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State and local welfare administrators have tended to purchase and
pay for more of the same kind of care that poor people were obtaining previously. The personnel and facilities in neighborhoods where poor people obtained care were often inferior and, most important, medicaid offered no inducement to improve. It simply financially supported what was present.
In some parts of the country, particularly in California, those responsible for medicaid (or Medi-Cal, as we call it) have endeavored to link it up with the quality standards of medicare. To the extent that this has been possible medicaid patients have benefited from the medicare standards.
On the second question, what can the Federal Government do to improve the quality of health care, I would suggest three approaches. The first is to incorporate into all Federal medical care programs a legislative framework for establishing standards of quality, such as was done in the medicare.
Second, the Federal Government should assure payment of reasonable amounts for the services provided. It should not leave such determinations, as in the case of medicaid, to local officials who do not appreciate the fact that in health care, as elsewhere, you usually get second-rate service-or worse--if you try to get by cheaply.
Senator RANDOLPH. Could I interrupt at that point, without breaking your continuity?
Now, does your statement lend itself to an opposing or an agreeing viewpoint with that of Speaker Unruh?
Dr. BRESLOW. Well, he made a number of statements.
Dr. BRESLOW. The point that I would emphasize with respect to the fee issue that was raised by Speaker Unruh, is this: Much more important than the question of whether you pay $1 or $2 for an injection, or whether you pay $200 or $400 for the appendectomy is the question of whether you needed the injection or the operation in the first place. I believe that a tremendous amount of the waste in medicaid results from a failure to take into account that aspect of the problem.
So I must direct attention to the question of the quality of care. To provide the care that is needed when it is needed, rather than the issue of fees.
I think, really, that fees are a secondary issue although they have attracted the greatest attention.
Senator RANDOLPH. Thank you, doctor.
NEED FOR DATA ON QUALITY OF SERVICE Dr. BRESLOW. Further, I believe the Federal Government should insist that its programs include a health data system that routinely turns out information on the quality of the service being provided. This is now possible through computer technology.
Senator WILLIAMS. I as sure you are right on your conclusion, but I am sure a fellow whose discipline is not medicine-not technology, who practices the inexpert profession of law and politics, I wonder just how would this help a doctor in his office?
Dr. BRESLOW. The State department of public health, in the early days of Medi-Cal, developed just such a system which disclosed particular physicians and other providers of care who were “way out” in their practices.
For example—and these are only crude examples—some physicians gave far more injections or did far more operations of certain types than usual in a community.
Now, to answer your question a little more fully—this system identifies and puts onto computer tape every service provided to every patient in medicaid, giving the place of the service, the name of the provider, the patient, the charge for the service.
Running out tables from such data, one can therefore identify individual physicians who, for example, give on the average more than one injection per patient visit.
Senator WILLIAMS. They have to feed that data in it?
Dr. BRESLOW. They have to feed that data in, because they must submit bills in order to collect payment for their services.
What this system does is to take advantage of bill submission in order to examine, not only the issue of the fees, which can also be done of course, but also to examine the issue of quality.
The system permits identification of physicians and other providers—not a few, there are several score of them—who have far exceeded the norms of practice.
One can identify physicians, for example, who do a great many operations for umbilical hernia on infants, which in most physicians' judgment can usually be treated effectively without the operations.
Senator WILLIAMS. By the way, this idea—who would be the recipient of this bank of information
Dr. BRESLOW. In the early days of Medi-Cal, the information came to the State agencies, in those days to the State department of public health, which developed and maintained the State observation over the system.
It also, of course, was in the hands of the bill-paying agency—the fiscal intermediary, Blue Shield. Now, the State, I understand, has abandoned its direct surveillance of this operation, and has left it entirely up to California Blue Shield.
Senator WILLIAMS. Well, you used to be in State government?
Dr. BRESLOW. Well, sir, in California the director of the State department of public health, which was the position I occupied just before leaving, is an office for a term which expires 1 year after the coming in of any new administration.
That's when my time expired.
Dr. BRESLOW. California Blue Shield has taken over this system. I believe, senator, it would be useful for your committee to explore this system in some detail with a view to incorporating some such system into all medical care programs that are supported by Federal funds.
It certainly would be a vast improvement over the situation in many States where there is no statewide medicaid data, even on the eligible population or on the services provided.
Information on each of the individuals served and each of the services provided them, as in the California plan, could become the basis for quality control.
Senator WILLIAMS. Would the doctors welcome this opportunity to contribute their information?
Dr. BRESLOW. There are probably some physicians who resent the fact that they are, so to speak, locked into such a system, but I think it is to the credit of the California Medical Association, and California Blue Shield, that they have supported this system.
I think there might be some debate about the vigor with which there is pursuit of the so-called deviant practitioners. But there is no doubt about the overwhelming support of the medical profession, in California, for a system like this.
PREVENTIVE MEDICINE; MULTIPHASIC SCREENING On the last item, in which I know I share a considerable interest with you, Senator Williams, namely the incorporation of preventive medicine in the form of multiphasic screening into Federal health programs, I would say that this is desirable and feasible.
It is technically and economically possible, as well as medically useful to detect evidence of many significant diseases by a series of simple tests, now largely automated or performed by technicians under medical direction. When these diseases such as diabetes, certain forms of heart disease and cancer, anemia, and many others are detected in their early stages, the outlook for success in treatment is much more favorable than if they are allowed to progress into advanced stages. In fact, the difference not infrequently is life or death.
