The Evolution of Modern Medical Practice

Strategic Management of Health Care Organizations26 Jan 2006

Edward P. RichardsProfessor of Law, LSU Law Center

History of Medicine and Medical Science

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Shamanism

Oldest Medicine Primitive Tribes Integrates Religion And Medicine Persists Even Today In So Called Modern

Cultures Alternative medicine Psychotherapy?

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Explicitly Ministers To The Psyche And The Body

Often Sophisticated Rituals And Herbals Driven By Myths Trial And Error And Careful Observation Some Cure, Most Do Not Leviticus

Public Health Code Rules Reduce Food Poisoning

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Useful Pharmacopeia

Ethnobotany Study Of Plants Used By Ritual Healer Many Drugs Have Been Discovered Witches Used Foxglove - Digitalis

Medicinal Chemists Refine And Modify Botanicals Who owns the IP?

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Greco-Roman Rationalism

Galen And Successors Driven By Rational Theories Religion Is Left To Priests Observations Forced To Fit Into The Theory

Plato Was Terrible About This Mistakes Are Not Corrected

Persisted Until 16th Century

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Hospitals as Religious Institutions

Started in Europe in the Middle Ages Some of the Oldest Institutions in

Continuous Operation Run by Nursing Sisters For the Poor More Egalitarian in the United States

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Nursing Only

Church Did Not Sanction Medical Care Goal Was to Alleviate Suffering Ease the Transition to Heaven Most Died From Their Illnesses

Only the Very Sick Entered Excellent Environment for Infectious

Diseases Changed With Technology in the 1880s

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Scientific Medicine

Not The Philosopher's Scientific Method The Imperative To Disprove Theories The Full Disclosure Of Information

Science Is Constantly Questioning And Rethinking Scientists are also people They are susceptible to conflicts of interest Fame is often more important than money

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Paracelsus

Philippus Aureolus Theophrastus Bombastus Von Hohenheim

Early 16th Century Transition From Alchemy Experiments And Systematic Observations Antimony

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Anatomy And Function

Andreas Vesalius Mid 16th Century Accurate Anatomy

William Harvey Early 17th Century Flow Of The Blood And Operation Of The

Heart

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Edward Jenner

Smallpox Major Killer Along with Measles, Wiped Out The

Indigenous Peoples 1798 – Published His Book On Cowpox

First specific treatment based on scientific observations

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William Morton

Dentist Ether Anesthesia 1846 Rejected by the medical profession and died

penniless

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Ignaz Philipp Semmelweis

Childbed Fever Fellow Medical Student Died Controlled Studies 1849 Rejected by the medical profession and died

penniless

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John Snow

Cholera In London Broad Street Pump Proved Cholera Is Waterborne 1854

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Louis Pasteur

Scientific Method Germ Theory Vaccination For Rabies Pasteurization 1860s-1880s More powerful than the medical profession

Was friends with the wine growers

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Joseph Lister

Antisepsis 1867-1880s Listerine

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Koch - 1880s

Koch’s Postulates Agent Must Be Present In Every Case; Agent Must Be Isolated From The Host And

Grown In Vitro [In A Lab Dish]; Agent Must Cause Disease When Inoculated

Into A Healthy Susceptible Host; And Agent Must Be Recovered Again From The

Experimentally Infected Host. Limitations

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Organic Chemistry – 1880s

German/Swiss Dye Industry Bayer Hoffman La Roche Ciba

Became Drug Chemistry

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Sanitation Movement in Public Health

Shattuck Report - 1850 Water Sewage Food Sanitation - FDA - 1905 Life Expectancy Goes from 25 – 50+ fast Slowly Rises to 76.5

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Tuberculosis Control - 1900

The Major Killer Koch And Pasteur Sanatoria Pasteurization Of Milk Disease Control Of Dairy Herds Effective Drugs Came Later

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Antibiotics

Sulfa Drugs In The 1930s Penicillin

Alexander Flemming – 1928 Purified By Chain And Florey In 1939

Streptomycin – 1944 First Antituberculosis Drug Selman Abraham Waksman – 1944 (Coined The Term Antibiotic)

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Medicine and Surgery - 1890s

Medicine Starts to Work Surgery Can Be Precise Patients Do Not Get Infected Professionalism Starts to Matter

What is a Quack if Nothing Works? Why Train if Training Does Not Matter?

