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Chapter 1 From Community Care to 'For Profit' Industry |
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Concern for community care has existed in the United States all through its history. It has often been accompanied by efforts to provide medical services to the poor and the indigent, or to those who had common interests in the community or at work. |
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The growth of medicine has never been linear. New ideas emerge in many places that compete with others and eventually lead to evolution and compromise. In psychiatry, throughout the country's history, the surviving efforts have often been those of people concerned with the community. In colonial times, Benjamin Franklin was an advocate for the care of the mentally ill at the Pennsylvania Hospital since its opening in 1752. The first public asylum followed in 1773, at Williamsburg, Virginia. |
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The Quakers, well known for their community work, were behind efforts to create asylums in the early 18O0's that were later transformed into leading medical centers. That was the case with the Friends Asylum in Philadelphia, the McLean Asylum in Massachusetts, and the Hartford Retreat in Connecticut. In general medicine, in the late 1800s, early benevolent societies and religious groups attempted to provide non-compensated services to selected populations. |
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In psychiatry, in the mid-1800s and for 40 years, Dorothea Lynd Dix led a revolution in the community care of the mentally ill. As noted by Breakey (1), between 1825 and 1865 the number of mental hospitals in the United States grew from nine to sixty two. The Association of Medical Superintendents of American Institutions for the Insane, founded in 1844, was the beginning of The American Psychiatric Association. |
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It may be long before we have a true perspective on the accumulation of immigrants, chronic patients and elderly people in state facilities in the second half of the 19th century and the first half of the 20th century. The decline and fall of state facilities in the recent decades has been a mixed blessing, or no blessing at all for many.(2) |
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Industrialists such as Henry Ford in 1914 and Henry J. Kaiser in the 1940s, proposed employer-sponsored plans to provide medical care. Health care cooperatives existed in the first half of this century. Such was the case of the Health Care Cooperative proposed by Michael Shadid in 1929, and the Twin Cities Group Health Association in 1938.(3) |
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In general, these early programs had a limited focus, either in relation to the services or to the target population, were not for profit, did not try to include unwilling participants, nor did they try to define the scope of medical practice. |
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Also in general, the new managed care industries of the end of the twenty century have distinctive characteristics, which happen to be the opposite to those of the early groups: |
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1) They call for top-to-bottom imposition of structures of services. Room for internal debate has been painfully limited. |
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2 ) They are applied to any community regardless of its differential characteristics. One size fits all has been the rule. |
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3) They call for obligatory use of new and untested strategies to diminish the role of physicians. The treating physician has regularly been second-guessed regarding diagnosis and treatment. In an atmosphere of oppression generated by gag-rules, defending patients has become a regular source of confrontation. |
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4) By controlling the patient's ability to choose physicians, the new companies have become unwilling partners in an enterprise they loathe. The consequences have been properly expressed in JAMA(4) (275, 957 -1196)History, not to mention common sense, also tells us that the oppressed, miserable, angry physicians do not provide good patient care. It was one thing for physicians to form or joint early experimental entities because of a commitment to the model; many did so at great personal and professional cost because they believed in what they were doing. Besides, if it did not work out, they could always return to a vibrant fee for service, solid practice environment. |
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©2000 Munoz and Eist, The People v. Managed Care |
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