Oct 05, 2013, 05:01 AM
Joined Feb 2013
Here's an article to think about. This was written over 40 years ago
AMERICANS are great social idealists and are forever endeavoring to aid natural evolution. Some attempts have been successful, others have failed. We are now in the process of witnessing such a failure in Medicare. Without question, its aims and intent are unchallenged. However, its operation and course indicate an early and expensive debacle.
Let there be no misunderstanding, Medicare or some government health subsidy is here to stay, but its glamour is dimmed by faults and unsuspected deficiencies. These loopholes will continue to grow and become more painful. A health plan which was originally to cost about three billion dollars, now in a brief four years has reached many times this. More discouraging is the fact there are no signs it will even hesitate at this point.
What are the causes of these miscalculations? Why are things not going as expected? Of course the problem is very complex with escalating medical costs closely tied with inflation. High among the many discouraging features of Medicare progress is the human element which originally was not completely assessed. It is the purpose of this discussion to point out some of these overlooked features in the hope that a more intelligent approach might bring some order out of chaos. Although there is much overlapping these particular human frailties may be directed into three categories: the patient, the hospital, and doctor.
The 65-and-over patient has suddenly become the center of much care, thought and attention. No longer is the oldster sloughed off as of secondary concern. He likes this and quickly accepts all as his just due. He demands and gets the best. That is, of course, fitting and proper but some of trimmings are by no means necessary and at times not desirable. He and his family want all the scientific studies that the law allows. These are myriad, with the medical profession keeping well ahead in presenting new angles of exploration. Some laboratory work is necessary, some desirable and some
completely unnecessary. Who calls it quits? Certainly not the patient or his family, who want all angles explored. Most laboratory and x-ray studies can be done on an outpatient basis, but why do this when hospital admission is easier for all? It sounds more professional and Medicare paper work is greatly simplified. A free trip which isn't to be missed, and the patient wants to make the most of it.
A patient in his early sixties facing a non-emergent situation most likely will delay his hospital visit until his 65th birthday. Why not- for it is then free. If Aunt Alice in her late seventies isn't doing so well and her doctor can't say if the cause might be arthritis, chronic heart or kidney disease or just plain old age - put her in the hospital for study. It’s free if she has supplemental health insurance and costs only a few pennies on the dollar if she hasn't. The doctor likes it that way and so does the family, for Aunt Alice is getting the best, even though the best will not cure her. The endless gamut of laboratory tests is justification for continued hospitalization and study.
When Medicaid first came into being there were groans from hospital administrators. The allocations from the government were below actual per diem costs and lower than
those from Blue Cross. This was true but the entire plan has been a God send to those institutions with a heavy charity load of oldsters. Medicare took up the slack and paid for many of these patients who were cared by charity before. After all, the hospital voluntarily participates in Medicare. They are not forced to join, so there must be an overall advantage. While Medicare covers about three fourths of the costs, most patients have supplemental coverage so that the hospital ends up subsidizing less than three percent of the Medicare patient's bill.
Many administrators seem to have taken the attitude of just watching hospital costs reach their own level. When it can be shown actual costs are greater than receipts, there will be an increase in both Blue Cross and Medicare allowances. Added costs are passed on to one of these agencies or the patient himself. To the hospital the economic importance of the true charity patient becomes secondary. These statements won’t receive universal acceptance but nevertheless contain much truth.
The x-ray department and laboratories are money makers. Their use is urged for all and their cost, but not their profit, is passed on to the patient, Blue Cross or Medicare. That per diem hospital costs are so staggering is a mystery to everyone except the administration. At present hospital services are very little more than room service in a not too good hotel. Ancillary needs of x-ray, laboratory, surgery, etc., pay for themselves. It may be that demonstrations by such hospitals as those in the Kaiser
Foundation, indicating lower costs are possible, may lead to a more economical management. Practically all hospitals now have a group of physicians known as the Bed Utilization Committee. Medicare uses this committee to check on hospitals and doctors to rule out "feather bedding." This group reviews representative Medicare charts to determine if the admission was for a bona fide ailment or was completely unnecessary. Of course the decision is simple in most instances; the fractured hip, the auto accident or cancer patient. On the other hand, some admissions defy decisions as to whether an arteriosclerotic patient with mild kidney trouble and milder diabetes must or must not be accepted as a Medicare admission. This is a question only the patient's own doctor can answer and not a review committee looking at ach art. The writer has served on two such groups at different hospitals and has never known of a Medicare admission to be questioned to the point of recommending refusal of aid to that patient. This is a decision the committee has not seen fit to make, no matter how often it may secretly feel the patient could just as well be cared for at home.
Is it any wonder hospital beds are at such a premium? True, medical practice has become more complicated and this demands more inpatient care, but there is much over use and abuse. Who dies at home these days?
Lastly, the doctor is human and therefore not without blame. Before noting some of his Medicare failings it should he definitely remembered that the doctor and organized medicine fought this movement down to the last ditch. Smarting with accusations of self-interest and patient neglect, the physician finally decided to join them for he could not beat them. Since then he, too, has gained undesirable traits.
