Healthcare Blog: Conclusion (for now, at least) Posted by ccpetersmd

Posted 01/18/10 Last updated 01/18/10

Monday, 04 January 2010 

I have learned two important things with this attempt at a blog regarding healthcare reform.  

First, I realized that blogging doesn’t appear to be my forte, as it has been over two months since I last updated this site.  I realized very quickly that as I wanted to be as thorough and thoughtful as possible with this blog, it took more time than I was willing to commit.  In addition to this feeble attempt, my other online activities began to distract from the real life in front of me; most importantly, my wife and three sons.  Two months ago, I made a decision to decrease my online presence, and that was a very good choice, at least for me.  Still, not wanting to leave this effort completely unfinished, I will quickly summarize my thoughts and provide some resources that I think might be of value.  I may or may not return to this site in some fashion in the future; time will tell.

Second, it seemed quite apparent that some form of healthcare “reform” legislation will be passed, and that it was equally apparent that said legislation will do nothing to address the fundamental issues that plaque our current healthcare system.  It is quite dispiriting, but not surprising, to realize that in 5-10 years, assuming the U.S. economy does not implode beforehand, that we will be rehashing the same arguments we have been considering now.  What we have seen play out in this healthcare debate has been politics as usual, with no effort toward meaningful reform.  In my opinion, this is not a matter of either major political party being “right”, as both have entirely missed the mark, and corporate interests have, as usual, maximized their interests, to the detriment of the taxpayers.

A brief summary of my recommendations regarding meaningful, and sustainable, healthcare reform follows:

We must return to a customary model of “insurance” for healthcare, which provides coverage for unexpected and potentially catastrophic illnesses and injuries.  This is best accomplished through what is known as “catastrophic” healthcare insurance.

For routine healthcare needs, excepting the unexpected and catastrophic events which would be covered by insurance, costs should be met by individual patients, which would allow market forces to decrease the costs of medical services, decrease unnecessary utilization of healthcare services, and hopefully also promote healthier lifestyles.  Routine healthcare expenditures would be best funded through individually managed Health Savings Accounts (HSAs), which are tax-deferred accounts akin to IRAs or 401Ks, and can be rolled-over year-to-year, and even used for retirement funding.

Insurance should be purchased individually, rather than through an employer, which affords much greater flexibility and security in the event of change in occupation.

The federal government could play an important role, for example in enacting legislation that would make individually purchased healthcare insurance as affordable as employer provided insurance, encouraging “catastrophic” healthcare insurance, and allowing the purchase of FDA-approved medications from outside of the U.S.

I would prefer that the federal government not get further into the business of providing healthcare coverage outside of our armed services, but I could see a role for state governments providing “catastrophic” healthcare insurance for those unable to afford such coverage on their own, and possibly also the provision of funding for basic healthcare maintenance for those unable to adequately fund an HSA.  The states could also greatly facilitate healthcare insurance reform by allowing the purchase of insurance across state lines, thereby eliminating the healthcare insurance oligopoly that exists in most states.

There are many more items that I could list, but I think this is a relatively concise and useful summary.  If the above recommendations were realized, I suspect that we would reach roughly 90% of the goals necessary to achieve true healthcare reform.

One word of warning to those of a certain age (I was born in 1960): I would recommend not counting on Medicare or Social Security when you retire.  We are far too indebted as a nation to reasonably expect that those benefits will continue beyond the next decade or so.

Finally, I would like to provide several references that I think are of value.

First, I highly recommend the Crash Course.  This was one of my first introductions to the perils that we are facing.  Dr. Martenson provides the most succinct yet comprehensive review of what he refers to as the “Three Es”: Economy, Energy and Environment.

Second, for an excellent discussion of the underpinnings of our current economic crisis, I think the folks at NPR’s This American Life and Planet Money have provided an invaluable service with the following programs:

Healthcare Blog: A Fundamental Flaw Posted by ccpetersmd

Posted 01/18/10

Tuesday 27 October 2009 

Regardless of whether a given healthcare plan is provided by a private insurer or a public source, almost all share a fundamental flaw, a violation of the very principles underlying the traditional model of insurance.  As we have discussed, the customary concept of insurance is to provide some financial protection in the event of a potentially catastrophic but statistically unlikely event.  In purchasing insurance under this model, you are essentially sharing your personal financial risk of such a calamity with hundreds or thousands of other insureds, brokered through an insurance company (or, through the government, with the financial backing of millions of taxpayers).

