The Cost of Meeting Unmet Medical Needs

Medical Claims

For fifteen years before Medicare, I practiced medicine in Philadelphia. At that time, the backlog of unmet medical care seemed infinite, impossible to satisfy. For one thing, we didn't have enough hospitals to fix all the hernias, gallstone, rotten teeth, festering bad leg veins, positive blood tests for syphilis, and a dozen other matters. But we set about it, doubling the number of medical students in each school's class, and doubling the number of schools. We built or renovated and re-equipped 124 hospitals in Philadelphia alone, as I remember.

Well, we were successful. It is no longer true that everybody's teeth are rotten, or that one Wasserman test in six is positive. Instead of throwing up our hands at an infinity of unmet elective surgical cases, we now hear suspicions that perhaps cataracts are being "harvested", cardiac pacemakers becoming universal apparel, tummies being tucked. But professional jealousies to one side, an undeniable statistic emerges. We only have thirty hospitals.

Backlogs are like waterfalls. The level seems limitless, until it suddenly disappears from sight. We spent far too much money on new hospital capital construction, and that spending spree has to account for a major portion of the cost of medical care that now doesn't seem to be producing anything worthwhile. These are the trailing costs of what can now be seen as temporary construction.

These thoughts came to me when a visitor to the Federal Reserve from Kazakhstan talked recently about medical care in that vast wasteland. At a time when petroleum supplies are short, Kazakhstan has discovered it has possession of the largest new oil field in the world. The social scene is like Texas in the Twenties, or perhaps the Yukon fifty years earlier. Whereas today it is questionable whether to spend the money to perform a Wasserman in America, positive tests are widely abundant in Kazakhstan. I daresay the hernias, varicose veins, bad teeth and whatnot are just as bad there as they were in America in 1960. And they are gunning up their engines to build lots of the biggest most expensive hospitals anywhere, because they can afford them.

Prediction: in 2050 nobody will be able to explain why medical costs are so high in Kazakhstan. After all, at that time there will be no positive Wassermans, no hernias, no gallstones.

Replacing Employer-Based Health Insurance

Employer-group health insurance will surely decline because so many are dissatisfied with it.

Dr. Fisher

Preamble

It might take a hundred pages to describe America's dissatisfactions with its health insurance system, but we mean to limit the grousing to features which could usefully be changed. The present system served us well enough for sixty years, and we tip our hat to those who struggled during depressions and war years to cobble together some kind of health financing system, never claiming it would be perfect. For reasons that were sufficient at the time, we ended up with a dominant system which is employer-based and reflects that fact. In this book we skip the quaint history, going right to the advantages of gradually migrating to better systems, which surely means migrating away from employer group purchasing. An important word is gradual, because we must fix this engine without turning the motor off.

Later on, we'll return to what's significantly awkward about employer group policies, but here let's summarize complaints in a paragraph. The predicament of employers, first, is that instead of pre-paying for health care which defines what it covers and how much the items will cost, employers now pay for "service benefits". That's merely a best-efforts description of the scope, while the associated prices no longer relate to either costs or the marketplace -- undefined scope and prices are blank-check health insurance indeed. Next, many employees feel they receive a poisoned pill. They get "job lock", where insurability is suddenly in doubt whenever they change employers. Even more, employees fear what might happen to their health care if the employer must suddenly reduce expenses. Third, being outside this system is no escape from it. Congressional tax preferences seem entirely unfair to anyone who doesn't get them. In fact, even those who do get tax breaks suspect hospital cost shifting merely taxes it back. Taken as a whole, employer group benefits are a third-party system twice removed: those paying the bills suspect their insurance vendor doesn't supervise enough. But employers are reluctant to pay insurance companies more money to supervise services because they know neither one of them can directly observe it. Economists mutter the insight that health benefits really aren't employer-stockholder money at all. The money belongs to employees in lieu of higher wages, so what right do employers have to constrain how it's spent? Both employers and employees view health benefits as a boomerang they can't even throw away without getting hurt. Fairness notwithstanding, the American Academy of Actuaries estimates the waste in the third-party arrangement is at least 30% more than people would pay with their own money; that's roughly what they get as a tax deduction. Finally, the uninsured don't complain about exclusion as bitterly as you might suppose; roughly half of them could afford to buy it. The country struggles to give health insurance to absolutely everyone, but a growing number of people absolutely don't want it. There's more to say, but this should get us started.

