CRISIS IN THE HOSPITALS

...There is no getting away from the fact that the kind of medical care made possible by the spectacular progress of medicine is inherently expensive...

...He has the free use of an organization whose maintenance, on the average, costs about $7,500 per bed a year...

...When it comes to laboratory and X-ray studies paid for wholly or in part by insurance, some practicing physicians and many interns and residents shoot the works in the hope that one or two of the tests will make the diagnosis...

...Under domination by hospital trustees and the medical profession, Blue Cross has become little more than a collection agency for the hospitals...

...The Columbia report, moreover, recognizes that the implementation of these and other economy moves depends on basic organizational reforms in the health insurance and hospital fields...

...First and foremost in the picture is the key role played by the medical profession in the functioning of hospitals and in the pyramiding of their costs...

...Lack of medical society membership is in itself an automatic bar to hospital privileges...

...In the better hospitals, the organized staff has contributed materially to raising the level of medical practice by enforcing higher standards...

...Among the measures advocated by the Columbia study group to combat unnecessary and overly long hospitalization are insurance coverage of ambulatory diagnostic services and nursing home care, the development of effective mechanisms for reviewing hospital admissions and checking on length of stay, and the expansion of hospital outpatient facilities in order to reduce the use of costly services designed for the acutely ill...

...The trustees appoint members of the medical staff after review of their professional qualifications and also name the chiefs of the various services...

...It therefore proposes greater representation of consumer interests on Blue Cross governing boards and development of a state master plan for hospital expansion...

...But in many hospitals, particularly the smaller ones, staff controls are weak...

...Many doctors have an appointment on the staff of only one or, at the most, two hospitals, and some physicians have no hospital privileges at all...

...Expert opinion is that the team work of group practice within hospitals would greatly increase efficiency and cut overhead costs...

...A New Jersey state commission named to investigate the justification for the latest rate increase sought by Blue Cross has reported that an exhaustive analysis "leads one to the inescapable conclusion that medical influences, as they are exerted by doctors individually, in staff and through their professional bodies, are five times as great a factor in the increase in hospital costs as all the other influences the hospitals have to encounter in their services...

...But logic runs into two big roadblocks—the separative interests of hospitals and restrictive hospital staff policies...

...It is he alone who determines how long the patient should stay...

...A difference of even a decimal point in the frequency of hospital admissions and in average length of hospital stay can play hob with Blue Cross finances...

...The result is that the doctor is eager to send his patients to the place where he is on the staff, regardless of whether or not there is sufficient demand at that hospital for the kind of procedures involved to enable efficient use of the necessary equipment and personnel...

...Having grown at random rather than by design, these hospitals operate without any effective public controls and continue to expand in a hit-or-miss fashion that frequently makes for wasteful duplication of facilities and services...

...Not only are institutional controls over the physician's hospital practice inadequate but the prevailing form of health insurance is wide open to abuse...

...Doctors control all of these cost-factors, which determine the level of Blue Cross premiums...

...If a doctor were to send a patient to a hospital where he is not on the staff, he would have to turn him over for treatment to another physician who is on the staff there...

...Far too many elderly chronic patients who primarily need custodial rather than professional care are now occupying expensive general hospital beds...

...With the revolution in the science and economics of medicine and the mounting concentration of medical services within the hospital, there is an urgent need for a thorough reexamination of physician-hospital relationships...

...The Philadelphia Blue Cross estimates that it would save $3,000,000 a year if the average stay of its hospitalized subscribers could be cut by half a day...

...People are increasingly asking questions about hospital charges and doctors' fees...

...HIP patients receive preventive services which sometimes curb incipient disease before it becomes serious...

...Significant is the experience of the Health Insurance Plan of Greater New York (HIP), one of the nation's largest group practice prepayment programs...

...Organized medicine's party line has long been that the doctors themselves are in no way responsible for mounting hospital charges and that the steady upward spiral is due primarily to the growing intricacy of medical care and to the "hotel" aspect of hospitals, especially their rising labor costs...

...Further aggravating the situation is the prevailing pattern of health insurance with its built-in incentives toward over-use of hospitalization because of inadequate coverage of diagnostic and treatment procedures on a much more economical outpatient basis...

...They often suffer from an "edifice complex," pushing for more and bigger buildings and for every new piece of equipment invented, or they are pushed in that direction by their medical staffs...

...This is particularly true of such intricate procedures as eye, brain, or cardiac surgery...

...Greenberg has twice been honored by the Lasher Foundation for his distinguished writing on medicine...

...Medicine is probably the only profession whose practitioners are furnished with workshops at public expense...

...The same holds true of the hospitals, which are not only inhibited by the archaic piecework approach of the present organization of medical practice but often operate without regard to overall community needs and duplicate expensive facilities and services in a race for prestige or because of competitive pressures by their medical staffs...

...Yet to be fully explored is still another area of potential savings by tailoring hospital facilities to the degree of the patient's illness...

