Document 2jdRO383Q7vE900mGDVw3xdLN

HEALTH / PAC BULLETIN BULLETIN Policy HeAadlvtisho ry Center 1 Kennedy Mills: A FUNNY THING HAPPENED ON THE WAY TO THE WHITE HOUSE. Kennedy beats a re- treat on national health insurance. 6 Patient Dumping: PRIVATES PICK PUBLIC PATIENTS. Cali- fornia's private hospitals select profitable patients. 11 Medicaid Mills: PING PONG REBOUNDS. Bronx Medicaid pa- tients organize. 15 Media Scan Marcus Welby et al. 17 Peer Review 19 Vital Signs ' L: aes. No. 58 May June / 1974 Kennedy - Mills A FTUHNINNYG MMaannyy supporters were shocked and dis- HAPPENED mayed in early April when Senator Edward ON THE WAY Kennedy retreated from his cradle - to - grave TO THE Health Security Act and, with Representa- WHITE HOUSE tive Wilbur Mills, introduced into Congress a more limited, compromise measure - the National Health Insurance Program (NHIP). Plympton While Senator Kennedy's retreat may have been disappointing, it should not have been a surprise. For the economic and po- litical climate has shifted dramatically since the introduction of the Health Security Act in 1971. And if the earlier measure ever had political viability, in the last year it has run up against a three - way roadblock which has rendered it a virtual dead letter. First, the introduction of the Health Secur- ity Act followed on the heels of a decade of economic prosperity. By 1972, the beginning of President Nixon's second administration, however, it was clear that the American economy was in serious trouble. And one of Nixon's answers was cuts in the federal budget, particularly the domestic budget, and most particularly, the largest and most inflationary sector of the domestic budget: health care spending (see BULLETIN, May 1973). Although the expected hue and cry followed, and Watergate has since moder- ated the President's original heavy handed- - ness, there is now a widespread acceptance of the necessity of tightening the govern- ment spending belt hardly - the friendliest environment for a bill which would have added over $ 100 billion to the public purse. Secondly, the public, while it may not un- derstand the causes and solutions to the eco- nomic crisis, intimately understands its im- pact. While once the consumer worried that health care would exceed his economic grasp, now he has begun to worry about food, clothing, shelter and his standard of living as well. And if it comes down to choosing among these, he wants to make the decision himself, and not have it made for him by the federal government. Conse- quently, whatever consumer base the Health Security Act may have had has been seri- ously eroded. Finally, introduction of the Health Secur- ity Act also followed on the heels of a dec- ade of social unrest - urban riots, student pro- test, marches on Washington - which seemed to call not only for a change in foreign pol- icy, but for significant domestic reform as well. Although it was hardly an organized constituency, these social forces created an environment for domestic reform programs- OEO, Model Cities, Urban Renewal, not to speak of Medicare, Medicaid and Neighbor- hood Health Centers. Yet by 1974 this move- ment had virtually disappeared, and with it 2 the reform environment as well. Facing severe economic obstacles, falter- ing consumer support and the absence of any social movement, it is hardly a mystery why Kennedy pulled back from the Health Security Act. The only mystery is why there is any momentum whatsoever for national health insurance at the present time. The an- swer has more to do with the internal ma- neuverings of Congress and with political opportunism than it does with the needs, sentiments or organization of the health constituency. While the base may not exist for a more thoroughgoing national health insurance, there is still a felt need, particularly among the middle class, for protection against cata- strophic illness. And, of course, this is the narrowest, least expensive need to meet. When the 93rd Congress convened, the Long- Ribicoff catastrophic health insurance mea- sure, sponsored by the powerful Senate Finance Committee chairman, had built up a head of steam. Seeing this, and pos- sibly seeing also an opportunity to deflect Watergate criticism, President Nixon added his weight to national health insurance's mo- mentum by sponsoring an apparently liber- alized, more politically viable version of his former bill. Either sincerely fearing the pas- sage of one of these bills, or seeking a legis- lative coup prior to the 1976 presidential campaign, or both, Senator Kennedy then withdrew his support for the Health Security Act, sponsoring instead the National Health Insurance Program. Senator Kennedy clearly felt uncomfort- able with the compromises involved, but pro- claimed that NHIP " represents a practical embodiment of these principles that can be enacted into law in the next year or two. " NHIP retains two important principles of the Health Security Act which distinguish it from other bills: financing of the bill is entirely public and the measure is compulsory. But it made three probably more important con- cessions: OE Acceptance of out pocket - of - costs: NHIP incorporates a set of deductibles and coin- surance very similar to, if slightly less than, those in the Nixon bill. Each individual must pay $ 150 in medical expenses annually be- fore receiving health insurance benefits. Families pay a total deductible of $ 300 a year (compared with Nixon's $ 450). After that, they must pay 25 percent of succeeding costs up to a maximum of 1,000 $ a year (compared with $ 1,500 under the Nixon bill). For the poor, these out pocket - of - costs are graduated according to income. For this concession, Kennedy reaps for the government several of the assets of the Nixon bill. Out pocket - of - payments (plus a few other measures) will significantly reduce the cost of the bill both - in direct govern- ment outlays and in the indirect cost sav- ing stemming from the deterrent effect of out- of pocket - costs on utilization. Consequently, the Kennedy - Mills bill has the same public price tag as the Nixon bill: $ 40 billion. The consumer, of course, reaps the flip side of this out pocket - of - coin: These costs will transform the Kennedy bill into one of primarily catastrophic illness insurance, dis- couraging early diagnosis and treatment (ex- cept for children). But more than this, if health care costs continue to rise, as they surely will, these out pocket - of - costs may come to overshadow the benefits of the bill, as has happened under Medicare. (Medi- care recipients pay more out pocket - of - costs today than they did in 1966 when Medicare was established.) OE More regressive financing: In a serious step back from the earlier bill, NHIP will be financed entirely by payroll taxes, 1 percent for employees up to 20,000 $ and 3 percent by employers. There are no additional taxes on income above 20,000 $ , so an executive making $ 100,000 per year will pay the same amount as a colleague making $ 20,000. At least in the earlier Kennedy bill 50 percent of all costs came from general revenues (graduated income taxes, industrial tax, etc.), although the rest also came from Social Se- curity - type payroll taxes. In the new Ken- nedy - Mills bill, the concept of " sharing cost -" is carried to the obscene length that even recipients of welfare and unemployment must pay a 1 percent tax on their income. OE Role of insurance companies: The old Kennedy bill would have eliminated the in- surance industry from the national health insurance scene altogether, and this was, no doubt, the source of some of the bill's most serious opposition. NHIP will allow private insurers to act as fiscal intermediaries, re- ceiving the money from the federal govern- ment and reimbursing providers, as they presently do under Medicare. Also, Kennedy says, NHIP will allow the insurance indus- try a profitable business in supplementary insurance covering initial and other med- ical expenses not covered under NHIP. In their role as fiscal intermediaries, the health insurance industry has been primar- ily responsible for the runaway inflation which took place under Medicare and Med- icaid. Not only does it have no vested inter- est in controlling costs, since it can always turn around and charge the government or the consumer more, but there is reason to think that the health insurance industry may have a positive interest in rising costs. Its profits are not simply related to the surplus of income over expenses, but also to the ab- solute size of cash flow, since the large sums of money passing through insurance com- pany hands can yield considerable interest even on short - term investments. More than that, Blue Cross, the giant of health insurers (40 percent of the market), has had until re- cently such strong links to hospitals that many have claimed they constituted a con- flict of interest. Under recent public pres- sure, and probably as a cosmetic job in an- ticipation of national health insurance, Blue Cross has sought to sanitize, if not break those ties, and has begun to make motions toward cost control and innovations in health care delivery. But even these criticisms, which pertain to all the bills currently under consideration in Congress, pale beside the chief shortcoming of all national health insurance measures, including the old Health Security Act: failure (Continued on page 10) Published by the Health Advisory Center, 17 Murray Street, New York, N.Y. 10007. Telephone (212) 267-8890. The Health / PAC BULLETIN is published 6 times per year: Jan./Feb., Mar. Apr., May June /, July Aug /., Sept./Oct. and Nov./Dec. Special re- ports are issued during the year. Yearly subscriptions: $ 5 students, $ 7 other individuals, $ 15 institutions. Second - class post- age paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Oliver Fein, Nancy Jervis, David Kotelchuck, Ronda Kotelchuck, Louise Lander and Howard Levy. San Francisco staff: Elinor Blake, Thomas Bodenheimer and Judy Carnoy. San Francisco office: 558 Capp Street, San Francisco, Cal. 94110. Telephone (415) 282-3896. Associates: Robb Burlage, Susan Reverby, Morgantown, W. Va.; Constance Bloomfield, Desmond Callan, Kenneth Kimmerling, Marsha Love, New York City; Vicki Cooper, Chicago: Barbara Ehrenheich, John Ehrenreich, Long Island. BULLETIN illustrated by Bill Plympton. 