Page images
PDF
EPUB

change can be ascribed to increases in health care costs, probably a third of it can be so attributed.

Thus, Mr. Chairman, Congress is already painfully aware of the effect which increasing health costs have had on Federal programs designed to assist the aged in financing their health costs.

The effect of these increasing costs has been to bar countless numbers of older people from seeking the care they need under Medicare. This recently announced increase in the deductible under Part A of medicare from $40 to $44 is a straw in the wind—a sure sign that hospital costs will continue to rise. Next year the deductible may even go as high as $52, because of still higher hospital costs. The question of just when a deductible becomes a barrier to obtaining medical care is a question which cries out for an answer. I hope that the testimony before this committee will show, in more detail than is now available to us, the effects of the medicare deductibles and co-insurance provisions on the health of older people.

Those of us in Congress need to spur our efforts and the efforts of others to take the steps necessary to stem the swelling tide of increasing health costs. This is the bitterest form that inflation can take for our older citizens. Neither the Nation as a whole nor its older citizens as a group can bear indefinitely the increasingly heavy burden inflicted by the runaway inflation of health costs.

The problem of rising medical costs is a compelling aspect of the most serious of all the problems facing older Americans-that of achieving and maintaining an adequate income. The massive loss of real income through inflation must be recognized for what it is: the Number One economic public enemy in this Nation today.

Americans who have reached the age of 65 now number almost 20 million. By 1980 there will be approximately 25 million in this age group. With such a rapidly growing aging population, we will be faced continually with the necessity to deal with new problems as they arise. To deal effectively with new problems, whatever they may be, we must first solve the most basic of them all-the economic problem.

ECONOMIC PLIGHT OF THE ELDERLY

The bills that I have introduced during the 90th Congress seek to relieve the economic plight in which so many older people live, while yet preserving their independence and sense of dignity. To strive for one goal without the other would be shabby treatment indeed for all those who fought and survived two world wars, who weathered the great depression, and who have borne the brunt of entry into the atomic age. It is a matter of plain justice for this Nation to help protect its older citizens against the skyrocketing cost of living-amounting to nearly 20 percent in the last eight years alone. Periodic increases in social security benefit levels will not suffice of themselves. For no matter how great the benefit increases are, they always lag behind the increase in prices. Nearly all of us are hurt by inflation; but no single group suffers more than older Americans. One obvious way to protect the elderly is to provide an automatic cost-of-living increase in Social Security benefits every calendar quarter, to adjust benefits according to rises in the Consumer Price Index. H.R. 5347, which I introduced in February of last year, would do just that.

There are other ways in which the economic situation of older Americans can be protected, and I have introduced several measures accordingly. H.R. 5158, for example, would amend title II of the Social Security Act to increase the benefits of a surviving widow to 100% of her husband's allowance.

EARNINGS LIMITATION CAUSES PROBLEMS

There is also injustice in the regulation that a Social Security recipient must keep his earnings below a certain level, or otherwise lose his benefits. I think that the limitation on allowable earnings should first be raised and then eventually done away with altogether. As a first step in this direction, I introduced H.R. 5157, which would permit those receiving Social Security to earn as much as $3.000 annually instead of the present $1,680 before their benefits are diminished.

From even the briefest review of the problems facing the majority of older Americans, we can see that new legislation to protect and assist them is essential. But legislation can only be as good as the architects who draft it. We must be sure that these architects are the best informed people available. They

must have a thorough knowledge and understanding of the complexities of aging in the modern world.

It is essential that we pause from time to time, to take stock of present programs and policies concerning the elderly, and to consider what directions our future efforts should take. The 1961 White House Conference on Aging is widely recognized for the vital role it played in stimulating significant new programs for older Americans. I am confident that the 1971 White House Conference will prove equally fruitful.

In summary then-we have a problem today-we will have a larger one tomorrow. Our attention today must be to reducing costs. Law generated requirements (red tape) must be reviewed and reduced. Private industry handles credit at a profit-so government could well learn from private industry.

Second, let us ask the Medical Profession for its recommendations for implementing the law without comprising quality or quantity of health services. And finally let's ask the Hospital to recommend solutions to reducing costs. Legislation, subsidies, and political polemics are not the sole solution. Thank you for your interest.