In contrast, most Americans currently receive healthcare benefits, which look little like traditional insurance.  These healthcare plans typically cover routine healthcare needs, to include physician visits, elective procedures and diagnostic testing, pharmaceuticals, etc.  Individual plans may differ on the particular range of services provided, but the concept is the same.  Such plans as sometimes referred to as “first dollar” or “front end” insurance, meaning that they cover the initial, frequently routine, costs of healthcare, but may not cover all costs in the event of a truly catastrophic illness or injury.

This fundamental flaw in turn leads to a plethora of other problems, but we will herein limit our discussion to two: rising healthcare premiums and increasing medical bankruptcies.

Let us first consider rising healthcare premiums, but translate our current healthcare model to the realm of automobile insurance.  Imagine that your automobile policy, instead of just providing coverage for liability (paying someone else for any damage you may cause) and any repair or replacement costs you may incur, also covered your routine automobile needs.  These might include gasoline, oil changes, tire rotation or replacement, minor body work, etc.  Excepting the cost of your regular premium installments, your costs for these services are minimal, consisting of a small co-pay or a small percentage of the total costs.

It is easy to imagine that many automobile owners covered under such a plan might regularly fill their gas tank with premium gasoline, get more regular oil changes, use brand name replacement parts and lubricants, etc.  They might even chose to drive faster or further, consuming more fuel, and increasing the wear on their vehicles.  The automobile servicing industry, sensing the money to be made with such increased interest, would respond in kind, offering regular brake checks, wheel alignments, underbody inspections, performance modifications, etc.  The net effect on the automobile insurer, however, would be to see increased claims, and needing to offset those losses, would transfer those costs along to you in the form of higher premiums.  These increases would also likely affect you, even if you had not altered your automobile servicing practices!

As far-fetched as this analogy may sound, it is directly applicable to the healthcare industry.  By transferring our “first dollar” healthcare costs to a “third party”, the insurer, we do not directly appreciate the financial impact of our elective healthcare decisions.  Because of this lack of immediate financial impact, demand for elective medical care increases, and the healthcare industry responds, in the form of new services, new procedures, and new pharmaceuticals.  But, if you will recall from my last entry, there is no “free lunch”.  The costs of this increased demand for healthcare services will return, in the form of rising healthcare premiums.  Or, in the case of publicly-sponsored healthcare, in the form of an increasing federal deficit, and a subsequent claim to an increasing portion of the income of future generations of Americans.

According to a study by the McKinsey Global Institute, the fastest growing segment in the healthcare marketplace is for outpatient care, comprising greater than 40% of our total healthcare costs, and is the single largest factor explaining the increased cost of healthcare in the U.S. when compared to other developed countries.  Growth in outpatient care has averaged 9% per year over the past 20 years, compared to 5.2% growth per year in inpatient services over the same time period.  

It is true that if a given condition can be treated equally well as an outpatient than as an inpatient, cost savings will generally be realized.  However, much of this growth in outpatient services is for routine and elective care, not the catastrophic, life-threatening, medical conditions for which most of us choose to acquire insurance coverage.

With these increase costs of providing elective care, in addition to other factors, we are not only experiencing regular increases in our annual healthcare premium rates, but we are also noting an increasing number of people filing for bankruptcy due to healthcare costs.  According to a study by Dr. David Himmelstein published in the American Journal of Medicine, 62% of bankruptcies filed in 2007 were related to medical expenses, and nearly 80% of those filing for bankruptcy had some form of medical insurance.

One of the ways that insurers can help to protect themselves (and their shareholders) from excessive losses is to limit the maximum amount they are liable.  This comes in the form of maximal allowed expenditures per year per insured, and/or to the exclusion of certain potential high-cost medical conditions.  With rising financial exposure to the costs of routine or elective care, and increased resistance to rising healthcare premiums, insurers have attempted to minimize their financial exposure at the other end of the healthcare spectrum.  

From a business perspective, I can certainly understand this decision, but it again violates the fundamental reason for purchasing insurance in the first place, which is to provide financial protection in the event of a catastrophic but unlikely event.