We will see that this is key to legal regulation of medicine

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Hospital-Based Medicine

Started With Surgery Medical Laboratories

Bacteriology Microanatomy

Radiology Services and Sanitation Attract Patients

Internal Medicine Obstetrics Patients

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Reformation of Hospitals

Paralleled Changes in the Medical Profession Began in the 1880s Shift From Religious to Secular

Began in the Midwest and West Not As Many Established Religious Hospitals

Today, Religious Orders Still Control A Majority of Hospitals

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Post WW II Technology

Ventilators (Polio) Electronic Monitors Intensive Care Shift From Hotel Services to Technology

Oriented Nursing Became capital intensive

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Post World War II Medicine

Conquering Microbial Diseases Vaccines Antibiotics

Shift to Chronic Diseases Better Drugs Better Studies Leukemia

Chronic Diseases are much more lucrative

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Hospitals Shift From Nuns to Paid Staff

Advantages of Nuns Work Cheap Work Long Hours Well Organized and Disciplined Keep Physicians In Line

Supply Plummets Replaced With Paid Staff Not Many Nuns Even In Religious Hospitals

Governmental and Private Regulation of Medicine

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Pre-Constitutional Period

Limited Occupational Licensing NY Passed Licensing Law in 1760s Not Enforced

Extensive Public Health Regulation Old Notion of Dirt Nuisance

Managing Fear People Terrified of Epidemic Disease Yellow Fever and the Constitution

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Constitution - Post Civil War

Jacksonian Populism and Distrust of Institutions

Decline of Occupational Licensing Existing Laws Were Rescinded Doctors Lawyers

Continued Growth of Public Health Regulation Driven by Snow’s Discoveries Shattuck Report – Boston - 1850

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Schools of Practice – Mid 1800s

Allopathy Homeopathy Naturopaths, Chiropractors, Osteopaths, and

Several Other Schools

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The Profession - 1870s

Most Medical Schools are Diploma Mills No Bar to Entry to Profession

Small Number of Urban Physicians are Rich Most Physicians are Poor

Cannot Make Capital Investments Training Medical Equipment and Staff

Physicians Push for State Regulation

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Authority to Regulate Medical Care and Public Health - The Police Power

Historical Right of Societal Self-Defense Central Colonial Function

Not Police Forces Public Health and Safety

Left to the States by the Constitution Can Be Preempted by Federal Legislation

Tobacco Labeling Medical Device Labeling

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Constitutional Attacks on State Regulation of Medicine

Equal Protection/Due Process Discriminating Based on Training Discriminating Based on Theory of Practice

License as Property Right Inception of Licensing Laws Discipline of Licensees

All Trumped by Police Power

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Constitutional Limits on the Police Power

Civil Rights Chinese Laundry Cases Other Shams for Discrimination

Contraception Sterilization and Abortion Access to Adequate Pain Relief?

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The Role of Legal Regulation in Professionalizing Medicine

Protection of Licensees Quality of Care Availability of Care Fair Pricing Governmental Interests

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Protection of Licensees

Critique from the Left Paul Starr - Social Transformation of

American Medicine Critique from the Right

Milton Friedman “Hostile” v. “Friendly” Licensing Not Incompatible with Other Goals

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Improving Quality and Availability of Care

Require Training Exclude Unorthodox Practitioners Discipline Incompetent or Impaired Docs Subsidize Indigent Care with Required

Treatment Mandates EMTALA Medicare/Medicaid Non-Discrimination

Rules

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Fair Pricing

Sustain Prices to Assure Supply Prevent Monopoly Pricing Prevent Gouging Based on Patient’s Limited

Bargaining Position Emergency Conditions Emotional Vulnerability Lack of Knowledge

This never worked very well

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Governmental Interests

Cross-Subsidize Government Programs Tax the Profession Political Influence of Professionals Draw on Professional Expertise

Traditional Public Health Traditional Mental Health

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Licensing and Education

Mid to Late 1800s Physicians are Solo Practitioners Most Make Little Money Have Limited Respect

Effective Medicine Drives Licensing Licensing Limits Competition

Physicians Start to Make Money Makes sense to invest in training

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Consolidation of Power

American Medical Association Gains Power Linked State and Local Societies to the National

Society Linked Medical Staff Membership to Local and State

Society Members Exclusionary Politics

Blacks Women Jews

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Reform of Medical Education

Schools with High Standards Could not Compete Degree Cost More Took More Time Did not Affect Entry to Practice or Success

Race to the Bottom Schools Were Closing Curriculum was Weakening

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Outside Forces

Carnegie Foundation “Flexner Report” Most Schools Failed Not Like US News and World Report Rankings

Incentives to Change Foundation Money Student Selection Pressures

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Effect of Licensing

State Required Training in Approved Programs Some Programs Were Not Approved Some Unorthodox Practitioners Had Their Own

Schools so They Cooperated Students Had an Incentive to Attend a Better

School

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How Did Medical Schools Change?

Professionalism of Faculty Full-Time Salaried Positions Education Requirements

Emphasis on Research Driven by Outside Money Reinforced by the Success of the Research

Development of Modern Residency Training

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What Happened to Unorthodox Practitioners?

Homeopaths and Osteopaths Homeopathic Schools Closed Osteopathic Schools Evolved to be Much the Same as

Other Medical Schools Osteopaths are Now Licensed and Treated the Same

as Other Physicians Chiropractors

Politically Very Powerful Got Their Own License and Allowed to Keep Practicing

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Where Are We Now?