Mr. REINECKE. Rather than to summarize what is in the statement, because it is already in the statement-I would simply say that we hope it is recognized that the law alone will not solve the problems. We need a great deal of cooperation from the citizens, from the State and county governments, from the medical profession, and the hospital people.

I would hope that we could recognize, too, that perhaps a reduction in some of our own paper work that we have generated through our legislation--and I supported medicare when it came on the floor a few years ago, so I do support this program-but I recognize also the financial risk and the problems that have developed since that time.

It was not my intention to make any political comments, but in view of some of the statements that have been made by the previous witness, and in view of the fact that you gentlemen are vitally interested in getting an objective story, and further, in view of the Senator from West Virginia's statement that some of Mr. Unruh's statements called for further study, I would hope that part of that further study would come from a rebuttal statement from our own Governor's office.

I sincerely question several statements made-but I do not want to get involved in a political debate it is unfortunate that politics does get into health problems. Certainly that is no place for it, but it is here, and you just heard it a few minutes ago.

I would hope very sincerely that you would submit Mr. Unruh's statement to the Governor's office1 and ask him for his comments, so that you, in your judgment, could find from that the statements that would affect the future legislation of our country.

Gentlemen, I won't take any further time. I am most grateful to you, and happy that you did find a good day here in Los Angeles. And I say thank you, again.

Senator WILLIAMS. Well, I have just conferred with Senator Randolph. We feel that it would be appropriate to do exactly what you just suggested.

Mr. REINECKE. I thank you kindly, Senator. Thank you also for allowing me to appear here out of order.

Senator WILLIAMS. Of course we do have the Governor's representatives here, but we certainly will give the Governor an opportunity to submit a statement.

1 Statement by representatives of the Governor appears on p. 675.

24-798-69-pt. 3—3

Senator RANDOLPH. What is your district?

Mr. REINECKE. Twenty-seventh Congressional District. It is part of Los Angeles. Most of the constituents do live in Los Angeles, or Los Los Angeles County. We have about 50,000 up in Kern County. Senator WILLIAMS. The metropolitan area?

Mr. REINECKE. Yes, metropolitan. Many senior citizens projects are very much concerned. I have sponsored a great deal of legislation concerning benefits that are necessary to allow our senior citizens to remain their prideful selves and productive citizens of our community. Senator WILLIAMS. Thank you very much.

What term are you in, by the way?

Mr. REINECKE. This is my third term-coming up.

Senator WILLIAMS. Confidence will get you everywhere.

Who is next here?

Dr. Lester Breslow. Where is Professor Breslow? There he isfrom the UCLA health services.

STATEMENT OF LESTER BRESLOW, M.D., M.P.H., PROFESSOR OF HEALTH SERVICES ADMINISTRATION, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF CALIFORNIA AT LOS ANGELES

Dr. BRESLOW. Mr. Chairman and members of the committee, I am pleased to have this opportunity of appearing before you to discuss a subject of great consequence to the American people.

I am conscious of the fact that your committee has already covered a good deal of the subject in previous hearings, so I will confine my remarks to three points:

(1) Are the medicare and medicaid programs raising or lowering the quality of health care?

(2) What can the Federal Government do to favor higher quality

of care?

(3) Can and should preventive medicine in the form of multiphasic screening be incorporated into federally supported health care?

One must carefully differentiate medicare and medicaid in considering their impact on quality because they have had opposite effects. Part A of medicare, because the legislation specifically provided for it, has tended to raise the quality of hospital and related care. The legislative requirements of standards for hospitals, utilization review, agreements between hospitals and extended care facilities, standards for home care agencies, have encouraged nationwide attention to the problems of quality of care.

The impact of part A of medicare on the quality of institutional health services in this country has been favorable. It has been good not only for older persons but for the entire population receiving hospital and related care.

IMPACT OF MEDICAID

Medicaid on the other hand, the welfare medical care program, has tended to bolster the poorest kind of medical care. This has occurred because the basic legislation gave no attention to the matter of quality. Contrary to the medicare legislation which established a framework for quality standards, especially in part A, the medicaid legislation ignored this critical problem.

State and local welfare administrators have tended to purchase and pay for more of the same kind of care that poor people were obtaining previously. The personnel and facilities in neighborhoods where poor people obtained care were often inferior and, most important, medicaid offered no inducement to improve. It simply financially supported what was present.

