The Boston Phoenix
December 10 - 17, 1998


The mad doctors of Massachusetts

Doctors say cost-cutting is ruining medicine, but can they offer a solution that won't break the bank?

Medicine by Tinker Ready

The scene at Faneuil Hall on December 2 had all the trappings of a pep rally, including balloons, skits, and sing-alongs. But the overflow crowd of doctors, nurses, and medical students who make up the Ad Hoc Committee to Defend Health Care had little to cheer about. They're mad -- really mad -- about changes to the medical and insurance systems in recent years that have affected the way they deliver health care. They're outraged over the growing number of uninsured patients. And they want to take another stab at change.

"Never before have I encountered such a breakdown in our system of care," committee chairman Bernard Lown, a cardiologist, told the audience. Lown shared the 1985 Nobel Peace Prize with Dr. Eugene Chazov on behalf of International Physicians for the Prevention of Nuclear War, an organization they cofounded.

The villain, according to committee members, is managed care, the system of insurance coverage that was designed to cut the cost of health insurance and solve the problem of double-digit medical inflation. Instead, they maintain, "profit-driven" managed care is failing patients by giving bean-counting insurance bureaucrats too much control over life-and-death medical decisions.

And they brought Harvard economist John Kenneth Galbraith to the Faneuil Hall meeting to say it for them. "This is a situation that is inherently, basically wrong -- that is inherently, basically cruel," he told the crowd. "Community control of our health service is the only proper way."

Could this be the makings of the next wave of health care reform, a movement paralyzed by the failure of President Clinton's Byzantine "managed competition" proposal? Probably not. It is, after all, in the words of the Ad Hoc Committee's executive director, physician Susan Bennett, a "small grassroots movement with no money and very little political clout."

Still, the group reflects the state of near-panic among doctors coping with the brave new world of medicine. Gone are the days when insurance companies simply paid the bills. These days, cost-conscious insurers tell doctors such things as what drugs they can prescribe, who qualifies for bone-marrow transplants, and how much they're allowed to charge for procedures.

So we now have doctors -- members of society's elite -- complaining about "profiteering," the "commodification" of health care, and the evils of the corporate bottom line. Some of them, like David Himmelstein, a Cambridge doctor and long-time advocate of national health insurance, are veterans of health-reform battles of the past. Others are recent converts who are more certain about the problem than they are about the solution.

"My most right-wing colleagues -- who used to say, `You communist bastard, stop doing this' -- are now asking where they can sign up," Himmelstein says. In fact, more than 2300 Massachusetts doctors, nurses, and other health workers signed their names to "For Our Patients, Not for Profits," the group's founding statement, which appeared a year ago in the Journal of the American Medical Association.

"Mounting shadows darken our calling and threaten to transform healing from a covenant to a business contract," the statement read. "The time we are allowed to spend with the sick shrinks under the pressure to increase throughput, as though we were dealing with industrial commodities rather than afflicted human beings in need of compassion and caring."

The level of dissatisfaction is so high among doctors that even the staid New England Journal of Medicine took note. "Many physicians are dismayed," executive editor Jerome P. Kassirer wrote in a recent editorial. "Some are frankly morose. . . . There has been an undercurrent of unhappiness among physicians for many years, but the complaints seem more widespread and more strident now."

This may be a case, though, of a cure that's as bad as the disease. The stringent oversight of medicine came about as a result of runaway health care costs, which doctors had a hand in driving up. The nation's overall tab for health care -- including federal spending and private insurance costs -- rose by between 10 and 12 percent every year from 1970 to 1990. An oversupply of hospital beds, the high cost of drugs, and the advent of expensive new medical technology such as the MRI helped fuel those increases. But so did waste, unnecessary testing and treatment, and outright fraud.

For the past few years, the annual increase has been shrinking; it's now down to 4.9 percent. Much of that decrease is due to limits on government spending for programs such as Medicare. But analysts at the Health Care Financing Administration, the federal agency that runs Medicare and monitors national health spending, credit the rise of managed care with tempering the cost of insurance on the private side.

Consequently, all this doctor angst makes Brandeis University health care economist Stuart Altman uncomfortable. The crisis defined by the Ad Hoc Committee to Defend Health Care, he says, springs not just from the drive for corporate profits, but also from a well-intentioned, much-needed effort to control costs. Altman, a front-line player in Washington-based health care reform efforts, worries that by making "for-profit" managed care into a "bogeyman," the doctors may be losing sight of what caused the problem in the first place.

"I think we've got to get at the real issue -- do we want to contain the cost of health care?" says Altman. The doctors say they do, but they also want a system that allows for high-quality care, and coverage for the more than 40 million Americans without insurance. Just how to achieve that is the $1.1 trillion question -- the amount of the nation's 1997 health care bill. And although the angry Massachusetts doctors promise to play a role in bringing back a professional ethic to displace the corporate ethic now taking root, some critics say the doctors may be too narrowly focused to serve as the catalyst for true reform.

The doctors' group is working toward a 2000 statewide referendum calling for a ban on for-profit health care in the state and the creation of a statewide coverage program for the uninsured. Lofty goals, but the last attempt at universal health insurance in Massachusetts unraveled before it ever became a reality. And most of the major hospitals and insurers in the state are already not-for-profit.

In the meantime, the momentum is moving toward piecemeal solutions like the "patients' rights" legislation pending in both Washington and Boston, which would give patients more power to challenge insurance-company rules. But even that approach can't seem to get out of the gate, in no small part because of the $60 million spent by the insurance lobby to fight it.

In the meantime, health care consumers can expect the worst of both worlds. Costs are beginning to creep up again, promising higher insurance premiums. And horror stories about the excesses of managed care abound. The Faneuil Hall meeting featured a parade of doctors, nurses, and family members with tales of patients who were denied needed treatments or discharged from the hospital too soon (video of the meeting is available on the committee's Web site, at

And, according to NEJM editor Jerome Kassirer, you're not likely to find your doctors in very good moods these days, which in itself may not be good for your health. "One thing we know," Kassirer wrote. "Disgruntled, cranky doctors are not likely to provide outstanding medical care."

Tinker Ready, a freelance science writer living in Cambridge, can be reached at

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