This blog was originally posted on August 7, 2009
By Ginny McPartland
Isidore “Ig” Falk was a 20th Century hero, but most Americans have never heard of him. Falk was a major figure in the 1930s to 1980s discussion of how health care should be organized in America. He was the head of research for the Senate Committee for the Costs of Medical Care (CCMC), whose voluminous report was published in 1932.
Falk, educated at Yale with a PhD in Public Health, was largely responsible for writing the committee’s recommendations that called for prepaid group practice and integrated health care in America. The committee said that fee-for-service health care should continue to exist, but that in some fashion, quality health care should be made accessible to everyone, rich, poor, and in-between. The committee majority figured that prevention of illness, like public education, was good for the country, as well as for the common man.
Garfield—A grass roots approach
As Ig Falk pursued these ideals on a national scale, another of my heroes—Sidney R. Garfield—was busy putting these ideas into practice on a grass roots level. Born in humble circumstances, Garfield attended medical school at his parents’ insistence and was out to make a living in California during the Great Depression.
For all the right reasons, Falk spent a good chunk of his life advocating for the principles embodied in the committee recommendations. Alas, due to political circumstances, i.e., charges that he was pushing socialized medicine, and a lack of public understanding and support, Falk didn’t succeed in achieving prepaid, coordinated medical care for all Americans. (He’s still a hero in my book.)
Sidney Garfield took care of industrial workers in the California desert on a fee-for-service basis. He soon realized he couldn’t make it if he waited for the patients to come to him. So he made a deal with the workers’ insurance company to pay him in advance for the workers health care. Voila! Prepaid health care that was affordable and sustainable.
Garfield’s troubles begin
With the help of industrialist Henry J. Kaiser, Garfield enhanced and refined his methods of health care delivery and brought them to the World War II home front, and in 1945 introduced his brand of care to the public. That’s when his troubles really began.
Like Falk, Garfield had to fight. He had to fight to keep himself out of jail and in the business of taking care of people. Not only did they call him a socialist or communist, his opponents said he was violating medical ethics, and he was brought up on charges for running a group practice. Anyone who tried to join Garfield’s medical group was scorned by their peers and warned against ruining their careers by being associated with this renegade doctor.
Fortunately, Garfield did not fail. Amid all the obstacles, Garfield kept it together and with the support of organized labor and physicians in academic medicine, today his legacy lives on in Kaiser Permanente. He’s the fellow who pushed his colleagues to get into computers in the early 1960s. He’s the one who pushed the idea that if you screened patients for signs of early chronic illness, you could slow down or stop the advance of disease.
A great model of health care
Garfield is my hero because he persisted in his mission to keep his modest plan alive. He won myriad battles and left us Kaiser Permanente as one of the U.S. models of health care that works. I’m personally glad because I’m one of the lucky ones who have good, no great, health care.
One period of my life when I wasn’t a member of Kaiser Permanente, I sought a mammogram, a vital preventive screening for women. I picked a radiologist out of a network book and I had the exam. Up to a year later, I was still receiving past due notices that my insurance had not paid the claim.
In contrast, in the past two months, I’ve received several letters and phone calls from Kaiser Permanente reminding me that it’s time for a mammogram. When I went in for the exam at a convenient evening hour, my copayment was waived. Somehow I get the feeling that someone is watching over me. Wow!
Health care reform still a discussion
As I’m sure you know, the people in Washington today are wrangling over health care reform again (read, still). Right now the quest for change seems to be stymied by political special interests. Reminiscent of Falk’s time and renewed conversations in the 1940s and the 1990s, transformative change remains elusive. Perhaps a 1997 discussion of Falk’s challenges by Alan Derickson, PhD, in the American Journal of Public Health can help us reach a solution to benefit all Americans:
“If a chorus of demands from many sources were to drown out overheated ideological claims, public discussion might shift to a fuller consideration of human need and the capability of an affluent society to meet it.”
To learn more about Sidney R. Garfield, MD, you can read: Dr. Sidney R. Garfield: the Visionary Who Turned Sick Care into Health Care. The newly released book illuminates for the first time the details of Garfield’s professional and personal struggles and triumphs.
By Ginny McPartland
As we wonder and worry about the fate of health care in America, it’s interesting to look back at how Kaiser Permanente physician leaders saw the future just after the 20-year-old health plan got a firm foothold in the 1960s.
Cecil Cutting, MD, executive director of The Permanente Medical Group, told of his worst fears in a talk to a group of hospital administration graduate students at the University of Chicago on Nov. 17, 1966.
