The mad doctors of Massachusetts
Doctors say cost-cutting is ruining medicine, but can they offer a solution
that won't break the bank?
Medicine by Tinker Ready
The scene at Faneuil Hall on December 2 had all the trappings of a pep
rally, including balloons, skits, and sing-alongs. But the overflow crowd of
doctors, nurses, and medical students who make up the Ad Hoc Committee to
Defend Health Care had little to cheer about. They're mad -- really mad --
about changes to the medical and insurance systems in recent years that have
affected the way they deliver health care. They're outraged over the growing
number of uninsured patients. And they want to take another stab at change.
"Never before have I encountered such a breakdown in our system of care,"
committee chairman Bernard Lown, a cardiologist, told the audience. Lown shared
the 1985 Nobel Peace Prize with Dr. Eugene Chazov on behalf of International
Physicians for the Prevention of Nuclear War, an organization they cofounded.
The villain, according to committee members, is managed care, the system of
insurance coverage that was designed to cut the cost of health insurance and
solve the problem of double-digit medical inflation. Instead, they maintain,
"profit-driven" managed care is failing patients by giving bean-counting
insurance bureaucrats too much control over life-and-death medical decisions.
And they brought Harvard economist John Kenneth Galbraith to the Faneuil Hall
meeting to say it for them. "This is a situation that is inherently, basically
wrong -- that is inherently, basically cruel," he told the crowd. "Community
control of our health service is the only proper way."
Could this be the makings of the next wave of health care reform, a movement
paralyzed by the failure of President Clinton's Byzantine "managed competition"
proposal? Probably not. It is, after all, in the words of the Ad Hoc
Committee's executive director, physician Susan Bennett, a "small grassroots
movement with no money and very little political clout."
Still, the group reflects the state of near-panic among doctors coping with
the brave new world of medicine. Gone are the days when insurance companies
simply paid the bills. These days, cost-conscious insurers tell doctors such
things as what drugs they can prescribe, who qualifies for bone-marrow
transplants, and how much they're allowed to charge for procedures.
So we now have doctors -- members of society's elite -- complaining about
"profiteering," the "commodification" of health care, and the evils of the
corporate bottom line. Some of them, like David Himmelstein, a Cambridge doctor
and long-time advocate of national health insurance, are veterans of
health-reform battles of the past. Others are recent converts who are more
certain about the problem than they are about the solution.
"My most right-wing colleagues -- who used to say, `You communist bastard,
stop doing this' -- are now asking where they can sign up," Himmelstein says.
In fact, more than 2300 Massachusetts doctors, nurses, and other health workers
signed their names to "For Our Patients, Not for Profits," the group's founding
statement, which appeared a year ago in the Journal of the American Medical
Association.
"Mounting shadows darken our calling and threaten to transform healing from a
covenant to a business contract," the statement read. "The time we are allowed
to spend with the sick shrinks under the pressure to increase throughput, as
though we were dealing with industrial commodities rather than afflicted human
beings in need of compassion and caring."
The level of dissatisfaction is so high among doctors that even the staid
New England Journal of Medicine took note. "Many physicians are
dismayed," executive editor Jerome P. Kassirer wrote in a recent editorial.
"Some are frankly morose. . . . There has been an undercurrent
of unhappiness among physicians for many years, but the complaints seem more
widespread and more strident now."
This may be a case, though, of a cure that's as bad as the disease. The
stringent oversight of medicine came about as a result of runaway health care
costs, which doctors had a hand in driving up. The nation's overall tab for
health care -- including federal spending and private insurance costs -- rose
by between 10 and 12 percent every year from 1970 to 1990. An oversupply
of hospital beds, the high cost of drugs, and the advent of expensive new
medical technology such as the MRI helped fuel those increases. But so did
waste, unnecessary testing and treatment, and outright fraud.
For the past few years, the annual increase has been shrinking; it's now down
to 4.9 percent. Much of that decrease is due to limits on government
spending for programs such as Medicare. But analysts at the Health Care
Financing Administration, the federal agency that runs Medicare and monitors
national health spending, credit the rise of managed care with tempering the
cost of insurance on the private side.
Consequently, all this doctor angst makes Brandeis University health care
economist Stuart Altman uncomfortable. The crisis defined by the Ad Hoc
Committee to Defend Health Care, he says, springs not just from the drive for
corporate profits, but also from a well-intentioned, much-needed effort to
control costs. Altman, a front-line player in Washington-based health care
reform efforts, worries that by making "for-profit" managed care into a
"bogeyman," the doctors may be losing sight of what caused the problem in the
first place.
"I think we've got to get at the real issue -- do we want to contain the cost
of health care?" says Altman. The doctors say they do, but they also want a
system that allows for high-quality care, and coverage for the more than
40 million Americans without insurance. Just how to achieve that is the
$1.1 trillion question -- the amount of the nation's 1997 health care
bill. And although the angry Massachusetts doctors promise to play a role in
bringing back a professional ethic to displace the corporate ethic now taking
root, some critics say the doctors may be too narrowly focused to serve as the
catalyst for true reform.
The doctors' group is working toward a 2000 statewide referendum calling for a
ban on for-profit health care in the state and the creation of a statewide
coverage program for the uninsured. Lofty goals, but the last attempt at
universal health insurance in Massachusetts unraveled before it ever became a
reality. And most of the major hospitals and insurers in the state are
already not-for-profit.
In the meantime, the momentum is moving toward piecemeal solutions like the
"patients' rights" legislation pending in both Washington and Boston, which
would give patients more power to challenge insurance-company rules. But even
that approach can't seem to get out of the gate, in no small part because of
the $60 million spent by the insurance lobby to fight it.
In the meantime, health care consumers can expect the worst of both worlds.
Costs are beginning to creep up again, promising higher insurance premiums. And
horror stories about the excesses of managed care abound. The Faneuil Hall
meeting featured a parade of doctors, nurses, and family members with tales of
patients who were denied needed treatments or discharged from the hospital too
soon (video of the meeting is available on the committee's Web site, at
http://www.defendhealthcare.org/).
And, according to NEJM editor Jerome Kassirer, you're not likely to
find your doctors in very good moods these days, which in itself may not be
good for your health. "One thing we know," Kassirer wrote. "Disgruntled, cranky
doctors are not likely to provide outstanding medical care."
Tinker Ready, a freelance science writer living in Cambridge, can be
reached at tinkerr@mindspring.com.