployed or on employable and can't afford it it should be paid for out of tax money in fact that's what's happening right now. Number three once the policy in the financing is set the control and evolution and development of such plans should be left to the private regional sector in combination with public representatives in that area we've got to somehow decentralized the power of federal government back to local states cities and regions. This is not easy I agree but it's got to be done. We're asking for the development of statism and as it happened in Germany over 100 years the ultimate development of fascism. The price of freedom from central control is local responsibility to the public interest and this is what doctors and hospitals have got to

do to maintain their precious autonomy and freedom from central control. We're talking with Dr. John Knowles who's director of the Massachusetts General Hospital. Perhaps one of the most renowned hospitals in the western world. Dr. No's Let's shift the questioning at this point to the quality of medicine dispensed by the doctors here in this country there was a spate of articles and books a couple years ago which seemed to indicate that the myth of infallibility of the American doctor was just that a myth that the doctors only people in any other profession lawyers teachers they all make mistakes and they make mistakes or rather often you have 15 to 20 top hospitals in the country where your quality medicine is dispensed but on the the grassroots level very often the quality of medicine is rather primitive. People have not kept up. Well I think that that is generally true I think that in medicine all of professions and like all

occupations has its good guys and its bad guys. I think that if you had five 10 or 15 percent of the physicians in this country were perhaps you might be judged inadequate to the task. Not all tasks but some of that they take on. But I think the majority of physicians are extremely well intentioned and do a fine job as recipients of medical care above all we would hope that our physician who deals in matters of life and death and limb and sight and so on would make no mistakes and as long as there is a smile even a small segment of the profession that does make mistakes and does not pay attention to quality and doesn't give us what we should have in a country that spends more for medical services than any country in the world. Then with a this is intolerable to us and we must figure out ways of improving quality. Now various forms of insurance have not done this the way they should have done it. Medicare is the only form of insurance today that builds in quality and utilization controls

and for too long commercial insurance companies and Blue Cross and government ever represented as much the producer's interests the hospitals and the doctors as they have the consumer's interest. For example before we're paid it should be required that we have a level of quality in a quality review carried out so that our practices will be what they should be. This long however is we have inadequate physicians doing damage and charging exorbitant fees. We will not and cannot tolerate that and I say it's the business of organized medicine to drive those people out. And I don't think they've done it perhaps as a city was sleepy as they might. It is wrong to expect too much of our doctors here in America. But frankly I'd die just soon have you continue to expect too much from I think the fine doctors there are very few people more valuable than a community and I would like to see the public demand more of their physicians in terms of their honor their compassion their intellectual capacity their willingness to take refresher

courses and so on. A profession is no better and no worse than the society in which it sits. And I say society at large should demand more of its professionals where profession has got to spend more time on improving quality and policing its own ranks. And I say it has not done it as well as it should. There is a reluctance to put the pressure on your colleague. If your colleague is in the medical profession it's one of the hallmarks of a profession that professionals do not police themselves as well as a professional and nonprofessional group will do. I dare say the Supreme Court has had some difficulty in policing its own members. This is to be expected from a profession within certain ways they protect each other. Unless the wrongdoing is absolutely blatant I do think that we have the right to ask a little better. Improvement in quality than that. It's a common complaint among people who at 12 o'clock at night with their son Johnny sick call the doctor and have the doctor say well I

can't make a house call come in and see me tomorrow. My hours are 10 to 12 or 10 to 3 Why is this the case it used to be that doctors would go just like the male rain snow sleet or hell couldn't stop them from getting to your front door. Well it's true and course in those days I was all the doctor had to offer was the housecall and the personal human caring element and that was crucial. He now he's in short supply with an expanding population with more and more demands on his time and he can make better use of his time instead of taking 3 hours to go out in the woods by dog sled to see the patients sick at night. I say look you get the dog sled and bring your child in here and while you're coming over that two and a half hour period I'm going to see eight other children who have asked to come in here too. I bear in mind you might think that I as a physician and the director of a hospital when one of my six children gets sick that we have house calls made not a toff we're told just like everybody else to bring in right into the office because there he's got the