“Looking ahead, there seems little doubt but that our present ‘derangement’ of providing medical care is totally inadequate to absorb the onrush of the technological revolution that is now upon us, even if the rising personnel costs can be absorbed,” Cutting lamented.
“The tempo of the hospital has changed from a relatively easy-going, low cost charity institution to a competitive, high cost one, with third parties paying the costs and becoming ever more critical of hospital management,” Cutting said.
A 1935 Stanford Medical School alumnus, Cutting joined Sidney Garfield when he established a medical care program at the Grand Coulee Dam job site in the late 1930s. During the war, Cutting also took a leading role in Garfield’s Kaiser wartime shipyard program in Richmond, California.
1960s changes threatened traditional medical care delivery
Cutting was talking about the mid-1960s climate that included newly enacted government-paid Medicare-Medicaid programs for the elderly and poor, a flood of new medical technology, health care professionals’ demands for higher pay and a proliferation of union and company health plans for workers.
With the blessing of KP founding physician Sidney Garfield, Cutting laid out the problem: “Today we have many individual, unrelated, competitive hospitals seldom organized among themselves as a team, for the most part with unorganized staffs of physicians, serving an unknown population – a population unknown both in numbers and in health requirements.
“The consequences of continuing along our present path of complete disorganization are staggering and make the need to change methods of organizing medical care inevitable,” he told the group.
Cutting warned that high technology was too expensive for an individual institution to purchase on its own. He said a system should be established in which medical facilities are designated as one of three types: a community preventive health center; a service hospital for routine care, such as trauma, appendectomy, hysterectomy, maternity, hernias, cancer surgery, pediatrics and psychiatry; and a “super-specialty” hospital.
‘Super-specialty’ hospital to optimize high technology use
The highly specialized treatment facility envisioned by Cutting (perhaps the precursor of a center of excellence) would be designed for handling neurological cases, open-heart surgery, megavoltage radiotherapy – the types of cases that required the most sophisticated equipment.
Here, specialists would take care of a sufficient number of patients referred from other facilities to optimize utilization of the equipment and highly skilled staff.
As it happened, Kaiser Permanente was in the process of developing such a system by this time, and Cutting could report its success to his audience. “In Northern California area the Kaiser Permanente program is working along these lines, though it is by no means a finished demonstration,” Cutting said.
“The (Kaiser Permanente) group practice-prepayment arrangement is, in itself, a step toward improving organization of medical care and undoubtedly makes accomplishment of further organization considerably easier to attain.”
Health center concept proposed
The health center concept, which Cutting called “predictive and preventive medicine,” had already been developed and was in operation in KP Northern California. “Forty thousand patients a year are being given an extensive health questionnaire (to complete), updated each year, and an automated battery of some 20 test measurements plus 18 laboratory procedures amounting to almost 1,000 different characteristics on each patient,” Cutting continued.
With this information, all recorded in a computer data base, KP physicians compiled knowledge of each patient’s changes from year to year. This information helped physicians to predict illness and to advise patients and their families about how to prevent chronic illnesses such as diabetes, heart disease and cancer.
Data compiled about whole populations, i.e. KP members, also helped researchers answer such questions as: Can treatment of asymptomatic patients with a slight increase in blood sugar prevent diabetes altogether or merely postpone the disease? With data from a questionnaire about a patient’s psychological state, researchers compared the effectiveness of psychiatric services versus medical office visits for reducing total visits for emotionally disturbed patients.
Too many specialists spoil the broth
Cutting complained to his audience that medical schools were turning out too many specialists, a trend that threatened basic medical care. “It would appear that the rush for super-specialization may be leaving behind an ever widening gap in well rounded, competent medical judgment.
“Though the individual episode of care may be superb, it certainly does little for the orderly development of efficient, economical medical care as a whole.”
In what must have surprised many, Cutting suggested that medical education should develop a new type of medical doctor: the preventive, predictive specialist. “Following the natural development of disease of entire families over long periods, alerted to early changes through the screening program, he becomes a health specialist.”
Today, both primary care and preventive medicine are specialties recognized by the American Board of Specialties.
Kaiser Permanente has advanced Garfield and Cutting’s ideas about preventive care and health appraisals in a variety of ways over the decades. KP physicians promoted healthy eating and exercise for the workers in the World War II Kaiser Shipyards, and they began offering preventive testing in the 1950s for members of the longshoremen union and other groups.
KP’s ‘Total Health’ concept emerges
In the 1970s, health education centers were established to teach patients how to stay well; Garfield’s Total Health Research Project launched in the 1980s led to the opening of special centers where healthy patients received their routine care.
