What's Wrong With Health Care?

Arnold-Relman is the man who decides what will appear in the New England Journal of Medicine. The man who writes the editorials that continually have him embroiled in controversy. The man who called the ethical foundation of medicine outdated, who has challenged doctor's conflicts of interest, who has questioned whether capitalism should rule medicine.

He hasn't written an editorial he'd retract, he says with frankness bordering on the glib. Not yet, he laughs.

Crimson: In march nearly 2000 physicians-intraining struck eight hospitals in New York City claiming that patients were dying needlessly because of staff and equipment shortages. Do you support such strikes and if not, what other ways would you suggest for the strikers to bring about the enforcement of standards in patient care they feel are lacking?

Relman: I think that withholding services is a totally inappropriate technique for physicians to use because they can only damage people who they're supposed to be serving. A strike is a legitimate social technique when it's a weapon against an employer but when physician strike, who are their Employers? The city of New York is not going to be hurt financially or economically by the strike. The people who are going to be hurt are the people who need the services in the hospital...I'm in total sympathy with their objectives if they are as stated to improve the quality of care in hospitals which are probably not very organized and not very well maintained. But that's not the way to do it.

Crimson: What is the way?

Relman: One way is to withhold professional approval of such hospitals as teaching hospitals. The city would respond I think, to pressure from the accrediting bodies which decide whether hospitals should be approved for teaching or not. Simply to walk off the job is nothing for a doctor to do. A doctor doesn't have any right to walk off the job.

Crimson: I think the striker's argument would be slightly different. They see no other way to bring dangerous conditions to the attention of the public. They are not trying to hurt the city, they were not striking for more money. They were simply striking for attention.

Relman: I don't wish to tell the interns and residents of New York what to do, but I do wish to suggest that withholding professional services is not the best way to call attention to your situation. If I were a patient in one of those hospitals. I would not appreciate what the residents did even though they say they were doing it in my interest.

Crimson: About one-eighth of all doctors in the United States are now part of physician's unions. Are you in favour of such unions?

Relman: I'm totally opposed to them. Unionization is for workers in an industry. Medicine is not an industry. Medicine is not a business. Medicine is a profession and the economics and ethics are entirely different. It's very sad to see that medicine is being treated more and more by both the profession and the public as a business. But I think that it's not in the best interests of the public...in the long run.

Crimson: What are you blaming this condition on?

Relman: I think there are many reasons. The main reason I think is simply the tremendous economic burden that health care now carries. Health care is the second largest industry in the country. There are tremendous pressures on the part of government to control the costs, there are temptations to the profession to profit from the enormous amount of money that's being spent on health care and I think that there are many people who view it simply as another business. But it isn't.

Crimson: Advances in technology have virtually transformed medicine several times since 1945 yet you have said that we overuse technology that are of marginal benefit to the patient and drive costs up unnecessarily. What can we do to stop this?

Relman: I think there are two general approaches that have to be taken. One is that government and the insurance companies and all third parties that pay for health care have to remove the perverse economic incentives that stimulate doctors to overuse medical technology. Doctors are only human and theyrespond to economic incentive just as any other human being would and the system that we now have...encourages overutilization of intensive, elaborate procedures...Any procedure that is recognized as safe and is believed to be effective is accepted by the profession and will be reimbursed. And usually the more expensive and more elaborate and more technical, the more it's reimbursed for...If the money is there to pay for them and the patient likes the idea of having these elaborate tests done and the doctor is trained to do them, they're gonna be done.

Secondly, the profession has to pull up its socks and take more responsibility for monitoring what it does. The profession has to be more critical of itself, it has to set up more rigorous systems for evaluating its own technology, making rigorous decisions about what's justified and what isn't.

I think also in that connection that third parties who pay for the costs of medical care have a responsibility for funding technology assessment. I think it's a crying shame that the Reagan Administration evidently intends to allow the National Center for Health Care Technology to die. It's falls economy. For an Administration which says that it's interested in reducing the cost of health care, that's a very foolish thing to do, because more effective assessment of health care technology is one of the best ways to save money.

