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Originally Processed With FOIA(s): FOIA Number: 1998-0004-F[2] S FOIA MARKER This is not a textual record. This is used as an administrative marker by the George Bush Presidential Library Staff. Record Group/Collection: George H.W. Bush Presidential Records Collection/Office of Origin: Chief of Staff, White House Office of Series: Sununu, John, Files Subseries: Issues Files OA/ID Number: 29160 Folder ID Number: 29160-005 Folder Title: Health Care 1991 [5] Stack: Row: Section: Shelf: Position: G 15 25 2 5 JAMA May 15, 1991 The Journal of the American Medical Association M.D. ADDRESS 00000 LIC 000000 Rx AGE DATE Valium (diazepam) 5mg #30 Summan M.D. VALIUM Your Rmay be open to 17 interpretations*. ROCHE Roche Products *According to the Orange Book, 10th ed, US Department of Health and Human Services, 1990, diazepam tablets ® Roche Products Inc. may be available from as many as 17 companies. Tablets Manati, Puerto Rico 00701 shown represent 5 mg diazepam tablets. TEL 000-0000 NAME STMFRD M.D. ADDRESS 00000 LIC 000000 Rx AGE DATE Valium 5mg #30 Do not substitute M.D. NALIUM ON unless you settle the issue. VALIUM® diazepam/Roche 2 ... 2-mg 5-mg 10-mg scored tablets The final choice should really be yours The cut out "V" design is a registered trademark of Roche Products Inc. Copyright © 1991 by Roche Products Inc. All rights reserved. A continuing commitment to cardiology 1960's- 1970's 1980's 1990's Xylocaine® metoprolol tocainide The commitment continues For over 30 years, Astra advances have resulted in Today, our commitment to developing new and products that have become trusted standards in the better therapies for cardiac patients continues. field of cardiology. Metoprolol Soon to be even better. ANTRA® The originators of metoprolol © Eastman Kodak Company, 1989 The Kodak DT60 analyzer delivers hospital- proven chemistry results on the spot, in minutes. It's the kind of service your patients expect. Now you can perform tests in your office, while patients are still there, with the accuracy and consistency enjoyed by hospital laboratories using Kodak Ektachem analyzers. The kind of efficient, worry-free healthcare service your patients expect. The Kodak Ektachem DT60 KODAK Andyaw CHEMDT6O analyzer comes with a menu of over 27 chemistries, including complete lipid profiles with micro HDL, all on a fingerstick. All done with dry reagents, eliminating hidden operating costs. Desktop in size and modest in cost, DT60 analyzers come with the best STATE service in the business. We've even designed them to help you comply with anticipated federal regulations governing in-office quality control practices. For details, talk to a Kodak representative, or call 1800 445-6325, Ext. 480. YOUR PATIENTS ARE IMPATIENT! CALL KODAK Clinical Products Kodak 2440 May 15, 1991, Vol 265, No. 19 JAMA To promote the science and art of medicine and the betterment of the public health. Caring for the Uninsured and Underinsured The Journal of the American Medical Association The Uninsured: From Dilemma to Crisis 2491 107 Years of Continuous Publication E. Friedman, Chicago, III All articles published, including editorials, letters, and book reviews, represent the opinions of the authors and do not reflect Health Insurance Values and Implementation the official policy of the American Medical Association or the in the Netherlands and the Federal Republic institution with which the author is affiliated, unless this is clearly specified. of Germany: An Alternative Path to Universal Coverage 2496 Editor: George D. Lundberg, MD B. L. Kirkman-Liff, Tempe, Ariz Deputy Editor: Richard M. Glass, MD Deputy Editor (West): Drummond Rennie, MD Health Access America-Strengthening Senior Editors: Helene M. Cole, MD, Don Riesenberg, MD Senior Contributing Editors: Bruce B. Dan, MD, M. Therese the US Health Care System 2503 Southgate, MD J.S. Todd, S. V. Seekins, J. A. Krichbaum, L. K. Harvey, Chicago, III Contributing Editors: Charles B. Clayman, MD, David S. Cooper, MD, Harriet S. Meyer, MD, Carin M. Olson, MD, Jeanette M. Smith, MD, Jody W. Zylke, MD A Call for Action: The Pepper Commission's Consulting Editor: Roger C. Bone, MD Blueprint for Health Care Reform 2507 Statistical Editor: Naomi Vaisrub, PhD J.D. Rockefeller IV, Washington, DC Assistant to the Editor: Annette Flanagin Medical News-Editor: Phil Gunby; Associate Editors: Paul Cotton, Marsha F. Goldsmith, Charles Marwick (Washington, DC), The Physicians Who Care Plan: Preserving Teri Randall, Andrew Skolnick Quality and Equitability in American Medicine 2511 Associate Editors: Charlene Breedlove, Roxanne K. Young R.S. Bronow, R. A. Beltran, S. Cohen, P.T. Elliott, Special Assignments Editor: Dennis L. Breo Editorial Services Manager: Elaine Williams G. M. Goldman, S. G. Spotnitz, San Antonio, Tex Production Manager: M. Kathleen Berka Electronic Manager: Mary C. Steermann Restructuring Health Care in the United States 2516 Editorial Processing Manager: Cheryl Iverson D. O. Nutter, Chicago, III; C. M. Helms, lowa City, lowa; Assistant Editorial Processing Manager: Paula Glitman Stone M. E. Whitcomb, Seattle, Wash; W.D. Weston, East Lansing, Mich Staff Assistants: Diane Darnell, Bonnie Van Cleven Electronic Coordinator: Mary Ellen Johnston Expanding Medicare and Employer Plans Production Supervisors: Barbara Clark (Proofreading), Betty Frigerio (Production), Thomas J. Handrigan (Illustrations), JoAnne to Achieve Universal Health Insurance 2525 Weiskopf (Layout) K. Davis, Baltimore, Md Copy Editing: Vickey Golden (Free-lance Coordinator), Paul Frank (Senior Copy Editor), Susan R. Benner, Susan L. Mcllwaine, A Framework for Reform of the Richard T. Porter, Anne Schmidt Ryan, Jennifer Sperry Proofreading: Gwen Gilberg, Margaret Johnson, Teresa H. US Health Care Financing and Provision System 2529 Omiotek, Jennifer Reiling The Kansas Employer Coalition on Health, Production Associate: Melinda Arcabos Senior Production Assistants: Karen Branham, Brenda Chan- Task Force on Long-term Solutions, Topeka, Kan dler, Anita Henderson, Marci A. Kayne, Debra Lucas, Sharon Lynch, Christine Metzler, Debbie Pogorzelski, E. Ruth White, Universal Health Insurance Through Incentives Reform 2532 Lynn Yuill A. C. Enthoven, Stanford, Calif; R. Kronick, San Diego, Calif Production Assistants: Laslo Hunyady, Dorothy Patterson, Sandra Sanders, JoAnne Turner Illustrations and Layout: Leslie Koch, Juliana K. Mills, Linda An American Approach to Health System Reform 2537 Schmitt J. Holahan, M. Moon, W.P. Welch, S. Zuckerman, Washington, DC Cover Editor: M. Therese Southgate, MD Editorial Coordinator: Lenette Williams A Tax Reform Strategy to Deal With the Uninsured 2541 Editorial Supervisors: Steve Sarang, Gale Saulsberry S. M. Butler, Washington, DC Editorial Assistants: Mary Cannon, Kemberly Evans, Anne Frecka, Helen M. Giese, Shirley Goines, Sharon Iverson, Patricia Joworski, Andrea Kanter, Mary Ann Lilly, Ethel Pinkston, Dan The USHealth Act': Comprehensive Reform Reyes, Dorothy White, Helga Wutz for a Caring America 2545 Electronic Input Specialist: Vee Bailey Scientific and Socioeconomic Indexing Department: Norman E.R. Roybal, Washington, DC Frankel (Director), George Kruto, Susan McClelland, Mary Kay Tinerella Liberal Benefits, Conservative Spending: The Physicians for a National Health Program Proposal 2549 JAMA, The Journal of the American Medical Association K. Grumbach, T. Bodenheimer, D. U. Himmelstein, (ISSN 0098-7484), is published four issues per month by the American Medical Association, 515 N State St, Chicago, IL S. Woolhandler, Cambridge, Mass 60610. Phone (312) 464-5000. Cable address "Medic" Chicago. SUBSCRIPTION RATES-The subscription rate per year is $20, The Health Security Partnership: A Federal-State which is included in the annual AMA membership dues. Nonmem- bers are charged a higher than basic rate of $79 for 1 year, $143 Universal Insurance and Cost-Containment Program 2555 for 2 years in the United States and US possessions; in all other R. Fein, Boston, Mass countries, 1 year $99; 2 years $183 (add $40 surcharge to each 1-year subscription and $80 surcharge to each 2-year subscription for air delivery available to most countries). Medical students and Beyond Universal Health Insurance to residents are also charged a higher than basic rate of $39.50 for Effective Health Care 1 year, $71.50 for 2 years in the United States and US posses- 2559 sions. Rates for subscriptions for delivery to Japan or South E. Ginzberg, M. Ostow, New York, NY Korea are available through respective exclusive agents. Address all subscription communications to American Medical Associa- tion, Circulation Division, 515 N State St, Chicago, IL 60610. Editorials Phone: (312) 670-SUBS. CHANGE OF ADDRESS-POSTMASTER, send all address Caring for the Uninsured: Choices for Reform 2563 changes to JAMA, The Journal of the American Medical Associ- ation, attention: Subscription Department, 515 N State St, Chi- R.J. Blendon, J. N. Edwards, Boston, Mass cago, IL 60610. Notification of address change must be made at least 6 weeks in advance; include both old and new addresses, a National Health Care Reform: recent mailing label, and your new ZIP code. Second-class postage paid at Chicago and additional mailing An Aura of Inevitability Is Upon Us 2566 office. JAMA® Registered in the US Patent and Trademark Office. G.D. Lundberg, Chicago, III Copyright © 1991 by the American Medical Association BPA 2441 The Cover 2445 Jamie Wyeth, Kalounna in Frogtown, M. T. Southgate, Chicago, III JAMA Medical News & Perspectives 2451 The Journal of the American Medical Association Preexisting Conditions 'Hold Americans Hostage' to Employers and Insurance Should Insurance Cover Routine Immunizations? Groups Survey Health EDITORIAL BOARD Care Costs, Charges School-Based Health Clinics Provide Essential Care Kenneth A. Arndt, MD, Boston, Mass Byron J. Bailey, MD, Galveston, Tex Robert J. Blendon, ScD, Boston, Mass From the Health Care Financing Administration 2461 James E. Dalen, MD, Tucson, Ariz Lois DeBakey, PhD, Houston, Tex R. Gordon Douglas, Jr, MD, New York, NY Ronald G. Evens, MD, St Louis, Mo From the Health Resources and William H. Foege, MD, Atlanta, Ga Renee C. Fox, PhD, Philadelphia, Pa Daniel X. Freedman, MD, Los Angeles, Calif Services Administration 2464 Vincent A. Fulginiti, MD, New Orleans, La Morton F. Goldberg, MD, Baltimore, Md Marilyn Heins, MD, Tucson, Ariz King K. Holmes, MD, PhD, Seattle, Wash Abstracts Robert J. Joynt, MD, PhD, Rochester, NY 2469 Gordon K. MacLeod, MD, Pittsburgh, Pa William W. McLendon, MD, Chapel Hill, NC Arno G. Motulsky, MD, Seattle, Wash Claude H. Organ, Jr, MD, Oakland, Calif Letters 2480 Edmund D. Pellegrino, MD, Washington, DC Robert E. Rakel, MD, Houston, Tex Caring for the Uninsured and Underinsured A. O. Goldstein, L. Enyedi, M. Calderon, David J. Shulkin, MD, Philadelphia, Pa J. Babb, S. Bennett, G. H. Holman, E.S. Medley, T.J. Moore, H. J. Geiger, R. Zufall, Thomas P. Stossel, MD, Boston, Mass S. Helig, D. Wlodarczyk, B. Harris, D. G. Spigos, B. G. Langer, M. Frenkel, A. R. Barnosky, B.L. Farkas Anne Colston Wentz, MD, Chicago, III The Oath of the Healer L. Weinstein INTERNATIONAL ADVISORY COMMITTEE Prof Luigi Allegra, JAMA-Italy At Large With Dennis L. Breo 2573 Basel Atallah, MD, JAMA-Middle East Michèle Deker, MD, JAMA-France HHS Secretary Louis Sullivan speaks out for improved health Yuichiro Goto, MD, JAMA-Japan Dr Ragini Jain, JAMA-India Ivan Lambic, MD, JAMA-Yugoslavia Yong Kak Lee, MD, JAMA-Korea Obituary Dr Mehmet Pekus, JAMA-Turkey 2581 Azam Soorma, MBBS, JAMA-Pakistan Prof David Todd, JAMA-Southeast Asia Nicholas Edward Davies Zhang Hongkai, MD, JAMA-China Ryszard Zochowski, MD, JAMA-Poland Books 2588 AMA Officers President: C. John Tupper, MD* Medicine and Money (Marsh and Yarborough) Reviewed by R. M. Veatch President-Elect: John J. Ring, MD* Immediate Past President: Alan R. Nelson, MD Out of Bedlam (Johnson) Madness in the Streets (Isaac and Armat) Reviewed by C. C. Bell Secretary-Treasurer: Jerald R. Schenken, MD* Speaker, House of Delegates: John L. Clowe, MD Medical Technology and Society (Bronzino, Smith, and Wade) Reviewed by J. M. Humber Vice-Speaker, House of Delegates: Daniel H. 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Lundberg, MD Director, Publication Production and Printing Division: JAMA Journal Club Reading Assignments 2624 Nawin Gupta, PhD Director, Advertising Sales and Promotion Services Division: Dennis Joseph Dennehy Director, Advertising Services: Raymond Christian Index to Advertisers Director, Circulation Department: Beverly Martin 2624 Director, Fulfillment Department: Ray Healy ADVERTISING OFFICES: Eastern: 600 Third Ave, Suite 3700, Reference Directories New York, NY 10016 (Representatives: Alice Harvey-Herman, Cliff Vanderhoof [212-867-6640]); Midwest/Farwest: 515 N State AMA Officials, April 3:US Meetings, May :Organizations of Medical Interest, January 9; St, Chicago, IL 60610 (Manager: Thomas J. Carroll [312-464- State Associations and Examinations and Licensure, January 16; Meetings Outside the 2472] Representative: Daniel T. Mjölsness): Classified Adver- United States, January 23/30 tising: Michele Hanrahan (312-464-2456) ADVERTISING PRINCIPLES Advertisements in this issue have been reviewed to comply with the principles governing advertis- Instructions for Authors See January 2, 1991, p 49. ing in AMA publications. A copy of these principles is available on request. The appearance of advertising in AMA publications is not an AMA guarantee or endorsement of the product or the claims made for the product by the manufacturer. 2442 JAMA, May 15, 1991 Vol 265, No. 19 Early in heart failure treatment When ankles ask for diuresis the heart is calling for CAPOTEN* CAPOTEN complements diuretics and digitalis by reducing afterload and preload - improves cardiac output and left ventricular function. 1-3 CAPOTEN is indicated in patients with heart failure Include who have not responded adequately to treatment with diuretics and digitalis. CAPOTEN should generally be added to both of these agents except when digitalis use is poorly tolerated or otherwise not feasible. In using CAPOTEN, consideration should be given to the risk of neutropenia/agranulo- cytosis. Use special precautions in patients with im- paired renal function, collagen vascular disorders, APOTEN or those exposed to other drugs known to affect the white blood cells or immune response. Evaluation of heart failure patients should always include assess- (captopril tablets) ment of renal function. Please see INDICATIONS AND USAGE, CONTRAINDICATIONS WARNINGS, PRECAUTIONS, and ADVERSE REACTIONS in the brief summary on the adjacent page. Relief for the failing heart. References: 1. Captopril Multicenter Research Group A placebo-controlled trial of captopril in refractory chronic conges- Lithium-Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients live heart failure JACC 755-763, 1983 2. The Captopnl-Digoxin Multicenter Research Group: Comparative effects of ther- receiving concomitant lithium and ACE inhibitor therapy. These drugs should be coadministered with cau- apy with captopril and digoxin in patients with mild to moderate heart failure JAMA 539-544 1988 3. Packer M. Lee tion and frequent monitoring of serum lithium levels is recommended. If a diuretic is also used, it may in- WH, Yushak M. et al: Companson of captopril and enalapril in patients with severe chronic heart failure N Engl Med 315.847- crease the risk of lithium toxicity. 853, 1986 Drug/Laboratory Test Interaction: Captopril may cause a false-positive urine test for acetone. Carcinogenesis, Mutagenesis and Impairment of Fertility: Two-year studies with doses of 50 to 1350 CAPOTEN TABLETS mg/kg/day in mice and rats failed to show any evidence of carcinogenic potential. Studies in rats have re- vealed no impairment of fertility. Captopril Tablets INDICATIONS: Hypertension-CAPOTEN (captopril) is indicated for the treatment of hypertension. Pregnancy: Category C: Embryocidal effects and craniofacial malformations were observed in rabbits. Consideration should be given to the risk of neutropenia/agranulocytosis (see WARNINGS). CAPOTEN is ef- Human Experience-There are no adequate and well-controlled studies of captopril in pregnant women. fective alone and in combination with other antihypertensive agents, especially thiazide-type diuretics. Data are available that show captopril crosses the human placenta. Captopril should be used during preg- nancy only if the potential benefit justifies the potential risk to the fetus. Heart Failure: CAPOTEN (captopril) is indicated in the treatment of congestive heart failure in patients Based on post-marketing experience with all ACE inhibitors, the following information has been collected. who have not responded adequately to treatment with diuretics and digitalis. CAPOTEN should generally Inadvertent exposure limited to the first trimester of pregnancy does not appear to affect fetal outcome adversely. be added to both of these agents except when digitalis use is poorly tolerated or otherwise not feasible. Fetal exposure during the second and third trimester of pregnancy has been associated with fetal and neona- CONTRAINDICATIONS: CAPOTEN is contraindicated in patients who are hypersensitive to this product tal morbidity and mortality. or any other angiotensin-converting enzyme inhibitor (e.g., a patient who has experienced angioedema When ACE inhibitors are used during the later stages of pregnancy, there have been reports of hy. during therapy with any other ACE inhibitor. potension and decreased renal perfusion in the newborn. Oligohydramnios in the mother has also been reported. Infants exposed in utero to ACE inhibitors should be closely observed for hypotension, oliguria WARNINGS: Angioedema-Angioedema involving the extremities, face, lips, mucous membranes, tongue, and hyperkalemia. If oliguria occurs, attention should be directed toward support of blood pressure and glottis or larynx has been seen in patients treated with ACE inhibitors, including captopril. If angioedema renal perfusion with the administration of fluids and pressors as appropriate. Problems associated with involves the tongue, glottis or larynx, airway obstruction may occur and be fatal. Emergency therapy, in- prematurity such as patent ductus arteriosus have occurred in association with maternal use of ACE in- cluding but not necessarily limited to, subcutaneous administration of a 1:1000 solution of epinephrine hibitors but it is not clear whether they are related to ACE inhibition, maternal hypertension or the under- should be promptly instituted. lying prematurity. Neutropenia/Agranulocytosis-Neutropenia (<1000/mm³) with myeloid hypoplasia has resulted from use There is no experience with exchange transfusion, hemodialysis or peritoneal dialysis for removing cap- of captopril. About half of the neutropenic patients developed systemic or oral cavity infections or other topril from the neonatal circulation. features of the syndrome of agranulocytosis. The risk of neutropenia is dependent on the clinical status Nursing Mothers: Concentrations of captopril in human milk are approximately one percent of those in of the patient: maternal blood. Because of the potential for serious adverse reactions in nursing infants from captopril, a In clinical trials in patients with hypertension who have normal renal function (serum creatinine less than decision should be made whether to discontinue nursing or to discontinue the drug, taking into account 1.6 mg/dL and no collagen vascular disease), neutropenia has been seen in one patient out of over the importance of CAPOTEN to the mother. (See PRECAUTIONS: Pediatric Use.) 8,600 exposed. In patients with some degree of renal failure (serum creatinine at least 1.6 mg/dL) but no collagen vascular disease, the risk in clinical trials was about 1 per 500. Doses were relatively high Pediatric Use: Safety and effectiveness in children have not been established. There is limited experi- in these patients, particularly in view of their diminished renal function. In patients with collagen vas- ence reported in the literature with the use of captopril in the pediatric population; dosage, on a weight cular diseases (e.g., systemic lupus erythematosus, scleroderma) and impaired renal function, neu- basis, was generally reported to be comparable to or less that that used in adults. tropenia occurred in 3.7% of patients in clinical trials. While none of the over 750 patients in formal clinical Infants, especially newborns, may be more susceptible to the adverse hemodynamic effects of capto- trials of heart failure developed neutropenia, it has occurred during the subsequent clinical experience. pril. Excessive, prolonged and unpredictable decreases in blood pressure and associated complications, Of reported cases, about half had serum creatinine 2 1.6 mg/dL and more than 75% received pro- including oliguria and seizures, have been reported. cainamide. In heart failure, it appears that the same risk factors for neutropenia are present. CAPOTEN (captopril) should be used in children only if other measures for controlling blood pressure have not been effective. Neutropenia has appeared usually within 3 months after starting therapy, associated with myeloid hy. poplasia and frequently accompanied by erythroid hypoplasia and decreased numbers of megakaryocytes ADVERSE REACTIONS: Reported incidences are based on clinical trials involving approximately 7000 (e.g., hypoplastic bone marrow and pancytopenia); anemia and thrombocytopenia were sometimes seen. patients. Neutrophils generally returned to normal in about 2 weeks after captopril was discontinued, and serious Renal-About 1 of 100 patients developed proteinuria (see WARNINGS). Renal insufficiency, renal fail- infections were limited to clinically complex patients. About 13% of the cases of neutropenia have ended ure, nephrotic syndrome, polyuria, oliguria, and urinary frequency in 1 to 2 of 1000 patients. fatally, but almost all fatalities were in patients with serious illness, having collagen vascular disease, renal Hematologic-Neutropenia/agranulocytosis has occurred (see WARNINGS). Anemia, thrombocytopenia, failure, heart failure or immunosuppressant therapy, or a combination of these complicating factors. and pancytopenia have been reported. Evaluation of the hypertensive or heart failure patient should always include assessment of renal Dermatologic-Rash, (usually maculopapular, rarely urticarial), often with pruritus, and sometimes with function. If captopril is used in patients with impaired renal function, white blood cell and differential counts fever and eosinophilia, in about 4 to 7 of 100 patients (depending on renal status and dose), usually dur- should be evaluated prior to starting treatment and at approximately 2-week intervals for about 3 months, ing the 1st 4 weeks of therapy. Pruritus, without rash, in about 2 of 100 patients. A reversible associated then periodically. In patients with collagen vascular disease or who are exposed to other drugs known to pemphigoid-like lesion, and photosensitivity, have also been reported. Flushing or pallor in 2 to 5 of 1000 affect the white cells or immune response, particularly when there is impaired renal function, captopril should patients. be used only after an assessment of benefit and risk, and then with caution. All patients treated with cap- Cardiovascular-Hypotension may occur: see WARNINGS and PRECAUTIONS [Drug Interactions] for topril should be told to report any signs of infection (e.g., sore throat, fever). If infection is suspected, per- discussion of hypotension with captopril therapy. Tachycardia, chest pain, and palpitations each in about form white cell counts without delay. Since discontinuation of captopril and other drugs has generally led 1 of 100 patients. Angina pectoris, myocardial infarction, Raynaud's syndrome, and congestive heart fail- to prompt return of the white count to normal, upon confirmation of neutropenia (neutrophil count <1000/mm³) ure each in 2 to 3 of 1000 patients. withdraw captopril and closely follow the patient's course. Dysgeusia-Approximately 2 to 4 (depending on renal status and dose) of 100 patients developed a Proteinuria: Total urinary proteins >1 g per day were seen in about 0.7% of patients on captopril. About diminution or loss of taste perception; taste impairment is reversible and usually self-limited even with con- 90% of affected patients had evidence of prior renal disease or received high doses 150 mg/day), or both. tinued drug use (2 to 3 months). The nephrotic syndrome occurred in about one-fifth of proteinuric patients. In most cases, proteinuria sub- Angioedema-Angioedema involving the extremities, face, lips, mucous membranes, tongue, glottis or sided or cleared within 6 months whether or not captopril was continued. The BUN and creatinine were sel- larynx has been reported in approximately one in 1000 patients. Angioedema involving the upper airways dom altered in proteinuric patients. Since most cases of proteinuria occurred by the 8th month of therapy has caused fatal airway obstruction. (See WARNINGS.) with captopril, patients with prior renal disease or those receiving captopril at doses 150 mg per day, should Cough-Cough has been reported in 0.5-2% of patients treated with captopril in clinical trials. have urinary protein estimates (dip-stick on 1st morning urine) before therapy, and periodically thereafter. The following have been reported in about 0.5 to 2 percent of patients but did not appear at increased Hypotension: Excessive hypotension was rarely seen in hypertensive patients but is a possible conse- frequency compared to placebo or other treatments used in controlled trials: gastric irritation, abdominal quence of captopril use in salt/volume depleted persons (such as those treated vigorously with diuretics), pain, nausea, vomiting, diarrhea, anorexia, constipation, aphthous ulcers, peptic ulcer, dizziness, headache, patients with heart failure or those patients undergoing renal dialysis. (See PRECAUTIONS [Drug malaise, fatigue, insomnia, dry mouth, dyspnea, cough, alopecia, paresthesias. Interactions].) In heart failure, where the blood pressure was either normal or low, transient decreases in Other clinical adverse effects reported since the drug was marketed are listed below by body system. mean blood pressure >20% were recorded in about half of the patients. This transient hypotension is more In this setting, an incidence or causal relationship cannot be accurately determined. likely to occur after any of the first several doses and is usually well tolerated, although rarely it has been General: Asthenia, gynecomastia. associated with arrhythmia or conduction defects. A starting dose of 6.25 or 12.5 mg tid may minimize Cardiovascular: Cardiac arrest, cerebrovascular accident/insufficiency, rhythm disturbances, ortho- the hypotensive effect. Patients should be followed closely for the first 2 weeks of treatment and when- static hypotension, syncope. ever the dose of captopril and/or diuretic is increased. Dermatologic: Bullous pemphigus, erythema multiforme (including Stevens-Johnson syndrome), exfo- BECAUSE OF THE POTENTIAL FALL IN BLOOD PRESSURE IN THESE PATIENTS, THERAPY liative dermatitis. SHOULD BE STARTED UNDER VERY CLOSE MEDICAL SUPERVISION. Gastrointestinal: Pancreatitis, glossitis, dyspepsia. PRECAUTIONS: General: Impaired Renal Function-Hypertension-Some hypertensive patients with renal Hematologic: Anemia, including aplastic and hemolytic. disease, particularly those with severe renal artery stenosis, have developed increases in BUN and serum Hepatobiliary: Jaundice, hepatitis, including rare cases of necrosis, cholestasis. creatinine. It may be necessary to reduce captopril dosage and/or discontinue diuretic. For some of these Metabolic: Symptomatic hyponatremia. patients, normalization of blood pressure and maintenance of adequate renal perfusion may not be pos- Musculoskeletal: Myalgia, myasthenia. sible. Heart Failure-About 20% of patients develop stable elevations of BUN and serum creatinine >20% Nervous/Psychiatric: Ataxia, confusion, depression, nervousness, somnolence. above normal or baseline upon long-term treatment. Less than 5% of patients, generally with severe pre- Respiratory: Bronchospasm, eosinophilic pneumonitis, rhinitis. existing renal disease, required discontinuation due to progressively increasing creatinine. See DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS [Altered Laboratory Findings]. Hyperkalemia: Elevations Special Senses: Blurred vision. in serum potassium have been observed in some patients treated with ACE inhibitors, including capto- Urogenital: Impotence. pril. When treated with ACE inhibitors, patients at risk for the development of hyperkalemia include those As with other ACE inhibitors, a syndrome has been reported which may include: fever, myalgia, arthral- with: renal insufficiency; diabetes mellitus; and those using concomitant potassium-sparing diuretics, gia, interstitial nephritis, vasculitis, rash or other dermatologic manifestations, eosinophilia and an elevated potassium supplements or potassium-containing salt substitutes; or other drugs associated with increases ESR. Findings have usually resolved with discontinuation of treatment. in serum potassium. (See PRECAUTIONS: Drug Interactions; ADVERSE REACTIONS: Altered Laboratory Findings.) Valvular Stenosis-A theoretical concern, for risk of decreased coronary perfusion, has been noted Altered Laboratory Findings: Serum Electrolytes: Hyperkalemia: small increases in serum potassium, es- regarding vasodilator treatment in patients with aortic stenosis due to decreased afterload reduction. pecially in patients with renal impairment (see PRECAUTIONS). Surgery/Anesthesia-If hypotension occurs during surgery or anesthesia, and is considered due to the ef- Hyponatremia: particularly in patients receiving a low sodium diet or concomitant diuretics. fects of captopril, it is correctable by volume expansion. BUN/Serum Creatinine: Transient elevations of BUN or serum creatinine especially in volume or salt de- pleted patients or those with renovascular hypertension may occur. Rapid reduction of longstanding or Drug Interactions: Hypotension-Patients on Diuretic Therapy-Precipitous reduction of blood pressure may markedly elevated blood pressure can result in decreases in the glomerular filtration rate and, in turn, lead occasionally occur within the 1st hour after administration of the initial captopril dose in patients on diuretics, to increases in BUN or serum creatinine. especially those recently placed on diuretics, and those on severe dietary salt restriction or dialysis. This Hematologic: A positive ANA has been reported. possibility can be minimized by either discontinuing the diuretic or increasing the salt intake about 1 week Liver Function Tests: Elevations of liver transaminases, alkaline phosphatase, and serum bilirubin have prior to initiation of captopril therapy or by initiating therapy with small doses (6.25 or 12.5 mg). Alternatively, occurred. provide medical supervision for at least 1 hour after the initial dose. Agents Having Vasodilator Activity-In heart failure patients, vasodilators should be administered with caution. OVERDOSAGE: Primary concern is correction of hypotension. Volume expansion with an I.V. infusion of Agents Causing Renin Release-Captopril's effect will be augmented by antihypertensive agents that cause normal saline is the treatment of choice for restoration of blood pressure. Captopril may be removed from renin release. the general circulation by hemodialysis. Agents Affecting Sympathetic Activity-The sympathetic nervous system may be especially important in DOSAGE AND ADMINISTRATION: CAPOTEN (captopril) should be taken one hour before meals. In hy- supporting blood pressure in patients receiving captopril alone or with diuretics. Beta-adrenergic block- pertension, CAPOTEN may be dosed bid or tid. Dosage must be individualized; see DOSAGE AND AD- ing drugs add some further antihypertensive effect to captopril, but the overall response is less than ad- MINISTRATION section of package insert for detailed information regarding dosage in hypertension and ditive. Therefore, use agents affecting sympathetic activity (e.g., ganglionic blocking agents or adrenergic in heart failure. Because CAPOTEN (captopril) is excreted primarily by the kidneys, dosage adjustments neuron blocking agents) with caution. are recommended for patients with impaired renal function. Agents Increasing Serum Potassium-Give potassium-sparing diuretics or potassium supplements only for documented hypokalemia, and then with caution, since they may lead to a significant increase of serum Consult package insert before prescribing CAPOTEN (captopril). potassium. Use potassium-containing salt substitutes with caution. HOW SUPPLIED: Available in tablets of: 12.5 mg in bottles of 100 and 1000; 25 mg in bottles of 100, 1000, Inhibitors of Endogenous Prostaglandin Synthesis-Indomethacin and other nonsteroidal anti-inflammatory and 5000; 50 mg in bottles of 100 and 1000; 100 mg in bottles of 100; and in UNIMATIC* unit-dose packs agents may reduce the antihypertensive effect of captopril, especially in low renin hypertension. of 100 tablets. (J3-658U) 1991 E.R. Squibb & Sons, Inc., Princeton, NJ 810-507 Issued: January 1991 2444 The Cover James (Jamie) Browning Wyeth (1946-) was born on July 6, Wyeth had been struck by the sight of a huge red truck parked 1946, in Chadds Ford, Pa, the youngest child of a family in front of a house that had matching shutters. With just three already noted for two generations of famed artists. His 29- subjects-Kalounna, the truck, the house- Wyeth has man- year-old father, Andrew, was among the country's most widely aged to pose questions that will not go away. At first glance known painters. And Andrew's father was N. C. Wyeth, the the painting is as simple and as straightforward as the frontal illustrator of classics beloved through the years by children of pose of Kalounna, but on further reflection questions as deep all ages. Two of Jamie's aunts and an uncle were also artists. and as indefinable as the expression on the boy's face arise. Jamie dropped out of school after completing the sixth Who, if anyone, lives in the house? Why is the truck sitting idle grade and pursued his studies with a tutor. The schedule was on the grass? Is it because of lack of work? Lack of parts? Lack demanding: 3 hours of school studies with his tutor in the of money to repair? Where did Kalounna get his T-shirt with morning, 4 hours of artwork with his Aunt Carolyn Wyeth in the logo of the soap opera "Dallas"? Did he ever wonder who the afternoon, studying such basic shapes as the cube, the shot JR? Who killed JFK? Why is one hand clenched in a fist, cone, and the globe, reminiscent perhaps of Cézanne's dictum the fingers of the other splayed like the tree limbs behind him? that nature should be treated "in terms of the cylinder, the What is Kalounna's future? Who is Kalounna? sphere, the cone, all in perspective." In 1960, at the age of 14, These are just some of the questions Wyeth's painting asks. Jamie began his studies with his father. Three years later he But they are questions about particulars and presumably will moved to New York City, where he studied anatomy firsthand have specific answers now or later. The painting raises other, at a hospital morgue and, before age 20, had his first major universal, questions as well, questions that have no easy show. answers-ifany. Kalounna's three-quarter figure, silhouetted Born as he was into post-World War II America, Jamie against an uncertain sky, for example, nearly divides the Wyeth's paintings punctuate the history of the country since painting in half. To the right on the side of the clenched fist, that time. Beginning with Draft Age, a major painting com- stands the truck. In the left half, on the side of the splayed pleted in 1965, when Jamie was 19, they progress through fingers, stands the house. Kalounna thus stands between two space launches, a posthumous portrait of John F. Kennedy, the cultures: that of home, comfort, security, submission; and that Watergate proceedings, the first moon landing, and the Lao- of the open road, uncertainty, freedom, self-determination. tian boat people. Interspersed are private scenes from his His red shirt, in which the red of the truck and the red of the personal history at his summer home in Monhegan, off the house are linked, suggests that the reconciliation of the two coast of Maine, or at his farm in Delaware: gulls, sheep, pigs, cannot be made without pain for Kalounna himself. But, says, starfish, a herd of Hampshires. Most difficult for him are Wyeth, such a task does not face just Kalounna. It is a portraits, and he accordingly limits himself to perhaps one a universal task that faces all equally. Like Kalounna, all must year. His greatest joys are painting out-of-door scenes and reconcile their opposing halves: home/adventure, security/ animals. freedom, East/West, masculine/feminine, need/resource, ob- Kalounna in Frogtown (cover) is one of Jamie Wyeth's more ligation/right. Like Kalounna, we know such a task brings recent paintings, completed in 1986, when Wyeth was 40. His pain, but also, like Kalounna, we are not afraid to confront it. friend, Kalounna, was 11 years old and a Laotian refugee. Head-on, if necessary. - M. Therese Southgate, MD Frogtown was a community near Chadds Ford where one day Jamie Wyeth (1946- ), Kalounna in Frogtown, 1986, American. Oil on canvas. 91.1 127.3 cm. Courtesy of the Terra Museum of American Art, Chicago, Ill; Daniel Terra Collection. JAMA, May 15, 1991 Vol 265, No. 19 The Cover 2445 CLEARER EYES. DRIER NOSE. OUTSTANDING SYMPTOM RELIEF. © Janssen Pharmaceutica Inc. 1991 Once-a-day HISMANAL (ASTEMIZOLE) 10mg Tablets OUTSTANDING SYMPTOM RELIEF HISMANAL offers proven relief of runny nose, sneezing, PHYSICIAN AND PATIENT GLOBAL EVALUATION and itchy/watery eyes.¹,² And HISMANAL symptom relief % EXCELLENT/GOOD RESPONSE starts on day one. 80 70 With HISMANAL, patients benefit from the convenience 60 68% of once-a-day dosing with no sedative effect greater 50 than placebo. % 40 30 When your patients need an antihistamine that leaves 20 30% them alert, choose HISMANAL. After all, they deserve a 10 product that really works at relieving symptoms. 0 HISMANAL PLACEBO p<0.05 Adapted from Knight1 Please see brief summary of prescribing information on adjacent page. Once-a-day HISMANAL Get the facts (ASTEMIZOLE) 10mg Tablets Before prescribing, please consult complete prescribing information of which the following is on every physician in the U.S. a brief summary. DESCRIPTION: HISMANAL® (astemizole) is a histamine 1,-receptor antagonist available in scored white tablets for oral use. CONTRAINDICATIONS: HISMANAL is contraindicated in patients with known hypersensitivity to astemizole or any of the inactive ingredients. PRECAUTIONS: General: Caution should be given to potential anticholinergic (drying) effects in patients with lower airway diseases, including asthma. Caution should be used in patients with cirrhosis or other liver diseases (See Clinical Pharmacology section). HISMANAL does not appear to be dialyzable. Caution should also be used when treating patients with renal impairment. Information for Patients: Patients taking HISMANAL should receive the following information and instructions. Antihistamines are prescribed to reduce allergic symptoms. Patients should be questioned about pregnancy or lactation before starting HISMANAL therapy, since the drug should be used in pregnancy or lactation only if the potential benefit justifies the potential risk to fetus or baby (see Pregnancy subsection). Patients should be instructed 1) to take HISMANAL only as needed, 2) not to exceed the prescribed dose, and 3) to take HISMANAL on an empty stomach, e.g., at least 2 hours after a meal. No additional food should be taken for at least 1 hour post-dosing. Patients should also be instructed to store this medication in a tightly closed container in a cool, dry place, away from heat or direct sunlight, and away from children. Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenic potential has not been revealed in rats given 260x the recommended human dose of astemizole for 24 AMERICAN months, or in mice given 400x the recommended human dose for 18 months. Micronucleus, MEDICAL INPECTORY dominant lethal, sister chromatid exchange and Ames tests of astemizole have not revealed mutagenic activity. Impairment of fertility was not observed in male or female rats given 200x the recommended human dose. Pregnancy: Pregnancy Category C: Teratogenic effects were not observed in rats administered 200x the recommended human dose or in rabbits given 200x the recommended human dose. Maternal toxicity was seen in rabbits administered 200x the recommended human dose. Embryocidal effects accompanied by maternal toxicity were observed at 100x the recommended human dose in rats. Embryotoxicity or maternal toxicity was not observed American in rats or rabbits administered 50x the recommended human dose. There are no adequate and Medical well controlled studies in pregnant women. HISMANAL should be used during pregnancy only Directory if the potential benefit justifies the potential risk to the fetus. Metabolites may remain in the body for as long as 4 months after the end of dosing, calculated on the basis of 6 times the terminal half-life (See Clinical Pharmacology section). Nursing Mothers: It is not known whether this drug is excreted in human milk. Because certain drugs are known to be excreted in human milk, caution should be exercised when HISMANAL is administered to a nursing woman. HISMANAL is excreted in the milk of dogs. Pediatric Use: Safety and efficacy in children under 12 years of age has not been demonstrated. ADVERSE REACTIONS: The reported incidences of adverse reactions listed in the following table are derived from controlled clinical studies in adults. In these studies the usual maintenance dose of HISMANAL® (astemizole) was 10 mg once daily. Percent of Patients Reporting The American Medical Directory, 32nd Edition Controlled Studies* The single most authoritative source of information about the physicians in Hismanal Placebo Classical** (N 1630) (N 1109) (N 304) the U.S. - completely updated and ready for immediate shipment. ADVERSE EVENT % % % Central Nervous System Drowsiness 7.1 6.4 22.0 Demographics, Credentials, and Professional Details Headache 6.7 9.2 3.3 Fatigue 4.2 1.6 11.8 More than 633,000 entries. Complete information, from primary sources, Appetite increase 3.9 1.4 0.0 Weight increase 3.6 0.7 1.0 on every physician in the United States. 30,000 brand new entries. 300,000 Nervousness 2.1 1.2 0.3 Dizzy 2.0 1.8 1.0 updated addresses. Gastrointestinal System Nausea 2.5 2.9 1.3 Diarrhea 1.8 2.0 0.7 Abdominal pain 1.4 1.2 0.7 Choose the Four-Volume Set or Compact Computer Disk Eye, Ear, Nose, and Throat Mouth dry 5.2 3.8 7.9 Select either the traditional handsomely bound, 5,300 page, four- Pharyngitis 1.7 2.3 0.3 Conjunctivitis 1.2 1.2 0.7 volume set; or the new 4 3/4 IBM compatible CD-ROM laser encoded Other Arthralgia 1.2 1.6 0.0 disk. The same information in the format most convenient for you. *Duration of treatment in Controlled Studies ranged from 7 to 182 Days **Classical Drugs: Clemastine (N 137); Chlorpheniramine (N 100); Pheniramine Maleate (N 47); d-Chlorpheniramine (N 20) Order Your Copy of the American Medical Directory Adverse reaction information has been obtained from more than 7500 patients in all clinical trials. Weight gain has been reported in 3.6% of astemizole treated patients involved in 32nd Edition Today! controlled studies, with an average treatment duration of 53 days. In 46 of the 59 patients for whom actual weight gain data was available, the average weight gain was 3.2 kg. Hard Bound Edition, $495.; Less frequently occurring adverse experiences reported in clinical trials or spontaneously from marketing experience with HISMANAL include: angioedema, bronchospasm, depression, CD-ROM Laser Disk (single user system), $695.; edema, epistaxis, myalgia, palpitation, photosensitivity, pruritus, and rash. Marketing CD-ROM Laser Disk (network system), $1095. experiences include isolated cases of convulsions. A causal relationship with HISMANAL has not been established. OVERDOSAGE: In the event of overdosage, supportive measures including gastric lavage and Call toll-free 1-800-621-8335 emesis should be employed. Cases of overdose have been reported from foreign marketing experience. Although overdoses of up to 500 mg have been reported with no ill effects, cases VISA, MasterCard, American Express and Optima only. of serious ventricular arrhythmias, including Torsades de pointes, following overdoses of greater than 200 mg have been reported. Patients should be carefully observed and ECG monitoring is recommended in cases of suspected overdose. An appropriate antiarrhythmic treatment may be needed. HISMANAL does not appear to be dialyzable. Care should be taken Reference 0P390890 (hardbound edition) not to exceed dosing recommended in the DOSAGE AND ADMINISTRATION section. Oral LD50 values for HISMANAL were 2052 mg/kg in mice and 3154 mg/kg in rats. In neonatal rats, the 0P391390 (single user system) oral LD50 was 905 mg/kg in males and 1235 mg/kg in females. 0P391490 (network version) NDC 50458-510-01 (10 X 10 blister) NDC 50458-510-10 (100 tablets) Store tablets at room temperature (59°-86°F) (15°-30°C). Protect from moisture. References: 1. Knight A. Astemizole-a new, non-sedating antihistamine for hayfever M J Otolaryngol. 1985;14(2):85-88. 2. Howarth PH. Holgate ST. Comparative trial of two non-sedative H1 antihistamines, terfenadine and astemizole, for hay fever. Thorax 1984;39:668-672 AMERICAN JANSSEN MEDICAL PHARMACEUTICA Appropriate U.S. state and Canadian December 1988 sales tax will be added as applicable. 40 Kingsbridge Road U.S. Patent 4,219,559 Piscataway, NJ 08855-3998 May 1991 JPI-HS-103-2 1P41N98A-M 2448 Improvement that depressed patients can wake up and notice THE THE 11111 <<<<<<<<<<<<<<<<<<<<<<<<< in THE THE IIIIIII Better days start with better nights Up to 97% of depressed patients experience some kind of sleep disturbance, and often it may be the presenting sign.¹ Sleep disturbances respond particularly well to once-a-day Sinequan® (doxepin HCl) as it works to relieve underlying depression and anxiety.².³ The possibility of drug interaction should be considered if the patient is receiving other drugs concomitantly. Antidepressant ® effectiveness with the nighttime advantage SINEQUAN (doxepin HCI) 150-mg.* 100-mg, 75-mg. 50-mg, 25-mg, and 10-mg CAPSULES ORAL CONCENTRATE, 10-mg/mL, 120-mL (4-oz) bottles . The 150-mg capsule strength is intended for maintenance therapy only and is not ROERIG Pfizer recommended for Initiation of treatment. A division of Pfizer Pharmaceuticals Please see brief summary of SINEQUAN® (doxepin HCI) prescribing information © 1989, Pfizer Inc. on next page. 2449 CHIEF OF DIVISION OF References: 1. Goldberg HL: Sleep disturbance as a manifestation of depression, in Somatic Depression: Insights for Primary Care Physicians. Proceedings of a symposium held in Miami, Dec 4, 1978. New York, Postgraduate Medicine Communications, pp 13-18. 2. Karacan I. Blackburn AB, Thornby JI, et al: The effect of doxepin HCI (Sinequan) on sleep HEAD AND NECK SURGERY patterns and clinical symptomatology of neurotic depressed patients with sleep disturbance, in Sinequan® (doxepin HCI). A Monograph of Recent Clinical Studies Princeton, NJ, Excerpta Medica. 1977 pp 4-22. 3. Goldberg HL, Finnerty RJ: The use of doxepin in the treatment of symptoms of anxiety neurosis and accompanying depression: A collaborative controlled study. Am J Psychiatry 1972;129(July):74-77. The Department of Surgery of the UCLA School of Medicine is searching for a tenured SINEQUAN (doxepin HCI) faculty member to serve as the Chief of the Division of Head and Neck Surgery. One of BRIEF SUMMARY nine surgical divisions in the Department, SINEQUAN* (doxepin HCI) Capsules/Oral Concentrate Contraindications. SINEQUAN is contraindicated in individuals who have shown hypersensitivity to the drug. Possibility Head and Neck Surgery has approx. 20 full- of cross sensitivity with other dibenzoxepines should be kept in mind. SINEQUAN is contraindicated in patients with glaucoma or a tendency to urinary retention. These disorders should be ruled out, particularly in older patients. time faculty members, 32 residents and fel- Warnings. The once-a-day dosage regimen of SINEQUAN in patients with intercurrent illness or patients taking other medications should be carefully adjusted. This is especially important in patients receiving other medications with lows, and 45 staff members. Candidates for anticholinergic effects. Usage in Geriatrics: The use of SINEQUAN on a once-a-day dosage regimen in geriatric patients should be adjusted this position will be surgeons with proven carefully based on the patient's condition. Usage in Pregnancy: Reproduction studies have been performed in rats, rabbits, monkeys and dogs and there was no evidence of harm to the animal fetus. The relevance to humans is not known Since there is no experience in pregnant contributions to research, with strong commit- women who have received this drug, safety in pregnancy has not been established. There has been a report of apnea and drowsiness occurring in a nursing infant whose mother was taking SINEQUAN ments to education and training, and recogni- Usage in Children: The use of SINEQUAN in children under 12 years of age is not recommended because safe conditions for its use have not been established. tion as an excellent surgeon and clinician. Drug Interactions. MAO Inhibitors: Serious side effects and even death have been reported following the concomitant use of certain drugs with MAO inhibitors. Therefore. MAO inhibitors should be discontinued at least two weeks prior to the cautious Recommendations and inquiries should be initiation of therapy with SINEQUAN The exact length of time may vary and is dependent upon the particular MAO inhibitor being used. the length of time it has been administered, and the dosage involved. directed to: Cimetidine: Cimetidine has been reported to produce clinically significant fluctuations in steady-state serum concen- trations of various tricyclic antidepressants. Serious anticholinergic symptoms (i.e., severe dry mouth, urinary retention and blurred vision) have been associated with elevations in the serum levels of tricyclic antidepressant when cimetidine therapy is initiated Additionally, higher than expected tricyclic antidepressant levels have been observed Michael J. Zinner, M.D., Chairman when they are begun in patients already taking cimetidine In patients who have been reported to be well controlled on tricyclic antidepressants receiving concurrent cimetidine therapy. discontinuation of cimetidine has been reported to decrease established steady-state serum tricyclic antidepressant levels and compromise their therapeutic effects. Department of Surgery Alcohol: It should be borne in mind that alcohol ingestion may increase the danger inherent in any intentional or unintentional SINEQUAN overdosage. This is especially important in patients who may use alcohol excessively. UCLA School of Medicine Tolazamide: A case of severe hypoglycemia has been reported in a type II diabetic patient maintained on tolazamide (1 gm/day) 11 days after the addition of doxepin (75 mg/day). 72-131 CHS Precautions. Since drowsiness may occur with the use of this drug. patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug. Patients should also be cautioned that their response to alcohol may be potentiated 10833 Le Conte Avenue Since suicide is an inherent risk in any depressed patient and may remain so until significant improvement has occurred. patients should be closely supervised during the early course of therapy. Prescriptions should be written for the Los Angeles, CA 90024 smallest feasible amount Should increased symptoms of psychosis or shift to manic symptomatology occur, it may be necessary to reduce dosage or add a major tranquilizer to the dosage regimen. Adverse Reactions. NOTE: Some of the adverse reactions noted below have not been specifically reported with SINEQUAN use However, due to the close pharmacological similarities among the tricyclics. the reactions should be UCLA is an affirmative action employer. considered when prescribing SINEQUAN (doxepin HCI). Anticholinergic Effects Dry mouth, blurred vision, constipation, and urinary retention have been reported. If they do not subside with continued therapy. or become severe, it may be necessary to reduce the dosage Central Nervous System Effects: Drowsiness is the most commonly noticed side effect. This tends to disappear as therapy is continued. Other infrequently reported CNS side effects are confusion. disorientation. hallucinations, numbness. paresthesias, ataxia. extrapyramidal symptoms, seizures, tardive dyskinesia, and tremor Cardiovascular: Cardiovascular effects including hypotension, hypertension, and tachycardia have been reported The benefits of occasionally. Allergic: Skin rash. edema, photosensitization, and pruritus have occasionally occurred. Hematologic: Eosinophilia has been reported in a few patients. There have been occasional reports of bone marrow depression manifesting as agranulocytosis, leukopenia, thrombocytopenia, and purpura. Gastrointestinal: Nausea, vomiting indigestion, taste disturbances, diarrhea, anorexia. and aphthous stomatitis have group practice. been reported. (See anticholinergic effects.) Endocrine: Raised or lowered libido, testicular swelling, gynecomastia in males. enlargement of breasts and galactorrhea in the female, raising or lowering of blood sugar levels, and syndrome of inappropriate antidiuretic hormone secretion have been reported with tricyclic administration. Physicians who want to enjoy the advantages of group Other: Dizziness, tinnitus, weight gain, sweating, chills, fatigue, weakness. flushing, jaundice, alopecia, headache, practice without an administrative burden will really appreci- exacerbation of asthma. and hyperpyrexia (in association with chlorpromazine) have been occasionally observed as adverse effects ate CIGNA Healthplan. As a physician at one of our health Withdrawal Symptoms: The possibility of development of withdrawal symptoms upon abrupt cessation of treatment after prolonged SINEQUAN administration should be borne in mind. These are not indicative of addiction and gradual care centers, you'll join a team of equally dedicated physi- withdrawal of medication should not cause these symptoms. cians practicing within a consultative environment. But, un- Dosage and Administration. For most patients with illness of mild to moderate severity. a starting daily dose of 75 mg is recommended Dosage may subsequently be increased or decreased at appropriate intervals and according to individual like a group practice, your administrative work is carefully response. The usual optimum dose range is 75 mg/day to 150 mg/day. In more severely ill patients higher doses may be required with subsequent gradual increase to 300 mg/day if orchestrated by a competent staff of CIGNA Healthplan em- necessary. Additional therapeutic effect is rarely to be obtained by exceeding a dose of 300 mg/day ployees, enabling you to focus on patient care. In patients with very mild symptomatology or emotional symptoms accompanying organic disease, lower doses may suffice. Some of these patients have been controlled on doses as low as 25-50 mg/day. Currently, we have practice opportunities available for: The total daily dosage of SINEQUAN may be given on a divided or once-a-day dosage schedule. If the once-a-day schedule is employed the maximum recommended dose is 150 mg/day. This dose may be given at bedtime The 150 mg ARIZONA capsule strength is intended for maintenance therapy only and is not recommended for initiation of treatment. Anti-anxiety effect is apparent before the antidepressant effect. Optimal antidepressant effect may not be evident for General & Vascular Surgeons two to three weeks. Overdosage. A. Signs and Symptoms Positions available for BC/BE surgeons. MUST be able to 1. Mild: Drowsiness, stupor, blurred vision, excessive dryness of mouth. 2. Severe: Respiratory depression, hypotension, coma. convulsions, cardiac arrhythmias and tachycardias. acquire vascular surgery privileges by submitting vascular Also: urinary retention (bladder atony). decreased gastrointestinal motility (paralytic ileus). thermia (or hypo- case list or by training. Practice is approximately 50% gen- thermia). hypertension, dilated pupils, hyperactive reflexes. eral surgery and 50% vascular surgery to start. B. Management and Treatment 1. Mild: Observation and supportive therapy is all that is usually necessary. We provide competitive compensation and benefits pack- 2. Severe: Medical management of severe SINEQUAN overdosage consists of aggressive supportive therapy. If the age, paid malpractice insurance and continuing medical edu- patient is conscious, gastric lavage, with appropriate precautions to prevent pulmonary aspiration, should be performed even though SINEQUAN is rapidly absorbed. The use of activated charcoal has been recommended, as has been cation. To receive more information about becoming a continuous gastric lavage with saline for 24 hours or more. An adequate airway should be established in comatose patients and assisted ventilation used if necessary. EKG monitoring may be required for several days. since relapse after CIGNA physician, call or send CV to: apparent recovery has been reported. Arrhythmias should be treated with the appropriate antiarrhythmic agent. It has been reported that many of the cardiovascular and CNS symptoms of tricyclic antidepressant poisoning in adults may be CIGNA Healthplan of Arizona reversed by the slow intravenous administration of mg to 3 mg of physostigmine salicylate. Because physostigmine is rapidly metabolized, the dosage should be repeated as required. Convulsions may respond to standard anticonvulsant Professional Staffing therapy. however barbiturates may potentiate any respiratory depression. Dialysis and forced diuresis generally are not Dept. 26 of value in the management of overdosage due to high tissue and protein binding of SINEQUAN P.O. Box 16145 More detailed professional information available on request. Phoenix, AZ 85011-6145 800-252-2471 ROERIG Pfizer EOE A division of Pfizer Pharmaceuticals New York, New York 10017 CIGNA Healthplan CIGNA Team with results. SM 2450 Medical News & Perspectives Preexisting Conditions 'Hold Americans Hostage' to Employers and Insurance "MILLIONS OF hardworking, honest out health insurance. Parsegian notes research and publishing firm in Wash- Americans are being held hostage by that those who have applied for exten- ington, DC. insurance companies. I am one of them." sions have had trouble with the paper- A 1987 survey of 2000 employers who So begins a letter to President George work and bureaucracy involved. offer insurance, conducted by Foster Bush from Mary Evans, a Columbus, Parsegian says she gave up on finding Higgins, an employee benefits consult- Ohio, woman with an increasingly com- another group policy after even top-rat- ing firm in New York, NY, found that mon tale to tell: ed companies insisted on excluding peo- 57% had preexisting condition clauses in Savings wiped out after payment ple who had things "that didn't seem the health policies they offered to em- denials for treatment of preexisting terribly risky," such as mild hyperten- ployees. Though more common with conditions (in Evans' case, surgery to sion or diabetes, or who had counseling, small employers (64% of firms with less remove breast cancer that her insurer "for depression in particular, but even than 500 employees), they were still says she "should have" found before she family and marital counseling. They very prevalent in large companies (45% had to switch policies because of her would just not insure these people." of firms with more than 10 000 employ- husband's job change); Parents whose children are born with ees). And exclusions and waiting peri- Fear that recurrence would require disabilities often become unsuspecting ods for coverage of preexisting condi- a bone marrow transplant she could not victims of their policy's fine print. "They tions are even more frequently used afford if her insurance would not pay; change jobs, or their employer will now, says John Erb, a managing consul- Disgust with what Evans calls the change insurers, and they will be unable tant with Foster Higgins. "mountain of paperwork" and "snippy, to enroll their dependent child in the "People get ensnared without any haughty, surly" treatment from insur- new plan," says Kilb. malfeasance on their part, caught not ance companies; Federal law enables policyholders to even through carelessness but simply No apparent way out. If she dared get 18-month extensions when they no fate," says Sara Watson, PhD, director to change insurers, a new policy would longer qualify as members of a group of the Institute for Rehabilitation and almost surely exclude cancer coverage. policy. But, Kilb says, "ultimately they Disability Management of the Washing- "If you have the misfortune of getting lose coverage." ton Business Group on Health. And the a catastrophic illness, you are literally Some people with preexisting condi- harm preexisting condition clauses cre- held hostage by the company that is tions succeed in getting on a spouse's or ate "is just SO evident." presently insuring you," says Evans. some other large group policy with loos- "It's an easy area of the law to advise er rules, but that itself is a gamble, says Insurers Protected, Not Insured people in because they have no rights," Oakland, Calif, attorney Steve Schear. The insurance industry says high pre- says Linda Kilb, staff attorney for the "If people disclose every little thing miums, waiting periods, condition-spe- Disability Rights Education and De- wrong, they could be refused coverage. cific payment denials, and even com- fense Fund, Berkeley, Calif. "It is legal If they don't, and they make a substan- plete denial of coverage to people who discrimination. If there is any evidence tial claim, they are commonly denied have preexisting conditions are neces- that [a medical condition] is going to cost coverage" for failing to provide full dis- sary to protect companies from people the insurer money, they don't have to closure of medical history. who only want to pay for insurance cover you." Not wanting to be held hostage can when they need it. cause people to put off needed care. There is, however, no protection from 'Ditching' Moderate Risks? Schear says he has clients who are "ac- these rules for those paying for insurance Even reputable companies are "ditch- tually afraid to go to a doctor, because all along. "The people who most need ing" moderate risks. Blue Cross of Illi- something might be documented on coverage are least able to get it" if they nois in December yanked coverage from their records that will make it difficult have to change policies, says Schear. the Independent Writers of Chicago. for them to get health care" coverage if Even some in the industry acknowl- "They said we did not fulfill underwrit- they ever need or want to change jobs. edge that things are out of hand. "There ing guidelines because we were an asso- One million eighteen thousand Amer- has been a substantial increase in rating ciation and not an employer, but they'd icans were laid off in 1990, according to and underwriting practices that are in- covered us for 10 years," says Nancy the federal Bureau of Labor Statistics. appropriate," says Tom Buchberger, di- Parsegian, who heads the group's insur- The average length of time a job was rector of policy and strategic issues for ance committee. held, according to a 1987 bureau survey, Aetna Life & Casualty, Hartford, Conversion policies are too expensive was 4.2 years. The average job turnover Conn. for some of the 60 members who were rate in 1990 was 10.8%, according to the Preexisting condition clauses "cause covered, and are now completely with- Bureau of National Affairs, a private a lot of people to hang onto jobs because JAMA, May 15, 1991 - Vol 265, No. 19 Medical News & Perspectives 2451 they're scared that if they switch they High-Risk Pools Help Few which rejection letters are not required will go uncovered for a period of time for State governments are trying to re- to prove uninsurability, but "we could the condition they have," says Blue spond to the problem. Nearly half have probably add to the list," she says. Cross spokesperson Julie Boyle. special "high-risk pools" for "uninsura- For people denied coverage only for a Restrictions on their use in the small- bles," usually defined as those who have preexisting condition but offered a poli- employer market, which accounts for been denied coverage as individuals, cy covering everything but treatment the majority of uninsured and underin- had coverage terminated, or had been for that condition, "99% of those cases sured Americans, are being proposed asked to pay excessive premiums. But we can't help," says Vande Boche. by the National Association of Insur- these programs are themselves often ance Commissioners, the Health Insur- too costly for all but the upper middle Small-Group Reforms Go for 'Chunk' ance Association of American, and Blue class. The insurance industry's proposed Cross and Blue Shield. "Most people with medical conditions limits on preexisting condition clauses But the reforms would leave most af- are unable to afford the higher premi- are limited to the small-group insurance fected people "still out in the cold," says ums" in Maine's risk pool, which has market, policies for between three and David Lyons, Iowa's insurance commis- only 600 enrollees, says a member of 25 persons. Up to 75% of Americans sioner and spokesperson for the Nation- that state's legislature, Rep Charlene who lack access to health care are small- al Association of Insurance Commis- Rydell of Brunswick. business employees and their depen- sioners' Health Care Access Working California's major risk medical insur- dents, says Health Insurance Associa- Group. ance plan enrolled 3000 people in its first tion of America spokesperson Richard Entire professions, ranging from 2 months, and is getting 100 applications Coorsh. health care professionals to restaurant a day. With its unique tobacco tax sub- The reforms would provide coverage workers, florists, and car salesmen, are sidy, it will be able to handle 10 000 for up to 40% of the uninsured, says redlined, offered rates that few can af- people. But "hundreds of thousands of Lyons. "We're trying to carve [the ford, or are refused any coverage at all people in California are eligible," says problem] into achievable chunks. If the by many insurers, says Mary O'Sulli- executive director John Ramey. reforms work, there's no reason we van, executive director of the Health Illinois' comprehensive health insur- can't expand them" to larger groups and Access Foundation in San Francisco, ance program, another of the few high- individuals, he says. Calif. "The range is extraordinary, and risk pools with a state subsidy, has a Policy prices are SO high and denials pretty arbitrary. It doesn't have to be year-long waiting list. are SO frequent in this segment of the actuarially sound, they can just do it." For those individuals who cannot get market partly because one or two seri- The smallest employers, those who in, "a lot of them are just stuck," says ous, chronic conditions can bankrupt have less than 50 employees, are often Norman Godden, director of the Illinois the premium pool from such small denied coverage for their whole group Insurance Information Service hotline. groups, says Coorsh. unless individuals with preexisting con- Some exclusions are written for as Key to the reform proposals is a rein- ditions are excluded, says Karen Hor- long as 7 years, and the reasons for ex- surance mechanism, invisible to con- kitz, senior research assistant at the clusion are expanding, adds Gail Edler, sumers, to respread the risk, a "safety Employee Benefits Research Institute, who staffs the hotline. "It used to be if valve for carriers that might end up Washington, DC. someone had a diagnosis but no treat- with a disproportionately large number ment" for a condition, insurance compa- of high-risk cases," says Lyons. 