Daniel W. Brake, M. D., oral history interview, June 12, 1992

              Mr. Robinson: And I thank you for joining us today.
(unintelligible ) This is an interview with Dr. Daniel W.
Brake of Charleston, South Carolina, who served as
President of the medical association from 1989 to 1990.
This interview is being conducted by Bruce Robinson in
Charleston, South Carolina, June 12, 1992. Dr. Brake,
where were you born?
Dr. Brake: I was born in Lake City, South Carolina, a
small rural community of about eight thousand population.
Mr. Robinson: Um, Who were your parents? Were they from
Lake City?
Dr. Brake: My, um, mother grew up in Lake City. Her
grandfather was granted some farmland from the King of
England and had a large, large family in that community.
My father moved to Lake City from North Carolina to come
work for his sister's husband who was a general
practitioner in Lake City and owned a drug store. And he
came to work for him. He met my mother and they married
and stayed in Lake City where I grew up.
Mr. Robinson: Well, obviously, medicine runs in the
family.
Dr. Brake: Yes.
Mr. Robinson: Um, you will excuse me. I'm sorry, sir.
Let me stop for just a second. (Pause) This is interview
with Dr. Daniel W. Burke of Charleston, South Carolina. My
name is Bruce Robinson. I'll be conducting the interview.
Dr. Burke served as President of the South Carolina Medical
Association . . .
Dr. Brake: Brake.
Mr. Robinson: I'm sorry.
Dr. Brake: You're fine.
Mr. Robinson: This is an interview with Dr. Daniel W.
Brake of Charleston, South Carolina, who served as
President of the South Carolina Medical Association from
1989 to 1990. Dr. Brake, where were you born and who were
your parents?
Dr. Brake: I was born in Lake City, South Carolina, a
small rural community of about eight thousand population.
My mother was (unintelligible) Brake. She grew up in Lake
City, South Carolina and had a large family in Lake City.
My great-grandfather had a large farm that was granted to
him by the king of England. They had large families of
seven or eight children and all of them married and all of
them had children, they had children. The convenience of
that was I was related to just about everybody in this
small town. My father was from North Carolina and he moved
to Lake City to work in a drugstore that his sister's
husband owned. He was a general practitioner in Lake City.
He met my mother and they married and had me and my Sister
and we grew up in that small rural community.
Mr. Robinson: So, was this much of an influence on you, in
your decision to become a physician.
Dr. Brake: Yes. My uncle, who was Dr. Dexter Evans, uh,
was, uh, the ideal old general practitioner and he had a
son that went to med school and came back to practice with
him. And, like you said, my uncle, his whole life was
dedicated to the people in that community. We never had
dinner with him that he didn't get a phone call or have to
go out and leave and take care of a patient. Uh, I never
heard him complain. When he died in that community, I've
never seen a funeral like that where people were out in the
streets and people could not get in the church and
everybody just paid their respects to a man who had
dedicated his life to that community. Um, those kind of
physicians and that kind of dedication back in the forties
and fifties are something that it is difficult for me and I
think, for younger physicians to understand. They
basically gave their entire life to that community. They
had very little family life and they were all called . . .
they were individual practitioners and it was a tough life.
And I admired him greatly and went into family practice.
Mr. Robinson: He sounds respected. I can think of a
stronger influence for anything else than to enter family
practice. Did you know this then, when you were an
undergraduate, that you were on the road to becoming a
family physician?
Dr. Brake: Yes. Actually, um, I was one of the fortunate
ones, I guess, because by the time I was eight or nine
years old, my views of my uncle and feelings of wanting to
be a general practitioner were very strong at that time.
And, those were my goals. I headed in that direction and I
never turned in any other direction except medicine. Um,
it was family practice at the time. It was general
practice when my uncle was growing up. The large
percentage of physicians at that time were general
practitioners. And then we evolved into kind of a
specialty are where everybody was specializing in one area
or another and the general practitioners seemed to be dying
out. So, as I went through med school, and I went through
residency, each service that I was on, whether I was in
internal medicine or pediatrics, I loved the service. And
the people in that, the professors in those areas told me,
"Well, you don't want to be a general practitioner, you
want to go into internal medicine (or pediatrics or
whatever), because general practice is dying."
Fortunately, the general practitioners got together and
formed their own specialty called family practice and set
up a three-year residency program where we could get better
education and continuing education and recertification of
our boards and provide quality care for the entire family.
And so, um, at times I got a lot of pressure not to go into
family practice, but I always wanted to do that, and I'm
very glad that I did.
Mr. Robinson: Do you see a lot of students today entering
the family practice?