Crimson: You have taken the position, as did your predecessor, that any article whose contents have appeared elsewhere will not be accepted by the Journal. Lawrence Grouse, one of the editors of the journal of the AMA has said that this policy has had "a chilling effect on the reporting of medical news in this country." Such a policy is said to make researchers reluctant to speak with reporters which slows the delivery of scientific breakthrough to the public. could you defend your policy?

Relman: I think those charges are really silly, and they are very far from the truth. We are a private journal and we have a policy which our authors are free to accept or not as they see fit. Authors who don't agree with our policy or philosophy can send their manuscripts elsewhere. We're not the only weekly journal in the English speaking world. There are many excellent journals with wide circulations that have different policies. So I don't understand why we not entitled to follow what we think are appropriate policies for us. A while ago I spoke about the pluralism in our society. I think it would be too bad if all journals had the same policy. We happen to believe that our policy is a sensible one. We happen to believe it's in the public interest. We also happen to believe that it actually is supported by the vast majority of people who do medical research in this country and by the vast majority of our readers.

Crimson: Is it in the public interest because...

Relman: Because it helps maintain the quality of information that gets to the public. The public interest is not served by rapid dissemination of premature, incomplete, inaccurate, sensational information. The public interest is better served by getting the facts straight, by getting reliable information at a time when the medical profession also has the information and can advise and can help explain what it means. When patients hear on TV or read in the headlines of newspapers some sensational story about some putative cure for a disease or some marvelous diagnostic technique that may or may not turn out to be true and they hear about it in the medical literature I don't think that's in the public interest.

Crimson: Has your policy affected reporting as far as you can tell?

Reiman: That's hard to say. I think that here are some science reporters and medical reporters who may be persuaded by our position although they may not say so.

Crimson: You mentioned in an editorial in July 1979 that there is an oversupply of doctors in this country and that "we are training more than enough students." Yet in some areas of the United States there is insufficient health care. This seems paradoxical. How do you explain it and more important how would you remedy the demographic problem?

Relman: You're right in pointing out that on that one hand the total number of doctors were producing seems to be, by all criteria, adequate or maybe excessive but that the distribution of doctors inappropriate...It's a very tough problem. I don't think you can solve it simply by throwing more doctors as it, by producing more doctors in medical schools. The new doctors that you produce are going to go to the same places that the old doctors went. The fact is...where solid citizens don't want to live, doctors don't want live and practice either. You are gonna have to figure out some way of getting health care to those devastated areas of the inner city and the rural slums where doctors don't want to practice.

Now the National Health Service Corp was one approach, giving scholarships to medical students in exchange for time spent working in underserved areas. That problem is going to be cut now along with many other health care programs.

Another approach of course is to improveiedical care facilities in those areas...to set up clinics and group health plants that will enable doctors to practice good medicine under good circumstances where they can earn a decent living without fear of their lives...

Another approach is simply to provide better transportation, to get people out of the South Bronx into other areas of the city for their health care...It's a social problem. It has to do with how you deal with the problem of slums in this country. It seems to me that the medical profession by itself can't solve that one. That's a total community problem.

Crimson:How would you change the reimbursment program to save money? Relman: The fee system should be changed so that there is not such a high payment for technical procedures as compared with personal services. As it is now, a few minutes spent peering through the end of some sort of instrument...is reimbursed at a rate that may be literally an order or two of magnitude greater than time spent, talking to the patient, examing the patient, counselling the patient or staying up with a sick patient at a hospital. These kinds of personal services that require a lot more time and no less skill are reimbursed at a fraction of the rate of the technical procedures...The insures, the government, and the bureaucrats are much more impressed by a procedure. If you bill a patient and say I'm charging you $50 because I spent an hour with you, talking to you and examing you the patient's not as much impressed as if you bill them $100 for carrying out some sort of technical procedure. It looks very impressive, maybe frightens the patient and seems to be worth much more.

