POLICY WATCH

ing from this one report; however, some additional facts peel off the first few layers of the onion. Their very heavy emphasis upon ambulatory care is counterbal- anced by hospital admission rates that are almost half that of the U.S. and much lower surgical volumes (22.0 per 1,000 popula- tion, compared with our 91.0 per 1,000). The average cost per inpa- tient day, including physician ex- penses, is only $101, and outpa- tient visits, including medication, average only $33. Fees for diag- nostic tests such as an MRI or regular CT body scan would be considered impossibly low in the U.S.

How they do it: Fees are set by the central government and are uniform in all settings and across all payers. There are no add-ons for capital expenses. Balance bill- ing is prohibited. The govern- ment also regulates prices for most everything else, including medications and laboratory fees. There are no local negotiations to expand benefits; these decisions are also made centrally. Finally, the centrally set uniform fees and benefits simplify claims process- ing ai@ eliminate insurance mar- keting expenses, with the result of an average administrative ex- pense of only 2.5% of total expen- ditures. (Only Medicare ap- proaches this administrative efficiency in the U.S.)

There is no doubt much more to be learned about how the Japa- nese do it, but one must start with the fundamentals: a firm, centralized political will to en- sure universal coverage and to contain costs. It obviously works for them: the average worker’s health care costs are 3.7% of in- come, about the same as in the mid-1970s. We have “none of the above”: no universal coverage, no meaningful cost containment, and no political will to accept their degree of centralized au- thority and control. It remains to

be seen whether we can achieve the first two attributes without the third.-WFB

What Do We Do, Just Let Them Die?

[Anderson W. The New York needle trial: the politics of public health in the age of AIDS. Am J Public Health 1991; 81: 1506-17.1

P urchased in boxes of 100, fresh, clean syringes cost less than 50 cents each.

Twenty-eight-day inpatient drug treatment and rehabilitation pro- grams typically cost upwards of $20,000 with relapse rates well over half. The costs of medical care for an AIDS patient average about $5,000 per month during the clinically active phase of the infection, or somewhere between $50,000 and $100,000 between onset and death.

If the distribution of 200,000 free sterile syringes to intrave- nous drug abusers prevented a single new AIDS infection, the distribution program would be cost-effective. Every shred of available evidence from around the world suggests a “success rate” for needle exchange pro- grams vastly better than 1 in 200,000. John Daniels, the first black mayor of New Haven, has argued that although needle ex- changes are certainly no substi- tute for adequate treatment, they would at least keep people alive until they could be helped. It is, one would think, hard to fault this logic.

In New York City, law enforce- ment officials and conservative politicians opposed a pathetically limited needle exchange program because it seemed to condone il- licit drug use, just as free condom programs are often opposed be- cause they seem to promote (or at least legitimize) promiscuity. Many health professionals op-

posed the program for fear that it would increase the rate of addic- tion. Black leaders opposed the program because they feared it would become a substitute for ad- equate anti-drug education and treatment; the black churches were opposed because the very notion of free needles was offen- sive to standards of conventional morality. (Mayor Koch, it ap- pears, opposed the program be- cause everyone else did.) The ex- tremely limited program that was eventually enacted was possible only because it was disguised (thinly and persuasively) as a necessary clinical trial that would provide valuable data on the ef- fectiveness of needle exchanges in slowing the spread of HIV infection.

Many found a darker motive in the intense opposition to the New York “experiment.” One addict is quoted as saying, “This talk about addicts liking to share nee- dles is a lie. They don’t want to give out free needles because they want us to die, and they see it (AIDS) as a good way to get rid of US.”

Persons who understand the magnitude of the AIDS crisis do not lightly surrender any effec- tive weapon against the disease. Still, in the United States, igno- rance, prejudice, political postur- ing, and moral Puritanism have prevented any large-scale needle exchange scheme. Limited ex- change programs can be found in a few U.S. cities, but in most cit- ies where such programs have been suggested, the experience has been a replay of the New York City scenario. Elsewhere in the world, in Europe and Austra- lia, these programs “continue to expand in pragmatic ways.”

