survival of the fittest?

2
POLICY WATCH The authors conclude that eas- ing the eligibility requirements for Medicaid will worsen, not im- prove, the access of the poor to OB/GYN services since the prin- cipal effect would be to increase the demand for a finite number of practitioners. In the end, the problem of access is one of a large and increasing inadequacy in the supply of physicians willing to practice in the central cities. Ex- panding support for community health centers, local public health clinics, and the like is one approach to a solution; reinstate- ment of the National Health Ser- vice Corps is another. Policymak- ers concerned about maternal and child health in the inner cit- ies would do well to give serious consideration to these sugges- tions.--JDW When Less .is Better for the Elderly [Brook RH, Kamberg CJ, Mayer- Oakes A, Beers MH, Raube K, Steiner A. Appropriateness of acute medical care for the elderly: an analysis of the literature. Health Policy 1990; 14: 225--42.] T he elderly as a group are dis- proportionately heavy users of care. There is a great clamoring to reduce the costs of care, accompanied by recommen- dations that rationing might well be based on age. Before our soci- ety tackles the emotionally wrenching task of denying care to older persons, we would much prefer to show that they might be better served with less care. A RAND research team re- viewed the literature from 1980 to 1988. Of 300 articles found, only 17 explicitly cited appropri- ate or inappropriate care and ad- dressed persons aged 50 or older. The methodology scores assigned were generally low (except for ar- ticles done by RAND research- ers). Another 19 articles present- ed data on inappropriate use of medications in the elderly. Virtu- ally every article in both groups emphasized inappropriate rather than appropriate care. The level of inappropriate care was identi- fied as overuse in nine of 10 stud- ies of procedures and in five of six studies of hospitalizations. The excess use rate was often in the double digits. The medication studies also showed a preponder- ance of excess use in various set- tings. It is unclear if this pattern of prevalent inappropriate care represents a reporting bias in the literature or a serious problem of excessive care. This study thus contains good news and bad. If the pattern of inappropriate excess is correct, we can save money and improve quality if we can redirect efforts away from the excessive use of ex- pensive services. At the same time, the literature indicates that we have not been paying enough attention to studying the care of older persons. The need to fall back on a definition of age 50 as the onset of being elderly sug- gests that insufficient work is di- rected towards the study of the population group that uses the largest proportion of medical care. Judging from this review, we have too few and too poorly done studies of a socially signifi- cant issue.--RLK Survival of the Fittest? [Johnson RE, MuUooly JP, Greenlick MR. Morbidity and medical care utilization of old and very old persons. Health Serv Res 1990; 25: 639-65.] reat care is needed in inter- preting cross-sectional studies of age groups. On the one hand, we are interested in the proportion of health Care used by different ages; on the other hand, comparisons can lead to incorrect conclusions about the effect of age because of selec- tive survival. Differences, or their absence, may be attributed to factors associated with a portion of the population dying from cer- tain conditions at younger ages rather than to effects of aging itself. This study, based on a sample of enrollees in a risk-based HMO at Kaiser Permanente in Oregon, illustrates this phenomenon. Those aged 65 to 79 who had been enrolled in the program for at least 6 months were compared to those aged 80 or older. Not sur- prisingly, persons in the younger group were four times as numer- ous as the very old. The surprise for many was that the probability of being treated for one of several conditions was roughly the same in both groups. In some cases, the very old were less likely to have been treated for conditions like hyper- tension, obesity, and anxiety ten- sion, all of which were more com- mon among women. Very old persons reported themselves in better health but were more like- ly to have spent days in bed. They saw physicians more often and were substantially more likely to be admitted to the hospital. They were more likely to have prescrip- tions for cardiovascular drugs, analgesics, antiulcer drugs, and vitamins but not for other classes. When the drug use pattern was examined more closely, very old hypertensive persons were less likely than younger ones to re- ceive cardiovascular drugs, but those with congestive heart fail- ure were more likely to receive such drugs. Very old persons with osteoarthritis were more Hkely to receive analgesics than younger persons with osteoarthritis. This study supports the find- March 1991 The American Journal of Medicine Volume 90 III

Post on 10-Oct-2016

225 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: Survival of the fittest?

