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and psychological distress for the newborn's mother. Inappropriate use of antibiotics may expose patients to unjustified side effects and result in the proliferation of antibiotic-resistant organisms.95 The Food and Drug Administration (FDA) reported that in 1986, adverse drug reactions caused more than 1,300 deaths and over 4,400 hospitalizations. 96
Organizations, utilization management entities that oversee the quality of care for the nation's larger employers, and inspections by state survey and certification teams. 103 Bad medicine can take many forms, including patients being discharged prematurely from hospitals; errors in diagnosis, medication, and treatment; faulty laboratory tests; hospital-induced infections and other complications resulting from medical treatment; and similar misadventures.
Analysts also differ about how much of medicine is of unambiguous value to patients. Some have estimated that as little as 15 percent to 20 percent of all contemporary clinical interventions are supported by objective scientific evidence that they do more good than harm.97
Malpractice Litigation: Protection or Problem?
The validity of the evidence supporting various procedures has also come under question. The Office of Technology Assessment (OTA) has estimated that only 10 percent to 20 percent of medical practices are supported by randomized controlled trials.98 A review of statistical methods in the published medical literature concluded that as many as half the articles that used statistical methods did so incorrectly. Another study found that the methodologies reported in 39 scientific papers on the use of percutaneous transluminal angioplasty were deficient for evaluating the procedure. None of the papers considered outcomes that patients might think important, such as relief from pain and continued ability to walk. 9
Malpractice litigation provides consumers with a private course of action when they believe that the quality of the care required falls below acceptable standards. 104 At the level of the individual patient, poor quality medicine is often the catalyst leading to such a suit. But the evidence is strong that malpractice litigation does not adequately protect against or compensate for poor quality care.
A recent study of malpractice claims in New York showed that adverse events due to negligence occurred in 1.0 percent of all hospital discharges. Eight times as many patients suffered an injury from negligence as filed a malpractice claim, and 16 times as many patients suffered an injury from negligence as received compensation from the tort liability system. 105 This is consistent with evidence from the mid-1970s suggesting that at most one in 10 persons injured as a result of negligence actually filed a claim, and evidence from claims data of the early 1980s that one in five persons claiming negligence brought suit. 106, 107
Not all quality problems reflect overuse of service. Underuse is a quality problem as well. Some underuse reflects barriers to access. Underuse of services that is not due to direct access barriers may be classified as underdiagnosis or undertreatment.100 Malpractice suits frequently allege that the physician or provider underdiagnosed or undertreated by missing a diagnosis or failing to follow-up on an abnormal test result. 101 Medicare Peer Review Organizations (PROs) include various screens for undertreatment in their quality reviews. For example, each PRO has to screen a sample of medical records to determine whether a patient was discharged prematurely or received an adequate discharge plan. These screens have detected few cases of underservice of Medicare patients, however. More prevalent, it would appear, are other types of underservice, such as less complete diagnostic services and fewer rehabilitation services than experts judge the elderly need. 102
The same study also found that fewer than half the claims made by patients lead to payments by physicians or their insurers—suggesting that negligence did not occur.
Not only does malpractice litigation provide limited protection; it creates cost, quality, and access problems of its own. The costs of malpractice premiums raise the costs of medical care. And the risk of litigation may distort physicians' practice patterns.
Bad medicine resulting from errors, negligence, incompetence or unprofessional behavior also jeopardizes the quality of care. Knowledge of such problems results from existing quality assurance mechanismssuch as Medicare Peer Review Organizations, the Joint Commission on Accreditation of Healthcare
Total malpractice premium costs of doctors and hospitals were over $6 billion in 1987, about 2 percent of dollars spent on these services. 108 Professional liability premiums paid by self-employed physicians nationwide averaged $15,900. There is a great deal of variation in premium by specialty and by geographic location. Of the surveyed specialties, obstetricians/ gynecologists averaged the highest premiums ($35,300), while psychiatrists averaged the lowest
It is difficult to measure how much defensive medicine exists or how much it costs. By one estimate, about $11.7 billion out of the $82.8 billion paid to physicians in 1985 was attributable to service-increasing defensive medicine. 112 These numbers may overestimate the amount of potential harm, of course, because much of what might be labeled defensive medicine is good medical practice. But it is significant that a large portion of the medical profession believes that physicians have modified their practice patterns, and in some cases left the profession, in response to both malpractice premiums and their perception of the legal consequences of their medical decisions.
UNDERSERVED AREAS AND SPECIAL POPULATION GROUPS
The Commission's deliberations on health care focused chiefly on the financial barriers to access. But there is more to access than simply paying the bills. Even if health care were financed in full for everyone, some people would still have trouble obtaining adequate care for a variety of reasons-geographic, systemic, cultural, and personal. Like financial barriers to access, these nonfinancial barriers often result in people getting care later or less often than needed. As a result, their medical conditions become more severe and require more acute, and therefore more costly, treatment.
In rural and urban communities without enough doctors, millions of Americans cannot get needed care.
Medically Underserved Areas
Both rural and inner city areas have trouble recruiting or maintaining physicians and other health care professionals—in part because of the perceived undesirability of living or working in these areas, and in part because of the economics of maintaining a practice in places with large numbers of uninsured. 113 In 1988 there were 33 million people living in federally designated health manpower shortage areas (HMSAS). This population was about equally divided between urban and rural areas. 114
availability of such physicians declined in poverty areas, despite growth in the overall number of practicing patient care physicians. 122 This puts even greater burdens on the hospitals, which are beginning to close emergency rooms and trauma centers to avoid the increasing demand for uncompensated care. Finally, community health centers in urban underserved areas face the same financial and personnel strains as their rural counterparts.
