The Role of Health
Organizations
Daily Observer
S.Q.
Lapius awakened me early. He was already dressed. He had taken the trouble to put on his gray
striped cashmere, replete with vest, across which he had threaded a gold chain
from which the gold honor society keys dangled.
“Come Harry. We are going to the
state capital to testify before an August body.”
I
dressed quickly, and we were off. “It
seems strange,” I noted. “The sun is
just rising. What sir, may I ask, is the
purpose of the trip? What August
body? And furthermore, might I ask, why
don’t you learn to drive, so that I won’t be encumbered with your chores.”
“The
August body decides medical matters at the state capital; the purpose of the
trip to try to make points there; and I haven’t learned to drive precisely
because I have you.”
The
August body at the state capital convened in an elegant paneled room, high
polish and walnut, with shiny desks and imposing podium and bench where the
state gods of medical matters sat importantly in magisterial robes. Lapius was
apparently only one of a number of witnesses, but after some humdrum
beginnings, I breathed a sigh of relief when I learned that he would be the
first to make testimony, render advice, or whatever his purpose there was.
Dr.
Snodgrass seemed to be the chief inquisitor, in the seat of high honor on the
podium. He gathered his robes
solemnly. “The purpose of this hearing
is to determine the future of the health maintenance organizations. For this purpose we have gathered distinguished
witnesses, doctors, community members, to hold a hearing that will help the
legislature determine whether the health maintenance organization should be
written into law.”
Lapius leaned towards me.
“It took all the forbearance at my command to keep from flunking
Snodgrass when he was a student of mine.
Now look at him. Never a day in practice, deciding the medical needs of the
community.”
Snodgrass
nodded towards Lapius, introduced him, and asked Lapius if he were prepared to make a statement. Lapius stood up,
opened his coat to bare the glistening gold medallions that adorned his vest,
and bowed slightly. “Yes,” Lapius said, “I have a brief statement.”
I
sat back and closed my eyes. A brief
statement by Lapius was usually on the order of a doctoral
dissertation. It would be a long
morning, I figured. Lapius
was speaking.
“First,
of course, it should be made clear that Health Maintenance Organizations are
what we know as HMO’s. They have a place
in the community. But I fear that you,
Dr. Snodgrass, and I, will not agree on where that place is. The idea, of course, is some sort of prepayment concept, where patients can for a
predetermined sum, procure an assortment of medical services from a medical
corporation. They can have periodic testing,
diagnostic screening, medical care, hospitalization and so forth. I am not sure that this will be more
beneficial than the current modes of practice, although it does limit the out
of pocket expenses for medical care. It
has the advantages of an insurance plan.
Its purpose is to provide an incentive for abbreviating hospitalization,
because the corporation will go bankrupt if it must meet excessive hospital
bills.”
“My
objection of course, is that the length of hospital stay must be dictated solely
by the condition of the patient, and that fiscal considerations have no place
there. I also object to the HMO because
it becomes an instrument to use the profession of medicine to hide the failure
of the government, or the economic system, which cannot run its affairs so that
everybody will be able to afford proper medical care. Governments have a tendency to do this. They spend billions of dollars wastefully
then when it comes to their attention that there are inequities in our society,
instead of correcting their own abuses of the system, they try to bastardize
institutions such as the medical profession to make up for their own
shortcomings.” I would have no objection
if I believed that this would solve the problem; but I do not think HMO’s are
the answer necessarily.”
Snodgrass
leaned down from his bench on high.
“Then I am to understand, Dr. Lapius, that you
believe HMO’s have no place in our society?”
“Quite the contrary.
They do have a place,” said Simon, “but not the same place that you would
have them.”
“I
am confused,” Snodgrass admitted.
Lapius smiled. “Well
then permit me to clarify. I don’t
believe that the cost-benefit ratio of HMO’s in the general community would
prove advantageous. Where the HMO
concept could play an important role is not so much in the general community
but rather in the nursing home. It is
here that periodic screening for anemia, blood chemistries, urinary infection
and the like would be very helpful.
After all, the younger people of a community develop symptoms when they
become ill and go to a doctor. Almost
invariably early cases of hypertension are detected and treated. Diabetes causes uncomfortable symptoms, and
patients seek care. There is no proof
that HMO’s have increased longevity by early detection of tumors. The point is, that the working members of the
community seek medical care when they develop symptoms, and the system accounts
for that.
“But
nursing home inhabitants are a different matter. Here the patients are old, possibly senile,
often suffering incurable chronic disease; perhaps paralyzed, unable to
communicate. They develop their diseases
silently and without fanfare. They do
not react as violently to infection as the younger people do. They accept pain more stoically or perhaps
they do not feel it as sharply among their other aches as the young. In short, illness in the elderly is
surreptitious, and their state of health could best be maintained by screening
techniques proposed for the HMO’s.”
“But”,
Snodgrass interpose, “The convalescent homes and nursing homes are not
structured for the HMO concept, legally, that is.”
“I
appreciate that,” said Lapius, “But they should
be. It is there that your money would be
the best spent.”
“But
it would be impossible. The charters
would have to be changed. After all the
doctor-patient relationship would be disrupted.”
Lapius snorted, “Please don’t shed your crocodile tears for
the doctor-patient relationship. You
seem to have no objections to disrupting it by disseminating HMO’s throughout
the community. But when it comes to the
nursing homes, where the doctor-patient relationship is much more tenuous
because the institution itself is parentis-in-loco
and is truly an intermediary between the doctor and the patient, you suddenly
become sanctimonious. I will reiterate
my position but once.”
“If
you want to test the HMO concept, the best place to try it out, the area of
easiest surveillance and greatest return, would be the nursing home. It would not interfere with the relationship
between doctor and patient. It would
preempt merely one area, that is periodic screening of
pertinent parameters of patient care.
The results would be forwarded to the doctor who would then be alerted
to respond with appropriate remedial measures.”
“What
you propose will, of course, be taken under consideration, but the proposals
were not the topic of the day. Thank you
anyway for coming.”
Lapius bowed again and sat down. He gathered his papers into his brief case
and tugged at my arm. “If we leave now,
we might be home by
It
was, nevertheless, a long drive home.