In closing, it is worthwhile to consider why and when our current healthcare model acquired this fundamental flaw.  As was reviewed in the post on the history of modern health insurance, our current model developed as a response to two major historical events, The Great Depression and World War II.  In an effort to preserve a stable revenue stream during the 1920s and 1930s, hospitals and physicians embarked upon the Blue Cross and Blue Shield experiment, which paved the way for employer-sponsored healthcare benefits.  During the 1940s, in response to existing prohibitions on wage increases, government exempted healthcare benefits from taxation, cementing the association of healthcare benefits to employment, and the provision of comprehensive benefits.

In short, our current model of healthcare benefits did not develop primarily in response to consumer demand for such a product, but as the result of outside influences and government involvement.  At this point, in the early 21st century, we are so accustomed to our current model as to assume that it is the best way to provide for our healthcare needs.  However, we are now seeing the effects of this model, and I believe that our only hope for “real” healthcare reform is to realize the shortcomings of this model, and to return to a traditional definition of insurance.

Discussions about a public option (or, “Medicare-for-all”), tort reform, etc., all fail to address this fundamental flaw.  Until we do so, we will continue on our current unsustainable path, regardless of whether or not any of the current legislation before Congress eventually becomes law.  Unfortunately, based upon the public discourse thus far, and the pronouncements of our politicians, I suspect that we are years away from meaningful healthcare reform.

Resources:

Uncertainty and the Welfare Economics of Medical Care

McKinsey Global Institute (Part 1)

McKinsey Global Institute (Part 2)

American Journal of Medicine

BNET

Healthcare Blog: Is Healthcare a Right, or a Business? Posted by ccpetersmd

Posted 01/18/10

Tuesday, October 13, 2009 

From our preceding brief historical review, we have learned that the era of modern medicine is only around a century old, and that outside influences, in the form of insurance companies and the government, have had been present from nearly the beginning.  In fact, while some bemoan the current “capitalistic healthcare system”, I would argue that we have barely had any experience with truly free-market capitalism in the era of modern medicine.  One can argue whether or not a free-market economy is the best model for the efficient, effective and fair delivery of healthcare services, but one should not argue that the failure of our current system is due to unencumbered capitalism.  The healthcare market has been encumbered by excessive governmental regulations, mandates, and incentives throughout much of its history.

Before I proceed, I wish to discuss two comments I have heard frequently with regard to our healthcare system.

The first is that “healthcare is a right”.  I presume this to mean that those that make that claim mean that healthcare is a “right” in the sense that we have a right to freedom of religion, freedom of speech, freedom of the press, freedom of assembly, freedom to keep and bear arms, freedom from unreasonable searches or seizures, etc., as spelled out in our Bill of Rights.  I have read the entire Constitution, including the Amendments, and I cannot in any way imagine that healthcare is defined therein as a “right”.  If someone can garner the necessary votes (it requires a 2/3 vote in both houses of Congress, and ratification by 3/4 the states, by the way), we could make healthcare a “right”, but until that is done, I simply do not see how that claim is valid.

Or, perhaps, those that claim that healthcare is a “right” mean that it should be so, in the sense of the natural rights of life, liberty and property.  I can understand this claim, somewhat, as an extension of the natural right to life, but one must try to understand the concept of natural rights in greater detail before making that assumption.  The idea behind natural rights is that you should have an expectation that your rights to life, liberty and property would not be violated by another, and that, in turn, you should not violate their rights.  Natural rights do not mean that you should have longevity, creative abilities, or wealth, but simply that nobody should interfere with your efforts to acquire those goals.  With regard to healthcare, I see the concept of natural rights as being solidly in favor of an individual’s responsibility to ensure their health, but not a right to that health.  In my view, healthcare is a personal responsibility, not a right.

The second is that “healthcare should not be a business”.  Whenever there is an exchange of goods or services for another set of goods or services (or, “money”, which represents future goods or services), that is a business transaction.  If goods or services are provided without the expectation of some form of remuneration, that is charity.  I provide my services on a charitable basis periodically, for example on an occasional mission trip, or when I agree to perform surgery on a patient without the means to pay, and I am happy to do so.  Generally, however, I expect some payment for the services which I provide, and for which I trained to acquire the necessary knowledge and skills.  Until bakers provide bread for my family, and a builder provides a home for my family, all without expectation of payment, I think I have every right to expect compensation for my services, except in those situations in which I freely donate my care.