POLICY WATCH

The authors conclude that eas- ing the eligibility requirements for Medicaid will worsen, not im- prove, the access of the poor to OB/GYN services since the prin- cipal effect would be to increase the demand for a finite number of pract i t ioners . In the end, the problem of access is one of a large and increasing inadequacy in the supply of physicians willing to practice in the central cities. Ex- panding support for community h e a l t h cen t e r s , local p u b l i c health clinics, and the like is one approach to a solution; reinstate- ment of the National Health Ser- vice Corps is another. Policymak- ers concerned about maternal and child health in the inner cit- ies would do well to give serious consideration to these sugges- t ions . - -JDW

When Less .is Better for the Elderly

[Brook RH, Kamberg CJ, Mayer- Oakes A, Beers MH, Raube K, Steiner A. Appropriateness of acute medical care for the elderly: an analysis of the literature. Health Policy 1990; 14: 225--42.]

T he elderly as a group are dis- proportionately heavy users of care. There is a great

clamoring to reduce the costs of care, accompanied by recommen- dations that rationing might well be based on age. Before our soci- e ty t a ck l e s the e m o t i o n a l l y wrenching task of denying care to older persons, we would much prefer to show that they might be better served with less care.

A RAND research team re- viewed the literature from 1980 to 1988. Of 300 articles found, only 17 explicitly cited appropri- ate or inappropriate care and ad- dressed persons aged 50 or older. The methodology scores assigned

were generally low (except for ar- ticles done by RAND research- ers). Another 19 articles present- ed data on inappropriate use of medications in the elderly. Virtu- ally every article in both groups emphasized inappropriate rather than appropriate care. The level of inappropriate care was identi- fied as overuse in nine of 10 stud- ies of procedures and in five of six studies of hospitalizations. The excess use rate was often in the double digits. The medication studies also showed a preponder- ance of excess use in various set- tings. It is unclear if this pattern of prevalent inappropriate care represents a reporting bias in the literature or a serious problem of excessive care.

This study thus contains good news and bad. If the pattern of inappropriate excess is correct, we can save money and improve quality if we can redirect efforts away from the excessive use of ex- pensive services. At the same time, the literature indicates that we have not been paying enough attention to studying the care of older persons. The need to fall back on a definition of age 50 as the onset of being elderly sug- gests that insufficient work is di- rected towards the study of the population group that uses the largest propor t ion of medical care. Judging from this review, we have too few and too poorly done studies of a socially signifi- cant issue.--RLK

Survival of the Fittest?

[Johnson RE, MuUooly JP, Greenlick MR. Morbidity and medical care utilization of old and very old persons. Health Serv Res 1990; 25: 639-65.]

reat care is needed in inter- p r e t i n g c r o s s - s e c t i o n a l studies of age groups. On

the one hand, we are interested in the propor t ion of heal th Care used by different ages; on the other hand, comparisons can lead to incorrect conclusions about the effect of age because of selec- tive survival. Differences, or their absence, may be attributed to factors associated with a portion of the population dying from cer- tain conditions at younger ages rather than to effects of aging itself.

This study, based on a sample of enrollees in a risk-based HMO at Kaiser Permanente in Oregon, i l lus t ra tes this phenomenon . Those aged 65 to 79 who had been enrolled in the program for at least 6 months were compared to those aged 80 or older. Not sur- prisingly, persons in the younger group were four times as numer- ous as the very old. The surprise for many was that the probability of being treated for one of several conditions was roughly the same in both groups.

In some cases, the very old were less likely to have been treated for conditions like hyper- tension, obesity, and anxiety ten- sion, all of which were more com- mon among women. Very old persons reported themselves in better health but were more like- ly to have spent days in bed. They saw physicians more often and were substantially more likely to be admitted to the hospital. They were more likely to have prescrip- tions for cardiovascular drugs, analgesics, antiulcer drugs, and vitamins but not for other classes. When the drug use pattern was examined more closely, very old hypertensive persons were less likely than younger ones to re- ceive cardiovascular drugs, but those with congestive heart fail- ure were more likely to receive such drugs. Very old persons with osteoarthritis were more Hkely to receive analgesics than younger persons with osteoarthritis.

This study supports the find-

March 1991 The American Journal of Medicine Volume 90 III

Page 2: Survival of the fittest?