Centers for preventive medicine functioned within KP for many years, largely giving way to periodic screenings for particular diseases such as breast and colon cancer, heart disease, hypertension and diabetes. Healthy Living programs, an expansion of member health education, have flourished in the past decade offering many classes in good nutrition, exercise, smoking cessation and stress reduction.
Cutting ended his talk with a few wishes for the future: community institutes to teach people to preserve their good health, easily shared electronic medical records, and above all, cooperation among health organizations to provide a broad spectrum of care – from the preventive to the most complicated.
“When (all) care, whether in super-specialty hospitals, service hospitals, extended care, office or home, is correlated . . . I will begin to see hope,” he said.
By Ginny McPartland
The Rosie the Riveter National Park, established in 2000 to commemorate American workers who toiled during World War II to build ships, aircraft, tanks and munitions for the Allied Forces, is now officially open for business.
You can learn just about anything you’d like to know about the World War II home front by taking a tour of the sparkling new Visitor Education Center located on the waterfront in Richmond, California.
The National Park Service (NPS) center is housed in the restored historic brick Oil House that once powered the humongous Ford Assembly Plant next door. At long last, the center brings cohesiveness to the park made up of sites around Richmond. The small city was forever transformed by the wartime activity of the Kaiser Richmond Shipyards.
Until now, the park has had no place to exhibit its rich compilation of stories and photos of the people of the American home front.
Inside the center, you’ll find many historical exhibits recalling the home front. For example, the Rosie the Riveter Trust has a display of “Rosie’s Girls,” a trust-funded program that encourages high school girls to find inspiration in the Rosies’ stories. Other exhibits highlight the origins of the Kaiser Permanente Medical Care program in Henry Kaiser’s wartime Richmond shipyards.
A gift shop operated by the Rosie the Riveter Trust offers World War II-related books, films and Rosie paraphernalia. Downstairs, the theater provides space for NPS ranger talks and the showing of films about local and national domestic efforts that supported the overseas battlefronts during WWII. An original film, made just for the Richmond visitors’ center, is the jewel of the collection.
The Visitors Education Center is open from 10 a.m. to 5 p.m. every day, except Christmas, New Year’s Day and Thanksgiving Day. A ranger program begins at 1:30 p.m. in the theater with the showing of an orientation film, followed by a 45-minute guided walk or indoor program.
The center is located at 1414 Harbour Way, South, which is in the area that was Shipyard No. 2 during the war.
Also at Shipyard No. 2 is the Ford Assembly Plant (now the Craneway Pavilion), whose workers assembled 49,000 jeeps during the war. “Its claim to fame,” according to the park service Web site, “was becoming one of only three tank depots in the entire United States. Every combat vehicle used in WWII was processed by one of these depots. Here (at the plant) the finishing touches were put on 91,000 tanks, half-tracks, armored cars and other military vehicles destined for combat.”
The National Park Service, the City of Richmond and Orton Development Inc. pooled resources to fund the restoration of the Oil House as a visitors’ center. Marcy Wong Donn Logan Architects created the restoration design, and Dalzell Corporation performed the restoration/construction work.
If you go to Richmond, you may also want to visit the SS Red Oak Victory, another feature of the Rosie park. The ship is located at Shipyard No. 3, which is accessed via Canal Boulevard from Interstate 580 West.
The cargo ship, built at Richmond during the war, has been restored as a museum and is operated by the Richmond Museum of History. The Red Oak volunteers offer tours and special events, including a World War II summer film festival.
The current festival, 7 p.m. Thursdays during June, July and August, features:
June 14 – “Confessions of a Nazi Spy”
June 28 – “All Through the Night”
July 12 – “Desperate Journey”
July 26 – “Watch on the Rhine”
Aug. 9 – “Thirty Seconds over Tokyo”
Aug. 23 – “The Clock”
Here’s a tidbit meant not only for military aficionados but also for gardeners:
On Memorial Day this year, the SS Red Oak Victory received a Blue Star Memorial in its new garden on the Victory Ship’s deck. The El Cerrito Garden Club, working with the Richmond Museum of History, dedicated the marker to honor the men and women who served in the American armed forces. The Red Oak’s marker is the first Blue Star to be installed in the city of Richmond.
What is a Blue Star? you may ask. National Garden Clubs, Inc., formerly the National Council of State Garden Clubs, started the program in 1945 after World War II. The blue star was used on service flags to denote a service member fighting in the war.
For more: SS Red Oak Victory.