This book asks the reader to trace complaints back to causes, and unite around objectives. The employer-based system stands in the road of other approaches, some of them quite attractive. We could rather easily work for a system where each person selects and owns an individual policy. Right now, workers participate in a group policy owned and selected by an employer. As a matter of fairness, employees ought to own and select their own health insurance, and it wouldn't be terribly hard to do. Even if you regard fairness as a loser's argument, the switch might be made so that much better products --currently blocked -- can flourish. The main focus of this early chapter is on some potential opportunities within individual ownership of health insurance, gained by employers surrendering ownership of group policies, one by one, on request by each employee. The first of the advantageous opportunities, the Health Savings Account, already exists after a long struggle. Other alternatives which follow might be even better, but experience with this one teaches some important lessons. Primarily, almost all variants require legislation, because the existing system has resorted to government to enforce its bargains. Furthermore, sufficient public enthusiasm must emerge to persuade insurance executives that enough market exists to justify the development effort. Both Congress and the Insurance industry must be persuaded the public is behind them, and both are tough to convince. By far the best way to convince anyone of anything is to conduct demonstration projects, experiments if you will, capturing what works and discarding what doesn't.

Health Savings Accounts

Health Savings Accounts started in 1980 and by 2007 have slowly grown to insure 13 million persons. Because of impediments in various state laws, the distribution of HSAs is uneven geographically (see Figure 1). Since the pattern closely resembles the red and blue maps of the 2004 presidential election results, observers have perhaps unfairly attributed HSA resistance to devious politics. That may be true in part, but the pattern more likely follows the distribution of laws intended to foster employer group insurance, and thus reflects concentrated industries, especially the steel, coal and auto businesses. HSAs therefore tend to be legally hampered in areas of heavy union influence, although seemingly they should not injure unions or provoke their opposition, and unions may not be mainly at fault.

These HSA accounts have two components, the catastrophic health insurance policy, and the tax-sheltered savings fund. These two structures revolve around the familiar advantages of high-deductible insurance, which is considerably cheaper than fully inclusive insurance because it avoids the heavy processing costs of myriads of small claims which most people could afford to pay for in cash. That concentrates the coverage to high-cost claims which, although less common, present the dual catastrophe of often being unaffordable and almost always putting the beneficiary out of work. Almost everybody needs some kind of catastrophic protection, although the size of the deductible might vary among income levels. Secondly, to be attractive to young people and others without significant savings, the savings account feature was added, as a way of providing the funds to pay for small claims and deductibles, without losing the cost awareness of paying for services directly. This savings and insurance combination was made tax-exempt in an effort to enhance attractiveness in competition with the tax shelter now accorded to conventional health insurance provided by employers and covering the same range of services. The Health Savings Accounts therefore were a step in the direction of extending health cost tax exemption to everyone, and shifting cost control decisions into the hands of the patient by awarding the savings to him. Permission to save unspent funds in the accounts from year to year created portability between jobs, and thus lifetime coverage. A final incentive, the ability in theory to strive for paid-up lifetime insurance, was thwarted in Congress by prohibiting the money in the accounts being spent on the premiums of the catastrophic insurance. It would be of some interest to know who in Congress promoted this prohibition, and what the reasoning was.

Proponents of this reform measure proceeded in their advocacy with the charming innocence of those who believed they had a splendid idea for the benefit of everyone. Anyone who resisted, must not understand the issue very well, and needed only to have it explained in greater detail. This feeling was heightened by seeing groups oppose the HSA who would seemingly only stand to benefit from it. Since experience has shown that a third of those who enroll in HSAs have previously been uninsured, it would seem reasonable to expect the uninsured and those who work in their behalf, to support it. Sellers of individual health insurance were expected to recognize the enhanced commissions of selling lifetime portable insurance compared with the drudgery of flogging annual renewals. Insurance company risk was removed entirely except for the catastrophic coverage portion. Unions, who prize their ability to pressure health insurance companies on their members' behalf should welcome a role in advising members on best choices for their money. Those who negotiate for higher wages and benefits would seemingly welcome the diminution of vague "service benefits" as a tool and the substitution of visible actual dollars into the accounts as a collective bargaining achievement. Union members individually would seem likely to carry their objections to managed care plans to the logical conclusion of reaping the rewards of cost containment for themselves, without impairing freedom to spend extra for luxuries if they please. One would have supposed union members would actively welcome the sort of insurance that gave them free choice of their doctor or hospital. Ultimately, you would suppose that union members would wish to lighten the burden of health costs of their employers, if only to demand higher pay in return, or alternatively to preserve their jobs from the ravages of foreign competition. But alas, legislative experience has been quite different. Prohibiting the use of tax-sheltered accounts to pay health insurance premiums is an inexplicable clause inserted by opponents of the proposal. Prohibiting the use by employers of more than fifty employees was another. Limiting the number of people who could have these accounts to 750,000 was still another unaccountably restrictive Congressional feature. It is almost as though there were some strategy of inhibiting the spread of these policies, with the ultimate goal of calling for total elimination based on lack of interest. The original pioneers of this program, now twenty years older, trudge on in bafflement at resistance, but rather steadily enlisting new subscribers in the states where they are permitted by local law. One consequence would appear to be a resurgence of local state resistance to interstate sale of health insurance.