1974. ELIGIBILITY BENEFITS OUT POCKET - OF - COSTS 4 FINANCING CATASTROPHIC HEALTH INSURANCE AND MEDICAL ASSISTANCE REFORM ACT (Ribicoff Long -) Title: Catastrophic Illness Insurance, covers Social Se- curity beneficiaries; compul- sory. Title II: Medical Assistance (for the poor), covers every. one with income under $ 2400 / individual, $ family 4800 / of 4. Other coverage: completely voluntary, privately - negoti- ated, regulated by federal govt. Title benefits same as Medi- care Parts A & B; Title II benefits designed to mesh with Title I. 1. Physicians services. 2. Physicians psychiatric services, Title I limited as in Medicare; Title II: 5 private visits for crisis intervention; unlimited community mental health cen- ter services. 3. Dental services -- none. 4. Hospital services. 5. Home health services, unlimited. 6. Inpatient psychiatric care, active treatment, 90 day life- time maximum. 7. Post hospital - extended care, 100 days benefit / period. 8. Drugs none. 9. No hearing aids, glasses, false teeth, dental care. 10. Optometrists services none. 11. Podiatrists services- -none. 12. Diagnostic services, indep. labs (?) 13. Ambulance services. 14. Supporting services none. 15. Psychiatric day cn aro e ne. 16. Preventive services: Title II, pre natal -, well child -, family planning, screening, diagnosis & treatment for children under 18, immunizations. -Title I: a) Hospitalization: 60 day deductible, $ day 21 / co- insurance thereafter. b) Non hospital - services: $ year 2000 / deductible per family; 20% coinsurance up to $ 1000. -Title II: No deductible; co- insurance of $ 3 for first 10 physician visits per year. -- Title I: 3% tax on payroll up to annual income of $ 9,999 paid by both employer & employee. Title II: 75% federal through general revenues, 25% state. COMPREHENSIVE HEALTH INSURANCE PLAN (Nixon) Anyone who wishes & can afford it; coverage voluntary; everyone presumably fits into 1 of 3 plans: 1. Employee Health Insurance Plan (EHIP). 2. Assisted Health Insurance Plan (for poor, unemployed, high risk persons). 3. Medicare for elderly. Part - time & temporary workers virtually left out. NATIONAL HEALTH INSURANCE PROGRAM (Kennedy - Mills) Everyone except Medicare --- Compulsory coverage. Uniform benefits for all groups. 1. Physicians services, unlimited. 2. Physicians psychiatric serv- ces, 15 visits to private doctor, 30 to community mental health center. Uniform benefits for all groups. ~ 1. Physicians services, unlimited. 2. Physicians psychiatric servces --costs of 30 private visits or equivalent of 60 private visits if to OPD, community mental health center. 3. Dental services to age 13. 3. Dental services to age 13. 4. Hospital services, unlimited. 5. Home health services, 100 visits / yr. 6. Inpatient psychiatric care, 30 full days or 60 partial. 4. Hospital care, unlimited. 5. Home health services, 100 visits / yr. 6. Inpatient psychiatric care, 30 full days or 60 partial. 7. Post hospital - extended care, 100 days per year. 8. Prescription drugs. 7. Post hospital - extended care, 100 days year /. 8. Outpatient prescription drugs, drugs for chronic illness; $ 1 co payment -. 9. Eye, hearing services to age 13. 10. None. 11. None. 12.? 9. Eye, hearing services to age 13. 10. None. 11. None. 12.? 13. Ambulance services. 14. None. 13. Ambulance services. 14. None. 15.? 16. Preventive services: prenatal, well child - to age 6. family planning. 15.? 16. Preventive services: prenatal, well child - to age 6, family planning. Deductible: $ person 150 / , $ family 450 / per year; per- tains to all services. $ 50 deductible on drugs. insurance --Co - : 25%. Maximum liability: $ family 1500 / of 4 per year. -Premium share: a) EHIP 35% of premium cost 210 ($); employer pays 65% (390 $) (to change to 25% & 75%). b) AHIP & Medicare: premium share graduated according to income. -EHIP: paid for entirely by by employer and employee. -AHIP: 75% federal from general revenues; 25% state. --Medicare: Social Security payroll taxes as presently financed (%.9 on salaries up to $ 13,200 paid by both employer and employee). - Deductible: $ person 150 / , $ family 300 / per year; preventive services exempt. Co insurance -: 25% -Maximum liability: $ 1000 / yr. for family of four. Deductible, co insurance - & maximum liability graduated according to income for the poor. 1% employees'payroll tax up to income of $ 20,000 (also on unearned income). 3% employers'payroll tax. 2.5% self employment earnings. General revenues and state contributions equal to present Medicaid contributions to off- set money lost on graduated deductibles, co insurance - maximum liability for poor. HEALTH SECURITY ACT (Kennedy) (For comparison only) All Americans Compulsory Coverage. Comprehensive benefits, few limitations. 1. Physicians services, unlimited. 2. Physicians psychiatric services, 20 visits benefit / period except thru HMO or Community Mental Health Center. 3. Dental services to age 15, to be extended annually. 4. Hospital care, unlimited. 5. Home health services. 6. Inpatient psychiatric care, 45 days / benefit period. 7. Post hospital - extended care, 120 days benefit / period. 8. Prescription drugs through inpatient, outpatient, skilled nursing home or organized patient care program. 9. Medical appliances, including eyeglasses & hearing aids. 10. Optometrists services. 11. Podiatrists services. 12. Diagnostic services in independent. labs. 13. Ambulance services. 14. Supporting services by institution, e.g., psychological, nutrition, social work, health education. 15. Psychiatric day care, 60 days. 16. Preventive services. No deductibles, co insurance - or premium shares. 1% employees'payroll tax up to income of $ 15,000 (also% 1 of unearned income). 3.5% employers'payroll tax. 2.5% self employment earnings. 50% of total from general revenues. ADMINISTRATION PAYMENTS TO PROVIDERS COST AND QUALITY CONTROLS IMPACT ON OTHER PROGRAMS CATASTROPHIC HEALTH INSURANCE AND MEDICAL ASSISTANCE REFORM ACT (Ribicoff Long -) Both programs administered same as Medicare. --- Administration by Social Security Administration. -Miscellaneous 1. Insurance companies will serve as fiscal intermediaries. 2. No provision for consumer input. Title II: must be accepted as payment in full. 1. Institutions paid on basis of reasonable costs. 2. Individual providers paid on basis of reasonable charges. Payment subject to same quality, safety, utilization controls as Medicare. Physician controlled - PSRO review. 1. Continues Medicare. 2. Supercedes Medicaid. 3. Leaves VA, DoD, PHS for Indians & prisoners, work- men's compensation & disability intact. COMPREHENSIVE HEALTH INSURANCE PLAN (Nixon) Federal role: administer Medicare, establish benefits & eligibility, approve state plans. --State role: administer Govt. Assisted Plan, regulate cost & quality controls, provider reimbursements, insurance company profits. -Miscellaneous 1. Insurance companies will serve as fiscal intermediaries for Medicare & probably Govt. Assisted Plan. Will handle Employee Plan entirely. 2. No provision for consumer input. 3. No grievance or appeals provision. Providers paid in full by credit card issued to consumer by govt. or insurance company. Out pocket - of - expenses collected from con- sumers by agency. Physicians allowed to charge patients under Employee Plan direct fees in addition to what natl. health insurance pays. 1. Institutions paid by prospective reimbursement. HMO incentive. 1. Hospitals: Construction must be approved by planning agency. Physician controlled - PSRO review. 1. Continues Medicare, makes benefits commensurate with rest of program. 2. Supercedes Medicaid. 3. Leaves VA, DoD, PHS for Indians & prisoners, work- men's compensation & disability intact. NATIONAL HEALTH INSURANCE PROGRAM (Kennedy - Mills) Will be part of new inde. pendent Social Security agency, directly under President. -Health Resources Develop. ment Board, will eventually be funded at 2% of national health insurance revenues. --Miscellaneous 1. Insurance companies will serve as fiscal intermediaries as they do presently with Medicare. 2. No provision for consumer input. Providers paid in full by credit card issued to consumer by govt. or intermediary. Cost sharing collected from consumer by agency. 1. Institutions paid by prospec- tive reimbursement with incentive for efficiency. 2. Individual providers reim- bursed according to fee schedule established by profession, approved by govt. HMO incentive. 1. Hospitals: a) Must have planning agency approval of character & quantity of services for reimbursement. b) Standards similar to Medicare, monitored by states. c) Physician controlled - PSRO review. 1. Continues Medicare, makes benefits commensurate with rest of program. 2. Suprecedes Medicaid. 3. Leaves VA, DoD, PHS for Indians & prisoners, work- men's compensation & dis- ability intact. HEALTH SECURITY ACT (Kennedy) (For comparison only) 5 member - natl. board, appointed by the President & confirmed by Senate, under Sec'y of HEW; Duties: general administration, policy, regula- tion, control of reimbursement, quality & cost. -Natl. Advisory Council, 20 members appointed by Sec'y of HEW; consumer majority. -Basic administration through regional & local offices. -Regional & local advisory councils set up like Natl. Advisory Council. Commission on Quality of Health Care set up in HEW. -- Health Resources Develop. ment Board will eventually be funded at 5% of natl. health insurance revenues. Miscellaneous. 1. No role for insurance companies. 2. National, regional, local consumer advisory boards. 3. Grievance hearings, appeals, judicial review. --Providers must accept na- tional health insurance as payment in full. - Natl: Board determines annual budget, allocates it to regions on per capita basis. -Regional boards subdivide it among categories of services. 