Even if all physicians were employed, by hospitals or the government, there should be the expectation that the employing organization would conduct itself with sound business practices.  (Not, of course, that our federal government does so in practice, but it should.)  Apart from physicians, should we also expect nurses, other ancillary staff, pharmaceutical companies, and medical device companies, to also provide their services for free?  It may be a utopian ideal, but I do not see that working in the real world in which we live.  

I will admit here a bias, in case it is not already apparent, that I believe that a truly free market provides the best opportunity to maximize efficiency and productivity, to accurately gauge the value of a given good or service, and to allow the most appropriate utilization of limited resources.  Please note that I mentioned nothing about maximizing profitability.  Profits may come, if a given individual provides a good or service that is in demand, and can do so efficiently and economically, but it is not guaranteed.  A truly free market works best to protect the consumer, not the producer.  As I hope to make it obvious in future posts, our history of governmental intrusion has helped to make insurance companies, pharmaceutical companies, medical device manufacturers, and, yes, even some physicians, more profitable than they would likely have been in a truly free healthcare market.

And, who pays the price?  You do!

We will end here with one final idea:  “There is no free lunch.”  We will see this time and time again in future posts, so it is worth emphasizing here.  If you receive healthcare insurance from your employer, you do not get it for “free”, you receive it in the form of decreased wages.  If a patient without the ability to pay for their care presents to your local hospital, that hospital will attempt to subsidize the cost of that care through increased charges upon those with an ability to pay.  If the American Medical Association, the American College of Surgeons, or America’s Health Insurance Plans come out in favor of a particular piece of legislation before Congress, you can be certain that they do so with the expectation of economic reward (or, at least, less economic punishment), not an altruistic pursuit of the common good.

I, on the other hand, am trying with this particular blog to be idealistic, and even altruistic.  From a financial point of view, I benefit from the current healthcare system, and would likely continue to do so under any of the so-called “reforms” being considered by Congress.  If free-market economic principles were allowed to act unencumbered in our healthcare marketplace, I fully expect that I would receive less in the way of personal remuneration, but the overall system would be much more efficient, effective, and fair.  As I sometimes tell my patients, “when a surgeon advises against surgery, you should be sure to listen, as they have a built-in incentive to recommend surgery”.  When I post here, it is not with the expectation of self-serving results, but the hope of improving our healthcare system for all.  Corny, I guess, but true.

Healthcare Blog: The Growth of Governmental Involvement Posted by ccpetersmd

Posted 01/18/10

Friday, October 2, 2009 

Prior to the 1950s, governmental involvement in healthcare had been largely peripheral.  The preferential treatment afforded Blue Cross and Blue Shield in the forms of tax-exempt status and freedom from customary insurance regulation has already been discussed.  

I have also previously noted that tax-exempt status for employer contributions to their employee’s healthcare premiums that helped to establish our current employer-based healthcare insurance system.  Prior to the middle of the 20th century, however, the federal government’s involvement in the direct provision of healthcare services had been limited.  

The government had, of course, provided healthcare services for members of its active duty military since the days of the Revolutionary War.  The “Army Hospital” was founded in 1775, forming the basis of the future Army Medical Department (AMEDD) and, ultimately, the Department of Defense’s Military Health System (MHS).  Healthcare for veterans has a similar early history, having been authorized by the Continental Congress of 1776, and was followed by the founding of the Veterans Administration in 1930.  Healthcare services for Native Americans was established in 1787, and through subsequent laws and treaties, culminated in the formation of the Indian Health Service (IHS) in 1955.

Care for dependents of active duty military members was initially limited, offered on a “space available” basis through the MHS and its precursors.  Care for military dependents through the civilian sector, but funded by the government, was established in 1966 through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and its current incarnation, TRICARE.  Healthcare for non-military federal employees began to be provided in the 1950s, culminating in the Federal Employee Health Benefits Program (FEBHP) in 1959.  Aid to Families with Dependent Children (AFDC) was begun in 1935, providing assistance to children of families with limited income.

