MEDICAL COSTS – WHO SHOULD PAY?
Gerald M. Peterson, M.D.
During World War I and shortly thereafter an effort was made to institute compulsory health insurance in the United States. For the most part, the discussions never got out of the committee stage but a plan in the New York legislature was even passed through the Senate. The A.M.A. actually participated in preparing a “Standard Bill”. But opposition triumphed and the movement died.
The movement has been resurrected. Five main plans are presently being sponsored and one of them, The Reuther Plan, should give the average American doctor the shakes.
I do not believe this society has had a paper on the history of health insurance. It was my thought that a brief review of the background of our present insurance practices would be of interest. In the coming months we must all give much thought to the future of health insurance. Meanwhile we should make every effort to implement our present plans successfully.
The subject I have chosen has proven to be so diverse and complicated that I can really do little more than introduce it to you. I have as my guests people who have more experience and knowledge and I know they will greatly illuminate the subject by their discussions. I hope they will help me answer any questions.
Early History of Health Insurance
Ancient Chinese culture contains references to provisions for medical care. The Greeks had what might be termed socialized medicine, for they hired city physicians paid by taxes to provide medical care to people without physicians. Through the centuries rulers of various categories probably permitted their personal physicians to provide care for the members of their courts. The first occupational group provided with disability and sickness benefits was seamen. In 1693 the French, and soon thereafter the British, took steps to care for their injured seamen. In 1798 the U.S. Marine Hospital Service was instituted to care for disabled seamen. The funds used were deducted from the seamen’s wages.
The Industrial Revolution really created the background for planned prepayment of medical costs. Great numbers of people were compressed into urban groups where they shared the vicissitudes of factory work, crowded housing, intermittent layoffs, inability to work because of injury or illness. They apparently first pooled resources for recreational activities but soon recognized the value of setting up funds to help workers and their families when injured or ill.
In England the Friendly Societies were thus formed. In 1793 the British Parliament passed an Act to assist the formation of these societies – probably the earliest enabling legislation on record. The idea spread to the Continent in the form of sickness funds. In the U.S. many similar Fraternal and Mutual Benevolent groups were formed. One of the earliest mutual aid societies was formed in Philadelphia. It was set up by a group of freed slaves in 1787 and was called the Free African Society. They banded together for religious as well as mutual aid purposes and started the Masonic Order. They hired lodge doctors to care for their sick. An outgrowth of this group was The African Insurance Company formed in 1810 in Philadelphia.
Between 1793 and 1867, 38,000 mutual benevolent societies were formed in the U.S. They had variable success and some 16,000 failed because of poor planning and management. In 1819 a law was passed in Philadelphia requiring the services of actuaries or persons skilled in calculation. Up to this time anyone could form a beneficial society at will. Standardization followed. Some states passed legislation that restricted the ease with which such societies could be formed.
By 1900 there were 2,500,000 members with insurance of over $4,008,000,000, and $38,000,000 in benefits.
Some of these societies have continued into modern times – a good example being the French Mutual Benevolent Society formed in San Francisco in 1851.
Meanwhile commercial insurance companies had entered the field of health and accident insurance. In 1847 The Massachusetts Health Insurance Company issued sickness insurance. The idea was income replacement rather than payment of doctor and hospital bills. The Franklin Health Assurance Company of Massachusetts offered the first accident insurance in 1850. In 1863, Travelers Insurance Company offered accident coverage. In 1907 the first non-cancelable, guaranteed renewable accident and sickness insurance was made available by the National Masonic Provident Association of Mansfield, Ohio.
There were but a few of the companies entering the field of health and accident insurance. Some had limited coverage, such as injury in railway travel only. There were ups and downs and some failures but their experience ultimately permitted the development of plans which were broad in scope and adaptable to varying needs and changing conditions. More will be said about commercial insurance later.
In Europe between 1860 and 1911, a trend developed toward government involvement in health insurance. Peter the Great of Russia established the Zemstvo medical system in 1864 to provide medical care in rural areas. It was run by provincial or district councils called Zemstvo, and was tax supported. Hospitals were built and physicians appointed. – Bismarck is credited with starting modern socialized medicine in 1883 when he established compulsory insurance for industrial workers. Alas, he was motivated by political rather than sociological considerations for he was competing with the Marxists. Similar plans were instituted in Austria in 1880, Hungary in 1891, Luxemborg in 1907, and in Switzerland and Great Britain in 1911.