All States Require A Medical School Degree Most Require One Year Post-Graduate Residency

Training No States Have Separate Licenses for Specialties Private Certification of Medical Specialties

Required by Most Hospital and Health Plans Extra Training and Examinations

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Joint Commission on Accreditation of Hospitals

1950s Now Joint Commission on Accreditation of

Health Care Organizations American College of Surgeons and American

Hospital Association Split The Power In Hospitals

Medical Staff Controls Medical Staff Administrators Control Everything Else

Enforced By Accreditation

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Contemporary Hospital Organization

Classic Corporate Organizations CEO Board of Trustees Has Final Authority Part of Conglomerate

Medical Staff Committees Tied To Corporation by Bylaws Headed by Medical Director

Constant Conflict of Interest/antitrust Issues

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Hospital Economics - Old Days

Patients Are Necessary More Patients Meant More Money Docs Admit Patients Insurance Was So Generous It Cross-

subsidized Indigent Care

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Hospitals Have High Fixed Costs

Capital Costs Not Built on the Donations of the Faithful

Anymore Ancillary Services

Lab, Etc., Must Be up for Even One Patient Nursing Can Be Cut Back, but Only by Closing

Units Pretty Hard to Get Excited About Malpractice

Risks Unless You Can Fill Every Bed in the Hospital

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Value of An Admitting Physician

Only 2 Cases a Day, Average Stay a Week Each Case Is Worth $15,000 to the Hospital Over

the Week 10 Beds Filled at Any One Time Take a Month Off, Have a Few Slow Days, Say

Only 400 Patients a Year. $6,000,000 a Year If You Are Sloppy, They Just Stay in the Hospital

Longer

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Physicians Owning Hospitals

Originally Was Unethical to Own a Hospital Conflict of Interest Exception for Small Towns

Changed When Hospitals Made Money Characteristic of Medical Ethics Lawyer Ethics Are Also Pretty Flexible

HCA Was The Model - Interesting Times

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Physician Practices Pre-1990

Sole Proprietorships Partnerships Mostly Small Some Large Groups

First Organized As Partnerships Then As Professional Corporations

Shaped by Corporate Practice Laws

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Corporate Practice of Medicine

Physicians Working for Non-physicians Concerns About Professional Judgment Cases From 1920 Read Like the Headlines Banned In Most States Real Concern Was Billing By A Non-

physician Not as strict in Louisiana, but followed

national staffing models

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Impact of Corporate Bans

Physicians Do Not Work for Hospitals Contracts Governed by Medical Staff Bylaws Sham of “Buying” Practices

Physicians Contract With Most Institutions Charade of Captive Physician Groups

Managed Care Companies Contact With Group Group Enforces Managed Care Company’s

Rules Physicians Can Be As Ruthless As Anyone

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Where Do Physicians Get Business?

No Referral or Finders Fees Unlike Lawyers, Docs Generally Do Not Pay

Them Because of Real Penalties Goodwill, No Grief on Peer Review Now Patients Are Controlled by Managed

Care Organizations Not as true in LA

Managed Care and DRGs

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Managed Care Pressures on Hospitals

DRGs Capitation Negotiated Reimbursement Still Need Butts in Beds Must Get Them Out Quick and Cheap Death Can Be Very Cheap Right to Die – Yes Please Do!!

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Right to Die - Old Days

Technological Imperative Every Day Every Procedure Every Increasing Stage of Intensive Care Big Money Just Making It Past Midnight Might Be Worth

Another $2,000.

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Managed Care Pressures on Docs

When is Denying Care Cheaper? What is the Timeframe Issue? Insurers Now Control the Patients Employee Model Contractor Model De-selection

Financial Death No Due Process

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Right to Die - Today

DRG payments do not increase with increased stay in the hospital

Most private insurance also has limits and will pressure the hospital to transfer the patient to a nursing home

Nursing homes do not do high tech care Limits on nursing home reimbursement

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Specialty Hospitals

Benefits Regionalization improves technical care Are we really seeing that?

Real Business Model No Emergency Room No EMTALA duties - more next time

Destabilize Community Hospitals No indigent patients Dump complicated patients back

New Challenges

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Emerging Infectious Diseases

Antimicrobial Failure New Agents HIV, Ebola, SARS Bioterrorism Flu pandemics Excess Capacity is Surge Capacity

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Managing Emergencies such as Hurricanes

Should major facilities be in evacuation zones? What should the planning look like? Who should pay?

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Obesity and Life Style Diseases

The medical care system, especially in LA, is geared to acute care and procedures

The medical needs are primary care to prevent and mitigate chronic diseases

The current system is the most expensive and least effective approach

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Aging Population

Politicians want to control the growth of Medicare

The population is aging so the number of enrollees will continue to rise

As the population ages, there will be more years in the program, and thus higher total costs

Health is not cheap

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Health Care as a Tax on Labor

Look at the airlines and the car companies Employer paid health care is a major tax on labor

intensive businesses Automate Ship jobs overseas

Not good for the economy Tax paid health care spreads the cost over all

businesses and individuals and does not penalize labor intensive businesses