Governmental involvement in healthcare expanded dramatically with the passage of the Social Security Act of 1965, resulting in the establishment of Medicare and Medicaid.  Medicare provides healthcare coverage for those 65 years of age or older, or who meet certain other specifications, while Medicaid is primarily designed to cover lower income Americans.  Medicare initially consisted of two components, Part A, which generally applies to inpatient care, and Part B, which generally relates to outpatient care.  It was patterned on the Blue Cross (Part A) and Blue Shield (Part B) model.  Medicare is entirely a federal program, whereas Medicaid is a joint federal-state program.  Medicare and the federal component of Medicaid are administered by the Centers for Medicare and Medicaid Services (CMS).

Additional legislation followed.  The Health Maintenance Organization (HMO) Act was passed in 1973.  The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986, as an unfunded mandate to provide care regardless of ability to pay.  In 1996, Aid to Families with Dependent Children (AFDC), was replaced by Temporary Assistance for Needy Families (TANF).  The State Children’s Health Insurance Program (SCHIP) was created in 1997.  Medicare was further expanded in 1997, with the establishment of Medicare Advantage (Part C), and in 2006, with passage of the Medicare Prescription Drug, Improvement and Modernization Act (Part D). 

One could spend a great deal of time arguing the merits and failures of each of the above programs.  This is not the goal of this post, although I will certainly return to discuss the ramifications of our largest healthcare entitlement programs, Medicare and Medicaid, in future posts.  Rather, the lesson to be taken from this post is that there has been no shortage of government involvement in our healthcare industry throughout the relatively brief history of modern medicine.  The question I would raise, hopefully to be answered in future posts, is has this involvement helped or hindered our healthcare system?

Resources:

Economic History Association

BNET

Wisconsin Policy Research Institute

Consumers Union

Encyclopedia of Aging

Wikipedia

Healthcare Blog: The Rise of Modern Health Insurance Posted by ccpetersmd

Posted 01/18/10

Thursday, September 24, 2009 

Perhaps surprisingly, the history of health insurance in the U.S. is actually quite interesting.  The story is a mixture of charitable instincts and self-serving interests, private and public endeavors, and a generous sprinkling of governmental involvement.  A complete history is beyond the scope of this simple blog, but I will provide a brief outline, and encourage the interested reader to reference the several resources cited below.

With the advancement of medical science and the birth of healthcare as an industry, spending on healthcare began to grow rapidly.  Even at the beginning of the 20th century, private citizens and public officials began to comment on the rising expenditures in healthcare.  In fact, the arguments one hears today regarding the need to control healthcare costs are remarkably similar to those heard a century ago!  The only difference is that now we must grapple with the effects of 100 years of outside influence, some good and some bad.

Anyway, let us return to the dawn of the modern medicine.  At that time, costs of medical care were largely borne “out of pocket”.  Much to their credit, many physicians and hospitals based their charges upon a given patient’s ability to pay.  The earliest form of health insurance came through fraternal societies, sometimes termed “lodge medicine”, and which provided what amounted to “sickness insurance”, covering some portion of the costs of an acute injury or illness.  Commercial insurers, in contrast, were unwilling to engage in providing insurance for healthcare.

It may be worthwhile now to review some basic ideas regarding insurance.  When you purchase insurance, whether to protect your home or your car, you are attempting to mitigate the costs of a catastrophic and unlikely event, whether that be a fire in your home or a serious car accident.  The insurance company, on the other hand, is willing to cover these potential costs, realizing that it can cover these expenses in the form of premiums collected from clients who do not suffer such a calamity.  For those that object to the idea that an insurance company should benefit financially from these decisions, let me point out that the same principles hold true for a non-profit organization; namely, that they need to at least cover their “losses”, even though the profit motive may have been eliminated.

For an insurance company to be profitable, or at least responsible, it must be able to make a reasonably precise reckoning of its “risks” regarding the issuance of any particular policy.  For example, an automobile insurance company could be expected to demand higher premiums from individuals with a history of speeding tickets, DUIs, etc.  And, they should be able to anticipate the cost of repairs if the insured drives a more expensive car.  Herein enters some important concepts related to insurance, to include adverse selection, asymmetric information, moral hazard, and others, which I will return to in greater detail in a subsequent post, but will briefly define below.