Crimson:Massachesetts recently asked the Federal Government to let it impose a fixed budget on the state millions of dollars. Are you in favour of it?

Relman:In principle it sounds like a good idea...A big part of the reason that health care costs so much is that the insurance principle says "we will pay whatever the usual, customary charges are all we ask is that there be evidence that the procedure or test or treatment actually been carried out." If you have a bottomless well of money from the Federal Government and it's reimbursing costs of health care that way, even if there were no inflation...you would expect utilization to keep going up and up. And that's what happened. And what the state is saying, very sensibly, is no, we're not gonna do that anymore. What we are going to do is try to get Medicaid into the prepayment principle...We'll pay the provider a fixed amount of money with the provider a fixed amount of money with the understanding that the provider is obligated to provide all the necessary services no matter what. And if the provider can be efficient and economical and if his prices are fair and appropriate, he can make some money. He's got to take that risk.

Crimson: It seems that under this system doctors would actually have an incentive to do less than they normally would. Would health care suffer because of this?

Relman: Well, that's the risk. Under the present mode, the prevailing mode, the risk is that the doctor is going to do too much. Under the prepayment mode, the risk is that the doctor will not do enough. You have to start from the assumption that most doctors, the vast majority of doctors, are conscientious and are not going to do what is inappropriate and will not fail to do what is necessary. You have to start from that assumption. If you don't then health care is chaotic anyway.

Crimson: What makes you hesitant about the program?

Relman: I started out saying in principle I'm in favour of prepaid health care, but it certainly should be explored...One of the great things about this country is that we're big enough and rich enough so that we can be very pluralistic and we don't have to commit ourselves to one solution for anything. I think we ought to try a number of different approches...And if you personally don't like one way of health care, you have a number of options and the same for doctors...We may fall flat on our face in this state because of bad implementation. The trick will be to get providers, high quality providers who'll be willing to go into this market.

Crimson: A recent editorial in the Wall Street Journal claimed that the American Medical Association (AMA) is losing the political clout it once had due to a drop in membership. Is this true and can you explain it?

Relman: The facts are the facts. They are not a matter of opinion. I think it is true that now that AMA has a smaller regular full-dues-paying membership and a smaller fraction of the total practicing population of American doctors than a few decades ago...It's posing a real problem because if the AMA wants to speak for American medicine, it has to be able to demonstrate that it represents at least a majority and right new it does not...Now what is this due to?...The first and most obvious reason why the AMA is having membership trouble I would suggest is that doctors belong to speciality societies and they feel more of an allegiance to their own specialty and Subspecialty...but some don't want to have leadership in the hands of the AMA leadership.

Another reason why the AMA may be having membership trouble is that the AMA has been very active politically and although I suspect that American physicians in general tend to be more conservative as a group than other segments of middle class America, they are still pretty heterogenous politically. I think there are many physicians, particularly young physicians, who hesitate to join the AMA because the AMA doesn't speak for their political views...I think that's too bad. I recognize the practical necessity of organized medicine to become involved in political affairs. You can't separate health care from politics these days. But I think that the AMA pays a price for this. The AMA, by taking political stands, alienates a very significant number of physicians who might otherwise be attracted to the noncontroversial professional activities of the AMA. The AMA, you must remember, does many...good things. It supports education, it supports research, it fights quackers, it's constantly working to improve the quality of American Medical care and when it was founded it was one of the major social forces in this country to professionalize the practice of medicine and move it out of occuitism.

STRIKES? "Simply to walk off the job is nothing for a doctor to do. A doctor doesn't have any right to walk off the job."

"The public interest is not served by rapid dissemination of premature, incomplete, inaccurate, sensataional information.:

"The profession has to pull up its socks and take more responsibility for monitoring what it does."