Report to Congress & the Nation On Health Care (Reel 2)

Supporters of the Kennedy national health security bill put great store in its quality controls its main quality control is that only board certified or qualified surgeons will be reimbursed for major surgery. There are currently 20 specialty boards in medicine and surgery in order to be board certified the doctor must participate in several additional years of post-graduate work after residency and must pass a rigorous written and clinical examinations. The reason the Kennedy bill focuses on surgery is because many people feel that far too much surgery is performed in this country. Of the 17 million surgical procedures that will be done in hospitals this year many doctors feel that a great number will be inadvisable as surgery always involves risk of post-operative infection or problems with anesthesia. The old adage When in doubt cut it out is not good medicine. Yet Fortune magazine quotes an official of the A.M.A. as saying that the rise in tonsillectomies under Medicaid verges on the scandalous this unnecessary surgery has become so prevalent that a new term remunerative maze has been coined by

its critics. Dr. Loeb Ellen concerned about unnecessary surgery does not think that even the Kennedy health bill has sufficient quality controls. You're not going to be addressing why we're not going to be a board certified. Or a board eligible surgeon who's going to be reimbursed for a service. There's no guarantee for example that a board certified surgeon is going to do the job properly. This is only one step forward we know for example in the famous study carried out by Dr. Trussell formally the hospital commissioner and dean of the Columbia School of Public golf some years ago here in the city of New York. And that a significant portion of the work in surgery in New York City is something like one third was found to be inadequate despite the fact that frequently and most of the time these were blood certified and board qualified surgeons. When the study was continued to actually ask the patients what did you think of the quality of work you received. About 85 percent of the patients who had received this care which Doctor trust was on the staff's opinion was completely inadequate. I was quite happy with that care to return to their

original doctor. So what I want I'm trying to point out is this and this is one step. But I'm even more concerned something more fundamental we're actually getting the right kind of structure to monitor this thing to prime a great number of standings and to make and 140 standards this is what's key to the entire issue. One of the basic reforms in the health system is the development of health maintenance organizations. HMO has both the Kennedy administration national health insurance bills provide funds and incentives for their creation. The largest HMO in the nation is the Kaiser plan on the west coast HMO those are actually prepaid group practices places where several doctors join together in a group practice and are paid a certain amount per patient per month regardless of how often the patient uses the services. This is called a payment on a capitation basis. Currently most doctors are paid on a fee for service basis. That is you pay them for each office visit and for each procedure they perform. Critics say that this encourages

a system of sickness care and not health care. There is no incentive now for the physician to keep the patient well when he is paid only when they are sick. And it led to Reverend Andrew Young the vice chairman of the Southern Christian Leadership Conference made a strong case for HMO. I'd like to think of versus working toward a health care system that rewarded people and doctors for health rather than for sickness. Right now the more operations they perform the sicker people get the riches doctors get. In fact it's even more ridiculous because you get to go to the hospital and get an operation and then your health insurance pays for it. When a doctor could probably do it in his office. And I think that the set up of our hospitalization insurance presently drives people to the hospital and encourages hospitalization. When I think

we've got to have some kind of health insurance or some kind of health plan that encourages people to stay it will along with this I think the kind of system that would reward people for good nutrition. I'd like to see a group of patients a community served by a team of physicians where at the end of the year they would get a bonus if they had less than the national average of operations for people in that age an income bracket. Revenue be rewarded for the more operations they have. I think in some of the health care plans that I've. This was true in the Kaiser plan where people were rewarded for going to get regular checkups and they found that there in certain categories of operations they were remarkably less. When people receive rewards to stay in well. Than they were when people almost had to get sick in order to get some