Adverse selection is the tendency of those who would most benefit from insurance to acquire said insurance.  For example, if you had a history of automobile accidents, you might be more likely to obtain automobile insurance.  If the insurance company had no knowledge of your past history, this would be an example of asymmetric information.  Moral hazard is the potential tendency of insureds to alter their behavior because they now have insurance.  If you didn’t have automobile insurance, would you drive more safely, or more recklessly?

Okay, back to health insurance.  At the beginning of the 20th century, commercial insurers could not see a way to avoid adverse selection (providing insurance to those most likely to need it), asymmetric information (the knowledge base of medicine only beginning to grow), and could not account for the potential of moral hazard (the possibility that insureds would alter their behavior in ways that would affect their healthcare needs).  Also, with the rapid growth of modern medicine, there seemed to be no end to the advancements we would see, and, therefore, no end to the costs that must be met.

The beginnings of the modern health insurance industry is easily traced to Texas, in 1929, when a group of teachers contracted with Baylor University to prepay hospitalization coverage for its members.  This plan helped to avoid some of the pitfalls of adverse selection; namely, if the teachers were well enough to work, they were less likely to require hospitalization.  The arrangement was beneficial to the teachers association, in the form of coverage for potential catastrophic costs, and to the hospital, in the form of regular payments during the onset of the Great Depression.  We see here also the beginnings of the association of health insurance with employment, a relationship which will only increase in importance in the decades to follow.

Gradually, other hospitals began to engage is similar arrangements with businesses and employee organizations.  Under the auspices of the American Hospital Association (AHA), at least in part to decrease competition between hospitals, these various plans eventually became consolidated as Blue Cross.  Medical care by physicians followed a similar course, with individual and group contracts with employers.  Despite initial reluctance, the American Medical Association (AMA) ultimately developed the principles that would become Blue Shield.  

We see here, also, the arrival and early influence of some of the major players on the healthcare scene, the professional associations.  The AHA and AMA would soon be joined by the American College of Surgeons (ACS), the precursors of the current America’s Health Insurance Plans (AHIP), the Pharmaceutical Research and Manufacturers of America (PhRMA), and other organizations.

The Blue Cross and Blue Shield programs were very successful.  Selecting relatively healthy enrollees from the existing employment pool, which helped to minimize their exposure risk.  Perhaps more importantly, Both Blue Cross and Blue Shield benefitted greatly by lobbying efforts by the AHA and AMA, allowing them to be declared nonprofit organizations, providing them an exemption from federal taxation, and not holding them accountable to the statutes that normally apply to insurance companies, both of which were tremendous advantages.

With the success of the Blue Cross and Blue Shield programs, commercial insurers soon entered the healthcare market, a field in which they had previously been reluctant to join, and soon realized their own advantage.  Blue Cross and Blue Shield, as nonprofit entities, were required to community rate their policies, meaning that they were had to charge the same premium to all enrollees, regardless of health status.  In contrast, the commercial insurers, not bound by this requirement, could experience rate their policies, charging healthier enrollees lower premiums, sicker enrollees higher premiums.  The result, as might be expected, was the rapid growth in commercial insurance plans, particularly among more desirable clients (younger and healthier), with some decrease in the rate of growth of Blue Cross and Blue Shield.

As has been noted, these early forays into what would become our current healthcare insurance system were already largely tied to employment.  This association became even stronger during and after World War II.  The 1942 Stabilization Act restricted wage increases that could be offered to employees, but healthcare policies were exempt, allowing companies another means to attract new employees and retain existing employees during the lean war years.  Additional legislation in the 1940’s and 1950’s further cemented this linkage of healthcare insurance to employment, to include ultimately making the costs of healthcare insurance tax-exempt for employers and employees.

In time, the distinction between the Blues and commercial carriers would be largely lost.  Blue Cross and Blue Shield eventually incorporated as a single entity, with various state and regional manifestations.  Many of the BCBS programs would become for-profit.  Both commercial insurers and the Blues developed various methods of managed care, such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

The above history has been factually accurate, but brief.  I have left out many details and glossed over others, but hoped to provide a useful overview for future discussion.  I feel the important items to keep in mind include: the relationship of health insurance to employment, the concepts of adverse selection, asymmetric information, and moral hazard, community versus experience rating, the rise of influential professional organizations, and the effects of even this early and limited governmental involvement.