Speaking of 1911 – that was the year Workman’s Compensation began and within a few years many states had passed such legislation. Provisions were made for medical care necessitated by occupational accidents or diseases.
Early Western Group Practice
Between l850 and the early 1990’s, the settlement and development of the West led to the establishment of what were called hospital associations. The railroads served unsettled country and the companies had to bring in doctors and, at times, build their own hospitals, if medical care was to be available. To finance the care the employees organized the hospital associations paid for through fixed periodic deductions from their wages. The Southern Pacific employees organized their association in 1869, The Missouri Pacific in 1876, The Northern Pacific in 1881. By 1930, 27 steam railroads had associations that provided care for 500,000 employees. Lumbering, coal, and metal mining industries developed similar arrangements. Doctors, singly and in groups, contracted to provide the medical services. These arrangements inaugurated two new variations in medical practice. First, contract medical practice was started and secondly, doctors began group practice. – Organized medicine opposed these practices on the grounds that patients did not have free choice of physician, the doctors were being exploited, and medical care was likely to be inferior without the usual doctor-patient relationship. Later some of the hospital associations came under lay control and the charge of corporate medical practice was made.
The doctors in the sparsely settled western states had difficulty in setting up sustaining practices in competition with these hospital associations. Doctors having contracts were looked down upon and dismissed from county medical societies. In 1912, the Pierce County Medical Society in Washington prohibited its members from any contract practice. Finally, the doctors decided to fight fire with fire. In1917 the same Pierce County Medical Society formed a medical bureau, actually a stock company owned by the participating doctors. They contracted through employers to provide medical care on a prepaid basis covering hospital and associated costs and when these expenses were paid the balance of funds was divided amongst the doctors on a prorated fee basis. By 1934, 14 other counties in Washington had similar bureaus. In 1930, a similar plan was set in Salem, Oregon, and in 10 years 10 other Oregon counties had such bureaus. In 1933, at the height of the Depression, the Kings County Medical Society met in Seattle to consider establishing a medical bureau. And Dr. Morris Fishbein, then editor of the J.A.M.A., hastened to Seattle to dissuade them from such a move. Even in his presence, they unanimously approved the proposal. Today, that group, modified somewhat, is called The Seattle Group Cooperative of Puget Sound.
Wartime discoveries in the fields of medicine and surgery became widely applied after World War I. New diagnostic and therapeutic services were introduced leading to increasing specialization in the practice of medicine. There was increasing longevity and thus greater numbers of patients suffering from chronic illnesses were encountered. There were further extensions of modified forms of group practice amongst the Industrial Groups. Some of these were supported by the employees, others jointly by the employers and employees, and in some instances, such as the Endicott Johnson Corporation, the employer provided medical services for the employees.
The Blue Cross
The crash of the Stock Market in 1929 and the years of depression that followed had profound influence on the development of modern health insurance, or prepayment, as we know it. In the early 1930’s, unemployment was widespread and the vast majority of the population had poor means with which to pay doctor and hospital bills, with the result that many hospitals became seriously in debt, some of them had to close, and even many doctors were on relief. In 1929 in Dallas, Texas, when Dr. Justin Ford Kimbell became Executive Vice-President of Baylor University, he found that unpaid medical bills of the teachers were among the large accounts receivable at the University’s medical facilities. He was instrumental in instituting a prepayment program for these teachers. On December 20, 1929, the prepayment plan went into effect. Seventy five percent of the 1,500 teachers chose to protect themselves in this voluntary plan at a total monthly cost of fifty cents. For $6.00 a year they were entitled to the use of a semi-private room and other services for twenty-one days at the Baylor Hospital. The next 344 days the subscriber would enjoy a one-third discount. Certain contagious disease's – tuberculosis, venereal disease, mental and nervous diseases - were excluded. As soon as the program for the teachers was found to be operating successfully, other groups in the Dallas area were permitted to join. By 1934, there were 408 participating groups with some 23,000 persons enrolled.
