October 1976 Volume 66, Number 10

Established 1911

Hospital Utilization and the Health Care System EDITOR

Alfred Yankauer, MD, MPH EDITORIAL BOARD A. Michel Ibrahim, MD, PhD (1977) Chairman Faye G. Abdellah, PhD (1977) Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) M. Allen Pond, MPH (1976) Pauline 0. Roberts, MD, MPH (1976) Ruth Roemer, JD (1978) Sam Shapiro (1976) Robert Sigmond (1976) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1976) Robert J. Weiss, MD (1977) STAFF

William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law

The fine analysis in this issue of the effects of two methods of regulation of patient lengths-of-stay in hospitals,I by Judith Lave and Samuel Leinhardt, has several implications beyond the hospital sector of the health services. The authors find that a control mechanism for Medicaid cases, based on "pre-discharge utilization review" (alerting the physician in advance when his patient is approaching the norm, in days-of-hospitalization, for the specified diagnosis, age level, etc.,) has no more influence on length-of-stay than a retroactive post-discharge review, in which the Medicaid agency withholds payment for hospital days it deems to have been excessive. Indeed, the post-discharge review process, which had been considered both vexing to hospitals and ineffective, was found to have somewhat greater impact in reducing average patient stays. As the authors point out, their findings "may simply be a result of the increased awareness of 'appropriate utilization' that any review system stimulates" (italic added). In other words, regulation may well exert its greatest effects by the self-discipline induced, from the consciousness of being observed, more than from its detection of occasional deviance. Everyone knows that traffic laws are obeyed as much or more from fear that violations may yield a penalty than from recognition of their inherent prudence for roadway safety; countless examples of these dynamics could be offered in our increasingly complex and therefore increasingly regulated society. In the health field, one might cite the drug control legislation, professional licensure laws, hospital tissue committee procedures, the risk of malpractice suits, and many other "regulatory" influences.2 Another finding of Lave and Leinhardt is that, quite aside from the method of deliberate regulation, "average length-of-stay of all patients fell most in those hospitals that maintained relatively high occupancy rates." While the authors do not discuss the point, we may note in Table I that the series of hospitals not participating in the pre-discharge utilization review test had a mean occupancy level of 86.7 per cent (with a range from 75.0 to 108.2 per cent), compared with a mean of 82.1 per cent (range from 74.2 to 89.0 per cent) in the test hospitals. One might infer that this differential exerted a substantial influence on the findings. In other words, regardless of surveillance procedures, the pressures felt for admission of new patients inevitably influence doctors to discharge old patients. The phenomenon is observable, in a dramatic form, whenever a massive catastrophe suddenly creates an urgent demand for hospital beds, and medical staffs then find numerous patients who can be promptly discharged. This relationship would seem to confirm once again the finding of some years ago that, under conditions of widespread economic support for hospitalization (insurance or public revenues), the available supply of hospital beds is a major determinant of utilization rates. While some 16 factors-involving characteristics of patients, physicians, and hospitals-could be identified as affecting hospital use rates in an area, none seemed to have a greater or more consistent influence than the available bed supply.3

More important would seem to be the great likelihood that, in the field of health service and probably in many similar service-fields, this is only one specific illustra-

AJPH October, 1976, Vol. 66, No. 10



tion of a general phenomenon. That is, the seller has an enormous influence on the buyer's "demands"; the provider of service largely determines the level of consumption. Almost everyone taking his car to a repair shop has had the experience of meekly accepting the verdict of the mechanic on what repairs are "needed" and, accordingly, to be paid for. This is without insurance for automobile upkeep. In a field like medical care, where so much third-party financing has eliminated monetary constraints (especially for hospitalization), the provider's influence on rates of demand would doubtless be greater. In medicine, moreover, with all its technical complexities added to crucial life-and-death import, the force of the provider's judgment is all the stronger. The generalized nature of this process in the health services is easily observable. John Bunker's impressive comparison of surgery in England and the United States found approximately double the rate of operations in America to be associated with double the English ratio of surgeons.4 Charles Lewis found the same sort of relationship in the counties of Kansas.5 The Canadian government has recently, decided to restrict the immigration of foreign physicians, less because the nation is considered to be well supplied with doctors everywhere than because of an estimate that each new doctor admitted costs the Canadian population $150,000 a year; this is referrable to $70,000 for the doctor's gross earnings plus $80,000 for the secondary costs (in hospitalization, prescribed drugs, x-ray examinations, etc.,) that he generates.6 One may note the galaxy of tests and procedures performed on a cardiac patient in 1971 compared with the same type of case in 1951, as Anne Scitovsky has shown, when the change over this period has manifestly come not from the demands of the patient but the offerings of the doctor.7 Arnold Kisch did a study of medical care utilization in 1967, the results of which may have greater meaning than any of us realized at the time. Examining some 35 characteristics of 1,600 persons in two health insurance plans (one based on salaried group practice and the other on the open market with fee payments), he found that all the consumer variables could explain only about 15 per cent of the utilization rate for ambulatory medical care.8 Not only were age, sex, race, religion, income level, education, etc., included in the analysis of insurance plan members, but even individual health status. Presumably 85 per cent of the utilization had to be attributable to other factors, not related to the patient but rather to the characteristics of the health care system, including the physician's practice habits. Reactions have obviously mounted against this relatively passive role of the patient in the medical care process. Regarding the contours of the health care system itself, there has arisen the whole consumer movement-an assault on "professional dominance."9 On a more clinical level, Julius Roth has written, as a serious sociologist, of the advantages of familial love and support over scientific training, for the proper care of patients.'0 In a far more extreme and anti-sdientific form, Ivan Illich has condemned modern medicine as doing more harm than good, and called for a return to "natural" living habits and self-care." The distortion and irrationality of such views should not obscure the understandable 954