Rural Areas-In 1985, there were 97.9 patient-care physicians per 100,000 population in rural counties, compared with 174.7 patient-care physicians per 100,000 population in urban counties. In rural counties with fewer than 10,000 population there were only 53 physicians per 100,000; and in counties with fewer than 2,500 residents there were only 29.9 per 100,000.115 Although physician supply has increased recently in the more populated rural areas, it is expected to decline in the less populated areas due to a projected 25 percent rate of physician retirement in rural areas and severe cutbacks in the National Health Service Corps (NHSC) program, which supplies physicians to HMSAs. Even areas that can hold on to their physicians may be deprived of some essential services. 116 The problem of too few providers in rural areas is compounded by a general decline in the growth of primary care doctors, who are uniquely suited for rural practice and the shortage of nurses and other midlevel practitioners in rural areas. 117, 118
The Poor-Even if their health care is paid for, persons in poverty may face significant logistical barriers to care. For those who cannot afford to maintain a car, take public transportation, or pay taxicab fare, travel to medical care is a serious problem. When public transportation is available and affordable, the effort required to get from home to the source of care may be extraordinary. 124 Providers' limited office hours can pose another obstacle for the working poor who cannot take time away from their jobs.
Minorities–Minorities are more likely than average to be poor and thus to face the access barriers associated with poverty. They also face additional barriers arising from residence in the inner city, discrimination, and a variety of socioeconomic and cultural factors that make some individuals less disposed to seek necessary services even when those services are available. 125
Problems facing rural hospitals and health centers aggravate the situation. Low patient volume (because patients are so widely scattered in rural areas), Medicaid and Medicare reimbursement policies, rising numbers of patients unable to pay, and personnel shortages have forced an increasing number of rural hospitals to close their doors—all trends expected to continue. 119 Community and migrant health centers—important sources of primary care in some rural communities—have been facing increasing financial strains due to the failure of federal funding to keep pace with inflation, the increase in patients without insurance, rising malpractice premiums, and NHSC's cutbacks. 120
High-Risk Pregnant Women and Their Infants-An estimated one-third of all mothers receive insufficient prenatal care. Of these, the highest proportions are black, low-income, unmarried, or still children themselves. 126 Even those with insurance coverage may not obtain services because of child care or transportation problems, ignorance of the importance of prenatal care, or inability to find an acceptable provider.
Inner Cities-In 1988, 17 million residents lived in medically underserved urban areas-primarily inner cities. These areas are unattractive to many physicians and may not be able to support an economically viable medical practice. 121 The shortages are particularly acute for office-based primary care physicians. One study found that, between 1963 and 1980, the
The Geographically Isolated-Despite their access to transportation, people may have trouble getting to the source of health care in a timely manner if they are geographically isolated. Living in isolated areas also makes it more difficult to obtain home care and social support services, such as counseling. 127
The Physically and Mentally Handicapped–The logistics of seeking health care can be particularly difficult for some groups. An escort or interpreter, or transportation accessible to the handicapped, may be unaffordable for low-income persons who are blind, deaf, or physically disabled, or may simply be unavailable in the community.
others are at risk of losing the resources they now have. Moreover, recognition is growing that many groups in the population need comprehensive care systems. Isolated doctors and hospitals do not suffice.
Mentally ill or retarded individuals may not have the skills necessary to negotiate the health system, such as making an appointment, arranging transportation, or getting a prescription filled. Some may not recognize their need for treatment. Those who do not have a friend or relative to assist them or urge them to seek care may go untreated, or may fail to comply with prescribed treatments.
Some federal programs remain targeted at these needs. The various Public Health Service grant programs described earlier not only help finance care for the uninsured but also work to overcome provider shortages in underserved areas or to help fund outreach, social services, counseling, and service coordination. Programs to improve provider supply include the National Health Service Corps; the community and migrant health center programs; and funding for Area Health Education Centers, which decentralize medical training in the hopes of encouraging new providers to locate in rural areas. Programs that fund outreach and social services include the maternal and child health services block grant and various programs targeted at special groups, such as federally funded demonstrations of coordinated AIDS services networks. 129
Others-Other populations, and often their families, have special needs requiring multidisciplinary health care or social services to complement or augment their health care. These groups include the elderly, the homeless, HIV-positive individuals and persons with AIDS, other chronically ill persons, and substance abusers. For all these groups, social problems compound medical problems. Experience shows that medical care cannot be fully accessible and effective for such segments of the population unless it is accompanied by education and outreach, and by systems to coordinate a broad range of services. 128
But the funding of most of these programs has failed to grow with the need and, for some, has shrunk during the last decade. The National Health Service Corps is a particularly dramatic example. The NHSC, which provides scholarships or loan repayments to medical students in return for service in underserved areas, has been cut back so dramatically that there were only 49 scholarship recipients in 1988, down from 6,409 in 1980.130
Current Programs to Address Delivery Barriers
From World War II through the 1970s, a major focus of federal health policy was to improve the availability of health services. The Hill-Burton program of hospital construction, support for medical education, and such programs as grants to community and migrant health centers all aimed to ensure that the best in American medicine would be available in every community. In recent years, federal support for these programs has diminished, partly because of budgetary constraints and partly because of a perception that—at least at the national level-we already have too many hospitals and too many doctors. Nevertheless, parts of the country still lag behind, and
Federal cutbacks are being partially made up with state or local funds. States have been particularly active in developing special programs to reach pregnant women and coordinated care systems for other special populations, such as the mentally retarded and the mentally ill. Valuable as these activities are, however, they involve coordination of health resources already present in the community rather than new funds. Bringing new providers to communities that lack them, and providing the assistance needed to keep essential facilities in areas that can no longer support them, require greater financial resources than many states and localities possess.