Third Party Medicine

Dr. Doenges, past president of the Associa­tion of American Physicians and Surgeons, is engaged in Private Practice-General Surgery in Anderson, Indiana.

No ethical physician would claim that he healed the patient’s wounds or made the patient well. None can do more than assist the natural processes. If the physician were the final authority, every pa­tient would recover quickly and none would die. No physician can fail to realize his personal limita­tions. He must admit the existence of a Greater Power. No other pro­fession renders services in this in­timate area in which the individ­ual faces life and death. This brings the physician into a more intimate relationship with the pa­tient than exists between the same individual and any other profes­sional person. Complete mutual understanding and confidence is essential and seldom exists outside this area of intimate contact.

The best interest of the patient requires that the individual pa­tient-physician relationship be held inviolate in every area. This includes every contact between the patient and his physician, whether it involves the history, examina­tion, and treatment, or the area of compensation for services.

Highest quality medical care cannot exist if the traditional moral and ethical concepts of medi­cal practice are violated. The key to good diagnosis is good, honest, and complete history. The knowl­edge that information confided to the physician will not be divulged to others permits even the most timid patient to give the most per­sonal, intimate, and confidential information to his physician. Con­sultants are frequently denied this same information which is freely given to the patient’s "own" doc­tor.

For thousands of years physi­cians have fought for the right to hold inviolate from all probers and other curious individuals facts elicited in the medical history and examination. These rights of privi­leged communication, granted and enforced by courts of justice, are essential for successful treatment.

In the final analysis only two individuals are involved in medical care: the patient, who has chosen the physician to whom he will en­trust his care and actually his life, and his physician, who has freely agreed to provide such care. (Due consideration is given to those in­dividuals for whom another acts "in loco parentis.") No other per­son, no "third party," is required. When any "third party" enters the picture, he is an intruder and can only reduce the uninhibited rap­port and confidence which must ex­ist between patient and physician.

Nongovernmental Bureaucracy

All are acquainted with the nu­merous difficulties and objections reported regarding the operation of "third party" National Health Insurance schemes, such as the "red tape," the innumerable form which costs with the associated tax in­creases, the increasing demands for nonessential services and sup­plies, the abuses which defy elimi­nation, the ever-increasing wait­ing lists for hospital admissions, the unreasonable delays in every area, the decreasing hospital serv­ices, the dissatisfaction among pa­tients, hospital personnel, and phy­sicians, as well as the wasteful operation and other evils to which every bureaucracy is heir. Bureau­cratic systems are not confined to governmental agencies. They can and do exist in most businesses, labor unions, and some medical or­ganizations.

These facts alone provide suffi­cient concrete reasons why govern­ment, and other "third party" "health programs" via "insurance" or "service" plans, historically re­sult in less satisfactory and in­ferior quality medical care.

Quality of Service Suffers

However, there are other and more important factors which make it impossible for medical care supplied through "third party" programs to equal or even ap­proach the quality of medical care supplied through private practice operating under the market economy.

An essential feature of quality medical practice is that the pa­tient is and must be regarded as an individual—a moral being. In­dividuality is the very basis of the practice of medicine. All medical tradition emphasizes the fact that every patient is an individual, that his ills are singular, and that he must be so regarded and treated. Health and disease are strictly personal matters.

Personal responsibility, upon which all freedom depends, is an­other basic essential in the success­ful practice of medicine. It applies to the patient as well as to the physician.

The patient’s responsibility can­not be eliminated or violated. If he withholds information or misrep­resents facts to his physician, he removes one of the basic require­ments for good care. He ties the physician’s hands. If the physician does not share the confidence of his patient, he cannot treat the patient adequately or properly and his chances of helping are greatly reduced. If the physician disre­gards the facts, the patient suffers. Medical care is not a mechanical f unction!

How Choice Is Limited

"Third party" medical care al­ways results in control of the patient and the physician by limit­ing the free choice of the patient in selecting his physician and by interfering with the individual patient-physician relationship. Physicians are frequently classi­fied, not according to ability, but on an arbitrary and unrealistic basis such as membership in cer­tain organizations or other inter­esting but relatively unimportant details. Experience, results, abil­ity, confidence of patients, and personal interest are relegated to a minor position. Physicians are rated by "third party" agencies as to the type of practice they may perform and the type of disorder they may treat.

Freedom of choice is further limited because the services which may be rendered by any classifica­tion are controlled and regulated by the "third party."

Under "third party" control, physicians are paid according to classification regardless of whether it is on a fee for services, per capita, panel, hourly, or salary basis. All "third party" programs eventually utilize the principle of "fixed fees."