Dr. Brake: The family practice has had its ups and downs,
and right now, because of a lot of things that are
happening with the family practitioner as far as the
government is concerned and Medicare reimbursement has been
extremely poor for the primary care physician in family
practice that a smaller number of physicians are going into
family practice. But, uh, the nation realizes how
important it is to have somebody at the front line of
seeing the patient. The sub-specialties really cannot
survive without a primary care physician seeing the patient
and making a diagnosis and referring them to the proper
sub-specialty area. There's another movement going on in
med school. There's a core curriculum in family practice
now to expose medical students to family practice. And I
think we are going to, in the end, see an increase in
family physicians as we did in the late sixties and early
seventies.
Mr. Robinson: So you believe these programs are, for the
Most part, effective.
Dr. Brake: Yes.
Mr. Robinson: That they will be more of an enticement to
family practice for today's modern medical student. Do you
believe that of today's modern medical students were not
made aware of the rewards of family practice, of the
rewards of follow-up, of seeing their patients birth to
death, of dealing with the family as a unit, of . . . Do
you believe those to be one of the shortcomings of why
people went into certain specialties? Do you believe it
was. in some respects, the lower monetary remuneration?
What do you think are some of the shortcomings? What
caused this lack of, uh . . .
Dr. Brake: I think, one, that, uh, as a medical student,
and even into internship, that as I would work on a
service, the pediatric service, I though highly of the
pediatrician. I loved the pediatric service and I thought
about being a pediatrician, although I knew in the back of
my mind that I was going to be a family physician. But if
I wasn't going to be a family physician, maybe I'd like to
be a pediatrician. I got on the internal medicine service
and the internists there and I became great friends and,
uh, and so, he said, listen, you ought to go into internal
medicine. I thought then that internal medicine was great,
but I knew still that I wanted to be a family physician.
You didn't have the exposure of what's family practice
like. You weren't at the family practice department. You
didn't have the exposure of what is family practice really
like. And without that exposure, students that really
don't know what they want to do, don't get a choice of
family practice. They get a choice of surgery and internal
medicine and pediatrics?
Mr. Robinson: Do you believe that South Carolina Medical
Association and with its powers and abilities and people
and membership could play in and influence in increasing
interest and stimulating interest in students becoming
family practitioners.
Dr. Brake: Yes, I believe the South Carolina Medical
Association as well as . . . Now, both our schools of
medicine, uh, the MUSC and South Carolina School of
Medicine in Columbia have core curriculums that actually
have medical students . . . We have medical students that
actually come out and work in my office. In fact, we've
got one now that is working with us to see what family
practice is really like. They find that you can't get in
med school in any field, that you can't be . . . You are
not there long enough to build relationships with patients
and the patient is what, to me, makes family practice so
rewarding because not only are you seeing a lot of variety
in interesting disease from the scientific standpoint, you
also are building a relationship with a human that you care
about and you can relate that to the patient and the
patient appreciates having a physician who cares about them
and they know when we care about them. They know if we
don't care and they know if we do care. So, plus to be
able to take care of them from the medical standpoint and
to be someone that cares about them, I think, is rewarding
for the patient and very rewarding for me as a physician.
Mr. Robinson: Earlier you mentioned that first residency
and medical school. I am going to backtrack a little.
Where did you do your undergraduate work.
Dr. Brake: I went to Wofford College in Spartanburg, South
Carolina, a very small college that is a liberal arts
school. We had, uh, interesting . . . We had thirteen
students out of a class of about ninety that went to MUSC
school of medicine. And, uh, a lot of doctors have come
out of that college.
Mr. Robinson: That's a big portion. Did you follow suit?
Dr. Brake: Yes.
Mr. Robinson: You were one of the thirteen.
Dr. Brake: Yes.
Mr. Robinson: Did you do your residency here also?
Dr. Brake: No, but I'll tell you something interesting
about when I graduated from Wofford. I came to the medical
college here. It was called the Medical College of South
Carolina in Charleston and now it is the Medical University
of South Carolina. I came into that class and we had a
small class. We had a dean at that time called Cheves
Smythe and Dr. Smythe, at that time South Carolina was not
rated high in the country for medical schools, and he
decided when we stepped in, the first day, he told us that
he was going to graduate the smartest class from South
Carolina or the smallest. And he was going to put South
Carolina on the map with our class. And he drilled for the
medical boards and he pushed us and we graduated the
smallest class that had ever graduated because he flunked
twelve out the first year of about eighty to ninety
students. But, uh, he, uh, he really worked us hard and he
actually helped to improve the quality of teaching and the
students at South Carolina . . . at MUSC.
Mr. Robinson: Your nemesis or your mentor, whichever way
you look at it.
Dr. Brake: Right.
Mr. Robinson: Your next . . .
Dr. Brake: Then I did my internship at South Carolina at
Charlotte Memorial and, uh, I did my residency in family
practice at Charlotte Memorial.
Mr. Robinson: Tell me some of the highs and lows of your
residency.
