private practice... because no matter how elastic and practice-related these allowed charges may be... that flexibility will ultimately disappear. As a result, pra titioners will be compelled by circumstances to relate their charges to thirdparty pornus, rather than the reverse."

The constriction that Ingegno foresaw is now upon us and getting worse, mainly been"in of Medicare administrative decisions-not Congressional ones-as to what prevailing" means Originally, it meant a fee that fell within the range of what 100 per cent of other local doctors charged for the same service. Now, after administrative tightening, a prevailing fee means one within the range of what 53 per cent of other local doctors charge. And John G. Veneman, Under Secretary of HEW, has just proposed that the fee ceiling be lowered still further-to the 75th percentile of 1969 average customary charges." That. in effect, would be something like lowering the ceiling to the 67th percentile of the 1970 usualandu-tomary fees.

“FOR PRACTICAL PURPOSES, THE PRESENT SYSTEM IS UNWORKABLE"

As physicians, we should face up to the fact that we're no longer masters of our own destiny. We've always shunned fee schedules as too restrictive of the ir i.vidual doctor's freedom to set his own price for his services. There was no fee schedule envisioned when we were taken in by Medicare. Our payments were to be based on usual-and-customary fees. Yet now, as a practical matter, we do have a Medicare fee schedule-with a vengeance. And the worst thing about it is we have no say in the matter.

To rectify the situation. I believe Medicare should start operating openly and franky on a fee-schedule basis arrived at by negotiation with doctors and bound

rely to the cost of living. Such an arrangement would effectively reverse M»«l, are ́s current inequitable payment trend. It could also do much to improve Medicare's wonderfully inefficient administrative system-under which you can't be certain in advance that your fee will be honored. But before going further into my negotiated fee-schedule proposal, let me describe some of the experiences that convinced me that Medicare's methods of payment are harmful and impractical.

My first case, one of many in my records, is a fine illustration of how the present system can cause a Medicare carrier to split hairs, rule first one way and then atether and finally be months late in paying all because of doubt as to whether a fee was a fraction too high.

On Feb. 27, 1968, I submitted a charge of $300 to Medicare for a common duct exporation and removal of an obstructing stone. As in all my Medicare cases, I indicated that I would accept assignment. Three months later, I received in the mail a Medicare Explanation of Benefits form stating that §5 of the $300 fee was not allowed An accompanying letter offered this explanation: “Federal Medicare regulations place with the carrier [here in Iowa that's Blue Shield] respon.bility for determining reasonable charges, these charges to be based on customary and prevailing factors.... Any reduction in the charges submitted is the result of the required application of the two preceding criteria to the gical information provided. ... Physicians may request review of cases by Cos.nty Medical Society Review Committees.”

*.new the $300 charge was my usual-and-customary charge and to the best of my knowledge was the prevailing fee in the community, I asked that the case be forwarded to the County Medical Society Review Committee. It never was. However after further correspondence, the additional $5 was allowed-five months after the original claim was submitted. There remained even then, of course, the final unraveling and settlement of the residual 20 percent payable by the beef lary

What is there to say about such a situation? To disallow $5 of a $300 fee is almart willy. Yet to make an issue of the $5 reduction seems hardly any better And here's another case. It demonstrates that Medicare can operate with even more confusion when doubt about a fee brings the case to a review committee. org. May 23, 1968, I submitted a charge of $250 to Medicare for a midthigh amputation On June 27, 1968, Medicare informed me that $25 of the $250 fee was not -wed I immediately challenged this reduction, and the case eventually ached the County Review Committee On Nov. 26, 1968, the County Review mittee surveyed 16 surgeons in the city doing this type of surgery. Of these, 10 charged $250 for a midthigh amputation, one charged $240, and the remaining five charged less. The committee judged my $250 fee to be reasonable and recommended payment in that amount. The Medicare carrier was so notified.

Nothing happened. So on June 2, 1969, I wrote the carrier as follows: "It has now been over a year since the surgery was done, and over six months since a rec ommendation was made by the County Review Committee in accordance with the agreed upon procedure. . . . I've received no aaditional word and no additional payment... It's difficult for me to understand such excessive delays."

