Memories
Shoe shine boys:
When I was growing up as a 11 or 12 y/o in Evansville, In. there were only a few jobs a kid could get that they could earn a little money. Errands , cutting grass, delivering papers all required working for someone.
The only truly independent job, though menial, was shining shoes.
This was a prized job, since Evansville was a leave destination for Camp Breckenridge, Ky. and every weekend soldiers flooded the city on leave,
and many wore " jump boots", which you shined for a quarter.
Now when you talk about entrepreneurship, this was classic. We took a wooden box, nailed an old belt as a strap, bought a can of brown and black polish added rags and were good to go.
Kids would literally fight to get a spot near the Greyhound bus station, but because there were so many soldiers, everyone got shines.
When I reflect back I never thought this menial. It was a way to have  money to buy comic books, "swingtime pies" and double colas. Now there's nothing safe a kid can do........sad 😩

What's wrong with today's doctors

I haven't blogged in my chronicles in a while because I try to put down something that the reader might find relevant. Since  retirement, I have had my share of old patients, friends and even strangers ask me what should I do about this or that condition. Mostly, it's "I have this complaint and what do you think it is". Most often, I tell them they should seek out a doctor that deals with that particular problem. That withstanding, I'm
at the point of exasperation on the advice and care people are getting.
Now granted, I finished training 50 plus years ago and kept current in the years before retirement but it
borders on criminal negligence the advice and care people receive now!
When I graduated medical school specialization in medicine had just begun to be popularized. It had become evident that medicine had become to vast for any one to master it solely, so the specialties and sub-specialties became the norm post graduate training. Unfortunately, common medical knowledge is being lost.or not taught.
I have always believed you are a doctor first and specialist second. For example, just because you are a skin specialist you should know that an irregular pulse is abnormal or if an OB/GYN yellow skin means possible jaundice.
Now here is recent event that I think proves my point. I was asked by a casual acquaintance why her heart seemed to be racing all the time and that she felt dizzy and faint. I asked was she seeing any doctor or on any medication she said she didn't have a doctor and usually went to the emergency room for care. So I said well what you have could be serious and you need have someone check out your heart. The next time I saw her I asked did she find out what was wrong......her reply was she was sent to see a heart specialist and she related her problem and was told to return in 3 weeks. I asked did they do an EKG, she said that the doctor
never even took her pulse or listen to her heart.Was that because she had no insurance?...... if so THAT'S CRIMINAL!
Medical education has changed. There is little clinical exposure to patients anymore. Students now examine manikins or surrogates that are hired to imitate clinical problems. Yes, technology has taken medicine to new heights but nothing can replace the hands of a knowledgeable physician examining  you!

E-mail about Camp River Cliff

Anonymous has left a new comment on your post "St Louis and Camp RiverCliff":

I found this blog searching for a specific reference about my grandfather, the "Mr. Cook" the writer describes as "short and pudgy." Note that he says nothing else of my grandfather, leaving the impression that he was little more than the greeter for the campers. Far from it!! I can only assume that Uriah knows nothing of the origins of Camp Rivercliff and nothing about how Camp Rivercliff was the first such camp in the country for inner-city Black male youths. I would be the first to admit that my grandfather was very overweight, but he was not "pudgy" and his stature was not what people remembered about him. He was a man of average height with an enormous heart and he had a warm and generous spirit. Reverend James E. Cook, my grandfather, was minister of the largest Black congregation (Antioch Baptist Church) in St. Louis at that time and, simultaneously, the first Black Executive Secretary of the Pine Street YMCA. Camp River Cliff was my grandfather's brainchild and he personally faced down the KKK's threats to make it possible for Black boys to escape the heat and tedium of the long summer months and to learn to swim, dive, fish, master archery and complicated crafts, and receive counseling. The camp offered educational programs and training skills for personal development and enrichment. Camp Rivercliff was a place where Black boys built self-confidence and were mentored by a caring, giving, dedicated staff. Though he could easily have delegated responsibilities such as meeting the new, incoming campers, my grandfather always chose that special duty as one of many that he eagerly, personally undertook. Rev. Cook never forgot his St. Louis roots and he lived his entire life in service to the Black communities of St. Louis. I assume the writer also knows nothing of the fact that a public school in St. Louis was named in honor of my grandfather or that Camp Rivercliff was operated with money earned from the "Y Circus," an annual gala at which big-name talent such as Nat King Cole, Eartha Kitt, Duke Ellington, Count Basie, Cab Calloway, Earl Hines, and Sammy Davis Jr., among others, performed for crowds specifically to generate funding for Camp Rivercliff. The "Y Circus" was another one of my grandfather' concepts. I could go on...but I think you understand where I'm going with all this. Uriah is free to post his memories, but unsubstantiated statements and ignorance of facts do little to enhance his soliloquy. It pains me when we Black folks know so little of our history yet feel so free to ramble! By the way, my grandfather died of a heart attack while at Camp Rivercliff. We ached to lose him, but we knew he died doing what he loved. Brenda Mitchell-Powell P.S. I hate listing myself as anonymous, but I don't have a gmail account or URL. You can reach me at

To Ms Mitchell-Powell,
I would like to apologize for any impression I gave of disrespect to your grandfather, Rev James Cook. I was writing from the vantage of a 12 year old going to camp for the first time. Not only did I know some of the history of Camp River Clift, I knew about Jodie Bailey and some of the other staff that made the camp so special.  I also remember the Camp Chapel on the hill overlooking the dining hall where every Sunday we would sing " The Old Rugged Cross." I was not writing about the history of the camp or the Pine St, YMCA. My chronicles are just a memoir of my life. If you read further in the chronicles, you will see I did my medical training at Homer. G, Phillips Hospital where my father was one of the first 27 interns to train there. I lived in thePruit-Igoe projects during my  5 years there  I know or am friends with most of the pioneer physicians in St.Louis. Camp River Clift and the Pine St Y have a warm place in my memories as does your Grandfather and I write this to you in that light, so I posted your comment to acknowledge your Grandfather properly.
Sincerely ,
Uriah/Earle U. Robinson,   Jr
( I would welcome a call @ 317.299.4781)

The Healthcare Dilemma Essay

The rising cost of health care in the US has become a national emergency.

The fact that 47+ million of this county’s citizens are without insurance and a large number of others are underinsured leaving them bankrupt in the event of a medical catastrophe makes the need for a national health care plan imperative and immediate.