kind of serious medical attention or some consideration from their insurance. Reverend Andrew Young of the Southern Christian Leadership Conference in San Francisco Republican Representative William my yard and Kaiser Foundation vice president Robert Erickson discussed how Kaiser has kept costs lower than commercial insurance plans. Congressman my art speaks first about commercial health insurance. The nature of the coverage is much more complete. If a patient is hospitalized and if they're kept out of the hosp. That's true and our system does have comprehensive outpatient coverage as well of inpatient coverage of so that the physician can choose the care that's most appropriate to the patient without being concerned about the out-of-pocket cost of the patient. I think the most unique feature of savings and hospitalization regarding Kaiser is the ability to keep costs down and hospitalization is lower than other plans and doctors receive extra bonuses if costs are

kept within a budget framework. Would you explain that please. There is an incentive program that gives the physician an added. Piece of the action you might say. And controlling cost and accepting financial responsibility. And if there is a surplus above the budget at the end of the year they receive a share of that surplus track. We hear that the surgical rate for those with group plans is half that for those with commercial health insurance and people who have indicated that there seems to be too much to a degree much unnecessary surgery in this country. I do know that studies have indicated that the rate of surgery in organized group practice programs including Kaiser is substantially less than it may resemble 50 to 60 percent rate and at least and in many of the studies I think it

may be even more marked in some of the truly elective type of surgeries as tonsillectomies. She why and I had surgeries that are truly elective. The incentive is for unnecessary surgery or remove from an organized system. And this may be a factor in the surgical rate anything in other words that the doctors under the group plan such as you as a remunerative on an annual basis and do not make extra money from doing surgery. That is correct they are paid so much per member per month despite the fact that most health reformers advocate HMO those. There are some who doubt their ability to improve the nation's health system. Dr. Oliver Fein of the Health Policy Advisory Center who has done extensive research on health expressed his misgivings about HMO has at our New York hearing for Health

Maintenance Organization program a program of mixed reorganization of the health system. Is pointed to as one program that was likely to keep costs down. But I say at the expense of the patients. Here's the way it works. The government contracts with an HMO to provide care to a certain population at a fixed prepaid price. If the cost of providing care exceed the pre-paid price the HMO will have to make up the deficit at style. If on the other hand the HMO keeps its costs under the prepaid amount then an HMO keeps the difference as profit. The profits lie in holding services to a minimum. HMO those are just one more way of reducing consumer demand. This will be done by long waiting lines and lines delays in elective surgery rather than in real preventive care.

Without consumer control to monitor the practices of HMO they will end up serving the doctors and the hospital centrists not the patient. Dr. Oliver fine at the New York Health hearing and this leads to a major issue for which we found a surprising amount of support. When one hears the words consumer control one tends to dismiss them as rhetoric of the left or stale slogans of the Great Society. Yet in every city we went we found support for a consumer to supply and even control of a revitalized health system. The support came from doctors from nurses and from Pennsylvania insurance commissioner Herbert Annenberg. I think the most important thing in the whole system and it's about the cost of quality control is to be certain that the consumers are in control and that the consumers are participating in these decisions as much as possible. All right health delivery system is a Frankenstein monster built on a Rube Goldberg principle. And it is now confronted by a

public with rising expectations and by a new technology that is that is dramatically expensive and dynamic. But it goes on its merry way indifferent to the needs of the community and its limited ability to pay ever increasing medical and hospital costs. The system is basically run for the benefit of the doctors hospitals the drug industry and the other providers of medical care. I have seen first hand the contempt for consumer input and participation in our hospitals while I participated in the negotiations of a new hospital Blue Cross contract as a result of this indifference and even contempt for the consumer. The system delivers bad medicine at high prices for example at duplicate facilities for open heart surgery for the convenience of doctors to the point where costs are way up while quality is way down because of the limited volume of each facility. The system's inability to control costs is exceeded only by its inability to control quality. In Philadelphia a spontaneous discussion developed on the issue of consumer control and peer review between Dr. Ted Tapper a recent Harvard Medical School