Two weeks later, the carrier's Medicare claims department replied: "We like wise are baffled by the unexplainable delays which occur. . . . You should receive the additional payment within two weeks."

I received it not two weeks later but two months later-15 months after sending in the claim. How do you explain to a patient, after 15 months, that he still owes his 20 percent as co-insurance when he has long since forgotten all the de tails except that the charge was said to be unreasonable in the first place?

Here's a case that shows how Medicare's compiling of individual doctors' fee profiles, a continuous process usually done by computer, is every bit as subject to error as department-store billing, also done by computer. In this case, the Medicare carrier confessed its computer error but took a year to correct it.

On Nov. 26, 1968, I submitted a charge of $275 to Medicare for a cholecystectomy. On Feb. 14, 1969, Medicare told be that $25 of the $275 was not allowed. I challenged the reduction and late in May received this reply: "... A December, 1968, Social Security Administration directive. . . specifically directs the carrier to pay on the basis of customary-and-prevailing fees as compiled by the actual claims received. For instance, in reviewing your claims for cholecystectomies in the year 1968, we have recorded you submitted the following: [A list of cholecystectomy charges followed, most of which were for $250.] By Government definition, your customary fee is $250 for a cholecystectomy, and that appears logical. You were, therefore, paid $250, a reduction of $25. To alter that customary

fee would violate the rules and regulations by which we are directed to pay Medicare claims. . . . I hope you can understand the carrier is committed to pay according to the standards and procedures I have explained."

"WE MUST CONSOLIDATE WHAT WE HAVE BEFORE IT DETERIORATES"

I wrote in reply: "I too have carefully reviewed all of my cholecystectomies for the year 1968 and have found a great discrepancy between your figures, as quoted in your letter of May 20, and mine. . . . Since your figures are the basis of your credibility as well as your payments, I assume you are prepared to prove their accuracy. . . . The basic problem is not with standards and procedures, but rather with the reliability of your figures and statistics. . . . I specifically question the accuracy of your figures relating to claims submitted by me for cholecystectomies done in 1968 and ask that you substantiate them."

A week later, Medicare answered: "Your point is well taken, and we will certainly investigate the credibility of our figures. . . . It will take some time to accomplish this."

It did. Late in September, they wrote me: "There were indeed errors made. ... Our corrected customary fee should indeed have been $275 for your cholecystectomy. . . . We shall, therefore, direct that these claims be reopened and paid as submitted."

On Nov. 5, the Medicare claims department phoned my secretary that the claim was being reopened-apparently confirming their letter. An error in the computer input, she was told, had caused the problem. As I write this, the date of payment will no doubt eventually be a full year or more after submission of the claim.

And one more case. It's closely related to the preceding one but with a difference: It shows how vulnerable Medicare's prevailing-fee concept is to computer and carrier error.

On May 22, 1969, I submitted a charge of $600 to Medicare for a pneumonectomy. In August, the carrier disallowed $130 of it. I challenged this. After further communications, including a conference, I received this letter, dated Oct. 6: "I have completed the investigation of the state's prevailing fee for pneumonectomy. You are correct: The allowance of $470 is inaccurate. [The] correct prevailing fee [is] $551. . . . duced because of this error, please notify me." If you have had claims for pneumonectomies re

This case, like the previous one, also seems to represent a computer error, but this time in the prevailing-fee category rather than in the usual-and-cus

tenary element. Incidentally, our local Peer Review Committee judged the $600 fee to be proper But the carrier then obtained a ruling from the state review ¤ tree that, under the latest Social Security directive, the amount of any perta ang fee arrived at by a carrier on the basis of its records could not be Peer Led That was that.

The foregoing cases more or less speak for themselves. However, this present n should not be taken as criticism of those administering the Medicare locally Many of the Medicare disputes are being adjudicated by physiepoyed by Blue Shield who have backgrounds of many years in private Pactive and a known understanding and sympathy for its problems. I wish to ---Im a system, not the individuals who must operate within that system. Is the usual and-enstomery fee system worth the price we pay in administrative delays and conf aston? Could there possibly be a better way?

