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We also add to medical costs when we don't give our patients credit for ordinary common sense. Most of them have it, and we can save them money by letting them take some responsibility for their own care. After I've dressed an un. complicated wound a time or two, for example, I let the patient dress it himself with only an occasional check by me. I simply tell him that if it should get red or drain, or in any other way look or feel as if it's not progressing well, I'll be glad to see him.

If your patient needs some physiotherapy, he may be able to do at least a part of it at home if you or a therapist will show him how. Most doctors have diabetic patients check their own urine, thus saving a lot of visits. Instead of waiting for such vague signs as fever blisters or a dry mouth, most patients can learn to take their temperatures so they'll know if they need to see you for a respiratory infection or other condition. Many doctors help chronic patients take some responsibility for their care by giving them appropriate pamphlets or by recommending books. One overburdened G.P. has found he can save much of his own time and his patients' money by preparing and distributing brochures containing his standard instructions on a topic like “Your Child and You."

We can save more money for our patients by avoiding "nuisance" consultations. I know some specialists who, when treating a fracture, for instance, won't treat the same patient simultaneously for a common cold. Some surgeons won't treat a catheter cystitis but will call in a urologist who has better things to do. A little myalgia doesn't require an orthopedist, nor a little anxiety a psychiatrist. When you call in another specialist you put him on the spot. You've made an issue of the problem, and he feels he has to be thorough. So the patient's little sniffle will cost him at least $10, and sometimes a lot more. It shouldn't be beneath our dignity to treat the simplest things, even if we don't treat them ordinarily. It's a way to show concern for the patient and his pocketbook, and I've found it's appreciated.

When you do refer to a consultant, be sure to tell him whether the patient has limited means. Since the consultant presumably hopes for more referrals from you, he may be spurred to effect some of the economies I've mentioned and will try to keep his own fees modest.

Remember that time is money, for both you and your patient. If he needs hospitalization, make it as brief as possible. Do what work-up you can while he's an outpatient, and get him out of bed and out of the hospital as soon as it's safe. Then get him back to work. Loss of income from not working may be a bigger financial blow to him than the medical costs. Furthermore, mental as well as physical rehabilitation is usually faster when the patient is back trying to lead a normal life. Oversolicitous delay can make a patient a semi-invalid for months.

Those are just some of the ways I've found to cut medical costs. No doubt you can think of many more. They're not likely to hurt your income because, as I've shown in some examples, your productivity will increase. And who knows, such savings may enable or even inspire-some otherwise nonpaying patients to pay your fees.

EXHIBIT C: MORE WAYS TO SAVE YOUR PATIENTS' MONEY

[From Medical Economics, Aug. 5, 1968) Among the physicians who read and commented on the preceding article before publication were three MEDICAL ECONOMICS contributing editors. They volunteered some cost-cutting tricks of their own.

Richard C. Bates, internist in Lansing, Mich., is down on medical tubes. He writes: “Avoidance of tubes of all sorts—I.V., nasal oxygen, and cathetersnot only permits the patient more freedom and comfort, but it cuts costs. I'd guess that over half the cases with such tubes that I see are being treated unnecessarily. When a patient is dehydrated and able to take oral fluids but won't. I give him a teaspoon of salt out of the shaker. For each teaspoon of salt he takes, he'll crave two glasses of water, which will give him the equivalent of 500 cc. of normal saline I.V. Taken intravenously, that would cost him $5."

Forrest P. White, pediatrician in Norfolk, Va., writes: "When I prescribe clubfoot shoes and Denis Browne splint for an infant, I have the mother bring the whole apparatus to me when the baby has outgrown it. She's usually glad to sell it for about 60 per cent of what she paid. So when the next baby with the same condition and shoe size comes in, I offer the used shoes and brace to that mother. If she accepts, she writes out a check to the first mother, and we mail it. The transaction never goes through our books; I'm just an unpaid middleman. Both mothers are happy—the first because she got some of her money back, the second because she got something she needed at a substantial discount. And when her time comes, she'll probably be able to sell the apparatus for 60 per cent of what she paid for it."

Curtis D. Benton Jr., ophthalmologist and pediatric otolaryngologist in Fort Lauderdale, also passes along certain temporary appliances from patient to patient, such as plastic shields to wear after eye surgery. But Dr. Benton's chief cost-cutting enthusiasm is for reducing the time that his younger patients spend in the hospital for T. & As. “Last year.” he writes, “my surgical patients were spared the expense and inconvenience of 300 unnecessary days—or more precisely, nights—in hospital beds. Most hospitals have regulations requiring patients scheduled for elective surgery to be admitted the night before their operation. But the period of hosptialization for T. & A.'s on children under 14 in this community has been cut to just 24 hours.