In a certain way, other obstacles in the road of HSA accounts do contain some understandable logic. For the most part, they are the residuals of old state laws which once enhanced other projects with at least comprehensible goals. For example, mandatory benefits. Chiropractors, optometrists, physiotherapists and a host of other limited licence practitioners fought long, hard, and expensively to lobby laws into existence mandating payment for their services as a condition for any health insurance in their state. These primarily outpatient groups see high deductible insurance as a way of raising the insurance threshold above the typical price of their services, thus excluding them from a federally subsidized system. Before ERISA was passed in 1973, special mandates were added in state legislatures by the hundreds each year. That led to interstate businesses going to Congress for relief from the need to satisfy varying requirements in fifty states. This difficulty was garrisoned by the McCarran Ferguson Act of 1945, which uniquely excludes the business of insurance from federal regulation. Just how we got here from the original antitrust dispute is hard to explain, but nevertheless anyone can see that toppling this complicated structure would require a fierce political campaign. Therefore, by far the easiest pathway is to amend federal law to make it clear that conflicting state laws are pre-empted. Essentially, that is what ERISA accomplished, and when amendments are proposed, why employers regard ERISA as so untouchable.

Ratio of Prices to Underlying Audited Costs

Beginning this book with a discussion of the struggles of the Health Savings Account brings us bang against what the reader will soon learn I consider the most intractable issue in American health care reform. It's an outward symptom of the issue which must be addressed if significant progress is to be made in health reform of any sort, and it won't be easy to address it. My plan is to defer analysis in depth until later, after first describing one by one how it blocks progress in every single promising proposal. Only when it seems likely the reader has become thoroughly fed up with it, will we attempt to lead through its very complicated analysis. Please be patient with a very brief introduction, first showing how destructive it is to Health Savings Accounts.

To be eligible for Medicare payment, every hospital must submit an audited Medicare Cost Report. That makes it public information, subject to the Freedom of Information Act (FOIA) of 1966, although rightly any competitive organization is uncomfortable about divulging business information. A significant item on the Medicare report is The Ratio of Posted Charges to Costs. That is, the audited costs are divided into posted charges of the same year. If a not-for-profit hospital just breaks even for the year, the ratio might be expected to be about 1.0. With the allowance of say 4% for bad debts, the ratio could be 1.04. Because Medicaid commonly underpays for its share, the ratio might have to be 1.20. But that reasoning gets you to the wrong conclusion; the ratio is commonly five or eight times greater than that. To make this idea more comprehensible, an electrocardiogram with costs of $25 carries a posted price of $380 in at least one hospital; that would create a Charge-to-Cost ratio of 15.02. Fifteen times its independently audited cost? There is considerable reluctance to defend or discuss this matter, so it unfortunately invites speculation, both fair and unfair.

The reason for introducing the charge to cost ratio at this point is to identify a vexing issue which makes health insurance seem so essential, while simultaneously interfering with making affordable insurance available. A person even a wealthy one, must have health insurance to protect himself against overcharging. Those who cannot easily afford health insurance look to high-deductible Health Savings Accounts because that makes insurance cheaper. Unfortunately, cash savings within the accounts can be quickly eaten up by even moderate exposure to huge price mark-ups. The attractiveness of these accounts is thus limited to those young healthy people who have no real health expenses, and to residents of those regions of the country where the practice of massive overcharging is uncommon. Without encumbering this narrative with too much detail, that is the explanation for the slow steady progress of HSAs, and their peculiar geographical distribution. If a representative charge for an electrocardiogram is $40, HSAs are a bargain. But if an electrocardiogram costs $380, purchase of HSAs is mainly restricted to those who have no great need for electrocardiograms. The outlook for HSAs is not completely bleak, however. At some time and in some areas the mass of subscribers will grow to a size where they can force the hospitals to confer a discount. Using collective purchasing power and the threat of publicity or even lawsuit, certain local brokers of HSAs have worked out arrangements for their members to receive market prices for their outpatient services. The most effective argument with hospitals has been that HSA holders do not create bad debts in their co-insurance. Unpaid deductibles and copayments are now the largest source of bad debts for most hospitals.

