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ITEM 7: LETTER FROM DAVID LITTAUER, M.D., EXECUTIVE DIRECTOR, CEDARS-SINAI MEDICAL CENTER, LOS ANGELES, CALIF.

NOVEMBER 18, 1968. DEAR SENATOR WILLIAMS: In 1965, before Medicare was available, the California State Department of Public Health studied all admissions for a 6-month period to 35 home health agencies in California. The Bureau of Chronic Diseases has furnished me with the following evaluation of the replies:

"One question on the discharge form asked the private physician, “After observing this patient in a program of home nursing care would you please answer the following question: If home nursing care had not been available would you have had to: Send the patient to the hospital? Send (or keep) the patient in a nursing home?" (For patients referred from a hospital the question was: “Would a longer hospital stay been required?") A majority of the physicians did not see these two choices as alternatives but physicians did indicate that one out of every five patients would have had to be in a hospital if home nursing services had not been available. One out of every six patients would have been sent to a nursing home. So for over one third of the patients (35.9 percent) a much more expensive form of care would have been imperative if these services had not been available to the private physician.

"There was considerable variation in alternate care needed depending upon the diagnostic condition which brought the patient under care. For example, 35 percent of the cancer patients would have had to be hospitalized and another 14 percent would have had to go to a nursing home. Twenty-six percent of the stroke patients would have been sent to nursing homes while an additional fifteen percent would have been in hospitals. An entirely different picture appears for patients with arthritis where 20 percent would have been sent to nursing homes and for only 6 percent would a hospital have been the alternative.

*This study was conducted before home health services were made available under Medicare and many physicians were not aware of this type of service. It seems reasonable to assume that early referral of patients was not always made. For example, agencies with liaison nurses in hospitals or some other similar arrangements had a much higher percent of their admissions made directly from a hospital. Vine agencies had at least 30 percent of their admissions made directly from a hospital while ten agencies had less than 10 percent of their admissions referred directly. Obviously, with a good referral system cases can be evaluated early and sent home as soon as feasible. Home nursing services would then be substituted for more expensive hospital care."

In 1961 I was project director of a comparative study of 15 home care programs, using the coordinated (comprehensive) home care program of the Jewish Hospital of Saint Louis, where I was then executive director, as the base. The answers to several of the questions posed in your letter are found in the report of this study, which was published as Monograph #9, Hospital Monograph Series, by American Hospital Association, Chicago, publication no. G164. A copy of this monograph is enclosed. The evaluation of benefits to patients is as valid today as it was then. I refer you particularly to the Critique (pp. 65–70), which I hope your staff will extract as a part of my comments as needed.

In September, 1967, the Division of Medical Care Administration of the Health Services and Mental Health Administration of the U.S. Public Health Service held an invitational conference on Home Health Agencies after one year of Medicare. I had the privilege of participating in this conference and of collaborating in the preparation of the final report: "Home Health Agencies After One Year of Medicare", published in mid-1968. (Since I have only one copy of the report in my possession, I cannot send it, but I am sure copies are available on application to the appropriate office of the Public Health Service).

It was the consensus of the conference group that ways must be found to bring home health services into the main stream of community health for patients of all ages and economic levels; home health services should be made a part of voluntary individual and group health insurance plans as well as of government programs. Home health services should be included by State and community

planning agencies under the provisions of P.L. 89–749 (Comprehensive Health Services) and P.L. 89-239 (Regional Medical Programs). Both rural and urban areas need networks of home health agencies capable of furnishing comprehensive services. The recommendations of this conference include:

Formation of a national organization for Home Health Services to facilitate continuing communication on a group basis among State agencies, providers of service, fiscal intermediaries and community leaders with the Federal agencies. (In California we recently organized the first state association, California Association of Home Health Agencies, of which I have the honor to be the first President).

Representatives of the medical profession should be invited to suggest ways in which physicians can be involved in planning and administering home health agencies.

The Social Security Administration should provide analyses of information that is accumulating regarding kinds of services being used by various types of patients.

Task Forces should recommend solutions to specific short-range and longrange problems.

The Public Health Service and the Social Security Administration should study home health services on a continuing basis as an appropriate health

entity within the health service system. I hope the above comments will be helpful to the deliberations of the Special Committee on Aging. If I can be of further assistance, please let me know. Sincerely yours,

DAVID LITTAUER, J.D.,

Elecutive Director.