Over the last 45 years the delivery of health care has been hijacked by the Hospital, Insurance and Pharmaceutical industry. Also, the way care is delivered has been a hugely profitable business venture that also has greatly benefited providers (i.e. hospitals, clinics, nursing homes and pharmacies).

I leave physicians out only to the extent that they are held captive to fees set by the parties that control reimbursement of services. But over ensuing years their fees rose largely because of the need to offset malpractice coverage whose exorbitant premiums forced many to give up their practices.

Historically, before the inception of Medicare in 1965, physicians saw patients on as cash or barter basis or accepted reimbursement from those patient’s fortunate enough to have some sort of health insurance (a small number of individuals had coverage through employers).The indigent were either given free care or were seen at city/county funded facilities.

When Medicare was proposed, it was to pay the physician roughly 85% of their usual and customary fee. There were a good number of physicians who did not treat indigent patients so there was no reason for them to sign on to the program Others did not enroll because of personal reasons. But many of those (mainly black) were treating these patient gratis and readily accepted this reimbursement since 85% was better than nothing. It is important to note that the NMA largely supported LBJ’s effort to establish Medicare in contradistinction to the AMA. Within a few short years, the 85% dropped to 60% and eventually much lower. Also, physicians could not set a fee (a violation of the Sherman Act). Fees were arbitrarily set by a formula that did not fairly adjust for the cost of providing the service.

Mind you, fees for services of plumbers, electricians, attorneys, etc., were set by the providers while doctors had no choice but to accept or deny the totally inadequate and fixed Medicare fee. If a surgeon accepted an assignment from Medicare for a hysterectomy billed $700 dollars, he might get $350 dollars. And if there were complications, he might appeal but would likely not be compensated for his services. Tradesmen would not accept a job without guarantee of their full fee.

This reduction in reimbursement led to a great deal of fraud where by providers used laboratory service as a means of billing for unperformed or unnecessary tests or procedures. This greatly increased the cost of providing medical care and led to a disgruntled medical community.

Most of the physicians who chose medicine as a profession did so to provide patient care and had been willing to do so at low or no fees to those who could not pay. I have personally seen many changes in medical education and medical care in the last 50 years. Technology has been a huge factor in the advancement of diagnosis and treatment of disease and has been an equally huge factor in the enormous costs that now threaten the provision of health care to all. I would like to outline what I see as the major problem confronting the health care system and suggest some possible solutions.

The Problem

It is important to understand that man is on this earth for a finite period of time and is likely to be exposed to a myriad of conditions (disease or injury) that could lead to illness or premature death. What was first considered an art, then later a science, and is now called the practice of Medicine, was established centuries ago to cure or relieve man from these conditions. Man’s life span has exponentially lengthened in relation to his knowledge of disease and his ability to treat it. That eventually led to a health industry that is hugely profitable in making longevity possible without cures, especially without cures (“the ideal drug neither kills nor cures”). And that is where the problem lies. Health care will always be a costly dilemma as long as man seeks too avoid the fact that death is inevitable and uses technology to delay it and that is not likely.

The Solution

The solution to this dilemma is complex and is addressed in the topics listed below

1. Medical Education (Physicians)

2. Hospital, Technology and Facilities

3. Pharmaceuticals

4. Insurance

5. Health Plans

Medical Education (Physicians)

Historically, medical education was basically a mentor/student type of learning which gradually evolved into a mishmash of non-regulated medical schools that had no standard curriculum. In 1910, a report (The Flexner Report) was presented that was instrumental in setting a standard for medical school certification which led to (what some believed to be) a better form of medical education. The study included things like facilities, methods of instruction and hands-on training. This study was instrumental in closing a large number of medical schools. Even today there is an organization that accredits medical schools based on strict standards. There was, and still is debate over the value of some of the concepts of teaching such as preceptor- ship, which some feel is invaluable because there is still a certain art to the practice of medicine.

Until recently, teaching hospitals that were staffed by private physicians required that these physicians supervise interns and residents who were enrolled in their graduate medical education program in exchange for the 24/7 care they provided their private patients. It was a quid pro quo, the private physician provided the patients in exchange for the resident gaining experience in care of them under supervision for a modest salary. Years ago the pay was a meager 15-30 dollars a month plus housing, uniforms and food, in exchange for the supervised learning. Later, municipal hospitals had programs that hired full time physicians to supervise interns and residents to care for the indigent at these same low wages. It was not uncommon for a house physician to work 100+ hours a week. This was the norm in training a doctor. It was not considered seriously detrimental to the resident’s welfare or patient care to work these hours since it had long been the traditional practice. Programs, at such prestigious institutions at medical schools as Johns Hopkins or Harvard, or municipal hospitals like Massachusetts General or Homer G. Phillips, were vied for as excellent residency training grounds. Many an antidotal tale of the harsh work experiences endured are retold by those of us who were part of that era.

In the 1960’s some private hospitals established teaching programs that paid residents considerably more to provide clinical care ($35,000+ per year).They then used volunteer attending staff to provide supervision. Clinics were established to care for the indigent and billing was done in the name of the attending physician that supervised care. If the patient had insurance, the payment was billed in the name of the attending physician who signed off on the charges and the payment directed to that physician. In many cases these funds were than returned to the hospital to support the residency program.

This system worked basically because there was a tacit understanding that the house staff provided care to the patient and the attending physician provided supervision to further the resident’s education.

Sometime after Medicare was enacted in 1965, institutions that provided medical care to their patients were reimbursed by a monetary formula based on the number of approved residents in their graduated medical education department. In the 1980’s this amounted to approximately $35,000 per resident with a sliding scale raise for each year up to 5 years. So a program with 120 residents would be paid $35,000 x 120, or 4.2 million dollars yearly. The institution, as I understand it, was under no obligation to use these funds in any specific way (i.e. medical education). They would go into their general fund. Every four years, each accredited residency was evaluated and recertified by the American Council on Graduate Medical Education (ACGME). (I am aware that there was complicated and confidential handling of this income the specifics of which I have no knowledge.) In early 1990, residency programs that did not have full time employed physicians to supervise their residents were being denied reimbursement for medical service that Medicare was being billed for.