While focused on the hospital markup issue, let's engage in some unproven conjecture about it. Hospitals actually construct these inflated prices, but at first glance they would seem to have no great motive to antagonize cash paying clients this way, or to injure poor people, or to drive outpatient work toward free-standing clinics and doctor's offices. As a matter of fact, there is a small incentive in the rare wealthy foreigner who pays full freight, and the Medicare inpatient loophole of charge reimbursement for "outliers", cases with unusual costs. However, regulators are struggling to close such loopholes and cash payments are rare. I remember one oriental dignitary, reputed to own 8% of his country's Gross Domestic Product, who pulled out a wad of hundred dollar bills to pay a hospital, but totally befuddled the hospital clerk who didn't know what to do with real money. For every instance of this sort of thing, there are a hundred instances of hospital administrators genuinely distressed by their own mandate to collect seriously inflated bills from poor people.

Well, if hospital top management is conflicted by devising this practice, and mid level employees are distressed to implement it, well, who else has a motive to continue this markup? The obvious suspects are two: health insurance companies and Medicaid agencies. Obviously, sellers of health insurance rejoice in a situation where even people without important need for health cost protection must nevertheless buy it to protect against gouging. Think of an insurance executive before his home television, watching Presidents of the United States searching for ways to make their product mandatory for every citizen, and weeping because it is unattainable. Yes, health insurance companies have incentive to favor high hospital posted prices, but still it is difficult to see why hospitals would cooperate. State Medicaid agencies might also develop a motive to increase their own Federal reimbursement, and have occasionally engaged in some questionable maneuvers to do so through the arcane formulas of federal-state cost sharing. What's more, state governments are often in a position to help hospitals who play nice. In a naughty world, some of that may go on, but massive conspiracy seems implausible. So, if those with potential incentives are unable to force compliance, why do hospitals do this? Why would they persist in something they privately deplore, silently biting their lips at the criticism it provokes?

Exit, Pursued by a Bear

Everybody ends up getting fired in a recent book by John Kastor about recent events at the University of Pennsylvania just like everybody ending up dead in an Elizabethan play. The vital difference, of course, is that the dramatis personae at Penn can still relate to a bewildered audience their own versions of those grand events. To protect himself, the author peppers his book with more footnotes than a PhD. thesis. And thousands of stakeholders at the University can now realize that during those eventful times they were as clueless as Rosencranz and Guildenstern.

One basic fact about that institution is that the medical school spends three quarters of the entire university budget. That leads to grudges in the little law school, the little engineering school, and the little president's office, as they knuckle under to the Golden Rule. The department chairman with the gold, makes the rules. Since most of that gold comes from research grants, hence ultimately from the federal government, the medical students and the teaching faculty don't have the same power they had during the Vietnam War era, either. Although medical school tuition imposes a crushing burden on the students and their families, leading to debts close to a quarter of a million dollars apiece, the tuition money doesn't amount to much in the university scheme of things, either. In some schools, tuition amounts to two percent of the medical school budget. You could eliminate the students entirely and not see much difference in the "school".

Unfortunately, when you become dependent on government grants, you find they can suddenly be terminated, or awarded without funding, or held up for several months by Congressional bickering. Meanwhile, there are salaries to pay, contracts to fulfill. Even if you can furlough some of the staff, it's not easy to see what you do about a thirty-year mortgage on a research building when there is a lull in its research funding. If you try to save money, the granting agency will try to get it back; they aren't authorized to make grants to be squirreled away. If you shift money to unauthorized uses, you risk going to jail. And yet, if you don't do something along those lines, the whole enterprise can collapse.

