Norman Rockwell gave us a mythical view of American medicine in one of his most famous Saturday Evening Post covers: family doctor of benign and merry countenance applies stethoscope to back of apprehensive lad with freckles.
The image conformed to a world in which the local general practitioner was still the patron saint of medicine -- someone to whom we could repair for the relief of everything from warts to whooping cough. Neither he nor we seemed to worry much about his bill.
That nostalgic picture may never have quite reflected the prevailing reality of health service in this country. But it is a reminder: there has been serious change in the last 30 years in how we regard doctors and how they treat us.
Health has become a national preoccupation in wealthy, self-indulgent, slowly aging America. And health care has became increasingly commercial, a confusing array of services that some people have for sale and others of us buy. The medical profession has become the prescribing and dispensing arm of an industry; it is part of business. You could call it the health business. One goal is to heal; another is to make a profit.
In Philadelphia several weeks ago, a drug company doctor -- Dr. Stanley Crooke of Bristol Myers -- was a featured speaker in a health care symposium for stock market analysts. His company manufactures cancer drugs. His remarks were entitled, "Cancer Chemotherapy: Market and Product Opportunities."
Among other things, he reminded the analysts that cancer is now "the second most common cause of death in the developed nations;" that as the incidence of cancer has increased in recent years, so has the number of oncologists, doctors who specialize in treating it; and that, "as this cadre of knowledge specialists increases in numbers, the number of patients receiving appropriate chemotherapy will increase (and is increasing) exponentially." And that took him to the bottom line, which was increased sales: "the impact of these changes is obvious," he said.
In another city, a busy surgeon tells a visitor of having been approached a few years ago by a large for-profit hospital company. The company offered to provide him with a custom-designed clinic in a hospital that it had taken over. The unspoken expectation: that he would then find it convenient to move all his patients there.
In the hospital business, a patient is a sale; "our definition of a sale is a patient stay," an executive of the hospital company says.The administrator of a not-for-profit hospital says almost the same thing: "The pressure on us is to use this place."
In a third city, a so-called "practice management consultant" tells of an ophthalmologist whose practice he reviewed. The consultant had been hired to help the eye doctor increase his income, and knew instantly one way to do it. The doctor had a below-average ratio of surgery to exams.
"In an hour of surgery you can make $700 to $800," the consultant explains. "In that same hour in your office doing three eye exams at $35 you will make $105."
"We look at it as a business," this consultant says. So, increasingly, do others. And business has been good in recent years.
In the years just after World War II, $1 out of every $22 that Americans spent went for medical care.
Today that figure is $1 out of every $12.
That means that the average American now works an entire month a year -- one-twelfth of his time -- to pay his or her share of the national medical bill.
He or she pays a large part of the bill in taxes. About 40 percent of this year's $200 billion in national health care costs will be met with public funds; health care costs are now one-eighth of the federal budget.
Part of the bill is also paid in the form of non-medical prices. The health insurance of auto workers is part of the cost of a new car. Both directly and in this indirect way, health care costs have been an important source of the high inflation of the last 10 years.
But they have also been an important source of income. There are about 320,000 doctors practicing in the country now. In the year that began Oct. 1 we will pay them -- and their nurses and suppliers, their landlords and their brokers -- about $40 billion.
The doctors are only the most visible provider of health services. The government estimates that almost 5 million workers are directly involved in providing such services today -- one U.S. worker out of every 20. And that does not count the supplying industries.
Americans will "consume" an estimated $250 million worth of suturing materials -- surgical thread -- this year. They will spend an estimated $54 million on artificial limbs and buy $112 million worth of hypodermic needles. Somewhere in the economy, people are being paid to make these things.
Those who make their living out of health are, willy nilly, a constituency for keeping health care costs high.
"It's not just doctors and hospitals," says Dr. Paul Ellwood, a former neurologist who now heads Interstudy, a respected health study group. "It's nursing homes, salesmen, banks, manufacturers, drug companies, franchisers, insurers, lawyers, accountants, medical schools, researchers. It's nurses and technicians and therapists -- each new piece of technology brings its own new jobs and 'professional accreditation' and turf.
"They're all organized, and they're all interested in increasing their share of the pie."
Against these interests, some resistance has developed. The government has been the leader, party because it pays so large a share of the bill. (Though it does not like to think of itself that way, the health industry is one of the nation's most heavily subsidized.) The Carter administration sponsored legislation in the last Congress to contain hospital costs. But Congress did not pass it (although hospitals put in a voluntary program of their own).
Some large corporations have also joined the resistance now, since they, too, pay a large part of the national medical bill through health insurance premiums. And large unions like the United Auto Workers are resisting. In trying to maintain and increase their health insurance benefits, they think they end up bargaining almost as much for doctors and hospitals at contract time as for their members.
But health care costs are still rising at a rate of about 12 percent a year, well above the 8 percent for prices generally; so far the resistance has had scant effect, for at least two reasons.
While everyone is opposed to rising health care costs in the abstract, no one wants there to be any stinting in his own care.
And more to the point, perhaps: only a third of the time do people any longer pay their own bills for health care in this country. Most bills are paid through insurance systems, the great banks we have created to spread out the costs of medical care and in effect anesthetize ourselves against them.
The Depression was one impetus for setting up these payment mechanisms. One of the first of them, Blue Cross, was created in the Depression, partly by doctors and hospitals themselves as a way of assuring payment. Its companion organization, Blue Shield, which deals more with doctor than hospital bills, was created in the 1940s.
A second impetus came during World War II, when the government restricted wages but let unions bargain for fringe benefits largely as they pleased.
Partly because of this, collectively bargained and other forms of private health insurance became common in the 1940s and 1950s. Commercial insurance companies competed with the non-profit Blue Cross and Blue Shield plans to write it.
The third great shaping event of the current payment system came in Congress: the passage in 1965 of Medicare and Medicaid. The government in these programs covered the two highest-risk groups in the population, the aged and the poor (though not all the poor; Medicaid varies by state).
To help win needed votes, however, Congress wrote the law so that Blue Cross and Blue Shield and to some extent other insurers would administer Medicare as the government's financial intermediaries. The government would not deal directly with hospitals and doctors; these familiar private insurers would.
That congressional decision created what some people now regard as a problem.
Under their own plans and those they administer for the government, Blue Cross and Blue Shield now pay almost 40 percent of the doctor and hospital bills in this country.
At the same time, the boards of directors of most of the Blue Cross and Blue Shield insuring organizations around the country are controlled by doctors and hospital people, who often hold their majority or set percentage of seats on the boards by law.
The staff of the Federal Trade Commission is investigating this for its price-fixing implications.
In short, the nation's doctors and hospitals have had an advantage over most other providers of services. To a large extent, they or people close to them have sat in judgment on their own incomes, since these insurers decide which fees and rates to accept and to pay.
They have been their own bankers.
In several states this has started to change. Some states, like Maryland, are developing strong hospital rate-control bodies. Several Blue Shield plans are clashing with the doctors who created them over the control and extent of doctors' fees.
NEXT: The new science of reimbursement.