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of self-destructive behavior patterns, most persons in the rectangular society will succumb to relatively short-term illnesses in the final senescent period of lite, natural death will occur at the end of natural lite.
''The rectangular society does not present a utopian society free from problems. The medical care delivery system must undergo a fundamental upheava-internists will become geriatricians, and acute care hospitals will be occupied primarily by geriatric patients. Costs of medical care can fall it heroic treatment methods are abandoned in favor of more rational therapeutic approaches at home, in hospice and respite care units, in convalescent facilities, and in modified nursing homes. When people develop cardiovascular or malignant diseases in their 80's and 90's instead of their 50's and 60's, therapeutic and diagnostic decisions should be more humane and less dramatic. Natural death cannot be avoided, no matter the expenditure...
"The integration of the older members of society into the mainstream of life is the challenge for the coming era. Free from the agony of lingering illness, filled with the vigor of natural life, the rectangular society represents a great hope for the fulfillment of human potential."'5
In rethinking Medicare to meet future needs, I suggest we look to such a vision of the future, rather than retreat to the obsolete constraints of the pre-Medicare past.
1. US Department of Health and Human Services, Health
Care Financing Administration, unpublished data, June
10, 1982 2. New York Times, April 20, 1982, 3. R. M. Gibson and D. R. Waldo, "National Health Expen
ditures, 1980," Health Care Financing Review 3 (Septem
ber 1981). 4. Alan Gregg, Challenges to Contemporary Medicine (New
York: Columbia University Press, 1956). 5. A. R. and H. M Somers, "Coverage, Costs, and Controls
in Voluntary Health Insurance," Public Health Reports 76 (January 1961), pp. 1-9. excerpted in Somers and Somers, Health and Health Care: Policies in Perspective (German
town, MD: Aspen Systems Corp. 1977). pp. 125-126. 6. H. M. Somers, "Medicare and the Costs of Health Ser
vices." in W. G. Bowen et al., eds. The American System of Social Insurance (New York: McGraw-Hill, 1968), pp. 119-151; excerpted in Somers and Somers, Policies in
Perspective, op.cit., pp. 170-177. 7. D. N. Muse and D. Sawyer, The Medicare and Medicaid
Data Book, 1981 (Washington, DC: Department of Health and Human Services, Health Care Financing Administra
tion, Publ. No. 03128, 1982), p. 61. 8. Ibid., p. 60. 9. Health - U.S. 1981 (Washington, DC: Department of Health
and Human Services, Publ. No. (PHS) 82-1232, 1982), p.
184. 10. U.S. Department of Health and Human Services, National
Center for Health Statistics, unpublished data, June 14,
1982. 11. Health-U.S. 1981, p. 177. 12. L. B. Russell, Technology in Hospitals: Medical Advances
and Their Diffusion (Washington, DC: Brookings Institu
tion, 1979). 13. S. A. Schroeder, "Medical Technology and Academic
Medicine: The Doctor-Producer's Dilemma," Journal of
Medical Education 56 (August 1981), p. 636. 14. L. A. Fingerhut "Mortality Among the Elderly," in Health
U.S. 1981, p. 17.
15. Health U.S. 1981, p. 111.
sclerosis 1981, Report of the Working Group on Arterio-
(Bethesda, MD: NIH Publ. No. 81-2034, 1981). p. 4. 17. Richard Freeman, President, National Kidney Foundation,
Written communication, June 8, 1982. 18. G. Hirshman, Acting Director, Chronic Renal Disease Pro
gram, National Institutes of Health, Bethesda, MD, Oral
communication, June 16, 1982. 19. J. K. Iglehart, "Medicare's Uncertain Future," New Eng
land Journal of Medicine 306 (May 27, 1982), p. 1311. 20. Health U.S. 1981. p. 148. 21. D. P. Rice, Director, U.S. Department of Health and Human
Services, National Center for Health Statistics, Written
communication, February 8, 1982. 22. James Marshall, American Dental Association, Oral com
munication, May 20, 1982. 23. Arteriosclerosis 1981, op.cit., p. 31. 24. M. B. Breckenridge, "The Senile Dementias: A Dual Per
spective on Their Epidemiology." in A. R. Somers and D. R. Fabian, The Geriatric Imperative: An Introduction to Gerontology and Clinical Geriatrics (New York City:
Appleton-Century-Crofts, 1981). p. 156. 25. Somers and Somers, Doctors, Patients, and Health Insur
ance Washington, DC: Brookings Institution, 1961), Chap.