X-ray machine the special testing devices they can tell me whether my child just has the flu or a pneumonia whether the child should be hospitalized or can be sent home what kind of antibiotic he should or shouldn't have and so on. So I think the price of. Of the inconvenience is more than outweighed by the benefit of better medical care in fact. I do wish that we hadn't lost some of the personal caring element. I think that's one of the things we've got to try to bring back into medicine. There are five thousand eight hundred fifty hospitals in this country and about 3100 and 14 of them are accredited. Now what does accreditation mean in this situation work on accredited hospitals handle about one and a half million patients every year. Well unaccredited ones as determined by the Joint Commission on hospital accreditation are ones that have not passed muster in terms of their of the services available or the staffing or the medical record keeping or the safety of their

procedures or the adequacy of their plant and so on. How is a patient expected to know the difference well he doesn't in fact because there aren't many sanctions that can be applied other than the knowledge that you don't that you're not accredited for example the Accrediting Commission comes to our hospital once every three years. We so far have been accredited every three years but each time they send us a list of 20 or 30 what turned out to be minor items that we have to correct and we're glad that they come in here and point out our inadequacies and we do correct them. Are you accredited by people right within your own profession O'Reilly. Well yes we are. There in lies the danger. Well they don't ask the. The chef to be checked up by started up on by another chef what about the guest who asked the food what about the customers issue of the patient. The interesting thing about this joint commission is it's situated quite distant from most Well it's situated in Chicago as representatives the A.M.A. the American College of Surgeons the American College of Physicians and the American Hospital Association. They've got a

very vigorous executive director and at times we think they delight in harassing us by being too picayune. So far there's been no sweetheart deal that I've been able to detect and they're just as tough on us as they are on everybody else I think in fact that hasn't happened in this particular instance. But isn't this a general problem in the medical profession too much in Group A self and forcing all of your politicians aren't accredited by other politicians the voter does the ex credit limits just like any union haven't songs like any vested interest any union of people. Well the American whatever level the American patient the average patient has come to see the doctor as above this kind of so shocking news that doctors are very sociable fellows they they group together they have all kinds of organizations and societies and and some of them perform a guild function some of them perform a very important educational function some of them just have a social function I'm a member of a doctor's club. Where we get people to speak to us about the problems of the city each time we get the head of urban renewal and we ask the mayor. Then we

get the head of the school system and we learn a lot and are able to participate in it. I'm a member of other organizations that spends all its time talking about what fees should be paid well in their performance of their guild function. Isn't there a tendency among doctors to spend much more time looking out for themselves than they spend looking out for the patient Well I think in however human this is I think they may spend more time looking out for themselves than they do looking out for the expanding social problems. I know that they spend more time with their patients than they do spend thinking about themselves and that's what they're doing about 18 hours a day and they're doing I think a heroic task under very difficult situations. I do think however that there has got to be a healthy balance of consumer vs. producer interests the producers are the doctors and the hospitals the consumers of the people who use them. I think the consumer interest has been out weighed a little bit by the producers in arrest in the last few years and I think there's got to be a redress of that healthy balance.

And I agree with you is Aristotle said the guest will judge better of the feast than the cook. It occurs to me that medicine is literally the only big business in this country in which the consumer has no control over the cost and the quality of the services that he must buy. He has precious little control there's no question in recent times he's looked to local state and federal government to solve his problems. Medicare is the case in point and Medicaid the Social Security Act itself. In 1935 with its current bills amendments and one thousand sixty. This is a citizenry that is looking to governmental sources for the solution of its problems. I think they're going to look more to government and less we in the profession in hospitals doctoring and so on do more to stop what they perceive as their problems that's why I think we've got to pay more attention to consumer groups. We've got to get them into our camp with us to look at these problems with us and figure out a