This ultimately led to a rule which has increased the cost of care and of resident education enormously. Basically every procedure or service that a resident performed had to be done with a physician who was fully credentialed by the hospital to staff resident cases so that reimbursement could be made. No resident’s service in any clinic, emergency room, or operating room could be billed for unless there was a private physician present at the point of service. This directive on Medicare reimbursement changed the whole paradigm of how graduate medical education would be delivered.

Hospitals have now had to hire FTE physicians to replace the volunteer physician to not only do what residents did 24/7 in the past, at an enormous cost, they could no longer use residents to work more than 80 hours per week ( which is good). The problem is now a no win situation for medical education. Can the system now in place be justified when to educate doctors it pays those who teach them based only to comply with reimbursement requirements?

This system of requiring the provider of the service being present started with Medicare and is now part of every insurance provider’s documentation of presence for payment. This one requirement has made the cost of graduate medical education almost unaffordable if not modified in some way.

In the past, medical knowledge/skill was passed down from Attending physician, to Chief Resident, to Resident, to Intern . The term resident meant just that….the physician was in residence (in the hospital); the draconian always “on call” From a practical teaching basis the supervision that is required to be reimbursed does nothing to improve or provide better skills or decision making. All it does is make sure that the institution gets paid.

A simple example of learning a skill is no matter how long or how close you sit to the student (your child) in a car they cannot really drive until you let them do it alone. There is a point in training that the resident must be left to make decisions without staff present, but if I have taught you how to make decisions my presence is not necessary. It makes no sense that to be paid for the service of a specific person’s presence is a requirement as proof of delivery of care.

The staggering cost of medical education is a major and continuing factor in this health care dilemma not being specifically addressed and it must be.

Hospitals, Technology, and Facilities

I reside in a Midwestern City with a city-county population of roughly 1.7 million in a state that has only one medical school for a population of

6.3 million. The 2009 medical school class admitted 335 students.

The city boasts 5 major hospital groups that strategically and geographically cover the city. Via the interstate beltway, there is no patient more than 30 minutes from any of these in an emergency. The problem is that duplication of services is costly and each of these hospitals built state-of-the-art heart centers with an investment of millions of dollars that they have to justify based on the population. So how many diagnostic tests or facility charges are generated to pay for this investment?

The Da Vinci Robotic operating apparatus is a unique and useful adjunct to performing cutting-edge surgical procedures but can the cost be of making it available in every hospital be justified? MRI units are being run 24/7 to justify and recoup the cost since an idle unit is not profitable. Technology drives up costs for the more sophisticated the equipment, the more costly to the hospital and the greater the need to use it. The cost of MRIs, CT Scans and PET Scans includes a professional fee for interpretation that can be equal to or more than the cost of performing the test. It may sound cynical, but a good diagnostician can be of more value, and can treat the patient more effectively, than a panel of studies ordered for screening.

Usually, as soon as a patient arrives in an emergency room, a battery of tests is ordered to rule out a condition often before a thorough history and physical exam are done. That is one of the reasons why ER care is so expensive. Most of the visits are for non emergency conditions. So the service is misused and over utilized. I have had patients go to an ER and have tests done before I was called to tell me that they were being seen when the diagnosis could have been given by me. It is a fact that technology has advanced medical diagnosis and treatment in the last 50 years but it has also been a major factor in the astronomical costs that we are presently encountering.

In the early 1970’s, Blue Cross and Blue Shield made a major change in how reimbursement would be made to hospitals. Payments were made on a formula of how many days a patient was allowed to be hospitalized. Each diagnosis was allowed a specific length of admission. This resulted in a reduction of in patient beds and a surge in outpatient facilities to provide

profitable surgery, lab, and x-ray fees. The whole delivery of care changed and corporations like Humana bought up hospitals and consolidated services to reduce cost, forcing those that were not profitable to compete or close.

This led to some areas being without service and required patients to travel to facilities that Humana owned (basically controlled delivery of care ).

These facilities were essentially for profit….huge profit. The original owners of Humana became multimillionaires from these mega-hospital sites strategically located across the country.

The system fed on itself and since profit was enormous there was no reason to control cost until Medicare realized that it was being charged exorbitant fees and that there was no way to equate the delivery of service with its quality. In the 1990’s an elaborate coding system was developed to standardize identifying diseases *(ICD9) and procedures *(DRG) in order to process reimbursement.

* International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases.

*The Diagnosis Related Groups (DRG) were developed for the Health Care Financing Administration as a patient classification scheme which provides a means of relating the type of patients a hospital treats (i.e., its case mix) to the costs incurred by the hospital. While all patients are unique, groups of patients have common demographic, diagnostic and therapeutic attributes that determine their resource needs. The DRGs form a manageable, clinically coherent set of patient classes that relate a hospital's case mix to the resource demands and associated costs experienced by the hospital. Each discharge in the UHDDB was assigned into a DRG based on the principal diagnosis, secondary diagnoses, surgical procedures, age, sex, and discharge status of the patient.

During this period, electronic data recovery (Information Technology) was being developed and it made possible the ability to collate to some degree the quality of service. Hospitals nationwide formed quality assurance committees to study the performance of individual physicians as well as the institutions themselves. The statistical data from these studies were then used to set up reimbursement schedules. In many cases, hospitals and physicians that were in the upper percentile of efficiency were rewarded by higher payments. One of the major ways that hospitals reduced cost and increased income was to build outpatient surgical facilities. These centers could efficiently perform the most profitable services at the lowest overhead. Some of these facilities became for-profit sub-corporations of the not-for profit major hospital and also co-ventures with private physician investor groups.

One can easily see how many procedures (eye, ortho, urology, gyn, plastics, etc.) could be done in large volume with efficient, rapid, profitable turn over.

Every hospital in any community that wanted to compete for market share

set up their strategically placed centers and marketing to the public became as solicitous as car dealers. Patients now became customers and treatment became known as services and physicians became providers. I do not condemn this concept of care delivery but do question how it led to the costly mega health delivery system we now are paying for. Multibillion dollar giants in the health industry such as HCA (Hospital Corporation of America) were the spin-off from the take over of hospitals by Humana mentioned before.

It would seem that the proliferation of facilities would have made health care more accessible to the general population but, to attract private insured patients, most of these free-standing centers were built with expensive appointments on beautiful grounds with the costliest equipment.

Naturally, all this must be calculated into the cost of providing service.

These extras can also be profitable as depreciation write-offs.

