Article — From the October 1960 issue
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The doctor likes to picture himself as a freewheeling individualist. But from the day he enters medical school he must learn—if he wants to succeed—to play ball with a tight bureaucracy. Mr. Chase, who has reported on various aspects of medical economics in other magazines, here explores the anatomy of power in American medicine at the grass-roots level of the county medical society.
Last June a forty-one-year-old obstetrician, Dr. Joseph Garabedian, died on Staten Island, a borough of New York City which is also known as Richmond County. The cause of death was overwork, according to press reports, which stirred a considerable commotion. Dr. Garabedian practiced in a medical group affiliated with the Health Insurance Plan of Greater New York (HIP). It has half a million subscribers, many of them city employees, and 24,000 of them live on Staten Island.
HIP members—with the aid of a contribution from their employers—pay by the year rather than by the visit for their medical care, which they must get from doctors in different specialties who work as partners, sharing expenses and income. Such groups—according to the demonology of organized medicine—are “closed panels”; and the prepayment system flouts the hallowed “fee-for-service” principle. For these heresies, HIP has been anathema to the general run of private practitioners. In the Richmond County Medical Society the local M.D.s found a ruthless champion.
Staten Island is one of the few uncongested areas left in metropolitan New York. Surrounded by the waters of New York harbor, it is within hailing distance of the Statue of Liberty and only a nickel ferry ride from downtown Manhattan. Its population has been growing rapidly in recent years and many of the newcomers have joined HIP. So the local medicos took corrective action. They agreed to deny any new HIP doctors the privilege of treating their patients at Staten Island’s three hospitals. Pediatricians, a surgeon, and other well-qualified specialists were turned down.
For Dr. Garabedian and his HIP colleagues this was an extremely grave matter. Unable to get hospital privileges for an assistant, Garabedian became the sole obstetrician for all HIP babies born in Staten Island hospitals. This would have been a considerahle workload for a healthy man; Dr. Garabedian suffered from a bleeding ulcer. When he died, the outrage of his patients ex- ploded publicly. Protest meetings were staged and the situation was universally deplored by the press. The temperate and judicious New York Times pointed out editorially that the blackball of HIP doctors was not “in the public interest,” adding that hospitals which receive tax exemptions and other largess from government funds are scarcely private concessions.
But despite the public outcry, the hospitals showed no sign of yielding. Whereupon a com- mittee of the New York State Legislature decided to look into the matter.
The hearing took place on a sweltering July day in an atmosphere further heated by TV lights and the passions of witnesses. For those in- terested in the politics of medicine it was a much more enthralling spectacle than the Democratic National Convention which was simultaneously going on in Los Angeles.
As a writer interested in medical economics I was particularly grateful for the candor of Dr. Herbert Berger, past president of the county medical society, who eloquently defended the lockout. His testimony stated in concrete terms the political philosophy of organized medicine as it operates on the grass-roots level of the county society.
At the hearings, both sides—though for opposite reasons—accused each other of obstructionism, unco-operative behavior, and monopolistic practices. An uninitiated observer might have had trouble, at the outset, in judging the merits of the case. But gradually a clear pattern emerged, as the medical society’s witnesses evaded pertinent questions, set up straw men, and adopted diversionary tactics. They argued, for example, that it would be unwise to let all doctors treat their patients in the hospitals. But HIP had made no such requests; it was pleading merely for privileges for those with unimpeachable professional qualifications. Similarly, the island’s three hospitals maintained that their facilities were overtaxed. Yet obviously their beds were the only ones available. Which particular doctors referred Staten Islanders to a hospital had no bearing on the bed supply.
Two fundamental questions were never really raised: Did HIP doctors provide good medical care? And if so, by what right could the ruling clique in their profession exclude them from the hospitals?
Soft-pedaling or side-stepping these issues blandly, Dr. Berger suggested that qualified HIP doctors could, of course, get hospital privileges. All they need do was resign from HIP. Nor did he feel that Dr. Garabedian’s death was traceable to overwork, for he was not only an ulcer victim but “a person of Turkish origin.” Hence “the fall of the Menderes government”—as well as a dozen other provocations—might just as well have brought on his terminal hemorrhage.
“Of all the multitudinous problems that beset him,” Dr. Berger said solicitously, “the one that he could have most easily solved was his association with HIP. He could have resigned.” Certainly the medical society had done its best to drive the point home to this stubborn man. His associates were kept out of the hospitals. They were also, as Dr. Berger put it, subject to “social nonacceptance by their colleagues.”
“No one denies,” he added, “that this can be a devastating experience. But they have made the mistake of isolating themselves from the rest of the profession. This can be readily rectified by resigning. Many of them do just this. More than half of the [HIP] physicians who came to this community have done so.” Others, it seems, moved away. The one substantive charge against HIP doctors, that they were “disputatious” and “transients,” thus stood revealed as the consequence, quite intended, of the county society’s campaign of ostracism.
At this writing the Staten Island controversy appears to be approaching resolution. The repeated demands at the hearing for legislation prohibiting discrimination against doctors because they choose to practice in groups financed by prepayment will likely go unheeded. But at the instigation of the state legislative committee, the hospitals have been forced to accept three new HIP doctors. HIP has interpreted this as “an interim agreement” hopefully pointing the way to “further steps necessary for an adequate solution.” In fact, it amounts to a considerable victory for HIP and one more of the increasing number of instances in which organized medicine has had to bow to public opinion.
Belatedly the county society has shifted its ground. It claims now (1) that the whole altercation could have been avoided if only city employees had a choice of alternate health-insurance plans and (2) that the Staten Island doctors were motivated all along by solicitude for them. A multiple choice may in fact be a good idea. But it is hypocrisy for the society to say at the eleventh hour that this is what’s been troubling it. As Dr. Berger stated in an astonishing exchange with the legislative committee chairman, State Senator George R. Metcalf: “Sincerely, this is a personal and social matter, not a medical one. I have no question about the medical competency of these [HIP] doctors.”
Senator Metcalf: “It is a medical problem.”
Dr. Berger: “No sir, it is not, not in my eyes.”
Senator Metcalf: “That is quite an admission.”
To date the hospital spokesmen have shown no misgivings as to the propriety of their ways or the probity of their motives. Their self-righteous unction seems impermeable. Doctors, in truth, are not given to arguing it out with the laity. They have been running their own show for centuries.
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