Dr. Brake: The interesting thing with residency was that I
made fifteen cents an hour. We had a flat monthly salary
that we got and we sat down and calculated the number of
hours that we were working and we made fifteen cents an
hour, uh, and worked extremely long hours. I had, uh . . .
I married between my junior and senior year. I married Sue
Roche from (unintelligible) in Monk's Corner, South
Carolina. Uh, we were there working extremely hard and
that was one of the happiest times in our lives. We stayed
in an apartment that was right beside Charlotte Memorial
Hospital that the residents stay in and we were all in same
boat. We had no money. We were working extremely hard.
We were learning a lot. It was an exciting time. And, uh,
it's just a fond memory for me and my wife. Um, and also
my daughter was born there, Shannon, which was an exciting
time for us, too.
Mr. Robinson: You have just one daughter?
Dr. Brake: I have two children. Shannon has, uh, just
graduated from Emory in Atlanta and is now doing research
with Yearkies (? - unintelligible) Primate Research and has
just been awarded a Fellowship in Cultural Anthropology at
Emory and we are real proud of her. And my son, Daniel,
was born in a rural area I practice in in Conway, South
Carolina, and he is a junior at Wofford College. Right now
he is at a university in Salisbury. Wofford has an
exchange program and he is spending a semester over there
which is a wonderful experience.
Mr. Robinson: Do you by any chance see him following in
your footsteps?
Dr. Brake: Daniel is just a wonderful young man and I
really, at this stage in his life, he's just one of those
undecided on where he wants to go. He knows that
physicians have to work hard and have long hours and don't
get to spend a lot of time with their family and I'm not
really sure where he'll head.
Mr. Robinson: Tell me about when you left Charlotte.
Where did you go?
Dr. Brake: At the time I left Charlotte when we were in med
school, everybody had to serve two years in the service and
what happened was you would finish med school and you got
in your internship and residency and you got drafted or you
finished out and you went out and started practicing and
you got drafted. So, the military allowed you to sign up
for something called the Barry Plan. And the Barry Plan
would allow you to finish your residency and then as soon
as you finished training, you could go in a serve your two
years in the military. And then as soon as you had
finished your two years, you could go out and get into your
practice and not worry about being drafted. So, I signed
up for the Barry Plan and as soon as I finished my family
practice residency at Charlotte Memorial, then I went to
Wright Patterson in Dayton, Ohio, at a base there and
worked in the family practice unit there for a year. And
while I was there I watched the hospital and I had a
general there one day who asked me how things were going
and I told him a number of things that he could do to
improve the quality of care in that hospital. And he was
30 impressed that he gave me my own hospital in Greenland.
He sent me to Greenland which is a remote assignment, uh,
for my second year in the service. And I had to send my
wife and my daughter, Shannon, to stay in Monk's Corner
with her parents while I spent a year in Greenland in this
hospital where I could give really good quality care
because I was the only physician there and we had about
fourteen coremen and administrators that worked that
hospital.
Mr. Robinson: At the very end of that, were you looking
very much forward to coming back to the United States?
Dr. Brake: Yes, I was very excited about getting out of
the military and getting into family practice. The sad
thing for me in that year was that that was the year that I
was going to spend deciding where I wanted to practice.
And, I knew that I wanted to be in a good hospital setting
and I know that I wanted certain things in that hospital to
provide the quality of care that I had been trained to
provide in my residency program. And, but yet, I couldn't
go from Greenland to look at different practices. So, uh,,
Dr. Dick Rush who was from Lake City was in practice in
Conway, South Carolina. And his mother contacted my mother
and they contacted me and said, "When you get out of the
service, why don't you go practice in Conway with Dick
until you can decide what you want to do and where you want
to go." So at least I would have a job when I left the
military until I could decided what I wanted to do. So,
uh, I went straight to Conway and started practicing there
and started looking around at other areas trying to decide
what I wanted to do and where I wanted to go. And I
actually ended up staying in Conway for ten years, uh,
before we moved to Charleston. The Conway experience, in
the kind of rural medicine that you practiced, was really
kind of like the medicine that my uncle practiced and was
fun.
Mr. Robinson: What was the population?
Dr. Brake: The population was about eight thousand and,
uh, it was in a county called, uh, Horry County. And it
was a very poor county where about thirty to forty percent
of the population was on Medicaid which was the insurance
for the indigent population. And the patients . . . There
was a lot of farming around and when I first opened my
practice, uh, a patient, after I saw him, and he got ready
to leave, he said, "Doc, I don't have any money." And I
said, "You just do what you can do." And, uh, he said,
"Well, do you like corn?" And I said, "Yeah, I like corn."
He said, "Where do you live?" And I told him where I lived
and he said, "Well, I'll go get you some corn and take over
to your house." And I said, "Well, that will be fine."