1., "The Paradox of Medical Progress." 26. Health U.S. 1981. p. 212. 27. Medicare and Medicaid Data Book, op.cit., p. 15. 28. Medicare Hospital Insurance and Supplementary Medical
Insurance Trust Funds, 1982 Annual Trustees Report. 29. Health Care Financing Administration, unpublished data,
June 10, 1982 30. C. P. Fisher, "Differences by Age Groups in Health Care
Spending." Health Care Financing Review 1 (Spring 1980),
p. 76. 31. Ibid., p. 87. 32. Medicare and Medicaid Data Book, op.cit. p. 13. 33. U.S. Department of Commerce, Bureau of the Census,
Statistical Abstract of the U.S. 1980 (Washington, DC:
1980), p. 6. 34. Medicare and Medicaid Data Book, op.cit., p. 27. 35. J. Lubitz and R. Deacon, "The Rise in the incidence of
Hospitalization for the Aged, 1967-1979" Health Care
Financing Review 3 (March 1982), p. 25. 36. American Hospital Association, Hospital Statistics, annual
editions (Chicago: The Association). 37. A. A. Scitovsky, "Changes in the Use of Ancillary Services
for Common Illness," in S. H. Altman and B. Blendon, Eds., Medical Technology: The Culprit Behind Health Care Costs? (Washington, DC: U.S. Department of Health, Education, and Welfare, DHEW Publ. No. 79-3216, 1979), pp.
A. Different View of the Contentious Debate Over Costs."
1979), pp. 1413-1419.
Consumers, April 1982. Table 2. 42. 1981 White House Conference on Aging Report of Tech
nical Committee on Health Services. J. C. Beck, Ch. (Washington, DC. Government Printing Office: 1981-720
019/6963), p. 41 43. A. R. Somers. "Social, Economic, and Health Aspects of
Mandatory Retirement," Journal of Health Politics, Policy, and Law 6 (Fall 1981), pp. 542-557.
44 HB Curry et al. Twenty Years of Community Medicine
(Frenchtown Nu Columbia Publishing Company, 1974). 45 LB Wescott Hunterdon The Rise and Fall of a Medical
Camelot." New England Journal of Medicine 300 (April
26. 1979). pp 952-956 46 AS Reiman, "The New Medical Industrial Complex,"
New England Journal of Medicine 303 (October 23. 1980).
po 963-970 47 J K Iglehart "Health Policy Report: Health Care and
American Business. New England Journal of Medicine 306 January 14, 1982). pp 120-124.
48. A. Pear, "Hospital Industry Proposed Fixed Payments for
Medicare Patients." New York Times, April 20, 1982. 49. AR Somers. "The Case for Negotiated Rates," Hospitals
(February 1, 1978). pp. 49-52 50. "Coalition Seeks to Curb Rising Health Care Costs," New
York Times, January 15, 1982 51. J. F. Fries and L M Crapo, Vitality and Aging: Implications
of the Rectangular Curve (San Francisco: W. H. Freeman & Co., 1981).
About the Author
Anne R Somers. Professor of Community Medicine, University of Medicine and Dentistry of New Jersey-Rutgers Medical School, is an author teacher, lecturer, and widely acknowledged authority on health care organization and financing. She has published numerous papers in these fields and written Hospital Regulation: The Dilemma of Public Policy and Health Care in Transition: Directions for the Future. With her equally famous husband, Herman Somers, she coauthored two books in the fields of financing and hospital organization: Medicare and the Hospitals, Doctors. Patients and Health Insurance and Health and Health Care: Policies in Perspective. More recently Mrs. Somers has also published articles on disease prevention and health promotion. Mrs. Somers is a member of the Institute of Medicine, serves on a number of editorial boards, and is an honorary member of the American College of Hospital Administrators.
About Government Research Corporation
The Government Research Corporation (GRC) is a private professional organization established in 1969 to provide independent analysis. forecasting and counsel on government, politics and public policy issues.
GRC provides direct and specific public policy research and analysis to clients to assist them in making decisions that appropriately reflect government developments in Washington.
GRC publishes the National Journal, a weekly publication providing in-depth coverage of Washington policy making, which has twice won the National Magazine Award for Specializeu Journalism in 1979 and for Reporting in 1981. GRC also publishes Opinion Outlook, a twice monthly report on the latest public opinion survey relating to government, the economy, business, labor, foreign attairs and domestic social trends
GRC also sponsors seminars and conferences on a wide variety of public policy issues Since 1976. GRC's annual Leadership Conference on Health Policy has provided a foruin for policy makers to meet and debate health issues with participants from labor, business, the professions, academia and state and local governments.
Mr. RINALDO. Thank you very much for a very well-thought-out presentation.
STATEMENT OF FAITH GOLDSCHMIDT Ms. GOLDSCHMIDT. Mr. Chairman, members of the committee, I am Faith Goldschmidt, a health economics research specialist, of the New Jersey State Department of Health's DRG project.