Having said that much to be fair, it is still uncomfortable to see the financial transparency of our most valued nonprofit institutions vanish behind a Byzantine fog of secrecy, out of which arise the magnificent towers of new buildings, and in front of which an occasional limousine is to be observed. No wonder the research scientists feel the constant pressure to produce. A Nobel Prize every ten years, or so, would go a long way toward quieting envious remarks from the liberal arts faculty.

Housed in those ivy towers are three institutions, the teaching hospital, the medical school, and the university, with three boards of trustees, and at least three ruling potentates. At irregular intervals, congressional committees do things to the Budget Reconciliation Act which enrich one of the three components of the institution, or suddenly impoverish another, or both. Integration of the three under one governance sounds plausible until you notice how radically different is the mission of each one. You can take a big building away from one component and rent it back to them, and things like that; but you can't do it without starting whispers about Enron. You can gather up surplus funds from one of them during the decade of the eighties, but you have trouble giving it back twenty years later. Officials at Blue Cross come snooping to see if health insurance premiums are passing through this shell game, ultimately paying salaries in the department of English Literature. Everybody distrusts everybody else, somebody sasses somebody, and everybody gets fired.

Nothing unusual about that. It happens at every medical school.

July 4, 1776

According to the records of the Pennsylvania Hospital, the following 48 persons were patients in the hospital on July 4, 1776:

The records indicate the following diseases were the reason for admission of those patients. Although in Colonial times there was no medical delicacy to avoid offending readers, present privacy standards require that we strip the diagnoses from the name of the patient and list them independently. There is some overlap, sometimes making it difficult to judge which disorder caused the admission.

• Sore, poisoned or ulcerated legs: 16 cases
• Lunacy, mind or head disorders: 10 cases
• Syphilis: 7 cases
• Fever and Rheumatic fever: 7 cases
• Dropsy: 5 cases
• Gunshot: 4 cases
• Diabetes: 1
• Blindness with clear pupil: 1
• Spitting blood: 1 case
• Dislocated arm: 1 case
• Inflammation of face: 1 case
• Scurvy: 1 case
• broken arm: 1 case

---

The following physicians were elected at the Managers Meeting dated 5/13/1776:

• Dr. Thomas Bond
• Dr. Thomas Cadwalader
• Dr. John Redman
• Dr. William Shippen
• Dr. Adam Kuhn
• Dr. John Morgan

Nation's First Hospital, 1751-2008

As commonly stated in medical history circles, the history of the Pennsylvania Hospital is the history of American medicine. The beautiful old original building, with additions attached, still stands where it did in 1755, a great credit to Samuel Rhoads the builder and designer of it. The colonial building on Pine Street stopped housing 150 patients around 1980, supposedly at the demand of the Fire Marshall, although its perpetual fire insurance policy still owes the hospital several thousand dollars a year as unspent premium dividend. There may have been one small fire during two centuries of use, but its true fire hazard would be difficult to assert. It was just out of date. The original patient areas consisted of long open wards, with forty or so beds lined up behind fluted columns, in four sections on two floors. The pharmacy was on the first floor, the lunatics in the basement, and the operating rooms on the third floor under a domed skylight. It was entirely serviceable in 1948, when I arrived as an intern doctor. Individual privacy was limited to what a curtain between the beds would provide, but on the other hand it was possible for one nurse to stand at the end of a ward and recognize any distress among forty patients immediately. In this trade-off between delicacy and utility, utility was certain to be the preference of the Quaker founders. Visitors were essentially excluded, and if a patient recovered enough to be unnaturally curious about other patients, well, he was probably well enough to go home.

Located between two large rivers, South Philadelphia up to ten blocks away was essentially a swamp until the Civil War. So, there were seasonal epidemics of malaria, yellow fever, typhoid and poliomyelitis at the hospital until the early twentieth century. Philadelphia was a port city, so sailors brought in cases of venereal disease, scurvy, even an occasional case of anthrax or leprosy. During the Industrial Revolution of the nineteenth century, tuberculosis, rheumatic fever and diphtheria were part of clinical practice. But underlying the ebb and flow of environmental effects, there was a steady population of illness which did not change a great deal from 1776 to 1948. These patients were all poor, because the rules in Benjamin Franklin's handwriting restricted service to the "sick poor, and only if there is room, for those who can pay." In 1948 there was a poor box for those who might feel grateful, but no credit manager or official payment office. The matter had been considered, but the cost of collection was considered greater than the likely revenue. When Mr. Daniel Gill was offered the position as the hospital's first credit manager, it was suggested that he be given a tenth of what he collected. To his lifelong regret, Dan Gill regretted that he refused the offer that he felt he could not afford to accept.