A prepayment plan had been established in 1921 by a single hospital in Grinnell, Iowa, and had successfully provided medical care on a prepayment basis. The venture into prepayment at Baylor University received national publicity as a result of a visit by Dr. Rufus Rorem, then of Rosenwald Foundation. The news of a successful prepayment plan was of great interest to hospitals everywhere because of the severe financial crisis which they all faced. In 1932 in Sacramento, California, a city-wide plan was instituted with all hospitals participating and in 1933 a hospital council for Essex County New Jersey was established. By 1935, there was a general shift to community-wide hospitalization plans rather than individual hospital plans. In 1933 in St. Paul, Minnesota, Mr. A. E. VanSteenwyk founded the Hospital Service Association of St. Paul and adopted a blue cross emblem for this plan. In 1939, the American Hospital Association officially adopted the blue cross emblem to identify plans which had been approved by the American Hospital Association.
In 1933 in New York City, a plan for prepayment was proposed but the State Superintendent of Insurance ruled that such a plan would be the conduct of the business of insurance and subject to all the laws applicable to insurance companies. All of the other prepayment plans which had been set up had been regarded as devices for providing hospital services rather than insurance. In 1934, the New York Legislature passed legislation enabling the hospital plan to be set up as prepayment for services rather than insurance and soon thereafter the various states also passed enabling legislation to set up the nonprofit payment plans patterned along the Blue Cross line.
In 1936, the Julius Rosenwald Fund granted money to the American Hospital Association to establish a Commission on Hospital Service. The function was to inform, advise, and otherwise assist hospitals or communities in establishing plans for the prepayment of hospitals services and to serve as a clearing house for information gained by experience in these various plans. By 1947, eighty-one plans had been approved with enrollment of 24 and one quarter million people.
Medical society sponsored prepayment of physicians’ services was started more than a decade before the antecedents of the Blue Cross Plan. In 1917, the Pierce County Industrial and Surgical Bureau of Tacoma, Washington was set up, thus establishing a group of doctors under the sponsorship of the County Medical Society. As already stated, many more county groups were formed in the states of Washington and Oregon.
In l939, the California Physicians Service was instituted and in the same year the Michigan Medical School was organized. These two groups were more or less state-wide in their distribution and are considered, although not so called at the time, to be the actual beginning if the Blue Shield Plans. Both offered service plans which were quite comprehensive in there scope, but they both ran into serious financial difficulties because of unexpected high utilization which they encountered. They soon had to restrict their benefits and to set ceilings and in effect tended to change from a comprehensive service to an indemnity plan. They did not fail because of the agreement with the physicians involved. The physicians had agreed to accept less than full fees in payment for their services if the plan was unable to meet its bills.
Between 1940 and 1942, plans of a similar nature were started in nine more states. In 1942, the American Medical Association endorsed the principle of medical service plans. In New York state in the city of Buffalo in 1939, a plan was instituted which was actually called the Blue Shield Plan and this was the source of the name which became applied later to all of these plans. In 1945, the House of Delegates of the A.M.A. directed the trustees of A.M.A. to establish a nationwide organization of locally administered prepayment plans sponsored by local medical societies. The Associated Medical Care Plans, Inc. was thus formed in 1946. In 1950, the name was changed to Blue Shield Medical Care Plans, Inc. and another change in the name occurred in 1959 when the name was changed to The National Association of Blue Shield Plans.
Insurance Company Plans
You will recall that in 1848 a health and accident insurance plan was offered in the state of Massachusetts and that subsequently many insurance companies offered accident insurance. The insurance companies extended the coverage gradually over the years and some of them in 1903 offered coverage for surgery, some for hospitalization and even for medical treatment. In the 1930’s when the Blue Cross Plans were beginning to sow a successful operation, the insurance companies began to extend their activities into the field of medical care costs. By the end the 1940’s the insurance companies were well-established in the field of medical care coverage. Hospital and surgical expenses were being included and the insurance companies were covering larger numbers of people.
