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Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received April 25, 2003; accepted May 5. Address correspondence to the author, 18961 Castlegate Ln, Santa Ana, CA 92705 (e-mail: rmfriede@uci.edu).
Index terms: Perspectives • Radiology and radiologists, socioeconomic issues
It is difficult to predict the future direction of medicine—much of it is not under the physician’s control. It is easier to describe the past—the changes that have occurred over the past 4 or 5 decades—and analyze those changes that have been of benefit to the patient and those that have not. I have previously discussed Relman’s (1) description of the three cycles in medical care. The first occurred between 1940 and 1960. This was the era of expansion of hospital facilities, increases in the number of physicians, new discoveries in science, advancements in technology, and rapid development of specialists in medicine. The second cycle occurred between 1960 and 1980 and was an era of cost containment. The cost of care, which exceeded 11% of the gross national product, led to regulation of payments, to diagnosis-related groups, and, finally, to managed care and health maintenance organizations (HMOs). His third cycle, which started in the mid-1980s, related to attempts to ensure quality of service, which some thought had decreased with HMOs, with evaluation of outcomes and establishment of effective quality control. This was an era related to quality and competence and was stimulated by public pressure.
As we enter the 21st century, we have entered what might be described as an era of automation and indifference, at least as perceived by many patients. This is an era in which health care has changed from the one-to-one relationship between physician and patient to the one-to-n relationship between physician and population. Medicine has produced its own version of smart bombs with literally amazing technologic developments during the past 30–40 years. However, medical practice, particularly HMO primary care practice, has diminished the very important personal relationship between physician and patient. In many cases, medical practice is now controlled by nonmedical personnel whose primary interest is cost containment and a positive bottom line. The physician-patient relationship is important to the healing of both disease and psyche. I am well aware of the need to use our resources carefully and to control spiraling health care costs. However, something is wrong with a system that depersonalizes medicine, supposedly as part of a social plan to benefit the majority of the population, and yet leaves approximately 43 million individuals lacking proper health care (2). Even those of us with contractual arrangements that provide health care coverage are at a disadvantage from the depersonalization of the system. After all, a large part of health care relates to the personal attention that our health care personnel give to and the interest that they have in our medical and social problems. Many primary physicians, overburdened with the volume required to maintain income, develop a cursory approach to the patient with a superficial examination and depend primarily on laboratory tests to define problems. This seems to be particularly true of young physicians who are entering managed care. Those physicians who want to develop a relationship with patients have to sacrifice income or extend their hours well into the evening.
I am not a psychologist, but I believe that the human relationship between physician and patient is a necessary part of therapy. If we do not think that our primary physicians have a personal interest in our well-being, we cannot relate to them. In some situations, it is nearly impossible for the patient to contact his or her primary physician, and the patient must rely on clerks or nurses for responses to questions. I have heard of several instances in which patients who are ill and desire to see their primary physician either are given appointments weeks later or are advised to go to urgent care clinics or emergency rooms by the nurse. The physician, who is protected by the administration and is faced with a tight schedule, never contacts the patient. This is certainly a symptom of a change in medical practice that severely affects the patient-physician relationship and is a major defect in managed care.
Where do we stand after 15 years of managed care? Initially, cost containment stopped the spiraling cost of medical care and reduced the percentage of the gross national product assigned to health care. Because managed care has developed its own bureaucracy, health care costs are again increasing. Managed care has expanded and improved preventive medicine but has depersonalized clinical care. Managed care has made life more difficult for those patients who need long-term care. As managed care became more profit oriented, with the virtual disappearance of nonprofit HMOs, a large segment of our population, estimated at about 43 million individuals, with no or inadequate insurance, have found access to care more difficult. I believe that the physician-patient relationship that would exist in national health insurance would not be worse than that which currently exists in HMO care.
There are fundamental differences in how individuals view access to health care. My belief is that health care is a fundamental right of every citizen and, therefore, a responsibility of our government. When I first stated this years ago, I received several responses. Most of the responses agreed with my statement, but some disagreed and stated that health care is a commodity to be purchased on the open market. If you agree with this latter statement, you will disagree with my whole approach.
I am well aware of the need to control costs in all aspects of our budget, including health care. How important is health care in relation to defense spending, other social entitlements, and tax cuts? What percentage of our gross national product should be allotted to health care? Is not health care more important than tax cuts? Is not financing health care as important as financing our world conflicts? As I noted in a previous article, we spend more on leisure enjoyment than we spend on health care (3). In 1999, we spent 22% more on recreation, restaurants, meals, tobacco, and travel (4). Perhaps 13% or 14% of our gross national product is not an excessive amount to spend on health care. Most of our legislators, who are aware of the financial effect and the negative corporate response, are against federal involvement in universal care and prefer that this be handled by insurance companies and venture capitalists.
I am a believer in a single-payer system provided by or at least regulated by the federal government. Some form of universal care is provided in every developed nation in the world except the United States (5). Why is it necessary to have dozens of different profit systems, many poorly supervised by states, to provide coverage when this should be the responsibility of our federal government? With these dozens of for-profit systems, we have no coverage for a substantial segment of our population. After all, why should for-profit institutions provide nonprofit coverage?
I am not an expert in health care, but it appears to me that we already have two working systems, Medicare and Medicaid. These could be adapted to provide a basic universal program to cover all citizens with access to health care. Because of our history in health care, we would need a layered system, which would allow individuals to purchase additional levels of access. Basic health care would have to include access to physicians, hospitals, and medications. The layered system would allow choice of physicians, specialists, hospitals, and a wider range of drugs. The fundamentalist in universal care would claim that offering additional advantages to some is unfair, but the additional layers would have to be purchased from national insurance companies and would not be provided by the government.
We have taken a major step from indemnity care to managed care, but we need to take the next step from managed care to universal care with a single-payer system. This will increase costs and, certainly, taxes, but we are currently spending about as much as or more on health care than do many countries with universal care (6). Perhaps this step will not cost as much as some fear. It is time to start working toward this end.
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