'Concept of Insurance' Eroding nies would provide coverage. "But now With the reinsurance mechanism in "The whole concept of insurance" as a that fine line is gone." place, the National Association of In- way to spread risk is eroding, says Hor- "The most encouraging thing I can surance Commissioners' proposal would kitz. Commercial insurers have been tell people is to hang in there until limit rates to 25% above the average for picking off the healthiest groups by of- they're 65 and can get Medicare," says each policy category, and that average fering lower prices than nonprofits like Edler. Some have moved out of state, could be no more than 20% above the Blue Cross and Blue Shield, leaving the she says, because neighboring Indiana's lowest-rated class of business. The nonprofits with the sickest populations. risk pool has no waiting list or enroll- maximum annual rate increase for the Now even the Blues have given up the ment limit and only a 90-day residency group's health status, claims experi- "mission" of community rating, and use requirement. ence, or duration of coverage would be preexisting condition clauses and expe- Cases of people moving into Indiana 15%, with further increases allowed for rience ratings, she says. because of the state's Comprehensive trends in health care cost and use. "Things have been escalating that Health Insurance Association, one of Insurers could not invoke preexisting way all during the latter half of this the oldest and most successful risk condition clauses when an employer century, SO that now in every part of the pools, have been noted, says services changes insurers or an employee system, people are saying 'I don't want coordinator Diane Vande Boche. Premi- changes jobs within the small-group to subsidize, [and] can't afford to subsi- ums are subsidized by assessments on market, and they could not terminate dize, other people," says Horkitz. insurers, based on the amount of premi- coverage of individuals or dependents Exacerbating the problem, says Ly- ums they bill in the state. within a group. ons, are predatory insurers who offer "We've had a jump in enrollment "These provisions would go a long cheap "teaser" rates to low-risk groups since last fall. A lot of underwriters are way toward guaranteeing continuity of with waiting periods for coverage of clamping down," says Vande Boche. coverage," says Lyons. Coorsh says preexisting conditions of (usually) 1 She notes that insurers are "using more they will cause "a little short-term pain year. "As soon as these underwriting combinations of conditions, for in- for the industry, but long-term gain. protections to the insurer wear off, they stance, hypertension and something Everybody believes the system needs raise the rates 100%" or more, pushing else, in rejection letters." improvement." the employer to look for coverage else- The state keeps a list of about 20 con- Advocates of total system overhaul, where before its employees develop ditions like cancer, diabetes, and ac- however, say the proposals are "Band- costly conditions. quired immunodeficiency syndrome, for Aids" and "survival" tactics. "They 2452 JAMA, May 15, 1991 Vol 265, No. 19 Medical News & Perspectives THE Break the UN-H2 HeHabit for Maintenance 200 CARAFATE TAGAMET THE 300 4 SKF 19m BID! Controlled studies confirm CARAFATE® (sucralfate) delivers unsurpassed duodenal ulcer remission rates¹-¹¹ OIXY Mucosal biopsy scores of healed ulcer tissue returned to near normal levels (P<0.02) during 1 year of EVE CARAFATE maintenance therapy¹ 150 No known systemic interactions with other medications 008 SKF CARAFATE® Nonsystemic maintenance therapy CAFAE327 PLEASE SEE BRIEF SUMMARY OF PRESCRIBING INFORMATION ON ADJACENT PAGE. 6167C1 in any benefits package is best decided by tion that we have." In addition, the National Vaccine Ad- individual corporations working volun- It seems paradoxical, Henderson visory Committee has formed a subcom- tarily with insurance companies or oth- says, "that insurance companies, which mittee to examine alternatives to the er third-party payers." The reluctance are endeavoring to minimize health care existing systems for paying for the na- of insurance companies to include child- costs, are not willing to pay for one of tion's immunization program. Bart ex- hood immunizations among their bene- the most cost-effective procedures in pects this subcommittee will report by fits reflects the industry's philosophy the entire medical armamentarium." the end of September. that the purpose of insurance is to cover Their reluctance to pay for immuniza- Henderson says that, as a result of risks, not to pay for routine or predict- tion is "idealogical rather than practi- the success of the immunization pro- able needs, Miller says. cal," he argues. "It has been very diffi- gram in the past, the health care system Nevertheless, the National Vaccine cult to get third-party payers to pay for has given a very low priority to vaccina- Advisory Committee's report recom- mammograms, Pap[anicolaou] smears, tions. "We're now beginning to pay for mends that "vigorous efforts should be or other preventive services. While you this lackadaisical attitude toward the made, including legislation, if neces- could argue that some of these proce- immunization of our nation's children," sary, to assure that all managed care dures may not be cost-beneficial, I don't he says. systems provide immunization and that think there is any question about the The National Vaccine Advisory Com- all third-party payers cover routine cost-benefits of childhood immuni- mittee's report concludes that, "be- childhood immunization as part of their zations." cause disease in any part of this country basic benefits package." Kenneth Bart, MD, is director of the is a threat to all, federal, state, and local According to Henderson, insurance National Vaccine Program Office, governments share responsibility for companies "will pay for treatments for Rockville, Md, which is the federal of- improving deficient delivery systems. acne and ingrown toenails, but they fice that oversees the nation's immuni- "The delivery of our most cost-effec- won't pay for immunizing children zation program. According to Bart, an tive health service cannot await the de- against measles and other life-threaten- interagency subcommittee was appoint- velopment of the ideal comprehensive ing diseases. In my opinion, this atti- ed to help develop strategic plans for child health system. Essential changes tude is strange and unconscionable. Im- implementing the panel's recommenda- in the childhood immunization system munizations are the simplest and the tions. The subcommittee is expected to can and should be made now." most cost-effective medical interven- finish its report by next month. -by Andrew Skolnick Groups Survey Health Care Costs, Charges A SERIES of reports, just completed or health care system needs to be com- ScD, of the foundation's staff. in preparation, indicates strong agree- pletely rebuilt or fundamentally The driving force is the rising cost of ment among government, medicine, changed. The survey included 10 specif- providing health care coverage, Cantor and business leaders that the remaining ic actions that government might take. suggests. In 1989, employers spent years of the decade will see a continuing The two proposals receiving the high- $176.8 billion to provide health care debate on the shortcomings of the na- est rating for immediate action are: (1) benefits for their active and retired em- tion's health care system. greater use of selective contracting to ployees. Health insurance, of course, One report is coming by late summer purchase Medicare and Medicaid ser- has become a issue between employees from the 1991 Advisory Council on So- vices (60%) and (2) tax incentives for who are eager to maintain or expand cial Security, another from the health small businesses to provide health bene- coverage and employers who are anx- subcommittee of the National Gover- fits for employees (51%). ious to keep costs within bounds. nors Association, and a third from the Slightly more than half of the execu- More than one third of the executives Department of Health and Human tives are in favor of government inter- surveyed said that, based on their expe- Services. vention to control costs. But a majority rience, health insurance costs were Meanwhile, President Bush's Admin- (268 of the 321 executives who were their top concern, compared with the istration, in the person of its budget asked this question) still favor company other costs of doing business. Almost director, Richard G. Darman, has gone responsibility for basic hospital care two thirds say this is a major concern. to Capitol Hill to warn that the rising coverage. Only 7% say such costs are a minor prob- costs of health care are "unsustainable." When it comes to coverage for cata- lem. Spending on health has risen from less strophic and long-term care, 186 of 312 Spending by employers for health than 6% of the gross national product executives who responded are in favor benefits has exceeded 50% of pretax three decades ago to around 12% today, of government intervention or at least corporate profits since 1982, the report Darman says. He predicts that expendi- having government take a share of the says. The relentless increase in costs tures will reach 17% of the gross nation- responsibility. has made these benefits the fastest ris- al product by the end of this century and The survey (Health Aff. 1991;10:98- ing component of employee compensa- 37% by the year 2030. 105) was conducted by the Gallup orga- tion, it says, and in 1989 in health insur- nization and is sponsored by the Robert ance premium increases averaged 20%. Executives Have Their Say Wood Johnson Foundation, Princeton, These concerns are echoed by Arnold And a just-published survey of 384 NJ. "There seems to be a growing de- Relman, MD, who is retiring as editor of executives, who head some of the na- termination on the part of business lead- the New England Journal of Medicine, tion's largest companies, reports that ers to proceed with major changes in the Boston, Mass. He points out that, since more than 90% believe that either the health care system," says Joel Cantor, (Continued on p 2458.) 2454 JAMA, May 15, 1991 265, No. 19 Medical News & Perspectives What's the best solution for preventing motion sickness? Staying home Using Transderm Scõp® scopolamine Transderm Scõp is more effective than So, with Transderm Scõp your patients don't Dramamine® 1 for preventing nausea and have to choose between staying home or suf- vomiting. And in a recent clinical study, fering the dizziness, nausea, and vomiting of Transderm Scõp was demonstrated to be motion sickness. significantly more effective than 25 mg meclizine². Transderm Scõp should not be used in children. Use with special care in the elderly and in patients The 72-hour transdermal delivery system taking drugs (including alcohol) capable of caus- means improved patient compliance since ing CNS effects. Dryness of the mouth occurs in multiple dosing of tablets is avoided. Further- about two-thirds of people. more, patients don't have to try to medicate during an activity. Transderm Scõp® ® Well tolerated — drowsiness occurs in only scopolamine 1 of 6 people. The motion-sickness solution™ See next page for brief summary of CIBA Prescribing Information. Transderm Scõp® scopolamine (formerly Transderm-V) The answer to a Transdermal Therapeutic System time-consuming task Programmed delivery in vivo of 0.5 mg of scopolamine over 3 days Credentials Verification - It's important to both physicians and those evaluating BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE INSERT) them. Now available in your area, INDICATIONS AND USAGE ADVERSE REACTIONS the National Physician Credentials Transderm Scöp is indicated for prevention of nausea and The most frequent adverse reaction to Transderm Scôp is vomiting associated with motion sickness in adults. The disc dryness of the mouth. This occurs in about two thirds of the Verification Service, AMA/NCVS,™ can should be applied only to skin in the postauricular area. people. A less frequent adverse reaction is drowsiness, which make the process easier and better. Clinical Results: Transderm Scop provides antiemetic pro- occurs in less than one sixth of the people. Transient impairment tection within several hours following application of the disc of eye accommodation, including blurred vision and dilation of Here's how behind the ear. In 195 adult subjects of different racial origins the pupils, is also observed. who participated in clinical efficacy studies at sea or in a The following adverse reactions have also been reported on For physicians: The AMA/NCVS sets controlled motion environment, there was a 75% reduction in infrequent occasions during the use of Transderm Scõp: up and maintains a permanent portfolio the incidence of motion-induced nausea and vomiting. disorientation; memory disturbances; dizziness; restlessness; Transderm Scôp provided significantly greater protection than hallucinations; confusion; difficulty urinating; rashes and of verified information that can be used that obtained with oral dimenhydrinate. erythema; acute narrow-angle glaucoma; and dry, itchy, or red as the physician applies for licensure or CONTRAINDICATIONS eyes. Drug Withdrawal: Symptoms including dizziness, nausea, privileges. The physician no longer Transderm Scõp should not be used in patients with known hypersensitivity to scopolamine or any of the components of vomiting, headache and disturbances of equilibrium have been needs to start from scratch each time reported in a few patients following discontinuation of the use the adhesive matrix making up the therapeutic system, or in of the Transderm Scôp system. These symptoms have an application is made. patients with glaucoma. occurred most often in patients who have used the systems for WARNINGS more than three days. For hospitals/boards: The AMA/NCVS Transderm Scôp should not be used in children and should be OVERDOSAGE provides a summary report of core used with special caution in the elderly. See PRECAUTIONS. Overdosage with scopolamine may cause disorientation, Since drowsiness, disorientation, and confusion may occur credentials that have been verified with with the use of scopolamine, patients should be warned of the memory disturbances, dizziness, restlessness, hallucinations, or confusion. Should these symptoms occur, the Transderm primary sources. And for the core possibility and cautioned against engaging in activities that Scop disc should be immediately removed. Appropriate require mental alertness, such as driving a motor vehicle or credentials it collects, the AMA/NCVS parasympathomimetic therapy should be initiated if these operating dangerous machinery. symptoms are severe. satisfies current standards defined in Potentially alarming idiosyncratic reactions may occur with ordinary therapeutic doses of scopolamine. DOSAGE AND ADMINISTRATION the Joint Commission Accreditation PRECAUTIONS Initiation of Therapy: One Transderm Scop disc (programmed General to deliver 0.5 mg of scopolamine over 3 days) should be Manual for Hospitals for primary source applied to the hairless area behind one ear at least 4 hours verification. The credentials verifier no Scopolamine should be used with caution in patients with before the antiemetic effect is required. Only one disc should pyloric obstruction, or urinary bladder neck obstruction. Caution should be exercised when administering an antiemetic be worn at any time. longer needs to reverify all information. or antimuscarinic drug to patients suspected of having Handling: After the disc is applied on dry skin behind the ear, the hands should be washed thoroughly with soap and The result intestinal obstruction. Transderm Scop should be used with special caution in the water and dried. Upon removal of the disc, it should be It's called a win-win situation and, discarded, and the hands and application site washed thor- elderly or in individuals with impaired metabolic, liver, or kidney functions, because of the increased likelihood of CNS effects. oughly with soap and water and dried, to prevent any traces of best of all, it's operated by the most scopolamine from coming into direct contact with the eyes. (A Information for Patients experienced provider of physician patient brochure is available.) Since scopolamine can cause temporary dilation of the pupils Continuation of Therapy: Should the disc become displaced, information: the American Medical and blurred vision if it comes in contact with the eyes, patients it should be discarded, and a fresh one placed on the hairless Association. should be strongly advised to wash their hands thoroughly with area behind the other ear. If therapy is required for longer than soap and water immediately after handling the disc. 3 days, the first disc should be discarded, and a fresh one Patients should be advised to remove the disc immediately For information on the Service, placed on the hairless area behind the other ear. and contact a physician in the unlikely event that they experi- contact your co-sponsoring Medical ence symptoms of acute narrow-angle glaucoma (pain in and The system should be stored between 59°-86°F (15°-30°C). reddening of the eyes accompanied by dilated pupils). CAUTION Society office or call the AMA at Patients should be warned against driving a motor vehicle or Federal law prohibits dispensing without prescription. 1-800-677-NCVS. operating dangerous machinery. A patient brochure is available. Drug Interactions Dist. by: Scopolamine should be used with care in patients taking CIBA Consumer Pharmaceuticals drugs, including alcohol, capable of causing CNS effects. Spe- Div. of CIBA-GEIGY Corp. cial attention should be given to drugs having anticholinergic Summit, NJ 07901 properties, e.g., belladonna alkaloids, antihistamines (including meclizine), and antidepressants. C88-5 (Rev. 2/88) Carcinogenesis, Mutagenesis, Impairment of Fertility No long-term studies in animals have been performed to evaluate carcinogenic potential. Fertility studies were per- formed in female rats and revealed no evidence of impaired CIBA fertility or harm to the fetus due to scopolamine hydrobromide administered by daily subcutaneous injection. In the highest- dose group (plasma level approximately 500 times the level References: achieved in humans using a transdermal system), reduced 1. Price N et al: Clin Ther 1979;2:258-262. Studies at sea The AMA/NCVS-i means maternal body weights were observed. that demonstrated a 75% mean reduction in the incidence of nausea and vomiting associated with motion sickness greater efficiency. Pregnancy Category C Teratogenic studies were performed in pregnant rats and with Transderm Scõp, compared to 50% with Dramamine* quality'assured. rabbits with scopolamine hydrobromide administered by daily (P>0.05). intravenous injection. No adverse effects were recorded in the Dahl E: Clin Pharmacol Ther 1984;36:116-120 A study rats. In the rabbits, the highest dose (plasma level approxi- of mild motion sickness in a laboratory setting in which mately 100 times the level achieved in humans using a Transderm Scõp demonstrated a significantly greater transdermal system) of drug administered had a marginal reduction in the incidence of nausea and vomiting than 25 mg meclizine = 0.01) and placebo (P 0.003). American Medical Association embryotoxic effect. Transderm Scõp should be used during pregnancy only if the anticipated benefit justifies the potential risk to the fetus. Nursing Mothers It is not known whether scopolamine is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Transderm Scöp is administered to a nursing woman. National Pediatric Use Physician Children are particularly susceptible to the side effects of Credentials belladonna alkaloids. Transderm Scöp should not be used in children because it is not known whether this system will M Verification release an amount of scopolamine that could produce serious Service™ adverse effects in children. © 1989, CIBA. 659-8071-A 2456 Changing the world of diabetes, one patient at a time A 12-year-old boy from Tokyo learns to monitor his blood glucose. In Buenos Aires, an expectant mother with diabetes is counseled on her diet and exercise. From Sydney to Berlin, Boehringer Mannheim is developing new products and programs to improve diabetes management. With our help, more and more healthcare professionals will become better equipped to diagnose, counsel, and treat diabetes than ever before. And that can make the world healthier, one patient at a time. If you're attending the 14th International Diabetes Federation Congress in Washington, DC, on June 23-28, visit us at booth #301. Making a world of difference through better diabetes management BOEHRINGER Boehringer Mannheim Corporation MANNHEIM Patient Care Systems Division 9115 Hague Road, P.O. Box 50100 CORPORATION mannheim boehringer Indianapolis, IN 46250-0100 © 1991 Boehringer Mannheim Corporation. All rights reserved. SMZ-046 (Continued from p 2454.) The survey queried a selected sample some compromises will have to be made. the 1960s, health care expenditures of nine groups. They included 201 physi- But there is by no means universal have been increasing at a compound cians, 50 union leaders, 1175 senior cor- agreement on ways to achieve this. For rate of between 5% and 6% a year. This porate executives, 251 hospital execu- instance, 70% of the union leaders que- is corrected for inflation, population in- tives, 21 major health insurers, 260 ried said that the health care system crease, and the increasing age of the members of Congress, 25 key commit- needs to be rebuilt. population, he says, adding: "We are tee staff, 50 state health commissioners, On the other hand, 4% of the physi- now spending $650 billion a year on and 15 executives in the Department of cians agreed with this. About one third health care. At this rate, we will shortly Health and Human Services. say that only minor changes are needed. be spending a trillion dollars a year." The groups were described as health The physicians say that they would care system stakeholders who were se- accept requirements to follow practice Looking for Common Ground lected for the survey because of their guidelines; suggested that patients Meanwhile, another survey-com- influential role as payers, regulators, should consult with, and obtain the missioned by the Metropolitan Life In- administrators, or providers. The phy- agreement of, a primary care physician surance Company (MetLife)-attempts sicians in the survey were chosen from before seeing a specialist; and urged to locate any common ground on which all of the medical societies listed in the that there be a fee-for-service system, to build an improved health care sys- current directory of the American Asso- paid out of a fixed budget. tem, and to discover what trade-offs ciation of Medical Society Executives. They also said they would be willing would be acceptable. It asks, assuming There was across-the-board agree- to take a 10% cut in fees if their paper- that changes are needed, if those indi- ment that the health care system itself work were "substantially reduced." But viduals who are involved are prepared is sick and in need of treatment. For this they were not in favor of national health to make compromises to achieve them. treatment to be successful, they say, insurance. -by Charles Marwick School-Based Health Clinics Provide Essential Care A WINNING season for the Westdale young people who do not have adequate a pediatric nurse-practitioner and a clin- Middle School basketball team in Baton access to care," and stated that federal ical nurse specialist in mental health, Rouge, La, was a sort of bonus for fam- and private employer reductions in and a coordinator/health educator. ily physician Holley Galland, MD. When benefits meant that "the number of un- There is also an administrator. the director of Westdale's school-based insured persons continues to rise." Shenker says that while the 4500-stu- health clinic gave preseason physicals to The present recession has made mat- dent high school is in a "nice lower-mid- the players, their prospects didn't look ters worse, according to Julia Graham dle class, multiethnic area and not the SO bright. Lear, PhD, codirector of the School- ghetto," its population comes from "a Galland tersely sums up what hap- Based Adolescent Health Care Pro- community where there are not a lot of pened: "In one afternoon of screening gram, which administers a $17 million private practitioners. Medical care is kids on the team, I picked up three asth- Robert Wood Johnson Foundation pro- episodic, emergency room, out of the matics, none of whom were stabilized, ject, begun in 1987, that helps fund 23 mainstream of private practice." all of whom I 'tuned up,' and we had a such health services across the country. Many adolescents have chronic dis- winning season. I'm hoping a little pre- Lear supplied the estimate of close to eases like asthma and diabetes, or nutri- exercise medication helped these kids 300 clinics; it includes about 100 that are tional deficiencies. The incidence of sex- plow down the opposition!" located in primary schools in New York. ually transmitted disease and other Most of the students who participate Usually when people talk about SBCs, issues related to adolescent sexuality, in the estimated nearly 300 school- they mean those that have been set up including pregnancy, is high. based clinics (SBCs) in the United primarily in high schools and occasional- Shenker estimates that 20% of the States are struggling against obstacles ly in middle schools (sixth, seventh, and students are eligible for Medicaid reim- more obdurate than rival hoopsters. eighth grades) to help those young peo- bursement, which is sought, but that all Recent interviews with the directors of ple "the system" has tossed aside. the students with parental permission several clinics and others who are in- to be in the program (a requirement at volved with such programs confirm New Kids (Care) on the Block all schools) are treated: "Nobody pays that, contrary to popular opinion, ado- Typical of these SBCs is one of the out of pocket." lescents require medical care for a wide newest, the student health center at "Since there's no way our staffing and range of problems-and a great many Franklin K. Lane High School in New our financing can take care of 4500 can't afford it. York City's borough of Queens, which kids," says Shenker, "we're targeting Two years ago, the first report on began full operation last month. It is one the ninth grade-in conjunction with a comprehensive school-based health pro- of five such facilities-one in each bor- special health program already in place grams by the American Medical Associ- ough-funded by the city last summer. in that grade-to see if we can improve ation's Council on Scientific Affairs Ronald Shenker, MD, its codirector, their health care. The hope is that (JAMA. 1989;261:1939-1942) estimated is chief, Division of Adolescent Medi- they'll still be in school when they're in that "approximately 12 million Ameri- cine, at Schneider Children's Hospital, the 12th grade, and not drop out." The can children and adolescents were with- New Hyde Park, NY. Codirector Holly clinic is open to all students, however. out public or private health insurance K. Shaw, RN, is at the clinic full time. "We see quite a number of kids with coverage." It added that "even this fig- Its staff members are another physi- emotional problems, and we find a high ure underestimates the number of cian and several more nurses, including incidence of mental illness," adds Mar- 2458 JAMA, May 15, 1991 265, No. 19 Medical News & Perspectives tha Arden, MD, an associate professor you are open to the possibility and de- from the program's approach to alcohol of pediatrics at Schneider Hospital who velop a relationship of trust with the and drug problems. A Denver school spends 60% of her time at the school. students you are caring for." policy provides that students caught us- One of the most unusual cases was a In the groups he leads, students ing or dealing drugs be suspended and, good student who came to the health spend at least one academic year, in says Kaplan, "these are usually margin- center with what was diagnosed as ap- once-a-week and some private sessions, al students to start with." The SBCs pendicitis. After transfer to Schneider learning to deal with their psychic trau- initiated a system whereby students Hospital-all of the SBCs nationwide ma. "Most of the parents don't know and parents write a contract with the have some affiliation with a local hospi- they're in therapy," he says; "many of school agreeing that, in order to stay in tal-and a thorough evaluation, it was them couldn't handle it." school, the student will join a compul- discovered that the girl had multiple In most cases the offender is no longer sory treatment program. personality disorder. Another "self" in the home; if he or she is, appropriate "Through that program, we were had no symptoms, Arden said. The stu- steps are taken through government able to reduce suspensions in the schools dent has been hospitalized-a suspect- agencies. The goal of therapy is to have by 80% in the first year of operation. We ed victim of sexual abuse-and the case students realize that they are not "dam- found, too, that the kids stayed involved reported to the proper authorities. An- aged goods," so they will not remain in the program beyond the compulsory other report was sent in on a girl who lifelong potential "victims" with all the period. That's one real good example of showed up at the clinic with back pain- further misery that usually entails. Cár- how education and health care can inter- "her mom had been beating her." denas says that while his work is far act," Kaplan says. from easy, the results are encouraging. A serendipitous result of having the Medical and Social Impact The physicians emphasize, however, professionals who staff the clinics inter- Such cases, which (except for the psy- that not all their tasks are onerous. Pro- act regularly with students is their ef- chiatric diagnosis) school clinic officials viding routine physical examinations fectiveness as positive role models. Ka- agree are not that rare, are one reason that make students eligible for employ- plan says he knows of at least three for the facilities' effectiveness in the ar- ment or athletic competition is one of students who have gone into nursing eas they serve. Even if parents could their responsibilities. It might not seem "because of getting involved in the pro- afford medical care, say the physicians, that important, but if they were not gram and having their lives touched by they would not seek it in some cases. there to do it, it probably would not get one of the staff members." In others, medical care simply hasn't done-and another door to full partici- Approximately 70% of the students been there for some families. When it pation in American life would be shut on are enrolled in the three clinics. Last becomes available, it changes lives. The poor youngsters. year more than 4000 visits were logged Johnson Foundation's Lear likes to David Kaplan, MD, chief of adoles- for 1600 students. Kaplan estimates quote the director of an SBC in the cent medicine at the University of Colo- that some 25% of the students in each Bronx, NY. He recently said, "This past rado School of Medicine in Denver, for school are without any form of health year, the first asthmatic graduated example, mentions that before clinics insurance and, since about 15% of Den- from Morris High School." were opened in three of that city's nine verites are covered by Medicaid, "we Medically unsophisticated listeners high schools, one third of the girls who think about half of the students are right who heard Steven Tames, MD, say this wanted to go out for volleyball teams on the edge in terms of having inade- on the Today show, Lear suggests, couldn't play because they could not get quate resources for medical care." probably didn't realize what a "miracle" the examinations. "It's a tremendously exciting pro- it represents. It is a refutation, she gram," Kaplan says. "The fact that we says, of the common scenario according A Different Approach have such high utilization from the stu- to which "kids with asthma got no medi- Kaplan says the impetus to establish dent body tells me that we're doing cal care, ended up in crises, were then the school health programs in Denver something right-if we weren't meeting treated in hospital emergency depart- 3 years ago came from "seeing a real the needs of the students, they wouldn't ments and as inpatients, missed many increase in the morbidity that adoles- be coming in." days of school and SO were held back, cents have in our society. It seemed that and therefore dropped out. Now, at we had to develop a different approach if More Than Reproductive Health Morris, that isn't happening anymore. we were to intervene significantly." He Students have been coming into That's a medical impact!" points out that, in Denver at least, "the SBCs in St Paul, Minn, since 1973. Ac- Improving the mental health of teen- kinds of problems that are seriously cording to the Center for Population Op- agers who have been sexually abused is jeopardizing kids are not serious medi- tions, a New York-based nonprofit or- a priority for Jose Cárdenas, PsyD, a cal problems in the strictest sense- ganization that keeps tabs on adolescent psychologist in the Teen Health Center they don't have a life-threatening illness health and reproduction issues, it was at San Fernando (Calif) High School, a that is going to interfere with their fu- not only one of the earliest such facilities largely Hispanic school where he was ture productivity." (the first opened in Dallas, Tex, in once a student. Shortly after starting However, he adds, "It's not unusual 1970), but also the first comprehensive work in 1987, he discovered SO many for us to find a teenager who comes into school-based health clinic that offered girls (and some boys) whose problems of the SBC and, finally, the fact will come family planning counseling services. suicide attempts, difficulty with peer out that he's been kicked out of the The five clinics, which continue to be relationships, and early pregnancy (or house, for any of a number of reasons, allied with St Paul-Ramsey Medical paternity) stemmed from prior sexual and has been moving around from one Center, are managed by a local nonprof- abuse that he set up therapy groups in friend's house to another for 2 weeks. it organization called Health Start, ac- English and Spanish. It's hard for a kid like that to think about cording to its executive director, Donna Cárdenas, like other physicians at his future in a way that makes him want Zimmerman, MPH. SBCs, says, "This sort of thing happens to stay in school and graduate. We try to Unlike most SBCs, those in St Paul much more frequently than we want to help them with that." care for an across-the-board array of believe. You learn about it only when One hopeful statistic has emerged patients, says Zimmerman, thanks to JAMA, May 15, 1991 Vol 265, No. 19 Medical News & Perspectives 2459 the open enrollment policy that allows lar ones in Minneapolis. "she immediately refers them to the students to attend any of the city's six Zimmerman estimates that the clinics Teen Advocacy Program (the social ser- high schools. This makes for a clinic cli- see as many as half the students during vice agency we work with), and then entele at each school that includes those any school year, and "that might be any- they immediately hook up with the from the upper-middle class to the poor. thing from a student who comes in for a nurse midwife program at the local pub- In fact, she says, at Highland Park High throat culture to one who has received lic hospital, and they immediately begin School in St Paul's richest neighbor- all her prenatal care." About 40%, she good prenatal care with close, ongoing hood, the only one that has no clinic, says, are students without any health follow-up at school, at home through the parents and teachers are working to get care insurance and another 25% have social worker, and at the hospital." The one because of a growing need. medical assistance, "so I think we are physician says, "I have to believe we've Health education aimed at disease reaching a group of students who might made a big difference here. After all, prevention has a high priority. Zimmer- not get health care in any other setting if everybody agrees good prenatal care man says many of the clinic staff speak they did not have the school-based does tend to help." to classes about a wide variety of physi- clinic." (Galland is circumspect regarding the cal and mental health issues. abortion option. No mention of this is The topics include nutrition, smok- An Urgent Need-A General Trend? allowed in Louisiana schools, and if ing-associated health problems, risk as- Galland in Baton Rouge and her col- pregnant high schoolers hear about it sessment regarding the acquired immu- league John Howe, MD, who directs the elsewhere, she prefers not to know.) nodeficiency syndrome (AIDS), and clinic at Istrouma High School in that The day after her interview with education about other sexually trans- city, agree. They say, "The clinics are JAMA, Galland said, she and others mitted diseases. There are also small important because the problem we most planned to present the SBC concept to group get-togethers devoted to such encounter is that the students haven't the Louisiana House of Representa- topics as raising self-esteem and sup- gotten access to health care elsewhere." tives' Health and Welfare Committee, port for teenaged parents. While they dispense medical care for because the Office of Public Health in "While the issue of teenage pregnan- illnesses ranging from the common cold the state capital is SO enthusiastic about cy is still a major effort," Zimmerman to systemic lupus erythematosus, says the programs now in Baton Rouge and says, "the centers have evolved into Galland-and even referred for success- New Orleans (a third one is planned for much more than a reproductive health ful surgery a student with coarctation of Shreveport). In Louisiana, she says, clinic." She says the clinics see "an awful the aorta-the provision of health edu- lack of access to medical care is not an lot of students who have been victims of cation sometimes can be problematic. issue of race SO much as one of poverty. physical and/or sexual child abuse or She said she finds it "ridiculous," for The majority of students at Westdale some kind of family violence," and ap- example, that the state-approved cur- and Istrouma come from one-parent propriately trained professionals pro- riculum for AIDS education "is not al- families, she says, and are "medically vide counseling to them. During the last lowed to mention the word condom." indigent. Their primary problem is few years, she says, the clinics' staffs An intriguing finding, however, is neglect." have seen a steep rise in the incidence of that when the word is spoken-licitly- "There's a real move in middle school sexually transmitted diseases. in the context of "safe sex" and preven- and high school education to do more Consequently, there is much empha- tion of sexually transmitted diseases, it linking of education and health services, sis on "teaching kids how to be safe seems to affect the rate of adolescent especially where this is the only place about sexual activity and certainly en- pregnancy. Galland explains that, al- students can receive care," Galland couraging the use of condoms." The clin- though it is illegal to counsel about or says. "It seems to be a general trend." ics do not distribute them, says Zim- dispense contraception in Louisiana Does anyone oppose this trend? Once merman. However, "students have schools, following rash of STDs at the their purpose is explained to students' access to a number of neighborhood clin- high school level after Christmas" a talk parents, those who were interviewed ics where they can go to pick up birth on prevention was given to the entire for this story all agreed, and community control supplies or condoms free of student body of Istrouma High. "To our concerns about adherence to local mores charge. That's part of the benefit of be- amazement," she says, "I just learned are adequately addressed, support for ing a Health Start patient." that our pregnancy rate seems to be school-based health centers seems to The variety of funding on which the St down 35% from last year." blossom. Paul clinics depend is fairly similar to Galland is careful to claim no un- What about their impact on private that of many others. First, says Zim- earned credit; she says another reason medical practice? The Johnson Founda- merman, "we are as aggressive as we for the drop may be newly efficient tion's Lear says, "The only opposition can be about recouping medical assis- networking with local service agencies you hear is philosophic or religious, not tance [Medicaid] or other third-party that offer counseling to victims of rape from physicians. Many organized physi- reimbursement, if at all possible." Then and incest and for other sexual issues. cians' groups, including the American there is a temporary grant from the "Our best statistic"-Galland fairly Medical Association, support their con- Robert Wood Johnson Foundation, crows-"and a real hotdog statistic it is, tinued development-and doctors have some money from the Children's Trust is that through this networking and never been shrinking violets when they Fund (for counseling to prevent child through a consistency of care, our per- have felt that someone might be attack- abuse by teenaged parents), federal centage of low-birth-weight infants ing their pocketbook. funding through the Department of born to high school girls went from 50% "My hypothesis is that school-based Corrections (for counseling students of babies 2 years ago to 0% this year." health centers have not provoked con- who are themselves victims of criminal She credits this to the efforts of a cern on the part of physicians in private child abuse), and federal Maternal and "low-key, very accepting nurse practi- practice because they are being devel- Child Health block grant money that is tioner" whom the students readily ask oped in communities that just are not distributed by the city. Some local foun- to perform a pregnancy test whenever being served by individual providers. dations and corporations also donate they miss a period. Nobody's losing nothing!" money to the clinics in St Paul and simi- "If they're positive," Galland says, -by Marsha F. Goldsmith 2460 JAMA, May 15, 1991 265, No. 19 Medical News & Perspectives Treat hypertension at its source with NEW, ONCE-A-DAY CARDURA (doxazosin mesylate) Scored Tablets 1 mg, 2 mg, 4 mg, 8 mg Please see brief summary of prescribing information on last page of this advertisement. NEW, ONCE-A-DAY Begin all patients Evaluate for blood Evaluate for blood 1 with CARDURA 1 mg 2 pressure control. 3 pressure control. CARDURA once daily to mini- Prescribe 4 mg once Prescribe 8 mg once mize side effects. Evaluate daily, if necessary. daily, if necessary. supine and standing blood Maximum recommended (doxazosin mesylate) Scored Tablets 1mg 2 mg 4 mg 8mg pressure. Prescribe dosage is 16 mg once CARDURA 2 mg once daily, daily. Convenient once-a-day dosage if necessary. Most responsive patients are 1 mg 4 mg 8 mg controlled with one daily dose of 4 to 8 mg² 2 mg -recommended initial dose is 1 mg, with dosage range of 1 mg to 16 mg per day. References: 1. Weiner N Drugs that inhibit adrenergic nerves and block dizziness lightheadedness, or palpitations are bothersome they should be reported DOXAZOSIN PLACEBO adrenergic receptors. in Goodman and Giliman, eds The Pharmacological Basis to the physician, so that dose adjustment can be considered Patients should also (N=339) (N=336) of Therapeutics ed 7 New York NY Macmillan Publishing Company 1985, pp be told that drowsiness or somnolence can occur with doxazosin requiring caution 181-214 887-907 2. Data available on request from Roerig 3. Talseth T in people who must drive or operate heavy machinery Kinetic Disorders 1% 0% Long-term comparison of doxazosin and atenolol in patients with mild or Drug Interactions: Ataxia 1% 0% moderate essential hypertension. abstract Presented as a scientific exhibit at a Most (98%) of plasma doxazosin is protein bound. In vitro data in human plasma Hypertonia 1% 0% program entitled Management of Coronary Heart Disease Risk Factors in indicate that CARDURA has no effect on protein binding of digoxin, warfarin, Muscle Cramps 1% 0% Hypertensive Patients Clinical Experience with Doxazosin London UK. January phenytoin or indomethacin There is no information on the effect of other highly 26. 1990, pp 18-19 4. Scheen AJ. Castillo M. Salvatore T. et al Lack of plasma protein bound drugs on doxazosin binding CARDURA has been AUTONOMIC Mouth Dry 2% 2% administered without any evidence of an adverse drug interaction to patients Flushing 1% 0% deleterious effects of the alpha,-adrenoreceptor blocking agent doxazosin on insulin secretion and insulin sensitivity in healthy men. Current Therapeutic receiving thiazide diuretics beta blocking agents. and nonsteroidal anti- SPECIAL SENSES Vision Abnormal 2% 1% Research 1989. 46 200-209 5. Wilner KD. Ziegler MG Effects of alpha, inflammatory drugs. Conjunctivitis/Eye Pain 1% 1% inhibition on renal blood flow and sympathetic nervous activity in systemic Drug/Laboratory test interactions: Tinnitus 1% 03% None known hypertension Am J Cardiol 1987 82G-86G PSYCHIATRIC Somnolence 5% 1% Cardiac Toxicity in Animals: Nervousness 2% 2% CARDURA (doxazosin mesylate) Tablets An increased incidence of myocardial necrosis or fibrosis was displayed by Depression 1% 1% Brief Summary of Prescribing Information Sprague-Dawley rats after 6 months of dietary administration at concentrations Insomnia 1% 1% INDICATIONS AND USAGE calculated to provide 80 mg doxazosin/kg/day and after 12 months of dietary CARDURA (doxazosin mesylate) is indicated for the treatment of hypertension administration at concentrations calculated to provide 40 mg doxazosin/kg/day Sexual Dysfunction 2% 1% CARDURA may be used alone or in combination with diuretics or beta-adrenergic (150 times the maximum recommended human dose assuming a patient weight of GASTROINTESTINAL Nausea 3% 4% blocking agents There is limited experience with CARDURA in combination with 60 kg). There is no evidence that similar lesions occur in humans. Diarrhea 2% 3% angiotensin converting enzyme inhibitors or calcium channel blockers Carcinogenesis, Mutagenesis and Impairment of Fertility: Constipation 1% 1% CONTRAINDICATIONS Chronic dietary administration (up to 24 months) of doxazosin mesylate at Dyspepsia 1% 1% CARDURA IS contraindicated in patients with a known sensitivity to quinazolines maximally tolerated concentrations (highest dose 40 mg/kg about 150 times the Flatulence 1% 1% (e.g. prazosin, terazosin) maximum recommended human dose of 16 mg/60 kg) revealed no evidence of Abdominal Pain 0% 2% WARNINGS carcinogenicity in rats. There was also no evidence of carcihogenicity in a similarly Vomiting 0% 1% Syncope and "First-dose" Effect: conducted study (up to 18 months of dietary administration) in mice The mouse RESPIRATORY Rhinitis 3% 1% Doxazosin, like other alpha-adrenergic blocking agents, can cause study however, was compromised by the failure to use a maximally tolerated dose Dyspnea 1% 1% marked hypotension, especially in the upright position, with syncope of doxazosin Epistaxis 1% 0% and other postural symptoms such as dizziness. Marked orthostatic Mutagenicity studies revealed no drug- or metabolite-related effects at either URINARY Polyuna 2% 0% effects are most common with the first dose but can also occur when chromosomal DI subchromosomal levels there is a dosage increase, or if therapy is interrupted for more than a Studies in rats showed reduced fertility in males treated with doxazosin at oral Urinary Incontinence 1% 0% few days. To decrease the likelihood of excessive hypotension and doses of 20 (but not 5 or 10) mg/kg/day. about 75 times the maximum Micturation Frequency 0% 2% syncope, it is essential that treatment be initiated with the 1 mg dose. recommended human dose This effect was reversible within two weeks of drug GENERAL Fatigue/Malaise 12% 6% The 2, 4. and 8 mg tablets are not for Initial therapy. Dosage should withdrawal Chest Pain 2% 2% then be adjusted slowly (see DOSAGE AND ADMINISTRATION section) Pregnancy Asthenia 1% 1% with increases in dose every two weeks. Additional antihypertensive Teratogenic Effects, Pregnancy Category B. Studies in rabbits and rats at Face Edema 1% 0% agents should be added with caution. daily oral doses of up to 40 and 20 mg/kg. respectively (150 and 75 times the Pain 2% 2% Patients being titrated with doxazosin should be cautioned to avoid maximum recommended daily dose of 16 mg assuming a patient weight of 60 kg). situations where injury could result should syncope occur. have revealed no evidence of harm to the fetus The rabbit study however, was Additional adverse reactions have been reported, but these are in general, not in an early investigational study of the safety and tolerance of increasing daily compromised by the failure to use a maximally tolerated dose of doxazosin There distinguishable from symptoms that might have occurred in the absence of doses of doxazosin in normotensives beginning at 1 mg/day only 2 of 6 subjects are no adequate and well-controlled studies in pregnant women Because animal exposure to doxazosin The following adverse reactions occurred with a frequency of could tolerate more than 2 mg/day without experiencing symptomatic postural reproduction studies are not always predictive of human response. CARDURA between 0.5% and 1% syncope, hypoesthesia increased sweating agitation, hypotension in another study of 24 healthy normotensive male subjects receiving should be used during pregnancy only if clearly needed increased weight. The following additional adverse reactions were reported by initial doses of 2 mg/day of doxazosin seven (29%) of the subjects experienced Radioactivity was found to cross the placenta following oral administration of <0.5% of 3960 patients who received doxazosin in controlled or open. short- or symptomatic postural hypotension between 0.5 and 6 hours after the first dose labelled doxazosin to pregnant rats long-term clinical studies including international studies Cardiovascular System necessitating termination of the study in this study 2 of the normotensive subjects Nonteratogenic Effects. In peri-postnatal studies in rats, postnatal development angina pectoris, myocardial infarction, cerebrovascular accident Autonomic experienced syncope. Subsequent trials in hypertensive patients always began at maternal doses of 40 or 50 mg/kg/day of doxazosin was delayed as evidenced by Nervous System palior; Metabolic thirst gout. hypokalemia: Hematopoletic: doxazosin dosing at 1 mg/day resulting in a 4% incidence of postural side effects at slower body weight gain and a slightly later appearance of anatomical features and lymphadenopathy, purpura: Reproductive System breast pain Skin Disorders: 1 mg/day with no cases of syncope reflexes alopecia dry skin eczema Central Nervous System paresis, tremor twitching in multiple dose clinical trials involving over 1500 patients with dose titration Nursing Mothers confusion. migraine, impaired concentration Psychiatric paroniria amnesia, every one to two weeks, syncope was reported in 0.7% of patients None of these It is not known whether this drug is excreted in human milk Because many drugs emotional lability. abnormal thinking. depersonalization: Special Senses parosmia. events occurred at the starting dose of 1 mg and 1.2% (8/664) occurred at 16 mg/day are excreted in human milk, caution should be exercised when CARDURA is earache taste perversion, photophobia, abnormal lacrimation: Gastrointestinal If syncope occurs, the patient should be placed in a recumbent administered to a nursing mother System increased appetite anorexia fecal incontinence gastroenteritis; Respiratory position and treated supportively as necessary. Pediatric Use System bronchospasm, sinusitis, coughing pharyngitis; Urinary System renal PRECAUTIONS Safety and effectiveness in children have not been established General: ADVERSE REACTIONS calculus General Body System hot flashes. back pain, infection, fever/rigors. 1. Orthostatic Hypotension: CARDURA has been administered to approximately 4000 patients. of whom 1679 decreased weight, influenza-like symptoms While syncope is the most severe orthostatic effect of CARDURA other symptoms were included in the clinical development program. In that program minor adverse CARDURA has not been associated with any clinically significant changes in effects were frequent. but led to discontinuation of treatment in only 7% of patients routine biochemical tests No clinically relevant adverse effects were noted on of lowered blood pressure, such as dizziness lightheadedness, or vertigo, can occur especially at initiation of therapy or at the time of dose increases These were In placebo-controlled studies adverse effects occurred in 49% and 40% of patients serum potassium serum glucose unc acid blood urea nitrogen, creatinine or liver common in clinical trials, occurring in up to 23% of all patients treated and causing in the doxazosin and placebo groups, respectively. and led to discontinuation in 2% function tests. CARDURA has been associated with decreases in white blood cell discontinuation of therapy in about 2% of patients in each group. The major reasons for discontinuation were postural counts (See Precautions) effects (2%), edema. malaise/fatique. and some heart rate disturbance. each about OVERDOSAGE In placebo controlled titration trials orthostatic effects were minimized by beginning therapy at 1 mg per day and titrating every two weeks to 4, or B mg per 7% The oral LD50 of doxazosin is greater than 1000 mg/kg in mice and rats The most day. There was an increased frequency of orthostatic effects in patients given 8 mg In controlled clinical trials directly comparing CARDURA to placebo there was no likely manifestation of overdosage would be hypotension for which the usual or more. 10% compared to 5% at 1-4 mg and 3% in the placebo group significant difference in the incidence of side effects except for dizziness (including treatment would be intravenous infusion of fluid. As doxazosin is highly protein Patients in occupations in which orthostatic hypotension could be dangerous postural). weight gain. somnolence and fatigue/malaise. Postural effects and edema bound, dialysis would not be indicated should be treated with particular caution appeared to be dose related DOSAGE AND ADMINISTRATION If hypotension occurs, the patient should be placed in the supine position and if The prevalence rates presented below are based on combined data from placebo- DOSAGE MUST BE INDIVIDUALIZED. The initial dosage of CARDURA in this measure is inadequate, volume expansion with intravenous fluids or controlled studies involving once daily administration of doxazosin at doses ranging hypertensive patients is 1 mg given once daily Depending on the individual vasopressor therapy may be used A transient hypotensive responsé is not a from 1-16 mg Table 1 summarizes those adverse experiences (possibly/probably patient's standing blood pressure response (based on measurements taken at 2-6 contraindication to further doses of CARDURA related) reported for patients in these studies where the prevalence rate in the hours postdose and 24 hours postdose), dosage may then be increased to 2 mg and 2. Impaired liver function: doxazosin group was at least 0.5% or where the reaction is of particular interest thereafter it necessary to 4 mg. 8 mg and 16 mg to achieve the desired reduction in CARDURA should be administered with caution to patients with evidence of blood pressure Increases in dose beyond 4 mg increase the likelihood of excessive impaired hepatic function or to patients receiving drugs known to influence hepatic postural effects including syncope postural dizziness/vertigo, postural hypotension metabolism (see CLINICAL PHARMACOLOGY). There is no controlled clinical TABLE 1 ADVERSE REACTIONS DURING PLACEBO CONTROLLED STUDIES At a fitrated dose of 16 mg once daily the frequency of postural effects is about 12% experience with CARDURA in patients with these conditions compared to 3% for placebo. 3. Leukopenia/Neutropenía: DOXAZOSIN PLACEBO HOW SUPPLIED Analysis of hematologic data from patients receiving CARDURA in controlled (N=339) (N=336) CARDURA (doxazosin mesylate) is available as colored tablets for oral clinical trials showed that the mean WBC (N=474) and mean neutrophil counts CARDIOVASCULAR Dizziness 19% 9% administration Each tablet contains doxazosin mesylate equivalent to 1 mg (white). (N=419) were decreased by 2 4% and 1 0% respectively, compared to placebo, a Vertigo 2% 1% 2 mg (yellow), 4 mg (orange) or 8 mg (green) of the active constituent doxazosin phenomenon seen with other alpha blocking drugs. A search through a data base of Postural Hypotension 0.3% 0% CARDURA TABLETS are available as 1 mg (white), 2 mg (yellow). 4 mg (orange) 2400 patients revealed 4 in which drug-related neutropenia could not be ruled out Edema 4% 3% and 8 mg (green) scored tablets Bottles of 100 1 mg (NDC 0049-2750-66). 2 mg Two had a single low value on the last day of treatment Two had stable, non- Palpitation 2% 3% (NDC 0049-2760-66). 4 mg (NDC 0049-2770-66). 