The insurance companies had had a long experience in writing accident insurance and they progressed slowly into the field of medical care insurance. Whereas Blue Shield and Blue Cross, by virtue of the legislation which permitted them to function as nonprofit institutions, were required to give protection to all people who apply, the insurance companies could be more selective and more experimental. In 1948, the Liberty Mutual Insurance Company began an unusually comprehensive type of coverage for a group of G.E. executives and in 1949 the first major medical expense program was offered. It attracted a lot of attention but was not seriously advanced until after 1952. Its apparent success at that time established the value of this type of program and by 1959, twenty-two million people had enrolled for this type of coverage under the various insurance companies.
By 1951, the insurance companies had surpassed the Blue Cross Plans in the number of persons protected against hospital expenses. The major insurance companies wrote group policies only until the 1950’s, and then some cautiously began to write individual policies.
Other Types of Plans
Contract practice by groups of doctors, started in Washington and Oregon, has been copied and modified by private groups as well as by medical society organizations. Doctors Ross and Loos started a private group in Los Angeles in 1929 which will serve as an example of a very successful group. They offered hospital, surgical, and medical care at the rate of $2.50 per member per month. Their contracts were limited to groups of patients at first but in recent years they have taken patients on an individual basis. They still function and in 1959 had a staff of 131 doctors with a patient enrollment of 128,000. Another California group was the Permanente medical group which is now associated with the Kaiser Foundation. A group organized to care for farmers was formed in Elk City, Oklahoma. In 1937, the Group Health Association was formed in Washington, D.C., to provide medical care for Federal employees. The Hospital Insurance Plan of Greater New York was formed in 1946 as a means of caring for city employees but soon was extended to include other groups with incomes under $5,000.
By 1946, fifty-six prepaid group practice plans were functioning. Hospitalization for some of these groups was arranged through Blue Cross. Medical service was provided by panels of doctors in contrast to the free doctor choice permitted by Blue Shield. In recent years, free doctor choice has been arranged as with Group Health Insurance, Inc. of New York and the Seattle Group Health Cooperative of Puget Sound.
Group practice is still opposed by organized medicine and in some states, laws impede or prohibit such practice. There is increasing demand by union and industrial groups for group practice arrangements.
Aftermath of World War II
Since World War II there has been a steady increase in the numbers of people covered by some form of insurance or health cost prepayment. One factor in this increase has been the extension of unions more widely throughout industry. Health and welfare provisions have become important bargaining points between unions and employers, especially since employers have had to pay an increasingly large share of the expense for these benefits. The public generally has become more health insurance conscious and the idea that health care is a civic right is now generally accepted. The concept has been implemented by the Medicare and Medicaid programs, which I will not discuss. These are the main factors in the overwhelming utilization of medical facilities, especially hospitals. It is an unfortunate circumstance that present insurance practices, with a few exceptions, demand that a patient be in a hospital if payment is to be made for such services as X-ray, laboratory, drugs, etc. The point is that many patients are hospitalized who could be cared for elsewhere. They help swell the hospital population.
The problem of providing coverage of outpatient X-ray and laboratory services, so that hospital admission or patient days may be reduced, has been the subject of several recent experiments. The Maryland Hospital Service agreed to pay for pre-surgical EKG, laboratory, and X-ray examinations. The examinations in question were to be done reasonably soon before admission. The average length of stay for surgical patients was reduced with improved efficiency of handling of such patients.
Another study, also sponsored by Maryland Hospital Service, Inc., dealt with a group of Baltimore steel workers. Providing certain outpatient studies actually led to an increase in hospital admissions.
The Kansas Blue Cross/Blue Shield attempted another study with and effort at controls. They permitted extensive outpatient laboratory and some treatment services in doctors’ offices as well as in the hospitals. The cost was borne by Blue Cross/Blue Shield and amounted to $200,000 in eight months. The cost of inpatient treatment was not reduced but there did appear to be a small reduction in short-stay hospital admissions and lengths of stay. Medium and long-stay hospital admissions were not favorably influenced. A saving of $34,300 was effected; a net loss of $165,700. The Blue plans participating indicated that they would like to pursue these studies further but ask for physician consideration aimed at preventing over-utilization and avoidance of repeating the outpatient studies once the patient gets in the hospital.