A freshent response to my melancholy cloakroom complaints about Medicare hoe twee', 'You're under no obligation to accept assignments. Deal with the patient directly. It's his responsibility to fight his own battles with Medicare." are thats true Yet whether or not I accept assignment, whenever the •striet di salows a part of my fee he damages my reputation. It's very easy for when having been advised by Medicare that your bill is not "reasonable” - re fore will not be paid in fu'l to conclude that you have been overcharging Just like all those crooked doctors he reads about in the newspapers. suti e doctors may shrug this off as just one of those things. But it isn't just if the things and it's folly to shrug it off. We're losing favor with the and are being socialized, not because of any Fabian machinations, but ** 3 18 of a day-by-day bit-by-bit erosion of our stature. There are doubtless 1 reasons for this but don't underrate the chipping-away process activated Miliare fee misunderstandings

The Medicare payment system can be indicted on three basic counts: 1 its not what it pretends to be. We're clinging to a mirage, for we are not instafor**y being paid usual-and customary fees, but often fees considerably **an that

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For a a practical purposes, the system is almost unworkable. The examples war witness to that.

The reduction by the carrier of charges submitted by doctors-the disvmature caf fees as not reasonable"-is a vicious and destructive process. Nor are wat reductions uncommon Last March 30, Medical Economics reported that atins were being effected by Medicare carriers on 30 per cent of all doctor •hifted In other words, almost one-third of all Medicare patients are officially" told that their doctor's charge is not reasonable, or words to We must consolidate as best we can what we still have before our condition fatamumates further If organized medicine has had one overriding shortcoming sos joseconott le affairs, it's been an inability to interpret trends, gauge public and thereby predict the future. We've never been able to lead because we te been too busy trying to catch up. That doesn't mean we've been wrong, • !t des mean we've been ineffective. I think we make the same mistake when y away from fee schedules. We commonly think of them as being both inate and immutable. That needn't be the case. Doctors may still be in a to achieve a favorable fee schedule, but time is short. time to begotiate-now. I don't mean nationally but locally. (Even the Finance Committee staff, now recommending that Medicare switch to fee Tweedentem, speaks of nine regional schedules rather than one national schedule.) any agreement should include a provision for a yearly revision of fees, • her up or down, to adjust to changes in the cost of living, the revision to be megusted by using the regional consumer price indexes published by the Bureau Labor Statistics.

Yes it's time to change course and secure a fairer, more workable, and less Jestrative system than Medicare offers to physicians today.

[From the Bulletin, August 1970]

AMERICAN COLLEGE PHYSICIANS PARTICIPATE IN THE VOLUNTEER PHYSICIANS PROGRAM FOR VIETNAM

(By Hal T. Wilson, F.A.C.P.*)

During the last four and one-half years, twenty-three members of the American College of Physicians have participated in volunteer physicians' activities in Vietnam.

The Amercan Medical Association's Volunteer Physicians Program was begun here in 1965 under the People-to-People program sponsored by the United States State Department. In 1966 the American Medical Association took over the program under the direction of Doctor Charles H. Moseley of that organization. Since the inception of the program, there have been fifty-seven internists amongst the 640 physicians who have participated in 730 tours of duty. Of these internists, twenty-three were Fellow or Members of the American College of Physicians.

It is difficult to say just what motivate these busy specialists to come to Vietnam to work under primitive medical conditions. It appears that curiosity about our nation's activity here is a prime reason to volunteer. Some doctors have worked in other foreign medical aid programs and many comment on the personal satisfaction of medical care amongst grateful patients with no interfering pecuniary bonds. Whatever the reasons for the initial venture, more than 14% of the doctors have returned one or more times. The internists have not only followed this pattern but four have accepted long-term positions here.

The quality of doctors participating in overseas medical assignments is impressive. Of those internists who have participated in the volunteer physicians program, thirty-five were board certified and twenty were board eligible. Surprisingly enough, not only did these doctors come from all fields of internal medicine practice, but thirty-seven of them were actively engaged in teaching or other academic activities.

The lot of the internist in practicing medicine in underdeveloped countries is a difficult one. Laboratory facilities are poor in Vietnam and the speed at which tests are returned is far slower than at home. Hospital conditions are primitive and histories and physical examinations are not the rule amongst Vietnamese doctors.