8 mg (NDC 0049-2780-66) progressive neutrophil counts in the 1000/mm³ range over periods of 20 and 40 Arrhythmia 1% 0% Recommended Storage Store below 86°F(30°C). weeks In cases where follow-up was available the WBCs and neutrophil counts 1% 0% CAUTION: Federal law prohibits dispensing without prescription returned to normal after discontinuation of CARDURA No patients became Hypotension Tachycardia 0.3% 1% 65-4538-00-0 Issued Nov 1990 symptomatic as a result of the low WBC Of neutrophil counts Peripheral Ischemia 0.3% 0% Information for Patients: Patients should be made aware of the possibility of syncopal and orthostatic SKIN APPENDAGES Rash 1% 1% symptoms. especially at the initiation of therapy, and urged to avoid driving or Pruritus 1% 1% hazardous tasks for 24 hours after the first dose, after a dosage increase, and after MUSCULOSKELETAL Arthraigia/Arthritis 1% 0% interruption of therapy when treatment is resumed They should be cautioned to Muscle Weakness 1% 0% avoid situations where injury could result should syncope occur during initiation of Myalgia 1% 0% doxazosin therapy They should also be advised of the need to sit or lie down when Pfizer symptoms of lowered blood pressure occur, although these symptoms are not CENTRAL & Headache 14% 16% Roerig always orthostatic, and to be careful when rising from a sitting or lying position If PERIPHERAL N.S. Paresthesia 1% 1% A division of Pfizer Pharmaceuticals From the Health Care Financing Administration Recent Medicaid Expansions: The and pregnant women. states to adopt Medicaid options that 1990 Budget Reconciliation Act con- About 70% of Medicaid funds now are are available for maternal and child tains several provisions that expand eli- spent on health care services and long- health programs. gibility to the Medicaid program. Med- term care for the elderly, blind, and dis- Under the 1989 budget act, HCFA icaid, which is jointly financed by abled. Mothers and dependent children will award a total of $30 million over 3 federal and state governments, provides constitute about three fourths of Medic- years to three Maine, health care for about 26 million poor, aid recipients, but account for about one and Florida-for innovative projects de- disabled, and elderly Americans. fourth of the program's expenditures. signed to extend services to indigent Despite a climate of fiscal restraint, Many challenges remain. While state children and pregnant women who are the legislation broadens the health care Medicaid programs do not cover every- younger than 20 years who currently safety net to cover more poor children. one below the poverty level, Medicaid are not eligible for Medicaid. The expanded Medicaid eligibility in- costs continue to mount. In 1989, total The 1990 budget act authorizes $40 cludes children up to 19 years of age in Medicaid benefit payments exceeded million over 3 years for demonstrations families with incomes at or below the $58 billion, with the federal government in up to four states to test extending federal poverty level. This expansion footing about $32 billion of the bill. Med- Medicaid eligibility to some families and builds on the current requirement to icaid is consuming increasingly larger lower-income working people who are provide Medicaid coverage for children portions of state budgets and was the currently ineligible. Other awards total- up to 6 years of age in families with second largest state spending category ing $5.6 million in up to five states will incomes at or below 133% of the federal in fiscal year 1990. help coordinate the substance abuse poverty level. The new provision will be Some states will have difficulty fi- treatment and prenatal care of pregnant phased in over a 10-year period, begin- nancing the recent Medicaid expan- women who abuse drugs. ning July 1, 1991. sions. The expansions mandated by the Improving the Medicaid program is a The law also requires states to make budget acts of 1989 and 1990 alone are top priority for HCFA. Earlier this efforts to inform mothers and pregnant expected to increase federal and state year, HCFA created a separate Medic- women that they and their children may spending by $6 billion over the next 5 aid Bureau, which will facilitate HCFA's be eligible for Medicaid. States must years by extending eligibility to several coordination with state Medicaid make simplified application forms avail- million children and pregnant women. agencies. able outside of welfare offices and at Meanwhile, several high-level com- As a nation, the more we can buy with other locations, such as hospitals serv- missions and task forces have been each dollar (while preserving high-qual- ing large numbers of the poor and feder- studying how to improve access for the ity health care), the easier it will be to ally qualified health centers. more than 33 million Americans who expand access to the health care system. The 1990 Budget Reconciliation Act lack health insurance, how to control The 1990 budget act brings the taxpay- also: health care cost inflation, and how to ers better value by requiring drug man- Requires continuous Medicaid eligi- ensure high-quality health care. ufacturers to offer discounts to state bility for 1 year for all infants who are President Bush and Secretary Sulli- Medicaid programs. The rebates will born to Medicaid-eligible women; van of the US Department of Health and put state Medicaid programs on a more Bolsters an existing program that Human Services have emphasized that equal footing with other large-scale pre- helps certain poor elderly individuals addressing these issues is a top priority. scription drug buyers. The almost pay Part B of Medicare's annual deduct- The US Department of Health and Hu- $2 billion that will be saved over 5 years ible and monthly premiums for physi- man Services Task Force on the Unin- through these rebates helped make it cian services; sured and Long-Term Care is preparing possible for legislators to support the Creates a new optional program to recommendations on how to address the Medicaid expansions. provide home care for frail and disabled nation's health care needs in a way that is Much remains to be done as Medicaid senior citizens; and fiscally responsible. evolves to meet the changing needs of Allows state Medicaid programs to The problems are technically complex the American population. Government finance community-based living ar- and politically volatile, and many of the efforts to improve access to the program rangements for the mentally retarded. solutions considered so far would be can succeed only with the support and Created in 1965 under legislation very expensive to implement. It is no participation of the nation's physicians. aimed at helping states provide health surprise that Americans have yet to More than ever, HCFA is committed to care for the poor, the Medicaid program reach consensus on how health care re- working with the states and the physi- grew quickly in its first decade. During form should take shape. In the absence cian community to ensure access to the 1970s, Medicaid expenditures con- of systemwide reform, incremental im- health care for our nation's most vulner- tinued to rise rapidly as the program provements to the health care safety able citizens. began financing nursing home care and net, such as the Medicaid provisions just -by Gail R. Wilensky, PhD institutional care for the mentally enacted, can offer help to people need- Administrator retarded. ing it the most. Health Care Financing During the early 1980s, lawmakers The Bush administration is particu- Administration tried to limit both Medicaid spending larly interested in commonsense ap- and eligibility. Since 1984, however, proaches to expanding access to health Congress has tried to hold down costs care for children and pregnant women. Editor's Note: Inquiries may be directed to Christine H. Nye, Director, Medicaid Bureau, HCFA, 6325 Security while gradually expanding the pro- The Health Care Financing Administra- Blvd, Suite 200, East High Rise, Baltimore, MD 21207. gram, especially with regard to children tion (HCFA) has been encouraging JAMA, May 15, 1991 Vol 265, No. 19 From the HCFA 2461 COMING SOON FROM BRISTOL-MYERS SQUIBB A new direction toward better lipid management © 1991 E.R. Squibb & Sons, Inc., Princeton, NJ 0541-507 Issued: March 1991 From the Health Resources and Services Administration A Primary Care System for the Under- cine's report, there has been increased of nine multicounty area health educa- served: The US Department of Health interest in strengthening public health tion centers. Training occurs in primary and Human Services is promoting a new agencies to better address pressing care clinics, public health departments, strategy to achieve better access to pri- problems such as human immunodefi- nursing homes, and other community- mary health care for underserved popu- ciency virus (HIV) infection and infant based sites. lations. It calls for the public and private mortality. HRSA is building these strategies of sectors to join forces at the national, Health professions training institu- coordination and cooperation into exist- state, and local levels to develop and tions are crucial to the success of such ing and new programs by supporting expand a more coordinated primary services. Their students' involvement in the following: care system. the care of the underserved should start The training of more minority Two recent publications, The Future early in training and include experi- health professionals. of Public Health (Institute of Medicine, ences in primary care and public health A targeted expansion of community Washington, DC: National Academy facilities. This will encourage career and migrant health centers to deliver Press; 1988) and Healthy People 2000; choices that should help to alleviate the primary care services to people in rural National Health Promotion and Dis- shortage of primary care and public and inner-city medically underserved ease Prevention Objectives (Washing- health professionals in rural and inner- areas. ton, DC: US Dept of Health and Human city areas. Better linkage of infant mortality, Services; 1990), are the blueprints for For optimal patient care, these three maternal and child health, HIV and ac- this new approach. cultures should share resources and co- quired immunodeficiency syndrome The responsibility of the Health Re- ordinate services. Outstanding exam- (AIDS), and other categorical public sources and Services Administration ples of cooperation are available. In health grants to primary care and aca- (HRSA) within the Public Health Ser- Dade County, Fla, for example, the Pri- demic entities. vice is to assess, develop policies for, and mary Health Care Consortium brought A large expansion of the National assure the provision of primary care to together five federally funded commu- Health Service Corps to increase the the uninsured, underinsured, and un- nity health centers, state and county supply of health professionals in areas derserved, and to encourage the public primary care programs, the county with shortages. and private sectors to collaborate in that health department, and a local teaching Linkage of health professions train- care. By using existing community- hospital. Working collaboratively, the ing grants to primary care practice in based, comprehensive models of care consortium strengthens primary care underserved areas. and expanded public and private re- delivery to the medically underserved A closer working relationship sources, this mission can be accom- by expanding care for patients in the among primary care, public health, and plished. The challenge is to organize the local hospital, sharing specialty services Medicaid programs to encourage early current "patchwork quilt" of public and and clinical equipment, using private Medicaid enrollment by eligible individ- private primary care providers into a physicians to fill in at the community uals. This includes implementing cost- coordinated system designed with the health centers, and placing trainees and based Medicaid reimbursement for com- underserved in mind. residents to obtain valuable experience munity-based health clinics under new HRSA's approach involves three dif- and provide additional care. "Federally Qualified Health Center" ferent "cultures" that care for the un- A South Carolina Community Health legislation. derserved: primary care, public health, Center, Beaufort-Jasper Comprehen- In its recent response to the Institute and health professions training sive Health Services, is another exam- of Medicine's report, the American Med- institutions. ple. With state maternal and child ical Association endorsed a stronger Comprehensive primary care should health funds, the center developed ex- linkage between medical and public include not only the treatment of com- panded, case-managed maternity care health practice. The challenge to mon illnesses and injuries, but also the programs. Under contracts with state HRSA-and the physician communi- delivery of preventive services. To reach and local health departments, the cen- ty-is to fill the gaps in the health sys- the needy, this care should be communi- ter provides Medicaid screening and im- tem SO that the underserved gain access ty-based, family-centered, comprehen- munization services. Center personnel to the benefits of comprehensive public sive, continuous, and accessible, re- staff the local Women, Infants and Chil- health and primary care. gardless of an individual's ability to pay. dren food clinic. With local funds, the -by Robert G. Harmon, MD, MPH A wide array of private and public pro- center supports care for indigents, Administrator viders deliver such services. school-based health programs, and en- Health Resources and Comprehensive public health refers vironmental health projects. Services Administration to preventive and primary care services The North Carolina Area Health that are provided through the coordinat- Education Centers program is an exam- ed efforts of state and/or local health ple of academic coalition building. Stu- Editor's Note: Inquiries may be directed to Sylvia W. departments, as well as through other dents and residents from four medical Shaffer, Associate Administrator for Communications, HRSA, Room 14-43, 5600 Fishers Ln, Rockville, MD public or private practitioners. Since schools, a public health school, and oth- 20857; telephone (301) 443-2086. the publication of the Institute of Medi- er institutions participate in a network 2464 JAMA, May 15, 1991 - Vol 265, No. 19 From the HRSA A BRIGHT IDEA TO START WITH IN MILD HYPERTENSION MILD ONCE DAILY 180mg alansR verapamil HCI) 180 mg SUSTAINED-RELEASE CAPLETS Please see last page of this advertisement for a brief summary of prescribing information. SEARLE FEELING GOOD WITH MILD HYPERTENSION HIGH SINGLE-AGENT EFFICACY LOW INCIDENCE OF SIDE EFFECTS" UNIMPAIRED QUALITY OF LIFE SHOWN IN THREE CLINICAL STUDIES²⁴ As determined in clinical studies with dosages titrated up to 360 or 480 mg daily. Total daily dosages above 240 mg were and should be administered in divided doses. Calan SR should be administered with food. Constipation, which is easily managed in most patients, is the most commonly reported side effect of Calan SR. Please see last page of this advertisement for references and a brief summary of prescribing information. © 1991, G.D. Searle & Co. ONCE 180 DAILY 180mg CalansR verapamil HCI) 180 mg SUSTAINED-RELEASE CAPLETS A BRIGHT IDEA TO STAY WITH IN MILD HYPERTENSION 180 ONCE DAILY 180m Single-agent efficacy. with CalansR 180 mg once-daily dosing LOW incidence of side effects Scored caplet provides easy titration verapami HCI SUSTAINED-RELEASE CAPLETS References: 1. Data on file, GD. Searle & Co. 2. Palmer A, Fletcher A, Hamilton G, et al: A comparison of verapamil and nifedipine on quality of life. Br Clin Pharmacol 1990; 365-370. Calan SR 180-mg 3. Fletcher AE, Chester PC, Hawkins CMA, et al: The effects of verapamil and propano- caplets are scored SR 180 SR lol on quality of life in hypertension. Hum Hypertens 1989;3.125-130. 4. Croog SH, Kong BW, Levine S, et al: Hypertensive black men and women: Quality of life and for easy titration. effects of antihypertensive medications. Arch Intern Med 1990,150:1733-1741. BRIEF SUMMARY Contraindications: Severe LV dysfunction (see Warnings), hypotension (systolic pressure lowering agents. Disopyramide should not be given within 48 hours before or 24 hours after < 90 mm Hg) or cardiogenic shock, sick sinus syndrome (if no pacemaker is present), 2nd- verapamil administration. Concomitant use of flecainide and verapamil may have additive effects or 3rd-degree AV block (if no pacemaker is present), atrial flutter/fibrillation with an accessory on myocardial contractility, AV conduction, and repolarization. Combined verapamil and quini- bypass tract (eg, WPW or LGL syndromes), hypersensitivity to verapamil. dine therapy in patients with hypertrophic cardiomyopathy should be avoided, since significant Warnings: Verapamil should be avoided in patients with severe LV dysfunction (eg, ejection hypotension may result. Concomitant use of lithium and verapamil may result in a lowering of fraction < 30%) or moderate to severe symptoms of cardiac failure and in patients with any serum lithium levels or increased sensitivity to lithium. Patients receiving both drugs must be degree of ventricular dysfunction if they are receiving a beta-blocker. Control milder heart monitored carefully. Verapamil may increase carbamazepine concentrations during combined failure with optimum digitalization and/or diuretics before Calan SR is used. Verapamil may use. Rifampin may reduce verapamil bioavailability. Phenobarbital may increase verapamil occasionally produce hypotension. Elevations of liver enzymes have been reported. Several clearance. Verapamil may increase serum levels of cyclosporin. Concomitant use of inhalation cases have been demonstrated to be produced by verapamil. Periodic monitoring of liver anesthetics and calcium antagonists needs careful titration to avoid excessive cardiovascular function in patients on verapamil is prudent. Some patients with paroxysmal and/or chronic depression. Verapamil may potentiate the activity of neuromuscular blocking agents (curare- atrial flutter/fibrillation and an accessory AV pathway (eg, WPW or LGL syndromes) have like and depolarizing); dosage reduction may be required. Adequate animal carcinogenicity developed an increased antegrade conduction across the accessory pathway bypassing the studies have not been performed. One study in rats did not suggest a tumorigenic potential, AV node, producing a very rapid ventricular response or ventricular fibrillation after receiving and verapamil was not mutagenic in the Ames test. Pregnancy Category C. There are no I.V. verapamil (or digitalis). Because of this risk, oral verapamil is contraindicated in such adequate and well-controlled studies in pregnant women. This drug should be used during patients. AV block may occur (2nd- and 3rd-degree, 0.8%). Development of marked 1st- pregnancy, labor, and delivery only if clearly needed. Verapamil is excreted in breast milk; degree block or progression to 2nd- or 3rd-degree block requires reduction in dosage or, therefore, nursing should be discontinued during verapamil use. rarely, discontinuation and institution of appropriate therapy. Sinus bradycardia, 2nd-degree AV Adverse Reactions: Constipation (7.3%), dizziness (3.3%), nausea (2.7%), hypotension block, sinus arrest, pulmonary edema and/or severe hypotension were seen in some critically (2.5%), headache (2.2%), edema (1.9%), CHF, pulmonary edema (1.8%), fatigue (1.7%), dyspnea ill patients with hypertrophic cardiomyopathy who were treated with verapamil. (1.4%), bradycardia: HR < 50/min (1.4%), AV block: total 1°,2°,3° (1.2%), 2° and 3° (0.8%), Precautions: Verapamil should be given cautiously to patients with impaired hepatic function rash (1.2%), flushing (0.6%), elevated liver enzymes. The following reactions, reported in 1.0% (in severe dysfunction use about 30% of the normal dose) or impaired renal function, and or less of patients, occurred under conditions where a causal relationship is uncertain: angina patients should be monitored for abnormal prolongation of the PR interval or other signs of pectoris, atrioventricular dissociation, chest pain, claudication, myocardial infarction, palpita- overdosage. Verapamil may decrease neuromuscular transmission in patients with Duchenne's tions, purpura (vasculitis), syncope, diarrhea, dry mouth, gastrointestinal distress, gingival muscular dystrophy and may prolong recovery from the neuromuscular blocking agent vecu- hyperplasia, ecchymosis or bruising, cerebrovascular accident, confusion, equilibrium disorders, ronium. It may be necessary to decrease verapamil dosage in patients with attenuated insomnia, muscle cramps, paresthesia, psychotic symptoms, shakiness, somnolence, arthralgia neuromuscular transmission. Combined therapy with beta-adrenergic blockers and verapamil and rash, exanthema, hair loss, hyperkeratosis, macules, sweating, urticaria, Stevens-Johnson may result in additive negative effects on heart rate, atrioventricular conduction and/or cardiac syndrome, erythema multiforme, blurred vision, gynecomastia, increased urination, spotty contractility; there have been reports of excessive bradycardia and AV block, including complete menstruation, impotence. 12/21/89 P90-W198V heart block. The risks of such combined therapy may outweigh the benefits. The combination should be used only with caution and close monitoring. Decreased metoprolol clearance may occur with combined use. Chronic verapamil treatment can increase serum digoxin levels by Address medical inquiries to: 50% to 75% during the first week of therapy, which can result in digitalis toxicity. In patients G.D. Searle & Co. Medical & Scientific with hepatic cirrhosis, verapamil may reduce total body clearance and extrarenal clearance of Information Department digitoxin. The digoxin dose should be reduced when verapamil is given, and the patient carefully 4901 Searle Parkway monitored. Verapamil will usually have an additive effect in patients receiving blood-pressure- Skokie, IL 60077 SEARLE G.D. Searle & Co. Box 5110, Chicago, IL 60680 A90CA5345T DATA UPDATE: THE EXPERIENCE BUILDS. Scanning electron micrograph of neutrophil engulfing Candida albicans. Both neutrophils and macrophages are responsible for phagocytosis of invading Candida albicans. ONCE-A-DAY Diflucan ORAL 100 mg, 200 mg Tablets /200mg, 400 mg IV Injection Please see brief summary of prescribing information on last page of this advertisement. E FFECTIVELY TREATS MUCOSAL & SYSTEMIC FUNGAL INFECTIONS WITH FEW SAFETY CONCERNS Neutrophil phagocytoses Candida albic *Due to the interim nature of these results, statistics are not provided. Results of multicenter, open-label, randomized clinical trial using Diflucan 100 mg/day for 7 days; clotrimazole 50 mg/day for 14 days. Results reflect clinical cure and improvement. *Due to the interim nature of these results, statistics are not provided. Endoscopic cure results of a double-blinded, randomized trial comparing Diflucan 100 to 200 mg/day; ketoconazole 200 to 400 mg/day. Open-label trial. Diflucan 100 to 200 mg/day. Due to the interim nature of these results, statistics are not provided. Open-label, randomized trial. Clinical cure and improvement results. Diflucan 200 to 400 mg/day or amphotericin B 0.3 to 0.6 mg/kg/day. Multicenter, comparative study. Results reflect successful maintenance without culture confirmed relapse and without toxicity necessitating treatment discontinuance as evaluated at a median of 258 days for Diflucan and 140 days for amphotericin B. Diflucan: 200 mg/day; amphotericin B: 1 mg/kg/week. Provides excellent clinical success in oropharyngeal, esophageal, and systemic candidiasis, and cryptococcal meningitis: MUCOSAL CANDIDIASIS OROPHARYNGEAL ESOPHAGEAL2+ (endoscopic cures) DIFLUCAN 96 % clotrimazole 78% DIFLUCAN 89 % ketoconazole 80% CURED 64% CURED 16% IMPROVED (205/214) (71/91) (54/61) 56 % 14% IMPROVED (36/64) SYSTEMIC CANDIDIASIS CANDIDEMIA³¹ URINARY TRACT3* PERITONITIS DISSEMINATED DIFLUCAN DIFLUCAN DIFLUCAN 69% CURED 91% 79% 91% % DIFLUCAN 53% CURED 66% CURED 52% CURED 22% IMPROVED (29/32) (30/38) (32/35) 71% 26% IMPROVED 25% IMPROVED 19% IMPROVED (22/31) CRYPTOCOCCAL MENINGITIS ACUTE THERAPY³⁵ MAINTENANCE TO PREVENT RELAPSE⁴¹ DIFLUCAN amphotericin B DIFLUCAN amphotericin B 58 % 26% CURED 55 % 26% CURED 92% 67% 32% IMPROVED (54/93) 29% IMPROVED (102/111) (32/58) (52/78) P=0.00001 Excellent safety profile and patient compliance In over 4,000 patients who received Diflucan for at least 7 days, the most common adverse events were nausea (3.7%), headaches (1.9%), and skin rash (1.8%).³ Rare incidents of serious hepatotoxicity has been reported, but the causal relationship to Diflucan is uncertain.³ Extensive penetration to key tissues, organs, and fluids Distribution throughout the body approximates that of total body water after oral or IV dosing.³ Oral bioavailability of Diflucan >90% and unaffected by agents that increase gastric pH.³ ONCE-A-DAY Diflucan 100 mg, 200 mg Tablets / 200 mg. 400 mg IV Injection ORAL The Antifungal Effectiveness You Need. The Safety You Want. Please see brief summary of prescribing information on last page of this advertisement The Antifungal Effectiveness You Need. ONCE-A-DAY The Safety You Want. Diflucan 100 mg. 200 mg Tablets / 200 mg. 400 mg IV Injection ORAL WARNINGS Patients who develop abnormal liver function tests during DIFLUCAN therapy should be monitored for the development of more severe hepatic injury Although serious hepatic reactions have been rare and the causal association with DIFLUCAN uncertain. if clinical signs and symptoms consistent with liver disease develop that may be attributable to fluconazole DIFLUCAN should be discontinued (See Adverse Reactions) BB Immunocompromised patients who develop rashes during treatment with DIFLUCAN should be monitored closely and the drug discontinued if lesions progress (See Adverse Reactions PRECAUTIONS Drug Interactions (See Clinical Pharmacology) PS011437 ARE DIFLUCAN (fluconazole) increased the prothrombin time after warfarin administration Careful monitoring of prothrombin time in patients receiving DIFLUCAN and coumarin-type anticoagulants is recommended DIFLUCAN increased the plasma concentrations of phenytoin Careful monitoring of phenytoin concentrations 200 in patients receiving DIFLUCAN and phenytoin is recommended flaconazole Injection DIFLUCAN has been infrequently associated with an increase in cyclosporine concentrations in renal transplant patients with or without impaired renal function Careful monitoring of cyclosporine concentrations in patients Roerig 100 receiving DIFLUCAN and cyclosporine is recommended Pliper Diflucan DIFLUCAN increased the plasma concentrations and reduced the metabolism of tolbutamide glyburide and fluconazole glipizide. When DIFLUCAN is used concomitantly with these or other sulfonylurea oral hypoglycemic agents blood glucose concentrations should be carefully monitored and the dose of the sulfonylurea should be adjusted as necessary Rifampin enhances the metabolism of concurrently administered DIFLUCAN Depending on clinical circum- stances consideration should be given to increasing the dose of DIFLUCAN when it is administered with rifampin Physicians should be aware that drug-drug interaction studies with other medications have not been conducted but such interactions may occur Carcinogenesis, Mutagenesis and Impairment of Fertility Fluconazole showed no evidence of carcinogenic potential in mice and rats treated orally for 24 months at doses of 2.5. 5 or 10 mg/kg/day (approximately 2-7x the recommended human dose) Male rats treated with 5 and 10 mg/kg/day had an increased incidence of hepatocellular adenomas Fluconazole with or without metabolic activation was negative in tests for mutagenicity in 4 strains of S typhimurium, and in the mouse lymphoma L5178Y system Cytogenetic studies in vivo (murine bone marrow cells following oral administration of fluconazole) and in vitro (human lymphocytes exposed to fluconazole at 1000 µg/mL) showed no evidence of chromosomal mutations Fluconazole did not affect the tertility of male or female rats treated orally with daily doses of 5. 10 or 20 mg/kg or with parenteral doses of 5. 25 or 75 mg/kg although the onset of parturition was slightly delayed at 20 mg/kg p.o. In an intravenous perinatal study in rats at 5. and 40 mg/kg. dystocia and prolongation of parturition were observed in a few dams at 20 mg/kg (approximately 5-15x the recommended human dose) and 40 mg/kg but not at 5 mg/kg The disturbances in parturition were reflected by a slight increase in the number of stillborn pups and decrease of neonatal survival at these dose levels The effects on parturition in rats are consistent with the species specific estrogen-lowering property produced by high doses of fluconazole Such a hormone change has not been WITH ONCE DAILY DOSING observed in women treated with fluconazole (See Clinical Pharmacology) Pregnancy FOR A WIDE RANGE OF Teratogenic Effects. Pregnancy Category C: Fluconazole was administered orally to pregnant rabbits during organogenesis in two studies at 5. 10 and 20 mg/kg and at 5. 25. and 75 mg/kg respectively Maternal weight PATIENTS gain was impaired at all dose levels and abortions occurred at 75 mg/kg (approximately 20-60x the recom- mended human dose): no adverse fetal effects were detected In several studies in which pregnant rats were treated orally with fluconazole during organogenesis. maternal weight gain was impaired and placental weights were increased at 25 mg/kg There were no tetal effects at 5 or 10 mg/kg; increases in fetal anatomical variants LOADING DAILY (supernumerary ribs. renal pelvis dilation) and delays in ossification were observed at 25 and 50 mg/kg and INDICATION DOSE THERAPY higher doses At doses ranging from 80 mg/kg (approximately 20-60x the recommended human dose) to 320 mg/kg embryolethality in rats was increased and fetal abnormalities included wavy ribs cleft palate and abnormal OROPHARYNGEAL CANDIDIASIS 200 mg 100 mg cranio-facial ossification These effects are consistent with the inhibition of estrogen synthesis in rats and may be a result of known effects of lowered estrogen on pregnancy organogenesis and parturition ESOPHAGEAL CANDIDIASIS 200 mg 100 mg* There are no adequate and well controlled studies in pregnant women DIFLUCAN should be used in pregnancy only if the potential benefit justifies the possible risk to the fetus SYSTEMIC CANDIDIASIS 400 mg 200 mg Nursing Mothers It is not known whether fluconazole is excreted in human milk Because many drugs are excreted in human milk CRYPTOCOCCAL MENINGITIS caution should be exercised when DIFLUCAN is administered to a nursing woman (acute) 400 mg 200 mg* Pediatric Use Efficacy of DIFLUCAN has not been established in children A small number of patients from age 3 to 13 years have CRYPTOCOCCAL MENINGITIS been treated safely with DIFLUCAN using doses of 3-6 mg/kg daily (maintenance to prevent relapse) 200 mg 200 mg ADVERSE REACTIONS Sixteen percent of over 4000 patients treated with DIFLUCAN (fluconazole) in clinical trials of 7 days or more Doses of up to 400 mg/day may be used based on medical judgment of the patient's experienced adverse events Treatment was discontinued in 1 5% of patients due to adverse clinical events and in response to therapy. 13% of patients due to laboratory test abnormalities In combined clinical trials and foreign marketing experience prior to US marketing patients with serious underlying disease (predominantly AIDS or malignaricy) rarely have developed serious hepatic reactions or References: 1. McCloskey R, Hathorn J. Buell D: Fluconazole (FLU) vs clotrimazole (CLO) treatment of extoliative skin disorders during treatment with DIFLUCAN (See Warnings) Two of these hepatic reactions and one oropharyngeal candidiasis in adults with malignancy. Presented at 30th Interscience Conference on exfoliative skin disorder (Stevens-Johnson syndrome) were associated with a fatal outcome Because most of Antimicrobial Agents and Chemotherapy Atlanta, GA, October 24, 1990 2. Laine L: Esophageal these patients were receiving multiple concomitant medications including many known to be hepatotoxic or associated with exfoliative skin disorders the causal association of these reactions with DIFLUCAN therapy is candidiasis in immunocompromised patients. Presented at a symposium entitled Advances in the Management of Opportunistic Fungal Infections. Atlanta, GA, October 21, 1990. 3. Data available on uncertain request from Roerig. 4. Powderly W, Saag M, Cloud G, et al: Fluconazole VS amphotericin B as mainte- Clinical adverse events were reported more frequently in HIV infected patients (21%) than in non-HIV infected nance therapy for prevention of relapse of AIDS-associated cryptococcal meningitis Presented at 30th patients (13%); however, the patterns in HIV infected and non-HIV infected patients were similar The proportions Interscience Conference on Antimicrobial Agents and Chemotherapy Atlanta, GA, October 24. 1990 of patients discontinuing therapy due to clinical adverse events were similar in the two groups (1 5%) The following treatment-related clinical adverse events occurred at an incidence of 1% or greater in 4048 patients receiving DIFLUCAN for 7 or more days in clinical trials nausea 3 7% headache 1.9% skin rash 1 8% vomiting 1.7% abdominal pain 7% and diarrhea 1.5% In two comparative trials evaluating the efficacy of DIFLUCAN for the suppression of relapse of cryptococcal meningitis, a statistically significant increase was observed in median AST (SGOT) levels from a baseline value of INDICATIONS AND USAGE 30 IU/L to 41 IU/L in one trial and 34 IU/L to 66 IU/L in the other The overall rate of serum transaminase DIFLUCAN (fluconazole) is indicated for the treatment of elevations of more than 8 times the upper limit of normal was approximately 1% in fluconazole-treated patients in clinical trials These elevations occurred in patients with severe underlying disease, predominantly AIDS or 1 Oropharyngeal and esophageal candidiasis DIFLUCAN is also effective for the treatment of serious systemic malignancies, most of whom were receiving multiple concomitant medications including many known to be candidal infections including urinary tract infection. peritonitis. and pneumonia hepatotoxic The incidence of abnormally elevated serum transaminases was greater in patients taking DIFLUCAN 2. Cryptococcal meningitis Specimens for fungal culture and other relevant laboratory studies (serology histopathology) should be concomitantly with one or more of the following medications rifampin. phenytoin isoniazid valproic acid. or oral oblained prior to therapy to isolate and identify causative organisms Therapy may be instituted before the results sulfonylurea hypoglycemic agents of the cultures and other laboratory studies are known: however, once these results become available anti- 65-4526-00-0 Issued Jan 1990 infective therapy should be adjusted accordingly CONTRAINDICATIONS Phzer Roerig DIFLUCAN (fluconazole) is contraindicated in patients who have shown hypersensitivity to fluconazole or to any of its excipients There is no information regarding cross hypersensitivity between fluconazole and other azole antifungal agents Caution should be used in prescribing DIFLUCAN to patients with hypersensitivity to other azoles © 1991 Pfizer Inc. Abstracts adequate manpower inputs, high bed occupancy rates, low surgery J AM GERIATR SOC New York, NY rates relative to the United States (not necessarily a negative phenomenon), and low relative wage inputs. The relatively limited available output indicators lead us to believe that productivity per Public-Private Solution to Protection person employed in the health services could be raised. The low Against the Cost of Long-term Care absolute levels of health expenditures in Israel are mainly due to a combination of a low GNP per capita and relatively low wage The demographics of our population and our current reliance on differentials between health service staff and other income earners. Medicaid with a means test that no one likes suggest the need for revising our financing of long-term care. Given that persons with (1990;26:625-629) G. Ginsberg et al, Department of Social Medicine, Hebrew Alzheimer's disease and related dementias are a substantial propor- University-Hadassah School of Public Health and Community Medicine, PO tion of those needing long-term care, support for research to cure or Box 1172, 91120 Jerusalem, Israel. control these problems should be part of a strategy for addressing the problem of long-term care. However, even if substantial progress is made, there is still a need for revising our method of ARCH INTERN MED financing long-term care. However, other pressing societal needs, Chicago, III such as reducing the $2 trillion federal debt, addressing the needs of the growing number of children in poverty, and caring for the more Health, Homelessness, and Poverty: than 30 million uninsured Americans, limit the role of the federal government in financing long-term care. A proposal to provide A Study of Clinic Users coverage for those with functional disabilities or cognitive impair- When seeking medical care, homeless persons often turn to health ment who need long-term home care and for the initial portion of centers that were designed to treat the poor who have homes. To nursing home stays within a social insurance program is outlined. provide for effective medical care, personnel in such facilities need More extensive coverage for nursing home stays would be provided to know how the health care needs of the homeless are different for those with community-dwelling spouses. Major financing would from those of other clinic users. To compare the physical health of be provided through a payroll tax or by a federal income tax for all these two groups, we conducted a health survey and screening age groups with supplementation from estate taxes or capital gains physical examination of 464 patients who attended the general adult taxes at death. Improvement of benefits in the Medicaid program and homeless clinic sessions of one of the main neighborhood health and an important role for private insurance in protecting the estates centers in Los Angeles County, California. As compared with the of those who become permanent nursing home residents are also poor who have homes, homeless persons were more likely to have suggested. dermatological problems (32% vs 21%), functional limitations (me- (1990;38:156-163) Robert M. Ball, 505 Capital Ct NE, #300, Washington, DC dian, 2 vs 0 per person), seizures (14% vs 6%), chronic obstructive 20002. pulmonary diseases (21% vs 12%), social isolation, serious vision problems (22% vs 12%), foot pain, and grossly decayed teeth (median, 1 vs 0 per person). We conclude that to care more optimally for homeless adults, health centers must pay attention to their functional disabilities, substance abuse, skin abnormalities, ISR J MED SCI Tel Aviv, Israel visual impairment, dental problems, and foot problems. (1990;150:2325-2330) Lillian Gelberg et al, Division of Family Medicine, Israel's Expenditure on Health Services UCLA, Room 50-071 CHS, 10833 Le Conte Ave, Los Angeles. CA 90024-1683. In 1986, the State of Israel used 7.6% of its gross national product (GNP) for health care. At first glance, this seems to be a reasonable level of expenditure when compared with the percentage of the S AFR MED J Cape Town, South Africa GNP devoted to health care in eight selected industrialized noncom- munist nations. However, Israel devoted fewer dollars per citizen to health care than any of the eight other nations. We investigated Trends in the Distribution of South African the role of three factors that contributed to this relatively low Health Care Expenditure expenditure level: (1) health personnel and bed supply levels, (2) rates of operations and procedures, and (3) relative wage costs of The lack of critical distinction between the public and the private health personnel. If Israel had the same level of per capita GNP as health sectors and what they represent has allowed the claim to be the United States, its annual health service per capita expenditure made that South African health care expenditure levels compare would increase from $472 to $1328. If, in addition, its health favorably with international standards. This study considers the personnel received the same wage differentials (in relation to the distribution of health expenditure between the public and the average wage levels) as those received by health personnel in the private sectors, within these sectors, and on the basis of population United States, it is estimated that Israel would spend around $1842 group in South Africa. We highlight the extent of maldistribution of annually per capita on health care (representing 10.7% of its GNP). health care resources among the people of South Africa. The data This figure is only $98 less than what the United States spends, and analyzed in this article indicate that an increasing proportion of creates a vastly different impression concerning the efficiency of the public sector expenditure has been spent on curative services, that health system than does the original unadjusted expenditure of only the gap in real per capita expenditure between the "homelands" and $472 per capita, which is $1468 less than that spent by the United other public sector departments has been widening, and that per States. The Israeli health system can be said to be characterized by capita expenditure has been increasing more rapidly in the private sector than in the public sector, particularly in the 1980s. Edited by Carin M. Olson, MD, Contributing Editor. (1990;78:125-129) D. E. McIntyre et al, Health Economics Unit, Department Abstracts are selected on the basis of interest to our readers. Publication herein of Community Health, University of Cape Town, Cape Town, South Africa. does not suggest an endorsement of content or a validation of conclusions. (Continued on p 2474.) JAMA, May 15, 1991 265, No. 19 Abstracts 2469 on just The NIH consensus "Corticosteroids are the most effective anti-inflammatory drugs for the treat- ment of reversible airflow obstruction."¹ "Inhaled corticosteroids are safe and effective for the treatment of asthma."¹ The only one with 250 mcg per puff High-dose 250 mcg/puff ® AER BID (flunisolide) For Effective Control of Airway Inflammation More mcg per puff AEROBID delivers 2.5 to 5 times as many mcgs per puff than those of the leading competitors. AEROBID® vs competitive inhalers Total mcg of inhaled steroid/puff² 250 AEROBID® (flunisolide) 100 Triamcinolone 42 Beclomethasone AeroBic at More mcg per day The only inhaled steroid that provides 2000 mcg per day. More convenient Fewer puffs per day and the only inhaled steroid that's always BID. F FOREST PHARMACEUTICALS, INC. P Subsidiary of Forest Laboratories, Inc. St. Louis, Missouri 63043-9979 Please see accompanying brief summary which follows. © 1991 Forest Pharmaceuticals, Inc. AeroBid® (flunisolide) Effective asthma control BID For oral inhalation only CONTRAINDICATIONS AeroBid Inhaler is contraindicated in the primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required. Hypersensitivity to any of the ingredients of this preparation contraindicates its use. The best things WARNINGS Particular care is needed in patients who are transferred from systemically active corticosteroids to AeroBid Inhaler be- cause deaths due to adrenal insufficiency have occurred in asthmatic patients during and after transfer from systemic corticosteroids to aerosol corticosteroids. After withdrawal from systemic corticosteroids, a number of months are re- quired for recovery of hypothalamic -pituitary-adrenal (HPA) function. During this period of HPA suppression, patients may exhibit signs and symptoms of adrenal insufficiency when exposed to trauma, surgery or infections, particularly in life are free. gastroenteritis. Although AeroBid Inhaler may provide control of asthmatic symptoms during these episodes, it does NOT provide the systemic steroid that is necessary for coping with these emergencies. During periods of stress or a severe asthmatic attack, patients who have been withdrawn from systemic corticosteroids should be instructed to resume systemic steroids (in large doses) immediately and to contact their physician for further instruction. These patients should also be instructed to carry a warning card indicating that they may need supplemen- tary systemic steroids during periods of stress or severe asthma attack. To assess the risk of adrenal insufficiency in emergency situations, routine tests of adrenal cortical function, including measurement of early morning resting cortisol levels, should be performed periodically in all patients. An early morning resting cortisol level may be accepted as nor- mal if falls at or near the normal mean level. Localized infections with Candida albicans or Aspergillus niger have occurred in the mouth and pharynx and occasionally in the larynx. Positive cultures for oral Candida may be present in up to 34% of patients. Although the frequency of clinically apparent infection is considerably lower, these infections may require treatment with appropriate antifungal therapy or dis- continuance with AeroBid Inhaler. AeroBid Inhaler is not to be regarded as a bronchodilator and is not indicated for rapid relief of bronchospasm. Patients should be instructed to contact their physician immediately when episodes of asthma that are not responsive to bronchodilators occur during the course of treatment During such episodes, patients may require therapy with systemic corticosteroids. There is no evidence that control of asthma can be achieved by administration of the drug in amounts greater than the recom- mended doses, which appear to be the therapeutic equivalent of approximately 10 mg/day of oral prednisone. Theoretically, AMERICAN MEDICAL ASSOCIATION the use of inhaled corticosteroids with alternate day prednisone systemic treatment should be accompanied by more HPA suppression than a therapeutically equivalent regimen of either alone. Transfer of patients from systemic steroid therapy to AeroBid Inhaler may unmask allergic conditions previously suppressed catalog by the systemic steroid therapy, e.g., rhinitis, conjunctivitis, and eczema. PRECAUTIONS General: Because of the relatively high molar dose of flunisolide per activation in this preparation, and because of the evidence suggesting higher levels of systemic absorption with flunisolide than with other comparable inhaled cortico- steroids, patients treated with AeroBid should be observed carefully for any evidence of systemic corticosteroid effect, in- cluding suppression of bone growth in children. Particular care should be taken in observing patients post-operatively or during periods of stress for evidence of a decrease in adrenal function. During withdrawal from oral steroids, some patients may experience symptoms of systemically active steroid withdrawal, e.g., joint and/or muscular pain, lassitude and depres- sion, despite maintenance or even improvement of respiratory function. In responsive patients, flunisolide may permit control of asthmatic symptoms without suppression of HPA function. Since flunisolide is absorbed into the circulation and can be systemically active, the beneficial effects of AeroBid Inhaler in minimizing or preventing HPA dysfunction may be expected only when recommended dosages are not exceeded. The long-term effects of the drug in human subjects are still unknown. In particular, the local effects of the agent on develop- Call for your free guide to mental or immunologic processes in the mouth, pharynx, trachea, and lung are unknown. There is also no information about the possible long-term systemic effects of the agent. The potential effects of the drug on acute, recurrent. or chronic pulmonary infections, including active or quiescent tuber- valuable information resources culosis, are not known. Similarly, the potential effects of long-term administration of the drug on lung or other tissues are unknown. Pulmonary infiltrates with eosinophilia may occur in patients on AeroBid Inhaler therapy. Although it is possible that in from the AMA. some patients this state may become manifest because of systemic steroid withdrawal when inhalational steroids are administered, a causative role for the drug and/or its vehicle cannot be ruled out. Carcinogenesis: A 22-month study was conducted in Swiss derived mice to evaluate the carcinogenic potential of the The AMA Product Catalog is your most drug. There was an increase in the incidence of pulmonary adenomas within the range of adenomas previously reported in the literature for untreated or control Swiss derived mice. An additional study is being conducted in a species with a lower convenient and comprehensive source for AMA incidence of spontaneous pulmonary tumors. Impairment of fertility: Female rats receiving high doses of flunisolide (200 mcg/kg/day) showed some evidence of publications and services regarding the practice impaired fertility. Reproductive performance in the low (8 mcg/kg/day) and mid-dose (40 mcg/kg/day) groups was compar- able to controls. of medicine. You'll find timely information on: Pregnancy: Pregnancy Category C. As with other corticosteroids, flunisolide has been shown to be teratogenic in rabbits and rats at doses of 40 and 200 mcg/kg/day respectively. It was also fetotoxic in these animal reproductive studies. There are no adequate and ll-controlled studies in pregnant women. Flunisolide should be used during pregnancy only if the Practice management potential benefit justifies the potential risk to the fetus. Nursing Mothers: It is not known whether this drug is excreted in human milk. Because other corticosteroids are excreted in human milk, caution should be exercised when flunisolide is administered to nursing women. Legislative and political issues ADVERSE REACTIONS Adverse events reported in controlled clinical trials and long-term open studies in 514 patients treated with AeroBid are described below. Of those patients, 463 were treated for 3 months or longer, 407 for 6 months or longer, 287 for year or Professional liability longer, and 122 for 2 years or longer. Musculoskeletal reactions were reported in 35% of steroid-dependent patients in whom the dose of oral steroid was being tapered. This is a well-known effect of steroid withdrawal. Quality assurance Incidence 10% or greater Gastrointestinal: diarrhea (10%), nausea and/or vomiting (25%), upset stomach (10%); General: flu (10%): Mouth and Throat: sore throat (20%): Nervous System: headache (25%); Respiratory: cold symptoms (15%), nasal congestion (15%), This new catalog also offers the latest CPT upper respiratory infection (25%): Special Senses: unpleasant taste (10%). Incidence 3-9% publications; the newest national survey data; Cardiovascular: palpitations; Gastrointestinal: abdominal pain, heartburn: General: chest pain, decreased appetite, edema, fever; Mouth and Throat: Candida infection: Nervous System: dizziness, irritability, nervousness, shakiness; Reproductive: and AMA Signature Accessories, a collection menstrual disturbances; Respiratory: chest congestion, cough, hoarseness, rhinitis, runny nose, sinus congestion, sinus drainage, sinus infection, sinusitis, sneezing, sputum, wheezing*; Skin: eczema, itching (pruritus), rash; Special Senses: of quality gift items and personal accessories. ear infection, loss of smell or taste. Incidence 1-3% General: chills, increased appetite and weight gain, malaise, peripheral edema, sweating, weakness; Cardiovascular: hyper- Call today to request your copy of the AMA tension, tachycardia; Gastrointestinal: constipation, dyspepsia, gas; Hemic/Lymph: capillary fragility, enlarged lymph nodes; Mouth and Throat: dry throat, glossitis, mouth irritation, pharyngitis, phlegm, throat irritation; Nervous System: anxiety, depression, faintness, fatigue, hyperactivity, hypoactivity, insomnia, moodiness, numbness, vertigo; Respiratory: Product Catalog. The call and the catalog - bronchitis, chest tightness," dyspnea, epistaxis, head stuffiness, laryngitis, nasal irritation, pleurisy, pneumonia, sinus discomfort; Skin: acne, hives, or urticaria; Special Senses: blurred vision, earache, eye discomfort, eye infection. are free! Incidences less than 1%, judged by investigators as possibly or probably drug-related: abdominal fullness, shortness of breath. "The incidences as shown of cough, wheezing, and chest tightness were judged by investigators to be possibly or probably drug- 1-800-621-8335 related. In placebo-controlled trials, the overall incidences of these adverse events (regardless of investigators' judgement of drug relationship) were similar for drug and placebo-treated groups. They may be related to the vehicle or delivery system. CAUTION: Federal law prohibits dispensing without prescription. For full prescribing information, please see package insert. M (NDC 0456-0672-99) Mid by: Riker Laboratories American Northridge, California 91324 For: Forest Pharmaceuticals, Inc. References: St. Louis, MO 63043-9979 ASSOCIATION AMERICAN MEDICAL Medical 1. National Heart, Lung, and Blood Institute National Asthma Education Program Expert Panel Report-Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services: 1991. Association 2. Physicians' Desk Reference® 45th ed. Oradell, NJ: Medical Economics Co Inc; 1991:955, 1862, 2026 F FOREST PHARMACEUTICALS, INC. 1991 Forest Pharmaceuticals, Inc. Subsidiary of Forest Laboratories, Inc. St. Louis, Missouri 63043-9979 AER-025-91 2472 GI safety profile superior to aspirin and even OTC ibuprofen In nearly 100% of patients, single 650 mg doses of aspirin are associated with endoscopically visible gastric mucosal injury' Substantial clinical and epidemiological evidence suggests that with repeated ingestion, aspirin can induce gastric ulcer disease' EASY OTC ibuprofen is also associated with GI irritation, although to a lesser degree than aspirin TO References: 1. Graham DY, Smith Л. Ann Intern Med. 1986;104:390-398. 2. Mehlisch DR, Frakes LA. Clin Ther. 1985;7(1):89-97. 3. Data on file, McNeil Consumer Products Company. 4. Aspirin or paracetamol? Lancet. 1981,11:287-289. Do not exceed eight Gelcaps per 24-hour period. Acetaminophen in large overdoses can cause serious adverse effects. In the event of accidental overdose, contact a poison control center immediately. STOMACH Unsurpassed relief of mild-to-moderate pain.2,3 Unlikely to cause GI injury.⁴ Recommend EXTRA-STRENGTH TYLENOL® THE acetaminophen 500 mg GELCAPS First choice for patients in pain McNeil Consumer Products Company Division of McNeil PPC, Inc. McNEIL © 1989, McN Fort Washington, PA 19034 USA (Continued from p 2469.) health status do not account for these findings. Especially among persons with chronic and serious illnesses, the uninsured are less likely than the insured to receive medical care. Further, the uninsured are significantly more likely to report needing but not J ADOLESC HEALTH CARE New York, NY receiving medical care, primarily for economic reasons and, al- though poorer, they have higher out-of-pocket medical expenses Financing Health Care for Adolescents: than others in the population. Problems, Prospects, and Proposals (1990;24:811-823) Howard E. Freeman et al, Department of Sociology, Uni- versity of California, 405 Hilgard Ave, Los Angeles, CA 90024-1551. Currently, one in every seven adolescents aged 10 to 18 years is uninsured. This translates to nearly 5 million uninsured adolescents nationwide. Uninsured adolescents, as opposed to insured adoles- N ENGL J MED Boston, Mass cents, are more likely to be members of poor and minority families. In addition, adolescents without health insurance use fewer health services than their insured counterparts even after controlling for How Does Canada Do It? A Comparison of Expenditures health status differences. Improving the health insurance status of for Physicians' Services in the United States and Canada adolescents is becoming an important public policy objective, al- though Congress recently rejected legislation that would have As a percentage of the gross national product, expenditures for expanded Medicaid coverage for poor adolescents. Despite this health care in the United States are considerably larger than in setback, legislators and child health associates are increasingly Canada, even though one in seven Americans is uninsured whereas all striving for public and private insurance expansions for adolescents. Canadians have comprehensive health insurance. Among the sectors These efforts are described, and the prospects for future improve- of health care, the difference in spending is especially large for ments in health insurance coverage of adolescents are discussed. physicians' services. In 1985, per capita expenditure was $347 in the United States and only $202 (in US dollars) in Canada, a ratio of 1.72. (1990;11:398-403) Paul W. Newacheck et al, Institute for Health Policy Stud- We undertook a quantitative analysis of this ratio. We found that the ies, University of California at San Francisco, San Francisco, CA 94143-0936. higher expenditures per capita in the United States are explained entirely by higher fees; the quantity of physicians' services per capita is actually lower in the United States than in Canada. Fees for S AFR MED J Cape Town, South Africa procedures in the United States are more than three times as high as Canadian fees; the difference in fees for evaluation and management services is about 80%. Despite the large difference in fees, physicians' Financing Health Care for All-Is net incomes in the United States are only about one third higher than National Health Insurance the First Step? in Canada. A parallel analysis of Iowa and Manitoba yielded results similar to those for the United States and Canada, except that Political changes are likely to lead to demands for a more physicians' net incomes in Iowa are about 60% higher than in Mani- equitable health care system. It will be necessary to pay for more toba. Updating the analysis to 1987 on the basis of changes in each health care for more people without a substantial increase in the country between 1985 and 1987 yielded results similar to those resources available. If a substantial proportion of the funds contin- obtained for 1985. We suggest that increased use of physicians' ues to come from private sources, then inequity in access to and the services in Canada may result from universal insurance coverage and distribution of health care is inevitable. Consequently, it is argued from encouragement of use by the larger number of physicians who are that this can best be achieved if the resources that are available to paid lower fees per service. Physicians' net income in the United pay for health care are controlled by a single, centralized coordinat- States is not increased as much as the higher US fees would predict, ing body. It is suggested that it will be more feasible to generate probably because of greater overhead expenses and the lower work- sufficient funds under central control through taxation supple- loads of America's procedure-oriented physicians. mented by a national health insurance scheme, rather than through simply expanding the contribution to health care that comes out of (1990;323:884-890) Victor R. Fuchs et al, National Bureau of Economic Re- general tax revenue. Given that private ownership of health care search, 204 Junipero Serra Blvd, Stanford, CA 94305. facilities and services is likely to continue for the foreseeable future, central control of the funding of health care will make it possible to regulate the private sector and bring it into a national health plan to J AM GERIATR SOC New York, NY provide health care for all. (1990;78:144-147) C. De Beer et al, Centre for the Study of Health Policy, Financing Long-term Care: Department of Community Health, University of the Witwatersrand, Johan- An Insurance-Based Approach nesburg, South Africa. A joint public-private insurance program is the best approach to resolving the problem of financing long-term care. In this report, HEALTH SERV RES Chicago, III we describe one possible approach in detail. A modest expansion of the current (ie, after repeal of the Medicare Catastrophic Coverage Law of 1988) Medicare benefit for persons needing relatively Uninsured Working-Age Adults: short-term nursing home and home care services would be a first Characteristics and Consequences step. For those with extended long-term service needs, a non-means-tested, publicly funded program with joint federal-state While estimates of the country's uninsured vary, ranging from financing and administration would provide coverage after a sub- 10% to 18% of the general population, virtually every study on use stantial elimination period and with an income-related copayment. of medical services reports that lack of health insurance represents Private long-term care insurance purchased through employers a major barrier to medical care. Based on the 1986 national Robert before retirement or in the periretirement period, through use of Wood Johnson Access Survey of 10 130 noninstitutionalized per- income or equity accumulated in life insurance, pension funds, or sons, the characteristics of working-age adults without health home ownership, would be used to fund the exclusionary period or insurance and the consequences are examined. Among working-age copayments of the public program by those who wish to have adults, the uninsured are most likely to be poor or near-poor, greater protection for income or assets. The role of Medicaid would Hispanic, young, unmarried, and unemployed. Compared with the be limited to paying for the deductible, copayments, and initial insured, they have significantly fewer ambulatory visits during a long-stay expenses of those with low incomes and limited assets. year, are less likely to have contact with a medical provider during a 12-month period, and are more likely to receive their care in a (1990;38:696-703) L. Gregory Pawlson et al, Center for Aging Studies and Services, Department of Health Care Services, George Washington University hospital outpatient clinic or emergency department. Differences in Medical Center, 2150 Pennsylvania Ave NW, Washington, DC 20037. 