FAILING HEALTH
Steinberg, Jon
FAILING HEALTH A sick medical system's Band-Aid solutions BY JON STEINBERG The American health-care system is undergoing a massive transformation on a scale not seen since the mid-1960s. New...
...Even the internationally famous institutions...
...As a consequence, patients may receive dangerously diminished care...
...Though the United States spends 10.5 per cent of its gross national product on medical treatment—a higher proportion than any other developed nation—many millions receive poor care, or none at all...
...But reformers who have championed DRGs and HMOs do have a point: The U.S...
...The United States ranks sixteenth in infant mortality, behind such nations as Spain and Singapore...
...Since treatment is paid for in advance, an HMO is under pressure to avoid expensive procedures, even if they are necessary...
...To compensate for the bias against poor people implicit in the DRG system, the state of New Jersey has provided additional funding to institutions that serve the needy...
...The enjoyment of good health should not be subservient to the profit motive, and it should not be the perquisite solely of the rich...
...It is a battle fought on two fronts: While the Federal Government acts to hold down Medicare and Medicaid expenditures, the business community tries to keep the lid on employee health benefits...
...Now, no matter how long a Medicare patient stays in the hospital, no matter what complications are involved, the amount paid by Washington will remain constant...
...Good health is a basic right...
...Practitioners should be expected to share their knowledge—"everyone a healer...
...And HMOs go to great lengths to limit their membership to healthier segments of the population...
...The Reagan Administration, however, recently declared that the New Jersey arrangement is too generous and has threatened to withhold Federal financing if it isn't changed...
...Under both reimbursement systems, the determining factor has been what is most profitable, not what is best for the patient...
...Over time, many such hospitals will go bankrupt...
...Such giant private health-care companies as Hospital Corporation of America and Humana have a definite advantage under the DRG system...
...DRGs have drawn scant attention in the major media, and the legislation that sanctioned them sailed through Congress last year with little investigation or debate...
...The DRG system constitutes a degree of hospital regulation unheard of in American medicine...
...What's more, struggling hospitals are less inclined than ever—because it costs too much—to admit patients who don't have insurance or who suffer from complicated illnesses...
...As an Arizona newspaper discovered, the administrators assigned costly patients to doctors "so far removed from their homes that they can't reach them...
...I asked...
...HMO coverage provides patients with a limited choice of physicians...
...HMOs offer comprehensive health care for an annual set fee picked up by individual consumers or, more frequently, by employers...
...At Evanston Hospital near Chicago, for instance, administrators persuaded orthopedic surgeons "to discharge artificial hip implant patients in eight days, half the previous time," according to The Wall Street Journal...
...In recent years, enrollment in HMOs has swelled dramatically, in large part because employers see them as an effective way to reduce their own outlays for health benefits...
...Small private companies, and public hospitals that serve the poor, have none of these advantages...
...Hospitals will no longer be able to boost charges arbitrarily for Medicare services and pass the higher fees on to the Government...
...The Government has divided hospital services into 467 categories and affixed a price tag to each one, from an appendectomy to a coronary bypass...
...Health care should, in fact, be available to all at no cost...
...With DRGs, the Government reimport Steinberg is the Editor of the New York-based Health/PAC Bulletin...
...Health, by its nature, is a social issue...
...Our pathological health-care system is not susceptible to reform...
...A recent Stanford University study found slightly fewer members—12.5 million at 280 HMOs nationwide—but predicted that fifty million Americans would be enrolled by 1990...
...Most nurses in New York wouldn't let any relative or friend go into any hospital in the city unless they had a friend there who could watch out for her," a registered nurse told me recently...
...Moreover, they recognized that DRGs would benefit the most powerful hospital chains...
...Though industry lobbyists did not welcome the development, they mounted no strenuous campaign of opposition...
...The United States needs a national health insurance policy that is Federally financed but locally controlled: Federally financed because care should be allocated by need, not by wealth...
...Their size allows them to buy supplies at low cost, they can afford sophisticated computer analysis to squeeze the most out of the reimbursement system, they can simply refuse to give services they find unprofitable, and they can fill most of their beds with higher-paying, privately insured patients...
...McAuto Systems Group, Inc., a subsidiary of McDonnell-Douglas, the aircraft manufacturer, won the state's Medicaid contract...
...Any sophisticated and expensive care required should be provided at a small number of facilities in each area, avoiding duplication and maximizing expertise...
...The recent innovations, though coated in soothing rhetoric, may spell increased hardship for many health-care consumers—particularly those who are old, poor, or seriously ill...
...Such corporate giants as General Motors, which spends more on health insurance than on steel, regard the present situation as a crisis...
...But just as Social Security stands unassailable today as a right, so a national health policy that meets people's needs may seem, tomorrow, to be self-evident...
...Liberal reformers have joined this alliance of industry and Government, lending an air of social consciousness to the partnership's most important inventions: Diagnostically Related Groups (DRGs) and Health Maintenance Organizations (HMOs), both of which threaten to cut quality of care as well as costs...
...we must seek answers in social and political forums...
...That isn't as easy to track as cost control, and Federal officials have had more success with devising systems to pinpoint hospitals that attempt to render fictional diagnoses so they will fall into more lucrative categories—a process called "DRG creep" in the trade...