ITEM 8: QUESTIONS SUBMITTED BY THE CHAIRMAN TO DR. GEORGE B. MARKLE. IV, DIPLOMATE OF THE AMERICAN BOARD OF SURGERY

1. What, if any, action by the Federal government would you recommend to reduce the number of unnecessary tests and examinations, thus saving money for both its medical care programs and for their beneficiaries?

2. Is any governmental action on this problem possible without interfering with and overriding the exercise of private medical discretion?

3. Your article seems to infer that utilization review procedures have thus far been ineffective to prevent unnecessary tests and examinations. Is that a valid conclusion? If so, why do you believe utilization review has been ineffective? Can anything be done to make utilization review more effective to prevent unnecessary procedures?

4. To what extent do you believe the ordering of unnecessary tests and examinations is caused by fears of malpractice suits? What, if any, solution do you believe there is to this problem?

5. Your article in Medical Economics points out that some physicians defend a liberal policy in ordering tests and examinations on the grounds that they have some value in early detection and prevention of unrelated conditions. To the extent that unnecessary tests cannot be eliminated, what, if anything, do you think can be done so enhance the preventive value of such procedures?

(The following reply was received :)

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NOVEMBER 8, 1968. DEAR SENATOR SUATIERS: Where I stand--on the front line of medical care in a moderate sized community--I can give your committee a perspective that will be different from the one you get from medical school deans and big medical center authorities. These men see all the complicated cases and the rare difficult cases, and really don't appreciate that the great bulk of medical problems are really quite ordinary and can be handled by ordinary means by ordinary doctors on the community level. If doctors would seek to be practical, we would cut costs considerably.

The article you refer to in Medical Economics Sept. 30, was published in slightly changed form in Hospital Physician in June 28. As I don't have reprints on the former, I enclose a reprint of the letter.

To answer some of your questions :

1. The Federal Government probably shouldn't try to rule on the necessity for specific tests. Conditions vary too widely, and what is necessary or unnecessary is too controversial in many cases. For example, in some areas, a routine V.D.R.L. (test for Syphilis) is a good thing from a public health point of view. There may be no more reason to do such a test, however, on a patient admitted with a broken arm than there would be to do one on any other group, whether in the hospital or on applying for a drivers license. Generally these routine tests are made obligatory by the hospital rules and by the record and utilization committees. Undoubtedly they are often good, but I would like the attending doctor to decide if there is advantage in them, not just as a routine.

2 and 3. Too often the value of a particular test or Xray is of such an individualized consideration that even a utilization committee might argue over it indefinitely. Thus, you can't make hard and fast laws. I suggest that Federal hospitals might be encouraged to drop most of their mandatory routines so that individual doctors may omit tests, etc., that have no bearing on the problem. Examples of this are mentioned in my article. On the other hand, use of tests which might expedite diagnosis and treatment should certainly be permitted so long as they are pertinent and not done just to display the erudition of the doctor, or for simple curiosity. Under research conditions, of course, a lot of tests are done, not to benefit the patient, but to enhance medical knowledge this is a special situation.

4. A lot of tests and Xrays are ordered more to protect the doctor and the hospital than for the benefit of the patient. Fear of malpractice is behind perhaps half of the Xrays we take in cases of trauma. A doctor by oversight in a career of 50 years of caring for sprained ankles, for example, can lose in court more money than he ever earned in that field. Loss of one life might cost him more than he earned in a life time of saving lives. It makes one inclined to limit his practice to safe and sure procedures and even then, to cover himself in every way possible by documenting everything with Xrays and tests. I have heard suggestions that malpractice be handled something like compensation cases. The patient, too, could share some of the risk.

A related influence towards excessive testing is the trend toward big medical center care. A big medical center is expected to never make a mistake and so they tend to test everything. A private doctor can Xray or test just what he is looking for, and then if results are negative, he can call the patient back for another test or two. The clinic can't easily do this if the patient lives at a distance from that city: hence the tendency to give a battery of tests and Xrays all at once, some of which would be unnecessary if the results of the first few were known at the time.

Both the malpractice threat and the "have to be perfect" concept are the result of the rising expectations of the public as well as rising standards among us doctors. This is good in a way, but fear of overlooking something does definitely increase the use of unnecessary (as far as the patient is concerned) tests and Xrays.