2474 JAMA, May 15, 1991 265, No. 19 Abstracts Now any allergic emergency is an indication for Epipen EpiPen EPINEPHRINE AUTO-INJECTORS Just remove safety cap and press into thigh. Fast, reliable self-administered first-aid for potentially-fatal anaphylactic reactions in sensitive individuals. Automatically delivers an accurate premeasured intramuscular dose of epinephrine: 0.3 mg (EpiPen®) or 0.15 mg (EpiPen® Jr.). Fits conveniently in pocket or purse. Always ready for immediate use; no filling, assembly or preparation necessary. Concealed needle helps overcome possible fear or resistance to self-injection. May be injected directly through clothing. Virtually painless; penetrates skin with little or no sensation. For literature and free supply of EpiPen® Rx pads, please write: Center Laboratories Replace the Auto-Injector if the solution is discolored or contains a precipitate. Avoid possible inadvertent intravascular Division of EM Pharmaceuticals, Inc. administration. Select an appropriate injection site such as the thigh. DO NOT INJECT INTO BUTTOCK Large doses or accidental intravenous injection of epinephrine may result in cerebral hemorrhage due to sharp rise in blood pressure DO NOT INJECT INTRAVENOUSLY. Rapidly acting vasodilators can counteract the marked pressor effects of epinephrine. Epinephrine is the preferred treatment for serious allergic or other emergency situations even though this product 35 Channel Drive, Port Washington, NY 11050 contans sodium metabisulfite, a sulfite that may in other products cause allergic-type reactions including anaphylactic symptoms or life-threatening or less severe asthmatic episodes in certain susceptible persons. The alternatives to using Tel. 800-645-6335. In NY: 516-767-1800 (call collect). epinephrine in a life-threatening situation may not be satisfactory. The presence of a sulfite in this product should not In CA: 800-824-8732. In AZ, ID, NV, OR, UT, WA: 800-824-8731. deter administration of the drug for treatment of serious allergic or other emergency situations. PRECAUTIONS Epinephrine is ordinarily administered with extreme caution to patients who have heart disease. Use of epinephrine with drugs that may sensitize the heart to arrhythmias, e.g., digitalis, mercurial diuretics, or quinidine, Distributed in Canada by Allerex Laboratories Ltd., ordinarily is not recommended. Anginal pain may be induced by epinephrine in patients with coronary insufficiency. The Montreal, Quebec, Tel. 514-489-9306. effects of epinephrine may be potentiated by tricyclic antidepressants and monoamine oxidase inhibitors Hyperthyroid individuals, individuals with cardiovascular disease, hypertension, or diabetes, elderly individuals, pregnant women, and Manufactured for Center Laboratories by Survival Technology, Inc., Bethesda, MD 20814 children under 30 kg (66 lbs. body weight may be theoretically at greater risk of developing adverse reactions after epinephrine administration. Despite these concerns, epinephrine is essential for the treatment of anaphylaxis. Therefore, U.S. Patent Nos. 3,882,863, 4,031,893 and 3,712,301 patients with these conditions, and/or any other person who might be in a position to administer EpiPen or EpiPen Jr. to a patient experiencing anaphylaxis should be carefully instructed in regard to the circumstances under which this life- Brief summary: Before prescribing, please consult package insert. saving medication should be used DESCRIPTION The EpiPen Auto-Injectors contain 2 mL Epinephrine Injection for emergency intramuscular use CARCINOGENESIS, MUTAGENESIS, IMPAIRMENT OF FERTILITY Studies of epinephrine in animals to evaluate the Each EpiPen Injector delivers a single dose of 0.3 mg epinephrine from Epinephrine Injection, USP, 1:1000 (0.3 mL) carcinogenic and mutagenic potential or the effect on fertility have not been conducted in a sterile solution. Each EpiPen Jr., Auto-Injector delivers a single dose of 0.15 mg epinephrine from Epinephrine Injec- USAGE IN PREGNANCY Pregnancy Category C: Epinephrine has been shown to be teratogenic in rats when given tion, USP, 1:2000 (0.3 mL) in a sterlie solution. Each 03 mL also contains 1.8 mg sodium chloride, 0.5 mg sodium in doses about 25 times the human dose. There are no adequate and well-controlled studies in pregnant women. metabisulfite, hydrochloric acid to adjust pH, and Water for Injection. The pH range is 2.5-5.0. Epinephrine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. CLINICAL PHARMACOLOGY Epinephrine is a sympathommetic drug. acting on both alpha and beta receptors. It is PEDIATRIC USE Epinephrine may be given safely to children at a dosage appropriate to body weight (see Dosage the drug of choice for the emergency treatment of severe allergic reactions (Type I) to insect stings or bites, foods, and Administration). drugs, and other allergens. It can also be used in the treatment of idiopathic or exercise-induced anaphylaxis. Epinephrine ADVERSE REACTIONS Side effects of epinephrine may include palpitations, tachycardia, sweating, nausea and when given subcutaneously or intramuscularly has a rapid onset and short duration of action. vomiting, respiratory difficulty, pallor, dizziness, weakness, tremor, headache, apprehension, nervousness and anxiety. INDICATIONS AND USAGE Epinephrine is indicated in the emergency treatment of allergic reactions (anaphylaxis) Cardiac arrythmias may follow administration of epinephrine to insect stings or bites, foods, drugs and other allergens as well as idiopathic or exercise-induced anaphylaxis. The OVERDOSAGE Overdosage or inadvertent intravascular injection of epinephrine may cause cerebral hemorrhage EpiPen Auto Injector is intended for immediate self-administration by a person with a history of an anaphylactic reaction. resulting from a sharp rise in blood pressure. Fatalities may also result from pulmonary edema because of peripheral Such reactions may occur within minutes after exposure and consist of flushing. apprehension, syncope, tachycardia, vascular constriction together with cardiac stimulation. thready or unobtainable pulse associated with a fall in blood pressure, convulsions, vomiting, diarrhea and abdominal DOSAGE AND ADMINISTRATION Usual epinephrine adult dose for allergic emergencies is 0.3 mg. For pediatric cramps, involuntary voiding, wheezing, dyspnea due to laryngeal spasm, pruritis, rashes, urticaria or angioedema. The use, the appropriate dosage may be 0.15 or 0.30 mg depending upon the body weight of the patient. However, the EpiPen is designed as emergency supportive therapy only and is not a replacement or substitute for immediate medical prescribing physician has the option of prescribing more or less than these amounts, based on careful assessment of or hospital care each individual patient and recognizing the life-threatening nature of the reactions for which this drug is being CONTRAINDICTIONS There are no absolute contraindications to the use of epinephrine in a life-threatening situation. prescribed With severe persistant anaphylaxis, repeat injections with an additional EpiPen may be necessary. WARNINGS Epinephrine is light sensitive and should be stored in the tube provided. Store at room temperature HOW SUPPLIED EpiPen and EpiPen Jr. Auto-Injectors are available singly or in packages of twelve (15°-30°C/59°-86°F). Do not refrigerate. Before using, check to make sure solution in Auto-Injector is not discolored. CAUTION Federal (U.S.A.) law prohibits dispensing without a prescription. Issued: April 1988 AMERICAN MEDICAL \ System Claim AND DRAINAGE the AMA \ 11 I as your il sole SUPPLIER supplier! BB AMA Health Insurance Claim Forms will help keep your Approved reimbursement process running smoothly, simply and reliably. for They're designed to assist you in accurately reporting your services to both government and private insurers. Medicare Approved for Filing With Medicare A recent Medicare mandate requires physicians to complete and submit claim forms for all Medicare recipients. Accurate and Economical AMA Health Insurance Claim Forms are the industry standard a standard the AMA helps design. So you know you're getting the most accurate, up-to-date forms available. They're also economically priced. Best of all, AMA members receive a 20% discount. Four Convenient Formats There's a perfect form for every office system: single form, snap- out form, and continuous form with and without bar code. Easy to use, economically priced and always accurate. With all of these benefits, there's no need to order from any other source. Make the AMA your sole supplier of Health Insurance Claim Forms! To order, call toll free: 1-800-621-8335. Or FAX your order: 1-312-464-4184. Monday through Friday, 8:30am to 4:30pm Central Time. Or use the order form. MasterCard and Visa are welcome. Order your Claim Forms today! Single Form 1-page, 100/pad, 10 pads/carton, Sub Total $ Please complete this order form and return it with payment to: Kodak bar code Book & Pamphlet Fulfillment AMA Member Price: $27.28/carton Sales Tax (see chart below) $ American Medical Association Non-member Price: $34.10/carton P.O. Box 2964 Order Number: OP050185 On orders less than $35, add Milwaukee, Wisconsin 53201 Cartons $3.50 shipping and handling $ Snap-Out Form 2-part NCR, 1000/carton, Kodak bar code TOTAL $ Name AMA Member Price: $39.60/carton Non-member Price: $49.50/carton Sales Tax Remember to include your Address Order Number: OP50285 sales tax, where applicable. Cartons StateTax StateTax StateTax City/State Zip Continuous Form AZ 6.70% IA 4.00% ND 5.50% 2-part NCR, w/pinfeeds for computer AR 6.00% KS 6.25% OH 7.00% Member Identification # (needed for discount) printers, 1000/carton, Kodak bar code CA 7.25% MN 6.50% SC 5.00% AMA Member Price: $41.50/carton CT 8.00% NE 6.50% TN 7.75% Enclosed is my check payable to: Non-member Price: $51.75/carton DC 6.00% NV 6.00% WA 8.10% American Medical Association Order Number: OP050385 GA 6.00% NM 5.875% WV 6.00% MasterCard Visa Cartons ID 5.00% NY 8.25% WI 5.50% Continuous Form IL 8.00% NC 5.00% 2-part NCR, w/pinfeeds for computer Card number printers, 1000/carton, NO bar code AMA Member Price: $41.40/carton Expiration date Phone # Non-member Price: $51.75/carton Order Number: OP050587 Cardholder's signature Cartons GW015 True once-daily antihypertensive control* Proved by countless patients well controlled on one ISOPTIN SR tablet per day- - 180 mg or 240 mg- - with virtually no change in metabolic parameters or quality of life (total daily doses above 240 mg should be administered in divided do. As evidenced by well-controlled, long-term studies at more than 4 US centers. With q.d. dosing, blood pressure was controlled at 24 hours as demonstrated by a drop in diastolic BP to target leve Supported by more than 32,000,000 prescriptions written for once-daily verapamil SR over the past 4.5 years. ONCE-DAILY ISOPTINSR (verapamil HCI) 180/240 mg Sustained-Release Tablets @ knoll *Clinical effectiveness is unrelated to drug-plasma levels. Constipation is the most frequently reported side effect of ISOPTIN SR and is easily managed in most patients. Please see back ISOPTIN SR should be administered with food. for brief summary of BASF Group tVerapamil SR produced by Knoll for Knoll Pharmaceuticals and G.D. Searle & Co. prescribing information. ONCE-DAILY ISOPTINSR Sustained- (verapamil HCI) Release Tablets Unsurpassed dosage flexibility 180 mg 240 mg 120 mg* The recommended For patients who require For elderly or small-stature patients starting/maintenance dose a step up in dosage who require lower doses *An economical choice for the few patients requiring a 120-mg dose (half of a 240-mg tablet). Sustained-release characteristics are not altered when the tablet is divided in half. From the originators of verapamil knoll Knoll Pharmaceuticals A Unit of BASF K&F Corporation 1991, BASF K&F Corporation Whippany, New Jersey 07981 BASF Group 11090/5/91 Printed in USA CONTRAINDICATIONS: 1) Severe left ventricular dysfunction (see WARNINGS), 2) Hypotension (less may increase verapamil clearance Cyclosporin: Verapamil therapy may increase serum levels of than 90 mmHg systolic pressure) or cardiogenic shock. 3) Sick sinus syndrome (except in patients cyclosporin. Anesthetic Agents: Verapamil may potentiate the activity of neuromuscular blocking with a functioning artificial ventricular pacemaker), 4) 2nd or 3rd degree AV block (except in patients agents and inhalation anesthetics. Carcinogenesis, Mutagenesis, Impairment of Fertility: There with a functioning artificial ventricular pacemaker), 5) Patients with atrial flutter or atrial fibrillation was no evidence of a carcinogenic potential of verapamil administered to rats for two years and an accessory bypass tract (e.g., Wolff-Parkinson-White, Lown-Ganong-Levine syndromes). 6) Verapamil was not mutagenic in the Ames test. Studies in female rats did not show impaired fertility Patients with known hypersensitivity to verapamil hydrochloride. Effects on male fertility have not been determined Pregnancy (Category C): There are no adequate and well-controlled studies in pregnant women ISOPTIN crosses the placental barrier and can be WARNINGS: Heart Failure: ISOPTIN should be avoided in patients with severe left ventricular dys- detected in umbilical vein blood at delivery. This drug should be used during pregnancy. labor and function. Patients with milder ventricular dysfunction should, if possible, be controlled before delivery, only if clearly needed Nursing Mothers: ISOPTIN is excreted in human milk. therefore, verapamil treatment ISOPTIN should be avoided in patients with any degree of left ventricular nursing should be discontinued while verapamil is administered Pediatric Use: Safety and efficacy of dysfunction if they are receiving a beta adrenergic blocker (see DRUG INTERACTIONS). Hypotension: ISOPTIN in children below the age of 18 years have not been established ISOPTIN (verapamil HCI) may produce occasional symptomatic hypotension. Elevated Liver Enzymes: Elevations of transaminases with and without concomitant elevations in alkaline phosphatase and ADVERSE REACTIONS: Constipation 3%, dizziness 3. 3%, nausea 2. 7% hypotension 5%. head- bilirubin have been reported Periodic monitoring of liver function in patients receiving verapamil is ache 2 2%. edema 1.9%. CHF/pulmonary edema 1.8% fatigue 1 7% dyspnea 1.4%, bradycardia therefore prudent. Accessory Bypass Tract (Wolff-Parkinson-White): Patients with paroxysmal and/or 4%. 2° and 3° AV block 0 8%. rash 2%, flushing 0 6% and elevated liver enzymes (see WARN- chronic atrial flutter or atrial fibrillation and a coexisting accessory AV pathway may develop increased INGS) The following reactions, reported in less than 1.0% of patients, occurred under conditions antegrade conduction across the accessory pathway producing a very rapid ventricular response or (open trials, marketing experience) where a causal relationship is uncertain; they are mentioned to ventricular fibrillation after receiving intravenous verapamil While this has not been reported with oral alert the physician to a possible relationship: angina pectoris, atrioventricular dissociation, arthralgia verapamil. it should be considered a potential risk (see CONTRAINDICATIONS). Treatment is usually and rash. blurred vision. cerebrovascular accident, chest pain. claudication, confusion, diarrhea, dry D.C. -cardioversion Atrioventricular Block: The effect of verapamil on AV conduction and the SA mouth, ecchymosis or bruising, equilibrium disorders, erythema multiforme, exanthema, gastroin- node may cause asymptomatic 1st degree AV block and transient bradycardia Higher degrees of AV testinal distress, gingival hyperplasia, gynecomastia, hair loss, hyperkeratosis, impotence, increased block, while infrequent (0 8%). may require a reduction in dosage or, in rare instances. discontinua- urination, insomnia, macules, muscle cramps. myocardial infarction, palpitations, paresthesia, psy- tion of verapamil HCI. Patients with Hypertrophic Cardiomyopathy (IHSS): Although verapamil has chotic symptoms, purpura (vasculitis). shakiness. somnolence. spotty menstruation Steven-Johnson been used in the therapy of patients with IHSS. severe cardiovascular decompensation and death syndrome, sweating. syncope, urticana have been noted in this patient population PRECAUTIONS: Impaired Hepatic or Renal Function: Verapamil is highly metabolized by the liver Treatment of Acute Cardiovascular Adverse Reactions: Whenever severe hypotension or complete with about 70% of an administered dose excreted as metabolites in the urine. In patients with impaired AV block occur following oral administration of verapamil, the appropriate emergency measures should hepatic function the dose should be cut to 30% of the usual dose and the patient closely monitored be applied immediately, e.g. intravenously administered isoproterenol HCI, levarterenol bitartrate, In patients with impaired renal function verapamil should be administered cautiously and the patients atropine (all in the usual doses). or calcium gluconate (10% solution). If further support is necessary, monitored for abnormal prolongation of the PR interval or other signs of excessive pharmacological inotropic agents (dopamine or dobutamine) may be administered Actual treatment and dosage should effects (see OVERDOSE). Use in Patients with Attenuated (Decreased) Neuromuscular depend on the severity and the clinical situation and the judgment and experience of the treating Transmission: Verapamil decreases neuromuscular transmission and may prolong recovery from physician neuromuscular blocking agents In patients with attenuated neuromuscular transmission lower doses of verapamil may be warranted OVERDOSAGE: Treatment of overdosage should be supportive Beta-adrenergic stimulation or paren- teral administration of calcium solutions may increase calcium ion flux across the slow channel, and Drug Interactions: Beta Blockers: Concomitant use of ISOPTIN and oral beta-adrenergic blocking have been used effectively in treatment of deliberate overdosage with verapamil. Clinically significant agents may result in additive negative effects on heart rate. atrioventricular conduction, and/or car- hypotensive reactions or fixed high degree AV block should be treated with vasopressor agents or diac contractility Excessive bradycardia and AV block, has been reported The combination should be cardiac pacing. respectively. Asystole should be handled by the usual measures including cardiopul- used only with caution and close monitoring. Digitalis: Clinical use of verapamil in digitalized patients monary resuscitation. has shown the combination to be well tolerated. However, chronic verapamil treatment increases serum digoxin levels by 50% to 75% during the first week of therapy and this can result in digitalis DOSAGE AND ADMINISTRATION toxicity Upon discontinuation of ISOPTIN (verapamil HCI), the patient should be reassessed to avoid Essential Hypertension underdigitalization Antihypertensive Agents: Verapamil administered concomitantly with alantihy- The dose of ISOPTIN SR should be individualized by titration and the drug should be administered pertensive agents (e.g., vasodilators, angiotensin-converting enzyme inhibitors, diuretics. alpha and with food Initiate therapy with 180 mg of sustained-release verapamil HCI, ISOPTIN SR, given in the beta adrenergic blockers) will usually have an additive effect on lowering blood pressure Patients morning. Lower, initial doses of 120 mg a day may be warranted in patients who may have an receiving these combinations should be appropriately monitored Antiarrhythmic Agents: increased response to verapamil (e.g. the elderly or small people, etc.) Upward titration should be Disopyramide: Disopyramide should not be administered within 48 hours before or 24 hours after based on therapeutic efficacy and safety evaluated weekly and approximately 24 hours after the verapamil administration Flecainide: Concomitant administration of flecainide and verapamil may previous dose. The antihypertensive effects of ISOPTIN SR are evident within the first week of result in additive negative inotropic effect and prolongation of atrioventricular conduction. Quinidine: therapy. In patients with hypertrophic cardiomyopathy (IHSS), concomitant use of verapamil and quinidine If adequate response IS not obtained with 180 mg of ISOPTIN SR, the dose may be titrated may result in significant hypotension Other: Nitrates: The pharmacologic profile of verapamil and upward in the following manner: nitrates as well as clinical experience suggest beneficial interactions Cimetidine: Vanable results on a. 240 mg each morning ciearance have been obtained in acute studies of healthy volunteers: clearance of verapamil was either b. 180 mg each morning plus 180 mg each evening. or 240 mg each morning plus 120 mg reduced or unchanged Lithium: Pharmacokinetic (lowering of serum lithium levels) and pharmaco- (1/2 240 mg tablet) each evening. dynamic (increased sensitivity to the effects of lithium) interactions between oral verapamil and C. 240 mg every twelve hours lithium have been reported Carbamazepine: Verapamil therapy may increase carbamazepine con- When switching from immediate release ISOPTIN to ISOPTIN SR. the total daily dose in milligrams centrations and produce related side effects during combined therapy. Rifampin: Therapy with may remain the same: rifampin may markedly reduce oral verapamil bioavailability Phenobarbital: Phenobarbital therapy 2767/2-90 Printed in U.S.A. THE THE 200194 TENDE AND PUE G 1 RIVATE DER 9461 FOR RALL DEBTS ALL THIS NOTE THIS DEBT: NOTE MGTON.D.C. 94 highl WASHING 637' START ON/OFF SELECT TRACER™ " Actual size THE WISDOM OF RECOMMENDING THE UNDER $50 BLOOD GLUCOSE MONITOR. For some of your patients, compliance with your diabetes management program depends on the cost of the monitor. For them, recommend the Tracer® II system. The accurate, high-performance monitor comes with a complete kit for less than $50 at participating dealers. The Tracer® II system. It's the best recommendation you can make, price-wise. C To find out more, call 1-800-858-8072. TRACER® II BOEHRINGER MANNHEIM mannheim boehringer THE UNDER $50 BLOOD GLUCOSE MONITOR CORPORATION Boehringer Mannheim Corporation, Patient Care Systems Division 9115 Hague Road, P.O. Box 50100, Indianapolis, IN 46250-0100 © 1991 Boehringer Mannheim Corporation. All rights reserved. TRT-405 THE HOW You, your medical problem You, your medical problem You. your medical problem You, your medical problem You, your medical problem and your treatment with TO and your treatment with and your treatment with and your treatment with and your treatment with LIMBITROL BOOK BACTRIM™ DALMANE® LIBRIUM ROCEPHIN® imand brand and (furstepam (ceftriaxone sodium Roche) sulf be) amitriptyline HC Roche e Diaretic ME ME ME ME ME ME DUCATION Inc. Inc. Inc law THE HOW You, your medical problem and your treatment with TO ROCALTROL BOOK (calcitriol/ Roche) Medication ME ME EDUCATION THE HOW TO You, your medical problem and your treatment with BOOK BUMEX brand or Tox bumetanide Roche Sleep Medication POCH ME 20 ME for IN THE THE HOW You, your medical problem You, your medical problem TO and your treatment with You, your medical problem You, your medical problem WHAT and your treatment with and your treatment with and your treatment with BOOK EFUDEX IF BEROCCA® FLUOROURACIL VALIUM BOOK (fluorouracil Roche) important Injection/Roche brand view Some to the Medication you are - - ME ME ME ME 2 ME ME EL EDUCATION EDUCATION A Decade of Commitment to Informed Health Care Roche Laboratories Since 1978, the Roche Medication Education Use this coupon to order your presents the (ME) Program has provided informational complimentary supply of Roche booklets designed to supplement rather ME patient information booklets Resource Library than supplant your own personal rapport with your patients. The booklets stress to Product Specific Booklets for Patient the patient the importance of following (English and Spanish) your instructions and address the questions Bactrim™ Information most frequently asked by patients in an (trimethoprim & easy-to-follow question and answer format. sulfamethoxazole/Roche) Berocca® Each booklet helps you provide. (multivitamin/mineral) ROCHE Reinforcement of your instructions Bumex® Enhancement of compliance (bumetanide/Roche)* Satisfaction with office visits Dalmane® ME (brand of flurazepam The program offers product specific and hydrochloride/Roche) @ general information booklets for you to give Efudex® to your patients. This extensive library of (fluorouracil/Roche) patient information booklets is available to Fluorouracil MEDICATION you without expense or obligation. To Injection/Roche obtain a complimentary supply of those Librium® EDUCATION booklets that are applicable to your prac- (brand of chlordiazepoxide tice, simply check the appropriate boxes on HCl/Roche) @ Copyright© 1991 by Hoffmann-La Roche Inc. the coupon and mail it to: Limbitrol® (brand of chlordiazepoxide and amitriptyline HCl/Roche) @ Roche Medication Education Rocaltrol® Hoffmann-La Roche Inc. (calcitriol/Roche) 340 Kingsland Street Nutley, NJ 07110-1199 Rocephin® (ceftriaxone sodium/Roche) Valium® (brand of diazepam/Roche) @ BUMEX (bumetanide Roche) The What If Book 0.5-mg, 1-mg and 2-mg scored tablets: 2-mL ampuls and 2-mL. 4-mL and 10-mL vials (0.25 mg/mL) Before prescribing. please consult complete product information, a summary of which follows: Large English Spanish type WARNING: Bumex (bumetanide/Roche) is a potent diuretic which. if given in excessive amounts, can lead to profound diuresis with water and electrolyte depletion Therefore, careful medical supervision is required, and dose and dosage schedule have to be adjusted to the individual patient's needs (See under DOSAGE AND ADMINISTRATION in complete product information.) How To Booklets INDICATIONS AND USAGE: Edema associated with congestive heart failure, hepatic and renal disease, including the nephrotic syndrome. Almost equal diuretic Title response occurs after oral and parenteral administration of Bumex. If impaired gastrointestinal absorption is suspected or oral administration is not practical, Bumex should be given by the intramuscular or intravenous route. Successful treatment with Bumex following instances of allergic reactions to furosemide suggests a lack of Antibacterial Medication cross-sensitivity. CONTRAINDICATIONS: Anuria Hypersensitivity and in patients in hepatic coma or in states of severe electrolyte depletion. Although Bumex can be used to induce diuresis in renal insufficiency, any marked increase in blood urea nitrogen or creatinine, or the development of oliguria during therapy of patients with Diuretic Medication progressive renal disease, is an indication for discontinuation of treatment. WARNINGS: Dose should be adjusted to patient's needs. Excessive doses or too frequent administration can lead to profound water loss, electrolyte depletion, dehydration, reduction in blood volume and circulatory collapse with the possibility of vascular Tranquilizer Medication thrombosis and embolism, particularly in elderly patients Prevention of hypokalemia requires ticular attention in patients receiving digitalis and diuretics for con- gestive heart failure, hepatic cirrhosis and ascites, states of aldosterone excess with normal renal function, potassium nephropathy, certain diarrheal states, or Sleep Medication other states where hypokalemia is thought to represent particular added risks to the patients. In patients with hepatic cirrhosis and ascites, sudden alterations of elec- trolyte balance may precipitate hepatic encephalopathy and coma. Treatment in such patients is best initiated in the hospital with small doses and careful monitoring of Please send my Roche ROCHE the patient's clinical status and electrolyte balance. Supplemental potassium and/or spironolactone may prevent hypokalemia and metabolic alkalosis in these patients. In cats, dogs and guinea pigs, Bumex has been shown to produce ototoxicity. Since Bumex is about 40 to 60 times as potent as furosemide, it is anticipated that blood representative ME levels necessary to produce ototoxicity will rarely be achieved. The potential for ototoxicity increases with intravenous therapy, especially at high doses. Patients aller- gic to sulfonamides may show hypersensitivity to Bumex. PRECAUTIONS: Measure serum potassium periodically and add potassium supplements or potassium EDUCATION sparing diuretics, if necessary. Periodic minations of other electrolytes are advised in patients treated with high doses or for prolonged periods, particularly in those on low salt diets. Hyperuricemia may occur. Reversible elevations of the BUN and creatinine may occur, especially with dehydration and in patients with renal in- sufficiency. Bumex may increase urinary calcium excretion. Possibility of effect on glucose metabolism exists. Periodic determinations of blood sugar should be done, particularly in patients with diabetes or suspected latent diabetes. Patients should be observed regularly for possible occurrence of blood dyscrasias, liver damage or Name (please print) idiosyncratic reactions. Especially in presence of impaired renal function, use of parenterally administered Bumex should be avoided in patients to whom aminoglyco side antibiotics are also being given, except in life threatening conditions. Drugs with nephrotoxic potential and bumetanide should not be administered simultaneously. Since lithium reduces renal clearance and adds a high risk of lithium toxicity, it should not be given with diuretics. Probenecid should not be administered concurrently Street Address with Bumex. Concurrent therapy with indomethacin not recommended Bumex may potentiate the effects of antihypertensive drugs, necessitating reduction in dosage. Interaction studies in humans have shown no effect on digoxin blood levels. Interaction studies in humans have shown Bumex to have no effect on warfarin metabo- lism or on plasma prothrombin activity. Pregnancy: Bumex should be given to a pregnant woman only if the potential benefit justifies the potential risk to the fetus. Bumetanide may be excreted in breast milk. Pediatric use: Safety and effectiveness below age 18 not established. ADVERSE REACTIONS: Muscle cramps, dizzi- City State ness, hypotension, headache and nausea, and encephalopathy (in patients with preexisting liver disease). Less frequent clinical adverse reactions are weakness, im Zip paired hearing, rash, pruritus, hives, electrocardiogram changes, abdominal pain, ar thritic pain, musculoskeletal pain and vomiting. Other clinical adverse reactions are vertigo, chest pain, ear discomfort, fatigue, dehydration, sweating, hyperventilation, dry mouth, upset stomach, renal failure, asterixis, itching, nipple tenderness, *See advertisement for summary of diarrhea, premature ejaculation and difficulty maintaining an erection. Laboratory abnormalities reported are hyperuricemia, azotemia, hyperglycemia, increased product information. serum creatinine, hypochloremia, hypokalemia, hyponatremia and variations in CO₂ content, bicarbonate, phosphorus and calcium. Although manifestations of the pharmacologic action of Bumex, these conditions may become more pronounced by intensive therapy. Also reported have been thrombocytopenia, deviations Roche Laboratories in hemoglobin, prothrombin time, hematocrit, WBC and differential counts. There have been rare spontaneous reports of thrombocytopenia from postmarketing experience Diuresis induced by Bumex may also rarely be accompanied by changes in LDH, total serum bilirubin, serum proteins, SGOT, SGPT, alkaline phosphatase, ROCHE a division of Hoffmann-La Roche Inc. cholesterol, creatinine clearance. Increases in urinary glucose and urinary protein have also been seen. DOSAGE AND ADMINISTRATION: Oral Administration: The usual total daily dosage is 0.5 to 2.0 mg and in most patients is given as a single dose. Parenteral Administration: Administer to patients (IV or IM) with GI ab- 340 Kingsland Street, Nutley. New Jersey 07110-1199 sorption problem or who cannot take oral. The usual initial dose is 0.5 to 1 mg given over 1 to 2 minutes. If insufficient response, a second or third dose may be given at 2 to 3 hour intervals up to a maximum of 10 mg a day. HOW SUPPLIED: Tablets, 0.5 mg (light green), 1 mg (yellow) and 2 mg (peach), bottles of 100 and 500; Tel-E Dose® cartons of 100. Imprint on tablets: 0.5 mg ROCHE BUMEX 0.5; mg ROCHE BUMEX 1: 2mg ROCHE BUMEX 2. Ampuls, 2 mL, 0.25 mg/mL, Working today for a healthier tomorrow. boxes of ten Vials, 2 mL, 4 mL and 10 mL, 0.25 mg/mL, boxes of ten. Store all tablets, vials and ampuls at 59° to 86°F. P.I. 0688 JAMA Letters Caring for the Uninsured and main without access to health care. veloped a consensus for a plan that will Underinsured Some academic medical centers have re- begin to address the spiraling premium To the Editor. Access to health care sponded to the current crisis by helping costs, decreased availability of health is a significant problem for mil- to establish and staff free medical clin- insurance, and lack of access to health lions of Americans, particularly for ics. Our survey shows, however, that care for more than 2.3 million uninsured those who are poor, homeless, lack the majority of medical universities Texans whose incomes are less than health insurance, and are unemployed. have not contributed resources for 200% of the poverty level. This plan will Proposed comprehensive solutions to these purposes, particularly private also address some of the issues experi- health care access problems, including medical centers where eight of nine cen- enced by the underinsured. mandated employer-based health insur- ters lacked formal programs. The consensus document, "Insuring ance, health insurance risk pools, and Academic medicine's clinical involve- the Uninsured: A Plan for Texas," will universal health insurance programs, ment in access to health care issues pro- serve as the basis for the TMA's legisla- may take several years of public and vides benefits to patients, students, and tive package on health insurance reform private debate before they are finally society. Patients benefit from having and cost-containment issues. The five- enacted.¹⁻³ direct health care access as well as from step plan proposes increased expansion In the meantime, physicians have an having a formal advocacy network. in eligibility for Medicaid recipients and obligation to provide a portion of their Medical students, residents, and other improvements in physician and provid- professional time to serving those with- health care professionals benefit from er Medicaid reimbursement, a state- out the resources to pay. Many physi- learning the importance of social con- created sliding scale entitlement pro- cians dedicate substantial portions of structs on disease processes as well as gram that offers a basic package of their efforts to providing such free care, by working with other health care pro- primary and preventive health care ser- acting as role models for their peers as viders and community agencies. Final- vices for the working poor, the creation well as for those still in medical train- ly, society benefits by the knowledge of a basic benefit package for small- ing.⁵ However, the extent to which the that within ongoing dialogues to im- group businesses, adequate funding of prove health care access, its health care the Texas Health Insurance Risk Pool academic medical profession and its educational processes support such ef- professionals are leading by example in created by the 1989 Texas legislative forts is unknown. The current study the struggle to eliminate inequalities. session for the medically uninsurable, was designed to assess the commit- Opportunities exist within our current and, finally, proposals for health care ments of US medical schools toward health care system for academic medi- cost containment and health insurance providing free health care outside their cine to increase its commitments to reform, including ERISA reform, stan- hospital environments and within their these problems. dardizing health insurance policy lan- respective communities. Adam O. Goldstein, MD guage, and holding health care provid- Laura Enyedi ers and insurance companies to high Study.- All US medical schools were Marlene Calderon standards of representation to the pub- surveyed to determine how many Jeff Babb lic. Several additional recommenda- schools sponsor or have affiliations with Scott Bennett University of North Carolina tions to implement health care cost con- free health care clinics serving indigent School of Medicine tainment are included in the proposal to or homeless populations. Of the 126 ac- Chapel Hill the Texas legislature. credited medical schools, 110 (87%) 1. Enthoven A, Kronick R. A consumer-choice health plan We hope that cooperative initiatives, were successfully contacted and agreed for the 1990s. N Engl J Med. 1989;320:94-101. 2. Himmelstein DU, Woolhandler S. A national health pro- which include the many interested par- to a telephone interview. gram for the United States. N Engl J Med. 1989;320: ties whom I have described, can provide Of these schools, 27% indicated that 102-108. they currently have affiliations with and 3. GinsburgJA, Prout DM. Access to health care, American College of Physicians. Ann Intern Med. 1990;112: provide care at local free medical clinics. 641-661. Although public medical schools ac- 4. Lundberg GD, Bodine L. Fifty hours for the poor. JAMA. 1989;262:3045. counted for 69% of the universities re- Guidelines for Letters 5. Hilfiker D. Are we comfortable with homelessness? sponding to the survey, they accounted JAMA. 1989;262:1375-1376. Letters will be published at the discretion of for 83% of those schools with free indi- the editor as space permits and subject to gent clinics. Only 12% of the private editing and abridgment. They should be To the Editor.- The availability and af- medical schools provided such services. typewritten double-spaced and submitted in fordability of health care is no longer Thirty-three percent of the free medical duplicate. They should not exceed 500 words only a medical concern. Our great state clinics involved medical students as the of text. References, if any, should be held to a of Texas has one of the highest percent- minimum, preferably five or fewer. Letters primary coordinators of the clinics. The ages of uninsured and underinsured citi- discussing a recent JAMA article should be primary medical school sponsoring de- zens in the United States. received within 1 month of the article's publi- partments for these free clinics were Recognizing this problem as it applies cation. Letters must not duplicate other ma- family medicine (n=15) and internal to the State of Texas, the Texas Medical terial published or submitted for publication. medicine (n = 5). Association (TMA), in response to its A signed statement for copyright, authorship responsibility, and financial disclosure is es- Comment. Until some substantial House of Delegates, in 1990 began a sential for publication. It is not feasible rou- changes occur in our current health care study bringing together a statewide co- tinely to return unpublished letters unless system, millions of Americans will re- alition with representation from busi- such is requested. Letters not meeting these nesses, consumers, hospital administra- guidelines are generally not acknowledged. Edited by Drummond Rennie, MD, Deputy Editor tors, insurers, legislators, physicians, Also see Instructions for Authors. (West), and Don Riesenberg, MD, Senior Editor. and trial lawyers. We successfully de- 2480 JAMA, May 15, 1991 Vol 265, No. 19 Letters an approach to solving what is fast be- tals have donated more than $482 in of providers could work together in a coming an intolerable situation. services to indigents in this area. We symbiotic relationship to help achieve Gerald H. Holman, MD have saved money by providing access each of their missions. Teaching young Texas Medical Association to hundreds of patients who would have physicians the art of providing primary Committee on Access to Health Care gone to the emergency department in family medical care will result in fam- Austin the past. In addition to confirming the ilies' receiving the care that CHCs To the Editor.-With more than 40 000 need for this program, the statistics strive to provide. In 1986 a national sur- people living below the poverty level in show that each of our three area hospi- vey by the US Public Health Service Alachua County, Florida, we are acute- tals participated equally. revealed that 44 CHCs had some type of ly aware of the problems facing the med- The We Care Network is not a solu- affiliation with a family medicine resi- ical community in caring for the unin- tion to the problems associated with dency program. There have been calls sured and underinsured. Though we do caring for the uninsured, but rather a for more alliances between these two not propose to have a solution for the part of a many-faceted and innovative entities,¹ but little has been done to pro- high cost of health care for the indigent, plan to reduce the cost of health care and mote affiliations. Such affiliations not we are proud of our local safety-net pro- improve access to health care for lower- only would provide an immediate source gram called the "We Care Physician Re- income Americans. I believe that only of care to the underserved, but also, as ferral Network." The network, which through the active involvement of phy- suggested by one study,² might lead to was established informally in 1985, pro- sicians will an equitable and effective more primary care physicians' serving vides an innovative way for physicians solution to this problem arise. in underserved areas in the future. to volunteer their time while providing E. Scott Medley, MD Unfortunately, as yet there has not access to specialty care for many of our Alachua County been an evaluation of CHC-family area's indigent. In light of our new gov- Medical Society medicine residency affiliations. It is un- Gainesville, Fla ernor's budget proposal to assess all known how many affiliations currently physicians $500 to help pay for health exist or what organizational structure is care for the indigent, I encourage others To the Editor.- Community health cen- successful. Nor has work been done to organize their indigent care pro- ters (CHCs) are federally funded clinics to determine what can lead to a posi- grams to show that physicians are al- that exist to provide primary health tive affiliation and prevent difficulties, ready donating more than that in free care services to underserved popula- though this information is necessary to health care. tions of the United States. Approxi- provide a framework for the expansion This is basically how our program mately 6 million of our country's poor of CHC-residency program affiliations. works. About 68% of the Alachua Coun- receive their health care at one of the Timothy J. Moore, MD, MS ty Medical Society membership have 600 CHCs. In addition, CHCs house ap- Sioux Falls Family Practice Residency volunteered to accept indigent referrals proximately 50% of all the nation's University of South Dakota School of Medicine from the We Care Network on a period- homeless health care projects and vig- ic, rotating basis. The We Care Net- orously pursue other issues including 1. Engebretsen BJ. Family medicine and community health centers: a natural alliance. Fam Med. 1989;21:417-418. work coordinator, who is stationed at the acquired immunodeficiency syn- 2. Gessert C, Blossom J, Sommers P. Family physicians for the public health unit, accepts patients drome, adequate prenatal care, and underserved areas: the role of residency training. West J Med. 1989;150:226-230. into the program on the basis of medical chemical dependency. The 1990s will be and financial need and county residen- troublesome for many CHCs as the real cy. Most of these patients, who are in federal dollars have decreased and it is To the Editor.-No approach to the need of specialty care, receive primary increasingly difficult to recruit and re- problems of the medically uninsured care from the public health unit or other tain providers. Because CHCs are dis- and underinsured-and, in particular, area clinics. The coordinator will refer tributed throughout the country, these to the desperate tragedies of the inner the indigent patient to the specialty problems will be felt in every geograph- cities-can succeed without addressing physician on the top of the list for that ic area. a crucial need: the recruitment and specialty. Once the patient has been Over the same area one also finds an- training of physicians specifically to seen, that physician's name is rotated to other source of health care providers. serve in the urban areas that represent the bottom of the list, ensuring equita- These are the primary care residency the greatest concentration of popula- ble patient distribution to all participat- training programs. Family medicine tions at risk. ing physicians and hospitals. No physi- residency programs have many charac- Decades of experience indicate that cian is asked to see more than one teristics similar to those of CHCs. Each the existing undergraduate and gradu- patient a month. took root in the mid-to-late 1960s after a ate medical education systems, even I do not mean to make the program period of experimentations and devel- with genuine commitment, are not at- sound deceptively easy. Much time was opments in the early 1960s. Both re- tuned to the task. Excellence of biomed- spent coordinating this program with ceived initial support from community ical education is necessary but insuffi- the county commission, the health care movements and the federal govern- cient for the effective practice of board, the health planning council, the ment. Both espoused, then and now, medicine and the management of com- primary care providers, the physicians, many of the same principles: a commit- munity-based approaches to health in and the hospitals. We fought hard to ment to the broader issues of health care these ravaged urban landscapes. The keep the program strictly voluntary, (such as equal access for all), a major lack of subsequent support structures without any contractual confinements. interest in prevention, and an interdis- for graduates intensifies the problem The county commission has agreed to ciplinary approach to the provision of even for those who are committed. Ex- provide funding for the coordinator po- health care. But at this time many fam- isting quid pro quo plans that provide sition and the data accumulation. These ily medicine residency programs are scholarships in return for subsequent are the only budgetary needs of the also struggling. They are experiencing service commitments (but inevitably program. financial difficulties and trouble enroll- have buy-out provisions) have failed to In our first 9 months as a formalized ing enough patients for "teaching." ameliorate the desperate shortage of program, the physicians and the hospi- It seems logical that these two types primary care physicians in underserved JAMA, May 15, 1991 265, No. 19 Letters 2481 urban areas. the Robert Wood Johnson Foundation. providing volunteer services, and one To provide physicians appropriately About 20 local physicians in various dermatologist has been conducting a trained and adequately motivated for specialties have agreed to see referrals very well-received monthly clinic for this task, we need to create something for no fee or a reduced fee, and patients the past 2 years. new: a public-sector, public-interest are also referred to the local hospital There is need for more physician vol- medical school explicitly committed to clinics, for example, the prenatal clinic. unteers. The lure of liability coverage this task that unites a public university, At the hospital they are screened and and teaching credit has not been as at- public hospitals, and community health pay on a sliding scale: up to $100 a visit. tractive as hoped, nor has offering to centers as teaching sites; includes a We perform urine tests, measure he- schedule clinic times at the discretion health department; and provides a cur- moglobin and blood glucose levels, and and convenience of the volunteer. We riculum that is enriched in both the bio- carry out pregnancy tests. Roentgeno- are now considering developing a list of medical and behavioral dimensions ap- grams and other laboratory work are physicians who would see a predeter- propriate to the needs of the target performed at the hospital. Prescrip- mined number of homeless patients in population. To provide a support struc- tions are filled at a local pharmacy that their own offices, and then providing ture for continuing practice in under- has agreed to give discounts. A local appropriate patients with those physi- served areas, we need an Urban Health optometrist provides glasses at cost. cians' business cards after initial assess- Corps with funding adequate to ensure The emphasis is on basic, no-frills medi- ment at the public clinics. decent salaries, professional fulfill- cine. Tests are ordered sparingly, and a Homeless people as a group have a ment, and continuing medical education drug supply house catalog is used to high prevalence of medical and mental throughout a 5- to 10-year service peri- check on the cost of medications. Immu- health problems, but many, if not most, od. Finally, we need the restoration of nizations are supplied free by the state. of such problems can be dealt with in the services removed by the devastating Because of our low overhead, services provision of basic primary and preven- cuts in the community health center net- can be provided much more cheaply tive care.¹ The most immediate need, work. The costs of all this would be more than in the hospital clinics, and the hos- therefore, is for a larger number of phy- than offset by the savings in hospitaliza- pital is relieved of a financial burden. sicians who consider this kind of public tion-and in productive lives. We are ourselves volunteers, and to service a part of the privilege and re- There is an analogue-the Uniformed some extent we depend on volunteers. sponsibility of their profession. Services University of the Health Sci- Medical care for the uninsured is going Steve Heilig, MPH ences, Bethesda, Md. Our nation's secu- to take either a lot of money or a lot of San Francisco (Calif) rity depends no less on the protection of volunteers. There's still a little public Medical Society our domestic health. And there is al- and private money around, and, with Daniel Wlodarezyk, MD ready a precursor: the City University proper organization and encourage- San Francisco (Calif) of New York (NY) Medical School, lo- ment, there may be enough volunteers. Department of Public Health cated in central Harlem and drawing on 1. Wlodarezyk D, Prentice R. Health issues of homeless Robert Zufall, MD persons. West J Med. 1988;148:717-719. the underserved population itself-a Dover, NJ vast, untapped human resource-for its To the Editor. practice with a multi- student body. Our experience demon- To the Editor. San Francisco, Calif, is specialty group in a city with a popula- strates that, even in the midst of depri- currently "home" to an estimated 6000 tion of 25 000. Our group draws from a vation and epidemic, there is no short- to 10 000 people with no place of their regional population base of approxi- age of able, committed students who own to live and sleep. Currently avail- mately 100 000. All of our physicians but want to serve. able medical resources are not adequate one have both office- and hospital-based H. Jack Geiger, MD to meet the needs of these people, due to practices. Our accounts department The City University of financial or geographic barriers. Even screens patients for us SO that elective New York (NY) Medical School with an existing network of public clin- services are provided only to patients ics and health care visits in homeless who have resources to cover the cost of To the Editor. -My wife and I operate a shelters, many go without needed care. the service. Individual physicians may, free clinic that might serve as one model In 1988, the San Francisco Depart- at their discretion, opt for less stringent for provision of medical care to the unin- ment of Health and San Francisco Medi- screening standards. Hospital services sured. The clinic provides basic primary cal Society embarked on a partnership are provided by physicians on an urgent care and pediatric immunizations to aimed at filling this gap. An arrange- or emergency basis almost entirely people who cannot afford $50 for a blood ment was made whereby the Depart- without knowledge of, or consideration pressure check or $100 for shots. ment of Public Health would provide for, a patient's ability to pay. Despite It is open one night a week in the liability coverage for any physician or our taking steps to limit elective ser- office of a local Hispanic community or- other health care provider who volun- vices for underinsured and uninsured ganization, and 15 to 20 patients are teered his or her services for the city's patients, our group wrote off over seen each night. They are screened for homeless program, and the local medi- $1 million in services as uncollectible in ability to pay, but almost everyone is cal school would provide teaching credit the fiscal year 1990. This amounted to accepted; a donation of $1 to $5 is en- to clinical faculty members who pro- over $50 000 per practitioner! One can couraged. There are two to four volun- vided care while supervising medical only wonder how staggering the write- teer physicians, one or two volunteer residents. off might have been had some sort of nurses, one or two volunteer secretar- The next step has been to recruit vol- screening policy not been adopted. As ies, and one or two paid translators. unteers, and two meetings at the medi- sizable as it is, the financial write-off is Modest overhead costs are paid. The cal society drew large numbers of only a footnote to the stress, sleep budget is under $10 000 a year, or about nurses and lesser numbers of physi- deprivation, health risks, and liability $10 per patient visit. Start-up costs for cians. Subsequent calls for volunteers incurred in caring for these patients. basic office equipment were about have gone out in local medical and lay I use the above data to support my $3000, given by Warner Lambert. We publications. Approximately half a doz- contention that physicians already re- also have grants from United Way and en physicians have followed through in semble White Knights rather than 2482 JAMA, May 15, 1991 265, No. 19 Letters Darth Vaders when it comes to the primary mission of the public hospital is strophic reserve of 15 hospital days plus plight of the underinsured and unin- the provision of health care. Day-to-day a specified medical and surgical reserve sured. I would suggest that our critics, hospital operations must be entrusted benefit; and (5) special provisions for be they members of government and to nonpartisan health care professionals medical care for chronic illness. business or the underinsured them- immune from political vagaries and ma- Those who wished and could af- selves, ask as much of themselves as nipulations. The task of these profes- ford supplemental coverage would find they do of physicians. If our critics are sionals must be efficient disbursement ready underwriters among the nation's willing to give their energy and re- of funds without influence (patronage) insurers. sources in the same proportion as physi- from the contributing governmental The cost of universal coverage would cians, then we will have come a long way bodies. be mitigated by (1) the savings derived toward solving this problem. A number of us did not go to medical from the elimination of the open-ended Bruce Harris, MD school to become wealthy, but rather to benefits of Medicare and Medicaid; Statesville (NC) learn to diagnose, care for, and heal pa- (2) the fact that relatively little hospital Medical Group tients. Public hospitals are unique in care is needed by the uninsured, since providing the milieu where idealists two thirds are believed to be under 24 To the Editor.- We have been fortu- provide gentle care with only a minimal years; and (3) a tax on currently tax-free nate to work at Cook County Hospital in interference from the business of medi- health care insurance premiums paid by Chicago, Ill, for the past 5 years and cine. We hope our society will recognize employers that could yield $30 billion. therefore have observed firsthand the the service provided by public hospitals Any reform of Medicare would have care provided to the indigents of our and elect to subsidize them. If not, their to grandfather current beneficiaries city. While almost every other hospital certain passing will bring to an end one and be implemented gradually. avoids admitting or even transfers to us of the noblest endeavors of mankind, To avoid the perils of a monolithic patients in unstable condition, our doors caring for our needy brothers and payment system and ensure uniformity are open for every patient who seeks sisters. and efficiency, yet maintain a role for medical care. Both inpatient and outpa- Dimitrios G. Spigos, MD the current insurance intermediaries, I tient care is based on what is best for our Bradley G. Langer, MD point to the successful example of the patients, not on DRGs (diagnosis re- Cook County Hospital Federal National Mortgage Association lated groups) or other reimbursement Chicago, Ill (Fannie Mae), which has greatly helped schemes. in ensuring liquidity for the home mort- Public hospitals have chronic prob- To the Editor.- In this country, we as- gage loan market. Private capital is uti- lems with recruiting and maintaining sert that everyone has a right to health lized with an implicit federal guaranty. professional staff. Part of the problem, care, yet we do not honor this promise. I could conceive of the creation of a of course, is attributable to low salaries. Instead, we have established a series of National Health Insurance Association The public health care commitment unlimited entitlements for some; their (Hallie Mae). Its shareholders would be must include realistic professional sala- enormous cost precludes the govern- the government and a consortium of the ries, such as those listed in the guide- ment from ensuring access to basic ser- current insurance carriers, who would lines published by the Association of vices for the uninsured and underin- name equal numbers of directors. The American Medical Colleges. Part of this sured. premiums for insurance benefits would cost can be defrayed by medical staff The curiosity of Medicare is that eligi- be set on an actuarial basis to fund de- affiliation with medical schools. Such as- bility is not gauged by need but by se- fined benefits. The government's only sociations can provide salary supple- niority, and the entitlement is open- role would be to guarantee the marginal ments, stimulate academic activities, ended above deductibles that have only risk of inadequate actuarial assump- and make research facilities available. recently become significant. Medicare tions for that year with a resetting of Although most of the public hospitals is not an actuarily based program and it rates the following year. A uniform set are general hospitals, the exact nature draws on general US Treasury subsidy. of guidelines would provide universal of services should depend on the needs All benefits are tax free, and decedents' standards of review and payment, elim- of the community. Unnecessary dupli- estates go to the heirs, unencumbered. inating the redundancies of multiple cation of highly specialized services An alternate to these entitlements payers. such as transplantation, especially if would be to abolish Medicare and Medic- Marcel Frenkel, MD, MBA they exist in adjacent institutions, aid and provide only a very basic pack- University of Illinois should be avoided. Although contractu- age of benefits, but to the population at at Chicago al agreements with these referral cen- large, to include the following: (1) de- College of Medicine ters are to be encouraged, they must fined prenatal, obstetric, and child-care clearly ensure reliable service to the in- services to the age of 14 years; (2) after To the Editor.- Although life and liber- digent. The indigent are not to be treat- this, a limited set of benefits such as 14 ty were considered as human rights un- ed as "second-class citizens." Referral days of hospitalization per year, togeth- der the 1776 Declaration of Indepen- institutions must demonstrate their er with defined, limited medical and sur- dence, happiness was specified only as a commitment and obligation to the care gical coverage. A specified number of pursuit, and health care received no of indigent patients and treat them as unused days (possibly 3 per year, sub- mention. It would appear, though, that human beings rather than simply a ject to a limit) and benefits could be contemporary societal philosophy con- source of easy cash flow. cumulated and applied to subsequent siders the pursuit of health care in much For public hospitals to survive, it is periods of illness. The benefits package the same light as the pursuit of happi- imperative that they become as efficient would also include the following: (3) af- ness: a greatly desired asset that all may as the best hospitals in the private ter 55 years of age, accrual of 1 extra day pursue equally, but that persistently re- sector. Public hospitals must be gov- per year of hospital benefit and a speci- mains beyond the grasp of a growing erned by community leaders with dem- fied increment in medical and surgical number of persons. This evolution of onstrated commitment to health care. benefits to account for increased inci- health care as a luxury item, in a free- These leaders must understand that the dence of disease; (4) a lifetime cata- enterprise democratic society, has cre- JAMA, May 15, 1991 265, No. 19 Letters 2483 ated a morally sordid situation that 1. Koop CE, Schaefer FA. Whatever Happened to the Hu- these populations, additional current raises the specter of profound class dis- man Race. 2nd ed. Westchester, III: Crossway Books; 1983. Medicaid dollars would be saved. 2. Ackerknecht EH. Rudolph Virchow. Madison: Universi- tinction between the insured and the ty of Wisconsin Press; 1953. Barry L. Farkas, MD uninsured, the enfranchised and the dis- Pittsburgh, Pa enfranchised, the entitled and the de- To the Editor.- The essence of my plan 1. Blendon RJ, Donelan K. The public and the emerging prived, the haves and the have-nots. is to allow those practicing physicians debate over national health insurance. N Engl J Med. 1990;323:208-212. This process of social cleavage has pro- and surgeons who wish to do SO to de- duced a group of people living in varying duct from their personal federal income The Oath of the Healer degrees of health care comfort and secu- tax returns their usual (or even dis- rity and a group whose lives are contin- counted) charges for care provided to To the Editor. In the eyes of God and ually exposed to the actual privation of the Medicaid and uninsured population. in the presence of my fellow students health care services. I am reminded of Federal and state Medicaid outlays in and teachers, I at this most solemn time the opening sentence of Whatever Hap- 1989 exceeded $71 billion (New York in my life do freely take this Oath, pened to the Human Race by Koop and Times. November 4, 1990:1, 14). If phy- whereby I shall pledge to myself and all Schaefer: "Cultures can be judged in sician-allocated payments are 20% of others the manner in which I shall live many ways, but eventually every nation that total, then approximately $14 bil- the rest of my days. in every age must be judged by this test: lion is being spent through Medicaid. I shall be ever grateful to my teachers how did it treat people?"¹ It would ap- There are 570 practicing physicians who have planted the seeds of knowl- pear that contemporary American soci- and surgeons in the United States; if edge, which I shall nurture forever. I ety has somehow missed the mark, each who elected to participate provid- thank them for allowing me to see the should we apply this test to health care. ed $100 000 in "free care" and their fed- importance of learning and realize that The 19th-century German patholo- eral deductions were discounted to 75% lifelong study is critically important to gist Rudolph Virchow had expressed of charges, then $75 000 per physician becoming a Healer. the view that physicians are the "natu- per year might be deducted. Assuming I realize that on this day, I become a ral attorneys of the poor" and that "so- the top marginal tax bracket for each physician for all eternity. I shall strive cial problems should be solved by one, this would result in approximately to be a person of good will, high moral them.' However, at present, it would $23 in reduced taxes. Multiplied na- character, and impeccable conduct. I be folly to assume that physicians as a tionwide, a $13 billion reduction in fed- shall learn to love my fellow man as group can single-handedly solve this eral tax revenues would occur. Offset- much as I have learned to love the art of contemporary American health care cri- ting this lost revenue would be the healing. sis that denies access to 37 million elimination of $14 billion in Medicaid's I shall always act in the best interests individuals. physician-allocated outlays. of my patient and shall never allow per- Long-term solutions to this crisis The benefits include increased access sonal reward to impact on my judgment. might best be met by the establishment "overnight" to physicians who are not I shall always have the highest respect of a congressional advisory commission providers now but who would be eager for human life and remember that it is charged with the responsibility of creat- to reduce their taxes and, in the pro- wrong to terminate life in certain cir- ing two viable proposals, each of which cess, cover 60 million people for the cost cumstances, permissible in some, and would guarantee a basic standard of of currently inadequately covering 24 an act of supreme love in others. I shall care for all Americans. This commission million. never promise a cure, as only death is would need to be formed by ethical and The problems are several. Eligibility certain, and I shall understand that pre- unbiased members of the professions of through a national registration system, serving health is as important as treat- medicine and law, in conjunction with perhaps using Social Security identi- ing disease. When a patient for whom I health care administrators, federal fication, and a method of reporting have been caring dies, I shall have the health officers, insurance executives, services to prevent fraud would be nec- strength to allow him or her to die with and legislators. These individuals would essary. Also, there is no implicit disin- dignity and in peace. need to understand each other, since to centive for use. Patient copayment at I shall have as a major focus in my life further the social progress of health the time of service and the use of a "vol- the promoting of a better world in which care, great concessions and sacrifices ume performance standard" might be to live. I shall strive to take a compre- would be required on all sides. In a dem- employed. Not least, the costs of medi- hensive approach to understanding all ocratic fashion, one of these two propos- cine for the currently uninsured might aspects of life. To become the Healer I als would be chosen by common vote as a be defrayed by an increase in "sin tax" wish to be, I must expand my thinking ballot item in a national election. revenues.¹ and practice from a system of episodic Because the problem is acute and se- While salaried physicians would not care to one of a preventive approach to vere, it is urgent that a way is found to be directly affected, I have tried to fair- the problems of mankind, including the break down the barriers of access to ly estimate the amount of care that social ills of malnutrition and poverty care for the uninsured. A reasonable would be provided by participating phy- that plague the world in which we live. approach would be the drafting of legis- sicians. It is clear that there would be an I am not a God and I cannot perform lation that would apply the Good Samar- unknown number who would continue miracles. I am simply a person who has itan standard to emergency medical to choose to receive dollars over deduc- been given the rights and responsibil- care and inpatient hospitalization of in- tions. But it is possible that Medicaid ities to be a Healer. I pledge to myself digent and uninsured patients. This patients, given new freedom to choose and all who can hear me that this is what would diminish the liability threat to their physicians, would transfer their I shall become. physicians and thereby allow physicians care to practices where quality is em- Louis Weinstein, MD to make themselves available to pa- phasized over quantity. Certainly the University of Arizona tients out of purely humanitarian uninsured could be expected to do so. Health Sciences Center Tucson concerns. And to the extent that emergency de- Andrew R. Barnosky, DO partments and hospital clinics are now Dr Weinstein recently presented this 21st-century version of the Hippocratic oath in his address to the University of Grosse Ile, Mich providing high-cost episodic care to Arizona chapter of Alpha Omega Alpha. ED. 2484 JAMA, May 15, 1991 - Vol 265, No. 19 Letters LOW 3 OZ baked red salmon, 5 g fat, 60 mg cholesterol¹ LOWER 3 OZ roasted chicken breast, skinless, 3 g fat, 73 mg cholesterol¹ LOWEST Combined Dairy Total: 2.5 g fat, 14.5 mg cholesterol¹ 8 OZ skim milk, 4 OZ soft-serve vanilla ice milk, 8 OZ nonfat yogurt LOW-FAT DAIRY. IT'S LOWER IN FAT THAN YOU THINK. For patients concerned about lowering cholesterol, fish and chicken are excellent food choices. But what about dairy? People often have mistaken ideas about how much fat dairy foods contain. Actually, the very low fat and cholesterol content of many dairy foods, combined with their high nutrition, makes them an ideal part of today's prudent diets. The National Cholesterol Education Program report recommends two servings a day of low-fat or nonfat dairy foods be included in all cholesterol-lowering diets because of their calcium content.