So, the wards were filled with victims of the diseases of poverty, punctuated by occasional epidemics of whatever was prevalent. And a second constant feature of the patients was their medical condition forced them to be housed in bed. For centuries, physicians dreaded the news that a new patient was being admitted with "dead legs". Mental and neurological diseases presented a second major imperative for admission; such patients either couldn't walk or couldn't be trusted to walk alone. Coma or raging fever was another category of mandatory admission.

Therefore, the roster of patients who were in the Pennsylvania Hospital on July 4, 1776 was not substantially different from those who were present on July 1, 1948. The turnover was greater, because antibiotics made it easier to treat the disabling diseases of the poor, but the causes of admission were essentially unchanged. Instead of treating five dead legs a month, a modern physician might treat twenty, but after you have seen and smelled one dead leg, you have seen and smelled them all. Under the circumstances one Pennsylvania Hospital surgeon, Dr. C. Alexander Hatfield, became an internationally famous expert on the management of this class of conditions. But although scientific rigor was much elevated in the meantime, both Benjamin Rush and his distant descendant Alexander Rush undoubtedly experienced the same sights and smells when dead leg patients were wheeled into that same ward. The nurses however almost seemed to welcome such cases. They had been told exactly how to spring into action, and within an hour the odor and slime had disappeared; the nurses were very visibly proud of their accomplishment. It was a miracle only they knew how to conjure up; you could tell from their beaming faces that they had accomplished a triumph. We today can be fairly sure the patients in the hospital paid scarcely any attention to the commotion in Independence Hall on July 4, 1776 four blocks away. Just as the patients in the same beds were later unaware and unconcerned about the explosion of an atom bomb in Hiroshima, their focus was much more pointed. What was surely overpowering to both groups was the unbearable summer heat in Philadelphia before air conditioning. Modern physicians are astonished to learn what was then a commonplace: during a heat wave, almost every patient runs a fever. No one was taking their temperature, but it seems possible the doctors and nurses were running a fever as well.

Venereal disease is a constant among the poor. At present, the most prevalent condition is HIV/AIDS, but syphilis was a regularly fatal condition until it disappeared within a few years of the introduction of penicillin. About a sixth of the patients in the old Pennsylvania were suffering from syphilis on the day the Declaration of Independence was nailed to a post. Two hundred years later, a survey of the Philadelphia General Hospital revealed one Wasserman test in six was positive. Prostitution was supposed to be the underlying source. One thing was more or less unique. Other hospitals serving the poor reported a great deal of drug addiction, now delicately called substance abuse, but Philadelphia had remarkably little of it. In another essay, we have speculated on the likely cause of this anomaly, although in more recent days there is far less reason to remark about it. Gunshot wounds, then and now, provided evidence of the interactions between criminals and police; these fierce combatants seem universally meek and humbled when the medical establishment gets to see them.

For two centuries, the more things changed, the more they stayed the same. And then, in 1965, the heavens opened and Lyndon Johnson rained money in all directions. It took a few years for a mistrustful system to adjust to the idea that things had changed forever. A doctor could really do anything he knew to do, without concern about cost. The nursing school, the heart of the hospital, was not only unnecessary as a source of free labor, but actually an impediment to full Federal reimbursement of costs. Not long afterward, the resident physicians were actually paid a reasonable wage, after two centuries of being paid nothing at all. The large open wards were eliminated and replaced with semi private rooms, as insurance regulations insisted. The definition of poverty was changed to include people whose circumstances would have been considered luxurious before Medicare, so there are still thought to be poor people in the hospital. But the diseases of poverty are hard to find among all those people who would once have been expected to be treated in their homes. The floor space tells a story. Up until 1965, patients would have occupied 90% of the floor space of the institution, now they scarcely occupy 15%. The presence of patients, the reason for the institution, is far less dominant; doctors and nurses are a comparatively small proportion of the thousands of employees. That makes a big psychological difference. At one time, there was hardly anyone present except patients, doctors and nurses. Today, the other members of the medical industry predominate within these walls. There are many more computers than patients. But what is ultimately most puzzling is that so much more money is being spent on so much less disease. Life expectancy has increased by thirty years, several dozen diseases have disappeared, the disorders of 1776 which took months to treat are now cured in three days. It's all a very good thing, but it is puzzling.

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