Such tests are now often incorporated into comprehensive health examinations for industry executives. The American Medical Association for several years has offered them to physicians attending their annual convention. The Kaiser health plan in northern California provides them. A joint labor-management trust fund in the California cannery industry has made them available through a mobile unit to thousands of cannery employees scattered throughout the State.
Several hospitals are now planning to install multiphasic screening.
I think that if it is good for all of these segments of society for physicians, for industry, for executives, for cannery workers and others then it has been tested well enough now to be able to say that it would be good for all the people.
Providing this service as part of Federal health programs would be a major contribution to improving health, especially for older persons who are more likely than younger persons to be affected by the chronic diseases that may be detected through multiphasic screening. It would be a positive contribution to health.
The success and growing acceptance of multiphasic screening make it timely for consideration of incorporation into Federal health programs.
Senator WILLIAMS. Are you familiar with the Kaiser program? Dr. BRESLOW. Kaiser health plan is the name for the plan, I think.
Senator WILLIAMS. Are you familiar with how the I talked about multiphasic screening. Someone, I don't know who it was, maybe it was Bill Oriol, my trusted leader of the staff--who had tabbed it "preventicare." I have talked about the Kaiser—they were pioneers, I believe Dr. BRESLOW. Right.
Senator WILLIAMS. I have talked about them a great deal and said that this is proof that it can work. An early incipient disease can be detected. And the earlier it is detected, the more likely we are to avoid costly treatment or surgery.
Now, how do they work? Who are the people who come in there to get tested?
KAISER HEALTH PLAN Dr. BRESLOW. In the Kaiser health plan--and I think it would be well if you had an opportunity, Senator, to actually visit the installation and see for yourself what is being done there—the subscribers to the Kaiser health plan—that is, the individuals who are prepaid through their unions or employers or themselves—for health care
Senator WILLIAMS. It is an in-house operation, is it?
Dr. BRESLOW. That is correct. These subscribers are eligible for examinations by physicians once a year, or oftener if necessary. A week or two before they see their own physician, they are scheduled to come in and have a series of tests called multiphasic screening.
When the physician sees the patient for the examination, he receives a brief history of the patient with the symptoms that the patient has written down ahead of time, and also the results from a quite wide array of laboratory, X-ray, and other tests. The physician can see these results when he first visits with the patient.
That means that he has a tremendous leap ahead in his examination. He doesn't have to order the tests of a routine sort that are included in multiphasic screening. He has the results when he first sees the patient.
He, of course, can and does follow up these screening tests with more elaborate examinations, X-ray, laboratory and others. This is the way it works in the Kaiser health plan.
They found a great economy as well as medical use for it.
Senator WILLIAMS. So it is a two-phase operation. The employee goes to the doctor, and then the doctor makes findings, and the next step would be the whole Kaiser program; is that it?
Dr. BRESLOW. The basis for the diagnosis and treatment plan is this survey which can be carried out now quite effectively through these series of tests organized, as has been done in the Kaiser health plan and in many other situations as well.
Senator WILLIAMS. I didn't know that there were two phases, to tell you the truth.
Dr. BRESLOW. Many of us feel that this is the best way to provide this service. You go first for the screening tests, provided incidentally at offhours, evenings, and so on, so as to make it more convenient for patients. This also uses their equipment most effectively:
Then the results are assembled by computer and given back to the physician at what you call the second phase, when he has an appointment to see the physician.
Now, multiphasic screening itself is of course just a series of tests, with results and the referral.
All of this is of no value unless it is followed up by the patient's physician.
Senator WILLIAMS. Why does he have to go through the screening process with the physician? Why not just go right into the multiphase operation? Isn't that supposed to determine
Dr. BRESLOW. Well, he does go directly into the multiphasic screening.
Senator WILLIAMS. I understand he went to a doctor first.
Dr. BRESLOW. I am sorry if I gave that impression. He has the appointment with the physician scheduled, but before he sees the physician a week or two before-he has the multiphasic screening.
Senator WILLIAMS. So the first phase is the
Dr. BRESLOW. The point is the findings from the multiphasic screening are referred to the physician.
Senator WILLIAMS. That I understand.
EXPERIENCE JUSTIFTES NATIONAL PROGRAM Senator WILLIAMS. By the Federal Government ?
Dr. BRESLOW. I would; I would recommend that as a national program.
I think we have had sufficient experience with it in different forms, different places, different circumstances, that it is certainly justifiable as a national program.
It is something like the situation with respect to home care, a few years ago. There were some demonstrations of home care. There were some questions as to how useful it might be, whether it should be incorporated into a national program. When the issue arose about incorporating home care into medicare, some asked whether we had sufficient experience with it, whether there were sufficient resources for home care available to justify putting it into medicare.
Many of us, at that time, took the same position that I would take now with respect to that multiphasic screening. We have had sufficient experience with it. It is sufficiently well known in the medical community that, if the Federal government were to incorporate it into a national program, then it would expand with the impetus of the funds available to pay for it.
Senator WILLIAMS. Are there any dissenters on that point ?
Mr. CUBBLER. As a matter of fact, it would be required for children after July 1, 1969, as a result of the 1967 amendments.
As long as it is used only for the purpose of identifying diseases in order to treat them, rather than excluding them from the program, it is a very, very good idea, sir.
Senator WILLIAMS. Will you identify yourself for our record?
Senator WILLIAMS. Dr. Breslow, you don't look as healthy as the last time we worked together on arbitrary labor. I don't think you have been taking enough grapes. [Laughter.]