5. As for using tests and Xrays for public health reasons or as preventative measures, the restriction is mostly economic. If 200 million Americans had annual physical exams, Xrays and basic laboratory tests, a lot of good would result, but obviously the cost would be enormous. Medicare couldn't provide routine complete exams for its millions of elderly without tremendous changes in its financing. There are not enough doctors to do all this anyway. Even if it were possible, we wouldn't eliminate all disease-probably we would be doing good in only 10 or 20%. One of the big problems, usually not mentioned in articles on medical planning is that over 50% of patient visits are more concerned with emotionally caused conditions than purely physical ones. I don't see how more frequent physical exams or tests can help that problem.

We can help to educate the public in when to see a doctor and what they can do to prevent illness themselves. The American Cancer's Society's 7 warning signals of cancer is a very good approach as to the former. I have written a book “How to Stay Healthy All Your Life", published by Frederick Fell Inc., New York, which can help in both these respects. This sort of book could cut down doctor-patient visits perhaps 20%. Probably 75% of ill health is preventable. I have asked my publisher to send you a complimentary copy. It is not the usual health book, and is quite readable.

There are now some ways to do a lot of this testing less expensively. Machines which larger laboratories can afford can now automatically do a dozen different tests on one blood sample that are quite reasonable, and so, even if you are not interested in half of the results, the total cost is fairly cheap. For a long time some hospitals have had miniature X-ray machines that take small films of the chest (a common requirement) as a screening procedure. The use of mobile, free chest X-ray units is standard in some communities, using this inexpensive method, and is a good thing.

The biggest variable in medical costs is up to the individual doctor; how he manages each case. I have illustrated this in another article published in Medical Economics, Aug. 5, 1968, "Spare the Purse and Please the Patient”, a reprint of which I enclose. The savings our profession could manage, if we were all as cost conscious as I am, are enormous, certainly hundreds of millions a year. However, I don't see how you could legislate that certain cases must be done as outpa. tients and others as inpatients, or whether or not to use general anethesia, etc. All we can do here is preach and teach. Some doctors don't have facilities for minor office surgery and some are not confident enough to do anything outside of the hospital atmosphere. Some just weren't trained to do things simply. Again malpractice threats influence some unduly.

I think your committee would be interested in a third article published in Medical Economies Sept. 3, 1968, “The Case for Small Town Specialism". Regional health planners are talking about sending more and more medical cases to big city centers or clinics and de-emphasizing community care. I refute that concept as being economically catastrophic and medically undesirable. This article describes the problems and how a community hospital really can give excellent care for all but the rare or unusual cases.

I am sorry that I am not in a position to supply your committee with meaningful statistics. I suspect you have enough of them already. All I can supply is the philosophy of the practicing doctor on the front line of medicine. As I say, spokesmen for medicine are mostly from medical schools or big centers and their view lacks total perspective. My articles and my book may, I hope, give you a different slant.

Please feel free to contact me at any time. I am very concerned about the cost of medicine and would be glad to help your committee in any way I can. Sincerely yours,

G. B. MARKLE, M.D. (Enclosures]

EXHIBIT A: SHOULD HOSPITALS REQUIRE SO MANY TESTS?

[From Medical Economics, Sept. 30, 1968 ]
Definitely not, says this doctor, who contends that too many hos-
pitals are routinely ordering medically unnecessary tests and exami-
ations. By reducing the number of such unnecessary tests, he argues,
physicians can help to cut the cost of medical care.

(By George B. Markle IV, M.D.)

Everyone is complaining about the sharp rise in health-care costs these days, but finding ways to reduce those costs is no easy matter. "Rising costs aren't our responsibility," physicians are likely to say. True, most higher costs are due to higher hospital bills, but we physicians do have a lot to say about those bills.

I'm not talking about reducing bills by cutting down on unnecessary admissions and shortening hospital stays. We're all aware of such important ways of saving the medical dollar, and we're probably doing about as much as we can in that direction. But I don't believe we're doing enough about doing away with medically unnecessary examinations and tests when we must admit our patients to hospitals.