So, I told him that I had a little patio on the back of my
house. And I got a call from my wife that afternoon and
she said, "Dan, what did you do?" And I said, "What do you
mean, what did I do?" And she said, "Some guy backed a
pick-up truck load of corn up and dumped it on our patio.
I've got a whole pick-up truck load of corn out here." So,
we had to got buy a freezer and put up all this corn and
put it in the freezer. But they paid us with butter beans
and corn and squash and potatoes and whatever they could.
And that was one of the things that I miss in medicine
today. Because of all the insurance and paperwork and the
expense. When I was practicing in Conway, and my uncle,
basically, in watching him, uh, he rarely sent out bills.
I mean, people cam in and that majority of people paid him.
And the ones that couldn't pay him gave him butter beans
and corn or nothing. And he didn't have all these
insurance claims to fill out and he got along fine. He
made a decent living and he was able to pay his staff
promptly and he didn't have to harass anybody. and that's
kind of the way it was in Conway when I first started
practicing. And it's sad to see us move to, uh, the
expenses that we have to deal with in medicine and the
expenses that patients have to deal with. And, uh, and
have to try to meet the tremendous overhead that we have in
practice right now. And that really discourages a lot of
your physicians going out and opening their own office.
Because it is so expensive to open an office today. Uh,
but those were fun times in the rural area there.
Mr. Robinson: Dr. Brake, what brought you to Charleston?
Dr. Brake: I think, probably, that my family and my
children grew to a point that we . . . We loved
Charleston. I spent my medical school years here and my
wife was from the Charleston area around Monk's Corner and
she had five brothers and sisters and they were all married
and they all had children and they all live in this area.
And so we just felt like it was time for us to, uh . . .
My daughter was into, uh, (unintelligible) and horse-back
riding , and, uh, was not able to get some of training that
she needed in that area which was available here. And my
wife came and looked . . . We talked about trying to move
back to Charleston and my wife came and looked and found
house site out at Middleton Place, Middleton Gardens, which
is the first landscape garden in America and Middleton
owned this plantation and he signed the Declaration of
Independence. So it's a beautiful old plantation of about
six thousand acres, and, uh, at that time Charles Doole,
who owns Middleton Place, opened up some house sites and
she found one of these and came and looked at it and got me
to come down and look and we walked over the plantation and
looked at this beautiful old plantation. And, uh, when I
was growing up, my mother took me to Georgetown where, uh,
there's an old plantation there that we rode down and I saw
these beautiful oak trees and I was ten years old then.
And I told my mother at that time that I was going to own a
plantation some day. Well, obviously, I could not begin to
afford a plantation, but here I could buy about an acre and
a half on this old plantation and have about six thousand
acres access to walk in the gardens anytime I wanted to and
so, we fell in love with that area. They had stables so
that my daughter could ride and all this property for her
to ride on. And so we decided to try city living for a
while, and, uh, I was forty at the time, and moved to the
Charleston area and opened an office. People told me that
i was middle-aged crazy and I probably was. I had not one
patient when I opened this office and I said I hope
somebody will come to see me, which they did and at the
present time now, we have three doctors in the practice and
we are looking for a fourth. So, uh, it really has worked
out well and we have enjoyed living in the Charleston area.
Mr. Robinson: It's probably best for the SCMA, too,
because, being in the Charleston area, is it safe to say
that that probably stimulates some of your interest in
being with the SCMA?
Dr. Brake: Well, the, uh . . . What happened in this in
May to me was, uh, at the time I was in Conway, we admitted
a young boy with Hodgkin's Disease who was not doing well
and I kept him in the hospital for three days. And I sent
the insurance company a bill for the history and physical
and the two days in the hospital and the discharge summary
for a total of thirty-five dollars. And the insurance
company sent me a check for thirty-five dollars. And about
six months later I got a check from the insurance company
saying that this was a diagnostic admission and that they
had denied the admission and I had to send them the thirty-five
dollars back or they were going to take it out of the
next check that they sent me for whoever I had in the
hospital. And I was just furious and I went to a doctor
named Dessie Gilliam. And Dessie was, at that time,
President of the South Carolina Medical Association. And I
said, "Dessie, this is just not right and you guys at the
medical association have got to do something about it."