joint way of solving them that will keep us private and voluntary which I hope will happen but with complete power in the hands of the doctor isn't it true that the patient is completely at the doctor's mercy search should there be some sort of institutionalized protection for the patient against these spiraling medical costs. Well there is some sort of bomb but. Perhaps Well there there is exactly that and in most of our urban teaching hospitals for example university affiliated teaching hospitals like this one we have full time chiefs of service who review the quality of the work going on on their service. There are types of patients practically daily. There are a multiplicity of meetings each week that review the quality of the care. We have a utilization review committee which reviews whether the patient should even be in the hospital or what was done to him was it necessary should he have had all those tests and that helps us to control costs. We have medical students House staff nursing students all looking at that patient and they're all keeping each other honest and vigorous in their best activities on behalf of the

patients so in fact there is quite a bit of protection for the patient and many of our urban Medical Center never count a good nurse out because she can exert counter pressure on doctors quite effectively and drugs. Also a very good administrator can do the same thing and furthermore there are boards of trustees who are supposed to field complaints from the community about the costs and the quality and the personal elements of care. So in many institutions they do a pretty good job I don't think they do is good a job as they might throw in this hospital for example we have nurses social workers administrators doctors and trustees who meet on a weekly basis to look at. The individual examples of what kind of care we're giving from the standpoint of quality and the necessity for hospitalization the cost of it and so on and all of that together in our doctors don't get high handed with our other people in the institution or vice versa. We've had a good example here though of where the doctors call the nurses on certain things and the doctors are right. We've had

examples where the nurses call the doctors on things. They all work productively and I think that the net result was a good one I agree that this institution is unique but it's institutions like this which are supposed to lead the way in this country and provide models for other institutions. And when we graduate to 300 doctors each year from this institution they go to other institutions and help to bring about certain practices that we've developed here. Doctor knows where the end of the program from this position as director of one of the most significant hospitals in the country what would you say is the future outlook for medicine in hospitals. In the last third of the 20th century for this country. Well I think first of all you're going to find is rapidly approaching a position where our urban hospitals are going to become a second line of defense and are going to be doing mostly acute and intensive care of work at three four and five hundred dollars a day quite frankly. And at that juncture you'll see developing what is developing right

now the public will be more concerned about our cost. The federal government which will be paying a good portion of these cost costs on the Pfaff and taxpayers will be joining us to keep them down and the union movement will be coming in the other door because they know that 70 percent of those costs are going into wages and salaries and fringe benefits. Therefore the hospital director is going to be walking a tightrope between the expectations of federal government and the people to keep costs down on one hand and the union pickets out of the front door on the other hand demanding that they go up so that wages and salaries can go up. I think that by the year 1975 1980 that our cost will not be a hundred dollars a day they're going to be closer to two or three hundred dollars a day and I am convinced that by the turn of the year 2000 they'll be at least 500 and probably closer to a thousand dollars a day if it keeps at the present trend but in the mean time we're going to be bringing about increased efforts to keep people out of hospitals to prevent disease to detect it's in its

incipient see and treat it for $10 in the home or the neighborhood health center and only the rare individual is going to need this very high cost lifesaving care. Well there's no question but that one cost that is increasing has been prevalent throughout this program and point of sound the audiences heard the jackhammers the pneumatic drills in the background just outside your window here in the trustees room of the Mass General Hospital. The sound of building and the costs of building more hospital building providing more beds for the American public. The idea of cost increase you've documented in this program Dr. Knolles. You've also added on a very happy note perhaps we will have fewer number of patients to be serviced and the average American hospital across the country due to programs which enable us to service patients in their homes or in satellite center within the city. Thank you very much for coming on this. Thank you.

Northeastern University has brought you Dr. John knows the director of the Massachusetts General Hospital discussing public medicine new prescription for the nation's health. The views and opinions expressed on the preceding program were not necessarily those of Northeastern University or this station. Questions I asked were the moderators method of presenting many sides of today's topic. Your program host has been Joseph R. Baylor Director Department of radio production. This week's program was produced and directed by Peter Lance with technical supervision by Michael ratio. Executive producer for issue and inquiry is Peter Lance. Issue an inquiry is produced for the division of instructional communications at the nation's largest private university. Northeastern University. Requests for a tape recorded copy of any program in this series may be addressed to issue an inquiry.

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