Resources:

Economic History Association

BNET

Wisconsin Policy Research Institute

Consumers Union

Encyclopedia of Aging

Wikipedia

Healthcare Blog: A Brief History of Medicine Posted by ccpetersmd

Posted 01/18/10 Last updated 01/18/10

Monday, September 21, 2009 

While there had been sporadic advances in the fundamental sciences which underlie medicine prior to the 19th century, I think it can be reasonably argued that dawn of modern medicine can be traced to the end of the 19th century, with particularly rapid development during the 20th century.  A few highlights might be of value:

1736    First successful appendectomy

1847    American Medical Association

1848    First use of anesthesia in surgery

1867    Principles of antisepsis (sterility)

1870    Germ theory of disease

1879    Cholera vaccine

1881    Anthrax vaccine

1882    Rabies vaccine

1895    X-ray

1898    American Hospital Association

1899    Aspirin

1901    ABO blood typing

1913    American College of Surgeons

1921    Insulin

1923    Diphtheria vaccine

1926    Pertussis vaccine

1927    Tetanus vaccine

1928    Penicillin

1935    Yellow Fever vaccine

1943    Dialysis

1952    Polio vaccine

1953    First heart surgery with cardiopulmonary bypass

1956    Cardiac catheterization

1960    Cardiopulmonary resuscitation (CPR)

1965    Ultrasound

1964    Measles vaccine

1967    Mumps vaccine

1967    First heart transplant

1970    Rubella vaccine

1971    CT scan

1980    MRI scan

1981    Hepatitis B vaccine

1992    Hepatitis A vaccine

Prior to the era of modern medicine, injuries and illnesses were, for the most part, events from which people were either fortunate to recover, or not.  There was little of value that could be provided beyond nutrition, rest, and comfort measures.  Also, prior to modern medicine, hospitals existed primarily as charitable institutions for those without the means to be cared for at home, which was the norm for those with means and family.  There existed very little in the way of a healthcare industry before the era of modern medicine.

If one just considered my field of surgery, prior to the 1870’s, such common theories and technologies as sterility, antibiotics, effective control of bleeding, safe blood transfusions, x-rays, and even anesthesiologists, were unknown.  In fact, bloodletting, using leeches or venesection, a technique practiced by most civilizations dating back to antiquity, was still popular as late as the 1870’s.  George Washington died in 1799, likely due to complications of treatments for pneumonia, to include bloodletting of five pints of blood!

With the maturation of modern medicine at the end of the 19th century and beginning of the 20th century, everything changed.  Gradually, illnesses and injuries which previously would have been fatal or permanently disabling were increasingly prevented, successfully managed, or even cured.  Hospitals became centers of healing, with the newly appreciated concept of asepsis and the developing medical science, rather than simply the last refuge of the desperate, ill or injured.  Physicians became increasingly respected member of society, and the process of assuring adequate training of new physicians was begun.  Healthcare as an industry began to develop.

Depending upon when one starts the clock, modern medicine is only a little over a century old, and the era of modern surgery is even somewhat younger.  The reason that I think it is valuable to consider the above timeline is that it provides a useful background for the discussion of two other developments in the world of medicine, health insurance and the role of government.  As we will see, medicine grew hand in hand with insurance companies and government regulation, and to such a degree that it can reasonably be stated that we have very little experience with a true free-market system of healthcare in the modern era in this country.  Whether that development has been good or bad, we will leave to future discussion; for now it is just an observation of fact.

Resources:

History World

History of Medicine Timeline

Medicine’s Great Journey: One Hundred Years of Healing

Wikipedia

Healthcare Blog: Concerns Regarding U.S. Healthcare Posted by ccpetersmd

Posted 01/18/10 Last updated 01/18/10

Saturday, September 19, 2009

Healthcare Blog: Introduction Posted by ccpetersmd

Posted 01/18/10 Last updated 01/18/10

Friday, September 18, 2009

Okay, I need to get started on this project.  Not that this project will necessarily be incredibly worthwhile to all that read it, or that it will go beyond it’s intended mission, but, if I don’t start it now, I don’t know when I will...