And he said, "Well son, if you want to do something about
it, why don't you get active in the South Carolina Medical
Association and do something about it yourself." And so,
uh, Dessie . . . At that time they formed a South Carolina
Medical Association Insurance Peer Review Committee. And
so he put me on this which actually was looking at
physicians that were utilizing services for hospitalization
and office work and it also gave us a look at insurance
companies and who they were using for doing their review
work to deny admissions on medical necessity. So they were
doing this retroactively. It was very easy to sit down and
look at a chart and say that this patient did not need to
be in the hospital because they did not turn out to have
cancer or whatever you suspected they had. But at the time
that you were looking at the patient trying to decide what
is best for them, if you feel that they needed to be in the
hospital and you admitted them, and it turned out it was
something bad, then you were okay, and if it didn't, then
you could get these retroactive denials. So, through that
committee and one of the things that I am proud that I was
able to accomplish at that time was that it was very hard
to fight retroactive denials. I told them that they needed
to do concurrent . . . to review at the time that the
patient was admitted to the hospital and decide at that
time whether we are going to pay for it or we are not going
to pay for it. Uh, and so, were able to get rid of the
retroactive denial process and we did it basically through
that committee, uh, and working through the South Carolina
Medical Association. I became Chairman of that committee
and then became, uh, was asked by some of the board members
to serve as a First Vice President which was really a
position that allowed the board to go out and get people
that they thought might be effective for the organization
and to get them in that position and sort of get them on
the board and take a look at them. So they kind of brought
me on the board that way.
Mr. Robinson: So that's was a stepping stone to the
Presidency?
Dr. Brake: Yes.
(TAPE ENDS)
Dr. Brake: One of the tragedies of my year in the
Presidency was that was the year that Hugo came to
Charleston and it really was devastating for us here in
Charleston and it really was hard for me at home. We
didn't get electricity at our house for three years, I mean
three weeks, and we lost fifty-three trees in our yard and
was had fourteen of them on the house. So we had a lot of
problems there and it made it difficult for me to do some
of the things that I needed to do for the medical
association. I had to go to Hickory Knob to talk to a
civic meeting that they had there, and, uh, I would have to
leave my home at five o-clock. Well, I finally bought a
generator that would get us water into the house and some
electricity, but not enough to get hot water and I wanted
to take a hot shower. I didn't want to get up and take a
cold shower at five o'clock in the morning. So, I got up
and headed to Hickory Knob with no shower and no shave. I
decided that I would do something on the way. Well, when I
came to Aiken, I said, well, why don't we try a motel. So
I pulled into a motel and said, "How much will you charge
me for a shower and a shave?" And he said, "Twenty
dollars." So I gave him twenty dollars and I went in and
got my shower and my shave and then left and went on to
Hickory Knob. But, uh, Hugo, uh, was a rough time for us.
A lot of doctors went out into the rural communities and
provided health care and the South Carolina Medical
Association got involved in funding some things to help
some of the devastated areas.
Mr. Robinson: Tell us about some of you administrative
policies during your tenure as President of the SCMA.
Dr. Brake: Well, the, uh, some of the, uh, some of the
things that . . . Well, uh, just let me tell you about
some of the things that were appropriate and outstanding
and tended to head us in certain directions. There was a
Personal Care program that we set up through the South
Carolina Medical Association that really came through
during Tommy Rowland's time. But what we were saying was
that . . . Medicare was, uh, the insurance plan that the
government set up for the over sixty-five population and
Medicare came out. The American Medical Association said
to the government, "You know you only need to take care of
the population that cannot afford to pay for themselves."
It's what the government should be doing in my opinion.
But the government moved to take care of everybody, so
everybody over sixty-five get Medicare. And Medicare was
initially paid at current fees. And it was not able to
keep up with it as government programs are usually not able
to, so they started having to play games to keep costs
down. So they started putting freezes on what they allowed
on lab charges and as inflation started to rise and in the
seventies we had sometimes as much as twenty percent
inflation rate, uh, the fees for Medicare reimbursement
were staying way down here. So, uh, the difference between
what Medicare would allow and what physicians were charging
was getting tremendous and the patients were not too happy
with that. So they went to the government and said, "Well,
we want you to force the doctors to accept these low fees
that you are paying." So if you had a twenty dollar
service, and Medicare would not allow but about ten, some
of which we ate, and the patient would be stuck with about
a twelve dollar bill. If they could get the physician to
accept the assignment, they would only have to pay . . .
that was all the patient would be charged. And so the
Medicare paid what the insurance charged and the patient
would be happy too. And so, uh, but, the, uh, allow charge
didn't cover your expenses, and so you couldn't do that and
keep your practice open. And so most of the physicians in
the primary care fields didn't accept assignment and they
pushed very hard to set the assignment. The personal car
thing, what the physicians said was that in South Carolina
we care about the older people on fixed incomes that can't
make ends meet and we will accept assignment on anybody
under one hundred and fifty percent poverty level. And so
we went through the Commission of Aging and I met with them
a number of times to shove them along on this plan. And we
then, said that anybody above that level, well, the
physician will deal with like he does any private patient.