...New practices and policies—in the private sector and in government—are producing fundamental changes in the way Americans obtain medical treatment...
...If a patient finds the service at an HMO unsatisfactory, there is little alternative but to quit and pay for outside care...
...Much of today's care could be provided by health-care workers other than physicians—nurses and midwives, technicians and professionals...
...Then, the only question will be why it took so long...
...Here, their hopes are riding on Health Maintenance Organizations...
...It is these damning statistics—and not just the costs of health care—that need to be addressed...
...Americans have not been receiving adequate health care...
...burses hospitals for the specific treatments given their Medicare patients...
...But it was also designed to provide a profit for McAuto—and this objective soon took precedence...
...The reorganization represents an ambitious attempt to contain costs, not to improve health care or make it more accessible...
...For those who are accepted, an HMO may turn out to be less than ideal...
...The neglect is astonishing, for DRGs amount to nothing less than a wholesale restructuring of the Federal Medicare system, which provides health care to the elderly...
...Blacks suffer from occupational diseases at a rate 37 per cent higher than the rate for whites, and die of diseases caused by hypertension at a rate fifteen times that of whites...
...The Government has developed no accurate method to monitor the quality of care under the new system...
...After two months on the job, the program's medical director resigned, citing hundreds of complaints of inadequate and abusive care...
...In the more intelligent ones, they're reducing the hours of each staff member by two to five hours a week...
...In many hospitals, they're cutting staff in each department by 5 per cent," says Bob Brand, assistant to the president of the National Union of Hospital and Health Care Employees...
...Medical personnel should be public servants, perceived and remunerated as such...
...DRGs, they believed, would ward off even more stringent Government controls and nip efforts to enact national health insurance...
...locally controlled to overcome the blunders associated with overarching bureaucracy...
...Right," she replied firmly...
...Talk of fundamental change in the health-care field inevitably meets with dire warnings of the sort hurled at those who introduced Social Security fifty years ago: that a rational and humane system would undermine free enterprise, deprive us of freedom, and usher in the twin evils of socialism and statist bureaucracy...
...The more frequently a surgeon performs a certain type of operation, the greater the likelihood that it will be successful...
...Medical education should be reoriented to emphasize not only cure and rehabilitation but prevention and nutrition...
...On the surface, this shift seems eminently reasonable...
...The amount of pollution we should tolerate in the environment, the emphasis we should place on occupational health and safety, the importance of nutrition, the allocation of resources between the old and the young—these are questions that cannot be answered by the marketplace...
...In extreme cases," he said, doctor groups "have actually attempted to disenroll these high-risk utilizers from their plan...
...According to the annual census conducted by InterStudy, a Minnesota research firm, HMOs had 13.6 million members in 1983...
...In the past, the Government payment was based on a patient's length of stay, number of tests, special care needed, and related factors...
...Twenty years after the enactment of Medicaid, half of all Americans living below the poverty line have no medical insurance...
...It must be totally scrapped and replaced by a national system designed not to fill corporate coffers but to meet human needs...
...Cutting costs can also mean reducing the number of nurses, orderlies, laundry employees, and other support workers...
...as such, it should bow to no consideration of price...
...But like DRGs, HMOs have a built-in financial incentive to provide as little care as possible...
...They are questions that address us as citizens, not as consumers...
...Proponents of HMOs hope such growth will drive down costs as HMOs vie against each other for patients...
...Because treatment of Medicare patients is less profitable under DRGs than it was under the old system, the reform could adversely affect those institutions that treat many Medicare patients...
...health-care system is a rip-off...
...But DRGs have an unfortunate side effect: They give hospitals an incentive to cut corners on health care...
...Twenty years after the adoption of Medicare, the elderly still spend the same proportion of their income on health care...
...Often, the physician a patient had been seeing does not belong to an HMO—or at least not to one that is conveniently located...
...In the manner of an HMO, the Arizona program was supposed to provide comprehensive care to all who enrolled...
...The potential for complications was dramatized in Arizona two years ago, when that state introduced an experiment for its Medicaid recipients...
...The hundreds of millions of dollars being spent on a search for cancer cures would save a lot more people if redirected toward reducing or eliminating environmental and nutritional causes of the disease...
...Surgeons are known to perform operations of questionable value, many hospitals keep patients for longer than necessary, and some sick people who could be treated as out-patients may find themselves confined to high-cost beds in impersonal institutions...
...The old system was cost-based...
...The United States spends only 3 per cent of its total health-care outlay on preventive health...
...Medicaid provides health care to the poor...
...A fair health-care system would emphasize the prevention of illness and accident...
...Few people outside the billion-dollar-a-day business seem happy with it...
...In the stampede to cut costs, health-care reformers are also placing their chips on old-fashioned competition...
...They may have been kept in the hospital too long before, but now they may be pushed out too early...
...They not only attempted, they actually succeeded...
...Since reimbursements are fixed, hospitals can make money by trimming services—having physicians perform fewer tests or reducing the amount of time nurses spend with patients—or simply by discharging patients sooner...
...To continue to tinker with the present, privately dominated system is no solution...
...the new one provides a flat-fee payment...
Vol. 48 • October 1984 • No. 12
