III. OUTLAYS FOR OUT-OF-HOSPITAL DRUGS "There are many elderly men and women who have some income and some savings-who may even have sufficient Medicare or other insurance to protect them against the bulk of hospital and medical costs of a brief illness-but who cannot pay for the out-of-hospital drugs and other costs of a long-continuing chronic illness without seeing their financial assets eroded or totally dissipated."-HEW Task Force on Prescription Drugs, final report, February 7, 1969. Drug costs rise sharply with age (Chart F). Like other medical needs, both the quantity used and the cost per acquisition is likely to be above the averages for younger persons. The situation is illustrated by the following table: Source: NCHS series 10 No. 33 "Cost and Acquisition of Prescribed and Nonprescribed Medicines, United States' July 1964-June 1965, PHS Publication No. 1,000, 1966. Averages, however, tell only a small part of the story of drug use and costs among the elderly. The HEW Task Force report makes it clear that the costs fall heavily upon those likely to be already under heavy financial pressures. Highlights from the report -Per capita expenditure for the elderly with severe disabilities was nearly three times greater than that for those with none. -A 1968 estimate indicates that 20 percent of the elderly have no drug expenses, while the costs will be less than $50 for 41.5 percent, between $50 and $99 for 19 percent, between $100 and $249 for 15.5 percent, and $250 or more for 4 percent. (NOTE: Half of all older people living alone or with nonrelatives, during 1967, had annual incomes of less than $1,480; one in four had as little as $1,000 or less.) -The average number of acquisitions for elderly women was nearly 50 percent more than for the men, and the per capita expenditure for elderly women was more than one-third higher than that for elderly men. (NOTE: Six of ten of all widows and other aged women living alone have incomes below the poverty line.) -For the elderly with one or more chronic conditions, the annual costs of prescribed medicines was $48.80; for those with conditions. which limit major activity completely, costs averaged $78.80. Prescription expenses of those of the elderly with severe chronic conditions about 15 percent of all elderly persons-were over six times as great as the expenses of younger people. Only 10 percent of the 65+ population had private health insurance for out-of-hospital prescription drugs at the end of 1966. Where such coverage is purchased, it is financially helpful only in so-called "catastrophic illnesses." It is generally included only in major medical policies involving deductibles of $100, $250, or $500 which the aged must pay himself. -Income tax deductions provide relief for only an estimated 8 percent of drug expenditures of the elderly, and such relief benefits only those elderly individuals who receive enough income to income tax payments. After surveying such data and studying the patterns of drug use among the elderly-for "therapeutic," "diagnostic," or "maintenance" purposes the HEW Task Force concluded that the disproportionately high expenditures among the elderly, combined with a widespread inability to pay for such drugs "may well be reflected in needless sickness and disability, unemployability, and costly hospitalization which could have been prevented by adequate out-of-hospital treatment." [Emphasis added.] Futhermore, declared the Task Force, the problem is destined to become increasingly serious as unit prices of prescriptions increase, and the armamentarium of useful drugs expands. This Advisory Committee emphatically agrees with the Task Force conclusion that "there is a need for an out-ofhospital drug insurance program under Medicare." This Advisory Committee also must point out, however, that while such action is vital for a significant number of highrisk elderly individuals, it will not materially reduce the overall medical expenditures facing the great majority of the elderly. IV. DENTAL CARE 4 National Health Survey data show that over half of the 65+ group have not seen a dentist in more than 5 years, and that even in high- or middle-income groups the average number of visits to the dentist is no higher than among those with less adequate income. One explanation for the limited demand for dental visits may be that the older population-after decades of inadequate care in the past-includes a large number of persons who are toothless. Among those 65 and over, between 50 and 60 percent have lost all their teeth; the proportion increases as age advances. Another reason may be that many older persons regard visits to the dentist as unnecessary once they have made the sizable outlay necessary to acquire dentures. There is little doubt, however, that neglect plays a large role. And, as a result of earlier neglect, 42 percent of the visits to dentists that those age 65 and over do make are for denture work, compared to 11 percent for the population under 65. This finding only emphasizes that those who still have all or some of their teeth are not taking adequate care of them, Further evidence to support this thesis was provided by a recent survey of dental services carried out by the Council on Dental Health and the Council on Hospital Dental Serv Series 10, No. 29 ice of the American Dental Association with the cooperation of the American Nursing Home Association. Forty-four percent of the nursing homes surveyed indicated that none of their patients had received any dental are. More than 63 percent of the homes for the aged (those without nursing care) reported that none of their patients received dental treatment. "Although dental care is needed by a significant percentage of these people, there was no demand for care," reported the American Dental Association, which also concluded: "* * * the attitudes and motivation of older persons toward dentistry need to be examined." Conditioned as we in this Nation are to dental care neglect among the elderly, we give