"We've been able to accomplish this by pre-admission preparation. When surgery is scheduled, the history and physical are done in the office. All necessary lab work is done in the hospital O.P.D. the day before the operation. Pre-op and post-up orders, plus the typed examination results, are in the hands of the admitting clerk when the child arrives at 6 A.M., with empty stomach and eyes wider than his mother's. Johnny goes straight to the children's ward, gets his sedative shot, and is on the operating table by 7:30 A.M., before he has the time to start thinking and sprout nervous second thoughts.

"I haven't yet convinced the hospital authorities that the same procedure would work just as well with adults. But my 300 younger patients last year were saved about $10,000 in hospital costs by not spending an unnecessary and probably sleepless night in the hospital awaiting surgery the following

ITEM 9: MATERIAL SUBMITTED BY DR. RUSSELL B. ROTH, VICESPEAKER, HOUSE OF DELEGATES, AMERICAN MEDICAL ASSOCIATION

EXHIBIT A.: THE PHYSICIAN AS A GUARDIAN OF HEALTH CARE COSTS

(By Russell B. Roth, M.D.) The concept of the physician as a guardian of anything other than the health and immediate best interests of his patient is, I believe, a relatively modern development. Certainly in those less turbulent Oslerian days at the turn of the century there were at best only minimal and incidental ways in which the physician was called upon to dilute his concern for his patients with consideration for the community, for hospitals, for third party payors, for government, or for the tax-paying public.

Times have clearly changed. Janus, the God of gates and doorways, needed only two faces—for looking in and looking out. The physician today, in his role of guardian, needs to be more Hydra-headed in order to keep primary focus on his patient, while casting a wary eye on the hospital to be sure it is not over-utilized, on the insurance company to be sure it is not over-charged, on the community to be sure it is well serviced, and on Medicare and the rest of the tax-financed programs to be sure they are not abused.

Nonetheless, it is the thesis of my presentation that the competent, ethical physician is indeed the only able guardian of the public interest in the area of consumer expenditure for medical care. As an aside, I should note that, despite my published title, I do not intend to deal with Health Care Costs, since, in the language of the economist "cost" is overwhelmingly a matter of the price-tag on labor, materials, supplies, utilities—elements generally apart from the influence or control of physicians. The area of physician concern, quite obviously, is that in which he influences expenditures by or on behalf of his patient for the goods and services of the Medical Care Industry.

It is important to recognize that the guardianship to be exercised by physicians is one dealing chiefly with specific services involved in individual cases. It is concerned with professional medical decision making. Is it necessary to hospitalize this patient? Do we need extensive laboratory and X-ray studies? How about private-duty special nursing care? What medications will do the job? Is surgery indicated? These are the decisions that translate into dollars—into many dollars per case, and these are decisions which can be made only by physicians.

Beyond this, of course, the physician has full responsibility for his own clients, and we will come back to this in due course, since it is a highly publicized issue at this point in history. The preponderant share of the medical care dollar, however, is not paid to the physician—it is paid for the goods and services which he recommends. It follows that this is the area of greater economic significance. In the $4.6 billion spent for Medicare in 1967, only 25% went for Part B payments to physicians.

It is worth contemplating for a few moments the track record of government as a guardian of the public pocket book. The chief and overwhelming distinction of government at the Federal level has been its unbridled enthusiasm for spending. For example, since 1961 the Gross National Product has increased 49%. During this time consumer spending increased 46% and Business spending 47%, but government spending went up 63%, and if one considers only non-military spending it went up 77%. The appropriations of Congress and of most State legislatures scarcely bear testimony to a philosophy of frugality. It is government which in effect has written the blank check for Medical Care and must look to someone else to fill in the amount. It is in large part this abundance of governmental dollars chasing after scarce services that has created the problem.

In the field of direct patient care government has long operated the world's largest hospital-medical-surgical program, in the Veterans Administration. Many kind things have been said about V.A. Hospitals, the quality of care, and the role they have come to play in teaching and research, but these compliments have not included any citations for economy and efficiency. Quite to the contrary there have been many allegations that when the government has been in complete control average patient stays for comparable illnesses are distinctly longer than in community general hospitals, that physician productivity is substantially less in terms of patients per doctor and in physician working hours per week. The V.A. Hospital System can be compared to a vast closed panel group practice plan, with prepayment of a sort. I have not heard that anyone has seriously championed the fiscal feasibility of extending this type of care to the entire population.

