Answers to these questions will not be found through comparison of disconnected studies with varying study designs. Although a few comparisons may be possible fortuitously, they lack the assurance which is to be derived from a well-designed study planned to give answers to specific questions.

FIGURE 14

Despite the action of the World Health Assembly, changes in the laws of the various countries were not achieved immediately or uniformly. For example, the change in definition of live birth to include "beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles" in addition to "breathing" as evidence of life was not adopted in Sweden until 1959. Even at present, Denmark has no legal definition of "signs of life." Furthermore, changes in law or regulation are not immediately transposed into action. Practices followed by physicians or midwives regarding their understanding, interpretation, and implementation of the law are difficult to assess. European practice continues to prefer "stillbirth" to "fetal death."

FIGURE 15

With the initiation of the National Health Service in Great Britain, a common base of antepartum, partum, and postpartum care became available to the entire childbearing population. Although there were significant declines in infant mortality in each of the social classes in the first half of this century, the relative differences between the classes have not decreased. In fact, the British Perinatal Study suggests that the gap between the classes may have widened even at a time when medical care was readily available to the entire population. 5

FIGURE 16

JANUARY 14, 1970.

Re Savings from Reducing Time Interval of Physician-Certification Periods Under Hospital Insurance Program (Continued No. 3).

Mr. ROBERT M. BALL,

Commissioner of Social Security.

With further reference to my memorandums of October 14, 29, and 30 on the above subject, I am further dismayed that the misinterpretation that I feared would happen did happen again in an official HEW document.

In What's New in HEW for November 1969, the following item appeared: "An amendment to social security regulations, effective Jan. 1, 1970, is expected to shorten hospital stays and reduce Medicare costs. The regulation, which changes the times a physician must certify the medical necessity of services given to hospitalized Medicare beneficiaries, could cut program costs as much as $400 million a year."

As I brought out previously, the savings for this change which is most cer tainly desirable-will probably be only about $5 million per year, not $400 million. Once again, I must state that I think that it is very dismaying that a credibility gap is being created for the present Administration, which could have been readily avoided.

ROBERT J. MYERS,

Chief Actuary.

OCTOBER 14, 1969.

te Savings from Reducing Time Interval of Physician-Certification Periods under Hospital Insurance Program.

Ir. ROBERT M. BALL,

"ommissioner of Social Security.

An HEW press release of October 13 announces that physican certification f the necessity for hospitalization of HI beneficiaries will be required (beginhing next January 1) by the 12th day of hospitalization, instead of the 14th lay, and the first recertification by the 18th day, instead of the present 21st day. It is pointed out that data on length of stays in hosptials show that the numer of discharges rises significanly on the 14th day and again on the 21st day. Finally, it is stated as an illustration of the potential cost savings that a reduction of each hospital stay by an HI beneficiary by one day would reduce rogram costs by about $400 million in 1970.

It is correct that there is a peak in the discharge rate for the 14th and 21st lays, but this amounts to only about 10% more than could be expected by the preceding and subsequent discharge rates (see Report HI-10 issued by ORS). I have made calculations of the effect that would be obtained if this peak in the discharge rate is shifted from the 14th day to the 12th day and from the 21st day to the 18th day. The net effect on the number of days of hospitalization is to reduce the average days of hospitalization per discharge by .014 days, which represents a savings of $5 million per year. It is important to note that the latter figure is far less than the illustrative figure of $400 million, which would result only if the average hospitalization stay were reduced by one day. It is my strong belief that the press release was most misleading-although technically accurate in quoting this $400 million figure (somewhat facetiously, I might say that it would have been equally accurate, but obviously ridiculous, to have stated if each hospital stay were shortened by 10 days, the program cost would be reduced by about $4 billion per year!).

ROBERT J. MYERS,

Chief Actuary. OCTOBER 29, 1969.

Re Savings from Reducing Time Interval of Physician-Certification Periods Under Hospital Insurance Program (Continued).

Mr. ROBERT M. BALL,

Commissioner of Social Security.

In my memorandum of October 14 on the above subject (to which I have as yet had no reply). I pointed out that the desirable change that is being made in the conditions for physician certification of the necessity for hospitalization of the beneficiaries is being misleadingly presented to the public by statements that are somewhat along the following lines:

"The potential cost savings can be illustrated by the fact that if each hospital stay is shortened by one day, then Medicare cost will be reduced by about $400 million per year." (Note that "will" is used, rather than “would”.)

A statement along these lines has just appeared in the HEW Field Letter of October 20. The casual reader could well infer that we expect to save $400 million a year by this change, which is admittedly very desirable regardless of the magnitude of the savings. The same "erroneous" logic could, of course, go on to say that the potential cost savings could be "illustrated" by the fact that, if each stay is shortened by two days, the cost will be reduced by $800 million-or, at the extreme of absurdity, if the average stay were reduced by 14 days, the whole program's cost as to hospital benefits would be eliminated (true, but completely irrelevant and meaningless).

I brought out that the savings for this change will probably be only about $5 million per year. I think that the method of presentation that was followed is most misleading and tends to create a creditability gap for the present Administration that could have readily been avoided. I feel that the present Administration has the basic purpose of avoiding any creditability gap-unlike the previous Administration, which in my opinion, intentionally acted in such manner in a number of instances-and it is unfortunate that the SSA should now have created a problem in this area.

ROBERT J. MYERS,
Chief Actuary.