If health cost are going to be reduced and care provided universally in the United States, then the huge profit-making facilities have to expand their services to a larger patient population and suffer reduced reimbursement.

Pharmaceuticals

The history of treating diseases with some sort of medication dates back to antiquity and basically little has changed. The clans and tribes that roamed the earth gathered plants, roots, bark and minerals and by trial and error learned that they had medicinal properties. Many of the medicines in use over the past 100 years were present in those same sources and have only been refined by man’s knowledge of the chemistry from which modern day pharmacy evolved. As the science of chemistry advanced, medicines were artificially developed and an industry was born. Whenever a medicine is discovered to treat a human disease with an acceptable mortality rate, it is highly profitable. The secret of the pharmaceutical industry’s profitability as stated earlier is for a drug not to cure and not to kill. One of the most frequent justifications of the high costs of drugs is the cost of their research and development. I feel that that what is spent in media advertising

may also be an unreasonable cost.

One of the basic flaws in man’s approach to living is denying the fact that death is inevitable and any thing that can prolong life is worth the cost.

We are living in a society in which technology preserves the lives of many premature infants that would not have survived in the past. Yet, they often live with developmental conditions only long enough to be enormously costly. The argument can be made that we are #37 in infant mortality world wide but that does not factor in the quality of life of those that survive. And at the other end of the spectrum, diseases that chronically ended life are now being treated by costly interventions that prolong the inevitable.

We live in a time when medical technology offers unheard of survival just as antibiotics and blood transfusions did several generations ago

There is a moral issue that has to address the ethics of the costs of health care vs the desire to live under any and all circumstances. Addressing this may be the ultimate dilemma in healthcare.

Insurance

The health insurance industry starting in the 1950’s basically was a spin-off of life insurance. Actuaries were established based on an individual’s probability of dying or contracting a disease within a pool of others, factoring in age, sex, race, environment with a risk-based index of those more likely to live than die. The benefits were based on the number of members in a particular plan that would always insure the company made a profit. Naturally those at high risk were uninsurable or their premiums were higher based on that risk. Originally, the health insurance was a package that the auto industry offered its employees in the union contract that gradually spread to union benefit packages in other industries Health insurance companies began to emerge that used risk as a basis of benefits and marketed their policies to individuals who were enrolled as part

of a specific risk profile.

One of the pioneers in the industry was Blue Cross/Blue Shield which was at first, only in selected states, and later, nationwide.

Because physicians originally were on a cash basis they could charge any fee that they wanted and reject anyone who did not want to accept that fee. Once patients had insurance, physicians had the option to accept what the insurance would pay for the service, or to refuse service to the patient. This was called “accepting assignment”. This gradually resulted in physician’s fees being set by the insurer. Once this occurred the insurer was able to make the industry highly profitable. The whole paradigm shifted to include hospitals, with the insurer controlling the reimbursement of services. Since physicians had to utilize hospitals in caring for their patients, they were forced to admit their patients to institutions that accepted their patient’s insurance. What evolved was a monopoly that dictated payment for care, and since it was illegal for physicians to organize or set fees, the physicians were no longer in control of in their patient relationship. Eventually patient services were dictated by the insurer based on contracts with hospitals that accepted their payments. Hospitals enacted staff privileges that closed their staffs. These privileges involved credentialing and the agreement to admit insured patients. It is clear that the insurance industry’s profits are directly related to what they are willing to pay to reimburse patient care. Generally, fees for services are quoted, and the individual has the option to pay or not receive the service.. With health care, it was considered unprofessional for physicians to advertise or set fees themselves, thereby violating the Sherman Act (antimonopoly).

With the major source of physician’s fees controlled by Health Insurer’s the doctor/patient relationship was fractured because a 3^rd party was involved in health care delivery. In 1965, an attempt to provide healthcare to the aged and the uninsured a government funded program called Medicare was established. This program, for all intents and purposes, put the government in the insurance business. Uninsured patients began to show up in the emergency rooms of hospitals nation wide. In the 1990’s a law was enacted that forbade hospitals from denying them medical care. This placed a huge financial burden on a system that was being bankrupted. Between the marked reduction in reimbursement by private insurance payers and the inadequate Medicare payments, hospital struggled to compete and exist. This has been a major cause of the health care dilemma

A huge secondary insurance cost that must be factored into healthcare is malpractice coverage that physician must maintain. This is passed thru to the patients and fuels a demand for tort reform in the health industry.

It must be acknowledged that medical accidents occur and some are truly the result of gross negligence that definitely be adjudicated. Unfortunately the legal cost of defending these claims has not only been exorbitant because the laws they differ state by state with no standard for award at settlement. Also many of these claims are frivolous which burdens the courts and drags out for years their resolution. Ideally, Medical Review Committees, which many states have adopted can and do weed out the claims that have no merit. And in the case of catastrophic damages a panel of judges could resolve the payment not a jury. No physician can continue to practice with the threat of a malpractice suit needing to maintain insurance that cost upwards of $85k in some states and for some specialties.

Heath Care Plans

In the 1973, the Health Maintenance Organization Act was passed and plans developed to control the spiraling cost of health care.

The two most popular were HMOs (health maintenance organizations) and PPOs (preferred physician organizations)*

*A health maintenance organization (HMO) and a preferred provider organization (PPO) have several differences. However, many of them offer quite similar services. Often the PPO will cost a little more because it provides greater flexibility in choosing doctors and seeing specialists than does the HMO.

With a PPO, one can see any doctor one wishes, or visit any hospital one chooses, usually within a preferred network of providers. Depending upon the terms of coverage, a doctor or hospital outside the preferred provider list will cost more and the PPO will pay a range of 70-80% of expenses. Conversely, an HMO requires one see only doctors or hospitals on their list of providers.

The basic idea for these plans arose from the Kaiser Permanente Plan which is described below:

Kaiser Permanente is an integrated managed care organization, based in Oakland, California, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney R. Garfield. Kaiser Permanente is a consortium of three distinct groups of entities: the Kaiser Foundation Health Plan, Inc. and its regional operating organizations, Kaiser Foundation Hospitals, and the Permanente Medical Groups. As of 2006, Kaiser Permanente operates in nine states and Washington, D.C., and is the largest managed care organization in the United States. Kaiser Permanente has 8.7 million health plan members,^[4] 156,000 employees,^[2] 13,729 physicians,^[3] 37 medical centers, 400 medical offices, and $34.4 billion in annual operating revenues and $1.3 billion in net income.^[1] The Health Plan and Hospitals operate under state and federal not-for-profit tax status, while the Medical Groups operate as for-profit partnerships or professional corporations in their respective regions.