1. Institutions paid by prospec- tive budget based on reason- able costs. 2. Individual providers can choose fee service - for - , salary. capitation; incentives provided in underserved areas. HMO incentive. Establishes Quality Control Commission which sets stand- ards for individual & institu. tional providers. 1. Hospitals: a) Must meet new national standards. b) Utilization review. 2. Physicians: Present MD's must be state licensed - & meet continuing education require- ments; new ones must meet new national standards. 1. Terminates Medicare. 2. Terminates federal share of Medicaid. 3. Leaves VA, DoD, PHS for Indians & prisoners, work- men's compensation & disa- bility intact. 5 Patient Dumping PRIVATES PICK The two class - health system usually oper- PUBLIC ates smoothly: people unable to pay for their PATIENTS health care go to public hospitals and stay away from the private sector where they know they are often considered " undesir- able. " But occasionally these " undesirables " ruffle the waters by showing up at the emer- gency room of a private hospital. Then the grossest manifestation of the two class - health system is witnessed: patient dumping. This means loading the poor, sick victim into an ambulance or car (or even pointing out the nearest bus stop) and shipping him to a pub- lic hospital. In Chicago, 18,000 persons were turned away from private emergency rooms in 1970; at least 50 died in the course of trans- fer to Cook County Hospital. (1) The Director of Washington's D.C. General Hospital emergency room testified before a Senate committee in 1970 that 20 patients die each year as a result of transfers from private hospitals. (2) Extrapolating from these fig- ures, 4,000 people can be expected to die each year from patient dumping. Though patient dumping is well recog- nized by everyone, few have documented it in detail. This study was done by surveying patient records of every emergency room visit and acute hospital admission at Ala- meda County's public hospitals for a two- week period in January, 1974. Data were col- lected on patients who had been transferred (dumped) from other hospitals. These data were analyzed in the context of hospital sta- tistics provided by the County. Who Gets Dumped? Alameda County, across the bay from San Francisco, is an urban and suburban area of one million population, with most poverty areas concentrated in Oakland, a city of 400,000. The county has two public hospitals: Highland General Hospital, a typ- ical large urban public hospital in Oakland, and Fairmont Alameda County Hospital, a chronic - care hospital with some acute ser- vices such as the emergency room. The rest of the county's 24 short - term hospitals are private, chiefly profit non - . Transfers constituted 2.4 percent of High- land's emergency room visits and 5.4 per- 6 cent of Fairmont's, a rate that yields 1,500 transfers annually. The transfers came from 12 hospitals, with two Herrick - Memorial and Washington - accounting for 40 percent of the transfers to Highland, and Washing- ton the source of 35 percent of the transfers to Fairmont. The vast majority of transfers are med- ically indigent of Medi - Cal (Medicaid) pa- tients. At Highland, 80 percent were med- ically indigent and 20 percent Medi - Cal. At Fairmont, 45 percent were medically indi- gent, 28 percent Medi - Cal, 16 percent private insurance, 9 percent Kaiser, and 2 percent Medicare. Almost all the private insurance transfers had psychiatric, drug or alcohol related problems, and all the patients trans- ferred from Kaiser had psychiatric problems. (Kaiser seldom offers its enrollees mental health care.) The percentage of medically indigent people transferred is far higher than the county hospitals'overall medically in- digent load. Transferred patients are far sicker than the average county hospital patient. Although only 12 to 16 percent of emergency room pa- tients are generally admitted to the county hospitals, 64 percent of the dumped patients required admission. Whereas overall 12 per- cent of Highland admissions go to the in- tensive care unit, 26 percent of transferred patients went to intensive care. Among the transferred patients were many with life- threatening diagnoses: a brain hemorrhage, a stroke, a possible heart attack, low blood sugar, three serious head traumas, a drug overdose, a skull fracture, a gunshot wound to the chest, two serious intestinal hemor- rhages, three broken legs and a fractured pelvis combined with severe head trauma. In their paper on patient dumping, Roemer and Mera note that one California county hospital keeps an " Atrocity Book " of patients dumped from private hospitals. (3) The char- acteristics of the transferred patients seem to be similar to those in Alameda County. Although the total number of transfers is not large, the impact on the functioning of the county hospitals is enormous. 74 per- cent of the transfers arrived between 6 p.m. and 2:30 a.m., a time when hospitals are short staffed. The transfers were sicker than the average patient, thus requiring more staff time; fully 20 percent of all Highland intensive care unit patients are private hos- pital transfers. And most of the transferred patients have no Medicare, Medicaid or hos- pital insurance at all, thereby constituting a financial drain on the hospital. Who Dumps? Why are patients transferred? The 1973 written policy of Samuel Merritt Hospital, a typical Oakland non teaching - private hos- pital, provides an answer: " Certain cate- gories of patients should be transferred to other facilities for emergency or hospital care when possible or appropriate... these categories include... Medically indigent [and]... Patients for whom Merritt Hospital does not have the facilities and / or staff for proper and safe care of their particular prob- lems, or whose admission to the Hospital would predictably jeopardize the care of other patients in the Hospital. " At Merritts'emergency room, a clerk asks patients upon arrival whether they have Medicare, Medi - Cal or health insurance. If not, they are told that a certain amount of cash is required before leaving the premises. Some leave at once; others stay, get treat- ment and pay. A bill is sent for any outstand- ing amount, and if not paid, it goes to a col- lection agency. Except in real emergencies, patients on Medi - Cal must have a Medi - Cal card with a valid sticker (each Medi - Cal pa- tient receives a new card each month with two removable stickers for the two doctor visits to which they are entitled); otherwise they are sent away. One emergency room (ER) physician at Merritt a hospital with declining occupancy says that hospital admissions have in- creased four percent since the ER opened in 1972. " That's why they opened it, " he added. The hospital makes money on laboratory tests, X rays -, pharmacy and inpatient ser- vices but loses on the ER itself. The hospital bills the ER patients for both hospital and doctor services, then pays the ER doctors 15 $ an hour plus part of any fees collected. over that amount. Thus it is in both the doc- tors'and the hospital's interest that patients pay. At the point that a patient needs to be ad- mitted, stricter financial screening is done. But the patient seeking admission faces an- other, equally serious problem: a private doctor must be found to care for him. The Merritt ER regulations state: " Every effort must be made to preserve and protect existing relationships between the private physician and the private patient. Thus every effort must also be made to refer pa- tients to private physicians only when it is appropriate to do so... inquiry will be made of every patient presenting at the Emergency Department as to whether or not he has a private primary physician... Patients will be considered then as either private or other. " Private patients are treated only after get- ting permission from their doctor; it is con- sidered improper to interfere with a doctor's clientele. But it is equally improper to bur- den the private doctors who make up the hospital staff with non private - patients. Doc- tors on hospital staffs are often reluctant to care for the poor, the uninsured, the very sick or anyone who is not their own patient. So both the hospital and doctor conspire to transfer precisely these categories of pa- tients to the public hospital. B. Plympton 7 Patient Tracking Patient dumping is only the tip of the ice- berg. Most poor, sick and uninsured people are channeled to the county hospital di- rectly, without the benefit of a side trip to the private emergency room. For example, the majority of Highland's patients (60 percent) come from " poor Oakland, " the core ghetto area of Alameda County. (Poor Oakland has 85 percent of Oakland's Blacks, 80 percent of its Latins, 79 percent of its poverty fam- ilies and 77 percent of its Medi - Cal house- holds. It also has a rate of infant deaths 1.9 times that of the rest of the City and similar statistics pertain for other illnesses.) About ten percent of households in Oakland are medically indigent and 25 percent receive Medi - Cal; yet 25 percent of Highland's pa- tients are medically indigent and 50 percent are on Medi - Cal. Only eight percent of Highland patients have private insurance and four percent have Medicare; these are the programs that reimburse most lucrative- ly and finance the vast majority of private hospital patients. One of the key mechanisms for channel- ing patients is referral. For example, in con- trast to legal authorities (police, courts, etc.), which deal largely with individuals unable to pay hospital bills, private employers refer their sick employees to private hospitals. Specifically, in Alameda County, referrals from legal authorities account for 40 percent of Fairmont's emergency room patients and 22 percent of Highland's. On the other hand, workplaces refer ten times as many patients to private hospitals as they do to public ones. Not unexpectedly, private doc- tors refer most of their patients to private ER's. Private physician referrals make up 30 percent