Debate over Healthcare Economics Nothing New

April 25, 2012

As the Supreme Court considers the fate of the Affordable Care Act, some guidance on the heart of the matter can be found from more than 60 years ago, from physician Warren Sisson.

"Whether we like it or not, we must admit that we are living and working in a period of basic changes in the economic aspects of the practice of medicine."

I, of course, could have come up with the words above, as they certainly hold true today. In a couple months, the Supreme Court will decide on President Obama’s signature piece of legislation, the Affordable Care Act, a rendering that may undo the basic changes that have already taken place and return us to a situation where basic changes are still necessary.

But, these words were in fact written in 1948, in the pages of Pediatrics, by a physician named Warren Sisson¹.

This is a fascinating read, with insight into the transition from pristine doctor-patient relationships (and conspicuous masculine-centric pronoun choices) to the employer and government-based systems that we have today.

"There was a day when the physician could make his visits on a completely individual basis …His bills were entirely between himself and his patients."

The articles reads, in parts, as a libertarian manifesto, and it is hard to conceive the passionate perspective of a physician in the 1940s facing the prospect of monumental change in the system.

"…it is not necessary to remind you that we are confronted with a plan for national health insurance administered by the Federal Government."

The title of the piece is "Pediatrics and Economics." More than 60 years ago - and probably in every year since - this has been an issue of considerable importance, and yet still there remains an incredible shroud over the topic. Some might argue that the placing of these terms next to each other with the collaborative conjunction "and" is heretical. Pediatrics, they might say, by definition falls outside the bounds of typical economic considerations because of the public health (and public relations) considerations.

Are we at a stage where someone can utter the word "profit" while still maintaining a credible outward attitude toward holistic, accessible pediatric patient care? We generally substitute euphemisms, such as "private" or "non-academic." We shield young physicians from the gory details of the dollar(s), often burying them in academic models that rarely disclose physician charges, let alone openly reveal true collections or the disbursement percentage of each collected dollar to the fingers in the till.

Further insights still, from 1948, suggest that the core challenges to the healthcare system have remained inert over 60 years even while the reimbursement model has shifted almost completely.

"Children in isolated areas are handicapped particularly in specialist care, clinic care, and the highly skilled diagnostic and treatment services… deficiencies exist in the distribution of physicians and medical care in some areas of the country in comparison with others…"

What remains the most challenging is to define the goals. We all would likely agree that things need to get "better," yet we are far from offering opinion that is widely embraced. Some of this falls in our own inability to answer the most basic of questions: What is equality? What is considered access?

Perhaps the answers reside in the whispers that tickle the walls in our living rooms, when taking into account the lengths we would go to for the health of our own children.

Economics and pediatrics will always be a complex topic. There will always be passionate debate. This is no better illustrated than in the very core premises of Medicaid financing, whereby children are entitled - by law - to any reasonable and necessary diagnostic or treatment modalities, yet obtaining these services are generally difficult because providers often describe that they aren’t remunerated adequately and thus limit their exposure to the Medicaid population.

It carries a wonderful irony that, in this age, a paper from more than 60 years ago could be published again - cleaning up the older-style English and reworking a few basic facts - and remain almost entirely current. There is a lesson here. What lesson? Well, that I’ll leave up to your interpretation, through the prism that shines light to your eyes.

¹ Sisson, Warren S. “Pediatrics and Economics.” Pediatrics. 2,1,89-96. 1948.

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