Rising Costs of Medical Care
One would think that increased numbers of patients would result in lowering of the cost per patient. During the time of increasing patient load, there has been greater demand for comprehensive coverage. The employee wants to have complete medical coverage without having to contribute anything himself beyond that included by his insurance. The insurance company tried to give service contracts but had to switch to indemnity contracts as a guard against over-utilization. The more comprehensive the contract the greater is the risk of overuse. Comprehensive insurance is costly. The other elements in the increasing cost of medical care have been a moderate increase in physicians’ fees. Some of the increase of medical care costs has been necessitated by the rising costs of medical liability insurance; increasing complexity of medical service; new tests, costly and elaborate X-ray procedures; and increased costs of hospitalization which have been dictated by the great increase in the wage scale of hospital employees and the tremendous increase in the cost of hospital buildings and equipment.
No doubt some of the increase in cost of current medical care comes from the fact that there is such great demand for all types of medical service. The medical schools are producing more physicians than they did a few years ago but not enough to match the increase in the numbers of people who demand medical attention. Doctors are in short supply. Hospital beds are also in short supply, and building onto hospitals to provide more beds must be accompanied by devices to increase the numbers of nurses, nurse aides, orderlies, and a vast assortment of technicians; all of whom are in short supply. The daily and weekly papers are filled with talk of producing a variety of doctor substitutes. There are many who believe that group practice would be a more efficient and better organized method of providing medical care. They claim that there would be less hospitalization of patients with resultant savings in cost and crowding. There are also many who believe that further government intervention, alone, can bring us to a solution of our problems.
Since World War I there have been almost continuous efforts to bring socialized medicine to the United States. There are currently a number of bills being studied in the Congress. We may be happy that the A.M.A. is involved because in those countries that now have socialized medicine the doctors fair least well where doctors did not participate in the planning and subsequent running of the medical programs.
In 1888, Austria, following the example of Bismarck in Germany, instituted compulsory health insurance. In the beginning, hundreds of locally controlled programs were started with a variety of costs and benefits that matched the needs in the given locality. The proud doctors, justifiably proud because they were world leaders, did not contribute to the planning or implementation of the programs. Over the years, there has been a gradual consolidation of the plans into 31 currently functioning elements called krankenkassen. The senior editor, John Carlova, of Medical Economics, in the September 28th issue, describes the result as a bureaucratic octopus with 31 tentacles. Each national health insurance administrative agency has its own gestapo. Patients and doctors hate the system and aid each other in cheating it. If a patient wants to see a doctor, he goes to the local health insurance office and gets a voucher or “sick slips”. He takes it to the doctor of his choice. It entitles him to as many doctors’ visits as he needed in that quarter. The slip is given to the doctor who turns such slips in at the end of the quarter. These slips are worth about two dollars to the doctor. Specialists in their offices have suddenly hired fees and those in the hospitals are salaried. The benefits of the 31 plans vary a little but most all medical and hospital costs are covered.
Comprehensive national health insurance went into effect in Sweden in 1955. The doctors did not like or want it and pointed to the fact that two thirds of the population had voluntary insurance programs and existing laws permitted health care for any others who needed it. For a few years the Swedish physicians resisted the program but finally realized that they must make it work. The Swedish Medical Association gave its support and the doctors began to play a larger part in the planning, organization, and administration. The program is financed through insurance premiums ranging from $15 to $60 per year, and by taxes. The national government pays 23% and local government 60% of costs and the patient and his employer provide the other 17%. The medical care is very comprehensive. Doctors’ incomes are two or three times what they are in Austria.
In 1911, national health insurance was provided for low income workers in Norway and through the years was extended to others until in 1956 everyone was covered. Doctors were closely associated with the program through its changes, helping to formulate each step. They are strongly represented on local and national boards of the health insurance scheme. Its coverage is generous, even including such things as speech therapy and sick pay. Patients pay some part of the Doctors’ fee’s, more of the first visits and less of subsequent visits. Ambulatory care is done for a fee or service. The patient may pay all the fee and get a refund from the local health insurance office that amounts to between 60% and 90+%, or the patient pays that part of the bill for which he is responsible and the doctor collects the rest from the insurance office under a contract arrangement. Doctors and the hospitals are salaried and are permitted seven hours of private practice each week. Many specialties have private offices only. These are subject to review. For health coverage, a tax is paid that ranges from 30 cents to just over $5. The government and employers pay the balance. Patients and doctors alike are satisfied with the program. They, too, have shortage of physicians and hospital beds.