of private ER patients, but only two percent of public ER patients. Public hos pitals also tend to get a disproportionate share of psychiatric, drug and alcohol cases. For example, Highland, which only gets 28 percent of all emergency room visits in the northern half of Alameda County, receives 53 percent of all psychiatric referrals, 84 per- cent of all alcoholic patients and 50 percent of all drug abuse patients in that area. In the southern half of the County, Fairmont, which gets six percent of the emergency room visits, sees 40 percent, 83 percent and 38 per- cent of these respectively. Ambulances are another way of routing patients to their " proper " destinations. Ala- meda County has a private system of ambu- lances with the ambulance stewards making the decision about ambulance destination 80 percent of the time. The case of Provi- dence Hospital demonstrates how it works. Providence recently opened a 24 hour - emer- gency room to bolster its sagging inpatient occupancy rate. Soon patients who before would have gone to Highland were being shipped to Providence. Whereas nine per- cent of Highland ER patients were covered by private insurance in 1972 before the op- ening of the Providence ER, by 1974 these patients had dwindled to three percent. The patients which Highland now gets from am- bulances are 33 percent medically indigent, 53 percent Medi - Cal, five percent Medicare, three percent private insurance, two percent police hold and four percent dead on arrival. According to an 18 month - study by a Uni- versity of California anthropologist, Stephen Frankel, " There is an informal system of am- bulance triage which is based on a variety of non medical - factors which include pa- tients'insurance coverage. " The ambulance stewards are treated well by the Providence emergency room; they have a room for cof- fee, whereas at Highland there are no such amenities. Clearly the stewards play an im- portant role in patient channeling. In obstetrics, where occupancy rates are particularly low and Medi - Cal reimburse- ments are high, the creaming off of paying patients by private hospitals is even more glaring. For example, while most pregnant women living in Oakland's poverty areas went to private hospitals (87 percent), those without health insurance of any kind are forced to utilize Highland's obstetrics service. Thus Highland receives only the poorest and sickest expectant mothers. About 50 per- cent are medically indigent or Medi - Cal pending (eligibility uncertain) so that they constitute a financial risk to the hospital - a far higher percentage than that for the rest of the hospital. The workload this entails is considerable. During a one week - period in April, 1974, seven out of 13 Highland deliveries involved complications, showing the enormously high risk group of mothers that Highland sees. Some of these deliveries were complicated in multiple ways, including three breeches, two markedly premature infants, several cases of fetal distress, one Caesarian birth and three infants requiring intensive care units. Of course all of this shuffling of patients is shaped by the amalgam of different needs and interests of the particular private hos- pitals involved. Hospitals such as private Samuel Merritt, which are staffed predom- inately by private doctors, have neither the need nor the interest to hospitalize patients without a private doctor (or at least not until their occupancy rates tailspin). On the other hand, hospitals with housestaff teaching pro- grams (only 16 percent of all hospitals, but the largest and most important hospitals), like Children's or Herrick, require patients as " teaching material. " And the best " teaching patients " are those who can pay but whose bill is financed by public monies. These pa- tients (e.g., Medi - Cal) are not a financial drag on the hospital, and because they must be grateful for being admitted to a hospital, even with public health insurance, they are in no position to decry their exploitation. Thus 62 and 30 percent of Children's and Herrick's ER patients are on Medi - Cal, whereas only six percent of private Alta Bates Hospital's ER patients are on Medi - Cal. The rejection and exploitation of poor pa- tients by both private doctors and hospitals is old and well documented. Nor has Med- icaid, which was supposed to give the poor access to private sector medicine, remedied the situation. (See article on Medicaid, page 11 this issue, and BULLETIN, July Aug /. '72). In New York City, four percent of the doc- tors collect 85 percent of Medicaid fees. (4) A 10 year - survey of welfare recipients in New York, entitled " Medicaid Benefits Main- ly the Younger and Less Sick, " reveals that the aged and disabled receive less care after Medicaid than before its enactment, con- cluding, " There are considerable limitations to the extent to which money alone will cure the health care ills of the urban poor. " (5) In Washington, D.C. less than one of three private doctors participate in Medicaid. (6) In Rochester, a study showed that declines in Medicaid reimbursement " led many pri- vate practitioners to withdraw from the pro- gram " (7), and similar observations have been made in other states. In Chicago, 100 of 9,000 physicians care for over one half - of the 275,000 Medicaid patients, with Cook County Hospital treating half of the County's Black people. (8) The same discrimination is practiced by hospitals, unless Medicaid re- imbursements are unusually lucrative or the hospital is in unusually desperate financial straits. In New Orleans, seven out of nine hospitals were sued for denying access to Medicaid patients. (9) In Ohio, 45 percent of Medicaid payments go to 15 hospitals, a mere four percent of the total hospitals in the state. (10) In Cook County (Chicago) 14 out of 95 hos- pitals account for 67 percent of the Medicaid payments to hospitals; most of these 14 hos- pitals are major teaching institutions. Cook County Hospital receives fully 22 percent of the county's payments. In one low income - neighborhood of Chicago 55 percent of Med- icaid patients have to travel outside the area for hospital care because six of the seven neighborhood hospitals see few Medicaid patients. The administrators of the seven hospitals report that " Even if a person were able to demonstrate Medicaid eligibility at the time he sought service, the hospital may not have enough house physicians to provide the needed care if the patient had no private physician of his own. " (11) If Medicaid patients have few options, medically indigent patients have even fewer. Anne Somers, nationally recognized spokes- person for private hospitals, states, " The pro- vision of free care is a disappearing phe- nomenon. " (12) The Wall Street Journal (August 8, 1972) asks, " Does tender loving care end at the cashier's window? " and an- swers, " Nearly all hospitals require evidence from patients as to their ability to pay the bill. " Perhaps the most revealing case study of private hospital behavior is the response to the 1946 federal law requiring that hospitals receiving Hill Burton - construction funds (about half the nonprofit hospitals in the country) must provide a " reasonable vol- ume " of free or below - cost service to people unable to pay. (13) For years the hospitals did not comply at all. Following a recent se- ries of law suits, they fought tooth and nail to minimize the amount of free care by weak- ening federal and state regulations. At pres- ent, most state Burton Hill - agencies have either failed to promulgate regulations on the matter or have issued illegal provisions favoring the hospitals. (14) In late 1973, the US District Court in Wash- ington, D.C. declared that the Internal Rev- 9 enue Service may not grant tax exempt - sta- tus to hospitals that fail to treat people un- able to pay. (15) The suit was filed on behalf of a number of organizations across the country and charged that nonprofit hospitals are dumping poor patients into overcrowded and underfinanced public hospitals. One example cited occurred in Prestonburg, Ken- tucky, where a 21 year - - old woman in labor was denied admission to Prestonburg Gen- eral Hospital because she couldn't pay a $ 250 deposit. 16 () The woman died shortly after childbirth. Immediately following the 1973 court decision, the American Hospital Association petitioned for a rehearing of the case. Though the court has just denied the petition, the plaintiffs expect further maneu- vering by the AHA to annul or limit the ef- fects of the decision. Patient dumping and patient channeling are but blatant and subtle aspects of the same phenomenon - the channeling of pa- tients by private hospitals so that the profit- able ones come to them (profitable financial- ly or in terms of teaching potential), while those who are unfunded or socially unde- sirable get shunted to public hospitals. The existence of this phenomenon means that financing mechanisms, a la national health insurance, are not enough to guarantee care for everyone in the private sector. As long as private doctors and hospitals are allowed to pick and choose their clients (which after all is one characteristic of being private), a sig- nificant minority of Americans will be de- nied access to care. -Barry Roth (Dr. Roth is an intern at Highland General Hospital in Oakland, California.) References 1. 1. de Vise, P. " Cook County Hospital: Bulwark of Chicago's Apartheid Health System " The New Physician 20 394:, 1971. 32.. CRoonegmreesrs,i oMn.aIl. R eacnodr dM,e Jruan,e J2.8A, .1 9"7'1P,a tp.i eSn t1 0D0u37m.p ing'and Other Voluntary Agency Contributions to Public Agency Problems " Medical Care, January February - , 1973. 54.. OColnegnrdezsksii,o nMa.lC .R e"c oMredd,i cMaairdch B1e2n,e f1i9t7s3 ,M api.n lEy 1t4h5e0 .Y ounger and Less Sick " Medical Care, February, 1974. 76.. RCoongghrmeasnsni,o nKa.lJ .R e"c oUrsde, oJfu nMee d2i8c,a i1d97 1P.a ypm.e n1t0 0F4i0l.e s for Med- ical Care Research " Medical Care, February, 1974. 8. Medical Care Review, December, 1968, p. 941. 9. 