and growing resentment in the general population over what is perceived as medical arrogance and even avarice. ' 2 These comments may seem far afield from the LaveLeinhardt study of hospital stays in Pittsburgh. Studies like theirs contribute greatly to clarifying the mode of operation of regulatory efforts in the American hospital system. But the broader implications of provider determination of "consumer demand"'--or more explicitly, the volume of services patients get and must pay for-should also be appreciated. If there were not so many unnecessary hospital days, unjustified surgical operations, needless injections, superfluous laboratory tests, and their associated spiraling costs, we could rest content with calm faith in the wisdom and integrity of the health care professions. But the evidence of these abuses is overwhelming.'3-'6 Some countervailing pressures to protect the interests of the consumer-his body and his pocketbook-are obviously needed. More compelling is the need for a health care system free from waste and commercialism. Happily, the movement for consumer protection is growing in the health services and in our society generally.'7 Regulation to protect quality and economy is expanding throughout the health care system of America, as of other countries.18 The use of patient co-payments to constrain costs, that are determined largely by the doctor, is becoming recognized as ineffective for both savings and health.'9 But regulation in a "free" and profit-motivated market is inherently difficult as well as onerous. We must keep fighting for a pattern of health care organization, financing, and deliverywith built-in incentives for socially sound behavior-a position which the American Public Health Association has advocated for more than 30 years.2022

MILTONI. ROEMER, MD REFERENCES 1. Lave, J. R., and Lienhardt S., An evaluation of a hospital stay regulatory mechanism, Am. J. Public Health, 66:959-967, 1976. 2. Carlson, R. J. Health manpower licensing and emerging institutional responsibility for the quality of care, Law and Contemporary Problems, 35:849-878, Autumn 1970. 3. Roemer, M. I. and Shain, M. Hospital Utilization Under Insurance, Chicago: American Hospital Association (Hospital Monograph Series No. 6), 1959. 4. Bunker, J. P. Surgical manpower: Comparisons of operations and surgeons in the U.S. and England, New Engl. J. Med., 282:135-144, 15 January 1970. 5. Lewis, C. E. Variation in the incidence of surgery, New Engl. J. Med., 281:880-884, 16 October 1969. 6. Roemer, M. I. and Roemer, R. J. Health Manpower Policies under Canadian National Health Insurance, Washington: U.S. Health Resources Administration, publication pending. 7. Scitovsky, A. and McCall, N. Changes in the costs of treatment of selected illnesses 1951-1964-1971, San Francisco: University of California, School of Medicine, Health Policy Program, September 1975. 8. Kisch, A. I. and Kovner, J. W. The relationship between health status and utilization of outpatient health care services, Archives of Environmental Health, 18:820-833, May 1969. 9. Freidson, E. Professional Dominance: The Social Structure of Medical Care. New York: Atherton Press, 1970. 10. Roth, J. A. Care of the sick: Professionalism vs. Love in Science, Medicine and Man, Vol. I, London: Pergamon Press, 1973, pp. 173-180. 11. Illich, I. Medical Nemesis: The Expropriation of Health, New York: Pantheon Books, 1975.

AJPH October, 1976, Vol. 66, No. 10

EDITORIALS 12. Harmer, R. American Medical Avarice, New York: AbelardSchuman, 1975. 13. Rayack, E. Professional Power and American Medicine: The Economics of the American Medical Association, Cleveland: World Publishing Co., 1967. 14. Cray, E. In Failing Health: The Medical Crisis and the AMA, Indianapolis: Bobbs-Merrill Co., 1970. 15. American College of Surgeons and American Surgical Associa.tion, Surgery in the United States, Chicago, 1975. 16. Unfit Doctors Create Worry in Profession, New York Times, 26


18. 19.