I am attending a political conference this weekend.  It was important enough to me that I will miss the birthday of my youngest son, Caleb, tomorrow.  (Caleb, I pledge to make it up to you on Sunday!)  Anyway, as part of the conference today, I learned some harsh political realities.  This included the argument that education of the populace is irrelevant; that impacting the 5-10% of “swing” voters is what is important.  While I recognize the likely political “truth” of this observation, I refuse to believe that education is entirely unimportant.  After all, I also learned that all of the attendees with whom I spoke this weekend had been only fairly recently “awakened” to the perils facing our country.  Those lessons were learned through the efforts of others, so I hope here to do my small part.

Until the economic collapse of 2008, I was politically and economically naive; a passive participant in government, and certainly a willing and even excessive economic consumer.  Since that time, I have become increasingly interested in the economic and political problems with which we are faced.  To the chagrin of my wife, I have spent many hours each day reading my fill of economics and politics.  Over the past several months, I have been particularly interested in the topic of healthcare reform, the topic which will consume at least my initial posts on this blog.  Healthcare is a particularly relevant topic, not only because it involves my particular focus of business, but also because it also combines those other issues of interest to me, politics and economics.

To begin this blog, I will post a letter below which I sent to President Obama and our Iowa representatives.  The goals of this letter were to highlight the repeated past government involvements in our healthcare system, the fundamentally unsustainable nature of our current healthcare system, and the fact that the current proposals to “fix” our healthcare system do little to address the underlying issues.  I wish I could have said more in that letter, as I have in other venues, but I felt compelled to limit the discussion to a particular point of view, if only to limit the length and complexity of the letter.  Unfortunately, healthcare is a uniquely nuanced and complex subject, and does not lend itself well to concise discussion.

To be absolutely clear on this subject, I am not arguing for preservation of the “status quo”.  In my opinion, we certainly need healthcare reform, as our current course is simply unsustainable.  Yet, to devise effective solutions, we must first properly understand the underlying problems.  These, then, are the goals of this blog; to identify the problems and to propose possible solutions.  A brief summary of our problems, which I will expand upon in future posts, involve two fundamental errors.  These include, first, a particularly unusual view of “insurance” when it comes to healthcare, and second, an extensive history of government involvement, with possibly good intentions, but with pernicious effects. 

Finally, before I leave this post, I would like to express some objectives and disclaimers.  As I promise my patients, I will tell you what I believe to be true, and also tell you when I do not know an answer.  I will try to be objective, and to provide useful resources.  If I am sharing my subjective perceptions, I will try to make that obvious.  As a disclaimer, I am a surgeon, and as self-educated as I may be in other areas, I am not a professional politician or economist.  I absolutely reserve the right to be wrong (as a husband and father, I have learned that lesson all too well).  In the end, you will have to educate yourself, and reach your own conclusions.  As a friend of mine so wisely stated, “trust yourself”.  If you disagree with me, that is certainly fine.  If you write to me, please try to be constructive and respectful, as if we were in the same room.

Christopher

http://sun-sationalsalon.com/2009-08%20Obama%20Healthcare%20Letter.pdf

My Healthcare Blog Posted by ccpetersmd

Posted 01/18/10 Last updated 01/18/10

I attempted a blog regarding healthcare reform, which I have tentatively terminated, as I came to realize that blogging is probably not my forte.

Still, I think I managed to bring together some useful insights and resources, and thought I'd share it here.

The link to my blog is below, but I have heard feedback that there are some compatibility issues with regard to certain platforms (PC, Mac, etc.) and browsers (Internet Explorer, Firefox, Safari, etc.).  I created the site on my Mac, using Apple's simple website program, iWeb.  I suspect the compatibility problems are related to iWeb, but I am not entirely certain.  If someone has useful suggestions in regard to the compatibility issue, I'd be thrilled to receive some help!

I'll try to upload the content of my blog in separate installments to this site.  In the meantime, here's the address to my healthcare blog, for those that are able to access it:

http://web.me.com/cpetersj/Christophers_Site/Welcome.html

The Atlantic: How America Can Rise Again Posted by ccpetersmd

Posted 01/18/10 Last updated 01/18/10

I thought the following article from The Atlantic well worth a read.  It was forwarded by our Iowa ACS (American College of Surgeons) president.