...As costs keep on climbing, they are no longer satisfied with the pat assurance that hospitals are non-profit institutions devoted to the public interest and that nothing can be done to reverse the upward cost trend...

...Hospital managements are sometimes more interested in the perpetuation and growth of their own institutions than in a balanced health care program...

...And since HIP doctors are paid a fixed annual fee for each subscriber, there is no possible incentive for unnecessary surgery...

...Substantial savings could be achieved if the handling of complex cases requiring highly specialized skills and elaborate equipment were confined to one or two hospitals, instead of letting every hospital do almost everything...

...It is he who decides what the patient should get by way of nursing care, medication, laboratory work, diet, and other services...

...Physicians play the dominant role in determining the character of hospital facilities needed...

...Basil MacLean, former president of the Blue Cross Association, has said, "we must keep the patient vertical whenever possible...

...Legally, doctors are subject to the authority of the hospital's lay board of trustees...

...Within the broad policies laid down by the board, the physicians have their own mechanisms for self-government and self-discipline...

...A crucial point to bear in mind is that the people who have the biggest say about hospital matters are for the most part not hospital employes at all...

...But it is the doctors who, in large measure, call the tune on how the hospitals are run and what their costs are...

...Among the new approaches under study are special self-care units for convalescing patients or for those who are admitted chiefly for diagnostic tests and who can manage without many of the services needed by the acutely ill...

...Both studies support the conclusion that the alarming inflation of hospital and medical costs is in significant measure the result of such uncontrolled practices by the doctors as diagnostic admissions to hospitals under the guise of therapy, the countenancing of unnecessarily protracted hospital stays, the indulgence of patients' demands for needless and expensive drugs and sometimes even the performance of unnecessary surgery...

...There are barriers of professional competition and the strong feeling that anything smacking of an "open staff," under which all doctors are granted hospital privileges, would have a disastrous effect on the quality of care...

...An even more serious obstacle to a better organization of hospital services is the prevailing staff system...

...Some doctors hospitalize patients for minor surgery or medical care that could be easily rendered in the office...

...What often runs up cost," one authority has said, "are hospital admissions for procedures that can be just as effectively and much more economically done on an outpatient basis, stays which could be shortened if the preliminary work-up were done before and not after the patient is put to bed, excessive use of laboratory tests and X-ray examinations, and lack of sufficient controls to make sure that costly drugs are discontinued promptly when the need for them is over...

...Once we put him between sheets, the bill begins to get out of hand...

...But this is easier said than done...

...All of this is admittedly a pretty tall order...

...There is reason to believe that doctors sometimes yield to the whim of patients who want a rest in a hospital at the expense of Blue Cross or hospitalize people because they feel they will be more certain to collect their own bills if insurance covers part of the costs...

...But in actual practice the board's control over them is often highly tenuous...

...A study of patients staying thirty days or longer in four Boston hospitals disclosed that forty-two per cent of these patients, most of them elderly people, did not require continuing active treatment...

...Since it is extremely difficult these days for a physician to practice up-to-date medicine without the team approach and professional stimulation provided by a hospital affiliation, the question inevitably arises as to why doctors who are not good enough for staff appointments should be allowed to practice at all...

...Because they are reimbursed only for bed care and not for less expensive ambulatory services, Blue Gross subscribers sometimes resort to needless hospitalization in order to qualify for insurance benefits...

...In my own small state of Rhode Island, an increase of about one-fourth of a day in the average length of hospital stay boosted Blue Cross payments in 1959 by more than $450,000...

...For a variety of reasons, a considerable number of doctors, mostly general practitioners, are excluded from hospital staffs and thereby relegated to a sort of second-class practice...

...This has already happened in most civilized countries in the world...

...Much of this waste could be eliminated with the provision of adequate nursing home facilities...

...In New York, where there has been much griping about a succession of Blue Cross premium boosts, the report of a two-year study by the Columbia University School of Public Health and Administrative Medicine has recommended coordinated hospital planning and far-reaching changes in the health insurance contract structure as essential steps for meeting the challenge of skyrocketing costs...

...A highly interesting feature of this arrangement is that HIP subscribers go to the hospital about one-fifth less often than other Blue Cross members in New York...

...So it is all the more vital that vested interests should not be allowed to stand in the way of providing good care at the lowest practicable cost...

...There are equal economy possibilities in wider use of hospital outpatient facilities...

...The union recently reported that its members in California had 1,032 days of hospital care a year for every 1,000 subscribers under Blue Cross as against only 570 per 1,000 under the Kaiser program...

...This seems to be an endeavor which is not within the power of the hospitals but rather must be left to the medical profession...

...The public builds the voluntary hospitals and supports them—by paying hospital bills and Blue Cross premiums, through taxes and through philanthropy...

...A large-scale survey made some time ago by the Michigan state medical society showed that nearly one out of every five days spent in hospitals by Blue Cross subscribers was "unnecessary to the recovery, safety, or reasonable comfort of the patient...