National Health Insurance Proposals in the_U.S.
Let us now briefly examine the proposals of national health insurance being considered by committees of the U.S. Congress. A Dingell Bill has been regularly introduced since 1943 and is given little chance of passing. It involves an extension of Social Security for payments.
The Griffiths Bill would provide comprehensive health care through a prepayment plan, setup by groups, medical societies and hospitals under the Federal Government. Coverage would be very broad and would include dental care to age 16. Financing would be by extended Social Security, 1% employee tax, 3% employer tax. The federal Government would match the employer contribution. The patient would pay $2.00 per doctor’s office visit after the first which would be free. This program would force doctors toward group practice.
The Javits Bill would extend Social Security coverage of the aged to everyone. Employees and employers would pay two thirds of the cost and the Federal Government would add about one third to cover the poor, unemployed, disabled, etc. There would be scrutiny or fees and some incentives to promote group practice.
The A.M.A.’s Medicredit Bill stresses a peer review system to control utilization charges, and quality of care. The benefits would include 60 days of hospital inpatient care per year, subject to $50 deductible, outpatient care and office care with 20% coinsurance on the first $500. Low income policy holders would have no deductibles. This program would be voluntary. Financing would be by the subscribers but the income tax credits would be such that if a person’s tax was $300 or less he would not pay anything toward the insurance but would have it supplied by the Government. The tax credit would be proportional to income in the sense and would be 10% if the tax was no more than $1,300.
The Health Security is also known as the Reuther Plan. Everyone would get everything in the way of health care, including optometrists and podiatrists, (one cannot help but wonder about chiropractors). Dental care up to age l5 would be included but psychiatric care would be limited. The program would be paid for: 40% from general federal revenues, employers would contribute 35% through a tax on payrolls, individuals would be taxed on earnings up to $15,000 which would add another 25% of the cost. The annual cost is estimated between $40 and $50 billion dollars. First call on Federal payments would to doctors who sign up with prepayment groups, to doctors who accept per capita payments, and to doctors salaried by various institutions. Physicians who insist on sticking to fee-for-service medicine would divide up the money left over from each area’s fixed annual budget. Usual and customary fees are not mentioned. Unit cost of all health services (e.g., fees) would be allowed to increase “only on a controlled and predictable basis.” Federal payments would have to be accepted as payment in full. A giant bureaucracy would be established with control of planning. Federal standards would be imposed on hospitals and the Joint Commission on Accreditation would soon disappear. Funds for all health purposes would be administered by this bureaucracy. "Peer review” would not be enough to ensure quality medicine. Superior review would be instituted.
Medical practice in the United States is sufficiently different from that in Europe that their systems would probably not be readily applicable. It must be evident increasing stress is being put on group practice. When so much money is allocated to the care for a given patient no matter how many visits or how many doctors are involved, it seems reasonable that the greatest possible efficiency will be sought.
In recent years, a new type of group has appeared in California. County medical societies are now forming medical foundations, the first in 1954 in the San Joaquin Valley. It was formed to prevent a Kaiser Permanent group from coming into the valley. It was also formed to improve efficiency in medical practice shifting from indemnity to comprehensive if not full service programs. Three key concepts guide the active county society committee in charge of the programs. They utilize private or voluntary insurance for prepayment, provide comprehensive care, and physicians who participate are subject to maximum charges and have a review of their modes of practice. They discourage anything unnecessary in the medical practice. Medi-Cal, California's Title XIX program, patients are billed through the foundation’s peer and utilization system and every claim is scrutinized. The 16 foundations now in existence have a joint state-wide system monitoring hospital admissions to eliminate those not truly needed. There is indication that neighboring states are soon to set up similar foundations. The government in California expresses satisfaction with the results of these foundations.
Let me conclude by saying that some form of group practice has a good chance of becoming a “way of life” in the future. Hopefully, some system, such as that currently in use by the foundations in California, might be implemented throughout the United States. Better that doctors should exert effective control of medical practice than federal Bureaucrats.
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