graduate and Dr. Benjamin Freedman a representative of the AMA. I think that physicians are reviewing their own quality and practices is like asking. The owners of the National League American League Baseball teams to review their programs and practices I think that if you have no outside people looking in especially people who have no vested interest as obviously physicians do in medical schools you know and practices in local areas and in hospitals if you have no outside people looking in you're going to get the same kind of system that you have now which in effect is no quality control and no peer review of the true nature. I don't want to comment about our peer review or approach our desire is to create a structure so that there would be constant review of quality. We have seen and I've been Nations where massive interference has resulted in declining in quality. It is our desire to set up a program which would not result

in such massive. Complicated bureaucratic procedures so that we could not to the best of our advantage discard our responsibility to our patients. I agree with you I think that it would be undesirable to set up a vast bureaucratic structure and I think would be undesirable to compromise quality of control. My only point is that if you have physicians looking after other physicians with no one else looking at them you're going to have the same kind of very quiet behind the scenes covering up of. Poor quality and caught the rampant cost non-control. I would hope that you would get much more truly representative consumers rather than some of the mainline types who run hospital boards of trustees on the utilization review committees and really get people who are going to start questioning doctors who are going to start start saying why it was that very minor surgical procedure kept in the intensive care unit for four days after his tonsillectomy.

Why was there a child with an upper respiratory tract infection admitted to the hospital in the first place. Until you start getting some people here and we're going to making make these questions very very vivid to the physicians and hospital in a stranger's. I think that you are going to have the same sort of system that you have now which is a very inadequate doctor Ted. Tapper in Philadelphia several witnesses criticized all of the proposed national health insurance bills as inadequate in providing accountability to health consumers. Dr. Oliver fine at our New York hearing if we look at all the proposed schemes on a spectrum from the Nixon administration proposal which is among the most conservative to the Kennedy proposal which is the most liberal it becomes apparent the Nixon administration proposals will change almost nothing. Just a larger number of people will be employed with adequate insurance. But Mrs. Cronenberg described earlier the Kennedy proposals will likely leave control of the

system unchanged or shifted toward control by the corporate forces such as the big hospitals medical centers and insurance companies to list dead end. I can only propose a fundamental alternative. The only way to change the health system so that it provides adequate dignified care for all is to take over the health system away from the people who now control it not merely the funding of the system but the system itself must be public. It then becomes possible to face such questions as how we decentralize the national health care system to make it responsible to the community and accountable to it and how we ensure that patient care is the primary priority of the system and how we ensure equal access to health institutions and to practitioners. That was Dr. Oliver final in New York. From Boston Mrs. Ann

Stokes head of the Columbia Point neighborhood health centers consumer organization health bills. The present time the action and the medical profession must begin with the community and the professional in the community will have to work together to develop a health plan to deploy in a den of which belong to the community which belong to the profession and the various will be due before they are implemented.

Mrs. and Stokes and Bostom Mrs and Garland chief outpatient nurse at Pennsylvania General Hospital minority patients have great resentment and are the first name basis. When the patient comes in the house of their own private room or ward they're not in the hospital five minutes before a nurse pops right into the room and greeted with a cheery smile. How would this Christian like to be addressed Tom or Thomas with a show coming right down. This time to make the patient not relate to the doctor or to the hospital they do not tell the truth about what's wrong with them. So the patient is not well informed about medical practice they do not know that the doctor cannot treat them unless they tell them what's wrong with them. They think the Doctor is all leopard and knows everything not knowing as we do that they know very little. Unless you tell them so when they do not tell the patient what's wrong. Doctor what's wrong with them in the treatment of course is stymied. There's a total lack of privacy offered to these patients in the interviews or in any examinations. The policies become non flexible with poor patients. Research is done on these patients with

