Collectivism in Medicine; J. Orient

Jane M. Orient,M.D. COLLECTIVISM IN MEDICINE: An Exception or(l Hook? "hook" (as a verp) may have entered common parlance via popular books on transactiona1 analysis, the term (as a noun) derives from Lenin's Thesis on Tactics. The Communist International advises searching for and taking adv41ntage of all sources of discontent aI!llongthe masses. 1 Is Medicinea UniqueEndeavor? Essential to! the tactic of using medicine as a hook is to emphasize ways in which, it appears to differ from other actiNities. One inherent difference is asserted to be the influ ence of physici~ns on the use of ser vices. Though pljlysicians' fees in 1973 constituted only 19% of total health expenditures,2, it is believed that "physicians are in the unique posi tion of being aqle to regulate the de mand for their! services."3 They or der admission to the hospital, labo ratory tests, drl!lgs, and surgical pro cedures.

Although pe~ple can live without dishwashers and automobiles, or 335 336 THE FREEMAN June without hairdressers and teachers, medical care is felt to be a matter of life and death. In some cases, deny ing medical care may indeed be the equivalent of a death sentence. Therefore, health care has been de clared a "right," presumably as a corollary of the right to life. A "two class system of care" (such as one which provides public hospitals for those unable to pay for private care) is considered an infringement of "equal" rights. Because of its neces sity, health care must not be treated as a commodity. The doctor-patient relationship has been invested with an aura of the sacred. The physician must always act in the best interest of the pa tient, maintain his confidences, be have honorably, and take all care that is humanly possible in his treatment. Grubby business consid erations seem sacrilegious when the physician "holds your life in his hands." The idea of profits in propor tion to misery seems obnoxious.

Let us compare other human en deavors with medicine. The idea that physicians alone create demand for their services, though repeatedly proclaimed with great authority, is patently implausible. Physicians do not appear on television, advertis ing for patients. They employ secre taries to say: "I'm sorry, but the doc tor can't see you for three weeks." In contrast, many products would be without a market if advertising were not allowed. Automobile mechanics, insurance salesmen, and stockbro kers all may take advantage of our fear and ignorance to sell us more of their services than we really need. The most notorious group for creat ing a need for their own talents must be lawyers in legislatures and regu latory bodies, who invent laws no layman could possibly interpret. Limited Powers While doctors do sometimes save lives, their power over life and death is often exaggerated in the public mind. They neither give life, nor vanquish death. Their occasional triumph in the struggle with the Angel of Death is only temporary. A substantial part of the doctor's time is spent treating colds and back ache, which are hardly life-threat ening, or diseases" like terminal can cer or cirrhosis of the liver, in which he may offer comfort but not cure.

The need for a given medical service is seldom absolute. Many illnesses can be treated just as well at home as in the hospital; many diagnostic tests are of marginal value; and many treatments improve some what the probability of a good out come, at the price of introducing new risks of harm from the treatment it self. Not only do doctors have limited weapons against premature death; they are by no means the only pro viders of the necessities oflife. If their 1982 COLLECTIVISM IN MEDICINE: AN EXCEPTION OR A HOOK? 337 services are conscripted with the justification of the right to life, then what about those who produce food and shelter, which are continual, not merely episodic needs? And while the physician has the responsibility of trying to save the sick and injured, how much heavier are the responsi bilities of those who can kill people in the best of health, such as engi neers who design bridges or power plants, airplane pilots, and mechan ics who repair brakes.

Marketable Qualities Health itself is not a commodity; it cannot be purchased for any amount of money. Things which can be purchased include drugs, diag nostic tests (and the equipment which makes them possible), and the time of people with expertise. Medi cal devices do not undergo sponta neous generation. Since somebody must invest money in creating them, to say that one person has a right to their use is incompatible with an other's right to his property. Medi cine is labor intensive. The nurse, the x-ray technician, the electrician, the cook, and the janitor must be paid, or they stop coming to work. Even the doctor must earn a living, and to take in laundry would inter fere with the ability to see patients. Because the doctor intervenes in areas related to the patient's physi cal and spiritual integrity, and be cause the patient is often impaired by sickness or anxiety , a violation of trust in the doctor-patient relation ship is particularly reprehensible.

Nevertheless, •the fundamental de mands made on the doctor are not unique. Bankers and lawyers must maintain confidences and put the interest of their clients ahead of their own. Professors must refrain from seducing students. Plumbing con. tractors must give honest estimates and do careful work. Honor is re quired of men of every calling in their relationships with others. Medicine is aquasi-priesthood only to the extent that magic is involved. In fact, magic ~nd art remain impor tant ingredients in healing. How ever, patients rightfully demand science and technical skill in addi tion' and for tp-ese payment has tra ditionally been expected. (If technol ogy become$ the only aspect of medical care !that is well compen sated, the sciepce fiction writers may be prophets: In The Empire Strikes Back, all the' doctors appear to be robots.) Do doctors ireally profit from pa tients' misery? If the doctor deliber ately made the patient sick, then the accusation w!ould be just. Bakers don't profit from causing human hunger, but from relieving it.