This plan, with some modification, could be the model for a Universal Health Plan now being crafted in the Congress. Two of the premier Medical Centers in the country ( Mayo and Cleveland Clinics ) have instituted innovative plans to deliver care to their patients that have drastically reduced cost.

Conclusion

The essay that I have written outlines the five major issues that need to be addressed to remedy the dilemma in Health Care. The major factor is not just cost but how these issues affect it.

Medical Education (Physicians)

The cost of training a physician from college through medical school is astronomical from the stand point of out of pocket and student loans (200K-250K). Post graduate stipends paid by hospitals to residents are largely subsidized by government programs that in the last 5 years require full time physicians to supervise their training when they provide patient care; such as being present the operating room when the resident is performing the surgery. From a teaching or quality of care standpoint this does not make for a better outcome. These requirements were adopted by Medicare, and later private insurers, so as not to reimburse for resident services, as the hospital cannot submit a bill with the resident as the provider. The provider must be an active member of the hospital staff. Unfortunately medical training has not been improved by this costly change in how graduate education is now supervised. Instead, it has increased the cost five-fold. In the past, a residency program had a ratio of 1 to 4-5 faculty to resident. Now, it’s 1 to 1. That means institutions are paying a proportionate number of FTEs salaries of 200K or more to do the supervision that one faculty FTE previously did.

Hospitals, Technology and Facilities

The trend towards competitive hospitals with duplication of services, especially with satellites facilities that market to a fixed population, has literally forced them to build beyond need. This in turn has led to long term debt, necessitating an increase in fees to offset this expense. The same is true with the need to install state of the art technology ( i.e. MRI, CT scanner, De Vinci robots, etc ) at every site, rather than have designated centers for specialized tests and procedures. Clearly, every hospital can’t do everything and control costs. All hospitals don’t need helicopters just as all hospitals can’t be Level 1 trauma centers. When medical care was merchandized and the patients became customers, the competition quickly escalated cost. It became a Coke vs Pepsi race for market share. There was a time that doctors and hospitals didn’t advertise, but now, it’s a huge part of their operating budget.

Pharmaceuticals

One of the largest expenses in health care is the cost of prescription and over the counter drugs. Granted the research and development of new drugs is a major expense, the profits exceed by far the initial investment. I remember in 1958, my senior medical school class visited a Pharmaceutical company. We chose Lederle, in Pearl River, NY, for a comped [?] trip. Their major product, which they had exclusive patent rights to, was their new tetracycline….Achromycin. During a tour of their manufacturing facilities we were shown how Achromycin was being packaged. A yellow powder was being poured into 55 gallon barrels labeled for animal consumption and I asked what the difference was from the one for humans. I learned that it was the identical product, though the price for humans was ten times that for the animals. Even back then, I realized that the pharmaceutical industry was making a tremendous profit on prescription drugs and extracted every bit of profit out of the proprietary product until the patent expired. Their explanation was the cost of research and development. And once patents expired, the generic equivalents reduced cost and profit significantly.

One has only to look at the compensation that the executives in the leading companies are paid and the dividends paid to stock holders for proof of the huge profits. Presently, large sums are set aside by the industry to lobby Congress to enact legislation favorable to them. The average patient is taking three or more prescription drugs that do not cure their disease but ensure constantly increasing profits for the industry.

Insurance

As previously stated medical health insurance is a spin-off of life insurance which is based on the risk of a particular event happening. With life insurance, it’s when death will occurs to an individual in a pool of those not likely to die based on a set of parameters (i.e. age. family history, job, etc).The same risk based management is used to calculate health insurance premiums and it has been a highly profitable business. What has made the profit so enormous is that the industry has carved out high risk patients and used preexisting disease to eliminate groups of patient that are outliers in their risk formulae. Congressional legislation is taking a step towards correcting this by making health care universal and mandatory and ideally single payer.

Health Plans

Health plans were created on the premise that they would structure how care was delivered. The two models were PPOs (preferred physician organizations) and HMOs (health maintenance organizations). Each has been of value. Unfortunately, costs have sky rocketed because of over utilization or a patient payee base unable to be supported by the plan.

The concept of “one stop shop” or “buy here and be serviced here” is basically a valid one. One of the faults is that the members have to be realistic in what services are available and not insist on over utilization.

It is unreasonable to believe medicine can make all people well and automatically reduce cost, because there are perinatal, chronic diseases and afflictions that are debilitating with many ending in death. These can essentially bankrupt any health care system.

And lastly, I believe the Insurance Companies, Hospital Corporations and Pharma are willing to compromise and bargain to save on health care, because they are fearful of losing control to exact their enormous profit

In this essay, I have tried to give my overview of the Health Care Dilemma

as I see it, realizing that a solution involves both medical and moral issues.

We, as humans, must accept that men are mortal and death is inevitable.

Whether it comes prematurely or at an old age, or at the end of an artificially sustained life (realizing that a person dependent permanently on artificially sustained life is already dead.) we will all die.

When society can determine and accept the difference between premature and inevitable death, it can rationally address this element of the cost of health dilemma. Further more, the current approach of crafting legislation based on how care is paid for rather than remedying the factors cited causing the dilemma.

