June 5, 1998
It is not the fault of our doctors that the medical service of the community, as presently provided for, is murderously absurd....to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity...and the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrown toe-nail receives a few shillings; he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.
George Bernard Shaw (1856-1950)
In the beginning (now where have I heard that phrase before?) doctors were mostly in the services of the well to do. Almost everyone else had to die or get well without the benefit of the medical profession. Delivering babies was the province of either midwives or grandmothers. Some women had the audacity to have their babies without any assistance at all. There were, of course, people who would now be called "native healers" or priests of one sort or another. Surgery was performed by barbers and almost anyone could set a broken bone. This resulted in a relatively large number of cripples.
Medicine gradually evolved to what it is today. While physicians are still relatively helpless in the face of diseases such as the common cold, and a variety of conditions associated with ageing, their ability to deal with injury and infectious diseases has advanced so much, that the physician of the past bear little resemblance to the physician of the present.
When I was growing up, the physician was paid directly by the patient. Often the amount charged was related to the financial status of the patient. A rich person was charged much more for a physician's service than a poor one. The country doctor often accepted his payment in chickens, produce or labor. In the cities, the teaching hospitals treated the indigent. It was part of the process for the training of physicians. The very high priced professors gave their services to the poor for no fee. Medical school professors were on salary and were also able to make money on the side by treating private patients. This is the way that it still is in most medical schools
The end of World War II saw the birth of the Blue Cross-Blue Shield system of medical insurance. This was called "the doctor's plan" since it was originally organized by, and for, physicians.In 1945, industrialist Henry J. Kaiser organized the Kaiser-Permanenty Medical Care Program. It was a non-profit HMO(health maintenance organization). It provided first-rate medical care at less cost than the fee-for-service Blue Cross. It had some advantages for doctors too. Physicians were salaried, and worked an 8 hour day. They were not available at all hours. Kaiser's doctors were not as well paid as the rest of the medical profession, but the advantage of being able to live a normal and regular family life overrode this for some doctors.
Starting in 1965, government-run Medicare provided medical insurance for people over 65 years of age. Medicare was passed despite the opposition of the American Medical Association.
One consequence of health insurance and HMOs was that the cost of medical care skyrocketed, while services have diminished. House calls are now a thing of the past.
It also became obvious that Kaiser's physicians, who were salaried, tended to order fewer unnecessary procedures and less surgery than did those who were paid for it. In other words, the profit motive has a profound effect on how medicine is practiced.
The new for-profit HMOs that are now growing rapidly, bear little resemblance to the non-profit Kaiser program. Their executives may be paid exorbitant salaries, even by industrial standard. Thomas Frist of Hospital Corporation of America gets an annual salary of $160,000,000. For that amount of money, a hospital could hire 1,600 physicians at $100,000/year, or 4,571 nurses at $35,000/year. A good deal of the money paid for medical care flows from the patient to these private enterprise bureaucrats, instead of to the physicians and hospitals. While the physicians may or may not deserve big bucks, depending on their competence, it is certain that those CEOs don't. If there is any relationship between the value of something and what is paid for it, I can't see how anyone is worth that kind of money.