That doctor, in turn, recommended the specialist and assigned a hospital as needed. Given that the first Kansas City
HMO, Prime Health, opened in 1976, the doctor did all of the above without help from “utilization specialists” or constraints imposed by those tightwad PPOs, HMOs and other uncaring offspring of the managed care Scrooge.

This is not a false memory, merely a partial one. Lost in the haze of time is a major transition that can be summarized
in the replacement of one concept, “patient,” with another, namely “customer.”

“Patient” is an apt word. One had to be that to survive the healthcare experience of 1975. Although we conjure this
Rockwell-esque scene of doctor and patient sorting through the patient’s medical choices, more often than not the doctor dictated those choices. He— and he almost always was a “he”—had real authority in 1975, and often let that authority define him. For better or worse, today’s doctors are more humble.

In 1975, in the 2,500 or so square mile Kansas City region, almost all of the very high end health care was centralized
in a roughly 12-square mile area that ranged from Hospital Hill in the north to Meyer Boulevard in the south, from Prospect in the east to Rainbow Boulevard in the west.

In the patient-oriented model, the patient came to the hospital. Convenience was not an issue, at least not for the hospital. In today’s customeroriented model, the service goes where the customer is. Virtually all the major hospitals have established centers north, south, east, west or all of the above. Some, like Children’s Mercy and Saint Luke’s, have established major campuses elsewhere. Others, like Menorah Medical Center, have picked up the whole enterprise and moved to where the population (or prreferred population) is, just as St. Joseph Medical Center had done before it.

Missing, too, in 1975 were the various independent surgi-centers, most of which now conveniently flank I-435 on its southern loop around town. Although the established hospitals complain that these centers drain paying customers while offering little in the way of indigent care, the surgi-centers obviously meet a need. Customers prefer their market orientation and their streamlined simplicity.

If hospitals can be intimidating today, they were much more so in 1975. Few enterprises were as firmly authoritarian
as the hospital. Patients were told where to go, when to get there, what to do, when to leave. Hospital stays were
longer then, often inexplicably so. In 1975 hospital patients stayed on average nearly eight days, now it is closer to five.

There have always been kindly nurses and doctors, but there was less formal expectation that staff be courteous and less reward for being so. Nor were the concepts of “quality” and “outcome” recorded and assessed.

In 1975, hospitals had to please the physicians above all other audiences. Consequently, they did not advertise or, in many cases, even have marketing departments. Without the pressure to advertise a given market position, hospitals
had no imperative to create one, at least as far as the consumer was concerned. Hospitals could be, and often were, friendly, caring, convenient, and efficient, but there was almost no way to project these virtues beyond word of
mouth and little payback for doing so.

“The changes since 1975 have greatly empowered the patient and expanded their prerogatives,” confirms John Hagan, M.D., the editor of Missouri Medicine Medical Journal. It was in 1975, by the way, that Hagan, an ophthalmologist with Discover Vision Centers, entered private practice.

In 1975, America had the world’s best health care and still does. It is just that given the evolving market pressures
since then, that healthcare has gotten less invasive, less painful and more efficient. Doctors cut to remove kidney
stones in 1975. They cut to remove gall bladders. They cut to repair an athlete’s knee. If you needed a new knee, your
old one was probably better than the artificial ones coming on the market. There was no ultrasound surgery for cataracts, no liposuction, no CAT-Scans, no MRIs, no coronary stents.

Perhaps more importantly, there was no formalized concept of “outpatient surgery.” The presumption was that all
surgeries required at least a couple of days in the hospital.

Although ours is about as far from a free enterprise model as a largely private healthcare system could be, market
forces have intensified since 1975, and those forces have favorably widened the gap between our care and that offered
in the rest of world. The largest international study on cancer care, for instance, just acknowledged that the United States has the highest survival rates in the world–not just for people with private insurance either, but across the board.

“For all its purported shortcomings,” argues Dr. Hagan, “the U.S. healthcare system is the most advanced in the world.” You would not know this from looking at comparative life expectancy figures, which continue to rise steadily in the U.S. in spite of the many unhealthy aspects of our collective lifestyle.