Tuesday, November 03, 2009


More Salt

NOTE: This document is Copyrighted 2009 by Joseph T. Cohn, M.D.

It is a preliminary draft

Chapter One:

The wonderful delicious and nutritious soup is ruined: there is much too much salt in the soup. All the delicate flavors produced by careful selection of numerous ingredients, combined and cooked carefully based on time-proven recipes and years of experience are ruined with the addition of too much salt.

A prominent visitor to the kitchen tasted the delicious soup and wanted, for many reasons, to alter it to a different taste. We offered only weak protestations to the addition of the salt. A little was added, then more and more, until the flavor of the soup was no longer discernible: it was now nasty brine. We could have said "No" and stopped the ruination at the beginning, but the arguments were persuasive and we were afraid that we would be replaced as chef if we did not allow the tinkering with the soup. We became complicit with the salter.

None-the-less, we served the soup. Our reputation as master soup-maker declined dramatically. Our patrons were no longer enjoying delicious and nutritious soup. The visitor to our kitchen who started the salting allowed other visitors to take over the serving of the soup and they took control. All the visitors caused tremendous price increases for the soup. Saltier and saltier and more and more expensive: the soup remained a necessity of life.

And now the prominent visitors are demanding that the recipe be fixed. Unfortunately, the fix is "more salt."

In the years after the Second World War, the practice of medicine was growing and changing rapidly. The model of a family doctor, a general practitioner, delivering nearly all the lifelong care for an individual and the family was evolving with the increasing specialization and sub-specialization of physicians. Surgery was becoming an increasingly valuable option for many illnesses and hospitalization was becoming a more frequent tool. Diagnostic tests were increasingly available and medications were being discovered.

By the mid-60's it was clear that the old GP needed to be replaced by a physician with much greater and broader training. Careful pragmatic and academic thought gave rise to a new specialty, Family Practice. A well trained family physician could deliver lifelong care, handling well 90% of an individual's well-being and illness issues without resort to consultation or referral. 95% could be handled with a specialist's assistance and only 5% would require ongoing subspecialty care.

The seventies showed the model to be both attractive and feasible. Family practice became the largest specialty in the country. Family physicians delivered more care, more efficieintly, more cost-effectively, and with greater satisfaction for physician and patient than ever before.

Until the mid-twentieth century medical care was not expensive. There were few medications and surgery was a rare option. Hospitalization was not expensive. Doctors made a good middle-class living, but did not become wealthy. Patients paid out of pocket for their medical care, surgery, hospitalizations and medication.

There was no medical insurance. Hospitalization insurance was available, but rarely purchased by an individual. After World War II the federal government gave companies the tax-break to offer their employees the benefit of hospitalization insurance. This became a popular benefit for companies and unions began to demand it.

Post-war physicians had served in the military and surgical care had advanced. Surgery and hospitalization were much more frequent options. Babies, previously frequently delivered at home, were then routinely delivered in hospital maternity wards (filled with newborn baby-boomers). Still, costs were affordable and were paid out of pocket.

Over the next decade, hospital care for the more ill patients, usually the elderly, became more sophisticated and more expensive. It became much more common to die in the hospital than in one's own bed. The cost of the terminal illness rose to almost 90% of a person's lifetime medical costs. Surviving spouses were becoming financially destitute because of the cost of their partner's last illness. Medicare was invented in the mid-60's as a financial safety net to protect the elderly from medical financial ruin.

Medicare contained provisions for the payment of out-patient care, but the costs remained trivial and only a small proportion of Medicare claims were filed. Private insurance companies, seeing the possibilities of a new market for new insurance began to market health-care insurance, modeled on Medicare.

The mid sixties to the mid seventies saw a massive boom in the technology of medicine. Medical and surgical subspecialization expanded as medical generalists became outmoded. The cost of the most mundane and usual medical care, previously delivered by the family doctor, now delivered by the expensive subspecialist, become expensive. The perceived value of insurance to cover these costs seemed attractive. Health insurance grew apace with the growth of subspecialization. Freed from burdening the patient with the expanding costs, physician specialist fees grew as well.