² Adequate lifetime calcium intake is associated with greater bone density and lower risk of osteoporosis.³ The three servings of low-fat dairy food shown above provide more than the entire RDA of calcium for most adults.4 So, when patients think they have to cut down on dairy to cut down on fat, surprise them. Recommend lean dairy- the high-nutrition, low-fat part of today's cholesterol-lowering diets. LOW-FAT DAIRY FOR LOW-FAT DIETS. Nutritive Values of Selected Foods' Fat Cholesterol Calcium Calories To help motivate your patients- 8 OZ skim milk Trace 4 mg 302 mg 85 "Low-Fat Foods 8 OZ nonfat yogurt Trace 4 mg 452 mg 125 for Low-Cholesterol Diets" 4 OZ soft-serve 2.5 g 6.5 mg 137 mg 113 Send for a free supply of this patient education pamphlet. vanilla ice milk Just mail this coupon to National Dairy Board, P.O. Box 1024, Fairview, NJ 07022-9024. 3 OZ roasted chicken 3g 73 mg 13 mg 140 breast, skinless Please print or type. 3 OZ baked red 5g 60 mg 26 mg 140 Name salmon Specialty References: 1. Nutritive Value of Foods, U.S. Department of Agriculture, Home and Garden Bulletin No. 72, 1985, 1989 (Supplement). 2 Report of the National Cholesterol Education Program Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults. Arch Intern Med 1988; 148:36-69. 3. Cauley JA, Gutai Address JP, Kuller LH, etal: Endogenous estrogen levels and calcium intakes in postmenopausal women: Relationships with cortical bone measures. JAMA 260:3150-3155,1988. 4. Recommended Dietary Allowances, ed 10, National Academy Press, Washington, DC, 1989. City State Zip ©1990 National Dairy Board Low-Fat JAMA If you prescribe 10-mg ACCUTANE 20-mg 40-mg capsules don't Until you have the facts 1-800-93-ROCHE PREGNANCY ORGANIZER. Roche Dermatologics ROCHE a division of Hoffmann-La Roche Inc. Copyright © 1990 by Hoffmann-La Roche Inc. All rights reserved. 2486 FACTS ABOUT FACTS ABOUT careful patient selection continuous patient monitoring A thorough pretreatment work-up, including a lipid profile, should be performed for all patients. What's more, laboratory profiles and all clinical findings should be monitored through- out therapy. The most common side effects are those associ- Because of severe adverse reactions associ- ated with hypervitaminosis A and include ated with its use, only patients with severe cheilitis and dry skin. Because of significant recalcitrant cystic acne unresponsive to other adverse effects associated with its use, such as standard therapies should be considered as pseudotumor cerebri, corneal opacities, hyper- candidates for treatment with Accutane ostosis, hepatotoxicity, elevation of plasma (isotretinoin/Roche). triglycerides and decreased night vision, Additionally, they must meet the qualifications Accutane should be reserved for patients with and agree to comply with the guidelines for severe cystic acne who are unresponsive to therapy. conventional therapy, including systemic anti- biotics. Most adverse reactions have been reversible when therapy has been discon- FACTS ABOUT tinued; however, some have persisted after the Pregnancy cessation of therapy. For a complete listing of adverse reactions, see complete product infor- Prevention Program mation on the following pages. There are additional spe- FACTS ABOUT cific guidelines that must be followed for females of the Follow-up Study childbearing potential. These patients must use The Follow-up Study is effective contraception for being conducted by the Survey Enrollment Form one month before, during PREGNANCY Slone Epidemiology and for one month after PREVENTION Unit, Boston University completing therapy with School of Medicine. It is they Accutane. It is recom- designed to provide mended that two reliable FOR ON valuable information forms of contraception be about the use of used simultaneously. Accutane (isotretinoin/ Use of the Pregnancy Roche) in female Prevention Program for Women on Accutane® patients of childbearing (isotretinoin/Roche) can help you counsel and potential. It is important select appropriate candidates. The Qualifica- that all female patients who take Accutane tion Checklist, Consent Form and Self- enroll in the survey. Evaluation Test are just a few of the elements Enrollment forms are included in the Pregnancy included in this Program. If you do not have an Prevention Program Organizer and in every Pre- organizer, please call 1-800-93-ROCHE scription Pak of Accutane. Please encourage all (1-800-937-6243). of your female patients to enroll. Contraindication and Warning: Major human fetal abnor- malities have been reported. Accutane (isotretinoin/Roche) must not be used by females who are pregnant, who may become pregnant while undergoing treatment, or who are unreliable or may not use reliable contraception for one month before treatment, during treatment and for one month after treatment. Accutane is contraindicated in women of childbearing potential unless the patient meets all of the conditions contained in the black box warning on the following pages. Please see complete product information on following pages. 2487 Avoid ACCUTANE® (isotretinoin/Roche) Pregnancy Decreased Night Vision: A number of cases of decreased night vision have occurred during Accutane therapy. Because the onset in some patients was sudden, patients should be advised isotretinoin/Roche of this potential problem and warned to be cautious when driving or operating any vehicle at night. Visual problems should be carefully monitored. Corneal Opacities: Corneal opacities have occurred in patients receiving Accutane for acne and CONTRAINDICATION AND WARNING: Accutane must not be used by females who are more frequently when higher drug dosages were used in patients with disorders of keratiniza- pregnant or who may become pregnant while undergoing treatment. There is an tion. All Accutane patients experiencing visual difficulties should discontinue the drug and have extremely high risk that a deformed infant will result if pregnancy occurs while taking an ophthalmological examination. The corneal opacities that have been observed in patients Accutane in any amount even for short periods. Potentially all exposed fetuses can be treated with Accutane have either completely resolved or were resolving at follow-up six to affected. seven weeks after discontinuation of the drug. See ADVERSE REACTIONS. Accutane is contraindicated in women of childbearing potential unless the patient Inflammatory Bowel Disease: Accutane has been temporally associated with inflammatory meets all of the following conditions: bowel disease (including regional ileitis) in patients without a prior history of intestinal disor- has severe disfiguring cystic acne that is recalcitrant to standard therapies ders. Patients experiencing abdominal pain, rectal bleeding or severe diarrhea should discon- is reliable in understanding and carrying out instructions tinue Accutane immediately. is capable of complying with the mandatory contraceptive measures Lipids: Blood lipid determinations should be performed before Accutane is given and then at has received both oral and written warnings of the hazards of taking Accutane intervals until the lipid response to Accutane is established, which usually occurs within four during pregnancy and the risk of possible contraception failure and has acknowl- weeks. See PRECAUTIONS. edged her understanding of these warnings in writing Approximately 25% of patients receiving Accutane experienced an elevation in plasma tri- has had a negative serum pregnancy test within two weeks prior to beginning ther- glycerides. Approximately 15% developed a decrease in high density lipoproteins and about 7% apy (It is also recommended that pregnancy testing and contraception counseling showed an increase in cholesterol levels. These effects on triglycerides, HDL and cholesterol be repeated on a monthly basis. To encourage compliance with this recommenda- were reversible upon cessation of Accutane therapy. tion, the physician should prescribe no more than a one month supply of the drug.) Patients with increased tendency to develop hypertriglyceridemia include those with diabetes will begin therapy only on the second or third day of the next normal menstrual mellitus, obesity, increased alcohol intake and familial history. period The cardiovascular consequences of hypertriglyceridemia are not well understood, but may Major human fetal abnormalities related to Accutane administration have been docu- increase the patient's risk status. In addition, elevation of serum triglycerides in excess of mented: CNS abnormalities (including cerebral abnormalities, cerebellar malforma- 800 mg/dL has been associated with acute pancreatitis. Therefore, every attempt should be tion, hydrocephalus, microcephaly, cranial nerve deficit); skull abnormality; external made to control significant triglyceride elevation. ear abnormalities (including anotia, micropinna, small or absent external auditory Some patients have been able to reverse triglyceride elevation by reduction in weight, restric- canals); eye abnormalities (including microphthalmia); cardiovascular abnormali- tion of dietary fat and alcohol, and reduction in dose while continuing Accutane.4 ties; facial dysmorphia; thymus gland abnormality; parathyroid hormone deficiency. An obese male patient with Darier's disease developed elevated triglycerides and subsequent In some cases death has occurred with certain of the abnormalities previously eruptive xanthomas.⁵ noted. Cases of IQ scores less than 85 with or without obvious CNS abnormalities Hyperostosis: In clinical trials of disorders of keratinization with a mean dose of 2.24 mg/kg/ have also been reported. There is an increased risk of spontaneous abortion. In addi- day, a high prevalence of skeletal hyperostosis was noted. Two children showed x-ray findings tion, premature births have been reported. suggestive of premature closure of the epiphysis. Additionally, skeletal hyperostosis was noted Effective contraception must be used for at least one month before beginning in six of eight patients in a prospective study of disorders of keratinization. Minimal skeletal Accutane therapy, during therapy and for one month following discontinuation of ther- hyperostosis has also been observed by x-rays in prospective studies of cystic acne patients apy even where there has been a history of infertility, unless due to hysterectomy. It treated with a single course of therapy at recommended doses. is recommended that two reliable forms of contraception be used simultaneously Hepatotoxicity: Several cases of clinical hepatitis have been noted which are considered to be unless abstinence is the chosen method. possibly or probably related to Accutane therapy. Additionally, mild to moderate elevations of If pregnancy does occur during treatment, the physician and patient should discuss liver enzymes have been observed in approximately 15% of individuals treated during clinical the desirability of continuing the pregnancy. trials, some of which normalized with dosage reduction or continued administration of the Accutane should be prescribed only by physicians who have special competence in drug. If normalization does not readily occur or if hepatitis is suspected during treatment with the diagnosis and treatment of severe recalcitrant cystic acne, are experienced in the Accutane, the drug should be discontinued and the etiology further investigated. use of systemic retinoids and understand the risk of teratogenicity if Accutane is used Animal Studies: In rats given 32 or 8 mg/kg/day of isotretinoin for 18 months or longer, the inci- during pregnancy. dences of focal calcification, fibrosis and inflammation of the myocardium, calcification of cor- onary, pulmonary and mesenteric arteries and metastatic calcification of the gastric mucosa were greater than in control rats of similar age. Focal endocardial and myocardial calcifications DESCRIPTION: Accutane (isotretinoin/Roche), a retinoid which inhibits sebaceous gland func- associated with calcification of the coronary arteries were observed in two dogs after approx- tion and keratinization, is available in 10-mg, 20-mg and 40-mg soft gelatin capsules for oral imately six to seven months of treatment with isotretinoin at a dosage of 60 to 120 mg/kg/day. administration. Each capsule also contains beeswax, butylated hydroxyanisole, edetate diso- In dogs given isotretinoin chronically at a dosage of 60 mg/kg/day, corneal ulcers and corneal dium, hydrogenated soybean oil flakes, hydrogenated vegetable oil and soybean oil. Gelatin opacities were encountered at a higher incidence than in control dogs. In general, these ocular capsules contain glycerin and parabens (methyl and propyl), with the following dye systems: changes tended to revert toward normal when treatment with isotretinoin was stopped, but did 10 mg oxide (red) and titanium dioxide; 20 mg- FD&C Red No. 3, FD&C Blue No. 1 and not completely clear during the observation period. titanium dioxide; 40 mg FD&C Yellow No. 6, D&C Yellow No. 10 and titanium dioxide. In rats given isotretinoin at a dosage of 32 mg/kg/day for approximately 15 weeks, long bone Chemically, isotretinoin is 13-cis-retinoic acid and is related to both retinoic acid and retinol fracture has been observed. (vitamin A). It is a yellow-orange to orange crystalline powder with a molecular weight of PRECAUTIONS: Information for Patients: Women of childbearing potential should be instructed 300.44. that they must not be pregnant when Accutane therapy is initiated, and that they should use CLINICAL PHARMACOLOGY: The exact mechanism of action of Accutane is unknown. effective contraception while taking Accutane and for one month after Accutane has been Cystic Acne: Clinical improvement in cystic acne patients occurs in association with a reduction stopped. They should also sign a consent form prior to beginning Accutane therapy. See boxed in sebum secretion. The decrease in sebum secretion is temporary and is related to the dose CONTRAINDICATION AND WARNING. and duration of treatment with Accutane, and reflects a reduction in sebaceous gland size and Because of the relationship of Accutane to vitamin A, patients should be advised against taking an inhibition of sebaceous gland differentiation.1 vitamin supplements containing vitamin A to avoid additive toxic effects. Clinical Pharmacokinetics: The pharmacokinetic profile of isotretinoin is predictable and can be Patients should be informed that transient exacerbation of acne has been seen, generally dur- described using linear pharmacokinetic theory. ing the initial period of therapy. After oral administration of 80 mg (two 40-mg capsules), peak blood concentrations ranged Patients should be informed that they may experience decreased tolerance to contact lenses from 167 to 459 ng/mL (mean 256 ng/mL) and mean time to peak was 3.2 hours in normal vol- during and after therapy. unteers, while in acne patients peak concentrations ranged from 98 to 535 ng/mL (mean 262 It is recommended that patients not donate blood during therapy and for at least one month fol- ng/mL) with a mean time to peak of 2.9 hours. The drug is 99.9% bound in human plasma lowing discontinuance of the drug. almost exclusively to albumin. The terminal elimination half-life of isotretinoin ranged from 10 Laboratory Tests: The incidence of hypertriglyceridemia is 1 patient in 4 on Accutane therapy. to 20 hours in volunteers and patients. Following an 80-mg liquid suspension oral dose of 14C- Pretreatment and follow-up blood lipids should be obtained under fasting conditions. After isotretinoin. 14C-activity in blood declined with a half-life of 90 hours. Relatively equal amounts consumption of alcohol at least 36 hours should elapse before these determinations are made. of radioactivity were recovered in the urine and feces with 65% to 83% of the dose recovered. It is recommended that these tests be performed at weekly or biweekly intervals until the lipid The major identified metabolite in blood is 4-oxo-isotretinoin. The mean elimination half-life response to Accutane is established. of this metabolite is 25 hours (range 17-50 hours). Tretinoin and 4-oxo-tretinoin were also Since elevations of liver enzymes have been observed during clinical trials, pretreatment and observed. After two 40-mg capsules of isotretinoin, maximum concentrations of the metabo- follow-up liver function tests should be performed at weekly or biweekly intervals until the lite of 87 to 399 ng/mL occurred at 6 to 20 hours. The blood concentration of the major metab- response to Accutane has been established. olite generally exceeded that of isotretinoin after six hours. Certain patients receiving Accutane have experienced problems in the control of their blood When taken with food or milk, the oral absorption of isotretinoin is increased. sugar. In addition, new cases of diabetes have been diagnosed during Accutane therapy. The mean + SD minimum steady-state blood concentration of isotretinoin was 160 +1 19 ng/ although no causal relationship has been established. Some patients undergoing vigorous mL in ten patients receiving 40-mg b.i.d. doses. After single and multiple doses, the mean ratio physical activity while on Accutane therapy have experienced elevated CPK levels; however, of areas under the blood concentration:time curves of 4-oxo-isotretinoin to isotretinoin was 3 the clinical significance is unknown. to 3.5. Carcinogenesis, Mutagenesis, Impairment of Fertility: In Fischer 344 rats given isotretinoin at Tissue Distribution in Animals: Tissue distribution of 14C-isotretinoin in rats after oral dosing dosages of 32 or 8 mg/kg/day for greater than 18 months, there was an increased incidence of revealed high concentrations of radioactivity in many tissues after 15 minutes, with a maxi- pheochromocytoma. The incidence of adrenal medullary hyperplasia was also increased at the mum in one hour, and declining to nondetectable levels by 24 hours in most tissues. After higher dosage. The relatively high level of spontaneous pheochromocytomas occurring in the seven days, however, low levels of radioactivity were detected in the liver, ureter, adrenal, Fischer 344 rat makes it a poor model for study of this tumor, since the increase in adrenal ovary and lacrimal gland. medullary proliferative lesions following chronic treatment with relatively high dosages of iso- INDICATIONS AND USAGE: Cystic Acne: Accutane is indicated for the treatment of severe recal- tretinoin may be an accentuation of a genetic predisposition in the Fischer 344 rat, and its rele- citrant cystic acne, and a single course of therapy has been shown to result in complete and vance to the human population is not clear. In addition, a decreased incidence of liver prolonged remission of disease in many patients.¹ If a second course of therapy is needed, it adenomas, liver angiomas and leukemia was noted at the dose levels of 8 and 32 mg/kg/day. should not be initiated until at least eight weeks after completion of the first course, since expe- The Ames test was conducted in two laboratories. The results of the tests in one laboratory rience has shown that patients may continue to improve while off drug. were negative while in the second laboratory a weakly- positive response (less than 1.6 X back- Because of significant adverse effects associated with its use, Accutane should be reserved for ground) was noted in S. typhimurium TA100 when the assay was conducted with metabolic patients with severe cystic acne who are unresponsive to conventional therapy, including sys- activation. No dose-response effect was seen and all other strains were negative. Additionally, temic antibiotics. other tests designed to assess genotoxicity (Chinese hamster cell assay, mouse micronucleus CONTRAINDICATIONS: Pregnancy: Category X. See boxed CONTRAINDICATION AND WARNING. test, S. cerevisiae D7 assay, in vitro clastogenesis assay in human-derived lymphocytes and Accutane should not be given to patients who are sensitive to parabens, which are used as pre- unscheduled DNA synthesis assay) were all negative. servatives in the gelatin capsule. No adverse effects on gonadal function, fertility, conception rate, gestation or parturition were WARNINGS: observed at dose levels of 2, 8 or 32 mg/kg/day in male and female rats. In dogs, testicular atrophy was noted after treatment with isotretinoin for approximately 30 Pseudotumor cerebri: Accutane use has been associated with a number of cases of weeks at dosages of 60 or 20 mg/kg/day. In general, there was microscopic evidence for pseudotumor cerebri (benign intracranial hypertension). Early signs and symptoms appreciable depression of spermatogenesis but some sperm were observed in all testes exam- of pseudotumor cerebri include papilledema, headache, nausea and vomiting, and ined and in no instance were completely atrophic tubules seen. In studies in 66 human males, visual disturbances. Patients with these symptoms should be screened for papil- 30 of whom were patients with cystic acne, no significant changes were noted in the count or ledema and, if present, they should be told to discontinue Accutane immediately and motility of spermatozoa in the ejaculate. In a study of 50 men (ages 17-32 years) receiving be referred to a neurologist for further diagnosis and care. Accutane therapy for cystic acne, no significant effects were seen on ejaculate volume, sperm count, total sperm motility, morphology or seminal plasma fructose. 2488 ACCUTANE® (isotretinoin/Roche) ACCUTANE (isotretinoin/Roche) Pregnancy: Category X. See boxed CONTRAINDICATION AND WARNING. HOW SUPPLIED: Soft gelatin capsules, 10 mg (light pink), imprinted ACCUTANE 10 ROCHE. Nursing Mothers: It is not known whether this drug is excreted in human milk. Because of the Boxes of 100 containing 10 Prescription Paks of 10 capsules (NDC 0004-0155-49). potential for adverse effects, nursing mothers should not receive Accutane. Soft gelatin capsules, 20 mg (maroon), imprinted ACCUTANE 20 ROCHE. Boxes of 100 con- ADVERSE REACTIONS: Clinical: Many of the side effects and adverse reactions seen or taining 10 Prescription Paks of 10 capsules (NDC 0004-0169-49). expected in patients receiving Accutane are similar to those described in patients taking high Soft gelatin capsules, 40 mg (yellow), imprinted ACCUTANE 40 ROCHE. Boxes of 100 contain- doses of vitamin A. ing 10 Prescription Paks of 10 capsules (NDC 0004-0156-49). The percentages of adverse reactions listed below reflect the total experience in Accutane Store at 59° to 86°F; 15° to 30°C. Protect from light. studies, including investigational studies of disorders of keratinization, with the exception of REFERENCES: those pertaining to dry skin and mucous membranes. These latter reflect the experience only in 1. Peck Olsen TG, Yoder FW, StraussJS Downing DT, Pandya M, Butkus D, Arnaud-Battandier J: patients with cystic acne because reactions relating to dryness are more commonly recognized Prolonged remissions of cystic and conglobate acne with 13-cis-retinoic acid. N Engl J Med as adverse reactions in this disease. Included in this category are dry skin, skin fragility, pru- 300:329-333, 1979. 2. Farrell LN, Strauss JS, Stranieri AM: The treatment of severe cystic ritus, epistaxis, dry nose and dry mouth, which may be seen in up to 80% of cystic acne acne with 13-cis-retinoic acid. Evaluation of sebum production and the clinical response in a patients. multiple-dose trial. J Am Acad Dermatol 3:602-611, 1980. 3. Jones H, Blanc D, Cunliffe WJ: The most frequent adverse reaction to Accutane is cheilitis, which occurs in over 90% of 13-cis-retinoic acid and acne. Lancet 2:1048-1049, 1980. 4. Katz RA, Jorgensen H, Nigra TP: patients. A less frequent reaction was conjunctivitis (about two patients in five). Elevation of serum triglyceride levels from oral isotretinoin in disorders of keratinization. Arch Skeletal hyperostosis has been observed on x-rays of patients treated with Accutane. See Dermatol f16:1369-1372, 1980. 5. Dicken CH, Connolly SM: Eruptive xanthomas associated with WARNINGS. Other types of bone abnormalities have also been reported; however, no causal isotretinoin (13-cis-retinoic acid). Arch Dermatol 116:951-952, 1980. 6. Ellis CN, Madison KC, relationship has been established. Pennes DR, Martel W, Voorhees JJ: Isotretinoin therapy is associated with early skeletal radio- Approximately 16% of patients treated with Accutane developed musculoskeletal symptoms graphic changes. J Am Acad Dermatol 10:1024-1029, 1984. 7. Strauss JS, Rapini RP, Shalita AR, (including arthralgia) during treatment. In general, these were mild to moderate and have Konecky E, Pochi PE, Comite H, Exner JH: Isotretinoin therapy for acne: Results of a multicen- occasionally required discontinuation of drug. Less frequently, transient pain in the chest has ter dose-response study. J Am Acad Dermatol 10:490-496, 1984. also been reported. These symptoms generally cleared rapidly after discontinuation of PATIENT INFORMATION/CONSENT: Accutane but in rare cases have persisted. Accutane must not be used by females who are pregnant or who may become pregnant while In less than one patient in ten - rash (including erythema, seborrhea and eczema); thinning of undergoing treatment. hair, which in rare cases has persisted. IMPORTANT INFORMATION AND WARNING: Accutane can cause severe birth defects if it is In approximately one patient in twenty - peeling of palms and soles, skin infections, non- taken when a woman is pregnant. There is an extremely high risk that you will have a severely specific urogenital findings, nonspecific gastrointestinal symptoms, fatigue, headache and deformed baby if: increased susceptibility to sunburn. you are pregnant when you start taking Accutane, Accutane has been associated with a number of cases of pseudotumor cerebri, some of which you become pregnant while you are taking Accutane, involved concomitant use of tetracyclines. See WARNINGS. you do not wait at least one month after you stop taking Accutane before becoming pregnant. The following CNS reactions have been reported and may bear no relationship to therapy - It is recommended that you and your doctor schedule an appointment every month to repeat seizures, emotional instability, dizziness, nervousness, drowsiness, malaise, weakness, the pregnancy test and check your body's response to Accutane. For your health and well- insomnia, lethargy and paresthesias. being, be sure to keep your appointments as scheduled. Depression has been reported in some patients on Accutane therapy. In some of these patients, this has subsided with discontinuation of therapy and recurred with reinstitution of THE CONSENT: therapy. My treatment with Accutane has been personally explained to me by Dr. The following reactions have been reported in less than 1% of patients and may bear no rela- The following points of information, among others, have been specifically discussed and made tionship to therapy- changes in skin pigment (hypo- and hyperpigmentation), flushing, clear: urticaria, bruising, disseminated herpes simplex, edema, hair problems (other than thinning), 1. I, hirsutism, respiratory infections, weight loss, erythema nodosum, paronychia, nail dystrophy, (Patient's Name) bleeding and inflammation of the gums, abnormal menses, optic neuritis, photophobia, eye lid understand that Accutane is a very powerful medicine used to treat severe cystic inflammation, arthritis, anemia, palpitation, tachycardia, lymphadenopathy, sweating, tinnitus acne that did not get better with other treatments including oral antibiotics. and voice alteration. INITIALS: A few isolated reports of vasculitis, including Wegener's granulomatosis, have been received, 2. I understand that I must not take Accutane if I am or may become pregnant during but no causal relationship to Accutane therapy has been established. treatment. In Accutane studies to date, of 72 patients who had normal pretreatment ophthalmological INITIALS: examinations, five developed corneal opacities while on Accutane (all five patients had a disor- 3. I understand that severe birth defects have occurred in babies of women who took der of keratinization). Corneal opacities have also been reported in cystic acne patients treated Accutane during pregnancy. I have been warned by my doctor that there is an extremely with Accutane. See WARNINGS. Dry eyes and decrease in night vision have been reported and high risk of severe damage to my unborn baby if am or become pregnant while taking in rare instances have persisted. See WARNINGS. Cataracts and visual disturbances have also Accutane. been reported. INITIALS: Accutane has been temporally associated with inflammatory bowel disease. See WARNINGS. 4. I have been told by my doctor that effective birth control (contraception) must be used for As may be seen with healing cystic acne lesions, an occasional exaggerated healing response, at least one month before starting Accutane, all during Accutane therapy and for at least manifested by exuberant granulation tissue with crusting, has been reported in patients receiv- one month after Accutane treatment has stopped. My doctor has recommended that I ing therapy with Accutane. Pyogenic granuloma has also been diagnosed in a number of cases. either abstain from sexual intercourse or use two reliable kinds of birth control at the same Laboratory: Accutane therapy induces change in serum lipids in a significant number of treated time. I have also been told that any method of birth control can fail. subjects. Approximately 25% of patients had elevation of plasma triglycerides. Five out of 135 INITIALS: patients treated for cystic acne and 32 out of 298 total subjects treated for all diagnoses 5. I know that must have a blood test that shows I am not pregnant within two weeks before showed an elevation of triglycerides above 500 mg percent. About 16% of patients showed a starting Accutane, and I understand that I must wait until the second or third day of my mild to moderate decrease in serum high density lipoprotein (HDL) levels while receiving treat- next normal menstrual period before starting Accutane. ment with Accutane and about 7% of patients experienced minimal elevations of serum choles- INITIALS: terol during treatment. Abnormalities of serum triglycerides, HDL and cholesterol were 6. My doctor has told me that I can participate in the "Patient Referral" program for an initial reversible upon cessation of Accutane therapy. free pregnancy test and birth control counseling session by a consulting physician. Approximately 40% of patients receiving Accutane developed elevated sedimentation rates, INITIALS: often from elevated baseline values. 7. I also know that I must immediately stop taking Accutane if I become pregnant while taking From one in ten to one in five patients showed decreases in red blood cell parameters and white the drug and immediately contact my doctor to discuss the desirability of continuing the blood cell counts, elevated platelet counts, white cells in the urine, increased alkaline phospha- pregnancy. tase, SGOT, SGPT, GGTP or LDH. See WARNINGS: Hepatotoxicity. INITIALS: Less than one in ten patients showed proteinuria, microscopic or gross hematuria, elevated 8. I have carefully read the Accutane patient brochure, "Important information concerning fasting blood sugar, elevated CPK, hyperuricemia or thrombocytopenia. your treatment with Accutane," given to me by my doctor. I understand all of its contents Dose Relationship and Duration: Cheilitis and hypertriglyceridemia are usually dose-related. and have talked over any questions I have with my doctor. Most adverse reactions were reversible when therapy was discontinued; however, some have INITIALS: persisted after cessation of therapy. (See WARNINGS and ADVERSE REACTIONS.) 9. I am not now pregnant, nor do I plan to become pregnant for at least 30 days after have Overdosage: The oral LD50 of isotretinoin is greater than 4000 mg/kg in rats and mice and is completely finished taking Accutane. approximately 1960 mg/kg in rabbits. Overdose has been associated with transient headache, INITIALS: vomiting, facial flushing, cheilosis, abdominal pain, headache, dizziness and ataxia. All symp- 10. My doctor has told me that I can participate in a survey concerning Accutane use in women toms quickly resolved without apparent residual effects. by completing an additional form. DOSAGE AND ADMINISTRATION: The recommended dosage range for Accutane is 0.5 to 2 mg/ INITIALS: kg given in two divided doses daily for 15 to 20 weeks. In studies comparing 0.1, 0.5 and 1 mg/ I now authorize Dr. to begin my treatment with Accutane. kg/day,⁷ it was found that all doses provided initial clearing of disease but there was a greater need for retreatment with the lower dose(s). It is recommended that for most patients the initial dose of Accutane be 0.5 to 1 mg/kg/day. Patient, Parent or Guardian Date Patients whose disease is very severe or is primarily manifest on the body may require up to the maximum recommended dose, 2 mg/kg/day. During treatment, the dose may be adjusted Address according to response of the disease and/or the appearance of clinical side effects some of which may be dose-related. If the total cyst count has been reduced by more than 70 percent prior to completing 15 to 20 weeks of treatment, the drug may be discontinued. After a period of two months or more off Telephone Number therapy. and if warranted by persistent or recurring severe cystic acne, a second course of I have fully explained to the patient, the therapy may be initiated. Contraceptive measures must be followed for any subsequent course nature and purpose of the treatment described above and the risks to women of childbearing of therapy. potential. I have asked the patient if she has any questions regarding her treatment with Accutane should be administered with food. Accutane and have answered those questions to the best of my ability. ACCUTANE DOSING BY BODY WEIGHT Physician Date Body Weight Total Mg/Day REVISED: MAY 1990 P.I. 0590 kilograms pounds 0.5 mg/kg 1 mg/kg 2 mg/kg 40 88 20 40 80 50 110 25 50 100 Roche Dermatologics 60 132 30 60 120 70 154 35 70 140 ROCHE a division of Hoffmann-La Roche Inc. 80 176 40 80 160 90 198 45 90 180 100 220 340 Kingsland Street 50 100 200 Nutley, New Jersey 07110-1199 2489 STRONG ORUDIS (ketoprofen) 50 mg and 75 mg capsules FASTSTRONG.NONADDICTING PAIN RELIEF ORUDIS® (ketoprofen) of implantation sites. Rats and dogs had inhibition of, or abnormal, spermatogenesis at high doses, and dog BRIEF SUMMARY OF PRESCRIBING INFORMATION: and baboon testes decreased in weight. Consult the package literature for full prescribing information. Teratogenic Effects: Pregnancy Category B: No effects seen in mice. Maternally toxic doses in rabbits produced embryotoxicity but not teratogenicity. CONTRAINDICATIONS: Hypersensitivity to ORUDIS. Do not give if aspirin or other NSAIDs have induced Use not recommended in pregnancy. asthma, urticaria, or other allergic reactions since fatal, anaphylactic reactions have been reported in such Labor and Delivery, Nursing Mothers, Pediatric Use: Use is not recommended. patients. ADVERSE REACTIONS: Incidence of common ADRs (>1%) was obtained from 835 patients on ORUDIS® WARNINGS: RISK OF GI ULCERATION, BLEEDING, AND PERFORATION WITH NSAID THERAPY: Serious GI (ketoprofen) in double-blind trials lasting 4 to 54 weeks. toxicity (e.g., bleeding, ulceration, perforation) can occur at any time, with or without warning symptoms Minor GI side effects predominated; more upper GI symptoms noted than lower GI. In controlled clinical during chronic therapy. Minor upper GI problems are common early in therapy but physicians should remain trials peptic ulcer or GI bleeding noted in <1% of 1,076 patients; open-label studies in 1,292 patients had alert for ulceration and bleeding even without previous Gl-tract symptoms. Occurrence of serious GI toxicity rate >2%. Peptic ulceration incidence in patients on NSAIDs depends on many risk factors, e.g., age, sex, is about 1% after 3-6 months of therapy, 2-4% after a year. Patients should be informed of signs and smoking, alcohol use, diet, stress, concomitant drugs such as aspirin and corticoids, plus dose and duration symptoms of serious GI toxicity and what to do if it occurs. Studies have failed to identify a patient subset of treatment with NSAIDs. Next in frequency were CNS side effects such as headache, dizziness, or drowsi- not at risk. Prior history of serious GI events and other risk factors of peptic ulcer disease (e.g., alcoholism, ness. Incidence of some ADRs appears dose-related (see Dosage and Administration in package insert). smoking, etc.) are the only factors associated with increased risk. Elderly and debilitated patients tolerate In double-blind trials, 233 patients on ORUDIS had fewer minor GI complaints, tinnitus and hearing ulceration or bleeding less well and have more fatal GI events. High doses probably carry a greater risk. impairment, fluid retention, and minor liver function test abnormalities than 228 aspirin-treated patients. Consider benefit versus risk (of GI toxicity) in prescribing higher recommended doses. Incidence >1% (Probable Causal Relationship): PRECAUTIONS: Chronic administration of NSAIDs causes nephritis in mice and rats. Interstitial nephritis Digestive: Dyspepsia (11.5%), nausea,* abdominal pain,* diarrhea,* constipation,* flatulence,* anorexia, and nephrotic syndrome have been reported with ORUDIS since it has been marketed abroad. A second vomiting, stomatitis. CNS: Headache,* dizziness, CNS inhibition (i.e., pooled reports of somnolence, form of renal toxicity is seen in patients having reduced renal blood flow or blood volume, where malaise, depression, etc.) or excitation (i.e., insomnia, nervousness, dreams, etc.).* Special Senses: prostaglandins support the maintenance of renal blood flow. In these patients NSAIDs cause a dose- Tinnitus, visual disturbance. Skin and Appendages: Rash. Urogenital: Impairment of renal function dependent decrease in prostaglandin synthesis and renal blood flow which may precipitate overt renal (edema, increased BUN),* signs or symptoms of urinary-tract irritation. failure. Patients with impaired renal or hepatic function, heart failure, those on diuretics, or the elderly are Side effects with incidence greater than 3%. at greatest risk. Discontinuation of NSAIDs typically leads to recovery. Since ketoprofen is primarily Incidence <1% (Probable Causal Relationship): eliminated by the kidneys and its pharmacokinetics altered by renal failure, patients with impaired renal Digestive: Appetite increase, dry mouth, eructation, gastritis, rectal hemorrhage, melena, fecal occult function should be closely monitored to identify a needed dosage reduction. Borderline elevations of liver- blood, salivation, peptic ulcer, GI perforation, hematemesis, intestinal ulceration. CNS: Amnesia, con- function tests may occur in up to 15% and may progress, remain unchanged, or disappear with continued fusion, impotence, migraine, paresthesia, vertigo. Special Senses: Conjunctivitis, conjunctivitis sicca, therapy. Patients with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver eye pain, hearing impairment, retinal hemorrhage and pigmentation change, taste perversion. Skin and test has occurred, should be evaluated further as serious hepatic reactions, including jaundice, have been Appendages: Alopecia, eczema, pruritus, purpuric rash, sweating, urticaria, bullous rash, exfoliative reported. SGPT (ALT) is the most sensitive indicator of liver dysfunction. To reduce or eliminate steroid dermatitis, photosensitivity, skin discoloration, onycholysis. Body as a Whole: Chills, facial edema, dosage during therapy, go slowly and look closely for any evidence of adverse effects, including adrenal infection, pain, allergic reaction, anaphylaxis. Cardiovascular: Hypertension, palpitation, tachycardia, insufficiency and exacerbation of arthritis. Anemia is common in rheumatoid arthritis and sometimes congestive heart failure, peripheral vascular disease, vasodilation. Hemic: Hypocoagulability, aggravated by NSAIDs. Patients with initial hemoglobin of 10 g/dL or less should have hemoglobin values agranulocytosis, anemia, hemolysis, purpura, thrombocytopenia. Metabolic and Nutritional: Thirst, determined frequently during chronic therapy. Peripheral edema was seen in about 2% of ORUDIS patients, weight gain, weight loss, hepatic dysfunction, hyponatremia. Musculoskeletal: Myalgia. Respiratory: SO use caution in patients with fluid retention, hypertension, or heart failure. Dyspnea, hemoptysis, epistaxis, pharyngitis, rhinitis, bronchospasm, laryngeal edema. Urogenital: Men- Information for Patients: Physicians should discuss potential risks (See Warnings, Precautions, Adverse ometrorrhagia, hematuria, renal failure, interstitial nephritis, nephrotic syndrome. Reactions) and likely benefits with patients especially when other drugs offer an acceptable alternative for Incidence <1% (Causal Relationship Unknown): less serious conditions. Advise patients what to do if they experience major or minor GI symptoms. Minor GI (listed as information to alert physicians) Digestive: Buccal necrosis, ulcerative colitis. CNS: Dysphoria, symptoms are sometimes prevented by giving ORUDIS with food, milk, or antacids. (Note that antacids do hallucination, libido disturbance, nightmares, personality disorder. Body as a Whole: Septicemia, shock. not affect bioavailability; food and milk affect rate but not extent of absorption.) Advise patients not to take Cardiovascular: Arrhythmias, myocardial infarction. Endocrine: Diabetes mellitus (aggravated). Meta- aspirin while on ORUDIS. bolic and Nutritional: Jaundice. Urogenital: Acute tubulopathy, gynecomastia. Drug Interactions: OVERDOSAGE: Reports are rare. Symptoms usually mild or absent. Vomiting and drowsiness have Diuretic: Patients on diuretics are at greater risk of renal failure secondary to decreased renal blood flow occurred. With large doses, empty stomach by gastric lavage or induced vomiting and use required support due to prostaglandin inhibition (see Precautions). therapy. ORUDIS is dialyzable; thus, hemodialysis may remove circulating drug or assist in renal failure. Warfarin: Because prostaglandins are important in hemostasis and ketoprofen also affects platelet Dosage and Administration: Rheumatoid Arthritis and Osteoarthritis: Starting dose 75 mg t.i.d. or function, concurrent ORUDIS/warfarin therapy requires close monitoring. 50 mg q.i.d. (range 150-300 mg daily). Mild-to-Moderate Pain and Dysmenorrhea: 25-50 mg q6-8h prn. A Methotrexate: Co-administration of methotrexate and NSAIDs has caused methotrexate toxicity due to larger dose may be tried, but doses above 75 mg have not been shown to give added analgesia. displacement of protein-bound methotrexate. How supplied: 25, 50, and 75 mg capsules. Keep tightly closed. Dispense in tight container. Lithium: Increased steady-state plasma lithium levels. Lithium levels should be monitored when given CI 3827-3 May 16, 1990 with ORUDIS. Concurrent use of aspirin or probenecid with ketoprofen is not recommended. Drug/Laboratory Test Interactions: Effect on Blood Coagulation: ORUDIS decreases platelet adhesion and aggregation and can prolong bleeding time by about 3 to 4 minutes. There is no significant change in platelet count, prothrombin time, partial thromboplastin time, or thrombin time. Carcinogenesis, Mutagenesis, Impairment of Fertility: No evidence of carcinogenic or mutagenic W WYETH-AYERST C 1990, Wyeth-Ayerst Laboratories LABORATORIES potential. No impairment of reproduction or fertility seen in male rats. Female rats had decreased number Philadelphia, PA 19101 Adv. #60089 Caring for the Uninsured and Underinsured The Uninsured From Dilemma to Crisis Emily Friedman SOME health policy issues are like bad The 1987 National Medical Expenditure Of those aged 25 to 54 years, 19.8% pennies; despite repeated efforts to re- Survey found that 47.8 million people were uninsured all or part of the year, as solve them, they keep coming back. lacked insurance for all or part of 1987, were 13.6% of those aged 55 to 64 Probably no health policy issue of this with between 34 and 36 million unin- years. 1,2 (Medicare covers virtually all century (with the possible exception of sured on any given day and 24.5 million Americans 65 years or older.) The fact insuring and structuring long-term uninsured throughout that year.¹,² that more than one in eight Americans care, which affects far fewer people) has The US Bureau of the Census found who are 55 to 64 years old lack coverage proven as intractable as access to acute that, from the first quarter of 1986 to at least part of the year is disturbing, in care for Americans who lack coverage the last quarter of 1988, 63.6 million that this group faces a much higher risk for the cost of that care. It was a prob- people lacked coverage for at least of serious health problems than do youn- lem for most Americans at one time; 1 month and 31.5 million lacked it in the ger Americans. after the introduction of private insur- final quarter of 1988.³ The Employee Racial and ethnic differences affect ance early in the 20th century, it became Benefit Research Institute reported rates of coverage. Of non-Hispanic a problem more of specific groups, nota- that, in 1988, 33.3 million Americans whites, 18.6% were uninsured for all or bly the elderly and the poor. Coverage had no private insurance and were ineli- part of 1987, as were 29.8% of black of those who were uninsured was a poli- gible for public coverage.⁴ Even the Americans and 41.4% of Hispanic cy centerpiece (largely unrealized) of more conservative figures represent a Americans.¹. Studies using differing President Harry S Truman's adminis- significant increase over the 26.6 million methodologies going back as far as 1978 tration. With the passage of Medicaid uninsured reported in the 1977 National have shown that Hispanic Americans and Medicare in 1965, it was thought the Health Care Expenditures Study. are the most likely to be uninsured of issue was largely resolved. When examined further, the statis- any ethnic group.⁷ As Hispanics repre- The uninsured, however, like the pro- tics provide a troubling picture. Al- sent the fastest-growing ethnic popula- verbial poor, seem always to be with us. though most figures discussed herein tion group in the nation, their consis- In fact, their numbers have grown sig- are from the 1987 National Medical Ex- tently low rate of coverage is a potential nificantly in the past 15 years. Proposals penditure Survey, virtually all other warning of worse yet to come. for solutions are rife, but consensus on studies have found substantially the Men are slightly more likely to be how to attack the problem has proven, same patterns. uninsured than women; 23.8% of men to say the least, elusive. Nevertheless, In terms of age, those who are 19 to 24 were uninsured for at least part of 1987 the dilemma of the uninsured has be- years old are most likely to be unin- as opposed to 21% of women. 1,2 This un- come a crisis, affecting all aspects of the sured; 20.3% of this group were unin- doubtedly reflects the fact that virtually health care system and many aspects of sured for all of 1987, and another 18.2% all men, regardless of their income, are society. were uninsured for part of the year.¹,² excluded from eligibility for Medicaid. Children younger than 18 years were Also, Medicaid now covers low-income WHO IS UNINSURED? the next most likely to lack coverage, pregnant women with incomes up to Most estimates place the number of with nearly one in four uninsured either 185% of the poverty line, as well as Americans lacking public or private all or part of the year. The National many mothers with dependent children. coverage between 31 and 36 million.¹⁴ Center for Health Statistics reports Furthermore, women are dispropor- that, in 1988, 17% of children under 18 tionately represented in the poverty Ms Friedman is a contributing editor for Hospitals, years had neither private insurance nor population, so, to the extent that Medic- Medical World News, and the Healthcare Forum Jour- Medicaid coverage.® Given the impor- aid covers that population, more women nal and is a contributing writer for Health Business, tance of preventive and early interven- Health Progress, and JAMA. than men are likely to be protected. Reprint requests to 917 W Wolfram, Chicago, IL tion care to the health of the young, Income level is also associated with 60657 (Ms Friedman). these rates are a cause of concern. lack of coverage. The uninsured repre- JAMA, May 15, 1991 Vol 265, No. 19 The Uninsured-Friedman 2491 sented 47.5% of those with incomes be- insured or not, face difficulty in obtain- This led to freezes and reductions in low the poverty line in 1987, 45% of ing obstetric care because of the de- both eligibility and provider payments. those with incomes between poverty creasing number of obstetricians willing The result was a basically stable num- and 125% of poverty, 36.7% of those to accept new patients (American Col- ber of beneficiaries despite an increase with incomes from 125% to 200% of pov- lege of Obstetrics and Gynecology, in the poverty population. Because of erty, 17.8% of those with incomes 200% news release, May 3, 1988). 9-12 Medicaid's categorical approach to eligi- to 400% of poverty, and 8.8% of those Physician resistance to treating such bility, certain groups-most low-in- with incomes above 400% of poverty. patients has been ascribed to many come men and childless couples, for ex- The proportion of uninsured varies by causes, including low and delayed Med- ample-do not qualify. However, there state, depending on several factors, in- icaid payments, fears of malpractice liti- was little growth between 1980 and 1985 cluding the level of Medicaid coverage in gation, paperwork, cultural or language even among potentially eligible the state, the demographics of the popu- problems, noncompliance, and other populations. lation, insurance practices, overall in- factors, including racial discrimina- Medicaid's fortunes began to change come, the nature of employment, and tion. 13 Certainly, the prospect of low or in the late 1980s, as Congress mandated state health policy. The National Medi- nonexistent payment is a disincentive to Medicaid coverage of pregnant women cal Expenditure Survey found lack of most providers. (at least for pregnancy-related services) insurance highest in the South (27.4% of The total number of uninsured and and young children with incomes as high the population were uninsured at least underinsured, even if the latter group as 185% of the poverty line. These man- part of the year) and West (27.2%) and has not been sufficiently identified, dates were resisted by many states be- lowest in the Midwest (16.7%) and could easily represent one in every four cause they required substantial in- Northeast (15.7%). 1,2 The Employee Americans on any given day. creases in spending; by 1990, the Benefit Research Institute found that governors of 49 states had asked Con- lack of coverage ranged from less than EROSION OF MEDICAID gress to refrain from further man- 10% in Massachusetts, Pennsylvania, How such a large number of Ameri- dates-a request Congress did not heed Michigan, Wisconsin, and Iowa to more cans came to be at risk, through lack of as it increased child eligibility that year. than 25% in Louisiana, Texas, and New coverage or lack of access or both, is a Medicaid faces another vexing prob- Mexico.4 However, with SO much cover- challenging question. Theoretically, lem: Although families receiving Aid to age tied to employment and with states coverage of health care costs is available Dependent Children constitute be- changing Medicaid and other health pol- to virtually all Americans through one tween 70% and 75% of the Medicaid pop- icies constantly, these figures are of four routes: Medicare for the elderly ulation, three fourths of Medicaid ex- volatile. and disabled, Medicaid for low-income penses go to the costs of care for the women and children (and some men) and aged, blind, and disabled, especially pa- MANY UNDERINSURED AS WELL those with certain disabilities, employ- tients in nursing homes. Indeed, Medic- If the policy debate is to be framed er-subsidized coverage at the work- aid has, perhaps in violation of the in- accurately in terms of issues of coverage place, or self-purchased coverage for tent of Congress, become a form of long- and access, a second group, the underin- those ineligible for the previous three. term care reinsurance for the Medicare sured, must also be mentioned. This However, as many as 10 million more population. In the absence of either ma- population is more difficult to define, Americans were uninsured at least part jor growth in affordable private long- because it faces risks that are more spe- of the year in 1987 than in 1977. What term care insurance or inclusion under cific. That is, a patient's diagnosis can happened? Medicare of more extensive long-term determine whether coverage is suffi- Of the four routes to coverage, Medi- care coverage, the stress on the Medic- cient or not, and surveys of whether a care has aged best. A universal enfran- aid program is likely to continue. person has coverage at all are unlikely chisement that is neither means tested As a result of the rather tangled path to reveal such gaps in protection. Where nor related to the workplace, Medicare it has traveled, Medicaid never covered a person receives care, how long the each year covers more Americans for the entire poverty population and was person is a patient, what types of treat- most acute care. Beneficiaries' out-of- estimated to cover only 38.7% of that ment are required, and whether there is pocket costs remain high, however, and group in 1983.¹⁴ By 1989, it was esti- a dollar or time limit to coverage all coverage for long-term care remains mated that only 40% of the poverty pop- affect the sufficiency of insurance. Nev- skimpy, especially with the repeal of ulation was covered by the program.¹⁵ ertheless, a 1985 estimate, based on Medicare catastrophic care coverage. Although congressional mandates may data projected from the 1977 National Medicaid, however, has suffered a boost that figure somewhat, the major- Health Care Expenditures Study, was more equivocal fate. Although passed ity of the poor remain unprotected by that 26% of the nonelderly population, by Congress, Medicaid is a state-level the program that was designed to cover or approximately 56 million people in program, with each state defining in- them. 1984, were "inadequately protected come levels and other standards of eligi- THE WORKPLACE CONNECTION against the possibility of large medical bility and the federal government subsi- bills."8 dizing a certain portion of expenses, The third route to coverage-em- To this population, whose major depending on the state's overall wealth. ployer-subsidized insurance for work- problem is insufficient overall coverage, Thus, coverage has always varied from ers and often for dependents-has also could be added those whose insurance state to state, with Northern states and seen serious erosion in recent years. precludes coverage of a given condition some Western states offering more gen- This was the cornerstone of health in- or imposes a waiting period before such erous benefits than Southern and other surance in the past-appropriate for a coverage becomes operative (which is states. nation steeped in the Puritan work ethic often the case with pregnancy). Also In the early 1980s, both the federal and even more appropriate in an age in included are those who are covered by and state governments sought to con- which labor shortages of many types are Medicaid but lack access to physician trol or reduce Medicaid expenditures in looming. The unspoken agreement was care because of physician reluctance to the face of tax cuts, growing costs, and that, if a person was employed, he or she treat Medicaid clients and those who, reduced federal funds for the program. would receive health insurance bene- 2492 JAMA, May 15, 1991 265, No. 19 The Uninsured-Friedman fits, subsidized to some degree by the pared with larger employee groups, poor or near poor, some are middle-class employer or at least priced lower than they are subject to more exclusions, people denied coverage by virtue of individual coverage to reflect the fact medical testing of applicants, and deni- poor health status or "risky" jobs. It is a that the subscriber belonged to an em- als of coverage because of health status highly heterogeneous population, with ployee group. and are less able to absorb the signifi- multiple reasons for being at risk. Nev- However, the workplace is no longer cant increases in premium prices that ertheless, it is safe to say that the origi- a guarantor of coverage, if it ever was. have been the pattern of the past two nal notion of tying coverage to employ- The National Medical Expenditure Sur- decades.¹⁶ ment is working less well with each vey found that, in 1987, of the uninsured Indeed, a major element in the crisis passing day. In times of economic down- population, 46.4% were working adults, of the uninsured is the simple fact that turn, when higher unemployment pro- 6.8% were nonworking spouses of work- health care costs a great deal more than duces more medical indigence and lower ing adults, and 23.6% were children of it once did. The US Department of tax revenues to fund public programs working adults. 1,2 In other words, 76.8% Health and Human Services reported in such as Medicaid, the fragility of the of the uninsured either were employed 1990 that, for 1989 (the last year for entire concept of linking coverage to or were nuclear-family dependents of which final data were available), nation- employment becomes painfully clear. the employed. 1,2 The Employee Benefits al health care spending increased Research Institute found that, in 1988, 11.1%, to $604.1 billion (US Dept of WHY A CRISIS NOW? 85% of the uninsured were either work- Health and Human Services, press re- Most crises are born of a series of ers or family members of workers.⁴ lease, December 20, 1990). This meant small events that one day reach critical The employed uninsured are uneven- that US spending on health care from mass. So it has been with the uninsured. ly distributed. The National Medical 1980 through 1989 increased 128%. In- The framers of Public Law No. 89-97, Expenditure Survey found that they surance premiums reflect those costs which brought Medicare and Medicaid were more likely to work part time or to plus insurers' own expenses and mar- into being in 1965, believed that univer- be self-employed and to work in settings gins, leading to average increases in sal health insurance was just around the with fewer than 100 workers, especially premiums that reached 18% in 1989. In corner, yet it failed to materialize. 18 in settings with fewer than 25 workers. addition to increasingly selective atti- When it was reported in 1980 that 26.6 In settings with fewer than 10 employ- tudes toward risk on the part of insur- million Americans lacked coverage, a ees, 26.3% of workers were unin- ers, insurance is becoming less afford- response might have been expected but sured. 1,2 able simply because the cost of the was not forthcoming. A large number of Service industries, as opposed to services it covers is doubling every few efforts-expansion of Medicaid; cover- manufacturing industries, were more years. age of children by Blue Cross and Blue likely to employ uninsured workers, re- If small businesses face problems in Shield plans; state insurance pools for flecting both the lack of a tradition of offering and retaining coverage, the in- the "uninsurable"; and coverage experi- employment-based coverage in the ser- dividual insurance market faces col- ments funded by states, localities, and vice sector and a much lower level of lapse. This is the population that insur- private sources-have attempted to ad- unionization, which is usually associat- ers characterize as the highest risk, dress at least part of the problem, yet it ed with generous health benefits. The requiring disproportionate administra- continues unabated. Employee Benefit Research Institute, tive costs and usually proving un- Has the issue reached critical mass? If using March 1989 data from the Bureau profitable. not, it is well on the way to doing so, for of the Census, found similar patterns.⁴ Medical underwriting, experience at least five reasons. Thus, the majority of the uninsured rating, refusal to cover those deemed 1. Although coverage is not the sole are tied, directly or through family rela- "uninsurable," cancellation of policies determinant of health status, it is a key tionships, to a workplace that is no long- on short notice, and high premiums are factor in improved health, as Medicaid er an automatic source of insurance. In common if not almost universal barriers data have demonstrated. 19 Although some cases the employer does not offer for those seeking individual coverage. availability of care does not guarantee it coverage. In others the coverage is of- As a result, for an individual unable to will be used, 20,21 the uninsured have been fered but is not affordable or is not pur- qualify for group or public coverage, shown to receive less care, even if they chased by the employee. In still others obtaining affordable insurance is depen- are able to gain entry to the system. It the employee acquires coverage for dent on having a sufficiently high in- is thus not unreasonable to assume that himself or herself but not for a depen- come and very good health status. This, medical indigence is associated with dent spouse or children. All of these needless to say, eliminates many of lack of care and poorer health status. In possibilities are more likely in small those who are most likely to need cover- other words, coverage does make a business settings. age, that is, those who are poor, sick, difference. Employers are not necessarily the and/or unable to acquire workplace- 2. The health care system is suffer- villains. Insurance products for small based insurance. ing damage as a result of being asked business are both limited and expen- The working uninsured are a complex (implicitly) to provide care for the unin- sive. According to the General Account- population, and even data-based gener- sured who cannot pay. Because the un- ing Office, small businesses have little alities are dangerous. Despite the insured often do not have access to ability to spread risk over a large num- small-business focus, many of the unin- physicians in private offices, health ber of employees, which results in high- sured work for large firms, as is the case maintenance organizations, or other er premiums, should an employee incur with agricultural and seasonal workers. settings, they disproportionately seek large costs. 