Evolution of health care in the United States

By Tom Putnam | Jul 21, 2010
Tom Putnam

I remember meeting a physician when I was in pre-med at the University of Cincinnati in the 1950s. He asked what I intended to do with my life. Proudly I announced, "I want to be a doctor." I was stunned by his response.

"Why do you want to do that?" he asked. "Medicine has changed so much. It is nothing like when I started out. I would look into something else if I were you."

My immediate reaction was, what does he know? He's such an old man anyway. Things have changed -- and for the better.

I continued along my path through medical school, the required military service, surgical residency and finally pediatric surgical residency at Boston Children's. There were many challenges, but I had a great time. I finally finished my training in my mid-thirties.

This could not have been done without the greatest wife, Barbara. We have two very fine children, now with grown children of their own. Barbara raised our two children, pretty much solo. Dad was busy: training, on call, meetings. Dad was devoted to his family, but also to his patients.

This lifestyle began while in training. Our chief of surgery at Case in Cleveland told us we would be on call every other night in the hospital. He said it was necessary to fully understand and deal with patients and their surgical diseases. Yes, we would nap frequently or infrequently during the day. On our night on call, we only had about two or three hours of sleep. We were young and enthusiastic and could deal with that. Also, our wives were at home raising our children. Yes, as you can tell, in those years we were mostly males who were in training. Women were just beginning to enter medical training. Not because they were less intelligent (most were more so), but because they were running the home and family. They were nurturing the growing children and instilling lifelong values in them.

Several things have changed since then. About half of today's physicians are women. The children are being raised either by a stay-at-home dad, or by a nanny. In order to lessen the number of medical errors made -- thought to be due to lack of sleep -- resident on-call schedules have been changed. There is much more time off (it made no difference that you had less exposure to medical diseases during their acute stages). The belief is that medical errors are made by sleep deprived residents. I seriously challenge that assumption. The really big change is that some of the emerging physicians are not totally devoted to the welfare of their patients above self: putting the patient first above all else. A patient can become much more of a commodity and less of a person that you have devoted yourself to return to good health.

As an example, when a medical problem became tough and the patient required hospitalization for more intensive treatment, your medical training years taught you to be able to continue the more challenging investigation and treatment of that patient. That gave you a tremendous psychological boost when the patient was discharged well. The converse was true also: if the patient did not do well, that was a real downer. Today, if a patient requires hospitalization, the care is frequently provided by the hospitalist: the physician on call in the hospital on that particular day for that particular duty. As a practicing surgeon, that would be like seeing a child in the office with a problem, and then sending that child off to the hospital for the hospital's surgeon to provide the surgical treatment. (Where's the satisfaction?) Many physicians today are being deprived of the ability to provide the patient care for which they trained. And the patient is deprived of service by the doctor they chose to manage their health care issues. Also, since residents train today with a limited number of on-call hours, many do not have the ingrained feeling of ultimate responsibility. The patient becomes more the responsibility of whatever is today's system.

Now I have to put myself in the place of today's physician. Go back to the beginning of this edition of Tom's Take: the first two paragraphs. Draw you own conclusions.

With the above in mind, let's veer this conversation off on an angle: health care in today's world, and particularly in the state of Maine. We are blessed with having a fine medical system, Pen Bay Healthcare, in our three-town area: Camden, Rockport and Rockland plus the environs both inland and down the peninsula. In the mid-1980s, the hospital in Rockland and the hospital in Camden merged into one medical center, Penobscot Bay Medical Center, which is principally housed in the Rockport campus along Penobscot Bay. In addition we have the Knox Center for Long Term Care for the chronically ill in Rockland, Quarry Hill, a retirement community with health care facilities for the chronically aging in Camden, and Kno-Wal-Lin Home Care and Hospice for home health services. There are more than 100 physicians on the medical staff and about 60 percent are full-time employees of Pen Bay Healthcare. (This is different from only a decade ago when most physicians were in private practice.) Pen Bay Healthcare's income principally comes from three sources: private insurance, Medicare and Medicaid. Medicaid is the responsibility of the state and it is chronically behind in payments in the state of Maine. Just recently, Maine owed Pen Bay Healthcare more than $5,000,000. Some of that has been paid. The end result is that Pen Bay Healthcare and other Maine hospitals, in order to break even, must over-charge the private insurance companies to make up for the underpayment from Medicare and even more so from Medicaid. These are not solely issues at Pen Bay Healthcare. They exist in all hospitals in Maine.

Eleven years ago, Maine Medical Center in Portland developed a new organization: MaineHealth. It was designed to be run by a board of directors and various hospitals would become members. Maine Medical Center was the first. To date, there are 10 units in MaineHealth, seven of which are hospitals. Eleven counties are represented. There are enormous advantages in joining. A big advantage is economy of scale: savings on purchases, costs and insurance. Each hospital has given up total local oversight of its operations; however, the individual boards of directors are still responsible for running their institutions with ultimate authority resting with the MaineHealth board. Most hospitals have a permanent member on the MaineHealth board. There are four affiliate members of MaineHealth and Pen Bay Healthcare is one of the four and has been for several years. This has given Pen Bay Healthcare the opportunity to work with MaineHealth and enjoy some financial economies. Waldo County General Hospital in Belfast and Miles Memorial Hospital in Damariscotta are full members, and with Pen Bay Healthcare, all three are involved in regional planning for health care in the three adjacent counties serving a population of more than 100,000 people. Earlier this year, the Pen Bay Healthcare Board of Directors, medical staff and incorporators voted to become a full member of MaineHealth. Pen Bay Healthcare will have a permanent membership on MaineHealth's board and Pen Bay Healthcare's board will continue to have responsibility for the governance of Pen Bay Healthcare with overall approval required from MaineHealth's board.

Currently, the application process is well under way: seeking approval from the state and the federal government. Final approval is expected by September of this year. This will put Pen Bay Healthcare in a much stronger position than being alone in its mission to provide the best health care for the citizens living in its environs. This is especially important for the transition that health care us undergoing in the United States.

The federal government is playing a larger and larger role in the provision of health care. Previously, individual citizens were responsible for their own health. In those days, there were not the immunizations, antibiotics, cancer treatments and surgical procedures available today. Eventually, health insurance was developed by private businesses, principally to take care of patients for in-hospital treatments. Over the decades, insurance programs have covered more and more medical treatments: either in-patient or out-patient in nature. People are living longer and are productive into more senior years. Witness the talk of delaying the availability of Social Security until age 70. Our neighbor to the north and European nations have developed universal health care systems for their citizens. I do not feel that the United States is far behind. Personally, I prefer the former private system, but you'll have to go back to the first two paragraphs again to keep this in perspective.

Now when the United States has a federally administrated health care system, a hospital system as small as the current Pen Bay Healthcare will have little clout or authority in providing the best health care for its citizens. By becoming a full member of MaineHealth, we will be moving in the right direction for securing a fine health care system for all citizens of Midcoast Maine. This will also involve a closer relationship with Waldo County and Miles hospitals for the care of all patients in the Midcoast.

Pen Bay Healthcare's success is assured by becoming a full member of MaineHealth.




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