One could cite other evidence of the fact that government has not pioneered in economy in medical care, but in addition government, through its democratic processes too often stands as a threat to quality of care as well. Perhaps you have seen the news stories about the Commissioner of Health in Cattaraugus County, New York, who resigned his position rather than to certify payments for Chiropractic services under Medicaid. I am delighted to report that he is now heading a Health Department in Pennsylvania, and I believe he is doing a great deal more to promote quality of health care than has the New York State Legislature, in foisting payment for chiropractic on the public.

Government could, of course, impose controls of various sorts. The popular one at the moment, called for by the AFL-C10, and assorted legislators and columnists, is for the establishment of fixed fee schedules. This of course addresses itself to the lesser part of the problem, since it does not touch utilization-only physicians fees. Presumably several investigations of the matter of physicians fees are to be conducted by Congress, or under its auspices, and it is my personal opinion that this should not be upsetting to any physicians who are charging reasonably and fairly by existing professional standards. It is surely not the policy of the profession or its organized societies to uphold the right of the individual physician to charge unconscionably or immoderately. One would hope that any “investigation" on this score would, in addition to documenting abuses, study carefully the opportunities for their elimination. If it is appropriate to investigate the financial dealings of Senators and Congressmen I would concede that it is all right to check up on physicians. It should be remembered that the medical profession itself has made considerable progress in the development of review committees, grievance committees, and the like. There must also be a preservation of perspective, since in respect to Medicare at least—the elimination of a full 7% increase in physicians fees, which constitute less than 25% of the program expenditures, would amount to a 1&34 percent saving, overall. Ill considered, punitive efforts to fix prices—a position generally abhorred by government in respect to most business—could be productive of unintended and unhappy results. I would submit that, compared to the capacities of the medical profession itself, government is ill equipped to remedy the difficulties.

The situation in respect to third party payors, or consumer groups, as guardians of public expenditures for health care, is quite different from that of government. Underwriters have obviously had a sincere interest in safeguarding their own funds. None of them could survive the sort of deficit operation which is a way of life in government. But among all of the voluntary prepayment plans, the prepaid closed panel group practices and the private insurance companies no alternative to physician review has ever been found. It is quite true that claims review is becoming automated and sophisticated to the extent that machines pick out cases which depart from a programmed range of acceptability, but the actual evaluation of the case and the charges depends upon physician judgment.

24–798-69—pt. 3— 12

This brings us back to my initial allegation that physicians are the only qualified guardians of the public interest in the realm of expenditures for direct patient care. It remains to consider the extent to which they are being helped or hindered in so functioning, and to discuss ways in which they may function more effectively.

UTILIZATION RELATED TO EXPENDITURES Utilization of hospital facilities and services, for example, is directly related to expenditures. But this is not a simple straight line relationship. That is to say, a reduction in use does not bring about a corresponding reduction in cost. The simple illustration is the hospital room. The most expensive item in the hospital is the unoccupied room. The cost of maintaining it in large part continues, without off-setting revenue. If a zealous utilization review committee should somehow decrease hospital occupancy to the 50% level for any significant period of time what would happen to the per diem cost? It would go up-not down. The most efficient, most economical form of hospital operation is that which uses its facilities and its personnel at close to tolerance levels. Without the application of a great deal of wisdom, the coalescent wisdom of the medical staff and the hospital administration, there may be great imbalances, to the disadvantage of the patient. Hospitals, per se, function poorly as conservators of the public dollar.

In order to judge the propriety of charges for goods or services it is necessary to know what the charge is, as well as the cost on which it is based. For this reason I feel that the flight from fee-for-service is progress in the wrong direction. How is it possible to judge the equity of a hospital charge which becomes unidentifiable with an overall per diem rate. How can one pass on the reasonableness of a fee which is never established as a charge against a pre-paid premium or as a credit toward the physician's salary? To abandon fee-for-service, as is currently championed by so many critics of medicine, seems to me to be forsaking the only real opportunity to identify and isolate the opportunities for economy, and to equate the price tag to the value of the item purchased. By this I imply that it is being made increasingly difficult for anyone physicians included—to appraise the value of goods and services when the charges are submerged and lose their individual identities.