Plumbers don't profit from the exis tence of human needs for drinking water and waste disposal, but for providing san~tary means for meet ing them.

338 THE FREEMAN June The ProfitMotivein Various PracticeArrangements To condemn the profit motive in medicine is a hook. By logical exten sion' one must condemn it every where. Yet the question .is not whether the profit motive will oper ate in medicine, as in any field of human action, but how, and to whose advantage, it will work. Profits are incentives, and may consist of money, power, prestige, or leisure time. Are incentives in a market economy more likely to benefit the patient than those in a socialized one? Aren't most hospitals and clinics nonprofit? Or weren't they before the intrusion of big health care corpo rations? Although many excellent voluntary hospitals exist, their non profit status does not exclude big re turns to some people affiliated with them. Returns may not be forth rightly called profits. For example, a dapper young man with a degree in social science is planning a health awareness program intended to pre vent illness by counseling people about their lifestyle. "It will be non profit," he emphasized.

"Oh, how will you make a living?" "I'll get a salary, of course." "What's the difference between your salary, and my taking home the profits of my business?" A benign smile was the only an swer. One difference, of course, is that the salary is paid regardless of whether or not there are profits. If income does not exceed expendi tures' then let the equipment sup pliers, the landlord, and the bank take the loss. Another difference is that he'll be charging more to tell people they are fat and flabby than I ask for a complete history and physical examination. Furthermore, he will not be paying personal prop erty or business license taxes. Given that doctors must earn a living (albeit not so much money that they must flaunt their conspicuous consumption), why should the pa tient want to pay him directly for each service, instead of by salary? The fee for service may encourage the doctor to prescribe unnecessary treatments. Unquestionably, some unscrupulous doctors make a lot of money from useles8 injections.

One reason for payment for extra services is that people are some times willing to do for money things they wouldn't do for love. Examples incl ude driving to the emergency room at midnight, listening to pa tients with endless vague com plaints, or looking up a bleeding rec tum on Christmas Eve. The tendency to "buff and turf' when confronted with an unpleasant and perhaps fu tile task is only human nature, es pecially when shirking is rewarded as well as volunteering. The importance of the fee as part of the treatment was first recognized by psychiatrists. If the patient hasn't sufficient investment in getting bet1982 COLLECTIVISM IN MEDICINE: AN EXCEPTION OR A HOOK? 339 ter, he may be evasive about coop erating with treatments such as psychoanalysis, which is demanding and painful. Perhaps the unshak able faith patients have in the en capsulated lake scum found in health food stores or in the bizarre pre scriptions of the quack is related to the outrageous price they pay. Free medicines often accumulate, un tried, in the cupboard.

The Patientas Employer The most important advantage to the patient in being responsible for his own bill is that he thereby be comes a customer, the physician's employer. While the physician is as sumed to have greater knowledge, the customer ultimately makes the decisions. If not satisfied, he may freely seek advice elsewhere. Al though the physician at times may be tempted to accede to harmful re quests, to avoid losing business, the challenge to his integrity is no greater than in a different system, where the threat may be a letter to a congressman. Just as an honest contractor may have to say "I won't put the roof on that way because it will leak; either do it my way or find another contractor," the physician can suggest finding another doctor. Both physician and patient are pro tected when they have freedom of association. The beneficiaries of public medi cine are no longer customers, but consumers. Unable to exert their in fluence directly with their dollars, they must be represented by a pa tient advocate.' The relationship be tween patient ~nd physician may in fact be involuntary for one or both parties. The agency dispensing the paycheck intrudes, dividing the physician's loyalty. The consumer may be considered an adversary of the agency, if he demands more than his "fair share" of services, while the physician is held responsible for preventing "overutilization." The doctor is the "gatekeeper" to expen sive consultations and diagnostic tests. The pati~nt has an investment in assuming aisick role, since more services and attention become avail able to him without additional charge. In a~repaid arrangement, that's the only' way to get his mon ey's worth. If the consumer is dis pleased, he cannot fire the physician as the customer would, but can com plain to the o~budsman, the chief of staff, or his s~nator. His influence may be negligible, or magnified out of all proportion.