Physicians who participate in such schemes must agree to render totally unknown and unpredictable quantities of service for a prede­termined fee. The "taxpayer" is promised by politicians or "third party" officials that physicians will deliver any and all services for a fee set by the "third party." In the final analysis, the "third party" always establishes the fee to its satisfaction! This procedure inevitably and obviously places the emphasis on the quantity of medi­cal care and relegates quality to a position of secondary importance.

No One Is Responsible

Under any system of "third party" medical programs the pa­tient must accept the "third party" into the patient-physician relation­ship in every area, not in the area of fees alone.

The physician is required to ac­cept the "third party" by reporting or certifying illness to someone other than the patient himself. This begins the deterioration of and destruction of the confidential nature of the patient-physician relationship.

The patient feels justified in relinquishing his responsibility in return for the "third party’s" pay­ment of fees. The physician also begins to look to the "third party" in this area of responsibility and justifies his attitude by the re­quirement of supplying the "third party" with information. The phy­sician even begins to hold the "third party" responsible for what he regards as the "proper" use of the funds removed from the pa­tient not infrequently by force, by dues, royalties, taxes, or other means.

These practices encourage the patient to divorce himself from his sense of personal responsibility to his physician in the area of fees. Having accepted the idea that someone else may rightly as­sume his responsibility, it becomes a matter of indifference to the pa­tient, and eventually to the physi­cian, who assumes this responsi­bility.

At the point where the physician accepts such an agreement, he joins his patient in flight from personal responsibility and accepts the idea that a "third party" is responsible for the payment of the patient’s bills, and in so doing, grants to the "third party" the right to establish his fees and the category in which he may func­tion.

Destroying the Market Economy

The attempt to establish "third party" medical programs is a defi­nite attempt to destroy the market economy.

Any argument in favor of "third party" medical programs may be used, by changing a few words, with equal validity to promote "third party" control of every other profession; every other need and desire; in short, of every seg­ment of the economy.

Highest quality medical care cannot survive under any system in which there is "third party" in­terference. This has been and will be true, always, regardless of the promises of politicians or business­men, the misrepresentations of labor union leaders, or the com­promises of some in the medical profession.

Remember one thing: Only doc­tors can deliver medical services. Only individuals trained and ex­perienced in the healing arts can fill the medical needs of the people of this nation.

Our obligation and responsi­bility is to the individual patient. All agreements must be with each individual patient!

We should never refuse to de­liver services to our patients but those services should be delivered to individuals as our own private patients, not as wards of the gov­ernment, a union, any insurance company, or any other "third party."

***

Socialized Medicine

Some scheme of compulsory sickness insurance [on the German pattern] exists in every European country ex­cept Switzerland where the govern­ment subsidizes the medical coopera­tives. The costs are rising relent­lessly, but nowhere as fast as in Britain. And nowhere was the insur­ance principle so completely per­verted into a communistic practice as in Britain.

Aneurin Bevan launched in 1948 the new health service that was to provide care in accordance with Len­in’s rule: Everything free of charge to everyone irrespective of means. The Bolshevists never put the idea really into operation; the British are finding out that they have caught the proverbial bear by the tail.

The experiment turned out to be much too expensive. The demand re­sponded to zero price. In nine years, British retail prices increased by about 40 per cent, the cost of govern­mental doctoring more than trebled. It amounts to more than 10 per cent of the over inflated national budget, not counting the cash payments by the "insured" or the municipal con­tributions.

What the zealous socialist could not foresee did happen: Something for nothing is extremely popular. Virtually the whole population, mil­lionaires and foreign visitors in­cluded, signed up. Aspirin was dis­tributed "by the ton," enhancing the Treasury’s headaches.

To 40 million people of England and Wales alone, 609 million pre­scriptions, 19¹/₂ million pairs of glasses, 7 million dentures, 700,000 appliances of "main types," and 130,­000 hearing aids were dispensed in less than three years.

The only check on the demand was the fact that the supplies ran out.

MELCHIOR PALYI

Nationalizations—Ten Years Later

Foot Notes

¹Tor the purpose of this discussion, the "third party" is defined as: any individ­ual, agent, or agency, through whose con­trol of persons or control and/or admin­istration of funds belonging to or assignable to the patient (or for his care), occupies a position capable of af­fecting the patient’s choice of a physician to provide medical care for himself and others for whose care he is legally and/ or morally responsible, or of affecting the freedom of the unrestricted bilateral patient-physician relationship.

This discussion does not include con­sideration of those special cases such as individuals in prisons, in military serv­ice, and the like, and the very special situation wherein industry is required by law to assume the position of "parent" in cases under workman’s compensation laws, which require more time than the patient receives, the sky-rocketing.