POLICY WATCH

ings of others about the lack of remarkable increases in morbid- ity with older age. The patterns of care are more, complex. It is hard to s~parate the effects of dif- ferential t r ea tmen t (including potential age bias) from the ef- fects of selective survival. It is reasonable to expect that, in at least some cases, those who sur- vive to old age represent the heartiest, and hence may appear even more fit t han groups of younger persons. At the same time, there is also some evidence that physicians treat older pa-

• tients differently~ usually offer- ing them fewer services than younger patients with the same problems. RLK

Physicians' Services: Canada Versus U.S.A.

[Fuchs VR, Hahn ,.IS. How does Canada do it? A comparison of expenditures for physicians' services in the United States and Canada. N Engl J Med 1990; 323: 884-90.]

p ublished as a "special arti- cle," this report on expendi- tures for physicians' ser-

vices is one of a series of articles in the New England Journal of Medicine over the last several years attempting to understand and explore various aspects of health care on both sides of the Canadian-United States border. Although the initial writings have been predominantly descriptive, qualitative, and often historical in perspective, recent articles have become increasingly quanti- tative and analytical.

This r e p o r t by Fuchs and HAhn deals with only one aspect of the difference in spending be- tween the two countries: expen- diture for physicians' services. Interestingly, the ratio of spend- ing on physician services between the U.S. and Canada is 1.72 (1985

figures), adjusted for size of pop- ulation and the variation in pur- chasing power of the two curren- cies. The au tho r s set ou t to investigate possible explanations for these differences on a quanti- tative basis. Data were drawn from published and confidential sources for Canada and the U.S. for 1985 and 1987. A similar anal- ysis was carried out for one state (Iowa) and one province (Mani- toba) for 1985.

Two major conclusions emerge from the data on spending for physician services: the quantity of services delivered per capita is much higher in Canada than in the U.S., and the U.S. uses more resources to produce a specified amount of services than Canada.

Eight questions are discussed to explain these findings. The most interesting are:

1. What effect does the avail- ability of universal insurance have on patients' demands for physicians' services? Use per capita is greater in Canada by over a third--and so are physi- cian contacts per capita--but these higher rates of use are not fully explained by the greater coverage and increased demand from patients.

2. What are the effects of physician-initiated activities on the ~emand for services under universal coverage? Higher utili- zation rates for diagnostic and management services could be explained in part by the greater proportion of general practi- tioners and family physicians in Canada who may be inclined to suggest more services because of the low fee per visit.

3. What are the relative billing costs? With only one source of payment, payment is punctual and complete in Canada--and al- though billing costs are undoubt- edly greater in the U.S., the exact amounts are not known.

4. What are the relative work- loads of procedure-oriented phy-

sicians? They estimate that there are 50% more procedure-oriented physicians per unit of population in the U.S. than in Canada, but the number of procedures per- formed is about 20% higher on av- erage in Canada.

Whatever the possible expla- nations for these findings, the study strongly suggests that the increased use of physicians' ser- vices in Canada results from both the universal insurance coverage and the mot iva t ion of larger numbers of lower-paid physi- cians to suggest more services. On the other side of the border, the more procedure-oriented Ameri- can physicians' net incomes are lower t h a n the i r h igher fees would forecast, perhaps due to l a r g e r o v e r h e a d and lower workloads.

Certainly the availability of these kind of data raises the de- bate on the relative merits of the Canadian sys tem to a loft ier plane. Facts are an amazingly helpful commodity! Yet the rela- tive effects of various factors on doctors' fees and the use of ser- vices are still in need of more study. As the authors suggest, one of their main conclusions, that American physicians' fees are double those of Canadian physicians but their net income is only a third greater than in Cana- da, is not likely to be changed.

In summary, this article estab- lishes what Canadian physicians and expatriate Canadian physi- cians have known for years: Doc- tors make more money and do less "work" in the U.S. Of more importance than the financial lot of physicians is the fact that the impact on health costs is signifi- cant--perhaps as much as $100 billion a year for the U.S. So how does Canada do it? Doctors are paid less but perform more ser- vices under universal coverage, whereas the U.S., to paraphrase a popular TV ad, "pays great - less testing!"--WDD

IV March 1991 The American Journal of Medicine Volume 90