16 Some of the uninsured simply choose care at hospitals. As an anonymous phy- Small businesses also face a far great- not to acquire coverage, although they sician once observed, "They do not go to er likelihood of premiums being based represent a small minority of this popu- the doctor; they go to the institution." on experience rating rather than on lation. Some are eligible for either pub- Nevertheless, it was estimated in community rating. Small employee lic or private coverage but are unaware 1985 that physicians provided $9.2 bil- groups are also seen by insurers as a of this and thus have never sought it. lion in bad debt and charity care in higher risk, which means that, com- Although most of the uninsured are 1982. A 1988 survey by the American JAMA, May 15, 1991 265, No. 19 The Uninsured-Friedman 2493 Medical Association found that physi- was removed from the federal tax code try-level workers have given way to a cians reported $6.3 billion in uncollected in 1969. much leaner supply. If health insurance revenues that year (Socioeconomic Should some hospitals have case loads benefits are not offered by employers, Monitoring Service data, American that are 10% or 20% uninsured while what will lure new workers? Asking Medical Association, 1988). others have virtually no uninsured pa- women, for example, to give up Medic- According to the American Hospital tients? Should indigent care provided aid coverage to become uninsured Association, hospitals in 1989 provided by hospitals be subsidized largely by a workers seems questionable in terms of $11.1 billion in uncompensated care, an haphazard patchwork of subsidies, tax incentives. In a labor-short era, the role increase of $7.2 billion over 1980. Al- levies, adjustments in Medicare and of workplace benefits is critical. though not all of this can be attributed to Medicaid payments, and other partial 4. Another force for a solution is the care of the medically indigent, most of it measures that are neither reliable nor interrelationship of the uninsured and does represent such services. However, well organized? health care costs. On the one hand, it not all hospitals are equally affected, 3. Another factor contributing to can be argued that, if health care for the because the uninsured are not equally calls for action on the uninsured is the more than 200 million Americans who distributed. Teaching hospitals, Veter- increasingly uncomfortable situation of have at least some coverage is SO expen- ans Affairs hospitals, public hospitals, employers. The number of employers sive, we cannot afford to cover the 31 to children's hospitals, and inner-city hos- who do offer coverage is dropping 37 million who have no coverage. On the pitals are harder hit, and the load among (Business Week. November 26, other hand, it can be argued that the even these facilities is unequal. Stag- 1990:187), which is not surprising in uninsured represent significant hidden gering under the pressure of the ac- view of the increasing cost of insurance costs. After all, most of them do receive quired immunodeficiency syndrome and the voluntary nature of the care, at least when their lives are at epidemic, drug abuse, increased trau- arrangement. stake or when they are having babies. ma, problem pregnancies, and other re- The playing field is becoming more Given their compromised or nonexis- sults of social change and social neglect, unequal: Some employers offer cover- tent access to primary and preventive most municipal and some private hospi- age, some do not. Some offer a lavish care, however, their point of entry into tals are barely coping with emergency benefit package, others offer a lean one. the system is too often a hospital emer- care and are hardly able to provide time- Some are self-insured and, because of a gency department. The timing of their ly-let alone elective-services to the federal statutory prohibition, cannot be seeking care is also often a case of too uninsured. Rural hospitals face prob- required by states to offer mandated little, too late. lems of their own, because of chronic benefits; others must provide a wide As a result, conditions that could have low occupancy; one or two long stays by range of benefits that raise the cost of been prevented or treated in a cost-ef- uninsured patients can doom a facility. coverage considerably. Whether one fective manner-from measles to carci- Care is often theoretically available has coverage no longer depends on noma of the breast to diabetes-become through public or private clinics and whether one is employed but rather on emergencies, with both higher costs other settings, both funded and volun- where and by whom. and worse outcomes. This, in turn, dis- tary. However, these are often SO over- Employer discomfiture is being exac- torts staffing and practice in emergency loaded that access is illusory. In Chica- erbated by calls for mandated employer services, leading, in the words of a go, Ill, for example, as of November coverage of all workers and even of de- health policy analyst many years ago, to 1990, pregnant women had to wait 125 pendents. Only the state of Hawaii has primary care in the emergency setting, days for an appointment with a physi- succeeded in legally requiring that most equivalent to tending a rose garden with cian at a public clinic (Chicago Tribune. people working more than 19 hours per a bulldozer. It is hardly a cost-effective November 25, 1990:$4, p 1). week be covered by employer-subsi- use of health care resources. Thus, a minority of US hospitals car- dized insurance. The larger economic issue is that most ry the majority of the burden of the The state of Massachusetts has of us pay the hidden costs of medical uninsured, and that burden is growing. passed legislation requiring most em- indigence, one way or another. Every As a result, there is quarreling among ployers to provide a certain level of cov- insurance premium includes some of the hospitals, between hospitals and physi- erage to workers or else pay an assess- costs of care of the uninsured. Even self- cians, and between hospitals and gov- ment; it is scheduled to go into effect in insured employers pay part of that cost. ernments as the cost of treating the 1992. However, the law is being chal- Paying patients subsidize nonpaying uninsured increases while subsidies (es- lenged in court, and the newly elected patients. The society as a whole pays pecially philanthropy) decline. With governor of the state has proposed re- the price of prenatal care that is not emergency departments in some cities peal of the employer mandate.² Other given, immunizations that are not pro- (including New York, NY) now the states are interested in some form of vided, cancers that are not detected, most common source of inpatient admis- employer mandate, but the federal pro- diabetes that is not monitored, mental sions, and with nearly 100 hospitals clos- hibition on state regulation of self-in- illness that is not discovered. The unin- ing each year,' more and more hospitals sured employers under the Employee sured can be very expensive. are facing a horrendous choice: caring Retirement Income and Security Act 5. The last factor driving the need for for all the uninsured and failing, or turn- makes it extremely difficult to require action may appear secondary in a health ing at least some of them away and these firms to participate (Hawaii has a care economy that has become hard surviving. federal waiver). Employers, anxious edged. Nevertheless, issues of ethics As a result, serious questions are be- about being forced to subsidize expen- and equity are as important and power- ing asked about the level of charity care sive benefits but concerned about unin- ful as the economic or logistical issues. that hospitals, clinics, physicians, and sured workers and unequal benefits, Foremost among these is whether a de- other providers should be expected to are also seeking a solution. mocracy that thinks of itself as the mor- provide. Certainly, those entities hold- The uninsured have become a work- al hope of the world can justify grave ing charitable tax exemptions should be place issue in another way. The youn- inequalities in access to health care, expected to provide some indigent care, gest baby boomer is now 26 years old; which in most countries is considered an although the requirement for such care nearly 20 years of large numbers of en- essential human need. 2494 JAMA, May 15, 1991 265, No. 19 The Uninsured-Friedman It is often pointed out that, among of its own destruction. Our system has Third World. Pressure is building to developed nations, only the United been built-properly, in my opinion- give up on our current system and de- States and South Africa have not imple- on a tradition of pluralism, public guar- velop another, based on the Canadian or mented universal access to care. This is antees and private largesse, and both some other centralized model. 28,29 The overstated; there are holes in every institutionalized and voluntary giving; a moral standing of American health care safety net. However, the holes in our tradition of faith, hope, and charity. is on the line. We must produce a work- net are more numerous and yawn deep- Should the public lose faith in that able answer to the crisis of the unin- er and wider than in many less-wealthy arrangement (and in recent years we sured, or all of us-health care provid- nations. have seen evidence of such a loss of con- ers and the society alike-could suffer We claim that other nations ration fidence2829), the very basis of the health the terrible and long-term conse- care because the insured must wait care system is in jeopardy. Health care quences of inaction. sometimes; however, in our nation, the providers can hold themselves out as It is to that search for solutions that uninsured can wait forever. We claim morally superior, but if they are not this issue of THE JOURNAL has been that ours is the best health care system seen as such by the populace, volunta- dedicated. in the world; however, if tens of millions rism and autonomy can easily be re- of Americans have little or no access to placed by fiat. I acknowledge the assistance provided in the care, the claim rings hollow. Many of our health status indicators preparation and revision of this article by William H. Dendle III, MPH, Irene Fraser, PhD, and Alan In addition, a health care system that are lagging or beginning to lag behind Sager, PhD. has become too selective in terms of those in the rest of the developed whom it treats carries with it the seeds world-and, indeed, in some of the References 1. Short PF, Monheit A, Beauregard K. National 9. Friedman E. Doctors, doctors everywhere: and 18. Friedman E. The Problems and Promises of Medical Expenditure Survey: A Profile of Unin- patients who can't get care. Health Business. Janu- Medicaid. Chicago, Ill: American Hospital Associa- sured Americans: Research Findings 1. Rockville, ary 4, 1991;6:1T-2T. tion; 1977. Md: National Center for Health Services Research 10. Medicaid participation declines. SMS Rep. 19. Friedman E. Medicare and Medicaid at 25. and Health Care Technology Assessment; 1989. September 1989;3:1-3. Hospitals. August 5, 1990;64:38-54. 2. Short PF. National Medical Expenditure Sur- 11. Yudkowsky BK, Cartland JDC, Flint SS. Pedi- 20. Aday LA. Access to what? for whom? Health vey: Estimates of the Uninsured Population, Cal- atrician participation in Medicaid: 1978 to 1989. Manage Q. Fourth Quarter 1990;12:18-22. endar Year 1987: Data Summary 2. Rockville, Md: Pediatrics. 1990;85:567-577. 21. Piper JM, Ray WA, Griffin MR. Effects of National Center for Health Services Research and 12. Access to normal obstetrical care: a disturbing Medicaid eligibility expansion on prenatal care and Health Care Technology Assessment; 1990. trend. SMS Rep. January 1989;3:3. pregnancy outcome in Tennessee. JAMA. 1990; 3. Nelson C, Short K. Health Insurance Coverage, 13. Fossett JW, Perloff JD, Kletke PR, Peterson 264:2219-2223. 1986-88. Washington, DC: US Dept of the Census; JA. Medicaid patients' access to office based obste- 22. Hadley J, Steinberg EP, Feder J. Comparison 1990. Current Population Reports, Household Eco- tricians. Presented at the 118th Annual Meeting of of uninsured and privately insured hospital pa- nomic Studies, Series P-70, No. 17. the American Public Health Association; October 3, tients: condition on admission, resource use, and 4. Chollet D, Foley J, Mages C. Uninsured in the 1990; New York, NY. outcome. JAMA. 1991;265:374-379. United States: The Nonelderly Population With- 14. Gornick M, Greenberg JN, Eggers P, Dobson 23. Ohsfeldt R. Uncompensated medical services out Health Insurance, 1988. Washington, DC: Em- A. Twenty years of Medicare and Medicaid: cov- provided by physicians and hospitals. Med Care. ployee Benefit Research Institute; 1990. ered populations, use of benefits, and program ex- 1985;23:1338-1344. 5. Kasper JA, Walden DC, Wilensky GR. Who Are penditures. Health Care Financ Rev. 1985;7(annu- 24. Medicaid Underpayments and Hospital Care the Uninsured? Hyattsville, Md: National Center al suppl):13-59. for the Poor: A Fact Sheet. Chicago, Ill: American for Health Services Research; 1980. National 15. Swartz K, Lipson D. Strategies for Assisting Hospital Association; 1991. Health Care Expenditures Study, Data Preview 1. the Medically Uninsured. Washington, DC: Urban 25. Friedman E. Hospital uncompensated care: 6. Bloom B. Health Insurance and Medical Care: Institute and the Intergovernmental Health Policy crisis? JAMA. 1989;262:2975-2977. Health of Our Nation's Children, United States, Project; 1989. 26. Friedman E. Analysts differ over implications 1988. Hyattsville, Md: National Center for Health 16. Health Insurance: Availability and Adequacy of more hospital closings than openings since 1987. Statistics; 1990. Advance Data From Vital and for Small Businesses. Hearings before the Sub- JAMA. 1990;264:310-314. Health Statistics of the National Center for Health committee on Antitrust, Monopolies, and Business 27. Massachusetts health care law threatened. Statistics, No. 188. Rights of the Senate Committee on the Judiciary, Med Health. February 11, 1991;45:2. 7. Treviño FM, Moyer ME, Valdez RB, Stroup- 101st Cong, 2nd Sess (1990) (testimony of Mark V. 28. Blendon R. Three systems: a comparative sur- Benham CA. Health insurance coverage and utili- Nadel, associate director for national and public vey. Health Manage Q. 1989;11:2-10. zation of health services by Mexican Americans, health issues, Human Resources Division, General 29. Blendon R, Leitman R, Morrison I, Donelan K. mainland Puerto Ricans, and Cuban Americans. Accounting Office). Satisfaction with health systems in 10 nations. JAMA. 1991;265:233-237. 17. Cerne F. Rate decreases unlikely despite Health Aff. Summer 1990;9:185-192. 8. Farley P. Who are the underinsured? Milbank health insurers' healthy profits. Am Hosp Assoc Mem Fund Q. 1985;63:476-503. News. November 5, 1990;26:8. JAMA, May 15, 1991 265, No. 19 The Uninsured-Friedman 2495 Health Insurance Values and Implementation in the Netherlands and the Federal Republic of Germany An Alternative Path to Universal Coverage Bradford L. Kirkman-Liff, DrPH The health care systems in the Netherlands and the Federal Republic of Germa- managers (60), health policy analysts ny are based on a set of values that involve mutual obligations between private (40), patient advocates (20), and gov- parties. These obligations are realized through systems incorporating private ernmental officials (20) during 18 practice physicians, community and church- and municipality-affiliated hospi- months of residence over a 3-year peri- tals, and nonprofit and for-profit insurers. The underlying values and implemen- od (August 1987 through August 1990). Three fourths of the interviews oc- tation approaches in these systems provide an alternative to the adoption of a curred in the Netherlands, one fourth in Canadian-style health insurance system. A discussion that focuses on "obliga- Germany. The interview protocol was tions" rather than "rights" may be a more useful approach for the design of based on an extensive literature re- reforms of the American health system in the 1990s. Such a discussion would view, initially revised with the assis- focus on the mutual responsibility of all parties to create and maintain a universal tance of university faculty in the respec- private health care system. tive countries and further revised as the (JAMA. 1991;265:2496-2502) interviews progressed. Some individ- uals were interviewed as many as three THE UNITED States is again in a peri- reimbursement structures within these times. Interviewee selection occurred od of intense discussion and debate systems can provide inspiration for through three mechanisms. First, gov- about national health insurance and uni- changes in the American system, more ernment ministries arranged inter- versal coverage, with several commis- important, a review of the underlying views with representative physicians sions and nearly every health policy ad- philosophical values demonstrates some and managers. Second, university fac- vocate proposing various forms of resonances with traditional American ulty were interviewed and asked for universal coverage in the expectation health care values. Values are relevant their assistance in contacting other phy- that the United States will enact such a to a discussion of schemes for universal sicians and managers. Third, all inter- program within the next several coverage. A lack of value congruence viewees were asked for names of other years. 1-9 The motivation for much of this between a proposed approach and over- persons to be interviewed. In this man- discussion is the serious problem of lack arcing American social and cultural val- ner, a broad cross-section of partici- of access to care for the uninsured. 10-16 ues will lead to failure. Such a lack of pants was interviewed. The interviews Many observers of the American congruence was one contributor to the were part of a broader investigation into health care system have pointed to the failure of health planning, in the form of physician and hospital reimbursement, Canadian system involving universal certificate-of-need legislation and cost-control mechanisms, and policy re- fee-for-service insurance, administered health systems agencies, to obtain last- forms in the two nations, and some of by a single regional entity, as one ap- ing political support. Following the the substantive results have been re- proach to fundamental reform of the discussion of values, the structure of the ported. 33-36 An extensive variety of docu- American system. 17-22 But that is not the health care systems in the Netherlands ments were reviewed as well, but no only approach that exists. This article and Germany will be reviewed; the in- written explications of the value struc- will first examine the values underlying terested reader can consult any number tures were found in those materials. the health care structures of two Euro- of more detailed descriptions. 24-32 Last, HEALTH CARE VALUES IN pean industrialized nations: the Nether- the article will draw from the experi- THE NETHERLANDS AND THE lands and Germany. While some of the ences of the Netherlands and Germany FEDERAL REPUBLIC to develop different recommendations OF GERMANY From the School of Health Administration and Policy, for health reform in this nation. College of Business, Arizona State University, Tempe, The description of values in the Ger- From an American perspective, and Department of Health Care Policy and Manage- man and Dutch health care systems was "rights" are rarely discussed in the ment, College of Medicine, Erasmus University Rotter- elucidated from more than 200 struc- health sector in the Netherlands or Ger- dam, the Netherlands. The views expressed are the author's own and not tured interviews that used a mix of many. Rather, the discussion focuses on necessarily those of any of the sources of support. open- and closed-ended questions posed "obligations" and the ways in which par- Reprint requests to School of Health Administration and Policy, College of Business, Arizona State Universi- by the author to physicians (30), hospi- ticipants in the health sector are bound ty, Tempe, AZ 85287-4506 (Dr Kirkman-Liff). tal administrators (30), insurance fund together by these mutual, interlocking 2496 JAMA, May 15, 1991 Vol 265, No. 19 Health Insurance Values-Kirkman-Lif obligations. It can be argued that as tion of the employee's wages and bene- lowest possible fees to the medical pro- there are no rights without correspond- fits. Over the last 100 years, assistance viders and to ensure that hospital bud- ing and concomitant obligations, and in the purchase of health insurance has gets are not excessive. The fact that one vice versa, the two concepts can be used been seen as an essential component of a half of the costs is paid by the employees interchangeably. However, a discus- minimum compensation package. How- leads to equal pressure from labor sion of rights in health care will often ever, such assistance never exceeds one unions and employers for low costs. focus on how society can meet the de- half of the cost of the family premium, as These fees and budgets are established mands of individuals, while a discussion the primary obligation to pay for insur- through regional and national negotia- of obligations in health care can focus on ance is on the employee. Relative to the tions between organizations represent- the responsibilities of individuals to United States, employees in the Neth- ing the insurers and providers. The pro- their society. erlands and Germany pay a far higher viders are obligated to take part in the This system of obligations starts with proportion of the premium costs of their negotiations, as they cannot refuse to an obligation on physicians, hospitals, health insurance, although the out-of- treat the obligatorily insured popula- and other providers to provide medical- pocket costs are substantially less tion, and the insured population is obli- ly necessary care for all patients. This (equivalent to the experience of many gated to pay premiums that will in turn obligation is seen as being central to the HMO [health maintenance organiza- be paid to the providers. The outcome of concept of an ethical professional and tion] members). the negotiation process is a set of fees, institution. At the same time, it is an The obligation of employers to assist rates, and budgets for all providers. obligation that retains a role for profes- in the purchase of insurance also applies Providers are required to accept these sional determination of need, as op- to retirement funds and unemployment fees and budgets, again in the spirit of posed to unlimited patient demand. funds, and it is through this mechanism the mutual obligations. Except for This obligation immediately translates that the elderly and poor are covered by minor copayments, providers cannot into an obligation on patients: they are health insurance. This system of obli- charge patients additional amounts. obligated to pay for care that they re- gated assistance for low- and moderate- The obligation on the providers to ac- ceive. However, the fact that patients income employees, retirees, and the un- cept the negotiated rates translates into may or may not fulfill their obligation employed has led to the expectation that an additional obligation on the insurers: does not allow a provider to refuse medi- employers should assist their high-in- they must contract with all medical pro- cally necessary care: it is only by accept- come employees in the purchase of their viders. All providers must treat the pa- ing the obligation to treat the needs of health insurance, if the employee tients of the insurers, and SO the insur- all patients that the providers can im- chooses to purchase insurance. The rea- ers must pay the costs for all providers. pose on the patients the obligation to soning is that employers should treat all Insurers cannot selectively contract, pay. Again, the obligation to assist all employees relatively equally in terms of and they must pay all providers the patients without regard to financial re- nonwage benefits, and as employers are same rates. Last, the system of obliga- sources is seen as a key element to making a contribution to the health in- tions as a whole places the responsibility professionalism. surance costs for low- and moderate- for much of the regulation of the health It has been recognized in Europe income employees, they should make a insurance system on the private sector. since the early years of this century that similar contribution to the health insur- All parties involved in these obli- it is not possible for low- and moderate- ance costs incurred by their high-in- gations-physicians, hospitals, labor income patients to pay for their medical come employees. unions, employers, sickness funds-are care costs out of their own pocket, espe- These obligations on the public, their obligated to participate in self-regula- cially hospital costs. Given their obliga- employers, and other providers of funds tion of the system. tion to pay for care, low- and moderate- to purchase insurance result in obliga- Within this structure of obligations is income patients are therefore obligated tions on the insurers. As everyone is the value of solidarity. The concept of to purchase health insurance. While the obligated to purchase insurance, insur- solidarity serves as a mechanism to pro- providers benefit from the public's obli- ers are obligated to insure everyone. In mote cohesiveness within and between gation to purchase insurance, as it en- practice, the obligation to accept all the disparate groups of participants sures that the cost of care will be paid, moderate- and low-income persons within the health insurance system. Sol- the insured also benefit, because it means that medical underwriting, ex- idarity helps justify the mandatory in- strengthens the obligation on the pro- clusion of preexisting conditions, exclu- clusion of all low- and moderate-income viders to treat all patients. High-income sion of small employers, and exclusion of employees in the insurance system (al- patients are not obligated to purchase employers in certain industries are con- though the obligation to pay providers is insurance. They are expected to pur- sidered unethical and have been incor- paramount). Solidarity promotes the in- chase health insurance, but they have porated into the self-regulating struc- clusion of retirees and the unemployed the right to put themselves at financial tures that apply to the obligatory in the same funds as the currently em- risk, keeping in mind that they are still insurance scheme. The result is commu- ployed. Solidarity helps justify the vol- obligated to pay for all care that they nity rating, based on income, with the untary payment by the employer of a receive. premium shared between the employer portion of the high-income employees' It is also widely recognized that it is and employee on an equal basis. The insurance premium. Solidarity pro- not possible for low- and moderate-in- requirement that all persons must pur- motes the bargaining between provid- come patients to be able to pay for the chase insurance also results in an obliga- ers and insurers and discourages efforts costs of their health insurance out of tion that the insurers must operate at at selective contracting or boycotts. their own pocket. Their obligation to the lowest possible costs. The result is The Figure displays the relationships purchase such insurance translates into that the health insurance funds are non- among these major obligations. The ob- an obligation on employers to assist profit, private sector organizations, ligations tie all participants together in their employees in purchasing this in- regulated as a public utility. a private sector structure that ensures surance. Given that all persons must These obligations and the self-regula- that all members of the society receive purchase insurance, employers are obli- tory pressure also mean that the insur- care, all providers receive compensa- gated to consider this in the determina- ers must make every effort to pay the tion for their efforts, all people with JAMA, May 15, 1991 265, No. 19 Health Insurance Values-Kirkman-Liff 2497 limited means can afford insurance, in- surers receive adequate revenue, and Medical Care Providers Patients the administrative cost of the system is 1. Medical Care Providers 2. Patients Are Obligated kept as low as is reasonable. Are Obligated to to Pay for Care Of course, there is on-going debate on Treat All Patients the strength and implementation of this structure. Insurers, especially in the Netherlands, do question their obliga- 7. Medical Care Providers 3A. Moderate- and Low-Income Patients tion to contract with all providers. Are Obligated to Accept Fees Are Obligated to Purchase Insurance There is a strong feeling that marginally Paid by Insurers 3B. High-Income Patients competent physicians are tolerated Should Purchase Insurance within the health system: the threat of contract termination could encourage more physicians to constantly improve Insurers their clinical skills. The employer orga- Employers and Other Sources of Funds nizations express support for greater 5. Insurers Are Obligated 4A. Employers Are Obligated to Assist to Accept All Moderate- and Moderate- and Low-Income Employees to use of copayments to deter unnecessary Low-Income Persons Purchase Insurance utilization, which is opposed by unions 4B. Administrators of Retirement Funds Are and consumer groups. Obligated to Assist Retirees to Purchase An interesting aspect of this struc- Insurance 6. Insurers Are Obligated to ture of obligations is that it casts a dif- 4C. Administrators of Unemployment Funds Keep Costs as Low as Possible ferent light on the issue of the uninsured Are Obligated to Assist Unemployed to Purchase Insurance in the American system. In their view, the lack of universal insurance is unfair to medical providers and to those who 8. Insurers Are Obligated to 4D. Employers Should Assist High-Income have insurance, because it forces pro- Contract With All Employees to Purchase Insurance viders to either refuse care to the unin- Medical Care Providers sured or shift costs to those who have insurance. The first option was seen as violating the obligations of providers, while the second was seen as an unfair Regulatory Bodies burden on the patients with insurance, 9. All Parties Are Obligated to who are obligated to pay the costs. In Participate in Self-Regulation Through Private Sector Bodies their view, it is the providers and the insured who should be demanding that the uninsured be brought into the Structure of obligations in Dutch and German health care. system. through one of approximately 35 region- sickness funds for those who are cov- al funds. Individuals must join a fund ered under the obligatory scheme. REALIZATION OF that serves the community in which The remaining 38% of the population VALUES IN HEALTH they live; although many communities purchases private health insurance INSURANCE STRUCTURES are served by more than one fund, there from nonprofit and for-profit insurers. These values are put into action by are areas where only one fund operates. As this is a voluntary choice, these in- the functioning health insurance sys- The administrators of the funds are obli- surers do not operate under any social tems in the two nations. Each will be gated to accept all applicants and cannot obligations, and so the exclusion of pre- described to demonstrate how the val- exclude preexisting conditions, perform existing conditions and medical under- ues affect structure and to describe dif- medical underwriting, or deny coverage writing is not uncommon. Private insur- ferences in the application of the values. to any category of employer. ance is available with a variety of An overview of physician and hospital The sickness funds receive their reve- deductibles (some as high as $1000), co- reimbursement mechanisms will be pre- nue based on their incurred costs for payments (such as 20% of charges), and sented; more details of those aspects are medical services from a single, national premium rebates for nonuse. The pre- in the previously referenced sources. "general fund." The funds' administra- mium is based on the age and sex of each tive costs are prospectively budgeted insured individual, although there is Health Insurance in the Netherlands on a per-enrollee basis. The cost of a government-sanctioned program to The described value structure draws the general fund is paid half by em- partly cross-subsidize the costs of the a distinction between those who are ob- ployees and half by employers, retire- elderly who are privately insured by ligated to purchase insurance and those ment funds, and unemployment funds surcharges on the nonelderly who are who can choose to put themselves at risk using a nationally uniform income-ad- privately insured. Employees who pur- of medical expenses. This feature is justed premium. The structure pro- chase private health insurance receive a most prominent in the Netherlands, duces strong incentives for the adminis- contribution from their employer to- where the structure of obligations takes trators of the funds to carefully manage ward these costs that is equal to the form in three distinct components of the their internal costs, while avoiding the employer payment for the sickness fund current health financing and insurance need to directly collect premiums from members. This contribution is not oblig- system. Some 62% of the public obtains persons who frequently live in a differ- atory in a legal sense, but represents an health services through sickness funds ent region than is covered by the fund extension of the solidarity value to up- in the Netherlands. These individuals for the area in which they work. In the per-income employees. In other words, and their families fall below defined in- Netherlands the application of solidari- upper-income employees have half of come levels (approximately $30 000 ty results in a general prohibition their premium paid by their employer to in 1991) and must obtain insurance against the creation of single-employer promote solidarity between the private- 2498 JAMA, May 15, 1991 265, No. 19 Health Insurance Values-Kirkman-Lif ly insured and sickness fund insured. ers, labor unions, patient advocacy private insurance and on a capitation This solidarity-motivated tradition is SO groups, hospitals, physicians, the sick- basis for patients in the sickness funds. strong that employers perceive that ness funds themselves, and the govern- Specialists are paid on a fee-for-service they are under a social obligation as ment. The council is technically not a basis by both sickness funds and private strong as their legal obligation to pay part of government but is endowed with insurers. half of the sickness fund premiums. legal powers to monitor the funds. The Hospitals in the Netherlands are all About one third of the private insur- position of the Sickness Fund Council is nonprofit institutions. The majority are ance is purchased under collective con- a clear example of an outgrowth of the community or church affiliated; there tracts, where all of the high-income em- value that universal health care insur- are a small number of municipal hospi- ployees of one employer receive group ance is an obligation within the private tals. Compared with those in the United rates from one insurer. Insurers are sector. The regulation of the health in- States, Dutch hospitals are much larger free to refuse to write collective con- surance structure in turn becomes a re- (in terms of the average number of beds tracts for small employers or employers sponsibility for the private sector, with in each hospital) and serve larger geo- in selected industries. However, many legal authority for this self-regulation graphical areas. This is a result of more private health insurance executives ex- extended by government. The Sickness than 40 years of hospital planning, pressed a sense of solidarity with small Fund Council also oversees the opera- which has focused on developing effi- employers with high-income employ- tion of the Exceptional Medical Ex- cient regional resource allocations. All ees: they make every effort to develop penses Act. The private health insurers hospitals have large ambulatory care affordable collective contracts. Large are not regulated beyond the general clinics, as almost all specialists are hos- employers can establish private health regulations imposed on all insurers in pital based. Hospitals negotiate a global insurance companies that will cover the Netherlands, reflecting the volun- revenue budget each year with the sick- only their high-income employees, a tary nature of health insurance. ness funds and major private insurers in form of self-insurance. While there is a A key element in the structure in the their area. These budgets involve esti- legal distinction between those econom- Netherlands is the definition of medical- mates of the volume of services to be ic groups who are obligated to purchase ly necessary care. This is also defined by provided to the population (admissions, insurance (to fulfill their payment obli- the Sickness Fund Council, which de- patient-days, ambulatory surgery, spe- gation to providers) and those who can velops a broad definition of the service cialist outpatient visits, and so forth). choose to be uninsured, solidarity stim- benefits to be provided by the sickness These volumes are combined with a set ulates private mechanisms to cover the funds. Furthermore, with the advice of negotiated cost factors to generate high-income employees, while social from the Health Care Council (a body of the revenue budget. This in turn gener- mechanisms cover the rest of the popu- appointed physicians), it reviews ad- ates per-day charges paid by the insur- lation in the Netherlands. vances in medical technology and evalu- ers. If the actual revenue is less than the Separate from both the sickness ates the inclusion of experimental pro- revenue budget, due to lower than pro- funds and private insurance is the Ex- cedures in the sickness fund benefit jected utilization, the hospital receives ceptional Medical Expenses Act, which structure. the additional revenue in the next year. covers the costs of long-term care, ma- This health insurance structure inter- If the actual revenue is higher than bud- ternal and child health services, mental acts with the physicians and hospitals in get, due to higher-than-expected utili- health care, and physical and mental the Netherlands. Physicians can be di- zation, the surplus revenue must be retardation programs on a national ba- vided into two major groups: general paid back to the insurers. These com- sis. This Act was created in the 1960s practitioners and specialists. (It should parisons of actual and budgeted reve- because no member of the society-re- be noted that general practitioners in nue are independent of the costs of the gardless of wealth or income-could af- the Netherlands complete a ≥2-year hospital: the hospital is responsible for ford to be at risk for these catastrophic residency and are equivalent to family costs in excess of the actual revenues costs. These services are no longer cov- medicine practitioners in the United and can keep any surpluses if actual rev- ered by either sickness funds or private States.) The general practitioners in the enues are greater than costs. This struc- insurance since the creation of the Act. Netherlands fulfill a "gatekeeper" role: ture creates strong incentives for oper- It was also believed that removal of they control all referrals to specialists ational efficiency and for substitution of these costs from the scope of benefits of and to hospitals. Patients are free to ambulatory care (especially ambulatory the private insurance system would choose their primary care physician. surgery) for inpatient admissions. support the continued operation of the Patients-regardless of form of insur- The Dutch system is not without dual system: maintenance of a volun- have a referral from a gen- faults. The structure of obligations can tary, unregulated system for the upper- eral practitioner before consulting a be a straitjacket that prevents innova- income employees would be feasible if specialist. Almost all specialists are hos- tions and experimentation. The three the scope of benefits to be covered by pital based. Patients can choose their systems of insurance (sickness funds, that system was reduced. specialist and hospital once they have a private insurance, and the Exceptional The Exceptional Medical Expenses referral from a general practitioner, but Medical Expenses Act) create adminis- Act is financed by government con- patients usually follow recommenda- trative complexities. Coordination of tributions and mandatory income-ad- tions to see particular specialists made services is difficult for the elderly, the justed employer (for employees) and by their general practitioner. Special- chronically ill, and other groups with personal (for self-employed) contribu- ists are required to contact the general unique health problems. Community tions and is administered at the regional practitioner before referring the pa- and regional planning efforts are basis by the sickness funds. It repre- tient on to a second specialist (such as an thought to be excessively bureaucratic sents an extension of the obligation to internist referring a patient to a sur- and slow. Health care inflation in the pay providers and the obligation to pur- geon). Specialists are also expected to Netherlands (while lower than in the chase insurance for catastrophic care. send the patient back to the general United States) was higher than general The sickness funds are regulated by practitioner after the episode of illness. inflation in the early 1980s. Various the Sickness Fund Council, which con- The general practitioners are paid on a kinds of social support services used by sists of representatives from employ- fee-for-service basis for patients with the chronically ill are provided by local JAMA, May 15, 265, No. 19 Health Insurance Values-Kirkman-Lif 2499 government, out of direct tax revenue, Netherlands, to serve the general popu- cians. The ambulatory care physicians and are not included under the insur- lation. Others serve only specialized in Germany partially fulfill a "gatekeep- ance systems. groups of workers, such as those in the er" role: they control all referrals to hos- In response to these issues, a govern- craft unions, agriculture, mining, or the pitals and to the hospital-based physi- ment-appointed panel of experts put merchant marine. Large employers are cians. However, patients are free to forward in 1987 a set of proposals that allowed to establish factory sickness choose their ambulatory care physician, have been partly adopted by the gov- funds, which serve all of their employ- who can be a specialist, and they can ernment. Briefly, these proposals call ees across the entire country in one switch their ambulatory care specialist. for the integration of the three forms of fund. There are also several national Patients can choose their hospital once insurance into one system, with social substitute funds, which tend to enroll they have a referral from an ambulatory support services used by the chronically white-collar and self-employed persons care physician, but patients usually fol- ill added to the benefit. 30,37 These "care who are free to choose their fund and do low recommendations to go to a particu- insurers" will receive per capita bud- not clearly belong in another fund. lar hospital. Hospital-based specialists gets from a central fund, along with Sickness funds receive their revenue are expected to send the patient back to nominal copremiums from members. from their members. The costs of each the ambulatory care physician after the The insurers will be allowed to compete fund are covered by an income-adjusted episode of illness. The ambulatory care on the basis of the nominal copremiums. family premium. The members pay half physicians are paid on a fee-for-service The insurers will be allowed to selec- of this premium, and the rest is paid by basis. For sickness fund patients, the tively contract with providers, with se- their employer, retirement fund, or un- mechanism uses regional expenditure lection based as much on quality as on employment fund. There is substantial pools that are paid into by the insurers marginal costs. The price-setting nego- variation in the premium across funds, on a capitation basis and are managed tiations will set maximum prices, and and the potential for employers to es- by associations of sickness fund physi- discounts will be allowed. The utiliza- tablish their own provides some incen- cians. A relative value scale is used to tion review activities of the funds will be tive for efficiency on the part of fund allocate the pool on a fee-for-service ba- strengthened, and more discharge plan- managers. Some of the variation is due sis to the physicians in each region. Pri- ning and case management activities to different benefits: some funds will vate insurance patients directly pay the will be undertaken. Many of the ele- cover a yearly visit to a health spa, while physician his or her fee and send the bill ments in the proposals are based on the others will not. Much of the difference in to the insurer for restitution. Hospital- concepts of Enthoven's "Consumer premiums reflects differences in the age based physicians are paid a salary by Choice Health Plan" and on the Medi- and disability levels of the enrollees, their hospital. In general, the only hos- care Competitive Medical Plan pro- and there are some governmental subsi- pital-based physicians to see patients on gram. 28,38 However, the change in gov- dies and cross-fund transfers to reduce an outpatient basis are the clinical direc- ernment from a center-right coalition to the magnitude of premium rate varia- tors of each service. At the same time, a center-left coalition has resulted in a tion. Still, the premium costs for the there are some ambulatory care physi- slowing in the implementation of the most expensive funds are double those cians who have admitting privileges at plan. of the lowest-cost funds. This aspect of selected hospitals. the German structure could be said to The majority of hospitals in Germany Health Insurance in the Federal involve less solidarity than in the Neth- are nonprofit institutions, although Republic of Germany erlands, where specialized funds do not there are some small, physician-owned, The structure in Germany is signifi- exist and the funds are paid from a Cen- for-profit institutions. As in the Nether- cantly different from that seen in the tral Fund. While proposals have been lands, German hospitals are much larg- Netherlands. Some 92% of the public put forward for reform of this aspect of er (in terms of the average number of obtains health services through sick- the German system, such proposals beds in each hospital), and serve larger ness funds in Germany. As in the Neth- have not advanced toward legislation. geographical areas, than US hospitals. erlands, these individuals and their The remaining 8% of the popula- This is again a result of more than 40 families generally fall below defined in- tion purchases private health insur- years of hospital planning, which has come levels. However, the income level ance from nonprofit and for-profit in- focused on developing efficient regional is much higher than in the Netherlands surers. Employees who purchase pri- resource allocations. (approximately $50 000 in 1991), and so vate health insurance receive a contri- Hospitals negotiate a set of per-day a higher proportion of the population is bution from their employer toward rates each year with the sickness funds in the obligatory system. In addition, these costs that is equal to the employer in their area. These rates involve an individuals over this income level can payment for the sickness fund mem- estimate of the break-even volume for voluntarily choose to be in the sickness bers. As in the Netherlands, collective the hospital and an allocation of total funds, an option no longer available in contracts can be written. The sickness hospital costs into fixed and variable the Netherlands. In these ways the Ger- funds and private insurers participate costs. The hospital receives a per-day man system represents the same values in a variety of self-regulatory efforts, rate that includes fixed and variable as in the Netherlands, but with a differ- through regional and national councils. costs for all patients until it reaches its ent definition as to those who should be The most significant is the Concerted break-even point; after that volume is obligated to purchase insurance, based Action in Health Care, a national forum reached, it receives a per-day rate that on a different judgment about the appli- that attempts to develop macroeconom- includes only variable costs. If the total cation of solidarity. From this perspec- ic health policy and targets that are used volume of patients was less than the tive, the German system contains more to frame the negotiation between insur- break-even point, then the insurers solidarity than the Dutch system. ers and providers. The federal govern- make an adjustment to the next year's Another significant difference is the ment in Germany is also involved in rate so that the hospital receives the large number and variety of funds in these forums. total fixed costs. Germany. There are currently approxi- Physicians in Germany can be divided The German system has not been mately 1100 funds, only some of which into two major groups: ambulatory care static: small reforms of the system were are organized on a local basis, as in the physicians and hospital-based physi- implemented in 1976, 1977, 1981, 1982, 2500 JAMA, May 15, 1991 265, No. 19 Health Insurance Values-Kirkman-Liff 1983, 1984, and 1986 that involved ad- Health Care Costs in the Netherlands, Germany, and the United States* justments to the hospital and physician Indicator Netherlands Germany United States payment structures and the manpower % GNP for health care and facility planning systems. In 1988 a 1975 7.7 7.8 8.4 more extensive reform was made, 1987 8.5 8.1 11.1 which expanded copayments for phar- % Change 9.7 2.9 33.5 maceuticals, durable medical equip- Per capita health costs ment, and some dental care, in some up 1975 $428 $409 $614 to 50%. At the same time, long-term 1987 $1038 $1072 $2051 home health care was added to the bene- % Change 142 162 234 fits of the sickness funds, as were more 1987 health expenditures, % preventive services. There will be in- Inpatient care 57 39 47 creased cross-subsidization between Ambulatory care 26 29 31 Pharmaceutical funds to lower the variation in fund pre- 10 22 7 Other health costs 7 mium rates. Last, the utilization review 10 15 activities of the funds will shift from a 1987 filled inpatient care beds per 1000 population 11.8 11.0 5.3 PRO (peer review organization)-style 1987 inpatient care costs approach to one involving more physi- per occupied bed $50 500 $38 300 $182 700 cian education and counseling. Howev- 1987 practicing physicians er, no systemic reform on the scale of per 1000 population 2.4 2.8 2.3 the Dutch efforts is contemplated, and 1987 ambulatory care costs per physician $114 500 $108 900 $275 300 the reunification of Germany has shifted the attention of the medical community *Data are from reference 39. GNP indicates gross national product. to integration of providers in eastern Germany into the overall financing and health care provision structure. ture, if not closer to our traditional val- population reflect the greater use of ues. Under these two systems it is the LESSONS FOR THE hospitals for rehabilitation and long- UNITED STATES private sector, not the government, term care. that is responsible for universal insur- These two systems have four lessons There seems to be a resonance be- ance. Universal coverage is not that can guide future policy: tween the values in the health care sys- achieved through a single governmental 1. Explicit public discussion about tems of the Netherlands and Germany agency, but through a variety of non- the underlying values is essential if a and traditional American values. Most profit and for-profit insurers. The sys- consensus is to be reached on the strate- American hospital executives would tems are generally not supported by gy to achieve universal coverage and state that patients and their insurers progressive income taxes, but by in- cost containment. should be obligated to pay for the costs come-based premiums. Fees and bud- 2. Substantial visible employee con- of their treatment. Until the aggressive gets are not dictated to providers, tribution, in the form of employee re- expansion of HMOs in the 1970s, most but arrived at through negotiation be- sponsibility for 50% of an income-based physicians expected that all insurers tween private parties. Determination of premium for family coverage, is impor- would contract with all physicians and health policy is shared by the federal tant to achieve employee cost-aware- hospitals. Most of the American public government, the regional authorities, ness and a sense of shared ownership in would state that physicians and hospi- and autonomous interest group associa- the financing structure. tals are obligated to serve all people who tions. Such systems seem closer to 3. Mandated employee-employer need care. Most employers would sup- American traditions than one involving coverage and mandated insurer offering port an obligation on their employees to government-provided insurance. are both essential to achieve universal pay half of the costs of their health in- As seen in the Table,89 these two na- coverage through a private sector ap- surance premium, and most employees tions have lower costs than the United proach. No workers-be they part- would support an obligation on their em- States, in terms of both the percentage time, seasonal, or temporary-should ployers to pay at least half of the costs of of gross domestic product and per capita be excluded from insurance coverage. their health insurance premium. Most spending. They have also had lower There must be no gaps or options for large American employers and their rates of inflation. There is no one single coverage: the unemployed must be obli- employees expect that insurers will cov- factor that explains these differences, gated to continue their insurance. er all of the members of a business, though relatively the United States 4. National and regional negotiations without medical underwriting or exclu- spends far more on administration than between insurers and providers, under sions for preexisting conditions. Insur- either of these systems. Differences in government "guidelines," are essential ers expect that providers will enter into the operations of the systems are re- to develop fees and budgets that ade- good faith bargaining and negotiation flected in these statistics. For example, quately compensate all providers while over fees and charges. Overall, there the very high percentage of expendi- ensuring that costs are controlled. All- are many parallels between the values tures on pharmaceuticals in Germany is payer DRG (diagnosis related group) described in the Dutch and German sys- a consequence of government policy to reimbursement systems for hospitals tems and values currently held by the subsidize biomedical research through and all-payer expenditure targets or various parties in the American system. higher prices for pharmaceuticals, rath- caps for physicians might develop from Compared with the often-mentioned er than direct grants, as in the United such negotiations. Canadian, British, and Swedish sys- States with the National Institutes of One possible configuration for a tems, the health care systems of the Health, as well as German clinical pref- health system that would reflect values Netherlands and Germany provide erences for pharmaceutical interven- of obligation and responsibility follows: American policymakers with models tions. The low cost per occupied bed and Insurers must offer community- that are closer to our own current struc- high number of occupied beds per 1000 rated family-coverage products and JAMA, May 15, 1991 Vol 265, No. 19 Health Insurance Values-Kirkman-Lif 2501 should be prohibited from medical un- Government regulation would be poor: the fiscal impacts of Medicaid expansion. greater than at present but would shift JAMA. 1989;261:1003-1007. derwriting, exclusion of preexisting 15. Thorpe KE, Siegel JE. Covering the unin- conditions, and exclusion of employ- from a micro-level focus, as in the PRO sured. JAMA. 1989;262:2114-2118. ment categories. Insurers would be free program, to a more macro-level focus. 16. Regula R. National policy and the medically to include whatever economic incen- The regulations would ensure that uni- uninsured. Inquiry. 1987;24:48-56. tives for efficient utilization (copay- versal coverage was achieved, that fa- 17. Himmelstein DU, Woolhandler S, and the Writing Committee of the Working Group on Pro- ments and deductibles) they desired, cilities and personnel were highly uti- gram Design. A national health program for the and selective contracting with provid- lized, and that the system, while United States. N Engl J Med. 1989;320:102-108. ers would be permitted for managed privately financed and privately oper- 18. Woolhandler S, Himmelstein DU. A national care programs. ated, would not impact macro-economic health program: northern light at the end of the tunnel. JAMA. 1989;262:2136-2137. All employed persons must obtain policy. Some regulatory duties could be 19. Relman AS. Universal health insurance: its health insurance coverage for them- delegated to private bodies, represen- time has come. N Engl J Med. 1989;321:117-120. selves and their families. tative of all parties in the structure. 20. Cyphert ST, Rohrer JE. A national medical Employees and employers would The achievement of universal cover- care program: review and synthesis of past propos- als. J Public Health Policy. 1988;9:456-472. share equally in the premium costs. age in the United States can follow sev- 21. Caper P. Solving the medical care dilemma. Individuals who are in part-time, eral paths. One route would build on N Engl J Med. 1988;318:1535-1536. seasonal, or temporary work would be widely held beliefs about mutual private 22. Dickman RL, Ford AB, Liebman J, Milligan S, required to obtain and continue their obligations and would develop mecha- Schorr AL. An end to patchwork reform of health care. N Engl J Med. 1987;317:1086-1089. coverage, even when unemployed, with nisms to support the fulfillment of those 23. Kirkman-Liff BL, Lapre R, Kirkman-Liff TL. the employer share covered by unem- obligations. While many parties could The metamorphosis of health planning in the Neth- ployment programs. object to some of the obligations being erlands and the USA. Int J Health Planning Man- Self-insurance would be possible placed on them, a recognition of the reci- agement. 1988;3:89-109. 24. Eichhorn S. Health services in the Federal for large employers. Mechanisms may procity of these obligations could lead to Republic of Germany. In: Raffel MW, ed. Compar- be necessary to correct for favorable significant reform of the American ative Health Systems: Descriptive Analysis of employee age and health status effects, health system in the 1990s. Discussion Fourteen National Health Systems. University to maintain viable community rating for should focus on efforts to create and Park: Pennsylvania State University Press; 1984:286-334. non-self-insured employers. maintain a health care system with 25. Tiddens HA, Heesters J, van de Zande J. Managed care programs would be shared responsibility between the pub- Health services in the Netherlands. In: Raffel MW, allowed under such a structure. Howev- lic and private sectors. ed. Comparative Health Systems: Descriptive er, they must operate with the same Analysis of Fourteen National Health Systems. restrictions on membership: communi- My research was supported in part by a World University Park: Pennsylvania State University Health Organization Fellowship. Travel support Press; 1984:371-418. ty-rated family coverage, no medical was also received from Arizona State University, 26. Light DW, Schuller A, eds. Political Values underwriting or medical exclusions. Erasmus University Rotterdam, the University of and Health Care: The German Experience. Cam- Their premiums under this approach the Army of the Federal Republic of Germany- bridge, Mass: MIT Press; 1986. Munich, and the Robert Bosch Foundation. 27. Van de Ven WPMM. The key role of health would represent their true abilities to The interviews were conducted in four periods: insurance in a cost-effective health care system: control utilization and hence costs, not between August 1987 and July 1988, between May towards regulated competition in the Dutch medi- just superior ability at attracting good and August 1989, in October 1989, and between cal market. Health Policy. 1987;11:253-272. risks. May and August 1990. I would like to extend heart- 28. Rutten FFH. Market strategies for publicly Medicare and Medicaid would be felt thanks to my many considerate and helpful financed health care systems. Health Policy. sources during my stays in the Netherlands and the 1987;7:135-148. retained, although Medicaid enrollment Federal Republic of Germany. 29. Lapre RM. A change of direction in the Dutch would shrink, due to increased employ- health care system? Health Policy. 1988;12:21-32. er coverage. Both programs could con- References 30. Changing Health Care in the Netherlands. Rijswijk, the Netherlands: Ministry of Welfare, vert to a voucher scheme, giving recipi- 1. National Leadership Commission on Health Health, and Cultural Affairs; 1988. ents the option to choose among various Care. For the Health of a Nation. Ann Arbor, Mich: 31. Stone D. Professionalism and accountability: managed care programs. Health Administration Press; 1989. controlling health services in the United States and All-payer global revenue negotia- 2. Enthoven A, Kronick R. A consumer-choice West Germany. J Health Polit Policy Law. health plan for the 1990s. N Engl J Med. 1987;12:32-47. tions would occur between hospitals and 1989;320:29-37, 94-101. 32. Altenstetter C. An end to a consensus on health insurers. The total budgetary needs for 3. Todd JS. It is time for universal access, not care in the Federal Republic of Germany? J Health each institution would be reviewed by universal insurance. N Engl J Med. 1989;321:46-47. Polit Policy Law. 1987;12:505-536. 4. Brown ER. Principles for a national health pro- 33. Kirkman-Liff BL. Physician payment methods those payers who utilized that institu- gram: a framework for analysis and development. and cost-containment strategies in the Federal Re- tion. Payers would recognize their re- Milbank Q. 1988;66:573-617. public of Germany: a source of ideas for Medicare sponsibility to ensure the financial sol- 5. Davis K. National health insurance: a proposal. reform. J Health Polit Policy Law. 1990;15:69-99. vency of those institutions with whom Am Economic Rev. 1989;79:349-352. 34. Kirkman-Liff Physician payment methods they contract, in exchange for institu- 6. Battistella RM. National health insurance re- and cost-containment strategies in the Nether- considered: dilemmas and opportunities. Hosp lands. Inquiry. 1989;26:468-482. tional recognition of the responsibil- Health Services Administration. 1989;34:139-156. 35. Kirkman-Liff BL, Lapre R, Kirkman-Liff ity for efficient and effective opera- 7. Kinzer DM. Universal entitlement to health The metamorphosis of health planning in the Neth- tions. Prospectively determined reve- care. N Engl J Med. 1990;322:467-470. erlands and the USA. Int J Health Planning Man- nues budgets would retain an incentive 8. Tupper CJ. Dreams, dollars, and deeds. JAMA. agement. 1988;3:89-109. 1990;264:1150-1152. 36. Kirkman-Liff BL, van de Ven WPMM. Im- for managers to manage their costs. 9. Shortell SM, McNerney WJ. Criteria and guide- proving efficiency in the Dutch health care system: In a similar manner, all-payer glob- lines for reforming the U.S. health care system. current innovations and future options. Health Pol- al revenue negotiations could occur be- N Engl J Med. 1990;322:463-467. icy. 1989;13:35-53. tween the medical community and in- 10. McCarthy CM. Financing indigent care: short- 37. Lapre RM. A change of direction in the Dutch and long-term strategies. JAMA. 1988;259:75. health care system? Health Policy. 1988;10:21-32. surers for care provided outside of 11. Ginzberg E. Medical care for the poor. JAMA. 38. Van de Ven WPMM. The key role of health managed care relationships. This could 1988;259:3309-3311. insurance in a cost-effective health care system: involve the operation of state volume- 12. Davis JE. National initiatives for care of the towards regulated competition in the Dutch medi- performance systems, using a relative medically needy. JAMA. 1988;259:3171-3173. cal market. Health Policy. 1987;7:253-272. 13. Tallon JR Jr. A health policy agenda proposal 39. Health care expenditure and other data. value scale and either a prospective or for including the poor. JAMA. 1989;261:1044. Health Care Financing Rev. 1989 Annual Supple- retrospective conversion factor. 14. Thorpe KE, Siegel JE, Dailey T. Including the ment:111-194. 2502 JAMA, May 15, 1991 265, No. 19 Health Insurance Values-Kirkman-Lif Health Access America-Strengthening the US Health Care System James S. Todd, MD; Steven V. Seekins, MPA; John A. Krichbaum, JD; Lynn K. Harvey, PhD Although Americans remain generally satisfied with the health care provided to ploys 7.7 million workers, 6.8 million of them, sufficient access to high-quality, affordable health care for citizens without whom are nonsupervisory personnel.8 health care insurance has become an increasing problem in the last decade. The health care industry employs 8.1% Using the policy development process of the American Medical Association, of the private labor force in the United Health Access America was conceived by the Association to improve access to States. The economic impact of the pro- affordable, high-quality health care. The proposal consists of six fundamental vision of health care has added to the principles and 16 key points. This article specifically focuses on the five points overall growth of the economy. The American Medical Association that, if enacted into law, would improve access to health care for Americans who (AMA) has a long history of concern and are, for various reasons, without health insurance. action directed toward solving prob- (JAMA. 1991;265:2503-2506) lems of the health care sector. Costs, access to health care, and quality of care have been recurring subjects of health FOR SEVERAL decades, American tented with this inequity despite the policy for a long time. In responding to medicine has led the world in scientific very high level of satisfaction with the these concerns, the AMA has often as- and technological advance. We have be- quality of medical care practiced in the sumed a leadership role, offering its come the premier nation in providing United States. 