Submitted by;

Earle Robinson, Jr. M.D.(retired)

Director of Gyn/Surgery Ed

Assoc. Director of OB/GYN Residency(1986-2002)

Methodist oHospital Indianapolis, IN

Assoc. Clinical Prof of OB/GYN

Indiana University School of Medicine

The Demise of my Teaching and the Methodist Program

Indiana is one of the 16 states with only one medical school (Indiana University School of Medicine). It’s funding is from taxes appropriated by the state legislature. The medical school’s primary mission is to produce physicians to care for citizens of Indiana. This has always complicated how private hospitals and physicians interact (town vs. gown) with the medical school.
For years, the medical school looked on all physicians in the surrounding communities patronizingly, which caused an acrimonious relationship.
The medical school had a group of hospitals the IU Hospital Group that was part of it’s clinical base, but with so many students it had to use several private hospitals for junior and senior clinical rotations. These rotations gave the students a perspective on how physicians in private practice ( the real world ) delivered health care. And these experiences influenced some students to choose post graduate training at some of these hospitals (i.e. Methodist, St Vincent’s, etc).
As one of the faculty at Methodist, I was instrumental in a number of potential candidates choosing us because of their exposure to advanced laparoscopic surgery. This influenced their choice in the resident matching program by ranking us #1 to the chagrin of IUSM. This produced a degree of acrimony and because the process of program accreditation required an on site recertification visit every 4 years, Methodist was cited for not having a full time Gyn Oncologist by the site reviewer and when one was recruited the IU OB/GYN Department Chair(an Oncologist) would not offer a clinical professorship to the prospective candidates apparently knowing that The American Council of Graduated Medical Education ( ACGME ) required that specialty directors be clinical professors. But in the mid 1990’s a new sub specialty Urogynecology was recognized as one of the required specialties to join Ob/Gyn, Reproductive Medicine, Maternal Fetal Medicine and Oncology. Dr Benson, the program, director of the Methodist program, was one of the pioneers to form the specialty and Methodist became the 1st accredited fellowship in the country under his direction. This produced a bargaining point with IU since they did not have this required service and were unable to meet the new requirements set by ACGME. This forced an agreement between the two programs and talk of integrating the programs began.
IUSM took 7 candidates/ year and Methodist 4/year. An agreement was made that any applicant that chose either program as their 1st choice would spend 75% of their rotations on a chosen campus. And when the 1st group graduated in 4 years the programs would be completely merged. This was a complex administrative dance requiring formation of a combined resident education committee with alternating the chairmanship between the two program directors yearly.
Bare with me because the details of this arrangement produced vexation as to function and how funds were allocated and revenue from fees for service assigned.
Because institutions with approved residency programs receive government funding of approximately 30k /resident/year for the service that is provided for Medicare and Medicaid. It became a financial issue as to what funds supported salaries for staffing residents. The University using full time employees (FTE’s) and Methodist both FTE’s and volunteer staff who donated their fees for service to the program. As in most things, money became an issue. Also it should be noted that the Dean at a medical school controls the funds like a fiefdom and there is a Dean’s tax assessed each Department Chair to which all faculty contribute. A custom that those of us at Methodist were not about adopting and Methodist Hospital Inc. was not about to split funds with IUSM. I know this is probably a little more than you want to know but it is important to understand what transpired next, because it had a huge affect on the direction medicine took and how it is being taught and practiced in the USA today.
Let me digress for a bit. When physicians are self employed it behooves them to be efficient and productive, but there is no incentive for salaried physicians to be equally motivated. This became one of the obstacles to any integration of the philosophies of the two institutions. A second impediment was that historically medicine was taught by mentoring and a new paradigm was being develop called evidence based knowledge. And though I agreed in principal with some of it’s merits teaching was losing it’s luster for me
What happened next led to the dissolution of the Methodist Residency program, a merger with IUSM and led to the end of my teaching career.
The changes made I came to really dislike and in the end both Dr Benson and my positions as full time faculty at Methodist were dissolved.
To finish out my schedule to retirement consisted of the mundane position as a physician in the Methodist HealthNet clinics which was basically a 9 to 5 job that I came to detest. And the program merger eventually help pave the way to the formation of a bigger consolidation, the formation of Clarian Health Services. The story of this will be in a following chapter.

The Teaching Years (continued)

The Teaching Years (continued)

What I enjoyed most about the years I spent in the academic environment was not only the interaction with medical students and residents, but the opportunity that was accorded me by Dr Benson to expand my knowledge and to do basic research and develop technology. I had at my disposal a lab that I had crammed with all sorts of surgical and technical equipment as well as a trove of “junk” that I could use to satisfy my imagination about what needed to be developed or improved.
Historically, tools are objects that man has adapted to perform specific tasks, I took this a step further by studying whether there were surgical instruments or procedures I could improve on their function. One of the things I tried to stress to my students was that if you understood how an instrument functioned, this knowledge could improve your surgical technique. An example of this was: why did a particular clamp have a curve or teeth in a certain pattern or why is a surgeon’s knot more secure and ideal for large vessels or the ergonomics of how scissor cut? When I showed them that speed in surgery was something that could be attained by eliminating purposeless movements, they could later see themselves developing into better surgeons.
One of the things most stressful in teaching surgery can be likened to teaching ones child to drive; except you’re dealing with trying to teach how to operate on a human being. At times it would be so much easier and quicker to do the surgery yourself but the student has to learn and the good teacher has to have the patience and temperament to endure the learning curve or one misstep could be catastrophic; not only to the patient but to the budding surgeon’s confidence. One of my better residents loss a patient and switched to a non-clinical program being unable to cope with the reality that death is always a part of medical care.
I had the philosophy that the earlier in ones career you are allowed to operate with the proper instructions, the more competent you would be later in your training. I am sure that most of the residents I trained would agree with this. It must also be said that some physicians do not have that special something that it takes to be a surgeon and it’s better to find this out early in ones training.
During these years, there were so many things happening in the field of Gynecology like new concepts of disease and the research and development of treatments were exciting and of enormous interest to me. I was extremely fortunate to have been totally supported by my director and also have the resources of the hospital’s research lab at my disposal.
My interest spanned a whole litany of subjects that I felt needed to be investigated or developed and I would sometimes awake at night and an idea would pop in my mind which I would jot it down and go into my lab to work out the merits.
Some of the many projects I worked on were either in conjunction with other
investigators or of my own interest. The list includes endometriosis, adhesions, tubal obstructive disease, sterilization methods, colposcopy, hysteroscopy, chorionic villous sampling , in-vitro-fertilization, Human porphyrin derivative use, use of Laser in gynecology, Electro surgery, hydro dissection and the use of fibrin glue. The list also includes development of better laparoscopic scissors, surgical staples and suturing techniques that were adaptable to using a cannula.
Some of the very first procedures done in Indiana like GIFT (gamete intrafallopian tube transfer) and laser ablation of the endometrium through the hysteroscope were done at Methodist Hospital under my tuteledge.
One of the things I foresaw was the ability to operate remotely with a video camera and a robotic device, this is now a reality in the “Da Vinci Operating System” being used today to perform a myriad surgical procedures.
My interest was not to just expand knowledge in gynecology but to stimulate other investigators to see the possible integration of techniques and instruments their specialties.
Though recognition of my contributions are buried in the details, I know that there is a light I lit among some of my students to question the status quo and expand it by their curiosity.
The teaching years lost it’s luster when the residency program started in a new direction. In the next chapter how a merger with IUSM became a reality and ended what I feel was one of the best OB/GYN programs in the country.