20. 21.

Address reprint requests to Dr. Milton I. Roemer, Professor of Public Health, School of Public Health, University of California, Los Angeles, CA 90024.


January 1976, first of a series continuing on 27-28-29-30 January 1976. Denenberg, H. S. The Shopper's Guide to ... Doctors, Washington: Consumer News, Inc., 1974, pp. 103-110. Roemer, M. I. The Expanding Scope of Governmental Regulation of Health Care Delivery, University of Toledo Law Review, 6:591-616, Spring 1975. Roemer, M. I., Hopkins, C. E., Carr, L. and Gartside, F. Copayments for ambulatory care: Penny-wise and pound-foolish, Medical Care, 13:457-466, June 1975. American Public Health Association, Medical Care in a National Health Program, Am. J. Pub. Health, 34:1252 ff., 1944. __, The Organization of Medical Care and the Health of the Nation, Am. J. Pub. Health, 54: 147 ff., 1964. , Policy Statement: A Medical Program for the Nation, Am. J. Pub. Health, 60: 189 ff., 1970.

Quality of Care in Free Clinics While the article by Grover and Greenberg in this issue of the Journall neither contributes to the art of medical care quality assessment nor describes a very complicated situation or methodology, it does convey some very important information which deserves some emphasis. Community-based free clinics are still very much in evidence these days, with an estimated 400 clinics around the country (180 in California alone). As their novelty has worn off our attention has been drawn in other directions. In the aggregate, these clinics take care of some 2 to 3 million outpatient visits a year. Some clinics have gone through their life cycle quickly, and quietly passed on; others have evolved into major neighborhood health care facilities, with the assistance of governmental funding; many persist relatively unchanged, as storefronts and converted homes, with a largely volunteer staff, lots of spirit, and slim resources. In the beginning free clinics rejected-often with resentment-the larger society's concerns for evaluation and quality of care. In the first place, it was felt that since most clinics were operating in communities where there had been little or no care available previously, the nuances of medical technology, zoning laws, professional credentials, and so on were of very marginal concern. In fact, in view of the great constraints on resources, it seemed that the only way to provide any care at all was to ignore the rules. Furthermore (while it was hardly expressed this way), many free clinic people operated with an understanding that all of the rules and regulations and many of the standards of care were merely input criteria for quality assessment, and the clinics, being community self-help programs, were much more pragmatically focused on output. This focus was reinforced by a philosophical emphasis on process criteria, involving patient education and responsibility, prevention, a caring and humanitarian approach, and patient advocacy. From the outset, the clinics' own perceptions of themselves revolved around these considerations, which they in turn criticized the rest of the medical care system for ignoring. Additionally, it was AJPH October, 1976, Vol. 66, No. 10

clearly evident that threatened public authorities, in certain cases, used regulatory codes which set standards of quality as weapons to close clinics down; and, in other cases, potential sources of funds, standing by the myths of the medical system, refused to recognize the criteria and accomplishments of the clinics. Thus, many clinics were realistically "paranoid" about quality issues. Nonetheless, responsible health workers in free and community clinics have been and are greatly concerned about providing medical services of a high technical quality. After all, these clinics are governed and staffed by community members, who are naturally greatly concerned about the quality of care provided. Thus it is a matter of basic self interest. In fact, free clinic people are somewhat amused at the haughty defensiveness organized medicine assumes when faced with PSROs and other quality review mechanisms. We are very familiar with the problems and frequency of unnecessary surgery because we often have to defend our patients from the surgeon's knife; we know how standards differ widely according to the patient's age, sex, class, and ethnicity; we spend a lot of time taking our patients off the valium, seconol, phenylbutazone, atromid, B-12, and other needless treatments carelessly dispensed by others in the medical system; we devote our resources to educating our patients on the physiology of what's happening to them, proper use of their medications, correct diets, and so forth, which their previous sources of care often omitted doing. Free Clinics have always considered themselves to be much more than "band-aids" on the health care system, and have vigorously tried to demonstrate that they, in fact, are doing things in a new way-and better. Now that many free clinics have had some time to mature, to routinize their functioning, and to gain some stable resources, we are better able to assert our roles as demonstrations to the larger medical system. Grover and Greenberg's article provides one of these demonstrations.1 Surely if free clinics can find a way to routinely monitor standards of care, it is difficult to under955

Hospital utilization and the health care system.

AMERICAN JOURNAL OF Public EdtoiasHealth October 1976 Volume 66, Number 10 Established 1911 Hospital Utilization and the Health Care System EDITO...
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