9. Schwartz, J. and Rose M. " Opening the Doors of the Non Profit - Hospital to the Poor " Clearinghouse Review, March, 1974; and California State Health Planning Coun- cil, Health Facilities Committee, Minutes of June 21, 1973. 10. Hospitals, September 1, 1973, p. 166. 11. Davidson, S.M. and Wacker, R.C. " Community Community Hospitals Hospitals and Medicaid " Medical Care, February, 1974. 12. Somers, A. Hospital Regulation: The Dilemma of Public Public 13. PHoelailctyh, L1a9w6 9N,e wps.l e4t1t.e r Newsletter, May and September, 1972 (10995 LeConte Ave., Rm. 640, Los Angeles, CA 90024). 14. Schwartz and Rose, op. cit. 15. Schwartz and Rose, op. cit. 10 16. California Council for Health Plan Alternatives Alternatives. Health and Welfare Report, November 15, 1971. Kennedy - Mills (Continued from page 3) to at least recognize the need for the re- structuring of the health system. For as long as the bulk of every health care dollar goes not for the delivery of health services, but for the profits of drug, insurance and hospital supply companies and the academic, teach- ing, expansion and other non patient - prior- ities of health care providers, consumers cannot expect their health care to improve with any national health insurance mea- sure. Indeed, to the extent that national health insurance bills beef up financing with- out speaking to these issues, they result in the redistribution of income - from workers and the American public to those who profit financially and professionally from the de- livery of health care. Maybe some inkling of this perception accounts for why the pres- ent interest in national health insurance is coming primarily from the latter group and not from workers and consumers. -Ronda Kotelchuck More on National Health Insurance WHO WILL PAY YOUR BILLS? A detailed analysis and an overview of the issues includes - supplement on Kennedy - Mills, Long Ribicoff - , and new Nixon Bills. 30 pp. $.50 apiece;.30 $ apiece for ten or more. A CONSUMER CRITIQUE OF NATIONAL HEALTH INSURANCE A quick way of getting a grasp on key issues, updated to include new ver- sions of all major bills. 8 pp. $.10 apiece. Write: Health / PAC 17 Murray St. New York, N.Y. 10007 Add 20% for postage (.10 $ minimum) Medicaid Mills What is exhilaratingly revolutionary about Medicaid is neither the program's more gen- erous enrollment of the medically indigent, Most Medicaid payments for ambulatory PING PONG care are on a fee service - for - basis - the more REBOUNDS patients seen, the more money received. In nor even its delightful smorgasbord of com- prehensive health services. No, Medicaid's New York City Medicaid pays private doctors 7.40 $ for the patient's first visit and 6.00 $ for critical innovation lurks elsewhere - in its ex- every visit thereafter. In contrast, outpatient clusively assigning to the Health Department the heady tasks of standard setting, surveil- lance, and enforcement of quality in every aspect and every locus of publicly funded, personal health care. - Dr. Lowell E. Bellin Former Executive Medical Director, clinics (OPD) at voluntary hospitals are typ- ically reimbursed at more than five times this rate (see chart). For example, Montefiore Hospital in the Bronx is paid $ 40.24 for each visit and Mount Sinai in Manhattan $ 46.66. True to form, the municipal hospitals receive a lower rate than most voluntaries (33.71 $ ), Medicaid New York City Department of Health At American Public Health although much more than the private doc- tors. Thus Medicaid's ambulatory program is primarily a funding mechanism for hos- Association convention, Nov. 1968 pital outpatient departments, helping them Mrs. Gloria King went to the Davidson Medicaid Building for treatment of migraine headaches. She saw a doctor. " He told me to stop taking the birth control pill I was using. Then he referred me to a podiatrist. " The to cut their losses on outpatient care. At the same time, though, it does provide a way for a few doctors willing to practice bad med- icine in poor neighborhoods to reap a finan- cial windfall. podiatrist took X rays - of her feet and diag- nosed the cause of her headaches as in- grown toenails. He removed the toenails from both her big toes and Mrs. King has been in pain ever since. Nine years after the inception of the Medicaid program, Mrs. King and other patients in the Bronx have tired of waiting for Dr. Bellin's'exhilarating revo- lution. They have joined the Morris Heights Ad Hoc Committee for Better Health Care. Since the beginning of the Medicaid pro- gram in 1966, newspaper reports document- ing instances of malpractice and outright fraud at neighborhood Medicaid clinics have made headlines. From time to time, local health and welfare officials have announced Medicaid Mills These inequities in reimbursement sched- ules when combined with a fee service - for - system produce Medicaid mills privately - owned, profit making - neighborhood health facilities. The system puts a premium on quantity, not quality. A solo practitioner who must pay all of his costs from Medicaid pay- ments - rent, equipment, salaries, etc. can - hardly be expected to deliver decent care at the rates currently in effect. A Medicaid doc- tor would have to see over 10,000 patients a year to earn a salary of $ 40,000 per year, MEDICAID OUTPATIENT REIMBURSEMENT new programs to curb abuses. But the Mor- RATES - per visit ris Heights Committee is the first to attempt -_ Hospital to organize patients to challenge such Beth Israel Medical Center Rate $ 44.69 abuses. Flower and Fifth Ave. Hospital 63.38 Mount Sinai Hospital ; Medicaid Financing Financing . 46.66 Medicaid Financing The problems of neighborhood Medicaid Medicaid clinics stem from the way New York City finances medical care for the poor. Last year the City reimbursed providers $ 1.3 billion. Three quarters - of this impressive sum went Montefiore Hospital Roosevelt Hospital St. Vincent's Hospital 7 40.24 50.41 41.64 Presbyterian Hospital 30.89 New York City Municipal Hospitals. 33.71 Medicaid Clinics 7.40 to hospitals and nursing homes. Only eleven percent, $ 145 million, was paid to private State of New York - Dept. of Health Memorandum Series 72-10 doctors, dentists, podiatrists and optometrists. 11 the average for a US doctor. As a result, doc- tors cut costs by turning to group practices in poor neighborhoods, which in turn be- come Medicaid mills (see BULLETIN, July- August 1972). Medicaid mills are usually organized by one or two enterprising individuals who buy or lease a building, often a storefront, and rent space to other practitioners. In some cases the tenants pay a fixed monthly rent, as is customary in New York City. But, typ- ical of the spirit which permeates these op- erations, many landlord - doctors charge rents on a sliding scale based on the num- ber of patients their tenant doctors - see. The more patients seen or recruited, the lower the rent. Another way Medicaid doctors increase their income is through a practice graph- ically called " ponging ping -. " One doctor in a clinic refers a patient to another, whether the referral is medically necessary or not; the second doctor then sends the patient back and so on. This practice of I'll scratch your back, you scratch mine drives up the volume of patient visits, resulting in Medicaid money for the doctors and many unnecessary ap- pointments for the patient. For example, in the Bronx, nearly every patient entering the Davidson building, regardless of complaint, was sent to the podiatrists. Medicaid patients use these facilities be- cause they are all that is available to them. Only 2,000 of the 19,000 practicing physi- cians in New York City earned any appre- ciable amount of income from Medicaid (see chart). Nearly all of these doctors practice out of one of the 362 profit making - neighbor- hood clinics. Of these doctors, 280 (about 10 percent) made over $ 50,000 last year from Medicaid alone. The Morris Heights Ad Hoc Committee Within the last half dozen years Morris Heights, a neighborhood in the Bronx, has changed from middle - class Irish and Jewish to predominantly Third World - 45 percent Puerto Rican and 45 percent Black. A sub- stantial minority of the residents are welfare recipients and slightly more are covered by publicly - funded health programs (Medicaid and Medicare). The 45,000 people of Morris Heights are served poorly by two municipal hospitals, Fordham and Morrisania. Both 12 hospitals are badly deteriorated and diffi- PHYSICIANS IN N.Y.C. RECEIVING SUBSTANTIAL AMOUNTS FROM MEDICAID. 1973 Number 580 560 567 220 Amount $ 5,000- $ 10,000 10,000 20,000 20,000- 50,000 50,000- 100,000 60 over $ 100,000 New York Medicine March, 1974, page 96 cult to reach. Thus, because the neighbor- hood falls between the cracks of the City's public hospital system, it is ideally situated for the establishment of private Medicaid clinics. Twelve have now sprung up. In March 1973, the Morris Heights Im- provement Association, a coalition of block associations and tenants groups, formed an Ad Hoc Committee to investigate the prac- tices of Medicaid offices. The group was composed of eight people, four of whom were Medicaid patients. One full time - paid organizer from the Improvement Associa- tion, Roger Hayes, was assigned to work with them. Surprisingly, their first task was to identify the clinics in their area, a diffi- cult chore because storefront offices are not licensed as group practices (they are called " shared facilities " by the Health Department) and practitioners often have separate billing addresses elsewhere. Even the Health De- partment does not have a complete list of these facilities. The Ad Hoc Committee, after locating the eight clinics then in operation, finding out the doctors'names and specialties, their hours and equipment, began interviewing patients: " Do you know what you are being treated for? What drugs were you given? Why? Did you see more than one doctor? Do you know why? Does the clinic keep a rec- ord of your health status? " Within two months, the Committee had generated enough community interest to hold a public meeting. Patients