The Teaching Years

While I was focused on developing Pelviscopy after becoming the Associate Director of the OB/GYN Residency program at Methodist Hospital my basic duty was to train residents in Gynecology according to specific guide lines set by the Council on Resident Education for Obstetrics and Gynecology (CREOG). After taking the position, I made a commitment to teach in a way I had wanted to be taught early in my career and strive to be recognized by the students and residents as one of the best teacher they had encountered. I have always believed that it is a duty to pass on knowledge and my love for teaching was a payment on the debt to the special teachers I was privileged to have.
I had a 3 ring binder that I kept all of my lectures filed and tried to make the difficult easy and fun to learn, spicing them with colorful anecdotes and in surgery dropping “pearls” about techniques to make them better surgeons.
One of the things I first noticed after I started was when cases were presented either for staffing or at grand rounds, the residents lacked skill in how to properly present them succinctly. So I introduced how to format cases into the curriculum and I tried to teach some basic things and develop lectures that covered subjects in a way that was not threatening. And over the years I was awarded both “ The Best Teacher and Distinguished Professor Awards” which I treasurer as a measure of my teaching ability and value to the program.
I have always believed that learning is a continuum of life’s experiences, so I incorporated what I had gleaned from nurses, surgical techs, professors and
other l ancillary personnel to create a lesson plan I could follow that would take advantage of my knowledge to train my residents and medical students to the best of their abilities. I always repeated to myself what would I like to know and how would I liked to have been taught. This was my mantra for teaching!
I put together a course that I directed towards medical students that covered basic surgical skills, things that I had never been formally taught but had picked up. Things like how instruments came into use and how they worked ergonomically, why you use certain suture and the reason that specific knots are used for different tissue (i.e. surgeons knot vs a granny knot). I showed student in their junior clerkship these techniques so they would not feel awkward when asked to perform in the operating room as I once had.
Every time I gave a lecture, I always put it in a way that challenged me to teach as I was learning the subject for the first time. And I believe that my awards were in recognition for that passion for knowledge I passed along.
It should be stated that the OB/GYN Residency program was in a state of transition when I joined. With only 3 programs in the state it was in competition with IU and St. Vincent’s Hospital for candidates in the national resident matching system. IU
had 7 residents/yr, Methodist 4/yr and St. V’s 3/yr. It seemed that the top candidates 1st choice was Methodist especially those who had attended IU School of Medicine.
One of the unique things about the Methodist program was the vast clinical exposure that resident were getting because they were assisting attending physicians on their private cases and that they had their “own clinic” called the OB/GYN Care Center that was run like a private office. A concept that was put together by Dr Benson the program director.
In 1989 to evaluate the program, a retreat was held, the entire staff along with the residents met at a near by lodge to brain storm what were the program’s weaknesses, strengths and direction.
Because I believed that gynecologist in general were poorly trained in surgery, I suggested to the resident education committee that methods be instituted to enhance our residents exposure to surgery by having them rotate on general surgery in their intern year, having surgical techniques taught both by lecture and animal labs and doing a rotation where they were assigned to my service.
What I suggested was that since one of the duties in my job description was to perform all the Gyn surgery for Healthnet, it would be a clinical bonanza for the residents to be assigned to me as part of their Gyn service. At the time the OB/GYN Department had a contract to perform all the Gyn surgery for the Healthnet a community based agency that provided care for the indigent at 5 centers around the city of Indianapolis and performing the Gyn surgery was part of my duties. With a patient base of approximately 14,000 patients seen a year this provided a ideal clinical exposure.
When graduating medical student are applying for residency one of the question most asked during interviews is how much surgery will I be allowed to do. And it is known through out the country that some programs offer a stronger clinical base then others. We at Methodist were in position to use this as a strong recruiting tool. This became a favorite rotation.
I think it is important to understand that one of the most sought after services in a residency that deals with surgical procedures is to be in situations where you can be 1st assistant or primary surgeon. It was what the Healthnet service provided. The resident tagged with me in their 2nd and 3rd year and saw the patients in the clinic, assisted in making the diagnosis and scrubbed on the surgery with me as the attending surgeon. No resident could be bumped from a special case unless the chief on Gyn had never performed the surgery, in those cases the resident that worked up the case was the 1st assistant. This particular benefit went a long way in making our program attractive in the matching choices.
From my point of view it was a real stimulation to teach one on one residents who wanted to learn and have them over 2 years and see their cognitive and clinical skills reach fruition. They could wait to be on my service and it was basically a 24/7 rotation except when they had OB night call. Our day would start with rounds on postop patients, see patients at one of the Healthnet sites, see my private patients in my office and scrub with me on all surgeries 2 days a week in what was called block time. Also they had the opportunity to observe any technology or research project I was currently investigating. This gave them so much experience by the time they assumed chief resident, that they were more than willing to give up operative cases to a lower year colleague. When case lists of procedures were turned in each quarter for the Resident Review Committee our residents were far more experienced than most programs in the country. This was one of the things I was most proud of having put together towards resident education.
The Methodist OB/GYN Residency Dr Benson took over went from a scale of 5/10 to 9/10 based on the total opportunity to learn and turn out superior graduates. I was just part of a total package that included the Center Maternal Fetal Medicine and Genetic Diagnosis and Counseling, The Center for Reproduction and Transplant Immunology and the Center for Urogynecology and Pelvic FloorSurgery. These were heady times and we were getting our residents accepted in post graduate fellowships at some of the most prestigious programs in the country.
I was basically a gynecologic surgeon with a fascination for technology that was coming on line in medicine that complimented advanced laparoscopy and minimally invasive surgery. Things like Colposcopy, Hysteroscopy, Micro-surgery and the use of Lasers in Gynecology. All these technologies I learned and began teaching to others on our attending staff and surgeons in our surrounding referral base and to our residents. I was then appointed to the position Director of Gynecological Surgical Education.
I like to think that I had a meaningful impact on Methodist Hospital’s place in teaching and research in the time I spent as a member of the faculty.
But as in life nothing is static and in an attempt to adapt to a growing changes in hospital and medical education the hospital and resident education began to go in a different direction. Most of it I believe they would now reverse if given the option. The changes that evolved will be related in the story that follows.

