200th Anniversary of the New England Journal of Medicine

Posted on | March 21, 2012 | Comments Off on 200th Anniversary of the New England Journal of Medicine

Mike Magee

The New England Journal of Medicine this year celebrates its 200th anniversary. When I first arrived in rural Massachusetts with my family in 1978 (fresh out of surgical training at the University of North Carolina), I was embraced by a physician on the Medical Staff at our 100 bed hospital, Percy Wadman MD. As it turned out, he was the incoming President of the Massachusetts Medical Society and made it his mission to sign me up as a member as soon as possible. It took little convincing since I was already biased toward the organization because I relied on its New England Journal of Medicine to keep me abreast not only of the newest advances in scientific and medical understanding and treatment, but also for their insightful articles on health policy. I anticipated the arrival of the Journal each week in my little town of 12,000 for those articles. They kept me connected and stimulated in a way that nothing else in medicine could. Now 34 years later – the NEJM continues to play that role.

Consider for example Victor Fuchs commemorative article in the March 15, 2012 issue titled, “Major Trends In The U.S. Health Economy Since 1950”.(1) It immediately caught my eye because of the author, the topic, and the fact that the Supreme Court will be addressing the current health reform bill this coming week. What better preparation for this critical debate then the opportunity, in just a few pages, to review the past 60 years in American Medicine?

If given only a Twitter number of characters to describe this insightful article, I would go with “3:2:1”. As the author describes, “Throughout the period since 1950, health expenditures have gone primarily to hospitals, physicians, and drugs. Moreover, the rate of growth of expenditures in each of these categories between 1950 and 2009 has been fairly close to the rate of growth of total health expenditures…. As a rule of thumb, the ratio 3:2:1 does a fairly good job of describing the relative importance (in dollar terms) of hospitals, physicians, and drugs.”(1)

Having been employed in each of these domains, as a private and academic physician, as a hospital administrator, and as a member of the leadership team at Pfizer during the heady Viagra years, I know a bit about these various cultures. Fuchs describes the dynamics of each concisely and accurately.

About hospitals: “The ability of hospitals to maintain their high share is particularly noteworthy, because between 1950 and 2009 the industry had several large shocks. Psychiatric hospitals virtually emptied out. Admission rates to acute care hospitals (“community” hospitals) dropped precipitously after 1970, as did the average length of stay. As a result, the average daily census, adjusted for population growth, has decreased by almost 50% over the past four decades. Hospitals have maintained and increased their revenues in part through more intensive treatment of inpatients. Despite shorter stays, the cost per case (in 2009 dollars) jumped from $6,600 in 1997 to $9,200 in 2009. Hospitals’ total incomes were also preserved through expansion of outpatient services, including same-day surgery, magnetic resonance imaging and computed tomography, and outpatient clinics for diagnosing and treating cancer, heart disease, and other illnesses.”(1)

About doctors: “The number of active physicians in the United States increased by a factor of approximately four between 1950 and 2009. As the population grew, the number of active physicians per 1000 population increased from 1.41 to 2.73, an annual growth rate of 1.1%. That figure may overstate the growth of physicians’ availability, however, since the number of hours the average physician worked probably decreased appreciably between 1950 and 2009. Major trends in the physician supply that had important implications for the health economy were large increases in the percentages of female physicians, specialist physicians, and hospital-based physicians….The shift away from office-based practice, along with possible changes in payment systems, may portend a time when most medical care will be delivered by teams of physicians and other health care providers (e.g., nurse practitioners and physician assistants) working in accountable care organizations.”(1)

About drugs and discoveries: “In 1950, health expenditures accounted for only 4.6% of the gross domestic product (GDP). In 2009, they accounted for more than 17%, a larger share than all manufacturing, or wholesale and retail trade, or finance and insurance, or the combination of agriculture, mining, and construction….From 1950 through 2009, there was an almost continuous increase in annual real per capita health expenditures, with the exception of one 2-year pause in the mid-1990s, when the effect of managed care was at its peak….The most important explanation for the increase in real per capita health expenditures is the availability of new medical technology and the increased specialization that accompanies it. Between 1974 and 2010 alone, the number of U.S. patents for pharmaceutical and surgical innovations increased by a factor of six. Second in importance is the spread of public and private health insurance, which diminishes the effect of health care prices on demand. There is a positive-feedback loop between new technology and the spread of health insurance: new technology stimulates the demand for insurance, and the spread of insurance stimulates the demand for new technology.”(1)

And 3:2:1 is just the beginning. Fuchs also touches on hospitalists, EMR’s and managed care along the way. Will we rationalize health care delivery in this country? Maybe. In his words, “It is difficult to see how the health sector can continue to expand rapidly at the expense of the rest of the economy, but every past prediction of a sustained slowing of the growth of health expenditures has been proved wrong. Rapid growth may continue as a result of political gridlock regarding the form that curbs on expenditures should take. There is no public consensus about how much care should be provided for the poor and sick or how it should be done. Similarly, there’s no public consensus regarding efforts to increase the efficiency of care. A rational approach to the financing, organization, and delivery of care seems politically impossible. However, the observation by de Tocqueville that in the United States ‘events can move from the impossible to the inevitable without ever stopping at the probable’ may prove to be prescient.”(1)

Now where can you get commentary like that but in the New England Journal of Medicine? Thanks to Percy Wadman, to the Massachusetts Medical Society and the Journal, and congratulations on 200 years of remarkable service and scholarship!

For Health Commentary, I’m Mike Magee

References:

1. Fuchs VR. Major Trends In The U.S. Health Economy Since 1950. NEJM 2012;366:973-977. http://www.nejm.org/doi/full/10.1056/NEJMp1200478#t=article