In this connection it may be of interest to report to you a small study which I have just made in my own 500 bed community general hospital. If, as I have postulated, the physician has this important role of guardian in respect to patient expenditures, how familiar is he with the prices charged to his patients in the hospital? I listed 20 of the more common things ordered by physicians in our hospital-items such as a blood sugar, a chest X-ray, a special duty private nurse, and the like. I asked 17 physicians to fill in what they thought each item cost the patient. 12 were practicing physicians with many hospital patients. 5 were residents in training, responsible for much of the ordering. The pattern became clear, and I didn't feel that I needed to add a lot more people in order to establish statistical validity. Doctors don't know very accurately what charges are made. The spread per item varied from 150% to 600%. 29% of the answers were correct, or close enough to count as correct. 31% of the guesses were high. 40% were low. Residents were a bit wilder than the attending men. All this, I believe, simply points up an important opportunity for improvement. I believe any business man would seek deliverance from a buyer who didn't know the price of what he bought.

You have been hearing much about group practice and especially about the notion that pre-paid closed panel group practice may conserve dollars. I regard this as undocumented, especially where quality as well as quantity requires consideration. No one, I believe, has suggested that any type of practice arrangement converts an inadequate physician into an adequate one. I don't recall who first said it, but I would agree that one thing worse than an incompetent physician would be a group of incompetent physicians. Our quest is not for bargain-base

ment medicine, but for competent medical care, fairly given and fairly compensated. In this quest there is still great room for innovation, experimentation and improvement. There is still much virtue in our non-system of care as against the rigidity of systems as devised by the British, the Germans, the Swedes and the others. It is naive of our government to think that the heart of the matter is how the doctor is paid, or how the patient pays.

If the common denominator is the ethical competent well-motivated physicianalmost any system will work well. If not, it seems impossible to devise a system which can't be beat. This is the quandry enveloping those who discredit the medical profession. They have no happy alternative to turn to.

Frankly, I believe that those who downgrade the medical profession, who diminish its status and who undermine its authority are self-defeatists. To the degree that estrangements have developed between government and medicine, between labor and medicine, between hospitals and doctors, there are tragedies of our time. It has indeed progressed to the point where a substantial number of physicians sincerely wish to have nothing to do with government subsidized programs of care. How much better off would we be if there were constructive cooperative attacks upon our problems of financing and the delivery of services by all parties involved. I believe the medical profession needs the understanding, the support, and the effective assistance of all interested parties to do the job that only it can do. And when that support and assistance is proferred I believe the medical profession should accept it.

Two Canadian physicians, in writing a book called "Medicine and the State” which analyzes in depth the principal government-operated care plans-England, Germany, Russia and the like, reach what I regard as a significant, a highly important conclusion. They state it this way “In the field of health care it does appear that once personal responsibility is removed, collective selfishness replaces the restraints of the individual experience. Experience suggests that individual morality declines as public responsibility increases". For patients and physicians alike we should consider the need to strengthen the sense of personal responsibility and to fortify the restraints of the individual conscience.

The professional association, in this country, has done much to potentiate the efforts of individual physicians, not only in pursuit of scientific excellence, but in the exercise of civic responsibility. Therefore all professional associations of physicians should dedicate a share of their efforts in this direction, but the one instrument best suited for the purpose is the County Medical Societyaccessible to the full complement of ethical competent physicians, each belonging to a vigorous progressive State Association, and all integrated in to the American Medical Association. Despite the abundance of brickbats aimed at the AMA, largely because of its conservatism and its resistance to government interventions and controls, it has generally been recognized as a major force for good in the advancement of scientific medicine, physician education, and the development of quality controls. The track record of the medical profession in respect to self discipline and the imposition of high standards is most encouraging. The admission requirements for medical school are self-imposed and they have been so high as to occasion howls of anguish. It was the profession itself, through the AMA that acted importantly in the elimination of medical diploma mills. All of the specialty societies and certifying Boards have been voluntary developments. The evolution of tissue committees, medical audits, and restrictions of privileges in hospitals have been developed by the profession itself, as have the mechanisms and organizations for accreditation of hospitals and other medical facilities. Insurance claims review committees and grievance or mediation committees are inventions and developments by physicians and their medical associations. That these self-imposed controls are less than perfect is not surprising. That there is room for improvement is obvious. But this is working machinery and these are functioning programs. The bright hope lies in perfecting what we have.

CONCLUSIONS Now I should like to try to pull these observations together in order to draw some useful conclusions.

1. Much of the expenditure of public and private funds under the general heading of medical service is outside the range of direct patient care and is beyond the immediate influence of the practicing physician. These elements relate to expenditures for research, education, capital construction, operation of institutional facilities, and the like. They need to be identified and financed as such.

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