Jy hospital's record committee, for example, has just returned some charts to me because physical examinations weren't complete. One chart was that of a young man who had suffered second-degree burns of his back and arms when a can of gasoline exploded. Although the burns were limited, I still hospitalized him for a couple of days to give him open-air-exposure treatment. He'd no other complaints, and he told me that he'd been in good health. In fact, he needed only a bit of nursing care and a bed where I could watch him. But the hospital insisted that he have a complete blood count, a urinalysis, a chest X-ray, and a V.D.R.L. These tests, like the complete physical that I'd omitted were strict hospital policy. Another patient had two toes crushed by a mine car. He needed bed rest, with elevation of his leg, frequent medication for pain, and observation for possible infection or gangrene. Though hospitalization was indicated, I saw no need for a complete examination, since he didn't require a general anesthetic. I didn't do a rectal exam, and I ordered no lab work. Of course, the work was done anywayand I was the recipient of a little billet-doux from the record committee.

In a third instance, a little boy fell off a horse and suffered a supracondylar fracture that I reduced under a general anethetic and immobilized in plaster. The boy's mother gave me a negative past history and a negative history for any of his current problems. So I checked his throat, heart, and lungs, and went to work. I admitted him to the hospital because of possible pain, possible ischemia of the arm, and to elevate the arm for a day or two under observation. Since I wrote no lengthy history, I got back the chart with snide remarks to the effect that it hadn't been completed. The lab work, to top things off, had been finished about an hour before the boy was discharged, and the lab report was sent to the record room for the greater glory of the record committee and the Joint Commission on Accreditation of Hospitals.

How often does this sort of thing occur in your hospital? Daily, I'd guess. Think of the unnecessary cost to the patient for tests that aren't likely to benefit him! And what about the doctor's time? You can't do a thorough systemic review, past medical history, social history, followed up by a complete physical examination in much less than 30 or 40 minutes. Of course, I'm talking about only the isolated injury or the simple complaint. If the patient seems to have other ailments or if the diagnosis is obscure in any way, then the execution of a good history and physical is obviously indicated, and routine lab work plus the needed specific tests and X-rays becomes justified.

Granted, we did all these tests and physical exams as a matter of routine when we were attending medical school. But, as part of our training, they were designed to benefit us as much as the patient.

What about annual physical exams? I'm all for them. Suppose that, in the absence of any medical indications for a lot of work-up, the hospitalized patient asks for a complete examination and is willing to pay for it. The doctor in charge should certainly agree to it. He can do the examination either then or later in his office if that is more convenient. But what if-as sometimes happens—the patient expects his hospital insurance or Medicare to pay for the exam? Health insurers and Medicare don't ordinarily pay for routine annual physicals, yet in some cases they're unwittingly paying for this extra work when it isn't medically indicated-all in the name of the record committee, the tradition, and the holy accreditation commission.

Many doctors and hospital administrators, I expect, will charge me with advocating sloppy medicine. They'll use statistics showing that in some communities the routine V.D.R.L. or other serology tests do pick up an occasional unsuspected case of syphilis and that some hospitals do find a few cases of active tuberculosis by routine X-rays. A heart murmur in a child may be picked up, and sometimes this is a good thing to know, and sometimes not. During physical exams, I sometimes find an unsuspected hernia, though the patient would probably have found it himself soon enough.

Well, I'll concede that routine testing has some merit-but only for certain types of patients. For example, those with a history of promiscuity probably should have a V.D.R.L. whenever you can catch them. Others, particularly heavy cigarette smokers, should have chest X-rays often. Elderly people, since they're more prone to various ills, should be given regular physicals. Last month, for instance, I discovered breast cancer in an elderly woman who had been admitted to the hospital for phlebitis.

What it boils down to is that all medicine, at best, is a compromise between the ideal and the practical. Ideally, we could pick up more diseases by giving people physical exams throughout the year. But, practically, we can't advocate that kind of medicine. If we did an upper G.I. series on all adults annually, we could find an occasional stomach cancer. But we don't because the yield is too low to justify the cost of such exams. And how many doctors regularly have sigmoidoscopies done on themselves?

Some physicians are just as guilty as hospitals are in overtesting. Rather than aim for individual tests, the diagnostician often resorts to a shotgun approach in the hope that some diagnosis will fall in his lap. Testing has become a matter of blindly following routine. Yet any doctor should be able to determine when a patient needs a physical exam and specific tests. By using this more selec

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