New Jersey acute-care general hospitals instituted the diagnosis related group (DRG] system as a means of hospital reimbursement for all patients, all payers in 1980.
Our hospitals were phased in over a 3-year period and all had implemented DRG's as of December 1, 1982.
We feel that the DRG system has the following benefits:
One, it is a clinically based system. The allocation of resources is equitable and based on a specific product, a DRG. Each hospital is reimbursed according to the complexity and volume of the cases it treats, not according to a fixed rate per day.
Two, hospitals and physicians are encouraged to use resources in an efficient manner by focusing on the DRG as the product plus the use of payment incentives for efficiencies and disincentives for inefficiencies. The DRG system provides valuable information for the hospital's management to communicate with its medical staff.
The physician is the resource consumer, because he or she admits the patient, orders all services and discharges the patient. Using a variety of reports, hospital management can and does work with physicians to more effectively and efficiently manage their patients. Three, in New Jersey, there is equity across all payers. Therefore, the massive cost shifting that occurs elsewhere in the country to cover discounts and uncompensated care does not occur in New Jersey. Four, uncompensated care, which primarily includes indigent care, is one of the hospital's financial elements.
By including uncompensated care as an element of cost, well managed inner-city hospitals can concentrate on effectively providing quality medical care to all patients regardless of social or economic status.
The following information might be of interest also: One, the DRG construction. The 467 DRG's used in New Jersey were constructed by Yale University and the National Steering Committee. There was a great deal of clinical input into these new DRG's, and they are meaningful both in a medical and a financial sense. New Jersey also uses seven categories to describe patients atypical in length of stay or resource consumption. The patients are called outliers and they are billed charges. Two, data requirements. There must be extensive computer capability for the hospital, the fiscal intermediary and for those who set the rates. There must also be the ability to check and correct DRG assignment and claims, and generate and interpret reports.
Three, implementation. Based upon New Jersey's experience the phasing in of the hospitals over a 3-year period was very important. It is not until a system is actually in place and being used, that many of the problems will be discovered.
Four, education. There is great need for education about the system at all levels, regulators, payers, hospitals, physicians, and patients.
Five, independent monitoring. There also is need for an independent monitoring system to insure that quality of care does not deteriorate because of the incentives to reduce expenditures. The department has seen no hard evidence in New Jersey that the DRG system has had any negative impact on the quality of care, and we can discuss that later if you would like.
Six, new technology. New technology and procedures are addressed in New Jersey by the Rate Setting Commission, either by a specific clinical appeal process or by the certificate of need system. Periodically, rebasing the system also will help incorporate advances in medical practice. Therefore, such advances are not stifled.
Seven, flexibility. Allowance should be made for States to have the flexibility to implement their own systems, provided such systems will meet the Federal objectives of cost containment. Of particular importance is to allow these States that are inclined to incorporate all payers to minimize cost shifting to do so.
In New Jersey we have found that management of the DRG system by the local State government allows rapid response in identification of problems, gathering of information, identification of solutions and implementation of solutions. Rapid resolution of problems encourages cooperation and leads to a better system.
In conclusion, we feel that the DRG system has been successful in containing health care costs in New Jersey. Former Secretary Schweiker's report shows that, in 1981, New Jersey was lower in percentage increase in cost per capita and in cost per adjusted admission than both the national average and the other regulated States. Now that all New Jersey acute-care general hospitals are
PREPARED STATEMENT OF CHARLES PIERCE, DEPUTY COMMISSIONER, NEW JERSEY DEPARTMENT OF HEALTH, SUBMITTED FOR THE RECORD BY FAITH GOLDSCHMIDT
You and your colleagues on this committee are faced
with an enormous task, one on which the future well-being
of literally millions of Americans will depend.
age of dwindling health resources, it is imperative that
health care services be provided in the most efficient
and effective manner possible.
But cost containment efforts,
if undertaken in haste and without adequate foresight, can
substantially impair the ability of many of our sickest
and most truly needy citizens to receive vitally necessary health services, and substantially damage, if not destroy, many of our most valued social institutions, such as urban hospitals, medical school teaching hospitals, and certainly
public hospitals, as well as
some rural hospitals that
serve many of the poor.
Since there is a need to reduce the costs of health
programs, you can do so either by reducing services or
by reducing the payment for each unit of service.
We are beginning to learn in New Jersey, as has been
previously demonstrated in Maryland, that well-conceived
state programs to regulate hospital costs can effect con
Such programs are being implemented without
serious restrictions on the availability of service or the financial viability of the providers of care, and indeed can
even do much to improve the financial status of well-managed
institutions which serve a disproportionately large number of
The evidence on controlling the rate of increases