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Rejection, Recognition and Reward

The idea that I had formulated in 1986 to advance Pelviscopy had reached fruition with the embracing of minimally invasive surgery in the 1990’s, primarily Cholecystectomy. But it did not come easily or without rejection, impediments and jealousy. I distinctly remember one member of our staff saying “since you didn’t learn how to do laparoscopy in your training who are you to teach us something so advanced”. To which I replied “I’m basically a surgeon, I can technically operate anywhere in the abdomen but I choose not to, so what about you!” There is an axiom that is often quoted in medicine about doing procedures that goes “See one, do one, teach one.” I had a hell of a surgical foundation in my residency, much better that most gynecologists and was complimented often by general surgeons as to my abilities. Indeed there was no gynecologist on our staff who could come close to out operating me. With this confidence I was ready to face any and all adversity.
My base of support was really Benson, who knew if I was given a task it
was done when I was involved.
I knew that the OB/GYN section was reluctant to embrace anything new or different from when I joined the staff in 1963 and things had not changed They were still having heated debates in section meetings about the most mundane procedural things, sometimes a 7 PM meeting would drag on until midnight with inane arguing.
I had received IRC approval to do animal studies to deal with the technical aspects of performing surgery but there was no administrative support from medical education for financial seed money
So when, I went to the Director of OR Services Dr. Edwards, I had only Benson’s support. But when it turned out that lapcholes were going to be a winfall the equipment couldn’t obtained fast enough once the general surgeons were all wanting to do the procedure.
It was as if my idea wasn’t worth supporting until another discipline (surgery) validated it. Dr. Edwards was now imploring me to use my contacts in the industry to obtain sets of instruments and equipment from any source available.
Since I was the expert in developing and teaching the technology, I had personal contacts with which company or supplier had what was needed and was advising Connie where to purchase the equipment, which was now scarce nationwide.


Once the first lapchole. was performed by Dr. Rich Graffis and I in 1990, we collaborated to put on a symposium with a practicum animal lab for surgeons in our surrounding communities. We had so many applications, we could only accommodate 16 attendees. This was so well received that it mushroomed into what we later called mini-fellowships in which we trained surgeons in a special course we designed. I taught the didactics of laparoscopy and Grafffis allowed them to scrub in with us on 10-15 cases a week. The $1,500 fee that was charged for these courses was turned over to the general surgery education fund. A total of 70+ surgeons were trained at Methodist by us over the ensuing year. We both were than asked to teach courses that were being given periodically nationwide due to the demand for instructors.
In 1992 the NMA ( the black medical society) held it’s annual meeting in Indianapolis, and I offered to provide a training symposium for the Surgical Section. The course was specifically designed to teach Black surgeons how to perform Lapcholes for all that wanted learn at a reasonable cost at a convenient location. I don’t know how many of the attendees expanded their training, but I have never had any acknowledgement of my contribution to their surgical skill by the NMA or it’s Surgery section. I think one has to remember that white surgeons had embraced lapcholes as the acceptable way of removing the gallbladder and the open method was basically not indicated. Financially any Black surgeon who could not do lapcholes was losing patients.
One of the things I stressed in courses and teaching my residents was safety and knowing the equipment so a procedure would not have to result in a laparotomy (open abdomen) because of technical problems. This was one of the reasons I insisted on having a dedicated team of nurses who were able to trouble shoot problems.
I remember after giving a presentation to the surgery section at Methodist only one of it’s members, Dr. Cedric Johnson, came up to me and thanked me on their behalf for sharing my knowledge unselfishly with them. It at least showed me that some one recognized my contribution, appreciated it and expressed it.
During this period a tragedy occurred that brought an interesting series of events that connected 2 countries Japan and the US. In the late 1980’s Subaru Motors built a factory in Lafayette, IN. One of it’s executives was brought to a local hospital and died of a heart attack probably due inability to communicate. The Subaru Corp had close ties to Purdue Univ. and Dr Lloyd the president of Methodist and Dr Beering the president of Purdue Univ. were close associates and set up an exchange so that bilingual physicians from Japan could come to the US to act as interpreters for their employee’s medical conditions and as a bonus could avail themselves to American graduate medical education at Methodist. One of the physicians happened to be a young OB/GYN who Lloyd told what I was doing with Pelviscopy and asked me to tutor him.
His name was Toshio and he would come every Tuesday for me to teach and to observe my cases in surgery. We became very friendly and I attempted to learn some Japanese words and phrases. The doctor’s dining room had a great luncheon menu and I would treat him every time he came. One of the selections they always served was a huge standing round of beef roast, which he ordered every time. I told him he could have as much as he wanted and he would make 2-3 trips to the carving board. So I asked him what was his favorite American food. He said steak and that he and his wife would go to Kroger and buy a dozen porterhouses at a time a bargain compared to the 30-40 dollar/ pound price in Japan, all the while scarfing down roast beef. So to practice my Japanese, I asked him what was the word for roast beef. He said “roooast ah beef”. I said,” no what is the Japanese word” for example I said octopus is “toku su”. I repeated my question and he replied “roooast ah beef”. I was getting exasperated and said “ bull shit Toshio” What is it in the Japanese?
“Roooast ah beef Robi san, that’s it”…… then I realized there was no translation. We laughed and really bonded and I would tease him about not having a translation for his favorite food.
When he left he thanked me profusely and some months later the president of Subaru Motors made a special trip to the US and personally visited Dr Lloyd and brought him a gift of thanks and I was given a kimona as a token. The act of respect and thanks that was given to us still impresses me to this day especially since it was not as forthcoming from some of my colleagues.
Though rejection finally led to some degree of recognition during any reward came from being commended for my teaching. The residents awarded me the honor of best teacher of the year in 1989-90 and the senior class at Indiana University presented me with the Distinguished Professor of the Year Award that year. This was the only time anyone at Methodist had be so honored. I was also elected to the American College of Surgery unanimously by the local chapter in the same time frame.
My goal was always to advance laparoscopy (i e. pelviscopy) to new heights and I feel I achieved that and more by the expanded applications of the technology that are now common place.