In some parts of the country, particularly in California, those responsible for medicaid (or Medi-Cal, as we call it) have endeavored to link it up with the quality standards of medicare. To the extent that this has been possible medicaid patients have benefited from the medicare standards.

On the second question, what can the Federal Government do to improve the quality of health care, I would suggest three approaches. The first is to incorporate into all Federal medical care programs a legislative framework for establishing standards of quality, such as was done in the medicare.

Second, the Federal Government should assure payment of reasonable amounts for the services provided. It should not leave such determinations, as in the case of medicaid, to local officials who do not appreciate the fact that in health care, as elsewhere, you usually get second-rate service-or worse-if you try to get by cheaply.

Senator RANDOLPH. Could I interrupt at that point, without breaking your continuity?

Now, does your statement lend itself to an opposing or an agreeing viewpoint with that of Speaker Unruh?

Dr. BRESLOW. Well, he made a number of statements.
Senator RANDOLPH. Well, I mean on the matter of cost.

Dr. BRESLOW. The point that I would emphasize with respect to the fee issue that was raised by Speaker Unruh, is this: Much more important than the question of whether you pay $1 or $2 for an injection, or whether you pay $200 or $400 for the appendectomy is the question of whether you needed the injection or the operation in the first place. I believe that a tremendous amount of the waste in medicaid results from a failure to take into account that aspect of the problem.

So I must direct attention to the question of the quality of care. To provide the care that is needed when it is needed, rather than the issue of fees.

I think, really, that fees are a secondary issue although they have attracted the greatest attention.

Senator RANDOLPH. Thank you, doctor.

NEED FOR DATA ON QUALITY OF SERVICE

Dr. BRESLOW. Further, I believe the Federal Government should insist that its programs include a health data system that routinely turns out information on the quality of the service being provided. This is now possible through computer technology.

Senator WILLIAMS. I as sure you are right on your conclusion, but I am sure a fellow whose discipline is not medicine-not technologywho practices the inexpert profession of law and politics, I wonder just how would this help a doctor in his office?

Dr. BRESLOW. The State department of public health, in the early days of Medi-Cal, developed just such a system which disclosed partic

ular physicians and other providers of care who were "way out" in their practices.

For example and these are only crude examples-some physicians gave far more injections or did far more operations of certain types than usual in a community.

Now, to answer your question a little more fully-this system identifies and puts onto computer tape every service provided to every patient in medicaid, giving the place of the service, the name of the provider, the patient, the charge for the service.

Running out tables from such data, one can therefore identify individual physicians who, for example, give on the average more than one injection per patient visit.

Senator WILLIAMS. They have to feed that data in it?

Dr. BRESLOW. They have to feed that data in, because they must submit bills in order to collect payment for their services.

What this system does is to take advantage of bill submission in order to examine, not only the issue of the fees, which can also be done of course, but also to examine the issue of quality.

The system permits identification of physicians and other providers-not a few, there are several score of them--who have far exceeded the norms of practice.

One can identify physicians, for example, who do a great many operations for umbilical hernia on infants, which in most physicians' judgment can usually be treated effectively without the operations. Senator WILLIAMS. By the way, this idea-who would be the recipient of this bank of information?

Dr. BRESLOW. In the early days of Medi-Cal, the information came to the State agencies, in those days to the State department of public health, which developed and maintained the State observation over the system.

It also, of course, was in the hands of the bill-paying agency--the fiscal intermediary, Blue Shield. Now, the State, I understand, has abandoned its direct surveillance of this operation, and has left it entirely up to California Blue Shield.

Senator WILLIAMS. Well, you used to be in State government?
Dr. BRESLOW. Yes, that's correct.

Senator WILLIAMS. You are no longer?

Dr. BRESLOW. No, except I am in the State university.

Senator WILLIAMS. Why didn't you stay?

Dr. BRESLOW. Well, sir, in California the director of the State department of public health, which was the position I occupied just before leaving, is an office for a term which expires 1 year after the coming in of any new administration.

That's when my time expired.

Senator WILLIAMS. I think I get the point you make.

Dr. BRESLOW. California Blue Shield has taken over this system. I believe, senator, it would be useful for your committee to explore this system in some detail with a view to incorporating some such system into all medical care programs that are supported by Federal funds.

It certainly would be a vast improvement over the situation in many States where there is no statewide medicaid data, even on the eligible population or on the services provided.

« PreviousContinue »