--Are the criteria used to select candidates for transplant equitable and appropriate? --What impact will increased transplantation have on health care expenditures? --What barriers exist that may prevent persons from receiving transplants? Are federally operated health care facilities the most cost-effective manner? Currently the federal government operates separate health systems for special segments of the U.S. population and also provides care for their dependants and survivors. Many of these beneficiaries are also eligible for care through Medicaid and Medicare, and some have private insurance. Do the federal direct care delivery programs provide cost-effective care? The federal direct care delivery programs operated by DOD and VA, have, for the most part, remained immune from cost containment strategies required in the Medicare and Medicaid programs. Nevertheless, some strategies have been employed, such as HMOs, preadmission testing, outpatient care, hospices, and adult day care programs. One of the most important issues faced by the VA concerns how care will be provided to an increasingly aged veteran population. Consideration needs to be given to the extent to which this care will be provided by the private sector and, therefore, how much will need to be supplied by the VA. In assessing how the direct care delivery systems provide care in comparison to other providers, several issues warrant attention. --Are the direct care delivery programs organized to --Are patients unnecessarily hospitalized when ambulatory care would be appropriate? --How do hospital lengths-of-stay compare with other --Are patients provided with the appropriate level of care? --Are patients afforded access to quality health care in federal facilities? --What plans have been made for taking care of an increasingly aged veteran population? Is there a continued need to maintain a direct care system in its present structure? Critics of the federal direct care delivery system have focused their attention on the VA. Some contend there is not a need to maintain a separate system for veterans. Rather, veterans could be afforded care in the private sector using vouchers or low-cost health insurance. Those who propose eliminating the VA system argue that it promotes duplication and inefficient use of bedspace and other health resources. The emergence of Medicare, Medicaid and private insurers has further lessened the need. On the other hand, proponents of the VA system maintain, among other things, that it represents a commitment to the nation's veterans and is an important contingency in case of war or other emergency. Issues that deserve study as part of efforts to contain spending in the direct care delivery programs include: --Is there a continued need to operate separate direct care delivery systems; should they be eliminated and care provided in the private sector, or should they be merged? --What would be the impact of efforts to eliminate or --Will veterans, military personnel and others have access Utilization issues Nine important issues relating to the utilization of health services were identified. In general, these issues relate to methods of altering the behavior of both consumers and providers to reduce utilization without adversely affecting health outcomes. Specifically, these include increasing consumer and provider cost-consciousness with regard to the appropriateness and necessity of treatment, reducing the practice of defensive medicine, encouraging utilization review programs, and promoting healthy lifestyles and prevention of disease. In addition, we discussed options for the provision of care to those without adequate health insurance coverage. The utilization issues are: 1. 2. 3. 4. 5. 6. 7. 8. 9. What utilization review type programs which focus on unnecessary or inappropriate admissions, readmissions, and other services to patients in hospitals and other facilities are cost-effective but not widely used? Will increased consumer cost-sharing reduce the utilization of health care services without adversely affecting the patient's well-being? What are the costs and benefits of various proposals for financing and providing medical care to that portion of the population without adequate third-party insurance coverage? How can the behavior of health care providers be changed to reduce variances in practice patterns which exist? What can be done to increase provider awareness of the need to use appropriate, less costly ways of providing health care services? How would the increased use of computers enhance efficiency? What actions can be taken to reduce the practice of defensive medicine and malpractice insurance premium costs while protecting patients' legal rights? To what extent does the inappropriate use of hospital emergency rooms increase health spending, and what actions can be taken to remedy this situation? What additional measures that can be demonstrated to be cost-effective can be implemented to further encourage people to improve their lifestyles? What should be the appropriate levels of government and private investment in disease prevention and health promotion? What utilization review type programs which focus on unnecessary or inappropriate admissions, in hospitals and other facilities are cost-effective but not widely used? Since the inception of the Medicare and Medicaid programs, hospitals have been required to establish mechanisms to review the care provided to beneficiaries. Another such step was the Professional Standards Review Organization (PSRO) program, in which physicians determined whether services delivered to federal beneficiaries were necessary, of good quality and rendered in an appropriate setting for reimbursement purposes. However, several of our reviews and reviews by others found the program to be hindered by numerous problems and only marginally cost-effective. The PSRO program was replaced by a similar one (the PRO program) which was authorized in 1982. The private sector also contracted for PSRO reviews to examine the costs and quality of care being provided in their programs. Other utilization review type activities have consisted of second surgical opinions, medical necessity programs, and other efforts. Several issues have surfaced in determining the extent that utilization review type activities will affect health care expenditures: PRO activities --To what extent has the PRO program overcome the difficulties experienced in earlier efforts? Are additional activities needed to make the program more effective? Second surgical opinion programs --To what extent have second surgical opinion programs been implemented and focused on specific procedures and how effective have they been in constraining expenditures? Medical necessity programs --To what extent have medical necessity programs been --What types of procedures are included in these programs and how often are they reviewed? Will increased consumer cost-sharing reduce the utilization of health care services without Most consumers have some form of public or private health insurance. Such coverage has encouraged patients to increase their demand for health care and minimized both patient and provider concerns about costs. Because of ever-increasing expenditures, the federal, state, and private sectors have attempted to reduce utilization of health care services through a variety of techniques, including increased consumer cost sharing. The objective of this approach is to encourage both consumers and providers to more judiciously use the health care system. A major study by the Rand Corporation found that cost-sharing was an effective technique in constraining health 142 care expenditures. The study found that expenditures per capita rose as cost-sharing was reduced. It also found little impact on health status as a result of free care or plans with substantial cost-sharing. Critics of cost-sharing contend that assessing health status is very difficult. For example, many people delay necessary medical care as a result of cost-sharing. While cost-sharing does prevent people from using medical services, not all who forego care are those with trivial illness. Thus, delaying care for these persons may worsen their conditions and make subsequent treatment more expensive. They therefore recommend studies of the long-term outcomes on health before expanding the use of cost-sharing programs. However, this would require full-scale, longitudinal epidemiological studies of the health of consumers. Such studies are difficult, expensive, and take a long time to complete. The following issues need to be addressed in terms of the effectiveness of cost-sharing: --What methods are available or need to be addressed to measure the impact of cost-sharing on the health status of consumers? --Are patients being unnecessarily denied care because of cost-sharing, and how does this affect expenditures? --What are the appropriate levels of cost-sharing that will constrain spending while continuing to afford patients with access to needed services? What are the costs and benefits of The Congressional Budget Office estimated that up to 8 percent of the population or as many as 18 million persons in 1978 had no health insurance coverage.143 More recent data published in 1984 showed estimates of the uninsured ranging from 25 million, at a given point in time, to 34 million who may be uninsured at sometime during the year. 144 The uninsured population consists primarily of the poor, the aged, the disabled, and racial minorities. |