1,3 own approaches as well as working with high-quality, comprehensive medical Even with these and other problems other organizations to build a consensus care and education. The vast majority of with our health care system, approxi- on appropriate solutions. Americans are satisfied with their phy- mately 87% of Americans have private In 1964 and again in 1977, indepen- sicians and the health care services they or public medical insurance.⁴ Of the ap- dent Commissions on the Cost of Medi- receive. 1,2 Most patients have the ability proximately 33 million uninsured in this cal Care were established by the AMA to freely choose their physician, hospi- country, roughly 26 million are working to study the causes of rising health care tal, and system of care. Medical profes- Americans and their families (not in- costs. The commission reports resulted sionals remain free to act as patient ad- cluding part-time workers).5 Approxi- in a range of recommendations from vocates rather than agents of the mately 3 million persons, some of whom which AMA policy concerning health government or other interests. are employed, are considered "medical- cost problems in the 1960s and 1970s However, these many pluses have ly uninsurable" by private insurance was developed. not provided answers to serious ques- companies due to preexisting health In 1982, the AMA and 172 other orga- tions that leave millions of Americans conditions.⁶ nizations initiated the Health Policy without health insurance coverage. De- Originally designed to serve citizens Agenda (HPA) for the American People spite most recent annual national who fell below the federal poverty level, in response to recognition of the grow- spending of over $600 billion and 11% of the Medicaid program is severely un- ing complexity of problems confronting the gross national product on health derfunded and has categorical eligibility the health care system. Four hundred care, more than 30 million Americans do requirements that are too strict. The twenty-five representatives of these not have affordable medical insurance program covered only about 13.2 million different health, health-related, busi- for themselves and their families, which of the 32.5 million Americans living in ness, labor, government, and consumer reduces their access to care. Many pub- poverty in 1987.⁷ Some of these individ- groups met over 5 years to develop the lic opinion polls find citizens discon- uals also were employed. Agenda. Over 150 principles were de- Although there is the need for reform veloped, on which more specific HPA From the American Medical Association, Chicago, III. of the US health care system, reform policy proposals were based.¹⁰ Reprint requests to American Medical Association, must be managed carefully. The private Many other AMA initiatives in the 515 N State St, Chicago, IL 60610 (Dr Todd). health care industry in this country em- development of practice parameters, JAMA, May 15, 1991 265, No. 19 Health Access America-Todd et al 2503 professional liability reform, and Medic- ty income levels would be eligible for ilies, with tax help to employers. About aid and Medicare reform led to the deci- and receive a uniform set of adequate 26 million of the approximately 33 mil- sion to develop a proposal for compre- benefits. The AMA believes strongly lion uninsured are employed individuals hensive reform of the health care that federal and state governments and their families (not including part- system. must ensure access to and funding for time workers).⁶ Tax incentives must be medical care for all persons with in- provided and risk pools created SO that HEALTH ACCESS AMERICA comes below the poverty level. new and small businesses can afford the The federal poverty level should be cost of such coverage. Initially, only The AMA's member physicians be- adjusted by a state cost-of-living modifi- larger businesses should be subject to lieve significant improvements in our er to ensure that Medicaid eligibility this requirement. system need to be made to improve ac- truly reflects the economic realities in To make the transition manageable cess, to ensure continued high quality, the various states. Income status for all businesses, the program should and to moderate cost increases. To ac- should be the only eligibility criterion; be phased in over several years. Addi- complish these system improvements, other existing categorical requirements tional elements in a legislative program the Association has developed and an- should be repealed. At the same time, to bring about required employer cover- nounced publicly a proposal called Health Access America." In developing using one national formula by which eli- age include: gibility will be determined in the vari- Preempt state-mandated benefit the specific provisions of this proposal, ous states will eliminate state discretion laws for employer health benefit plans the Association took into consideration what it believes are a number of funda- in setting the economic level of eligibil- to help small businesses afford a basic ity. This will avoid perpetuating the program. Such plans would be required mental principles that should under- widespread inequities existing across to meet minimum standards of cover- score the national discussion on improv- state boundaries in the Medicaid pro- age, including basic hospital, physician, ing the health care system in this country. These fundamental principles gram today. diagnostic, prenatal, and well-baby Medicaid benefits need to ensure pro- care, with reasonable annual limits on are as follows: vision of all medically necessary physi- employees' incurred expenses for pre- Improvements to the American cian and hospital services-and should miums, coinsurance, and deductibles. health care system should preserve the not differ across state lines. Because of The AMA has recently put forth such a strengths of our current system. the impoverished status of Medicaid minimum benefits proposal for the re- Affordable coverage for appropri- beneficiaries, added coverage for pre- quired employer insurance." ate health care should be available to all scription drugs, rehabilitative services, Amend the Internal Revenue Code Americans, regardless of income. Particular efforts are needed to as- and emergency services must be pro- or Employee Retirement Income Secu- vided. Because unrealistically low pro- rity Act (ERISA) to allow states to re- sure continued access by the elderly to vider reimbursement levels reduce ac- quire self-insured employers to partici- affordable health care services. cess, Medicaid reimbursement levels pate in private, not-for-profit uninsured Health care services should be de- should be increased to the Medicare and uninsurable risk pools established livered with high quality at appropriate level. pursuant to state law. costs. Because of the substantial costs of Establish a federal incentive pro- Patients should be free to deter- Medicaid expansion, some phased-in ap- gram for states to enact legislation to mine from whom and the manner in proach probably will be necessary. One set up private, not-for-profit health which health care benefits are possible approach outlined in the Health benefit pools (including the uninsur- delivered. Access America proposal would begin able, the uninsured, and small busi- All physicians should be committed expanding Medicaid by requiring a nesses). to the highest ethical standards in the phased-in coverage for pregnant wom- Require such pools to offer to small delivery of care to patients. en and children. The AMA's initiative businesses (<25 employees) access to a With these fundamental principles in was instrumental in accomplishing this basic benefits policy at group rates. mind, the Association developed 16 spe- initial expansion through the Omnibus Make permanent the temporary cific points that are designed to accom- Budget Reconciliation Act of 1990. Ad- 25% income-tax deduction for premi- plish the specific goal of expanding ac- ditional steps in the Medicaid expansion ums for health benefits plans for the cess to affordable, quality health care to all Americans. Although all of the 16 might include phasing in a requirement self-employed. Expand the deduction to that Medicaid eligibility shall equal 100% of the premium payment for the points in Health Access America have 100% of the poverty level (state ad- self-employed and others who must pay significance in the reform of the system, justed) and creating a basic national lev- 100% of a health benefit premium. we will explore specifically the five ma- el of Medicaid benefits that must be cov- Expand continuation coverage es- jor points relevant to encouraging ac- ered. The basic benefits should include tablished in the Consolidated Omnibus cess to health care insurance for those necessary inpatient and outpatient hos- Budget Reconciliation Act, 1985 who do not currently have it. These in- pital and emergency services; rural (COBRA), to require employers to pay clude enacting major Medicaid reform, health clinic and other laboratory and the same share of an employee health requiring employer provision of health x-ray services; home health services; benefit premium that was paid by the insurance, creating state-level risk pools, enacting Medicare reform, and early and periodic screening, diagnosis, employer, prior to termination, for up to and treatment for individuals under 21 4 months after the qualifying event. expanding coverage for long-term care. years of age; family planning; physician Require employers to offer an en- MEDICAID REFORM services; prescription drugs; and reha- rollment period for employees who lose bilitative services. coverage because a spouse or other fam- The AMA proposal for Medicaid re- ily member lost coverage due to change REQUIRED EMPLOYER INSURANCE form would set new national require- of employment. ments to ensure that no poor person is Health Access America requires em- Eliminate provisions that exclude left without access to needed health ployer provision of health insurance for preexisting conditions from employer care. In all states, persons below pover- all full-time employees and their fam- health benefit plans. 2504 JAMA, May 15, 1991 265, No. 19 Health Access America-Todd et al STATE-LEVEL RISK POOLS nior citizens continued access to quality Amending the Internal Revenue health care. Today, four workers' tax Code to allow businesses and individ- Health Access America will create contributions support a single Medicare uals to treat payment for long-term- state-level risk pools in all states. Risk beneficiary. As our population contin- care insurance in the same manner as pools would extend coverage to two ues to age, there will be only two work- health benefit plans are now treated. groups: (1) the medically uninsurable, ers paying taxes to support each benefi- Allowing individuals to deduct for for whom access to coverage is not avail- ciary by the middle of the next century. income tax purposes 100% of the cost of able, and (2) others for whom individual A shrinking worker base means sub- long-term-care insurance premiums health insurance policies are too expen- stantially higher premiums in the years without meeting the 7% floor for health sive and group coverage is not available. to come. Without further support, the costs or the 2% floor for miscellaneous A state risk pool is a legislatively cre- system will collapse. deductions. ated insurance program. Since premi- This reform would include a new ap- Amending the tax code to allow for ums generally do not cover all the costs proach to catastrophic benefits. The penalty-free and tax-free withdrawals of operating such a pool, states that cur- program would be funded through indi- from individual retirement accounts for rently have risk pools fund them vidual and employer tax contributions the purchase of long-term-care insur- through a variety of mechanisms. One during working years. There would be ance policies. common approach is to assess insurance no program tax on senior citizens, and Amending Medicaid to allow for an carriers in the state, sometimes subsi- all persons reaching the age of eligibility asset protection program so that re- dizing the assessment through some would be entitled to a voucher for pur- source eligibility requirements are ad- sort of tax credit. At least one state pays chase in the private sector of a compre- justed to allow an individual to retain for risk pool losses out of general tax hensive health insurance policy meeting assets up to the amount that private revenues, while another has placed a federal standards. Senior citizens would sector insurance pays on his or her be- tax on hospital patient revenues. retain freedom to choose their system of half for long-term care. As part of the Health Access America provision of care (eg, fee-for-service, proposal, risk pools help ensure that no health maintenance organization, pre- CONCLUSIONS American would be unable to obtain af- ferred provider organization). The cre- Many individuals and organizations fordable health insurance because of ation of an enhanced Medicare trust are suggesting differing reforms for a health condition. Small employers fund beyond immediate payout needs the US health care system, and some should have access to such risk pools so (prefunding) would create investment of the proposals advocate radical that they could acquire coverage for income and thus end up costing taxpay- change. America's physicians, repre- their employees at affordable rates if it ers much less than continuation of the sented through the AMA, believe it is was unavailable for a better price in the current system. better to build on a system that is cur- private market. Rates should be set at The reform elements noted above rently serving effectively the vast ma- standard group rates. Premium assis- were introduced in the last Congress as jority of the nation's population, 87% of tance from the state would be provided HR 2600 by Rep Charles Rose (D, NC). whom are insured. for those persons who are not covered through employment and who are be- EXPANSION OF LONG-TERM In a time when budget deficits are tween 100% and 150% of the poverty CARE FOR SENIOR CITIZENS running at record highs, when economic recession threatens our economic well- level. Health Access America proposes being, and when nearly every other Elements of a phased-in legislative to expand long-term care financing democratic nation is having health care approach that can accomplish extension through increasing private sector cov- system problems, it would seem pru- to the medically uninsurable and for erage, encouraged by tax incentives dent to approach reform in a carefully those otherwise unable to obtain cover- and an asset protection program, and to managed, incremental manner. This age include: provide Medicaid coverage for those be- proposal has been developed based on Requiring, as a condition of federal low the federal poverty level. The "as- the policy of the AMA. It is comprehen- tax deduction, that all payers for em- set protection" approach, in essence, sive and has been undertaken over a ployee health benefits (payment of pre- means that individuals who purchase long period of time with careful atten- mium, or direct payment for services by long-term-care insurance would be able tion to detail. The AMA will be develop- a self-insured plan) must participate in a to protect designated assets up to the ing refinements and modifications as private not-for-profit risk pool estab- dollar value of the insurance benefits lished pursuant to state law. The pool needed. We welcome input and sug- from being included in any eligibility gestions. would provide subsidized coverage for determination for Medicaid coverage The AMA has had preliminary actu- those who have been denied coverage or for long-term care. have lost coverage because of a medical arial studies performed, which do not This kind of program was introduced condition and underwriting rules. take into account potential offset sav- in the last Congress by Rep Barbara ings from various elements of the pro- Allowing a 100% tax deduction of Kennelly (D, Conn). Sliding scale subsi- posal. These studies indicate that, after premium payment for individuals who dies should be provided for the purchase purchase insurance coverage through full implementation, the proposal would of long-term-care insurance for individ- cost the federal government about $21 the pool. uals with incomes between 100% and billion per year in 1990 dollars (a figure MEDICARE REFORM 200% of the poverty level. Em- close to the new federal health care ployer-provided long-term-care insur- spending of $24 billion projected under To ensure continued access by senior ance should be treated in the same tax the Pepper Commission proposal). citizens to affordable health care ser- fashion as health insurance coverage. A Estimates of the aggregate net new vices, two major actions are needed. tax deduction or credit should be cre- costs to state governments, employers, First, we must enact Medicare re- ated to encourage family care giving. and individuals are much more difficult form to avoid financial bankruptcy of A phased-in legislative approach to to project because of the offsets in- the program by creating an actuarially accomplish the above elements would volved. Costs would not necessarily be sound, prefunded program to ensure se- call for the following: higher for all of these sectors. For ex- JAMA, May 15, 1991 265, No. 19 Health Access America-Todd et al 2505 ample, there would be a reduction of to be borne by a combination of govern- Satisfaction with health systems in ten nations. cost-shifting expenses for employers ment, business, and individuals and can Health Aff. 1990;9:185-192. 4. Nelson C, Short K. Health Insurance Coverage who now provide insurance. States come from taxes, reductions in lower- 1986-88: Survey of Income and Program Participa- would pay more for Medicaid, but a sig- priority spending, or discontinuance of tion. Washington, DC: US Dept of Commerce, Bu- nificant portion of such costs would be certain programs. We have no doubt reau of the Census; 1990. Current Population Re- offset by savings in their current expen- that what is required is a national "will" ports: Household Economic Studies, series P-70, No. 17. ditures for the uninsured. Many individ- rather than a national "won't." 5. Employee Benefit Research Institute Issue uals and families would obtain insurance Perhaps the most important chal- Brief 104. Washington, DC: Employee Benefit Re- coverage for expenses that are now paid lenge facing us as a nation is to place search Institute; July 1990. Utilizes data from the out of pocket. Others would pay premi- reform of the health care system on the March 1989 Current Population Survey conducted by the Bureau of the Census. ums they do not now pay. Employers national agenda. It is not there now. 6. American Medical Association staff estimate, who do not now provide coverage would America's physicians are committed to utilizing most recent HIV/AIDS estimates and in- have additional costs, but with a per- providing high-quality, affordable care formation from Health Insurance: Risk Pools for centage of payroll cap on such costs and and want to work with government and the Medically Uninsurable. Washington, DC: US with tax assistance from the federal other decision makers toward positive General Accounting Office; April 1988:5. 7. Bureau of the Census. Statistical Abstract of the government. Until policymakers decide solutions that ensure adequate health United States. 110th ed. Washington, DC: US Dept on the precise nature of the reforms insurance coverage for all Americans. of Commerce; 1990. they are willing to make and the phasing We invite all interested parties to bring 8. Donham CS, Maple BT, Singer N. Health care indicators. Health Care Financ Rev. 1990;11: in they want to undertake, exact esti- their proposals to the table and to join in 169-196. mates, particularly of the net costs of moving an action agenda forward. The 9. Report of the National Commission on the Cost the proposal, are not feasible. time for reform is now! of Medical Care. Chicago, Ill: American Medical It should come as no surprise that Association; June 1978. AMA Board of Trustees providing insurance coverage to over 30 References report A (Annual Meeting, 1978). 10. The Health Policy Agenda for the American million additional people will be costly. People. Chicago, Ill: American Medical Associa- We suggest that we all accept this idea 1. Taylor H. What Americans (and other coun- tion; 1987. tries) think of their health care system. Presented and get on with the discussion on the 11. Health Access America: The AMA Proposal to before the Pharmaceutical Manufacturers Associa- Improve Access to Affordable, Quality Health type of reform that would best meet the tion Public Affairs Meeting; October 30, 1989; Na- Care. Chicago, Ill: American Medical Association; nation's needs. Once the precise nature ples, Fla. Based on data collected by Louis Harris & 1990. of the reform is decided, these costs can Associates. 12. A Minimum Benefits Package. Chicago, Ill: 2. Health Care in the United States. Los Angeles be accurately estimated and sources of American Medical Association; 1990. (Calif) Times poll; March 20, 1990. funding committed. The costs will need 3. Blendon RJ, Leitman R, Morrison I, Donelan K. 2506 JAMA, May 15, 1991 - Vol 265, No. 19 Health Access America-Todd et al A Call for Action The Pepper Commission's Blueprint for Health Care Reform Sen John D. Rockefeller IV After a year of deliberation and investigation, the Pepper Commission recom- care costs. In 1987, employers' health mended action to ensure that all Americans would have health insurance protec- care spending was equivalent to 94% of tion in an efficient, effective health care system. Because it believes that action is after-tax profits, up from about 14% in urgent, the commission would build universal coverage by securing, improving, 1965 and 74% in 1984. Faced with these and extending the combination of job-based and public coverage we now have. cost pressures, employers have, not Reform would entail the following elements: a combination of incentives and surprisingly, tried to reduce the bene- fits they provide. Organized labor has requirements that would guarantee all workers (with their nonworking depen- resisted such reductions, as evidenced dents) insurance coverage through their jobs; replacement of Medicaid with a by the dominance of health care as an new federal program that would cover all those not covered through the work- issue in many recent strikes. In many place and workers whose employers find public coverage more affordable; cases, coverage has been preserved. guaranteed affordable coverage for employers-through reform of private insur- However, declines in coverage for ance, tax credits for small employers, and the opportunity to purchase public workers' dependents in recent years re- coverage; a minimum benefit standard for private and public plans that would flect, in part, the increased contribu- cover preventive and primary services as well as catastrophic care and would tions to premiums employers have re- include cost sharing, subject to ability to pay; and a combination of public and quired from their employees.² private sector initiatives to promote quality and contain costs. Finally, for small and large busi- nesses alike along with individuals and (JAMA. 1991;265:2507-2510) all levels of government, ever-increas- ing health care costs have raised ques- tions about value for the dollar in health THE 1990s is not the first time Ameri- threat to coverage comes from what can care spending. It has become almost cans have questioned the adequacy of legitimately be described as the disinte- commonplace to observe that the Unit- their medical care system. Millions of gration of the small group insurance ed States far exceeds other nations in Americans have long lacked the basic market. As employers faced with high per capita health care spending, while it insurance protection needed to assure costs shop for low premiums, insurers lags behind even many relatively poor access to care, and health care costs increasingly compete to insure the countries in its mortality statistics, es- have risen rapidly and almost inexora- young and healthy and avoid workers pecially for infants. High health care bly for more than two decades. Today, who have experienced illness or who, costs in the United States may reflect however, the call for health care reform for a variety of reasons, are seen as superior quality of treatment that is not seems to have reached new heights.¹ especially likely to use medical care. captured in gross mortality statistics, This new urgency may reflect the fact Whole groups may be denied coverage, and these statistics reflect many factors that not only are a large and growing have coverage terminated, or have other than medical care. Nevertheless, minority of Americans-well over 30 rates substantially increased, based as US health care expenditures contin- million people-without health insur- on the perceived risk their members ue to rise, Americans increasingly ask ance protection, but the majority now pose. Alternatively, individuals within whether we are using our money also see the system they count on in groups may be excluded from the wisely.2 jeopardy. group's policy, in total or for pre-exist- In September 1990, the US Biparti- Most Americans get insurance pro- ing conditions. These practices mean san Commission on Comprehensive tection through the workplace. Howev- that competition among insurers in the Health Care-the Pepper Commis- er, job-based coverage has become inse- small group market now focuses on sion-issued a call for action to address cure, even for those who are currently ways to avoid risks rather than on ways this growing crisis: to implement sys- well insured. 2,3 The reasons for insecuri- to share them. As a result, workers who tem wide health care reform that would ty differ for workers in small and large were once well insured face the possibil- guarantee all Americans health care businesses. In small businesses, the ity that coverage will become unavail- coverage in an efficient, effective health able when they need it the most. care system. This bipartisan commis- Senator Rockefeller (D, WVa) is the Chairman of the In large businesses, the threat to cov- sion, created by (and not repealed with) Pepper Commission. Reprint requests to 109 Hart, Senate Office Building, erage comes not from insurance prac- the Medicare Catastrophic Coverage US Senate, Washington, DC 20510 (Sen Rockefeller). tices but from ever-increasing health Act of 1988, included 12 members of JAMA, May 15, 1991 265, No. 19 A Call for Action-Rockefeller 2507 Congress (six from the House and six 4. Expanding access and controlling benefits) to all small businesses and from the Senate) and three presidential costs must proceed hand in hand. To their employees-without the discrimi- appointees. Its charge was not simply to pursue one goal without the other is to nation they now face based on insurers' study the problems facing the health further undermine a system already un- perceptions of industry "risk" or work- care system but also, and most impor- der serious stress. ers' pre-existing conditions. To ease the tant, to develop recommendations for In essence, the commission concluded burden of health insurance costs, the workable and enactable legislation that that, to achieve universal health care commission also recommends two kinds could resolve these problems. To fulfill coverage in the immediate future-as it of tax credits for small employers: (1) this charge, the commission heard testi- believed essential-we can neither allowing unincorporated businesses and mony from numerous witnesses in pub- patch nor replace current coverage. the self-employed, like incorporated lic hearings in the nation's capital and Rather, we must secure and extend the businesses, to deduct from taxable in- around the country, received a series of combination of job-based and public come the entire cost of their health in- expert briefings, and engaged in inten- coverage we now have into a system surance premiums and, (2) for a 5-year sive deliberations to consider all points that truly guarantees adequate cover- period, providing a 40% subsidy against of view, clarify objectives, and develop age for all Americans and that ensures premium costs for employers with few- recommendations to achieve them. effective and efficient operation in pri- er than 25 workers and an average pay- Agreement on those recommenda- vate and public coverage alike. roll of less than $18 000 per worker. tions required commission members to The following summarizes the com- The combination of insurance reform make hard choices and to compromise mission recommendations that lay out and subsidies should provide small em- strongly held positions. Members who the specific elements needed to build ployers with the opportunity many now believed action was critical refused to this job-based/public system of univer- lack to purchase insurance for their allow their personal vision of the best to sal coverage. workers. However, if after 4 to 5 years become the enemy of the good. small businesses have not availed them- In this article I will summarize the Ensuring Job-Based Coverage selves of that opportunity (that is, if commission majority's conception of To make job-based coverage univer- they have not covered at least 80% of that "good"-a blueprint for universal sal, all workers must be entitled to workers and dependents who now lack coverage that we believe is enactable health care coverage in their jobs, just coverage from their employers), the and that, in our continuing roles as as they are entitled to a decent mini- commission recommends that small members of Congress, we are commit- mum wage or participation in social se- businesses, like larger ones, be re- ted to enact. (The commission's recom- curity. Three fourths of American quired to purchase coverage. mendations for reform, in long-term workers now obtain coverage for them- care as well as health care, are fully selves and their families through the Providing Affordable Coverage developed in its final report to the Con- workplace. Three fourths of the unin- Just as it is businesses' job to provide gress. They have also been summarized sured are workers or are in workers' coverage, the commission believes it is and discussed in the New England families. If all employers covered their government's job to guarantee that af- Journal of Medicine.3) workers, as the majority do now, sub- fordable coverage is available. Rather stantial gains in coverage would result. than simply requiring businesses to buy BLUEPRINT FOR REFORM Because of the different circum- private coverage, whatever it costs, the The commission's blueprint for re- stances facing small and large business- commission would therefore give em- form rests on four fundamental conclu- es, achieving job-based coverage for all ployers a choice: purchase private cov- sions from its year-long investigations workers and their families requires that erage or purchase coverage from a new- and deliberations. they be treated differently. Almost all ly established federal program. That 1. Health insurance coverage must businesses with more than 100 employ- program could be administered in con- be universal. Only if everyone is ade- ees now provide adequate coverage for junction with or as part of the Medicare quately covered can we assure all Amer- most of their employees. Consequently, program. Like Medicare, it could be ad- icans access to care when they need it with a brief period for adjustment, the ministered through private insurers or and bring an end to "cost shifting" and commission would require all such busi- by states, subject to federal rules. The underservice to the uninsured. nesses to provide coverage to all their "price" for public coverage would be set 2. Simply patching the current sys- workers and nonworking dependents. as a specified percentage of the payroll, tem-for example, with Medicaid ex- In contrast, small businesses current- putting a cap on employers' obligations pansions-cannot achieve universal ly face significant barriers to purchas- and avoiding excessive costs for cover- coverage. Even if government were to ing insurance coverage. Although the ing part-time workers. The percentage cover all the poor (rather than the cur- majority of even the smallest business- would be set to encourage employers rent 40%) and subsidize private cover- es provide coverage, employers with who now purchase private insurance to age for the near-poor, insurance cover- fewer than 25 workers employ about retain that coverage and to establish a age would remain too expensive for half the working uninsured; employers fair balance of additional coverage re- about half the currently uninsured. In with fewer than 100 workers employ sponsibilities between private insurers addition, such an approach would have about two thirds. Rather than require and the public program. taxpayers bear the costs of low-income such employers to cover their workers, workers whom their employers (unlike the commission recommends special Establishing Federal Coverage most employers) fail to protect. measures to alleviate the barriers to Even if job-based coverage reaches 3. Replacing the current system with voluntary purchase of insurance that all workers, it cannot achieve universal government-run national health insur- these employers now face. coverage by itself. The commission ance is simply not practical. Shifting SO Specifically, the commission recom- would therefore require that govern- many people and SO many dollars from mends reforms in the private insurance ment do its share by assuring coverage the private sector to the public sector is market that would guarantee the avail- for those not covered through employ- too disruptive to be politically feasible in ability of a specified minimum benefit ment in a program that pays appropri- the near future. package (overriding state-mandated ately for services and guarantees access 2508 JAMA, May 15, 1991 265, No. 19 A Call for Action-Rockefeller to care. Medicaid-with its current eli- by averting the costs of expensive On the public side, increasingly so- gibility, payment, and benefit limita- treatment. phisticated Medicare rules for paying tions-falls far short of this objective. To promote sensitivity to costs, indi- physicians and hospitals would be ex- To guarantee coverage to all, the viduals would contribute to the costs of tended to the new federal program. commission therefore recommends re- coverage, subject to limits on out-of- These mechanisms-prospective pay- placing Medicaid with a new federal pro- pocket spending and ability to pay. Spe- ment for hospitals and the resource- gram for nonworkers and the self-em- cifically, individuals covered through based relative value scale for physi- ployed-the same federal program to be employment would pay a maximum of cians-aim to ensure efficiency and cost available for workers whose employers 20% of premium costs for private cover- control in the public program and would find it more affordable. (Because Medic- age or a contribution to the public plan serve as a model for payment in the aid now covers services not included in equivalent to 20% of the combined em- private sector. the minimum benefits described below, ployer-employee contribution, paid as a Other commission recommendations that program would not be completely percentage of wages. Individuals not would assure value for the dollar in the eliminated. It would continue in its cur- covered through employment would use of medical services in both the pri- rent form for benefits not included in the pay the full cost of public coverage, sub- vate and public sectors. The minimum new federal program.) The federal pro- ject to ability to pay. benefit standard establishes cost-shar- gram would pay providers rates deter- For all except preventive services, ing requirements SO that individuals mined according to Medicare rules, deductibles ($250 per individual and (subject to ability to pay) would take replacing the sometimes arbitrary Med- $500 per family) and coinsurance (20% costs as well as benefits into account as icaid payment limitations with rates for basic services and 50% for outpatient they use medical care. Equally impor- more likely to ensure access to care. mental health services) would apply. No tant, the commission recommends fed- Furthermore, the federal program individual or family, however, would eral action to help consumers and insur- would provide the same minimum bene- pay more than $3000 in cost sharing for ers become prudent purchasers of fits that employers must provide. The covered services. medical care. The commission would requirements would ensure national So that cost sharing does not become have the federal government undertake standards for eligibility, benefits, and a barrier to insurance coverage or ser- the data collection, outcomes research, payment that, in contrast to Medicaid, vice use, premiums and cost sharing and development of practice guidelines would guarantee all Americans, no mat- would be subsidized for low-income peo- and quality assurance mechanisms that ter what their income, employment sta- ple. People with incomes below 100% of are critical to helping public and private tus, or place of residence, access to af- the federal poverty standard would pay purchasers use their money wisely. Ini- fordable insurance protection. no premiums or coinsurance, and subsi- tiatives already under way in the re- dies would be available on a sliding scale cently created Agency for Health Care Defining a Minimum Benefit for people with incomes up to at least Policy and Research provide the foun- To assure access to care, private and twice the poverty standard. For this dation for these efforts. public insurance plans must provide an population, contributions to premiums Finally, the commission recognizes adequate minimum standard of cover- could not exceed 3% of income. Subsi- that more action may be called for to age. The commission recommends an dies would apply to both private and assure appropriate spending. Most crit- adequate minimum standard that is public coverage. ical in this regard is finding a better way similar to but less generous than cover- to deal with the problem of medical mal- age most employers now offer; that Promoting Quality and practice. Malpractice litigation, as cur- guarantees the uninsured, most of Containing Costs rently handled, fails to protect patients whom have low incomes, access to pri- Universal coverage can only be as and burdens the health care system mary as well as catastrophic care; that sound as the health care system itself. with high premiums and the costs of includes cost sharing (subject to ability Coverage that buys unnecessary or in- defensive medicine. Because at present to pay) to keep consumers conscious of appropriate care, pays for poor quality, there is no consensus on the best way to costs; and that emphasizes preventive fails to promote efficient delivery, or remedy these problems, the commis- services. shifts costs from some purchasers to sion calls on the Physician Payment Re- Although employers could offer more others wastes private and public expen- view Commission and congressional generous benefits, as most do now, the ditures that could be used elsewhere. committees to study the problem, con- commission recommends that coverage Just as its coverage recommenda- duct demonstrations, and make recom- in private plans and the public program tions would share responsibility be- mendations for appropriate federal ac- include hospital care, surgical and other tween employers and government, the tion. Furthermore, the commission inpatient physician services, physician commission recommends private and calls on both the Physician Payment Re- office visits, diagnostic tests, and lim- public initiatives to promote value for view Commission and the Prospective ited mental health benefits (45 inpatient the dollar in the use of health care. On Payment Assessment Commission-re- days and 25 outpatient visits). In addi- the private side, the commission's rec- sponsible for oversight of Medicare phy- tion, benefits would include preven- ommendations for insurance reform sician and hospital payments, respec- tive services-prenatal care, well-child that would prohibit competition based tively-to assess cost experience and care (including immunization), mammo- on a quest for good risks would promote initiatives to contain costs in the private grams, Papanicolaou smears, colorectal competition among insurers to manage and public sectors, and to make periodic and prostate screening procedures, and care efficiently. Furthermore, commis- recommendations to the Congress on other preventive services that evidence sion recommendations would not only the need for federal initiatives. shows are effective relative to costs. encourage employers to pursue the de- This emphasis on preventive services velopment of managed care in job-based Implementing Step by Step reflects the commission's view that ear- coverage, but they would also require Action cannot come too soon for the ly diagnosis and treatment may result in that insurers who offer managed care to millions without coverage and millions reduced mortality rates and increased large businesses extend it to small busi- more who see their coverage threat- quality of life and may produce savings nesses they cover. ened. However, an effective system JAMA, May 15, 1991 265, No. 19 A Call for Action-Rockefeller 2509 cannot be put into place overnight. The government would share in their insur- about that conclusion. However, other commission therefore recommends that ance premiums and health care costs. evidence supports my belief that know- its recommendations be implemented State and local governments would save ing what can and should be done will one step at a time over a 5-year period. an estimated $7 billion in payments they help the Congress move forward. The first step in expanding coverage is now make, beyond Medicaid, to finance That evidence comes, in part, from to ensure protection for pregnant wom- care to the uninsured. Because state three measures included in the 1990 en and young children who are now un- contributions to the new federal pro- budget agreement that actually reflect- insured, through access to the new fed- gram would be limited in real terms to ed the Pepper Commission recommen- eral public program, and to initiate the level of current Medicaid contribu- dations. At the same time the Congress insurance reforms to reverse the disin- tions, states would be relieved of the enacted major program cuts to reduce tegration of the private insurance mar- growing burden of that program. the federal deficit, Congress first ex- ket for small employers. These actions Employers who do not now provide panded protection for pregnant women would address the most urgent gaps in health insurance for their workers and and children. Federal law now guaran- coverage and would create an environ- the federal government would share the tees health care coverage through Med- ment in which employers will have an cost of new expenditures. Newly insur- icaid for all poor children by the year opportunity to provide the coverage the ing employers would face a total new 2002 and continuous coverage for low- commission expects. cost of about $28 billion-an average of income women throughout their preg- The second step, to take place in less than 4% of payroll after taxes. For a nancies. Second, Congress enacted years 2 through 5 of implementation, is single employer the increase could not Medigap insurance reforms that will to put in place the incentives and re- exceed the percentage of payroll speci- protect the elderly from risk selection. quirements for job-based coverage, giv- fied as the "price" of coverage in the new Third, Congress enacted Medicare cov- ing employers time to adjust to their federal program (estimated at 7% of erage for mammograms, reflecting the new obligations. The final step, to occur payroll, based on currently available strong emphasis on preventive services in year 5, is to extend the federal pro- data). embodied in the commission's benefit gram to all nonworkers. Finally, new federal expenditures un- package. At this point-with all public and pri- der the recommendations are estimated These are important steps because vate coverage mechanisms fully in at $24 billion-to cover nonworkers, to they promote access to care and place-all individuals would be required subsidize insurance costs for individuals strengthen some of the weakest parts of to obtain coverage through their em- and employers, and to pay providers at our health care system. Even more, ployers or the new federal program. rates set according to Medicare rules. they reflect the high priority members New federal expenditures require of Congress believe health care de- COSTS AND FINANCING new federal revenues. Consistent with serves, in spite of fiscal constraints. In Achieving universal coverage will re- its charge and its commitment that all fact, congressional leaders have placed quire an increase in the nation's health individuals, regardless of age or illness, health care reform at the top of the leg- care expenditures. However, because have adequate protection for health and islative agenda for the 102nd Congress we already provide and pay for consid- long-term care services, the commis- that is just now getting under way. erable (albeit insufficient) care to the sion recommends that new revenues be I intend to introduce legislation that uninsured, the increase is relatively raised to finance a full set of health and embodies the Pepper Commission rec- small. Furthermore, because this pro- long-term care reforms. Rather than ommendations early in the 102nd Con- posal for universal coverage is designed specify the taxes to be used-a task gress. Its provisions, which emerged in to share costs fairly among individuals, more appropriate to actual legislation- a process that might be considered a employers, and government, the bur- the commission identified a number of microcosm of congressional delibera- dens many now face-through cost revenue packages that could produce tions, will be assessed and refined in the shifting, uncompensated care, and the requisite funds while satisfying full legislative process. Hearings will be excessive out-of-pocket payments- three criteria essential to a fair and rea- held, support expanded, and enactment would be dramatically reduced. sonable package: vigorously pursued. I believe we can The commission's recommendations Taxes should be progressive, re- move toward enactment of health care would buy health coverage for all Amer- quiring a higher contribution from those reform in the 102nd Congress. That re- icans for less than 2% more than health most able to bear increased tax form, even if it is not identical to the care expenditures under the current burdens. Pepper Commission recommendations system. If implemented in 1990, that Revenues should be able to grow as they now stand, should incorporate would mean only a $12 billion increase in fast enough to keep up with population its basic tenets, because they offer a the nation's health care bill-from $647 and other sources of expenditure practical means of achieving the univer- billion to $659 billion. Of this overall growth. sal protection our citizens are coming to increase, just over half would go to hos- Contributions should come from demand. pitals and about one fourth to physi- people of all ages. cians. The remainder would go to other References MOVING TOWARD ENACTMENT professionals and services. 1. Blendon RJ, Donolan K. The public and the Not all sectors of society would have In my view, the Pepper Commission emerging debate over national health insurance. N to pay more. Employers who now offer blueprint for health care reform can Engl J Med. 1990;323:200-212. health insurance to workers and depen- serve as a rallying point for the political 2. A Call for Action: Final Report of the Pepper dents would save an estimated $13 bil- consensus that can make universal cov- Commission. Washington, DC: US Government Printing Office; 1990. lion per year, because they would no erage in an efficient health care system 3. Rockefeller JD IV. The Pepper Commission re- longer pay the costs of covering (as de- a reality. Criticism of the recommenda- port on comprehensive health care. N Engl J Med. pendents) individuals who work for oth- tions' substantial costs and concern 1990;323:1005-1007. er firms and of uncompensated care. In- about the nation's fiscal health-exacer- 4. Levit KR, Freeland MS, Waldo DR. Health spending and ability to pay: business, individuals, dividuals and families would save an bated by the savings-and-loan and the and government. Health Care Financ Rev. Spring estimated $19 billion, as employers and Persian Gulf crises-may raise doubts 1989;10:1-11. 2510 JAMA, May 15, 1991 265, No. 19 A Call for Action-Rockefeller The Physicians Who Care Plan Preserving Quality and Equitability in American Medicine Ronald S. Bronow, MD; Robert A. Beltran, MD; Stephen C. Cohen, MD; Paul T. Elliott, MD; Gordon M. Goldman, MD; Seth G. Spotnitz, MD THE AMERICAN health care system major elements: (1) universal employer- pability" to deal with the situation on its is under siege. The costs of advanced provided, community-related insurance own.⁶ technology continue to overwhelm any with high deductibles; (2) individual Canada, to its credit, has so far man- short-term savings from managing "Medi-Save" accounts; (3) long-range aged to constrain health care costs to a care. This has led to a crisis situation, private funding of Medicare; (4) long- relatively stable share of national ex- creating a need to develop new policies term care separated from Medicaid and penditures. With the aging of the Amer- immediately.¹ Medicaid eligibility expanded; and (5) ican population and runaway technol- During the past several years, it has scientific medical care guidelines. In ad- ogy, this has proved to be an impossible been generally agreed on that we must dition, we offer two minor recommenda- task in the United States. Canada has expand access to health care to all tions affecting the financing of health also accomplished universality of cover- Americans. But how? The issue is care: disclosure of physicians' financial age and eliminated the problems of un- whether we should build on the existing incentives and volunteer service by compensated care and an uninsured employer-based and private insurance physicians. Before examining each of population. system or abandon it and replace it with these proposals, let us first explain why The most striking difference between a taxpayer-financed system. Concerned we think the Canadian style of health Canadian and American spending is in parties across the country are now care is not the solution. administration and prepayment ex- choosing sides. In the Canadian system, which has penses (costs of handling paper and dol- One side argues that, in order to guar- usually been the model suggested for lars). Canadians spend 80% less than antee health care access to all, we the United States, the state-not the Americans to administer their univer- should have a national health care pro- physician or the patient-makes basic sal, comprehensive coverage. In addi- gram based on the Canadian system.² It health care decisions. Patients' needs tion, the lack of intrusion into the auton- is the belief of Physicians Who Care that take a backseat to budget constraints. omy of private practice physicians in such a program will not work in the Even though the system puts tight con- Canada is in stark contrast to the situa- United States. trols on physicians and hospitals and tion in the United States. American We propose, instead, an extensive re- delays buying high technology equip- physicians are increasingly frustrated shaping of our present health care fi- ment, funding is finite while patients' by the micromanagement of individual nancing mechanisms. The present sys- demands for care are not. To cope with patients by government and insurance tem, based on private and public the current funding crisis, politicians companies.⁷ funding, can and should be preserved. have restricted access to medical care There is evidence, however, that the However, it also must be revamped so and blamed physicians for deficiencies honeymoon may be ending for the physi- that everyone has access to health care in the system. According to the presi- cians in Ontario. Bureaucrats there are without unduly burdening any one seg- dent of the Ontario Medical Association, suggesting that the growth of the physi- ment of society. Our proposal has five relations between physicians and the cian population, with resultant in- government have reached an all-time creased billing, is evidence of irrespon- From the National Organization of Physicians Who low. In the view of the Ontario Medical sible behavior. It has been suggested Care, San Antonio, Tex. Association, the deterioration of health that "the number of doctors in the Prov- Reprint requests to National Organization of Physi- cians Who Care, 215 E Quincy, Suite 305, San Antonio, care in Ontario "demonstrates clearly ince should be cut and those remaining TX 78215 (Dr Bronow). that government does not have the ca- should be moved out of the fee-for-ser- JAMA, May 15, 1991 - Vol 265, No. 19 Physicians Who Care Plan-Bronow et al 2511 vice payment mode and into salary and sound. Costs can be kept down only if of the health care dollar: between 1929 capitation systems." everyone, including those at low risk for and 1980, 70% of expenditures went to- While Americans recognize that the illness and accident, are part of the in- ward the 10% of the population with problems of funding our present health surance pool. In voluntary arrange- severe or catastrophic illnesses. In care are serious ones, they are not will- ments, low-risk workers might opt out 1980, according to the study by Berk et ing to solve these problems by giving up of the plan in order to receive higher al,¹⁷ 1% of the population accounted for their claim to first-class medicine. At wages or other fringe benefits. This 29% of all monies spent. On the other the same time, most Americans want leaves the insurer covering only higher- hand, 50% of the population accounted health care to be available to everyone, risk employees, with resultant high for only 4% of health care costs. regardless of ability to pay (The Wash- rates (the principle of adverse selec- Considering this pattern of expendi- ington Post. April 18, 1990:A27). Fortu- tion). 12(pp26-27) tures, it makes sense to reserve insur- nately, it is possible to preserve our In order not to burden any employer ance coverage for major illnesses. In pluralistic system and guarantee access unduly, however, mandatory insurance addition, policies should have a cap lim- to care. This can be achieved by our five- has to be available at a reasonable cost. iting employee liability for physician part plan. This would be achieved through a high and hospital expenses. Catastrophic deductible, perhaps $1000, and provide coverage should be triggered when out- FIVE-PART PLAN only basic coverage. 18(pp15-17) All workers of-pocket costs exceed a certain per- Require Employer-Funded would be covered regardless of "preex- centage of adjusted gross income. 12(pp97-99) Health Insurance isting conditions," and rates would be Employees who do wish to buy addi- Today, 33 million Americans have no based on "community ratings." State- tional insurance, however, could do SO health insurance. A nationwide man- mandated coverage would be elim- with after-tax dollars, with tax deduct- date for employer-funded health care inated. ibility being determined by a sliding insurance would largely remedy this A high deductible is essential in keep- scale of family income. Moreover, basic problem. Such coverage would protect ing costs down for two reasons: it dis- coverage would not be limited to the two thirds of the uninsured (24 million courages a credit card mentality (if med- employer-provided policy but could in- workers and their dependents); if ex- ical care is free, overuse is inevitable), stead be chosen from an individually tai- tended to include the self-employed, it and it provides greater value. 3,12(pp17-18) At lored plan. In either event, the employ- would protect 78% of the uninsured. present, some employers offer low de- er would contribute the same amount. Currently, only 39% of businesses ductibles and copayments. Why? Be- All $1000 deductible policies, whether with 25 or fewer employees offer health cause employee groups demand that individual or group, would have the benefits, with cost being the most often their health care benefits be paid from same tax benefits (of not being taxable cited deterrent. Further, most unin- pretax dollars.¹ Unfortunately, since as income). In addition, tax credits sured workers earn too little to afford the insurance company pays the bill, should be considered for small business- private coverage of their own.¹¹ To ask neither provider nor patient has an in- es and low-wage earners. small businesses, in particular, to offer centive to economize. In Canada, the It is much easier to obtain health in- health benefits, we must offer a solution number of medical services per elderly surance as a member of a group than as that is economically feasible. However, patient has more than tripled since the an individual. In general, group insur- first we must explain the importance of institution of the national health pro- ance is issued without medical examina- making benefits mandatory. gram. 15 In the United States, there is tions or other evidence of insurability of Only benefits that are mandatory are evidence that a greater proportion of the individual members of the group. economically fair. If everyone has basic Medicare beneficiaries are filing claims For individual policies, on the other health insurance, the cost of insurance for services. McMenamin¹⁶ ascribes this hand, the insurer requires such evi- and health care is shared equitably. At to an increase in the number of physi- dence. Here, the underwriter evaluates present, people who are poor and unin- cians accepting assignment on all each risk, looking at state of health, sured do seek and do receive medical claims, with resultant decreasing costs medical history, occupation, and ha- care for serious illnesses and accidents to patients. bits. 12(p19) Applicants are frequently re- through emergency departments. The A high deductible makes patients jected or the policies contain riders be- cost is then borne by the rest of soci- more responsible about health care de- cause of "preexisting" illnesses. Small ety-through public subsidy, private cisions. Moreover, it also provides more businesses, especially those with older charity, or indirect subsidy by third- value for the money. Low-deductible employees or employees with preexist- party payers. Everyone pays more for policies are expensive, and employers ing illnesses, may find their premium medical insurance to cover those who often pay considerably more in premi- rates pushed up to an unacceptable lev- receive benefits but who have not con- ums than any value the policies hold for el. A recent survey from the Office of tributed to the insurance pool. A report their employees. For example, if an em- Technology Assessment found that, of prepared by the Congressional Re- ployer was to lower the deductible from 2.1 million applications in 1 year for indi- search Service states that this is a $250 to $100, each dollar of additional vidual health insurance, 20% of the ap- strong argument for requiring all per- coverage would cost $2.14 in additional plicants received a substandard risk sons eligible for insurance to accept the premiums. Insurance companies, ac- classification, leading to either a preex- coverage. It notes, however, that, "it is cording to Goodman,¹³ typically spend isting illness exclusion or an above-av- not necessarily an argument for requir- more than $50 to process a $50 medical erage premium. 12(p32) ing the level of health insurance cover- claim, effectively doubling the cost of Insurers also examine groups to de- age ordinarily available in employer- small medical bills. The annual premium termine whether they represent accept- based plans. Society could be saved by increasing the deductible from able risks. Employee groups found by indemnified for the risk of free-riders $100 to $1000 is nearly $600. potential insurers to be at excessive risk through a very limited insurance pack- One more reason for setting a high will find coverage progressively more age, providing coverage for urgent care deductible has to do with the source of difficult to secure and afford under this only. "12(p117) health care costs. Major illnesses and "experience rating" process. Here, the Mandatory benefits are economically catastrophes account for the lion's share past experience of the group to be in- 2512 JAMA, May 15, 1991 265, No. 19 Physicians Who Care Plan-Bronow et al sured determines the premium and Mandatory employer-provided cover- (New York Times. April 21, 1991;sect whether or not coverage will be age would relieve employers of the ex- 1:1). provided. 12(p21) tra premiums they must now pay to sub- Rather than basing Medicare premi- A second important feature of our sidize uncompensated care. In addition, ums on recipients' incomes, the usual mandated insurance, then, is setting high deductibles, elimination of state- bureaucratic solutions in such situations rates for basic coverage according to a mandated benefits, scientific guidelines are to either cut the program or to raise "community rating" process. Premium for care, and, it is hoped, tort reform taxes. Fortunately, there is a third solu- rates would be based on the allocation of should lower premiums significantly. tion that would protect the integrity of total costs to all the individuals or Those employers who self-insure and Medicare: change the nature of its fund- groups to be insured, without regard to currently provide generously low-de- ing. Instead of funding it entirely the experience of any subgroup. This ductible health care benefits should find through taxes received every year, it process has had the advantage of allow- the new insurance rates attractive. could be partially funded through medi- ing an insurer to apply a single rate or Our plan is predicated on the assump- cal individual retirement accounts set of rates to a large number of people, tion that every person will pay his or her (IRAs). An IRA would be a required greatly simplifying the process of deter- fair share to guarantee a high-quality, purchase for every child in the first year mining premiums. 12(pp22-23) It also has the high technology American health care of life. An IRA that cost $125 and benefit of eliminating the problem of system. American technology is now earned 10% annual interest would accu- adverse selection. In addition, commu- overwhelming all attempts to manage mulate to $65 by Medicare age. This nity rating would eliminate the necessi- care.