Although many wish that medical care were aloof from the market place, market' phenomena invari ably occur even as efforts are made to insulate health services from market pressures. As the price bar rier is removed, demand skyrockets. Sitting in the: waiting room at the local Veterans! Administration hos pital reminds! one of the gasoline 340 THE FREEMAN June lines, and many people withdraw from prepaid health plans because of the lengthy waits. Waiting time seems inversely proportional to the price of goods or services offered. People in queues have a natural an gry reaction: they demand some au thority who will see that the greedy providers allocate resources more equitably. Somebody must set up a priority system, or print ration tick ets. SubsidizedDemand While complaints arise that med ical care is still not adequately available to some, others cry that al ready we spend too much on it. Few recognize the explanation: people are always less thrifty when spending other people's money than when spending their own. In collectivized payment plans (whether govern ment or insurance plans), some way of controlling expenditures is clearly imperative. Insurance companies have discovered the price of social izing risks while individualizing benefits. Though providing for ca tastrophes by means of insurance is responsible and rational, even this approach entails moral hazard, in that beneficiaries may try to extract more from the insurance than is jus tified.

Fire insurance may reward arson, and health insurance may reward disability. 4 To attempt to insure rou tine expenses compounds the problem. A patient who really doesn't need an x-ray may want one any way, "just to be sure," because the insurance will pay for it. The pa tient who says "spare no expense" is seldom planning to pay the bill him self. While our society encourages people to become risk-averse and de mand a Cadillac insurance policy, the Chevrolet makes equally good sense in insurance and in transportation. The insurance premiums are a given. If one chooses a minimum policy for disasters, and invests the difference in premiums, with luck one may have a profitable investment. If not so lucky, routine out of pocket ex penses may still cost less than a de luxe policy. Cost-ControlMechanisms Having the customer pay a greater part of the bill is generally not the favored proposal for controlling costs or stimulating competition. Usually some type of prepaid plan is envi sioned. Not only are the risks to be socialized, but also the benefits. The availability of services is to be based on cost benefit analysis. Since soci ety pays, society must benefit. Are pneumococcal vaccines to be cov ered? Let us calculate the cost in curred by society from x preventable cases of pneumonia. Lowered pro ductivity, expenses for x-rays and antibiotics, and even some deaths will occur. Is this price greater than that of y immunizations? The anal1982 COLLECTIVISM IN MEDICIN1H:: AN EXCEPTION OR A HOOK? 341 ysis is much more complicated than the process of saying: "This vaccine reduces your chance of getting pneumococcal pneumonia. Is it worth $15 to you?" The former also multi plies many times the impact of an error in calculation, which must be based on uncertain data.

Some of the cost control (ration ing) mechanisms in prepaid or pub lic health plans are administrative. An algorithm may be devised, di recting that a chest x-ray shall be ordered if (and only if) certain indi cations are present. The physician or other provider, such as a nurse practitioner, may deviate from the recommendations, but will have to justify his action if audited. A "has sle factor" may be introduced. At a Veterans Administration hospital, the signature of the chief of service was required on all requisitions for brain scans, when it was felt that that service was being ordered too often. If the consumer's incentive to save money has been eliminated, why not invent one for the providers? Many health maintenance organizations have done just that. Instead of pay ing people for doing tests and per forming services, they are paid for not doing them. Money that is bud geted but not spent may be divided up among the physicians as a bonus.

The profit motive is neatly· turned around. Unless we assume that pre paid plans attract only physicians of sterling char~cter, surgeons who previously wel1e tempted to do un necessary surgery may now be re luctant to do operations from which the patient wO\illdbenefit. When entrusting planning and decision-making to a central agency, one assumes that the planners are smarter than ,individual practitio ners and, most ~mportantly, have the right values. N~turally, they may not correspond to the values of certain patients. As 0Ile Veterans Adminis tration physician said about "too many" hernia operations: "Let them wear a truss." I have yet to find a patient who p~eferred that alterna tive. All rules aIlid regulations can be circumvented by ingenious people. If Medicare doesn't cover custodial care, the doctor can lorder an intravenous feeding, and clilange·the category to skilled nursipg. Since Medicare doesn't cover housecalls to give ene mas or transportation for outpatient diagnostic test~, the patient may elect to be admittetl to the hospital for some x-rays. CQstcontrol devices may ultimately increase costs, as people respond to incentives the planners hadn't recognized.

Should the Doctor Be a Slave, a Keeper, or a iServant? Collectivism in medicine will un doubtedly cha~ge the doctor-patient relationship as well as altering the distribution of services. Such pro342 THE FREEMAN June posals are based on the idea that medical care is a right. The strategy ofthis hook is to divert attention from the question of the impact on per sonalliberty, by not mentioning the duty corresponding to the right. Physicians potentially become slaves, with the amorphous public (repre sented, of course, by an authority) as the slaveholder. Rather more likely is that they will become the keepers, depending upon how much influence they exert on the central planners. An ominous development in the medical literature is the frequent use of the term "noncompliant." More familiar in its use by bureaucrats regarding adherence to regulations, it now refers to patients who don't take their medicine or follow their diet.