Ironically, U.S. addicts are now the control group for an interna- tional clinical trial-and they are being denied an intervention that is evidently quite effective. In re- sponse to opponents of needle ex-

II February 1992 The American Journal of Medicine Volume 92

change programs, Yolanda Serra- no has asked “What do we do, just let them die and take their families with them?” Apparent- ly, our collective answer to this blunt question is “Yes.“-JDW

Those Wonderful Toys

[Brody B, Wray N, Bame S, Ashton C, Petersen N, Harward M. The impact of economic considerations on clinical decisionmaking: the case of thrombolytic therapy. Med Care 1991; 29: 899-910.1

H ow do physicians choose the technologies they order for their patients? The medical

literature? Continuing education courses? Information from phar- maceutical representatives? Col- leagues? The P&T Committee?

The introduction within a brief time period of two thrombolytic agents provided an opportunity to explore the factors that may affect a physician’s decision to se- lect one technology over another. Because new technologies are in- troduced so frequently, under- standing this selection process is particularly important. In the case of thrombolytic therapy, neither agent has been proven clearly superior over the other, yet tissue plasminogen activator (tPA) is used by more than 60% of physicians ordering thrombolytic therapy, despite its lo-fold cost difference from streptokinase W-9.

Brody and colleagues surveyed all acute care hospitals about their use of thrombolytic thera- py. Ninety-seven percent of the respondents were physicians, and the majority were clinical direc- tors responsible for the services where thrombolytic agents are used. More than 90% of the re- sponding institutions (46% of hospitals surveyed) reported use of either SK or tPA. Although tPA was used more frequently

(60%), its use varied widely be- tween types of institutions. On average, 53% of public hospitals used SK compared with 35% of private hospitals. Federal public hospitals used SK more often than non-federal public hospitals (69% versus 47%).

Of the physician respondents who indicated a reason for their choice of agent, 62% of SK users cited cost factors, while 14% indi- cated formulary restrictions. On the other hand, 73% of tPA users selected this agent because it was “clinically preferable.” All re- spondents were equally influ- enced by the medical literature and continuing education courses. However, tPA users were significantly more often influ- enced in their selection by drug company literature or sales rep- resentatives. Consistent with the fact that more SK users cited cost as their reason for selecting this agent over tPA was the finding that SK users were influenced more often by the hospital phar- macist, hospital administrators, and other senior professional staff than were tPA users.

The reasons physicians select a new technology are complex and would appear to be influenced as much by a product’s “newness” as by its demonstrable efficacy. Physicians using tPA seem to have a predisposition toward the perception of tPA’s clinical supe- riority, despite the absence of strong corroborating data. SK- using physicians seem embroiled in an internal conflict between cost-benefit considerations and a professional subculture that seems to accept “newer as bet- ter.”

While understanding the rea- sons that drive the selection of new and competing technologies is very germane in an era of in- creasing cost constraints, the fi- nal answers may have less to do with intellectual and market force considerations than with

POLICY WATCH

the sheer delight in the newest gadget. As the Joker said while Batman was swinging toward the museum door, “Where does he get those wonderful toys!“-MM

Medicaid Buy-In: Expansion or Contraction?

[Holahan J, Zedlewski S. Expanding Medicaid to cover uninsured Americans. Health Aff 1991; 10: 46-61.1

P olicy makers, elected offi- cials, and interest groups from across the political

spectrum are advocating expan- sion of Medicaid as a way to broaden health care coverage for the one in seven Americans under the age of 65 who lack health in- surance. To effectively open the program to more uninsured peo- ple requires decoupling Medicaid eligibility from participation in welfare programs such as Aid to Families with Dependent Chil- dren (AFDC), or from member- ship in certain “categorical” groups (e.g., poor pregnant wom- en and children under age 6). The most frequently mentioned Med- icaid reform would simply drop these welfare and categorical re- quirements and base eligibility solely on having an income below the federal poverty level or, un- der a less restrictive program, be- low 200% of the federal poverty level. In this study, Holahan and Zedlewski show that using in- come eligibility thresholds effec- tively reduces the number of low- income uninsured, but at a substantial cost; at the 200% eli- gibility threshold, added costs to present Medicaid spending would range from $14 to $55 bil- lion annually, depending on the number of persons with employ- er-sponsored insurance who might switch to Medicaid coverage.

February 1992 The American Journal of Medicine Volume 92 III