Minor Surgery Now Done in Hospital
Most min or surgery formerly carried out in the office has now been transferred to the hospital. This was done for several reasons. It is much easier, for there is no worry about set up, materials, equipment and laboratory facilities. They are all furnished and handy. True, Blue Cross or Medicare must pay an extra $40 to $80 for that service but it costs nothing to the patient or doctor. It also becomes a more important service to the patient than one performed in the office. The doctor learns early that removal of a mole
or wart in the office brings in only a few dollars. The insurance fee allowed for the same procedure in the hospital is easily triple. If the surgery can be construed as a plastic removal or repair, the price is much higher still. The result is an obvious more frequent use of the hospital with increased cost to the patient and insurance carrier.
No surgeon is going to minimize what he does, for the larger the operation looks in the eyes of the clerk who reviewed the insurance or Medicare form, the more the surgeon is paid. Most doctors do not consider this dishonest since they feel the fees paid by the carrier arc on the low side, and should be raised, possibly by this means. Also, the surgeon resents being told how much a given operation should bring. Too often the insurance fee sets the standard price even for those quite capable of paying much more. There is nothing more simple than the removal of the usual early acute appendix. But with an abnormally placed appendix things get pretty sticky. Add to this a ruptured appendix, and the best judgment and experience is demanded for some days. Yet, the fee paid the doctor is the same in all situations.
In the writer's area, un-needed operations are no problem. It is not doubted that they do occur and elsewhere this is common knowledge.
The first reaction to Medicare of the internist or general practitioner is apt to be resentment against regimentation and against the surgeon for having the better end of the deal. He has, therefore little compunction about taking what the traffic will bear. On the least excuse the oldster may be admitted to the hospital "for study" because of any infirmity. Who over 70 hasn't an infirmity- be it arthritis, dyspepsia or constipation? This, then, acts as a nidus which can be blown up into many days of laboratory and x-ray study. Who knows when to stop, for one of the tests might turn up some hidden ailment which no one had considered? There is no stopping in studying the patient completely. The patient's continued hospital stay is justified by tests still to come. The laboratory knows more when the usual ones wear thin.
Having patients in the hospital being tested or observed is a very convenient arrangement for the doctor. He can easily call on half a dozen in a matter of minutes where it would require half a day to see them in their homes. His charge for the hospital visit is reasonable--only a fraction of what Medicare is paying per diem to keep the patient there, but the doctor is in no hurry to distribute them to their various homes.
It is all free; who cares? Strangely enough, no one cares, including the taxpayer. Maybe he feels he will be the lucky one someday.
What can be Done about the situation? Is there any answer or must we continue to pay more and more, getting less and less in return? Will the loopholes become larger with time? Will it be t urned into an all-inclusive insurance plan which carries with it the same fault contained in Medicare?
It is contended that there is a way out of this morass which could lead to a better economic and permanent solution. Our solution is not one apt to be accepted because it does away with part of the cradle-to-the-grave promise. Too many wanting something for nothing, which is right up the Medicare alley.
The solution is a very simple one but a sure one. Ask every patient receiving Medicare to pay out of his pocket at the time, one quarter of every medical doctor's and hospital bill. This quarter of what Medicare allows must be paid at the time of service, out of pocket and not from supplementary insurance, which tends to perpetuate an undesirable situation. By this single move the patient would act as a committee of one (20 million!) to prevent over medication and over hospitalization. The outpatient status would he investigated and used when possible and the patient would learn in advance ways to decrease costs. It costs the patient if he doesn't. There is no incentive whatever for economy under the present system!
The obvious first rebuttal to this proposal is that the patient may have no money to pay his share. This inference that patients are turned away from our hospitals because of lack of funds is one used to glamorize free medical health programs. It simply is not true. The writer has never known of one patient who was turned away from any municipal or, for that matter, smaller county hospital because he had no money. This may not be true in certain areas in Appalachia but is true of the cities there. In spite of the unsavory recent reports about Chicago's Cook County Hospital, it cannot be denied that the medical care at that institution is superior to that in many of the carpeted private hospitals.
Costs can never be reduced so long as the patient doesn't care, the doctor doesn't care and the hospital doesn't care. With any form of prepaid insurance everyone is waiting to, get back his share. If the patient were asked to pay from his own pocket at the time he receives his medical service, he would he a watchdog on the entire system, cutting corners and investigating leaks.
It must be understood that, under the present system, the Medicare patient has paid for his service through Social Security and, except for a few cents, through supplementary insurance. Therefore, if there is the least question of hospitalization, he wants to use this paid-up excursion to the fullest. He wants to be the lucky person for whom others pay. The attitude would he far different if part of the fare came directly out of his immediate pocket.
Recent changes suggested by Congress are a step in the right direction but not far enough. We simply can not afford to continue down the path taken in the past five years. After many years, the Heath government in Britain is attempting to alter the National Health Service with partial on-the-spot payments to increase incentives for self-sufficiency.
While on the subject- the same criticisms of known wastes and loopholes may be leveled at the operation of Blue Cross-Blue Shield. It is even more pertinent with this organization, for coverage is often more complete. Paid-up policies result in the same indiscretions. A cure can only be obtained by removal of part of a prepaid clause. Such a change is not likely, since the patient wants ''complete coverage," especially since the employer so often foots the bill. What everyone fails to realize is that the saving in premium would more than compensate and the result would be a more efficient economic situation with less waste of medical service.
So the circle continues. Dec-1971