The scheduled operation was canceled in order to allow time for further pre-operative studies. A repeated gall bladder X ray definitely showed no filling, although this time the films were of good quality. A celiac angiogram was scheduled.
The weekend. Specialized procedures such as celiac angiography could not be done, and further work on the patient was postponed until Monday.
Celiac angiography was performed. Under local anesthetic, a thin, flexible catheter was passed up the femoral artery in the leg, to the aorta, and finally to the celiac axis, a network of arteries coming off the aorta to supply blood to all the upper-abdominal organs. A dye opaque to X rays was injected, and the vessels studied. No space-occupying lesion (tumor) was found and the vessels were normal in appearance. The patient made a good recovery from the procedure.
The abdomen was soft and non-tender. The patient felt well. He was still on chloramphenicol. Enzymes were, by now, fully normal.
The patient had no fever and felt well. The surgical staff decided to stop antibiotics and see if the fever and symptoms recurred. was now clear that he was not an operative candidate. Plans were made for his discharge the following day.
He was taken off antibiotics. Temperature and white cell count remained normal. The patient himself was in good spirits.
There was no demonstrable worsening of the patient's condition on his second day off antibiotics. His wife expressed the opinion that his mental state was entirely normal once more.
His condition remained stable on the third day. He said he felt well. He had no fever and no elevation in white count.
His condition was still good; his abdomen was soft without tenderness. He said he felt well. It
Discharged. His discharge diagnosis was fever of unknown origin with bacteroides septicemia. The opinion of the house staff remained that this patient had probably had a bile-collecting-system infection.
Five days after discharge, he was seen in the surgical clinic by Dr. Jack Monchik, who scheduled another set of gall bladder X rays for the future, and noted that if the patient had further trouble with infection, it would probably be necessary to remove the gall bladder. For the moment, however, the patient was fully well.
"To do nothing," said Hippocrates, "is sometimes a good remedy."
On the surface, Mr. O'Connor's hospital course seems proof of this ancient dictum of "watchful waiting." But this is not really so: had Mr. O'Connor received no treatment, he would almost certainly have died within twenty-four hours. He received vital symptomatic therapy (lowering his fever) as well as acute support of vital functions (assisted respiration). He was closely monitored by teams of physicians who were prepared to intercede in his behalf, supplying more assistance should his body require it.
He also received a vigorous diagnostic work-up, which did not produce as much information as one might like. His therapy was successful, but no physician at the hospital could claim, at discharge, that they really knew what was going on in his case. A diagnosis of cholangitis and cholecystitis was likely, but never demonstrated.
His hospital bill for a month of care was $6,172.55. This is just a few dollars less than Mr. O'Connor's annual salary. But he did not have to worry about it; unlike most patients with some form of health insurance, Mr. O'Connor had coverage that was essentially complete. His personal bill amounted to $357.00.
In this, as in many other things, Mr. O'Connor was a very lucky man.
The single most important problem facing modern hospitals is cost. This cost can be analyzed in a variety of ways, most of them confusing and unhelpful. But the following points are clear:
First, the cost of hospitalization has skyrocketed. The average MGH patient today pays per hour what the average patient paid per day in 1925. Even as recently as 1940, a private patient could have his room for $10.25 per day; by 1964, it cost $50.10 per day; by 1969, $72.00-$ 110.00 per day. This staggering increase is continuing at the rate of 6 to 8 per cent per year. Each year
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for the past three, the MGH has had to raise its charges. Nor is the teaching hospital unique in its financial squeeze. All American hospitals are raising their charges at this same rate.
Second, hospitalization cost has increased much more rapidly than other goods and services in the economy. Medical care is the fastest-rising item in the consumer price index in recent years, and per day hospital cost accounts for the largest proportion of this increase. [Physicians' fees have also been rising faster than other items in the consumer price index. However, hospital costs have been nearly doubled in the past decade, while physicians' fees have increased 30 per cent].
Third, the individual contemplating hospitaliza-tion no longer worries much, in a direct way, about cost. Third-party payment has led to public apathy about hospital costs, and this is unwise-if for no other reason than the fact that most people have only one fourth to one third of their costs paid by insurance, a fact they discover late in the game.
Fourth, the often overlapping coverage of health insurance permits some patients to make money from their hospitalization, while welfare reimbursements are always less than the true costs of care. In this situation, the hospital makes ends meet by overcharging private patients and their insurance companies to cover the welfare deficit-in the case of the MGH, roughly $10 a day overcharge.
Fifth, no single hospital stands alone in its financing problems, but rather is influenced by the activity or decline of other hospitals in the area. The decay of the Boston City Hospital, and its reduction in size to nearly half its earlier patient capacity, has created great pressure upon other Boston hospitals to take up the slack-by accepting precisely those patients on whom the hospital loses money, namely, patients covered by welfare.
The decline of Boston's municipal, tax-supported hospital is similar to the decline of other such institutions in other American cities. In each case, the reasons behind the decline are political and financial, but the consequences are always the same-to pass on costs to insured patients, and make them augment insufficient tax funding for welfare. In the long run, of course, it all works out to the same thing: one can either pay the money in taxes or in higher health-insurance premiums. But in such a situation, it is probably more efficient to choose one or the other-and the trend unmistakably is toward universal health insurance in this country. Dr. John Knowles notes that many Americans are required by law to arrange insurance for their cars; why should they not also be required to arrange health insurance for themselves?
Sixth, lest private health insurance seem a financial panacea, one should note that private companies are often irrational in their payment procedures. For example, for many years one could not collect for certain treatments-such as the setting of fractures-unless one were admitted to the hospital, at least overnight. Thus a person who might easily receive therapy in the EW and be sent home had to be admitted in order to receive insurance coverage. This unnecessary admission raised the total cost of health care, and ultimately such increases are passed on to the consumer in the form of higher premiums. Some of these odd payment procedures have been changed, but not all.