out their push Bush and they know nothing about it. They give no consent. There's a lot of drawing of blood for special studies not relevant to their illness. Drugs given for drug reactions for these companies these things should not be. Mrs. Ann Garland in Philadelphia if consumers had control over health expenditures then according to the people we just heard they would upgrade health care quality. They would presumably have a decisive voice in allocating health resources and could channel funds into areas not now effectively covered by health insurance. In Atlanta former Congressman James Mackey who is now the president of the metropolitan Atlanta Mental Health Association and Reverend Andrew Young of the Southern Christian Leadership Conference. Each expressed the desire for greater attention to mental illness. Mr. Mackey speaks first. Frankly I'm more concerned about a person's health than any other feature if you don't feel well you can't relate to your wife and children and you can't produce them where you work. And health is a fundamental need that we all have. And the thing that

bothers me I might say to the members of the panel is that all of these programs are frightened by mental illness and they generally cut you off pretty quick. And yet we know that. I think it's accepted that over half of the people in the hospital beds of America not the mental hospital bed but the general hospital beds have no objective evidence of illness. But they're not functioning well in mental health and physical health are inseparable. I happen to be in Chicago in 1967. When what's commonly occur called a riot began. We were having a meeting in a little church and heard a disturbance outside and got outside the church just is the police were coming to the scene and breaking up a group of kids that were in a fight around the water faucet in the summer time they wanted to be in the sprinkler system and the police turned it off and that started a little incident. The young people moved over into a housing project and we followed them over there trying to calm them down and they immediately

became inflamed by a young man who was carrying the Bible and quoting from the book of Obadiah and saying that this was the day of judgment the Lord. And the white man's day was done. And he proceeded to try to inflame that group of kids and did succeed. We were able to try to hold on to him we tried to get the police to come to get him to take him out of the crowd in hopes that we could control the crowd but we were unable to do that. And it was so obvious to us that what ended up being a full fledged riot running in the hundreds of millions of dollars in Chicago by the time it ended a week later. Really it was planned out of an incident by a young man who needed mainly mental health care. Now he will also need a job and I would not want to minimize the problems of unemployment an inadequate housing. And education and all of the things and causing urban unrest. But the primary

situation there was that here was a guy that needed a psychiatrist or at least an outpatient mental health clinic in this impoverished community. Now I say to you that Chicago nor Atlanta's health care will ever be secure so long as you have the level of mental illness which floods through our communities and I think one of the things I've been looking for in almost all of the present health care programs is some real full fledged attention to the problems of mental health when we have people living in overcrowded urban areas. It's not as though it was a century ago when we were living in small towns where you could get sick and you a hundred yards away from the next family and your disease whether it was mental or physical was not contagious in an urban area. Anything that happens to anybody in evitable it will affect everybody else. And so until we have a health plan that's so comprehensive that it gets the people who are

unemployed that it gets the people who are poorly educated that it gets the people who are mentally ill. Then I think any kind of health plan we come up will be inadequate. Reverend Andrew Young of the Southern Christian Leadership Conference in Atlanta. Another key area of controversy surrounding national health insurance is whether legislation should restructure the health system or simply provide health financing. Critics of the present health system feel that it is inadequate in producing enough manpower and rationally distributing the available resources. They point to the fact that certain suburban communities are replete with physicians while hundreds of rural counties have not one physician the nation's leading advocate for structure is Dr. SJ Axelrod of the University of Michigan. The proposed changes unvisited in the legislation with respect to the financing of health care and the emphasis is on the financing of health care. Whatever the source and the amount of funds is not

in and of itself adequate to handle the current deficiencies we have in our delivery system we must have a significant restructuring of what it is we have at present. There is no regulation or control of the kinds of positions that we produce or where they practice and we have situations therefore where we have many more neurosurgeons than we need and not nearly enough Family Physicians. We have an excess of physicians in affluent communities and a serious shortage of physicians and other health workers in our deprived communities. The major proposals that have been put before the Congress respond in varying degrees to what seems to me to be the basic necessity that it's that is to say to significantly restructure our medical care delivery system. Indeed some of the