Within medicine, the birth of the specialty of Family Practice was seen as the answer to the explosion in the cost of routine health care.

Another brilliant health care concept was also born at this time: the health maintenance organization, the HMO. Originally HMO's were viewed as a way of delivering lifelong preventative medical care, healthy lifestyle support, and family-physician (primary care doctor) centered care all for a fixed annual membership fee. The cost of health care, it was thought, would be controlled by the use of physician extenders and other health professionals for the routine and mundane tasks, as well as for counseling, and that healthier individuals would engender less medical expenses.

It did not work out. The idea was totally co-opted by the insurance industry that warped it into a gate-keeper, limited access medical system. Rather than lowering health care costs and increasing access and improving physician satisfaction, the HMO movement spawned several spin-off concepts and alphabet soup: PPO's, IPA's, and so on. Each intended to compete with the HMO and to offer alternative financing schemes for medical care. Each proved successively a greater failure and more expensive. The key element to all of them was that the fiduciary agent, the insurance company, was no longer providing insurance, it was managing every health care dollar. Primary care physicians were no longer cast as the center of providing care, but rather limiting care as gate-keepers to the medical system. Patients became consumers and participants. The doctor-patient relationship was completely altered.


Spread the risk of catastrophic financial loss over a group sharing a risk for that type of loss. The larger the group and the more predictable the risk, the more accurately the risk can be spread. The central agent for the group, the insurer, may profit in two ways: (1) charging an amount in excess of the anticipated losses, and (2) investing the collected funds.


1. charge fees in excess of anticipated expenses
2. invest monies collected
3. limit services provided
4. curtail payments to health care providers
5. control types of services
6. limit provider availability
7. manage the mundane: profit from the management of anticipated and routine events
8. market not to the individuals, but to employers

Whole new concepts were added to the management and practice of medicine. All the following concepts were invented by the insurance industry:

  1. gate-keeper
  2. pre-authorization (prior authorization)
  3. prescription plan
  4. preferred medication
  5. patient quotas
  6. mail-order pharmacies
  7. waiting periods
  8. pre-existing condition limitations
  9. non-covered procedures

    None of these improved patient care. None lowered the cost of medical care. All reduced patient and physician satisfaction and all spawned an industry of non-clinical paramedical technologists.

    With their deeply vested interests in the finances of health care, the federal government and the insurance industry have become very active in regulating and controlling the practice of medicine. Nearly all of the regulations that dictate how medicine must be practiced (particularly in the hospitals and nursing homes) did not exist twenty years ago. There is little evidence that these regulations actually improve anything, but they surely detract from the quality of care provided and the experience of the providers. Nurses spend the majority of their time in administrative tasks and documentation -- little of which (if any) is actually used to improve patient care. The financial burden of the administrative and regulatory requirements is staggering. The nature of many of the requirements is silly at best and damaging at worst.

    (A parallel development during this same time period has been the boom industry of malpractice suits. Although there are distinct links between this phenomenon and the problems already outlined, this "crisis" will be addressed separately. I leave it not because it is unimportant, but because the causality and results are tangential.)

    Shall we add more salt? I think we best dump the current batch and start anew. Can it be done? The question is, do we have a choice?

    Chapter Two:


    ( to be continued)

I look forwward to reading the litigation bit - I really thought that played a more prominent role in the current crisis. I have assumed that medical (mainly hospital) costs have skyrocketed primarily because of litigation (or is it technology? greed/corporate mentality of hospitals?), and if these costs were reigned in, perhaps insurance wouldn't be the necessity it has become. Anyway, you'll be my doctor for the rest of my life, so I don't need to worry about such things! :)
Please find the time in your busy life to work on a few more chapters.
When do you think we might see another chapter or two?

Tom Monchek
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