Testify Two of the local clinic doctors administra- / tors were invited to the meeting to hear the testimony of their patients. They hesitated, but when the Committee threatened to picket their storefronts, they came. The complaints they heard included: OE Unnecessary referral from one doctor to another (ponging ping -) . Mrs. Peggy Pierson went to the Davidson Avenue Center for a backache. " They suggested plastic surgery for my nose. Then they wanted to check my feet, my eyes, the whole works. " @ Endless visits for specious medical prob- lems. Mrs. Rose Ann Frey was told to come back every three weeks to have her " tilted uterus " examined. OE Patients poorly examined and given in- appropriate drugs. Mrs. Angie Reyes took her son to the University Avenue Medical Group. Dr. Malba examined the child quick- ly, diagnosed a bad cold and prescribed am- picillin. Since he did not get better, Mrs. Reyes took Daniel to Columbia Presbyterian - Hospital. After a spinal tap, he was found to have spinal meningitis. He was admitted to the hospital and stayed ten days. OE Incomplete or nonexistent medical rec- ords. Mrs. Sally Williams was being treated at the Davidson Avenue clnic for asthma. The same drug was given to her a second time although she had gone into anaphylac- toid shock after the first administration. " The next thing I knew, I woke up in the Fordham Hospital emergency room.'" OE Non Medicaid -p atients charged high fees for non service - . Mr. Henry Leisin went to the University Avenue Medical Group to take care of a mole on his face. The clinic manager collected $ 15 from Mr. Leisin before he saw a doctor. The visit with the doctor lasted less than one minute. He was referred to Lebanon Bronx - Hospital. On his way out Mr. Leisin asked for a receipt. The manager resisted, saying, " You don't want a receipt. " Mr. Leisin left in disgust. The two doctors present at the meeting were asked to sign an agreement which specifically prohibited the above practices, most of which in any case violate Medicaid regulations. They balked and agreed to sign only if the other clinics in the neighborhood did likewise. By mid July -, the Committee had coerced and cajoled seven of the eight clin- ics into signing. The one recalcitrant clinic was picketed. Fundamental to the Committee's strategy was the notion that the clinics were basically business ventures and vulnerable to the same tactics used to influence other neigh- borhood businesses. Because there were so many clinics in close proximity in Morris Heights, the Committee could exploit com- petition between them for the patients'bene- fit. Picketing was viewed as a way of put- ting economic pressure on the non comply- - ing clinic. People entering the storefront were asked to boycott it and take their Med- icaid business elsewhere. This strategy is, of course, of limited value if none of the avail- able facilities are delivering decent care. The New York City Department of Health, which had initially encouraged the Ad Hoc Committee, sent medical auditors to check out the clinics. This was pursuant to their re- sponsibility " to develop and maintain a sys- Plympton 13 tem of continuing review of the quality and extent of care provided Medical Assistance [Medicaid] recipients " (New York State Med- ical Handbook). The City Health Department, however, does not have the capacity to au- dit Medicaid facilities on a regular basis. In fact, it can only perform two audits a week on New York's 362 Medicaid clinics. So, teams are sent out only in response to spe- cific complaints, such as those from Morris Heights. The auditors found the services in Morris Heights to be about average for such facil- ities - a devastating comment on the quality of such clinics. Copies of the audits were turned over to the Committee. The Health Department report cited such violations as cockroach infestation, " prescribing in small amounts so as to increase the number of pa- tient visits, " illegible and incomplete med- ical records and " unnecessary referrals. " With the Health Department audits in hand, the Ad Hoc Committee went to see the administrators of several of the clinics. They accused the doctors of violating the agree- ments signed with the Committee since the audits clearly documented the continuation of abuses. They threatened these clinics with picket lines if the violations were not cor- rected. Only one of the clinic administrators refused to see the delegation. All of the others cleaned up their clinics and elim- inated some of the more glaring conditions. The storefront which refused to discuss the situation with the Committee was picketed every Saturday for several months. In addi tion, the suburban homes of two of the doc- tors were picketed and leafletted. Later on, the Committee investigated col- lusion between some of the storefronts and local pharmacies. First they surveyed drug prices. They found enormous discrepancies in prices which seemed related to the loca- tion of Medicaid mills. For example, forty 250 mg. tablets of ampicillin cost 16.95 $ in a drug store adjacent to a Medicaid office and $ 3.50 at a store further away. The drug price survey and other informa- tional leaflets were distributed to people en- tering and leaving Medicaid offices. One en- titled " How Good A Patient Are You " en- courages patients to ask for comprehensive and continuous care. For example it ques- tions, " Do you ask to see the same doctor on every visit? If the doctor tells you to re- 14 turn to the clinic, do you know why? Do you make sure that the doctor knows your com- plete medical history? " Other leaflets were information and evaluation sheets for pa- tients to use as a basis for judging the qual- ity of care they were receiving. One Year Later By March, 1974 the Morris Heights Com- mittee concluded that their strategy of pa- tient education and pressuring clinics with Health Department audits and picket lines was not enough. They felt they had made some inroads into the Medicaid situation and that community people looked to them as a watchdog and complaint bureau. One of the organizers commented that " At least the people identified with the Committee are getting better care. They think twice now about ripping off patients. " But, they felt services delivered in storefront clinics were still not very good and could not be made better without the intervention of other forces. They called another public meeting to chart their future course. The group de- manded that the Health Department, which had sent representatives to the meeting, fol- low up its audits and impose sanctions on clinics found in violation of standards of good medical practice. Dr. Lowell E. Bellin, New York City's re- cently appointed Health Commissioner, con- tends that he does not have the statutory authority to enforce standards of care. He tempers this legal assessment with political hesitancy. " We want to put pressure on suf- ficiently so we can reform them, if we put too much pressure we can drive them out com- pletely. " It is difficult to tell if Dr. Bellin is more concerned about his legal limitations or considerations of political realities. His re- cent action ordering the Bureau of Standards and Evaluations to stop distributing audit re- ports to community groups leads one to believe that the " problem " is a political one. Paul Brandt, chairman of Bronx Commu- nity Planning Board 5 and an active sup- porter of the Ad Hoc Committee, feels Bellin is side stepping - the issue. " The Health De- partment has a statutory responsibility as administrator of the Medicaid program to as- sure that the services are of good quality. Besides being a public health menace, the Medicaid mills are a tremendous drain on the taxpayer. " The Ad Hoc Committee does not believe that the Health Department has brought all of the authority it currently pos- sesses to bear. Bellin's argument might or might not be accurate, but the City has never behaved in a way to test it out. Despite its rhetoric of good intentions, the Health De- partment has had only minimal impact on Medicaid mills witness - the audit which found the Morris Heights clinics on a par with other Medicaid practices. The Ad Hoc Committee does agree with Bellin that some new and strengthened regu- lations are needed, and they have joined him in lobbying in the State Legislature and City Council. They see this as a major focus of their current program. Some of the changes proposed included expanding the legal definition of group practices so Med- icaid mills fall under customary licensing re- quirements, limiting the number of patients a doctor can bill (currently the City will re- imburse for up to 50 patients a day), pro- hibiting rent agreements based on the num- ber of patients seen, requiring facilities to maintain central records and increasing the penalties for non compliance - . Of course, all of these changes may be fine, but they are dependent upon the abil- ity and willingness of the Health Department to enforce standards and penalize violators. Dr. Bellin before becoming Health Commis- sioner was Executive Medical Director of New York City's Medicaid program from 1967 to 1972. A few practitioners were prosecuted for fraud and some claims were disallowed. But for the most part his track record in that job does not inspire confidence in the ide" that if a few laws are changed, giving the Health Department more power, Medicaid patients would get better care. For the time being the Ad Hoc Committee has hitched its star to Bellin's legislative pro- gram. Their experience with the Health De- partment before Bellin's installation was one of close cooperation. But under Bellin, the Department seems to have different agenda and is responding to political pres- sures often inimical to consumer interests. The reform of Medicaid mills is not high on - the agenda of the Health Department. Of course, public agencies have never been ad- verse to using community struggles to their own ends. And Bellin has openly advocated this position. In speaking of community boards he said: " In the 1970's