is little consensus as to the impact that possible changes in health services usage would have on the incidence of disease or on costs. There is evidence, however, that involving patients with certain kinds of health problems in their own care can improve their prognosis and save money. At the Tufts Medical Center, for example, it was possible to reduce hemophilia patient costs from $5,780 to $3,209 per patient by instructing the patients in self-infusion. At the University of Southern California Medical Center, it was possible to reduce emergency room visits by 50 percent for diabetics through a program of counseling and information developed by the Center. Finally, health education might be able to provide people with a more realistic assessment of the role medical care actually plays in maintaining and improving our health. Advocates of such measures contend that many people believe that larger health care expenditures will automatically bring better health care, and that this unrealistic expectation is the principle justification for increasing demand for more and more expensive health services. It is frequently noted that much disease and poor health, and the consequent costs, could be prevented or made less severe if we simply applied what we know today about prevention. Prevention, in addition to health education referred to earlier, includes such actions as maintaining clean water and air, sanitation, the fluoridation of water supplies, immunizations against specific diseases, and screening programs. Many of what might be termed traditional public health programs such as the chlorination and fluoridation of water supplies are widely perceived to be effective in reducing disease. Immunizations are also generally effective. There is widespread disagreement, however, about the effectiveness of such preventive efforts as screening programs and routine physical examinations. The major disagreements regarding screening programs which attempt to detect a wide range of diseases relates to the effectiveness of screening in influencing the incidence of any of the illnesses they attempt to detect. There is more widespread agreement concerning particular types of screening tests for segments for our population, e.g. hypertension screening, pap smears, screening for Rh incompatibility in pregnant women and serologic tests for syphilis in sexually active patients. Such tests meet the criteria of accuracy, physician acceptance of the findings, and the likelihood of patient compliance with prescribed treatment and behavior. An approach under increasing criticism by health care experts is annual physicals for everyone. Most of the criticism relates to their high cost and the limited use of the findings in maintaining or improving health. There is considerable, although not unanimous, agreement that annual physicals are useful for certain groups such as young children, persons over 40, and persons on their first visit to a new doctor. CRS-45 In speaking to the issue of prevention, Dr. Richard Spark, an associate clinical professor at Harvard Medical School, stated in a New York Times Magazine article of July 25, 1976: G. As unpleasant as it may sound to those who would Industry Efforts to Control Health Expenditures In commenting on the cost of health care to industry, the Council on Wage and Price Stability reported: If the trend in contributions to employee health benefit plans from 1965 to 1973 (the latest year for which data have been published) were projected forward to 1975, it would show contributions in 1975 to be over 300 percent of those in 1965. Health care is a larger cost component of a car built by General Motors than is steel. Business and labor, through payments for the Medicare program, health insurance and out-of-pocket payments for health care, occupational health and safety programs, and health expenditures under the employees compensation programs, may spend approximately as much as the Federal Government for health. Their large and rapidly rising expenditures for health insurance have prompted business organizations to look for ways of containing health costs. Some companies now advocate health maintenance organizations for their employees as an alternative to fee-for-service medicine. The R. J. Reynolds Tobacco Company in Winston-Salem, North Carolina, recently developed a health maintenance organization for its employees and their families. General Motors attempted unsuccessfully to persuade the auto workers union to increase employee co-payments as a means of reducing the use and cost of health services. Companies such as Goodyear Tire and Rubber Company have contracted with a medical society-sponsored peer review organization in an effort to cut down on the use of unnecessary hospital services. Many companies such as those in the Rochester, New York, area actively support health planning as a means of cost containment. The Council on Wage and Price Stability analyzed industry efforts to hold down the costs of medical care. They identified the following 93 projects, over half of which were begun during or after 1973. CRS-46 I A national health insurance program without strong expenditure controls could add substantially to the cost of health care. Some who criticize proposals for national health insurance on the grounds that it would be too expensive are concerned not only about meeting existing health care expenditures but also about the possibility that such a program, given the state of the art of applying controls, could not resist the pressures to increase expenditures. On the other hand, it could be argued that the present fragmented system for financing health services is itself a major handicap to expenditure control that could be remedied by national health insurance. If all or most of the health care providers' incomes were from a single program, a budget could be established that would set an overall limit on the nation's health care expenditures. Also, a single payment program might help restrain increases in health costs by strengthening health facility planning efforts and medical education and training programs designed to provide for a more efficient allocation and use of health resources. It could also be argued that a national health insurance program could offer meaningful financial incentives to encourage changes in the way medical care is provided that would make the health care delivery system more economical. Given our present knowledge, there is no sure way to determine which of these arguments will prove accurate. The choice will probably hinge more on values and goals--the willingness to pay for specified services--than on technical considerations. CRS-47 V. QUESTIONS FOR ANALYZING PROPOSALS TO CONTROL HEALTH EXPENDITURES A number of issues must be addressed in examining proposals to constrain expenditures for health care. The questions below are suggested as a general framework for analysis of expenditure control proposals. 1) Would the proposal work--does it provide an effective method of limiting spending? 2) Is the limitation temporary or permanent? 3) What is the impact of the proposal on providers with various characteristics (i.e., large hospitals, small hospitals, high cost hospitals, low cost hospitals, etc.)? 4) What is the impact of the proposal on consumers with various characteristics (i.e., low income, high income, those under governmental programs, those with health insurance, the uninsured, etc.)? 5) What is the impact of the proposal on the quality of services provided? 6) What is the relationship of the proposal to the general economy? What is the effect of limiting controls to one sector of the economy, such as health care, or even limiting only one sector of health care, such as hospitals? 7) How would the proposal be administered? It is currently impossible to answer many of these questions definitively for the proposals which have been made. Sufficient data are not available, and many are still in the developmental phase or are too recently implemented to begin evaluation. However, the questions can serve as a general framework for analysis and evaluation of proposals to limit the nation's spending on health care. CRS-48 O |