The doctors of the volunteer program work almost exclusively in province hospitals and in spite of the cross-cultural adjustment necessary, seem to enjoy very much their participation in the care of patients who are oftentimes desperately ill. The internists here have tremendous exposure to tropical medicine. Diseases which they have only read about before become everyday entities. Plague, tetanus, typhoid, hemorrhagic fever and typhus are present. Tuberculosis is the chief infectious problem but one can get a lifetime of experience with more exotic diseases like leprosy in a two month stint of service. The biggest problem is infectious diseases; also there are many degenerative and system failure medical problems related to the heart, liver and kidneys.

Educational activities that the internist can participate in whi'e spending two months in the volunteer program in Vietnam include bed-side teaching with senior medical students who are working in the hospitals at Hue, Danang and Nha Trang. Unfortunately, the students have to be led by the hand through the taking of the history and the examination of patients. Most of them have not had training in the approach to the patient before being sent to the province hospitals for practical work. The medical students speak fair Eng'ish and interpreters are generally on hand for morning rounds. Sometimes the attendance of these student clerks at Sunday morning and afternoon ward sessions is poor.

There have been some formal attempts in educational activities in the province hospitals. These have inc'uded weekly staff meetings where the Vietnamese and American staff discuss problems in common. There are also occasional regional medical meetings where the doctors from several nearby American and Vietnamese hospitals are encouraged to participate in discussions of cases, and in Can Tho and Danang Regional Hospitals series of lectures are held for the staff and students.

The American Medical Association has plans for sending teaching teams to the larger hospitals throughout Vietnam. This program will begin in the near future. *Field Director, AMA VP/VN, 1968–70.

These teams will include an internist as well as a pediatrician, surgeon and orthopedic surgeon. It is hoped that the present high quality of medical aid provided by the American specialist in internal medicine will continue and that many memhes of the college will see fit to return to Vietnam to participate in these educa' ral st»qəm

K-garding motivation, some clue can be gleaned from Doctor Harold A. Braun of Missoula Montana. "Finally, as no doubt has been said repeatedly by other returnees the chief value is to the VPVN himself. This value shou'd not be dis ́ed as several hundred American physicians have had an opportunity to erve the Vietnamese problem' firsthand, thus contributing to the pool of American opinion shaping our actions in that country."

The protletus of medical practice in an underdeveloped country are well outed by the comments of Doctor Hendrik Rozendaal, of Schenectady, New York. Heys The three hundred bed provincial hospital has a medical wing of gry beds and a building for infectious diseases that contains thirty beds for ↑ momis, ten beds for cholera and twenty beds for plague. This number of bexis is continually occupied with a very fast turnover of patients so that there is plenty of work. In addition, there is a very active medical out-patient clinic every morning except Saturday and Sunday. Most of the patients are very ill and the variety of pathology corresponds to that described by my predecessors. I fend it fascinating to see and treat such a variety of diseases and was particulary intrigued by the gratifying response to modern chemotherapy. The patients are curved for mostly by their relatives, and I was disappointed in the efficiency and interest of the Vietnamese nursing personnel. How we had to fight to clean up the wards and corridors and to give the patients some personal attention! Progress is being made, but it is slow and the patience of American physicians 28 sərviy tasted"

Itor Reverdy Jones, of Fairmont, West Virginia, echoed the conclusions of many of the internists when he said: "My two month tour of duty at Tay Ninh has been all too short; it has been highly pleasant and deeply rewarding. It has provided an opportunity to make the acquaintance of many fine American and Vietnamese and hopefully it has given me a chance to help my country and the 1 atnamese "*

Fellows and Members of the American College of Physicians who have participated in the Volunteer Physicians Program for Vietnam:

Senator EAGLETON. I understand that Dr. Fiordelisi has returned. Doctor, will you join us?

Dr. Fiordelisi is an intern in the St. Louis University School of Mesine hospital complex.

STATEMENT OF ROCCO FIORDELISI, M.D., INTERN, ST. LOUIS UNIVERSITY HOSPITALS

Dr. FIORDELISI. My comments will be very brief.

Mr. Chairman, members of the committee, I am pleased to be invited to at pear before your committee to discuss some of the problems in med. al education and to give you my opinion on several issues.