Imagine a land of physician entrepreneurs. They own their offices, decide which hours they'll work and choose their patients. And, yes, get paid pretty well. They've never worked for a third party, never had to offer a discount, and never had to justify or explain anything to anybody except maybe to their own consciences. They're seldom in accord with each other — indeed the cliché is "three doctors, four opinions" — but on one thing they agree: This is the good life for physicians. Let's not change it.
America before the mid-1980s?
No, Britain in the year 1948.
The parallels are striking, although the British National Health Service's version of managed care had an easier start than its business-style counterpart in this country. If we consider the experience of the United Kingdom, we can learn from its successes — and its problems.
Three years before left-winger Aneurin Bevan started the Great Experiment of socialized medicine, the British people had struggled to the end of World War II — the war that followed the Great War that was going to end all wars. The country was impoverished. The servicemen and women returning to civilian life were used to corporate-style military medicine and had lost contact with their prewar private physicians. The nation was prepared to be frugal, ready for a simpler, more structured health care system.
What came forth was essentially the most mammoth managed care system in the entire world. Capitation was set at £1 per patient per year, a fee considered by the planners to be appropriate because low-key, stiff-upper-lip British patients were not thought likely to abuse the system. The capitation fee, equal then to about $2.80, was often described by physicians as "one pound sterling per skull." Small additional sums were paid for a few items of service such as immunizations and Pap smears.
Actually, in many ways Britain's nationalized health service has worked fairly well for several decades. But the pent-up demand broke upon physicians like waters from a bursting dam.
I remember being tested for my first aid badge in the Boy Scouts in 1948 and asking my longtime family doctor, the examiner, why he was moving his magnificent burgundy red leather chairs out of his waiting room and replacing them with wooden benches.
"Ah, Eric," he said wistfully and, as it turned out, presciently, "I'm King Canute getting ready for the flood."
It came. Demand for medical services jumped so fast once they were "free" that the National Health Service became a national sickness service. It still is. It's never had the resources to prevent disease and so ensure the nation's health. The demand for treatment for real and imagined disease virtually broke the bank.
For the last 48 years, the British government has tried in several ways to balance the books by reducing this demand:
It increased the modest cost of prescriptions — several times. The public responded by visiting the doctor even more for trivial illness because, despite the increase, a big bottle of antacid on prescription for simple dyspepsia was still cheaper than pharmacies' over-the-counter charge for the same bottle.
To reduce demand for night house calls for overworked primary care physicians, the government created a cutoff time in the evening and appealed to the public not to telephone after that time unless it was a true emergency. What happened? Of course! Lots of requests for instant house calls for nonemergencies came during the 15 minutes before cutoff time.
It built barriers to reduce requests for durable medical supplies, and yet, when the dust settled, it seemed every bedside cabinet had its hearing aid, its set of eyeglasses — and for a while, even its wig. These objects were not necessarily worn, but they were obtained because the patient was "entitled."
Asked the biggest challenge faced by one of the few new hospitals in Great Britain, the award-winning Queen Margaret Hospital in Fife, Scotland, Paul M. White, its chief executive, replied: "the management skills to meet the sustained pressure of inexhaustible demands on scarce resources. Ahead lie many challenges: demands for new services, medical 'breakthroughs,' new technologies, an aging population and a national shortage of trained staff."
Doctors in the front line see overuse as a problem, too. At my 35-year medical school reunion in 1993 I asked an old friend, one of Britain's GPs, why their waiting rooms were always full. Hadn't we finally got them all healthy after nearly a half century?
"Yes, but you can't stop 'em coming," he said. "They know there is such a thing as a free lunch. Health care here in Britain is a banquet, and every bugger in this country thinks he's starving."
His dispirited response reminded me of the cliché that in America patients hate their doctors, but in Britain doctors hate their patients.
I'm surprised by those experts in the United States who don't seem to understand that if medical care has low or no copayments people will use the service more. If there were no charge for going to the movies, wouldn't we go more often? If we could get a baby sitter at little or no cost, wouldn't she be in our house all the time?
Similarly, when my San Diego group added 17,000 Medicare HMO patients in 1986, we found a very high percentage of frail, elderly, ill patients amongst those joining. The patients who flocked to us then were not vital, healthy souls with little previous medical expense; they were, in contrast, those who had been overwhelmed by constant visits to their doctors and were bewildered by the paper work of Medicare Part B.
Of course, not all demands on medical services are unwarranted. Still, my sense of déjà vu prompts the questions: What can the British experience teach the United States? What might help U.S. managed care executives and their doctors reduce unfair demand?
First, we require a consistent national policy to educate the public on what is proper use of the medical professional's time. This will not be easy given the sophistication of the American consumer, the pervasive influence of pharmaceutical advertising, the "hot news!" stories constantly on television and the public's fascination with science-by-anecdote.
Second, society urgently needs to set up panels to take a long, hard look at the aging demographics of America and make decisions about what is appropriate medical treatment for a nation whose source of medical funding, like that of all other nations, is not infinite.
We don't have to declare, like the British, that we can't afford to cover dialysis in end-stage renal disease in patients over the age of 55. But we do have to decide, for example, that if we're going to spend $500 million for the latest method of diagnosing osteoporosis — DXA, dual energy X-ray absorptiometry — then we have to drop something else that's costing us money. I would have said "like doing so many cholesterol levels in the healthy elderly," except that treating cholesterol has become another New Deal.
Third, patients have to take some responsibility for their own health. If patients want to be covered for extras like the right to rove far afield late in their pregnancy so that they end up being delivered by physicians outside their plan, let them pay extra for the privilege. If a person wants to be covered for bone marrow transplant for breast cancer at a time when the procedure truly is experimental, let her pay an extra premium and, if she doesn't, let's find a way to silence the lawyers.
Fourth, we need to find a way to make patients and the popular press think that they are part of the team, that we need to conserve resources and, if we do, that we all benefit. We have to explain the trade-offs — publicizing, for example, that because we don't cover futile care for every brain-damaged infant we can afford to offer all kinds of supportive counseling for many dysfunctional families. We have to help our patients realize that those choices are their decisions, not ours.
Society has to confront those issues. Individual physicians can't and won't. Yet indulgent, soft-hearted America has never been good with hard choices — not in politics, not in health care, not in life.
There's a lot to lose, however.
This is the nation that 74 Nobel prize winners in physiology and medicine have called home (vs. Britain's respectable 22). Yet if it swamps its physicians with a flood of excessive demands, those in the front line in the trenches will drown.
Before their last breath they'll have become the equivalent of the overwhelmed British GP — like the one my American neighbor called on recently in England when he went, by appointment, to inquire about his aged mother still living there.
He sat down opposite the desk. The busy doctor looked up and said, "Yes?" His hand, holding his pen, was poised above the prescription pad. Forgetting that this was a patient's relative, the doctor was all set to do what he often must do to handle the immense demands on his time: scribble a prescription without even examining the patient.