In 1974, a Columbia Medical School cardiologist named Irene Ferrer, a sister of the actor Mel Ferrer, argued that “periodic or sustained sinus bradycardia [that is, a slow heartbeat] can no longer go unchallenged, even if asymptomatic.” Pacemakers, she said, should be implanted on a “prophylactic” [preventive] basis, particularly in patients in a broad new diagnostic category called “sick sinus syndrome,” characterized by a variety of modest disturbances in the heart rhythm revealing themselves on newer, ever-more-sensitive diagnostic machines. Pacemaker implantations doubled year by year. The guiding principles of the day were maximum promotion and maximum treatment.
Behind the scenes, meanwhile, Medicare—which paid for about 85 percent of pacemaker insertions and thus was primarily responsible for the explosive growth of the industry—was changing the shape of American medicine. Medicare’s framers had hoped to provide better medical care for the elderly. They did. The average life span increased from sixty-five in 1940 to seventy-one in 1970. Deaths from heart disease fell. But because Medicare mimicked the fee-for-service structure of existing private insurance plans, it paid better for procedures than for time. It starved doctors who provided hands-on primary care and overrewarded specialists who churned out procedures. Pay for primary care doctors was so poor that some of them refused to take Medicare patients at all. Doctors peddled their wares on a piecework basis; communication among them became haphazard; thinking was often short-term; nobody made money when medical interventions were declined; and nobody was in charge except the marketplace.
Fueled not only by Medicare but also by private health insurance, doctors’ average incomes quintupled—from $50,000 a year in 1940 in 2011 dollars to nearly $250,000 in 1970. Most of the increase went to specialists. Doctors flocked to where the money was: by 1969, there were nearly three specialists for each primary care doctor in America. When Medicare approved coverage for routine colonoscopies, gastroenterology incomes rose, and so did the number of gastroenterologists.
Newly enlarged high-rise hospitals—technological palaces fueled by private insurance and by federal dollars for research, construction, and patient care—were built in cities across the country. In their shadows often lay neighborhoods of the impoverished and the working poor, served, if at all, by a dwindling pool of underpaid and low-status internists and family doctors who maintained close emotional relationships with their patients throughout their lifetimes. Among those who suffered most, along with the poor, were the chronically ill and elderly of all classes: those with problems that couldn’t be fixed, who most needed the soft technologies of thoughtful, old-fashioned doctoring; advice on lifestyle and adaptation; and the time-consuming hands-on attention of a general practitioner. Despite the best intentions of its framers, Medicare’s payment structure punished doctors who practiced the Slow Medicine the elderly often needed and rewarded those on the hard-tech cutting edge.
Cardiac hypermarketing, meanwhile, grew so outrageous that it drew attention outside the hermetically sealed worlds of the operating room and Medical Alley. In what turned out to be the first of repeating waves of scandals similar to those in the pharmaceutical industry, witnesses told a Senate subcommittee in 1981 that some doctors were deliberately performing unnecessary pacemaker implantations in return for device industry kickbacks. Sales reps at one pacemaker company—a company, as it happened, with a terrible product-safety record—gave their most “productive” doctors free stays at the company hunting lodge and on the company yacht. Others hired the comedian George Burns and the cheerleaders for the Dallas Cowboys to regale doctors at free dinners and parties. “In all my twenty years experience in the medical sales field, I have never seen a business so dirty, so immensely profitable, and so absent normal competitive price controls as this one,” one former salesman told the Senate subcommittee.