Making It Better

THE U.S. MEDICAL care system is not well. Politicians, academics and physicians agree on that. Even controversy-shy President Bok can feel safe writing in his latest annual report that society is deeply troubled over issues like the system's cost and the dubious benefits to health of the nation's massive outlays for care. Close to ten per cent of the gross national product is now spent on medical care. Bok suggests that Harvard--specifically the Medical School--should try to improve the effectiveness and efficiency of medical care. He also says the school should seek better ways of training physicians to deliver primary care.

Attractions like scientific prestige, high pay, and limits to financial responsibility have drawn increasing numbers of medical students into specialties. Most observers agree with Bok that an increase in the number of physicians working in the old general practitioner role could provide a major improvement in the country's health. These primary care physicians would bring together the disparate methods of specialists--such as lab tests and limited examinations--to take a better look at the whole patient. Primary care physicians can also add an understanding of the individual patient's personality, and the patient's life outside the hospital or clinic. Medicine is looking back to realize that a friendly ear and a sympathetic eye can sometimes do as much to keep a patient in good health as the most expensive and sophisticated equipment.

Bok's criticisms are safe because they are nothing new. Dr. Robert H. Ebert, dean of the Medical School, saw these troubles in American medicine and was already working on a way to overcome them when he came to the school as dean in 1965. Ebert came with the hope of setting up an alternate system of care that would over-come the problems of impersonal, over-specialized, costly care. His political ability proved stronger than the inertia of the staid Medical School faculty, and in 1969 the doors of the Harvard Community Health Plan (HCHP) opened.

Plans like HCHP were already in operation elsewhere, but HCHP was, and still is, the only plan of its kind in Boston. Like a conventional health insurance plan, HCHP collects a monthly charge from its members, who need only reside in the greater Boston area to join. But unlike those conventional plans, HCHP is non-profit, and is itself responsible for providing the health care that its monthly charge guarantees. Members go to one of two HCHP facilities for all basic services, which are provided either at no additional charge or in some cases at merely a nominal charge.

BUT HCHP facilities are not hospitals. Difficult cases are referred either to Cambridge Hospital or to one of five Harvard affiliates. Not only does HCHP bring the name of Harvard out to the people of Boston--it also brings the people of Boston in to Harvard teaching hospitals, for treatment by physicians who hold appointments on the Medical School faculty. Officials expect that the present enrollment of 65,000 Boston area residents will increase to between 125,000 and 175,000 in the next five years. By 1982, HCHP should provide Med School faculty members with a sizeable corner of the Boston area market for high-level care. The projected enrollment figures represent five to seven per cent of the area's population.

The HCHP board of directors adopted these figures as targets in a motion passed two weeks ago, but they were hardly aiming high. Richard Cannon, HCHP director of development and planning, said the figures were more reasonable expectations than they were difficult goals. But the plan's directors are not to be blamed for aiming low. They want to avoid turning the program into a health care monolith. As Cannon put it, "We don't want to create a McDonald's for medical care." However, if the plan reaches its expected enrollment for 1982, and if no competing plan has emerged in Boston, there will be good reason to worry. Someday HCHP's growth must stop, but an HCHP planning committee has reported that growth is needed to prevent the organization from "losing its vitality and sense of challenge." When growth stops, the idealists will move out and the bureaucrats will move in.

HCHP planners are idealists, but their plan is proving realistic. The plan--called variously a health maintenance organization or a prepaid group practice--is in theory the ideal answer to many problems in modern medical care. It reverses the medical establishment's economic incentives. While the conventional fee-for-service system gives physicians financial encouragement to provide more services regardless of their effect, the prepaid group practice system encourages the group to find the most efficient way to keep its members healthy. The prepayment plan thus discourages expensive overuse of highly sophisticated medical technology, and encourages the use of preventive measures.

The theoretical economic argument is working. HCHP monthly charges are in most cases below the total the participant would be charged if he held a conventional insurance policy. HCHP is also proving itself on the question of quality of care. In its own facilities, the plan relies mainly on primary care physicians, rather than on specialists.

The implementation of a comprehensive national health insurance plan, if the plan lacks special incentives for prepaid health plans, would halt the growth of HCHP and others. The advantage to potential members of lower total cost would be removed, and few would join for the advantages of group practice alone. The passage of a national health insurance bill would also take the lid off health expenditures in this country and leave no incentives for hospitals and physicians to avoid very costly and sophisticated equipment and techniques. The incentives to economize in plans like HCHP have proved that efficiency in health care does not necessitate an impersonal calculus for treatment. In fact, the kind of drastic and impersonal treatment that would be fostered by national health insurance has shown itself to be inefficient. The most economical means of keeping people healthy turns out to be preventive and primary care.