The emphasis placed on the im portance of lifesty Ie for health has disturbing implications. Normally, I am not inclined to care about how much my neighbor drinks, smokes, or exercises. But if I'm paying the intensive care bills resulting from his gastrointestinal bleeding, emphy sema, or heart attack, my interest in his private life mounts. In Com munist China, living a healthful life is considered a patriotic duty. Ev eryone becomes his brother's jailer, as he is taught to be responsible for the behavior of family and neigh bors. The physician will be the servant of whomever pays him (or risk his livelihood). All contracts are vali dated by "consideration," which is usually money. The same writers who condemn the avarice of physi cians under fee for service ask us to rely on the altruism of physicians under other economic arrange ments. As patients decline to pro vide the consideration, they relin quish their decision-making role, which many agencies are all too ready to take over.

Conclusions A hook is a condemnation of the status quo, without critical exami nation of the alternatives. Before dismantling our fee for service econ omy, we should outline our goals and see whether other systems can meet them better. Is the goal to reduce unnecessary surgery? The rate of tonsillectomies in China is very high, without the incentive of Blue Shield.5 Do we want to reduce hospital stays? The Mayo Clinic, a totally fee for service orga nization' has succeeded as well as prepaid plans. 6 The average length of stay is 15 days in the Soviet Union, compared with five in the United States. 7 Do we wish to distribute ex pensive equipment fairly? The re gional planners put the CT scanner, the cause celebre for cost contain ment, at St. Luke's Hospital rather than at Harlem, where head trauma victims are more commonly seen. As a result, in a single year only 14% of 1982 COLLECTIVISM IN MEDICINE: AN .EXCEPTION OR A HOOK? 343 the 1870 patients in whom the test was recommended actually received it under a "sharing" arrangement. 8 Are we concerned about reducing fear? Patients in the Soviet Union do not have to fear the cost of a se·· rious illness-they have prepaid in stifling if unacknowledged taxes. In stead, they fear the indifference of the doctor, the filth in the operating room, and shortages of the most ba sic drugs and supplies. 9 Are we in terested in making medicine re sponsive to consumer demand? In the Soviet Union, the logical endpoint of the total institutionalization of medicine has been reached: the Hip pocratic Oath is forbidden, because it might interfere with the physi cian's loyalty to the employer, the state. 10 "What about the poor?" is the most pervasive, recurrent question of the supporters of socialism. While med icine has a long history of helping the unfortunate, the results are called "inequitable," and the method "patching" or "reformist."ll Marx ists use our duty to help the poor as a hook for undermining the entire economic structure, with no concern for the observable consequences of worsening the plight of the poor and multiplying their number.

Once health benefits are social ized, on the basis that medical care is different from other economic ac tivities, the fundamental similari ties will become apparent. To be logically consis~ent, collectivization must be extended to other enter prises, or undpne in medicine. The former course is more probable; turning away I from collectivist mo rali ty is a pHenomenon rarely ob served to date. The hook is indeed a fearfulweapo~. Ii -FOOTNOTESIJames L. Tysom, Target America (Chicago: Regnery Gateway,!1981), p. 19. 2Cotton M. Lin<ilsay, ed., New Directions in Public Health Care: A Prescription for the 1980s (San Francisco: Institute for Contemporary Studies, 1980), p. 194. 3D. S. Brody, "Tpe Patient's Role in Clinical Decision-Making,'~ Annals of Internal Medi cine, vol. 93, 1980, pp. 718-722. 4GeorgeGilder, Wealth and Poverty(New York: Basic Books, 1981~, p. 108. 5William V. MGDermott, "The China Syn drome," Archives qf Surgery, vol. 116, 1981, pp.

245-246. 6Fred T. Nobrega, Iqbal Krishan, Robert K. Smoldt, et al., "Hospital Use in a Fee-for-Ser vice System," Joulrnal of the American Medical Association, vol. 2~7, 1982, pp. 805-809. 7William A. Kn~us, Inside Russian Medicine (New York: Everest House, 1981), p. 123. 8John C. M. Brust, :P. C. Taylor Dickinson, Edward B. Healton, "Failure of CT Sharing in a Large Municipal Hospital," New England Journal of Medicine, vol. 304, 1981, pp. 1388 1393. 9Knaus, op. cit. 10M. G. Field, Doctor and Patient in Soviet Russia (Cambridg~, Mass.: Harvard University Press, 1957), p. 1714. llHoward Waitzkin, "A Marxist View of Med ical Care," Annalsioflnternal Medicine, vol. 89, 1978, pp. 264-278.