one can hard- ly begrudge the poor the indulgence of serv- ing on boards.... The experienced adminis- trator should theoretically be able to work quite comfortably within the mandates of the board's broad policy and claim quite ac- curately that he is responsive to the will of the community. " -Barbara Caress Media Scan MARCUS WELBY ET AL Television medical shows reach more people than any other source of health care in- formation. TV medical miracle workers show up on three prime - time shows, two day- time soap operas and three non prime - time evening shows. Like their companion video shows their primary function is not to inform, or even to entertain, but to pro- vide America's businesses with convenient access in a supportive setting to a large number of consumers. The supportive setting goes beyond the use of medications on a medical show to reinforce the message of commercials -_ for over counter - the - drugs. Ad- vertisers, and therefore pro- ducers and networks, need to present viewers with pro- grams that idealize the eco- nomic and social systems from which they profit. In the med- ical arena this means that tele- vision's version of medical care is intensely personal, of high quality and readily avail- able to all who need it. The doctor invariably white and male - is deified, while other health workers - mostly _ fe- male and Third World - are relegated to trivial and sub- servient roles. The oldest and most popu- lar of the prime - time doctor shows is ABC's " Marcus Wel- by, M.D. " Welby is a greying, paternal family physician, who, with his young assistant, 15 Stephen Kiley, runs a lucra- tive practice out of their shared home - office. Most fam- ily doctors are largely occu- pied with administering phys- ical examinations and vacci- nations and treating sore throats and broken bones. The Welby - Kiley team, on the other hand, spends most of its time treating an enormously diverse range of rare medical maladies _ Hodgkin's disease, an exotic heart ailment caused by an African insect and a rare fatal disease found only in Jewish children, to name a few. Treating this range of med- ical problems takes up most of the doctors'waking - and even sleeping - hours. In one episode, Welby spends the night in his patient's hospital room just to be on hand should a complication develop. Young Kiley is constantly standing up his current girlfriend for the sake of a patient, smiling and shrugging it off as the price a doctor must pay in the service of his patients. In their rare leisure hours Welby and Kiley are usually found read- ing medical journals in their living room. Working and socializing flow together in the shows. Most of the patients are per- sonal friends of the doctors or become so by the end of the hour. Many episodes deal with the medical problems of Welby's neighbors in his plush suburban neighborhood, thus giving Welby the oppor- tunity to be a good friend and neighbor while being a good doctor. " Medical Center " is the CBS version of hospital centered - health care. Although 90 per- cent of hospital workers are not physicians, most of the program's footage centers on 16 a doctor star, Dr. Joe Gannon, a young athletic surgeon sporting skin tight - scrub clothes. Dr. Gannon emerges as the Renaissance man of modern medicine - an accom- plished cardiovascular sur- geon, neurosurgeon, thoracic surgeon, internist, gynecol- ogist, pediatrician and head of the Student Health Service as well. Much of Gannon's clientele, like Welby's, consists of per- sonal friends in need of spe- cial hospital treatment. Also like Welby, Gannon thinks nothing of giving his patients unique personal attention. In one episode the patient is a poverty stricken - elderly wo- man, suffering from a fatal disease, who wants to conceal her downtrodden status from her visiting daughter. Nothing being beyond the call of duty for Dr. Gannon, he cheerfully pays for a new wardrobe and the services of a beautician and then puts up the patient in his apartment for a week, while he camps out on the couch in his hospital office. One would never guess from watching " Medical Center " that 10,000 Americans die each year from unnecessary surgery. Surgery is frequently and expertly performed. The patient never suffers complica- tions and is always cured. The fallacious idea that surgery is frequently necessary and al- ways a life saving - grace is thus perpetuated and rein- forced. In January, CBS launched " Doc Elliot, " another prime- time doctor show starring a hip, young general practition- er who fled the city for the Colorado countryside. Elliot's base is a clinic staffed by one woman serving as combina- tion nurse, receptionist and housekeeper. He spends most of his time making house calls in his ham equipped - radio -, four whee-l dr-i ve ambulance. The maladies of Elliot's pa- tients are less exotic and less life threatening - than those of Welby and Gannon. But, like his video colleagues, Elliot manages to spend an inordi- nate amount of time with each of his patients. In one episode, concerned with the promising future of a young athlete, Elliot spends many hours run- ning with him, teaching him track skills and ultimately convincing him that his sud- den paralysis was psychoso- matic. In the medical fantasy- land of Drs. Welby, Gannon and Elliot, there is apparently a great surplus of physicians, all unaffected by the fee for- - service system's incentive to practice mass production - med- icine. Fees and hospital bills, in fact, are rarely mentioned on TV medical shows, even when the treatment being portrayed is a kidney transplant which in the real world costs about $ 16,000. What mention there is of the cost of medical care -which is the leading cause of bankruptcy in the United States - is vague and cursory. When a young woman asked Marcus Welby about how she (Continued on page 18) Peer Review BOSTON DISSENT Dear Health / PAC: Advocacy journalism per- forms a worthwhile function for the public. However, when such journalism relies mainly on conjecture rather than facts, readers can be confused and misled. The October ar- ticle " As the National Goes, So Goes Boston, " concludes that Boston would like to join other American cities in pull- ing out of the hospital busi- ness completely. This conclu- sion is drawn from three de- cisions made by the Board of Health and Hospitals in early 1973: (1) reduce the capacity of Boston City Hospital (BCH) to 500 beds; 2 () give Boston ton University Medical School (BU) sole responsibility for medical staffing; and (3) re- duce the hospital employment level consistent with the ex- pected number of patient days under the new arrangement. Since the advent of Medi- care and Medicaid, BCH has been under utilized -. As the data in Table 1 indicate, bed capacity had been lowered several times prior to the 1973 decision. Moreover, the table shows that occupancy has re- mained around 76 percent of capacity even as that capacity was being reduced. In 1972, though BCH had a count of 817 beds, it utilized only 572 on the average. Thus, the re- duction in beds to 500 com- bined with efforts to better utilize those beds has resulted in a relatively small effect on the number of patients admit- ted to the hospital. To survive, BCH must operate at 85 per- cent of capacity or higher. We feel that at 500 beds this is now possible. Tighter bed limitations have resulted in the transfer of some patients to other hospi- tals when occupancy limits have been reached, primarily in the medical service. On 60 occasions in the past 8 months, transfers have been made with no risk to the pa- tients involved. The article in- correctly states that " A ma- jority of admissions are on the danger list and cannot be transferred out. " Of course, danger list patients are not transferred, but the fact is that only about 12 of the 50 admis- sions per day are danger list. Beds are always left open for possible danger list patients. The BCH policy in relation to medically indigent patients has not changed. The City still accepts the responsibility of caring for patients who are un- able to pay. This does not mean, however, that the other Boston hospitals have no re- sponsibility at all. They must also provide reasonable levels of free care. Hospital staffing must relate directly to utilization. As the accompanying table indicates, utilization has been declining steadily since 1968. During the same time, the number of hos- pital employees had been in- creasing. Controls on employ- ment levels are now required if for no other reason than the tight economic squeeze in which the City finds itself. Hence, the Board had no choice but to push for a rea- sonable staffing pattern and greater efficiency. Increased efficiency was al- so a major factor in the de- cision to give BU sole respon- sibility for medical staffing. Boston University was chosen over Tufts and Harvard for several reasons. Boston Uni- 17 versity shares with BCH a strong commitment to the com- munity served by Boston City Hospital. Boston University al- ready had medical responsi- bility for more than 50 percent of BCH's beds. And BU was the logical choice geograph- ically. The article also contained the implication that Boston's Mayor is insensitive to the problems the poor have in get- ting medical care. Nothing could be further from the truth. Since Mayor White's first election in 1968, his ad- ministration has taken leader- ship responsibility for devel- oping a wide city - system of neighborhood health centers with strong hospital back - up. A community dental program has been developed. Many other community health proj- ects have been initiated to im- prove the health of Boston's poor and non poor - alike. May- or White and all other big city Mayors are worried about where they are going to con- tinue to get the money to pay for health care that is right- fully the Federal Govern- ment's responsibility. But un- til the President and Congress act, we will meet our health responsibilities in Boston to the best of our ability. -Leon S. White, Ph.D. Commissioner of Health and Hospitals City