-The lack of adequate and informative standards for services performed."

-Uneven impact of the deductibles and coinsurance upon those most in need of help and least able to pay.

-The dangers arising from fragmented treatment including failure to coordinate drug prescribing for a patient.

There is some danger that the current investigations of fraud and near-fraud in Medicaid and Medicare may lead to a defeatist or negative attitude toward each program. There is also a danger that such emphasis may well thwart efforts to deal with more fundamental deficiencies in each program.

Reform is needed, but it should be thoroughgoing and it should be positive. This Nation has declared that highquality medical care is the right of every American. We should be innovative and positive in making changes; we should be as insistent upon upgrading quality as we are insistent that wrongdoing be recognized and punished.

The case for setting quality standards was vigorously expressed by Dr. Martin Cherkasky, administrator of the Montefiore Hospital in New York City, during 1968 hearings before the Senate Subcommittee on Executive Reorganization. Here is an excerpt:

"Equally disturbing and certainly more dangerous is the total lack of quality standards for physicians treating Medicare patients. Here Congress should act and act quickly. For example, provisions for payment could require that major surgery only be paid for if carried out in an institution fully accredited by the Joint Commission on Accreditation and carried out by a surgeon who is either Board qualified or Board eligible.

"In other words, major surgery should not be paid for by the Government except in unavoidable circumstances unless the surgeon has evidence of the qualifications he should have.

"And, you know, Senator, this is not an insistence upon standards which are meaningless. Cancer of the cervix is a very dangerous and deadly illness. When early cancer of the cervix is operated on by qual ified Board-certified gynecologists, there is 80 percent cure rate. When it is operated on, as it often is, by people who don't have these qualifications, there is a 50 percent cure rate. The difference between insisting upon qualifications and no qualifications is the difference between 50 and 80. We are talking about human lives, not about money or anything else.

"Where a Medicare patient has a major medical problem, a consultation with a qualified specialist should be required."

PART THREE

SPECIAL NEEDS OF THE ELDERLY AND THEIR EFFECT UPON MEDICAL COSTS

I. EXTENT OF DISABILITY

As we get older, those of us who survive have increasing need for medical care. Evidence of our increasingly disabled state is not hard to find. For example, 34 percent of the population 45-64 has no chronic conditions, while only 20 percent of the population 65-74 has none, and less than 13 percent of the population 75 and over responds that they do not have one or more chronic conditions.'

Among those 45-64, only 3 percent are unable to carry on a usual major activity, such as working, or keeping house. In the 75 and over age group, the figure is 24 percent so disabled that they cannot work or keep house. Bed disability days as well as days of restricted activity increase as age rises.

Per person per year, those 45-64 spend 7.2 days in bed; those 75 and over, 19.4 days. Days on which activity was restricted were twice as high for the oldest group as for the age group 45-64 and three times as high as for the population as a whole. The age group 65-74 was intermediate.

PHYSICIANS' SERVICES

Other kinds of evidence of poorer health include an expanding volume of doctor visits and hospital care as age advances; only in exposure to surgical intervention is there a decline in the rates. Doctor visits outside the hospital rise from an average of five annually for the 45-64 year group to 7.2 for those 75 and over. There is an increase in the proportion of doctor visits to the home-a fourth of all visits for those over age 75 are to the patients' residence 2-which has cost implications since doctor charges are generally higher for home visits.

HOSPITALIZATION

Hospital admissions and discharges also rise as age increases, as the following tabulation 2 shows:

All the data in this section are derived from NCHS series 10 No. 32, Age Patterns in Medical Care Ilness and Disability. July 1963-June 1965.

NHS data vary slightly depending on the year in which the data are gathered. These figures are for July 1963-June 1965.

More time spent in the hospital connotes larger hospital and doctor bills as a concomitant of aging. As a result, the portion of any medical bills not met by Medicare benefits would also be larger for the oldest ages since the 20-percent coinsurance would be applied to a larger base.

II. LONG-TERM CARE

By definition, a long-term care hospital is one in which the length of stay exceeds 30 days on the average. Such beds are in short supply in the United States except for those in mental hospitals. Tables III IV indicates the national and regional averages in bed supply and demonstrate once more the uneveness of the distribution of facilities. The New England region (region I) has one long-term bed per 1,000 population of all ages and in addition has 2.2 extended-care-facility beds. The only other region coming close to this supply is the Pacific Coast region (region IX), where extended-care facilities are relatively abundant.

The right side of the table relates the bed supply to the population 65 and over. For short stay beds, the figures are relatively meaningless (since the aged compete with the younger population) but for long stay and extended care facilities, the aged occupy 90-95 percent. So the variation in supply from 11.1 to 33.8 per 1,000 means there will be problems in obtaining care in many places.

Nursing home care for the aged cost the Nation $1.2 billion

in fiscal year 1967. A little more than half of this amount
came from private resources.

With Medicare and the Federal share of title 19 paying for ECF care for 6 months of the 12 months of 1967, the Federal tax dollar paid for 26 percent of the total; State and local funds financed 18 percent. The public share will be rising as Medicare pays more throughout each year and more extended-care facilities and skilled nursing homes are constructed. Quite apart from inflation, to meet desirable standards established for acceptable care, costs will rise with expanded employment of better trained nursing personnel.

Data Center, Public Health Service.

Source: Based on data from Social Security Administration and Bureau of the Census, prepared by Community Profile

THE NURSING HOME POPULATION 3

Who are the people in nursing homes and personal care homes with nursing? By and large they are old-the median age is nearly 80-and unwell: 85 percent have two or more chronic conditions or impairments; nearly 25 percent have at least five such conditions. Only 10 percent have a living spouse; the balance are widows, 63 percent, divorced, separated, or never married. Nearly six in 10 were not living with their family or even a relative prior to admission to the home. The leading conditions and impairments afflicting the residents of these institutions in descending order are (1) vascular lesions affecting the central nervous system, (2) diseases of the heart, (3) arthritis and rheumatism, (4) chronic brain syndrome, and (5) hearing impairments. Together just these five conditions are found 1,249 times in each 1,000 residents, because the residents have more than one condition.

Not surprisingly the residents may spend years in the home. The median stay is about 18 months, the mean stay at least 3 years. Some 17 percent had been in residence 5 or more years.

Only scattered information came to the Advisory Committee's attention regarding monthly charges for care in nursing homes. We are of the opinion that charges have risen sharply from the level indicated by the NHS survey in May-June 1964.

At that time the average monthly charge in a proprietary home was $205, but 48 percent of the residents were paying more than this and 15 percent were spending $300 a month or $10 a day. A $10-a-day charge had become a relatively low charge by 1969.

An indicator of widespread variations in availability of extendedcare facilities is given in this table of ECFS now participating in the Medicare program.

TABLE IV.-REGIONAL DISTRIBUTION OF EXTENDED-CARE FACILITIES AND BEDS, PERCENT INCREASE, AND RATIO TO BENEFICIARY POPULATION, JULY 1968

Source: "Health Insurance for the Aged: Number of Participating Health Facilities, July 1968." R. S. Health Insurance Statistics, HI-14, June 20, 1969, p. 11; Öffice of Research and Statistics, Social Security Administration, D/HEW.

Data in this section are from NCHS series 12, Nos. 8, 9, 10, and 12 where the findings from the May-June 1964 survey are set forth.

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