...Unfortunately, this is precisely what not uncommonly happens under the health insurance programs now generally in effect...

...If a way is to be found to check the rise in hospital costs, the most fruitful line of inquiry would appear to be in the field of medical costs...

...It is estimated that the average member of a hospital medical staff is being provided, free of charge, with a capital investment of about $70,000...

...The reasons appear to be the same as those figuring in the lower HIP hospitalization rate...

...He won the Associated Press Managing Editors Association Award for his series of articles on the problems of the aged...

...They have the diagnostic work done without extra charge in the plan's own medical centers before they are admitted to hospitals...

...A step in the right direction urged in the Columbia report is the establishment of a central state agency, with a subsidiary chain of regional planning councils, to review and license all new hospital construction in order to assure a more orderly and efficient pattern of expansion...

...The trouble, however, is that no leverage now exists to force decisions in the public interest rather than the interest of the individual hospital and its staff...

...The reasons for this are fairly clear...

...The full impact of the doctor's dominant position in the hospital becomes clearer when it is viewed within the context of the setting in which he operates...

...It is the attending physician and no one else who decides if the patient should be sent to the hospital in the first place...

...The temptation to put the profit motive above efficiency is thus often irresistible in view of the doctor's status as a private entrepreneur in competition with his colleagues...

...CRISES in the Hospitals by 5ELIG GREENBERG This is the second of two articles on hospital costs by Selig Green-berg, writer on medical problems for the Providence, Rhode Island, Journal and Evening Bulletin...

...Major components of the hospital cost picture are the frequency of hospitalization, the average length of stay, and the quantity used of so-called ancillary services—such as various diagnostic tests, drugs, and medical and surgical supplies...

...They want concrete evidence of concerted efforts to provide up-to-date services at the lowest possible price...

...In practice, however, pecuniary motivations, professional jealousies, and personal prejudices frequently figure in the picture...

...Staff appointments are sometimes controlled by cliques of established specialists determined to preserve their monopoly and to keep out potential competitors...

...Such abuse requires collusion by physicians, since no patient can be admitted to a hospital without a doctor's approval...

...Closely related to this is the traditional autonomy, sometimes verging on anarchy, of the voluntary hospitals...

...But the medical profession resists both of these developments as an infringement upon its cherished prerogative to charge what the traffic will bear...

...Theoretically, hospital staff appointments are made purely on the basis of professional qualifications...

...Competent opinion is that the private practice of medicine and the present system of voluntary hospitals are doomed unless health insurance can be made a tool for keeping costs within reasonable bounds instead of the stimulant for inflation it now often is, unless wasteful hospital practices are corrected, and unless insurance can be provided at a price most people can afford...

...While there is considerable disagreement about the extent of improper use of hospitalization, several studies have come up with the conclusion that about twenty per cent of hospital patients need not be there at all and could be cared for adequately in outpatient clinics or in nursing and convalescent homes...

...Even more striking is a comparison of the hospitalization experiences of California members of the United Steelworkers of America who are covered by Blue Cross and of members of the same union who are insured by the Kaiser Foundation comprehensive health plan in that state...

...And in doing so, he would stand a good chance of losing the patient altogether...

...The Editors Any searching appraisal of the problem of high hospital costs, which in the past decade have soared at more than four times the rate of the general cost of living, must take into consideration three salient factors...

...But the alternative, many authorities are convinced, is a complete government take-over...

...The organized medical staff usually performs many functions which make for better medical service...

...So the community has pooled its resources in hospitals to furnish the required equipment for the physicians...

...The ideal solution would be some system of reciprocal staff privileges to allow doctors to treat their patients in any hospital...

...It is doubtful whether it can be made to move vigorously toward greater cost consciousness and coverage of a broader range of services without a strong infusion of the consumer point of view...

...At other times physicians have been kept off hospital staffs not because of any doubt regarding their professional competence but because they were affiliated with group practice insurance programs or because they were otherwise unorthodox in their views on medical economics...

...With the steadily growing complexity of medical science, no physician is now able to provide all of the elaborate and expensive diagnostic and treatment tools he needs for his patients...

...The combination of these three factors now all too often results in costs which are higher than they should be...

...HIP covers its members for virtually the whole gamut of medical services, except hospitalization, for which they must take out Blue Cross insurance...

...From the standpoint of economy, it would be logical to have a cooperative arrangement among hospitals in the same community for a sharing of functions, so that each institution would specialize in doing the things it can do most effectively and efficiently...

...It can happen here, too...

...They also are demanding more comprehensive insurance coverage for better protection against the financial hazards of illness...

...To keep medical costs within reason," Dr...

...Valuable lessons are sure to be learned from experiments along this line now underway in a number of hospitals throughout the country...

...This is vigorously disputed in two recent study reports in New Jersey and New York...

...They are insured for unlimited nursing service in the home and therefore are able to go home earlier...

...They are private businessmen who use publicly provided facilities for their own business...