of Boston Media Scan (Continued from page 16) was to pay for his care of her son, he ended the discussion with " We can work some- thing out. " When a script had one of Welby's associates commenting, " I'm sorry to say that many of those who need insurance most don't have it, " the line was censored by the network's AMA consultants before the episode reached the air. The present health care delivery system is thus legitimized by the implication that television - quality health care is readily available re- gardless of social class. Third World people rarely appear on the medical shows, either as doctors, a fact thut does bear a relation to reality, or as supportive health work- ers - an omission that is gross- ly misrepresentative of reality. Black patients occasionally appear, almost invariably suf- fering from sickle cell anemia, as if more common medical inflictions are only visited up- on whites. Women, when they appear, are typically portrayed in a manner that denigrates their role in the provision of health care. (Some 70 percent of all health workers are women, and nurses are frequently the workers most directly involv- ed with on going - patient care.) Dr. Welby's nurse, Consuelo, for example, spends most of her time on camera doing pa- perwork and engaging the pa- tients in small talk. Women doctors, when their existence is acknowledged, are charac- terized in ways that make their gender more important than their profession. In one " Medical Center " episode, a female surgeon is forced to leave her profession because it does not allow her enough time with her husband and family. A male surgeon in a later episode, on the other hand, divorces his wife rather than sacrifice his profession. Men, in other words, are justi- fied in being totally dedicated to their profession, while wo- men must ultimately be loyal to their marriage and family. Fantasy may make for good entertainment. It may even sell deodorants. But the con- tradictions between health care on television and health care in the real world are too great for the TV medium to successfully sell the proposi- tion that all is well with Amer- ican medicine. Written collectively by students at Theme House in Community Health at the University of California, Berkeley Year Personnel Beds Census Personnel / Bed Ratio Personnel / Census Ratio 1968 1969 1970 1971 1972 1973 * 1974 3569 3697 4145 3880 4157 3644 3287 1132 998 835 757 817 658 500 750 691 644 625 572 480 420 3.15 3.70 4.96 5.12 5.08 5.18 6.57 4.70 5.35 6.43 6.20 7.26 7.53 7.82 18 (* Personnel and bed figures are averaged for greater accuracy at beginning and end of year.) = Vital Signs MIDAS TOUCH IN REVERSE Nothing ever seems to go right for President Nixon. Re- member the Cedars of Leba- non Hospital in Miami, that paragon of the nation's " great private health care system " whose $ 75 million new wing President Nixon dedicated in February? What hospital officials didn't say in the dedication ceremony was that on that very day, the hospital was two weeks late on mortgage pay- ments of some $ 98,000 and had sustained operating loss- es of over $ 600,000 in the pre- vious year. In early April the hospital's director and board chairman were both fired for financial mismanagement and the hos- pital went into federal bank- ruptcy court to have its debts frozen. The hospital's debts total more than $ 9 million, in- cluding over $ 500,000 owed the Internal Revenue Service for employee withholding tax. Miami officials never thought the Cedars of Leba- non was a paragon of any- thing except runaway expan- sionism. They opposed its ex- pansion from the beginning, arguing that by 1975 Miami is expected to have a surplus of 4,000 hospital beds (out of a total of 12,000). The hospital went over their heads to the regional Federal Housing Au- thority (FHA) office and to Washington, and now connec- tions with Nixon aides Bryce Harlow and James Cava- naugh are being mentioned. The head of the regional FHA office is now in jail for accept- ing bribes in another case, and a Senate investigating committee is about to descend on the Cedars of Lebanon, looking, among other things, for links between the hospital and Presidential confidant Bebe Rebozo's Key Biscayne Bank. Maybe the Cedars of Lebanon is a paragon of more than we at first thought. SEXUAL DISCRIMINATION IN HEALTH INSURANCE Women get sick at an equal, if not lower, rate than men, yet they pay more for health insurance benefits, and suffer job discrimination as a result. So says a recent report of New York's Temporary State Commission on Living Costs and the Economy. Labor Department statistics show that men lost an aver- age of 5.1 days of work due to sickness and injury in 1971, compared to 5.2 days for wo- men, which included time off for childbirth and complica- tions of pregnancy. Women's illnesses kept them away from work for shorter periods than did men's. These findings are confirmed by a study Metro- politan Life Insurance Com- pany did of its own workforce. It found 88.7 of every 1,000 men were hospitalized during 1972 compared to 76 of every 1,000 women. Furthermore, hospital stays averaged 9.5 days for men and 9 days for women. Yet women pay substantial- ly more for the same health insurance policies than men. For example, a five year - acci- dent and sickness plan for men costs $ 496.70. Women of the same age and occupation pay 762.80 $ . Similarly, a one- year sickness and accident plan costs men $ 320 and wo- men $ 496. These inequalities were found in plan after plan, and are even more striking in the case of low income - wo- 19 men. The result is employer discrimination against the hir- ing of women, the report finds. Much of this discrimination lies in the attitude that women work by choice and out of per- sonal convenience, rather than out of necessity as do men, states the report. Yet it finds that 41 percent of the wo- men who work are single, widowed, divorced or sepa- rated, and another 21 percent have husbands who earn less than $ 7,000 a year. The New York Civil Liber- ties Union is filing a class ac- tion suit against the New York Insurance Commissioner Ben- jamin Schenck to halt such discrimination. GETTING PATIENTS WHOLESALE Southern California, that cradle of the new capitalism, has pioneered a new solution to the problem of empty hos- pital beds, reports New Times Magazine. It's called patient buying. The going rate is ap- parently $ 50 to $ 100 per pa- tient, although there are re- ports of hospitals offering doc- tors stocks, vacations, cars and free lab and X ray - work. The source of the practice lies in Los Angeles County's 32,230 hospital beds 10,400 - of which are vacant. Many of these are in newly - built pro- prietary institutions which lack the reputation, staff or fa- cilities to attract doctors vol- untarily. There are no statistics on ex- actly the number of patients bought and sold each year, but everyone involved admits the practice is widespread, not only in Southern California, but across the country. Said one patient " seller, " " Name me a major city with proprietary hospitals that have overbuilt, 20 and I'll guarantee you it's a place where patients are bought and sold. In New York City doctors get cash, autos, vacations and other gratuities from proprietary hospitals in exchange for regular deliver- ies. In Miami I know of phy- sicians who deliver all their patients to one hospital in ex- change for $ 3,000. " The practice is also sophis- ticated. Many doctors work through brokers who search among hospitals for the high- est bidder. Most patients come from private practice, but some of the biggest suppliers own or operate private emer- gency rooms. Hospitals often employ publicists or consul- tants who work on a retainer or commission basis. Named in the article are some of the na- tion's largest proprietary hos- pital chains American Med- ical International, the Los An- geles based - Century Medical, Inc. and the Seattle - based chain, Centennial Villas. " As long as these profit- oriented firms persist in over- building, hospitals will con- tinue buying patients. It's strictly a matter of survival. The doctors involved couldn't be happier. They've found a recession - proof business that just happens to be tax free, " says one broker. CHARITABLE INSTITUTIONS MUST BE CHARITABLE? Poor people may have won a potentially significant court victory recently. A federal district court in Washington in December ruled that to con- tinue to qualify for tax ex- emption (under IRS Code, Sec- tion 501 (c) (3)), hospitals must give free care to " patients in need of hospital care who can- not pay. " In January, the court extended this ruling to require hospitals to post such a notice " conspicuously " within the hospital so all patients can read it. It also ruled that the provision of free care cannot be limited to emergency serv- ices, although additional guide- lines are as yet unclear. The suit was brought by the Ken- tucky Welfare Rights Organi- zation, the Association of Dis- abled Miners and Widows, the National Tenants Organization and individuals against the IRS. PUBLIC PROGRAMS MUST BE PUBLIC? Hospital cost data filed un- der Medicare must be made available to the public upon specific request after May 1, according to James Cardwell, head of the Social Security Administration. He reports an increasing demand for this in- formation and has ruled that it must be made public under the Freedom of Information Act. Hospitals are asking for a delay while they study the legal issues. WHAT THE DOCTOR DIDN'T TELL YOU Presuming you can find it and pay for it, have you ever wondered exactly what you're getting when you seek health care? Several recent studies and congressional testimony suggest perhaps you should. For example: OE 30,000 people die each year, most needlessly, from adverse reactions to antibi- otics, charges Senator Edward Kennedy, chairman of the Sen- ate Subcommittee on Health. Kennedy bases his charges on testimony from highly diverse and respected witnesses ap- pearing at a recent hearing on drugs and the pharma- ceutical industry.