I've got private patients that don't pay many anything and
some that pay half of what I charge and some that pay me
all. But, you were dealing with them as an individual
patient, not as a Medicare patient, but the Personal Care
patient could bring their card in and the physician would
accept assignment. So, that was good program that is still
in effect, and we moved, uh, from that program to looking
at, during Tommy Rowland's era, to looking at the health
care crisis situation which has evolved now into 1992 and
everybody wants something done about the health care
system. It really is too expensive. The patients cannot,
uh, cannot afford the premiums for insurance. So, uh, if I
can move into my year and tell you what I think is the most
important thing that I did that I am proud of. Uh, is that
I had tremendous concerns about what was going to happen
with the health care for me, in my older years, and what
kind of health care my children would be able to receive.
And, so, uh, I formed a committee that I called Health Care
2000. 1 asked people from the government, people from
private insurance companies, hospital administrators,
nurses, we asked people from the AARP, DHEC, the recipients
. . . We asked anybody that provided health care, received
health care, or had anything to do with health care to sit
at that table. The first day I asked them, "What kind of
health care do you think we should have in this country?"
I asked them to take off their special interest hats and be
Americans and not try to set a system that would benefit
them in whatever system they were in, but a system that
would benefit all Americans. And I was extremely proud of
that committee. They did just that. We came us with some
recommendations. I told them, "Let's look at the old
socialized system and if medicine should be socialized,
then let's push and get the South Carolina Medical
Association to move toward socialized medicine." If we
felt like that was not the answer, then let's look at our
system and try to correct what was wrong with it. Well,
uh, we decided that, after looking at the socialized system
that they had big problems and that that was not what we
wanted. We decided that we had the best health care in the
world, but it just cost too much and it had some flaws in
it that needed fixing. And, so, briefly, to summarize what
they recommended and maybe to, uh, if somebody is looking
at this in the year 2090 or whenever, it would be
interesting to see what kind of health care system that you
have now compared to what we are recommending in 1992.
But, to summarize briefly what happened, was, when Medicaid
and Medicare were passed in 1965, the government paid for
things as they received them. When the services became so
large that they could not afford to pay for it, then they
started cutting reimbursements and they cut reimbursements
to the point that people were actually losing money taking
care of government patients. So the hospital ended up with
about fifty to fifty-five percent of their admissions on
Medicare and Medicaid and were losing money with all of
them. So all they could do was cost shift to the paying
patients. And as they would shift Costs to the paying
patients, then the insurance premiums for the paying
patients would continue to rise twenty to forty percent for
year to the point that there were now private patients who
could not afford health care. So those people ended us
going with no insurance. They would end up with a serious
illness, going in the hospital. We would not turn them
away. Everybody gets treated if they are ill and come to a
h03pital, uh, and so we would treat them, but that cost
would shift to the private pay patient. And right now
we've got about thirty-five percent of the people that go
into the hospital that pay a full dollar for a dollar
service and then they pay and additional premium to cover
the uninsured and the inadequately insured and to cover,
uh, the uninsured and the inadequately insured and to cover
the Medicare and Medicaid population. And we've got three
hundred thousand millionaires over sixty-five on Medicare
that don't need Medicare and that money can be utilized to
take care for the people that can't afford to pay for
themselves. So basically, the solution that Health Care
2000 recommended was, number one, from the Medicare
standpoint, that we accept the Personal Care Plan that I
told you about so we say to anybody under one hundred and
fifty percent poverty level, whatever the government can
pay for th03e services, we'll accept that. For anybody
over that, they will have to pay the same thing that
anybody else pays. And those three hundred thousand
millionaires can buy their own private insurance or they
can have Medicare, but they have to pay a premium to cover
their cost. So that Medicare monies are taken in can take
care of the indigent and poor people. We, uh, went into
some cost-savings things that I won't have time to tell
you, but there are a lot of ways to save costs and cut the
cost of health care. So, we had a long list of things that
we could do, and one of them had to do with Death with
Dignity and living wills and one of the things that we
recommended was that we educate people to help physicians
not put people on respirators and keep them alive another
three or four days when we know they are going to die, but
we are scared not to do this because we may be sued. So
living wills, now are, handed out in hospitals and in legal
offices and a lot more people are becoming knowledgeable
about this and we are getting them on their records and we
are not having to put them on respirators when we shouldn't
be doing that. Anyhow, without going into all that, there
was a lot of cost savings, but the Medicaid and Medicare
are now paying a dollar for health care, if we had this
system, for the dollar of health care they receive. We've
got the older population paying what they can afford to
pay. We did means testing of what they can afford to pay.
And then we required everybody to have health insurance.