too little heed to what may be a growing demand for dental services for individuals in the upper age groups. This demand could be a natural component of the current insistence on high-quality medical care for all, and it is a health demand which should be met. Such prepayment of dental care as there is, holds little promise for those whose teeth have been neglected over the years. PART FOUR DEFICIENCIES IN DELIVERY OF SERVICES As the preceding chapter suggests, Medicare and Medicaid helped create inflationary pressures by raising new demands for medical services that were unavailable or in short supply. Thus, deficiencies in the delivery system for health care services played a direct role in creating dollars and cents problems now encountered by elderly people who need medical care. Less apparent, but certainly of considerable impact, are other difficulties caused by faulty organization or nonexistence of services. Tables and statistics can tell only part of the story here. Perhaps several examples can make the following point: The elderly, along with other age groups, suffer, not only in terms of inconvenience, but also in terms of direct dollar outlays because of irrational or outmoded delivery systems for medical care and services. EXAMPLES Multi-Problems Cause Multi-Stops: Ill, elderly persons usually have more than one ailment at a time. If they cannot get "one stop" service for examinations or treatment, they become prime victims of a health care system recently described by Social Security Commissioner Robert Ball' as "largely decentralized, largely uncoordinated, and largely voluntary." Surgeon General William H. Stewart calls it a nonsystem. One poignant example, provided during a hearing by the U.S. Senate Special Committee on Aging, is repeated here because it offers a classic study of an aged man who, even with financial resources for treatment, paid a heavy price for having multiple health problems. It is a story of a patient who: * had a serious eye problem-actually two diseases: glaucoma and keratitis-for which he received care at a nearby medical center, in the department of ophthalmology. His personal doctor, a good internist, however, had diagnosed a mild diabetes, and for this periodic visits were necessary to an office 8 miles away. Painful corns and bunions, impairing the ability to walk, were not within the speciality of the personal doctor, so these required periodic visits to a podiatrist at an office 6 miles in another direction. Dental care, in an effort to save the few remaining teeth, so that dentures would fit more firmly and food could be more properly chewed, required numerous visits to a dentist at still another location. 1 In speech Jan 9, 1969, before the New York Regional Health Care Cost Conference. Then a bladder problem developed and prostatic disease was suspected. At about the same period, the patient showed lethargy and confusion, suggesting a mild cerebrovascular accident. The personal doctor made a home call and the decision was to hospitalize. A bed was not immediately available except in a small proprietary hospital which the family refused-and it was not till 10 days later that he could be admitted to a good voluntary general hospital 15 miles away. After X-rays, cystoscopy, and other examinations there, his treatment was stabilized. In the workup, it was discovered that a drug the ophthalmologist had been prescribing for many months was causing serious side effects, which had been missed by the internist since these two specialists had never communicated with each other. The patient was then admitted to a sanatorium, selected for its closeness to the family home, so that visits from the patient's children would be possible daily. This was one of the "better" nursing homes-it was certainly expensive enough at $32 a day paid by Medicare-but this was evidently not costly enough to support a proper staff. After a few days, because of lack of proper surveillance, this aged patient was found roaming on the street. When this happened a second time, the commercial proprietor decided to discharge the patient as "too difficult to care for." It took 5 weeks of nursing care at home, with daily problems of incontinence of urine and feces, before a bed in another nursing home became available. The latter facility proved to be better managed and the patient improved. After only 2 weeks, however, he was getting up from a chair one day, when he fell and fractured his left hip. This required an orthopedic surgeon, readmission to the hospital, and preparation for a major operation. But then complications to the diabetes set in, because of the traumatic shock of the fracture. A delay of over 24 hours in reporting a critical laboratory test nearly cost the patient's life at this time. Had the hospital been adequately staffed, this delay would not have occurred. A skillful operation, with a pinning of the broken bone, was done. Specialduty nurses costing $111 per day-over and above the Medicare coverage of the hospital bill-had to be hired because of the shortage of regular hospital nurses. I have not recounted the other details of multiple-drug prescriptions, special services of an appliance shop to adjust the bed at home, the physical therapy required for a knee injury, and much more. This patient was my widowed father, who lived with my wife and me for 9 years after his retirement from 51 years of medical practice. My abbreviated account of his medical care problems applies only to the last year, or it would be much longer. Accounts like this could be told thousands of times over, each day in the United States, and would doubtless be more complex and disturbing for a family less well informed about the jungle of medical care delivery. The witness before the committee was a professor of public health and a doctor of medicine. Even with Medicare, even with sympathetic and knowledgeable guidance netient in this case encountered expensive, disturbing t and appropriate treatment. For the low-income obsta |