bells like the AM ase medic credit bill and the catastrophic health insurance bills which are being proposed by two very important and influential legislators the chairman of the Senate Finance Committee and the chairman of the House Ways and Means Committee really make no pretense at all at restructuring the admittedly inadequate delivery system but they preserve the status quo and deal solely with the financing of care. The catastrophic health insurance bill has a lot of political attraction to it. That is it costs very little so few people get the benefits. More over. Everyone knows a case of a family that really went broke because of a truly catastrophic costs. And this kind of experience is a terrifying one indeed to large numbers of people. Other kinds of major proposals the administration's health insurance partnership and the health insurance industry's health care plan

rely heavily on the present health care system with emphasis on extending the admittedly inadequate private in its health insurance. Both of these latter schemes set up two standards of care one for the poor and one for the non poor. And they actually provide different levels of benefits different services for both categories of people. Leave it to you to decide which of the two groups get the lesser benefits. Really only one of the major proposals the Kennedy Gryphus bill the so-called health security bill. It seems to me addresses of self very seriously to the problem of organizing a more rational delivery system. There are incentives strong incentives to developing a primary health care centers. Having a full array of health personnel available in the centers to provide a full range of benefits like Kennedy

Bell carries with it important as incentives for establishing linkages between various parts of the system between hospitals and nursing homes that modifies current patterns of physician's care and reinforces the position of the family physician so that he is the one who refers to the specialist and at the same time is not in the uncomfortable position of having to carry on specialist work himself. Work for which he is not trained or is not qualified. The Kennedy bill for see these important redistribution of health personnel and carries with it cost controls. I would suggest to you that the leverage for structural change does exist in any national health insurance plan but only in a potential sense. And American medical care it seems to me cannot continue to be unresponsive to the need for change.

University of Michigan professor Dr S. J. Axelrod on the other side of the issue was Dr Roger a man who appeared in Boston on behalf of the enemy's many credit plan medic credit does not require restructuring of the entire health care system which provides care very well for the vast majority of Americans. Some of the other programs before Congress would dismantle what now exists and rebuild along untried lines. It does not hold up group practice or any other form of medical practice as the best. Or only effective. System of patient care. Finally America credit does not obligate the government. For the nation's taxpayers to pay for the care of people who can afford to handle most of their medical problems themselves. Dr Mann was referring to the Kennedy plan which some think by offering basic health care as a right to all U.S. residents would bankrupt the nation. H e w secretary Elliot Richardson appearing before the House Ways and Means Committee

so that the Kennedy bill will cost taxpayers 60 billion dollars in new taxes and is simply infeasible backers of the Kennedy bill deny this. They admit that it would cost about 60 billion dollars but claim that they would simply reallocate health funds currently misspent by a wasteful health system. When all is said and done a nation must be judged on how well it takes care of its citizens on how it provides for the needy and on how effective it is in assuring people a climate receptive to the accomplishment of individual potential sickness humbles it saps strength confidence and drive. We will have a national health insurance bill but we must make sure that the legislation that passes will indeed hold the cost line while upgrading quality. That's former Congressman James Mackey said in Atlanta within the next four to eight years there will be a national health bill passed. And I'm glad we got some lead time because I think this panel this morning is illustrated

how intricate the subject is and how much we need to know thinking in terms of politics. I think the real hazard ahead here is if we could pass a very bad bill. But I believe that we need legislation. But I don't think legislation is a panacea a very learned man has just written an article and said if we can pass a sweeping medical insurance bill that will not appreciably improve the services for the American people and I believe that only in a way or an informed public will assure passage of legislation which will truly protect its interests. It was the hope of National Public Radio that we might be helpful in this effort. This is Barbara Newman. This has been National Public Radio's report to the people and the Congress on the health care crisis that's presented to the House Ways and Means Committee by Donald Quale president of National Public Radio. The preceding program was made possible by a grant from the Corporation for Public Broadcasting.

This is NPR National Public Radio.