Now, it was interesting, after I announced this at the
Annual Meeting in the House of Delegates that approved
Health Care 2000, a newspaper reporter stood up and said,
"Dr. Brake, do you mean to tell me that you are going to
require me to have health insurance? This is a free
country. You should not have to require me to buy health
insurance if I don't want to buy it." And what I told him
was that if you want to go out and buy a motorcycle and
ride down the road, then it's a free country and you can do
that, but if you flip that motorcycle and you get a
fractured cervical spine or you get a serious illness that
puts you in the hospital and you run up a hundred thousand
dollar bill, then you have no right to make me pay for
that. And I'm the one that pays for your hospitalization
because my premium pays for it. When I pay my premium, it
pays for the people that go into the hospital that have no
insurance. And you have no right to make me pay for your
health care. You ought to have to pay for your own health
care. So, it's my opinion that everybody should have to
have health care and Health Care 2000 said that everybody
should have a basic benefit package. We drew up a basic
benefit package that says the things that we think every
American should have as far as health care is concerned.
And then you have to look at, well, how do you implement
everybody having health care. The debate is going on right
now. It will be interesting over the next few years as to
whether or not this is going to be required by employers to
provide health care for their employees or whether or not
(unintelligible) Within that there should be tax
incentives. My personal belief is that I think that we, as
Americans, should be responsible for ourselves and the more
we depend on the government to do for us, the more problems
we are going to have. And, so, from that standpoint, I
feel like that people should know what health care costs
and if I am going to have health insurance and I get a
salary, then the amount for that premium for that basic
benefit package should be included on my check and it
should be deducted from my salary and if we are going to
have a tax benefit, then the tax benefit should come to me.
So, I get the tax break for the amount that I pay. So,
that way, I can look at that and if it is going up too
high, then I can start looking into why. One of the
problems in this country had been that industry decided
that one of the benefits that we are going to give
everybody is going to be health insurance.' And at that
time it was cheaper. And now it is so expensive that
industry is having trouble paying for it. And, now,
everybody expects it and industry should give it to them.
And, so, Health Care 2000 says that we ought to have
everybody required to be covered. Now the interesting
thing that's going to happen. If everybody
(unintelligible), Medicare and Medicaid paid a dollar for a
dollar service, we don't have this cost shifting anymore.
Everybody that goes into the hospital now, the hospital
gets paid. All of a sudden we have an increase in money in
hospital. All of a sudden the insurance has an increase in
money because we have got all of these people that, the
thirty seven million people that are uninsured right now,
they are all paying premiums. Um, the doctors are getting
money because all of the people that they are treating free
now are paying through the insurance. So, within that
system, we should be able to see that the insurance
company's rates come down so that people can afford them
now, if we don't have the cost shifting. And within the
system is going to be some mechanism to monitor hospital
costs and physician costs and insurance costs to make sure
that they just don't take windfall of money and that they
are giving it back and that people get lower insurance
premiums. So that's what the Health Care 2000 of 1992 is.
And I wish I could be here fifty or sixty years from now
and find out what kind of system we have, but hopefully it
will be a good system where our children will have good
quality health care and we won't destroy this into some
socialized system.
Mr. Robinson: Tell me about, from your personal
perspective, what are some of your fond impressions of your
year as President of the SCMA.
Dr. Brake: Well, uh, being installed as President of the
South Carolina Medical Association at this big banquet with
your friends and dignitaries around and to have a standing
ovation of your peers and that they respect you is just an
overwhelming feeling and I had friends to come to that
banquet that haven't seen in a long time. I had phone
calls. I had letters. I had copies of newspaper articles
from people I hadn't heard from for ten or fifteen years.
And, uh, to have that kind of contact and those kinds of
friendships was tremendously rewarding to me and, uh, to
them.
Mr. Robinson: Are you enjoying more your return to private
practice?
Dr. Brake: Well, one of the things that I think, uh, the
medical association needs to keep . . . and I know that
this is the time that you dedicate to the medical
association, if you are dedicated, and, I know, for the
organization to function well, we need to keep expenses
down as much as we can, uh, but the time out of the office
that the President takes is a tremendous cost to him. We
had one President before me that basically lost his
practice. After serving, he went back . . . and his
basically was a solo practice . . . and his patients had
all gone to somebody else. He never got back into
practicing in that community. He did administrative work
after that and he was the one that recommended that some
reimbursement come back to the President and the Chairman
of the Board and there is now, uh, a small, uh, fee that's
paid to them. But, it really, right now, after two years
in my practice, Us, uh . . . it hurt my practice
(unintelligible) and my practice is just getting back to
the way that is was before. I have still stayed active in
the medical association and served as an Alternate
Delegates to the AMA and probably will do that until
medicine . . . the health care crisis is solved, depending
on the outcome that it has over the next three to five
years. And once that is done, then I'm willing to retire.
I think back to the early seventies when Dr. Gilliam told
me to get involved and serving on the Peer Review
Committee, we disciplined physicians, and, uh, I felt very
strongly as a young, idealistic doctor that the only person
that's capable of judging and disciplining a physician is
another physician. And, if we are not willing to stand up
and tell physicians when they are practicing poor quality
medicine or are over-utilizing services, we are just not
doing our job as a total physician and representing our
patients as we should. But, I. uh, felt strongly that we
should shape medicine to provide quality care for our
patients. I was active in the Academy of Family Physicians
in the early seventies, actually the early eighties, and
served as Chairman of their board and President of that
organization which started in 1985. 1 put more into the
South Carolina Medical Association because the South
Carolina Medical Association is more effective. It is a
larger organization. They are able to get more things done
through the legislature than the Academy of Family
Physicians was. And, uh, and the AMA is able to do more on
a National level that the Academy of Family Physicians are
and that's why, although I'm dedicated to family
physicians, I feel like I can have a greater impact through
the South Carolina Medical Association and the AMA.
Mr. Robinson: Are you optimistic about the future of
medicine?
Dr. Brake: Yes, I am, is we are . . . I'm concerned that
a lot of this has to be done through the legislature
because I have not been real impressed with our congress
over the past five or ten years, as I don't think anybody
has. They have rarely been effective in making decisions.
But, uh, in that . . . to see bills passed that impact
health care that we actually initiated and that we endorse
. . . And, actually, on a state level now we have people
calling us and asking our position and with us giving them
guidance have built a tremendous reputation and respect in
the legislature on a South Carolina level. One of the more
important bills that we passed that I am having a great
time with . . . For the people that may watch this years
from now, there was an evolution in the health care system
in trying to cut costs and since industry was buying all of
us health care, then industry decided that they would call
the shots. Now we are going to take over and we are going
to call the shots. And they started forming these
utilization review companies that actually pre-certified.
If somebody's going into the hospital now, you don't just
put somebody in the hospital. You got a call from the
insurance company wanting to know why they are going in the
hospital and what are you doing in the hospital and when
are they coming our of the h03pital. Well, the people that
have these companies have sold industry a bill of goods
that they are saving large amounts of money. So, they have
no regulations over these companies. Some of them are
operating out to California, uh, New York and all the other
areas that have nothing to do with South Carolina. They
are operating out of one room with one telephone and
patients now are aware that if they are not pre-certified
for the hospital, then they are going to to have to pay
because their insurance isn't going to cover them. So,
I've had patients that I couldn't get to go over to the
hospital until we could be sure, until we could get through
this phone. If you've got one or two phones in one room
and you've got five hundred calls coming in, you've got a
lot of busy signals. And so . . . And also the set up is
that, as far as who called you on the telephone, people
would call that had no medical knowledge. And if you put
somebody in the hospital with acute myocardial infraction,
uh, it's easy to say, "This patient has had a heart
attack." That's all I needed to say. they could open a
book and say how many days they would allow me and call be
back in that number of days. But they would ask you
questions like, "Well doctor, what did the EKG show?"
"Doctor, what are you doing for him in the hospital you
can't do for him at home?" Those are just standard forms.
And the people who have medical knowledge know that you
don't treat a myocardial infarction at home. We got a bill
passed in our state that said that these companies have to
register with the insurance commissioner and we set up some
guidelines. And now, we have to be able to reach them
within a certain period of time and they have to answer to
the insurance commissioner. And now, when I get calls,
it's, uh . . . they put me on hold for a long period of
time and when I finally get on the line, I ask what their
South Carolina number is. A lot of these companies, well I
say, "Where are you from?" And they say, "Well, I'm from
California." "What is your South Carolina number?" "Well,
what do you mean by South Carolina number?" "Well if you
are taking money from a company and you are going to do
review work and you are calling South Carolina, you are
operating illegally in this state. And I don't want to
give you any information about the patient and if you deny
this admission, then we'll have to notify the company that
you are taking money from them and you can't even operate
in this state." And so, it's been fun playing games with
them to get them on the defensive for change. And,
actually, I wrote a letter to the Insurance Commissioner
about a company that I tried three times to get through to
them and was on the phone for twenty minutes each time and
I got a call from the company apologizing. They set up
more phone people to cover the calls. So, that was a bill
that was passed that has helped the physicians and its
probably helped to control some of these companies.
Mr. Robinson: Perhaps it will be inextricably . . .
inextricably intertwined between the legislature and the
medical health and of medicine itself (unintelligible)
endeavor. Uh, would you do it all over again.
Dr. Brake: Yeah, I sure would. Uh, it was fun. It was
very fun and the relationships that I've developed with the
board members and Bill Mahon, our Executive Director, has
been, uh, a relationship of, uh, not only health care
providers that we work with, but, uh, friendships that are
there forever. And, uh, it's just a great experience. I
would recommend it to anybody.
Mr. Robinson: Thank you, Dr. Brake.
Dr. Brake: Yes, it's been my pleasure.