¹ It is the belief of Physicians Who money could then be used to obtain pri- ty of creating federal or state risk pools Care that, unless the American public is vate health care to supplement-or re- to provide health insurance for high- willing to pay for quality, they will lose place-government funds. Depending risk groups or individuals. it. on family income, this one-time $125 State mandates must be eliminated in payment could be partially or complete- the interest of keeping costs down. Over Individual 'Medi-Save' Accounts ly subsidized by the government. The 700 laws have been enacted by state Even small medical bills, as well as funds accumulated in this reserve would legislatures mandating benefits for such the $1000 deductible, can overwhelm not be used until the individual reaches things as drug and alcohol abuse treat- people of limited means. As an alterna- 65 years of age unless he or she suffers a ment, chiropractic care, in vitro fertil- tive to lower deductibles or third-party medical disability before that time. This ization, acupuncture, wigs, and pastoral insurers, special medical savings IRA would be modeled after the present counseling. These mandates raise insur- ("Medi-Save") accounts could be estab- IRA program, where at age 591/2 years ance rates by as much as 20%. Accord- lished with pretax dollars. As proposed the money can be removed from the ing to one study,¹⁸ one of four people lack by Goodman¹⁸ of the National Center for account. health insurance because state regula- Policy Analysis, a Medi-Save contribu- Medi-Save and medical IRA accounts tions have priced it out of the reach of tion (perhaps $300 to $500 a year) would would allow accumulation of funds to be the employer. be a form of self-insurance, giving work- used later to finance acute or chronic To get around such state-mandated ers direct control of their health care health care needs. So far, Congress has benefits, many companies have turned dollars. Workers would have strong in- refused to consider this avenue for pro- to self-insurance plans. Such plans also centives to be prudent buyers in the moting savings and minimizing govern- allow them to avoid certain regulations medical market place. Medi-Save ac- ment interference with medical deci- and state taxes on insurance premiums. counts would eventually become an im- sions. This type of funding, at present, While this avenue is open to some com- portant source of funds for purchasing is inconsistent with current govern- panies, it is not feasible for all and leads additional health insurance or paying ment policy since the administration is to inequities. Eliminating state-man- for uncovered medical expenses. 13(pp17-18) unwilling to divert any source of in- dated benefits and regulations would come. If there were 3 million births at lower costs for companies that cannot, New Funding for Medicare $125 per year, the government would or do not, self-insure (New York Times. The graying of the population and the only be missing $375 million a year. That August 3, 1990; sect C10:26). continued growth of technological inno- is literally a drop in the bucket for a It must be added that the passage of vation put increased pressure on Medi- program that would reap such tremen- the Employee Retirement Income Se- care. At the same time, the federal bud- dous benefits over the decades. curity Act in 1974 left self-insured plans get deficit threatens the economic essentially unregulated. There are nei- health of the program. Over the past Revamp Medicaid ther standards to ensure adequacy of 10 years, the Medicare budget has been Medicaid is another perennial prob- health care coverage nor safeguards to cut by more than $50 billion, with the lem. Set up 26 years ago to provide the guarantee that employers will be able to worst yet to come following the 1990 poor with health care, this joint federal- pay claims if they close their business or budget "negotiations." Cuts of this na- state health insurance program is now terminate the health plan. We believe ture are not surprising considering the experiencing severe financial difficul- that there must be regulatory safe- history of government-financed "enti- ties. The number of Medicaid recipients guards for employees of the self-in- tlement" programs. They are always has grown modestly, but expenditures, sured. 12(pp158-159) vulnerable in times of budget crunch. In in contrast, have increased dramatical- It can be argued that those companies 1991, the federal government, for the ly. Between 1980 and 1989, the number whose claims experience is below the first time, will weigh costs as a factor in of Medicaid recipients increased by 9%, community average will choose to self- deciding whether Medicare should pay while expenditures rose an astounding insure. The process of adverse selection for new medical procedures, devices, 123%. The Medicaid program has also would again raise the rates for those and drugs. As private health insurers taken a correspondingly bigger bite out remaining in the community. It is our often follow the government's lead in of state budgets: 9% in 1980, but 14% in belief that if our plan is enacted, this deciding whether to pay for goods or 1990. would be more than balanced by em- services, this could create an impact far As a sign of how serious the funding ployers reentering the insurance pool. beyond the government's program problem is, state governments and hos- JAMA, May 15, 1991 265, No. 19 Physicians Who Care Plan-Bronow et al 2513 pitals have become adversaries. States sociation of America. 22-28 Medicaid of health maintenance organizations cut payments; hospitals fight back in the should cover everyone below the pover- (HMOs), as it dropped six plans and courts. In the wake of a Supreme Court ty level, regardless of age, employ- encouraged employees not to enroll in decision (Wilder v Virginia Hospital ment, or family structure. Eligibility 19 others. The Florida Department of Association) permitting hospitals to sue requirements for Medicaid should be Insurance notes that, since 1988, 1628 over Medicaid disputes, hospitals are separated from eligibility for welfare. complaints have been filed against Hu- doing just that. California's 567 hospi- Further, persons just above the pover- mana managed care plans (Sun-Senti- tals, claiming that they are losing more ty level should be given the opportunity nel. October 21-24, 1990:2). Little more than $575 a day by treating Medic- to buy an income-related package of pri- than one third of these were from the aid outpatients, have filed a law suit mary and preventive care. Finally, Medicare component, indicating that against the California Department of states should offer spend-down pro- the majority of problems were not from Health Services. The hospitals claim grams for the medically needy. Here, federal regulations, but instead from that underpayment has forced closure persons not otherwise eligible for Med- the basic structure of the plans. of trauma centers and emergency de- icaid due to higher incomes would be- We are concerned that, in many "for- partments and has also placed crippling come eligible once out-of-pocket medi- profit" HMOs, the quality of and access restrictions on a variety of nonemergen- cal expenses had reduced their to services is secondary to the genera- cy procedures, including neonatal care, remaining income to the federal poverty tion of a profit for the corporation. This rehabilitative treatment, and diagnos- level. creates, for the physician, a basic con- tic medical examinations. flict of interest: physicians are re- However, lawsuits only deal with the Scientific Guidelines warded for deliberately limiting care. symptom, not the source of the prob- for Medical Care The director of quality assurance for lem. The primary reason Medicaid is in a Most of our suggestions for control- Humana Health Plans of South Florida crisis is that it dedicates almost half of ling medical costs involve business, gov- agrees: "In any HMO there is financial its payments to long-term care. In 1986, ernment, and insurance companies. In incentive to hold back on services" for example, 45% of total Medicaid one area, however, physicians can take (Sun-Sentinel. October 23, 1990). spending provided only 7% of its eligible the lead. Rather than allowing insur- Those HMOs that put physicians in a population with services in nursing fa- ance companies to set health benefits "gatekeeper" role by offering financial cilities or institutes for the mentally re- arbitrarily, physicians can insist on the rewards or penalties for tests or refer- tarded or mentally ill. As the population establishment of scientific guidelines rals place physicians in an ethically and ages, the problem will only grow for medical care. It is crucial that physi- professionally untenable position. A worse. 12(p63) The solution is to take long- cians themselves set up these guide- recent study on Medicare HMOs done term care out of Medicaid and change lines, for, as Moran²⁹ noted, "Only physi- by the General Accounting Office con- eligibility requirements. cians, not insurance companies, can cluded that, "the incentives of a capita- Long-term care could then be ad- change the way physicians practice tion payment system may encourage dressed as a problem that affects the medicine." Whether local or national the inappropriate reduction of neces- entire population, not just the poor. The guidelines are adopted is not as impor- sary services.' Approximately 30% of solutions are likely to be a combination tant as permitting local validation. Only Medicare HMO patients disenroll with- of private and public programs, such as with local validation will the greatest in 2 years, an indication of serious dis- those proposed by The Heritage Foun- number of physicians participate. satisfaction with the plan. dation. Its recommendations include Obviously, it will take time to estab- Physicians must feel free to make tax incentives, long-term care insur- lish guidelines for every possible medi- medical decisions based on the needs of ance, new methods of paying for care, cal condition and treatment, but patient the individual patient, without fear of and public assistance programs. Specifi- and physician preferences for treat- economic sanctions or reprisals. By the cally, it recommends (1) tax relief to ment must be given priority. Once the same token, insurers must reveal to the help families who pay for care of their guidelines are established, implementa- patient in advance the financial incen- elderly relatives; (2) a federal-state tion and monitoring will determine how tive of the physician.84 So far, legislation long-term care assistance program; (3) successful each treatment is. that would make full disclosure a law tax exemptions on affordable insurance has been supported by the Massachu- for long-term care; (4) life insurance pol- RECOMMENDATIONS setts and Missouri medical associa- icies that convert to long-term care in- tions. 35,36 More state medical associa- surance on retirement, with policies Disclose Physicians' tions should follow their lead. Financial Incentives paid for with tax-exempt monies; (5) tax-free purchase of long-term care in- Managed care was designed to pro- Volunteer Service by Physicians surance with retirement funds; and (6) duce cost savings and efficient care. In It will take time for all of our propos- home equity conversions allowed for many cases, its promises have not been als to be implemented. For that reason funding long-term care.2¹ fulfilled: employers have not seen the and as a gesture of good will, we recom- Medicaid would then be free to focus savings they had hoped for and employ- mend that physicians devote 1 day a exclusively on the health care problems ees are becoming increasingly dissatis- month to caring for persons who are of the poor. Eligibility requirements fied with the quality of care and limits on unable to afford medical services. Mem- should be made more flexible and realis- choice of physicians and treatment facil- bers of Physicians Who Care are strong- tic, and new programs should be estab- ities (reported in the St Louis Post Dis- ly urged to donate their services in their lished SO that health care can be made patch. May 12, 1989:F1; November 12, communities, making no charges and affordable to people who are above the 1989:C3; and April 8, 1990:D1; and the accepting no payments, and letting the official poverty level but are unable to Wall Street Journal. February 27, community know that this is part of the pay the full cost of their health care. In 1990:B1). General Motors, with the sup- Physicians Who Care volunteer pro- reviewing several proposals for financ- port of the United Auto Workers, re- gram. By stepping forward in this way, ing health care for the poor, we support cently announced that it was "sending a we hope to encourage other physicians the position of the Health Insurance As- message" about the "quality and access" to follow our lead. We believe it is our 2514 JAMA, May 15, 265, No. 19 Physicians Who Care Plan-Bronow et al responsibility to society. ling health expenditures: the Canadian reality. N ance in a system designed to promote quality and Engl J Med. 1989;320:571-577. economy. N Engl J Med. 1989;320:29-37, 94-101. CONCLUSION 8. Fletcher RD. A question of justice. Ontario Med 24. Himmelstein DU, Woolhandler S, the Writing Rev. 1990;57:12. Committee of the Working Group on Program De- Some people are now advocating that 9. Louis W. Sullivan. Forum on health care costs. sign. A national health program for the United we dismantle our present system in fa- Presented at Stanford University; October 23, States: a physician's proposal. N Engl J Med. vor of a nationalized system financed by 1990; Stanford, Calif. 1989;320:102-108. 10. Monheit AC, Short PF. Mandating health cov- 25. Waitzkin H. Why it's time for a national health taxes. Our political and economic cli- erage for working Americans. Health Aff. program in the United States. West J Med. mate, however, discourages such a 1989;8:22-38. 1989;150:101-107. drastic change. On the other hand, 11. Nadel M. Health Insurance: Availability and 26. Evans RG, Lomas J, Barer MI, et al. Control- many lawmakers are interested in ex- Adequacy for Small Businesses. Washington, DC: ling health expenditures: the Canadian reality. N General Accounting Office; 1989. Publication T- Engl J Med. 1989;320:571-577. panding access to health care, but they HRD-90-02. 27. For the Health of a Nation: A Shared Respon- want to do SO in incremental stages. 12. Congressional Research Service. Insuring the sibility. Washington, DC: National Leadership Because our current system of financing Uninsured: Options and Analyses. Washington, Conference on Health Care; 1989. and providing health care services is SO DC: Library of Congress; 1988. 28. Curtis R. Health Insurance in the Small Em- 13. Goodman JC. An Agenda for Solving Ameri- ployer Market, Testimony Before the Subcommit- large and complex, step-by-step ca's Health Care Crisis: Task Force Report. Dallas, tee on Antitrust, Monopolies, and Business changes make much more sense than Tex: The National Center for Policy Analysis; 1990. Rights. Washington, DC: Committee on the Judi- sweeping reform. Building on a system 14. Reinhardt UE. Health care spending and ciary; 1990. of private insurance encourages innova- American competitiveness. Health Aff. 1989;8:10. 29. Moran D. The Blues/ACP testing guideline: 15. Lomas J, Hertzman C, Barer M, Pulcins I, lessons from the past. Rep Med Guidelines Out- tion, preserves freedom of choice for Evans R, Anderson G. The Great Transformation comes Res. 1990;1:10. consumers, and offers autonomy for of the British Columbia Hospital Sector: Policy 30. Kendel P. General Motors drops six HMOs, providers. We believe it is the only rea- Design or Political Accident for the Elderly? Van- brakes enrollment in 19 others in effort to cut costs. sonable solution. couver: University of British Columbia; 1990. Pub- Mod Healthcare. 1990;20:3. lication HPRU 90:21D. 31. Toward full disclosure of referral restrictions References 16. McMenamin P. What do economists think pa- and financial incentives by prepaid health plan. N tients want? Health Aff. 1990;9:112-119. Engl J Med. 1987;317:1729-1734. Sounding Board. 1. Iglehart J. A conversation with William B. 17. Berk ML, Monheit AC, Hagen MM. How the 32. Wagner L. Medicare HMOs lack quality safe- Schwartz. Health Aff. 1989;19:71-73. US spent its health care dollars: 1929-1980. Health guards-GAO. Mod Healthcare. 1991;21:8. 2. Woolhander S, Himmelstein DU. A national Aff. 1988;7:46-60. 33. Managed Care and the Medicare Program: health program: northern light at the end of the 18. Gabel JJ, Jensen GA. The price of state-man- Background and Evidence. Washington, DC: US tunnel. JAMA. 1989;262:2136-2137. dated benefits. Inquiry. 1989;26:419-431. Congressional Budget Office; May 19, 1990. CBP 3. Bronow R. A national health program: abyss at 19. Tupper CJ. Dreams, dollars, and deeds: the Staff Memorandum. the end of the tunnel-the position of Physicians sacred fire and health access America. JAMA. 34. Financial incentives for physicians in HMOs: is Who Care. JAMA. 1990;263:2488-2489. 1990;264:1150-1152. there a conflict of interest? N Engl J Med. 4. Selmon C. Health Care in Ontario: Ontario Lib- 20. Burda D. The search for Medicaid money. Mod 1987;317:1743-1748. Special Report. ertarian Party Position Paper. Toronto: Ontario Healthcare. 1990;20:20-27. 35. An act relative to public disclosure by health Libertarian Party; 1989. 21. Haislmaier ES. Making long-term health care insurers. The Commonwealth of Massachusetts. 5. Johnston B. OMA joins with other service more affordable. Backgrounder. 1990;755. House Act No. 3812. 1989. groups to focus attention on health-care deficien- 22. Dickman RL, Ford AB, Liebman J, Milligan S, 36. General Assembly of the State of Missouri. cies. Ontario Med Rev. 1990;57:8-9. Schorr AL. An end to patchwork reform of health House Bill No. 247, introduced by Representative 6. Fletcher RD. The shape of things to come. On- care. N Engl J Med. 1987;317:1086-1088. Harpool. 1990. tario Med Rev. 1990;57:1-4. 23. Enthoven A, Kronick R. A consumer-choice 7. Evans RG, Lomas J. Barer ML, et al. Control- health plan for the 1990s: universal health insur- JAMA, May 15, 1991 265, No. 19 Physicians Who Care Plan-Bronow et al 2515 Restructuring Health Care AMA's "Health Access America" plan. A PLAN FOR RESTRUCTURING HEALTH CARE in the United States The goal of this plan is universal ac- cess to medically necessary health care A Proposal for the 1990s services. These services should include disease prevention and health promo- tion, medical and mental health care, Donald O. Nutter, MD; Charles M. Helms, MD, PhD; rehabilitation of physical and mental Michael E. Whitcomb, MD; W. Donald Weston, MD disability, and long-term care. The fol- lowing nine objectives for comprehen- A PLAN for restructuring the US health professionals, and the general sive system reform should be pursued to health care system to achieve universal public have focused on containing costs, achieve the overall goal: access to medically necessary health enhancing the quality of care, and pro- Appropriate roles must be defined care services has been developed by the viding access to necessary health ser- for business, government, and the indi- Medical Schools Section of the Ameri- vices for all our citizens. Recent propos- vidual in financing health care for all can Medical Association (AMA). The als for reform of the system reflect the citizens. plan is a pluralistic approach to compre- diverse views that are present in our The system must be organized and hensive system reform that requires society regarding the role of the individ- financed in a manner that will ensure both individual and institutional respon- ual and public and private institutions in responsible cost containment. sibility for the achievement of quality the provision, financing, and regulation Administration of the system must health care. A set of broad strategies of health care. 1-5 be simplified to the extent possible in a are proposed to reach the goal of univer- Although the concept of a federal na- pluralistic model. sal access to care in the context of re- tional health insurance program has re- A universal system of quality assur- sponsible containment of health care surfaced in the debate on health care, ance based on practice standards must costs. The plan proposes to achieve uni- the political-economic outlook for enact- be developed. versal access through reform of our ex- ment of this solution appears to be slim Effective methods of technology as- isting system of health care as follows: at present. An alternative strategy re- sessment that focus on clinical outcomes by restructuring and reforming Medic- quires building social consensus for a must be developed and linked to the aid and Medicare, by supporting univer- coherent series of reforms, involving process for quality assurance. sal provision of necessary health bene- both public and private institutions, Public and private support for basic fits through employers; and by the that will achieve the desired objectives. biomedical research and the develop- creation of regional insurance pools for In this context, the majority of policy- ment and evaluation of diagnostic and those individuals who are not covered makers and proposals for reform of our therapeutic technologies must con- by government programs or through health care system have accepted the tinue. their workplace. The additional cost of existing pluralistic approach to financ- Academic medicine must be more these strategies for universal access ing health care as the basis for any com- responsive to the nation's health man- would be shared by government, busi- prehensive approach to system reform. power needs in the areas of primary ness, and the health care consumer. This viewpoint seems compelling when care and geographic distribution. Mechanisms are proposed to control one considers the reluctance on the part Health care payers must continue to hospital and physician service costs and of the federal government to increase share responsibility, and in some cases to reduce the volume of unnecessary the nation's tax burden; the relatively accept greater responsibility, for the sup- services that are provided. fixed public budget that is available to port of graduate medical education to Uncontrolled health care costs, ineq- fund education, health care, and the na- meet the nation's health manpower uitable access to care, concerns about tion's infrastructure; and the recent his- needs. quality, and a bureaucratic morass in tory of increasing public debt (deficit The effectiveness of a restructured the administration of health insurance spending) that has been required to system must be measured against those programs have evoked widespread in- maintain a fixed budget for domestic changes in the health status of the na- terest in restructuring the health care social programs. tion's citizens that can be influenced by system in this country. Calls for reform The AMA has recently introduced its medical services. from business, labor, government, own proposal for reform of the US Achievement of these system objec- health care system entitled "Health Ac- tives and universal access to health care From the Office of the Vice Dean, Northwestern Uni- cess America. The AMA has also will require that we resolve the present versity School of Medicine, Chicago, III (Dr Nutter); the asked its Medical Schools Section to en- conflict in health care between individ- Department of Internal Medicine, University of lowa College of Medicine, lowa City (Dr Helms); the Depart- gage members from academic medicine ual and societal needs. This issue is cen- ment of Internal Medicine, University of Washington in a policy and planning process aimed at tral to many problems in our health care School of Medicine, Seattle (Dr Whitcomb); and the Department of Radiology, Michigan State College of reform of health care provision and fi- system and is explored by Bulger⁷ Human Medicine, East Lansing (Dr Weston). nancing that would correct substantial through what he characterizes as the This work was sponsored by the Medical Schools defects in the existing system. In re- Hippocratic and bureaucratic themes in Section of the American Medical Association, Chicago, III. The policy opinions expressed in this report are sponse to this challenge, the Medical American health care. those of the authors, and may not reflect those of their Schools Section requested that the au- STRATEGIES TO ACHIEVE academic institutions or the American Medical Associ- thors of this report develop the basic ation. Drs Nutter, Helms, and Whitcomb previously elements of a plan for restructuring the HEALTH CARE RESTRUCTURING served as Robert Wood Johnson Health Policy Fellows at the Institute of Medicine, National Academy of Sci- US health care system. Although simi- In order to restructure and reform ences, Washington, DC. lar in many areas, a number of elements the health care system, and thereby Reprint requests to Northwestern University Medical in the resultant proposal differ from, or provide an incremental increase in School, 303 E Chicago Ave, Chicago, III 60611-3008 (Dr Nutter). may be in conflict with, those in the benefits, integrated policies and strate- 2516 JAMA, May 15, 1991 Vol 265, No. 19 Restructuring Health Care-Nutter et al gies must be developed at the national large part, by the elderly using a graded allow states to spread the costs of subsi- level. Policies and implementation premium scale based on personal finan- dizing or operating group plans for needy strategies, if they are to successfully cial status. The authors believe a com- individuals who are not categorically eli- engage the support of major health care prehensive, single-source insurance gible for government programs among all constituencies, must be comprehensive, program for the elderly, with an appro- privately financed health plans. ie, they must address the issues of im- priate level of individual cost sharing, is proved access to care, cost contain- highly desirable, not withstanding re- Containment of Health Care Costs ment, administrative simplification, cent failed legislative attempts to ad- Individual Responsibility.-Cos quality assurance, and an adequate sup- dress this issue. If the additional funds sharing by individuals must be an im- ply of primary care manpower. We are needed to federalize Medicaid and re- portant component in the effort to re- proposing a comprehensive set of strat- form Medicare cannot be realized strain the rate of growth in health care egies that address these concerns, but through appropriate levels of taxation costs while funding universal access to in doing SO realize that they will require on employment-based health benefits care. Individual citizens should be re- hard choices and in some cases present and copayment by the elderly, an in- quired to assume greater responsibility business and government with financial crease in general tax revenues should be for their own health. In addition to dilemmas. In realistic terms, incremen- legislated. Any additional federal taxes adopting a more healthy life-style, indi- tal change is likely to be required. The to support these programs should be viduals should bear, to the extent possi- highest priority for reform and restruc- progressive in their structure. ble within their means, the costs of pur- turing under these conditions is access Universal Employment Benefits.- chasing health insurance, as well as to care for the uninsured. All individuals who are not covered by making copayment and first-dollar de- Universal Access to Health Care the Medicare or Medicaid programs ductible payment for the medical ser- should have access to a comprehensive vices they use. A Federalized Medicaid Pro- health benefits package. The source of The government's responsibility for gram.-Medicaid should be restruc- this health plan would vary depending subsidizing the purchase of health in- tured to provide a comprehensive pack- on the circumstances. All employers surance, or paying for health care ser- age of medically necessary health would be required to contribute to the vices, should be limited to those citizens benefits for all poor Americans. The fed- funding of health insurance for their em- who do not have the financial means to eral government should establish na- ployees. Universal provision of neces- bear the costs themselves. The costs of tional criteria for determining eligibility sary health benefits by employers will health insurance that are provided to for the program in order to provide all require tax reform to credit small busi- individuals as a benefit of employment the nation's poor and near-poor with ac- ness for the provision of health benefits, should be included in the calculation of cess to care, regardless of their state of the availability of rate-competitive the individual's taxable income. Exclu- residence. The restructured Medicaid group insurance plans that use commu- sion of the costs of employee health program should be financed by the fed- nity rather than experienced-based rat- benefits under existing tax law repre- eral government under a new arrange- ing, and the elimination of state-man- sents a substantial government subsidy ment. A separate federal trust fund dated health benefits. Recent estimates for citizens who are fully capable of should be established to pay for the of the potential for mandatory health bearing the cost of purchasing health costs of providing preventive, acute, benefits through the workplace to cor- insurance themselves. By considering and restorative care to the poor. The rect the problem of medical indigency the cost of employee health benefits as proposed Medicaid trust fund should be indicate that if all employees who are taxable income, and through the in- financed by additional tax revenues to working 20 hours or more a week and creased use of copayment and deduct- be raised by taxing employment-based their dependents were covered by their ibles for first-dollar coverage, employ- health insurance benefits. employers, two thirds of the currently ees will be more cost conscious when Medicaid should not be the source of uninsured would be covered.⁸ making decisions to use health care ser- funding for long-term care services. Individuals who are not covered by em- vices. The additional tax revenue that The federal Medicare program should ployment-based health insurance and are would be realized by eliminating the ex- provide inpatient long-term care bene- unable to afford an individual health in- clusion of employee health benefits from fits for the severely disabled and the surance plan, eg, many who are self-em- taxation should be earmarked for the elderly. Necessary home and communi- ployed and those who are medically unin- proposed Medicaid trust fund that ty care programs for the disabled and surable, should be offered access to would finance health care services for the elderly should be financed at the subsidized group insurance plans or risk the poor. state level using local revenues current- pools that are operated at a regional level. Prospective Pricing and Pay- ly devoted to the Medicaid program. Plans should be encouraged to provide ment.- second essential component, Medicare Reform.-The current long-term care options, and these bene- if we are to have affordable universal government subsidy provided to the el- fits should be classified as health insur- access to health care, is all-payer pro- derly through the Medicare program ance benefits for purposes of individual spective pricing and/or payment for should be continued, since it is consis- tax deductions. In order to ensure that all hospital and professional services. Re- tent with the income maintenance prin- privately financed health insurance plans imbursement of hospitals in each state ciple embodied in the Social Security contribute equitably to government pro- should be based on an all-payer, diagno- program. Medicare should be restruc- grams that provide access to citizens who sis related group (DRG) system. If the tured, however, to provide all elderly are too poor to purchase health insurance Medicare DRG system is used to imple- citizens with a comprehensive health or who are categorically ineligible for the ment this strategy, it probably will re- benefits package, including protection Medicare and Medicaid programs, the quire adjustment to ensure that equita- against catastrophic costs, as well as Employee Retirement Income Security ble funding is provided to hospitals in providing long-term care for severely Act should be amended to permit state rural and underserved areas. A Re- disabled individuals of all ages. regulation of employer-based self-insur- source-Based Relative Value Scale The program's expansion of benefits ance plans. This change in the Employee (RBRVS) should be adopted as the basis for the elderly should be financed, in Retirement Income Security Act would for paying physicians for services that JAMA, May 15, 1991 265, No. 19 Restructuring Health Care-Nutter et al 2517 are provided to beneficiaries of Medic- that are directed at defining quality care insurance information; enrollment in in- aid and Medicare. The government and developing practice guidelines to surance plans; and billing and payment should encourage private payers and in- guide physicians in their treatment of activities for all consumers, payers, and termediaries to adopt a similar RBRVS patients. In addition, undergraduate providers. This agenda should be ad- by writing appropriately designed in- and graduate medical education pro- dressed through nonprofit health insur- centives into the laws governing tax- grams should include more material on ance agencies that would be established ation of privately funded health insur- health policy, medical economics, and on a regional basis. The agencies, if es- ance plans. quality assurance activities in their cur- tablished and operated appropriately, Control of Service Volumes.- Re- ricula. Second, payments to physicians could serve to centralize and streamline cent experience in the United States and health care facilities that provide public and private health insurance pro- and other Western nations suggests therapeutic or diagnostic technological gram administration on a regional basis, that containment of total health care support must be designed to stop the and in SO doing reduce the aggregate costs, short of using central budgeting inappropriate use of these technologies, costs of administration. These agencies for all services, requires the use of pro- as well as the unnecessary duplication of would have the following responsibil- spective pricing, measures to control the facilities required to perform these ities: (1) to serve as the source of stan- the volume of services that are provid- expensive services. Third, a compre- dardized information on all available ed, and the regulation of capital expen- hensive program should be established health insurance plans (government and ditures by hospitals and health care cor- at the national level to evaluate the effi- private); (2) to serve as a purchasing porations. Both price controls and the cacy and appropriate use of new tech- agent for all health insurance plans from elimination of unnecessary services will nologies before their widespread intro- private insurance carriers and health be necessary if we are to control the duction to practice. A recent study by maintenance organizations; (3) to oper- aggregate expenditure on health care, the Institute of Medicine has examined ate the necessary group plans or risk while retaining the ability to introduce the questions of how to evaluate quality pools for those individuals without oth- new technologies that have the poten- and improve health care through quali- er means of access; and (4) to serve as a tial to substantially reduce mortality ty assurance, and has proposed a new clearinghouse for all provider billing and morbidity from illness. Adopting a quality review system for the Medicare and payment functions related to both universal RBRVS without controlling program.¹² public and private insurance programs. the volume of services that are provided These quality control strategies These agencies, however, should not be is unlikely to be an effective means of should be supported by the following responsible for setting hospital or pro- controlling the rate of growth in the cost two legislative actions. First, appropri- fessional payment rates. This function of physician services. Government and ations for the extramural grant pro- should be retained by the payers. private payers, therefore, should use grams and technology assessment ac- expenditure targets with the RBRVS tivities of federal agencies should be Primary Care Services to reduce the volume of unnecessary increased. Efforts should be focused on Universal access to care at an afford- services provided. This approach may the recently created federal Agency for able cost will require an adequate supply be easier to implement, and more wide- Health Care Policy and Research, of primary care physicians. Undergradu- ly accepted by consumers and provid- which has the potential to coordinate ate and graduate medical education pro- ers, than requiring that all health plans national activity in technology assess- grams must play a responsible role in be based on capitated payment to con- ment as well as the study of practice meeting this need. Medical schools must trol the volume of service. Negotiation patterns and guidelines. Second, the provide adequate time through their cur- of adjustments in both the RBRVS and schedule for incorporating capital costs ricula for student exposure to primary the expenditure targets of various pay- into Medicare's DRG payment should care in ambulatory as well as inpatient ers should occur on a regular basis be- be accelerated. Reimbursing hospitals settings. Program directors in family tween payers and providers. for fixed or movable capital expenses on medicine, internal medicine, and pediat- a cost basis does not place fiscal con- rics, with the support of the Accredita- Quality Assurance straints on the institution's capital ac- tion Council for Graduate Medical Educa- Attention to quality assurance will be quisition decisions. In order to include tion's residency review committee for necessary, if a reformed health care sys- all sources of capital funding in this each specialty, should develop innovative tem is to benefit patients. In addition, strategy, privately funded health insur- curricular tracks designed specifically to the level and rate of growth in health ance plans should adopt prospective train physicians for practice in under- care costs may be reduced, in part, by payment systems, as recommended served rural and urban sites. Appropria- measures designed to improve the qual- above, that incorporate regional or na- tions for primary care training grants ity of care. The effectiveness of, as well tional payment schedules similar to provided under the provisions of Title as the rationale for, technology assess- those used by the federal Medicare VII of the Public Health Service Act ment and quality assurance programs program. should be increased to allow the expan- as cost-containment strategies in our sion of training programs in family medi- health care system is an unresolved is- Regional Health Insurance Agencies cine, general internal medicine, and gen- sue." The main thrust of the strategy All insurers, both private and gov- eral pediatrics. should be to improve clinical decision ernment, should be required to develop A medical education loan forgiveness making and modify practice patterns, common formats for explaining bene- program, funded by federal and state thereby curtailing the unnecessary use fits, uniform enrollment procedures, government, should be developed to en- of diagnostic and therapeutic and centralized claims processing as a courage medical students to prepare for, technologies. means of simplifying and reducing the and practice in, a primary care specialty. A strategy to improve quality should administrative costs of the health care The program should provide partial loan be based on three important approach- system. forgiveness to practitioners who engage es. First, academic medical centers A clear need exists to simplify or in family medicine, general internal medi- should accept responsibility for expand- streamline the format or process for the cine, and general pediatrics. A greater ing health services research activities packaging and dissemination of health level of forgiveness should be provided 2518 JAMA, May 15, 1991 265, No. 19 Restructuring Health Care-Nutter et al for those physicians who choose to locate tem and the achievement of universal which will be influenced by a number of their practices in underserved rural or access, including our present proposal, factors, including the total price the na- urban areas. In addition to loan forgive- conform to this pluralistic model. tion is willing to pay for health care, the ness programs, the RBRVS should be Our plan, if fully implemented, should effectiveness of proposed cost contain- adjusted to provide reimbursement in- result in universal access to medical ment mechanisms, and the degree to centives that will encourage physicians care by virtue of (1) a federalized Medic- which we are willing to tolerate a multi- who are in needed specialties to practice aid program for all citizens who are be- tiered system of health care benefits. in underserved areas. low the poverty line, which could be We have not addressed the basic bene- Recognizing the importance of public extended by means of a "buy-in" to fits question since it falls beyond the facilities, as opposed to physicians' of- those citizens who are below 200% of the scope of this project, and its solution fices, as sites for providing health ser- poverty limit; (2) comprehensive medi- almost certainly will require panels of vices to most urban and some rural un- cal care for the elderly, and long-term experts from many disciplines. derserved citizens, federal and state care for the elderly and disabled The second issue is to determine what appropriations that support all forms of through Medicare; (3) provision of a additional costs would be incurred by community health centers should be in- health benefits plan by all employers; public and private payers if the reform creased. Attempts should be made to and (4) subsidized, regional health in- and innovation in health insurance pro- integrate local-area funding for the op- surance pools for those individuals who grams advocated in this plan are imple- eration of public health care facilities are not covered under the preceding mented. Estimating these costs is diffi- with state and federal support desig- programs. The strategy for limiting cult since even a simple, but realistic, nated for community facilities and pro- public and private sector expenditures calculation of supplemental costs to grams. In some areas, underutilized for the health benefits defined in our public and private payers requires a Veterans Affairs health care facilities proposal calls for universal application complex series of assumptions and esti- might be appropriate sites for these of DRG and RBRVS mechanisms to the mates. Critical determinations include health centers. Where feasible, the es- pricing of hospital and physician ser- the potential reductions in current costs tablishment of linkages between these vices, coupled with the use of expendi- resulting from reform and restructur- community centers and educational pro- ture targets by all payers, so that fiscal ing, the magnitude of cost shifting be- grams should be encouraged. performance would guide adjustments tween public and private payers that in the level of reimbursement for ser- COMMENT would occur as a result of restructuring, vices from a health plan or a provider the minimal level of benefits to be man- The most ambitious formula for univer- group. dated in the various plans, and, finally, sal access to health care and responsible Additional elements that should con- the additional costs of including those cost containment appears to be a federal tribute to cost containment include add- individuals who are presently unin- national health insurance program. It ed cost sharing through deductibles and sured in the new system. seems unlikely, however, that a national copayment to reduce the demand for Some would argue that the additional health insurance program will receive the services by consumers who are able to costs required to achieve universal ac- broad support necessary to achieve a leg- pay, and the development of practice cess to health and long-term care are islative mandate in this decade. A major guidelines and quality assurance pro- prohibitive. We disagree and believe factor supporting this viewpoint is the grams to discourage the unnecessary that recent cost estimates and the pro- failure of health care payers, providers, use of technology and services. Our pro- posed revenue sources for system re- and consumers to develop consensus on a posal to create nonprofit regional health form are manageable. 2,4,14 For example, national health care policy, or an agenda insurance agencies to simplify the pro- Thorpe and Siegel¹⁴ have analyzed the for health care reform. Other factors cess of enrollment in benefit plans, oper- new costs that would be incurred by that militate against the formation of a ate insurance pools, and centralize bill- enacting various combinations of ex- national health insurance program in- ing and payment for a pluralistic system panded Medicaid and employer health clude the widespread agreement that our of payers and intermediaries could con- insurance coverages. The public cost, as system should remain pluralistic with tribute to cost containment efforts but expressed in 1989 dollars, is estimated substantial roles for both public and pri- at the least should greatly simplify oper- to range from $11.5 to $29.5 billion. If, vate payers, and a lack of confidence in ations for both patients and providers. for example, Medicaid eligibility was comprehensive government social pro- If this plan, or any similar program, is extended to the poverty line for all citi- grams that is based on a record of ineffi- to be accepted and implemented, two zens, and those individuals who were ciency, rationing of services, and the issues must be addressed in a manner between 100% and 200% of the poverty perception of excessive regulation. Inter- that will prove satisfactory to health limit were permitted to buy-in by pay- estingly, the formation of a national care payers and consumers. In the first ing a premium, and all employers were health insurance program at present ap- instance, a comprehensive package of mandated to provide health insurance, pears to have more support from the busi- health care services that would consti- the new public cost would be estimated ness community, which has become seri- tute the minimum level of benefits to be at $17.1 billion. Regardless of the ap- ously concerned with the escalating costs provided by all public and private plans proach selected to achieve universal ac- of health benefits programs, than from must be defined. It will be necessary to cess to health care, there is little doubt the government or the public at large. set a basic benefit level for preventive that reasonable control of the total ex- Traditionally, health care in the Unit- medicine services, acute care (including penditure level, as well as the annual ed States has been a joint venture be- that for mental illness), rehabilitation, growth in costs for a restructured sys- tween the public and private sectors, and long-term care. At the same time, tem, will require implementation of cost with emphasis on employment-based we must decide whether all insurance containment mechanisms similar to, if health benefits and government pro- plans (eg, Medicare, Medicaid, employ- not more comprehensive than, those we grams for selected groups, such as the ee benefit plans, and risk-pooling pro- have proposed. elderly, the poor, the military, and war grams) would be required to offer the Several innovative plans recently veterans. Most of the recent plans for same minimum benefits package. These proposed for health care restructuring comprehensive restructuring of the sys- are difficult issues, the answers to have stimulated debate about our JAMA, May 15, 1991 265, No. 19 Restructuring Health Care-Nutter et al 2519 health care system in many quarters. port designed to meet the increasing our opinion, to solve the problems in our Three of these plans propose broad need for access to long-term care by all present system. changes in our existing pluralistic struc- segments of society deserves high In conclusion, we encourage the health ture for the provision and financing of marks. In this plan, the financing of professions and academic medical centers care and are similar in many ways to the long-term care would be a shared re- to work with business and government to present proposal. Enthoven and Kron- sponsibility of state and federal govern- achieve the goal of providing universal ick¹ have proposed mandatory employer ment and the individual. The commis- access to comprehensive, medically nec- health coverage of full-time workers, sion's public insurance plan, when fully essary health and long-term care services continuation of Medicare and Medicaid, implemented, would cost $66.2 billion in a manner that is compatible with the and federal incentives for states to act ($23.4 for full access to health care and principles and objectives outlined in this as "public sponsors" of private insur- $42.8 for access to long-term care) ex- report. Several major strategic initia- ance plans for those individuals who are pressed in 1990 dollars. This estimate tives will be required to achieve this goal. not otherwise covered. Their plan em- includes existing Medicaid dollars, new Fundamental changes in the administra- phasizes choice by the consumer of man- tax revenues, and payment from em- tion and financing of public and private aged-care plans that are competitive on ployers who choose not to provide pri- health insurance must occur. Providers, the basis of cost and service. It is not vate insurance. How the additional rev- business, and government must commit immediately evident that their "public enues required for the public health to contain the cost of health care through sponsor" program, in concert with the insurance program would be generated the prospective determination of prices present Medicare and Medicaid pro- is not specified. Despite the advantages for services and reduction in the volume grams, would be able to achieve univer- of this proposal in terms of programs for of unnecessary services provided. In- sal access to health care. health and long-term care, the authors creased effort must be devoted to quality The National Leadership Commis- believe that comparable results can be assurance aimed at the widespread use of sion on Health Care has clearly articu- obtained in a more straightforward appropriate practice guidelines and cost- lated the problems related to cost, ac- manner by the reform and restructur- effective clinical decision making. Final- cess, and quality of care that plague our ing of Medicaid and Medicare. In view of ly, a concerted effort by government and present health care system. Their Uni- the additional costs that this program the nation's academic medical centers is versal Access Plan calls for the defini- would add to the nation's health care necessary to provide adequate numbers tion of a basic health services package budget, the plan does not appear to con- of primary care physicians to serve the and a shared responsibility by the public tain sufficiently rigorous cost contain- public, especially in medically under- and private sectors for the provision and ment strategies. served areas. financing of care for all citizens and coin- The likely alternative to comprehen- cides with the key objectives and princi- sive reform of the health care system at ples presented in our plan. We also com- the national level is a variety of local References mend the commission's proposal for a solutions introduced state by state. 1. Enthoven A, Kronick R. A consumer-choice national quality improvement initia- Widespread activity on health care is- health plan for the 1990s: universal health insur- tive. A basic option health care version sues is under way in most state govern- ance in a system designed to promote quality and of the Universal Access Plan is estimat- ments and many proposals for health economy. N Engl J Med. 1989;320:29-37, 94-101. ed to cost $76.2 billion in 1988 dollars.2 care reform are pending or are in the 2. National Leadership Commission on Health Care. For the Health of a Nation: A Shared Re- In this case, the funding is to be ob- process of being enacted. One of the sponsibility. Ann Arbor, Mich: Health Administra- tained from existing federal and state most comprehensive, UNYCare, has tion Press; 1989. Medicaid funds, and the fees paid by been proposed by the New York State 3. Himmelstein DU, Woolhandler S. Writing Com- individuals and employers who do not Commissioner of Health. Individual mittee for the Working Group on Program Design. A national health program for the United States: a provide health insurance. The Univer- state action on health care, however, physician's proposal. N Engl J Med. 1989;320:102- sal Access Plan, however, may lack the may prove to be inefficient in both ad- 108. critical strategic elements necessary to ministrative and fiscal terms. From the 4. Preliminary Recommendations to the Congress point of effectiveness, the local ap- by the Pepper Commission. Washington, DC: US guarantee access and responsible cost Bipartisan Commission on Comprehensive Health containment. In the case of access, fail- proach may leave important gaps in ac- Care; 1990. ure to propose reforms in the Medicare cess to care, and could present problems 5. Health Access America: The AMA Proposal to and Medicaid programs, or to mandate for nationally based corporate employ- Improve Access to Affordable, Quality Health health insurance coverage by all em- ers who seek uniform benefits and rates Care. Chicago, Ill: American Medical Association; 1990. ployers, leaves potential gaps in a safety from insurance intermediaries and/or 6. Reinhardt UE. Health care spending and Amer- net to ensure universal coverage. Re- providers. Although local initiatives are ican competitiveness. Health Aff. 1989;8:4, 5-21. garding cost containment, the commis- often innovative, and sometimes suc- 7. Bulger RJ. Technology, Bureaucracy and Heal- ing in America: A Postmodern Paradigm. Iowa sion's reliance on quality improvement cessful at correcting specific local prob- City: University of Iowa Press; 1988. as the key to controlling costs, without lems, there is mounting evidence that 8. Monheit AC, Short PF. Mandating health cover- seeking specific reimbursement mecha- they are failing; for example, there are age for working Americans. Health Aff. 1989;8:4, nisms to control the pricing and volume excessively restrictive eligibility re- 22-38. 9. Aaron H, Schwartz WB. Rationing health care: of services provided, may not prove to quirements and subcost reimbursement the choice before us. Science. 1990;247:418-422. be effective. levels in the Medicaid programs of many 10. Fuchs VR. The health sector's share of the The Pepper Commission report offers states, there are budget shortfalls that gross national product. Science. 1990;247:534-538. a sound plan for universal access to preclude funding for recent health care 11. Ginzberg E. High-tech medicine and rising initiatives in Massachusetts and New health care costs. JAMA. 1990;263:1820-1822. health care through the replacement of 12. Lohr KN, Schroeder SA. Special Report: a Medicaid with a comprehensive public York, and there are low enrollments in strategy for quality assurance in Medicare. N Engl plan for the uninsured and a series of some state risk pool ventures for the J Med. 1990;322:707-712. incentives for expanded health insur- medically uninsurable. Although more 13. Ginzberg E. US health policy-expectations and realities. JAMA. 1988;260:3647-3650. ance coverage in the workplace that is difficult to achieve, a set of coherent 14. Thorpe KE, Siegel JE. Covering the unin- similar to our proposal.⁴ A comprehen- health care system reforms enacted at sured: interactions among public and private sector sive approach in the commission's re- the national level will be necessary, in strategies. JAMA. 1989;262:2114-2118. 2520 JAMA, May 15, 1991 265, No. 19 Restructuring Health Care-Nutter et al IN LOWER RESPIRATORY INFECTIONS CIPRO® MAKES A TOUGH THERAPEUTIC CHOICE EASIER. Cipro® achieved 96% clinical success in pneumonia, bronchitis, and bronchiectasis²*-even in patients who: smoke, drink *Achieves 96% favorable clinical response (resolu- live in nursing homes tion + improvement) of infections due to suscep- have underlying conditions, such have a history of repeated tible strains of indicated pathogens. See indicated as COPD organisms in prescribing information. antibiotic use that has proven tin vitro activity does not necessarily imply a correla- are elderly or immunocompromised ineffective tion with in vivo results. NOTE: Concurrent administration of ciprofloxacin with theophylline may lead to elevated plasma concentrations of theophylline and prolongation of its elimination half-life. This may result in increased risk of theophylline-related adverse reactions. If concomitant use cannot be avoided, plasma levels of theophylline should be monitored and dosage adjustments made as appropriate. TABLETS Antacids containing magnesium hydroxide or aluminum hydroxide interfere with the absorption of ciprofloxacin, resulting in serum and urine levels lower than desired; concurrent administration of these agents with ciprofloxacin should be avoided. ipro A history of hypersensitivity to ciprofloxacin is a contraindication to its use. A history of hyper- sensitivity to other quinolones may also contrain- dicate the use of ciprofloxacin. CIPRO® SHOULD NOT BE USED IN CHILDREN, (ciprofloxacin HCI) ADOLESCENTS, OR PREGNANT WOMEN. See next page for brief summary of prescribing information. The most potent fluoroquinolone. 2-4t TABLETS ipro IN LOWER RESPIRATORY INFECTIONS CIPRO® MAKES A TOUGH (ciprofloxacin HCI) THERAPEUTIC CHOICE EASIER. CIPRO TABLETS was produced and no embryotoxicity or teratogenicity was observed There are however no adequate and well- controlled studies in pregnant women SINCE CIPROFLOXACIN, LIKE OTHER DRUGS IN ITS CLASS CAUSES (ciprofloxacin HCI) ARTHROPATHY IN IMMATURE ANIMALS IT SHOULD NOT BE USED IN PREGNANT WOMEN (SEE WARNINGS) Nursing Mothers: It is not known whether ciprofloxacin IS excreted in human milk however. it is known that BRIEF SUMMARY ciprofloxacin is excreted in the milk of lactating rats and that other drugs of this class are excreted in human milk CONSULT PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION Because of this and because of the potential for serious adverse reactions from ciprofloxacin in nursing infants. a decision should be made to discontinue nursing or to discontinue the drug. taking into account the importance of the INDICATIONS AND USAGE drug to the mother Cipro* is indicated for the treatment of infections caused by susceptible strains of the designated microorganisms in Pediatric Use: Patients under the age of 18 were not included in the clinical trials of ciprofloxacin because ciprofloxacin as well as other quinolones causes thropathy in immature animals Ciprofloxacin should not be used in children or the conditions listed below: Lower Respiratory Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae. Proteus adolescents (SEE WARNINGS) mirabilis, Pseudomonas aeruginosa, Haemophilus influenzae. Haemophilus parainfluenzae, and Streptococcus ADVERSE REACTIONS pneumoniae. Ciprofloxacin is generally well tolerated During clinical investigation, 799 patients received 2.868 courses of the Skin and Skin Structure Infections caused by Escherichia coll, Klebsiella pneumoniae. Enterobacter cloacae, Proteus drug Adverse events that were considered likely to be drug related occurred in 7 3% of courses possibly related in mirabilis. Proteus vulgaris. Providencia stuartii, Morganella morganii, Citrobacter freundir, Pseudomonas 2%, and remotely related in 3 0% Ciprofloxacin was discontinued because of an adverse event in 3 5% of courses aeruginosa, Staphylococcus aureus. Staphylococcus epidermidis. and Streptococcus pyogenes. primarily involving the gastrointestinal system 5%). skin (0 6%) and central nervous system (0 4%) Those events Bone and Joint Infections caused by Enterobacter cloacae, Serratia marcescens and Pseudomonas aeruginosa. typical of quinolones are italicized Urinary Tract Infections caused by Eschenchia coir. Klebsiella pneumoniae, Enterobacter cloacae, Serratia mar- The most frequently reported events. drug related or not were nausea (5 2%). diarrhea (2 3%). vomiting 0%) cescens. Proteus mirabilis. Providencia rettgeri, Morganella morganii, Citrobacter diversus. Citrobacter freundii. abdominal discomfort 7%). headache 2%). restlessness 1%) and rash (1 1%) Pseudomonas aeruginosa, Staphylococcus epidermidis. and Streptococcus faecalis Additional events that occurred in less than 1% of ciprofloxacin courses are listed below Infectious Diarrhea caused by Escherichia (enterotoxigenic strains). Campylobacterje Shigella flexneri, and GASTROINTESTINAL (See above). painful oral mucosa oral candidiasis. dysphagia, intestinal perforation Shigella sonnei* when antibacteri therapy is indicated gastrointestinalbleeding *Efficacy for this organism in this organ system was studied in fewer than 10 infections CENTRAL NERVOUS SYSTEM above) dizziness lightheadedness insomnia nightmares hallucinations CONTRAINDICATIONS manic reaction. irritability. tremor, ataxia convulsive seizures lethargy drowsiness. weakness malaise. A history of hypersensitivity to ciprofloxacin is a contraindication to its use A history of hypersensitivity to other anorexia phobia depersonalization. depression paresthesia quinolones may also contraindicate the use of ciprofloxacin. SKIN/HYPERSENSITIVITY (See above). pruritus. urticaria. photosensitivity flushing. fever chills angioedema. edema of the face, neck. lips. conjunctivae or hands. cutaneous candidiasis. hyperpigmentation WARNINGS CIPROFLOXACIN SHOULD NOT BE USED NCHILDREN ADOLESCENTS OR PREGNANT WOMEN The adminis- eryihema nodosum Allergic reactions ranging from ur ticaria to anaphylactic reactions have been report (SEE PRECAUTIONS) tration of ciprofloxacin caused lameness in immature dogs Histopathological examination of the weight-bearing SPECIAL SENSES blurred vision. disturbed vision (change in color perception overbrightness of lights) joints of these dogs revealed permanent lesions of the cartilage. Related drugs such as nalidixic acid. cinoxacin, and decreased visual acuity. diplopia eye pain. tinnitus. hearing loss. bad taste nortloxacin also produced erosions of cartilage of weight-bearing joints and other signs of arthropathy in immature MUSCULOSKELETAL joint or back pain joint stiffness. achiness neck or chest pain Hare-up of gout animals of various species (SEE ANIMAL PHARMACOLOGY SECTION IN FULL PRESCRIBING INFORMATION). RENAL UROGENITAL interstitial nephritis nephritis renal failure. polyuria unnary retention urethral bleed- PRECAUTIONS ing. vaginitis. acidosis General: As with other quinolones, ciprofloxacin may cause central nervous system (CNS) stimulation, which may CARDIOVASCULAR: palpitations. atrial flutter. ventricular ectopy. syncope nyper tension angina pectoris, lead to tremor, restlessness, lightheadedness, confusion, and rarely to hallucinations or convulsive seizures There- myocardial infarction, cardiopulmonary arrest cerebral thrombosis fore. ciprofloxacin should be used with caution in patients with known or suspected CNS disorders, such as severe RESPIRATORY epistaxis laryngeal or pulmonary edema hiccough hemophysis dyspnea. bronchospasm. cerebral arteriosclerosis or epilepsy. or other factors which predispose to seizures (SEE ADVERSE REACTIONS). pulmonary embolism. Anaphylactic reactions following the first dose have been reported in patients receiving therapy with quinolones Most of the adverse events reported were described as only mild or modera in severity abated 5000 after the drug Some reactions were accompanied by cardiovascular collapse, loss of consciousness, tingling. pharyngeal or facial was discontinued and required no treatment edema, dyspnea. urticaria, and itching Only a few patients had a history of hypersensitivity reaction Anaphylactic In severa instances, nausea, vomiting. tremor restlessness agitation or palpitations judged by investigators reactions may require epinephrine and other emergency measures Ciprofloxacin should be discontinued at the first to be related to elevated plasma levels of theophylline possibly as a result of a drug interaction with ciprofloxacin sign of hypersensitivity or allergy. Other adverse events reported in the postmarketing phase include anaphylactoid reactions Stevens-Johnson Severe hypersensitivity reactions characterized by rash. fever. eosinophilia, jaundice, and hepatic necrosis with syndrome exfoliative dermatitis, toxic epidermal necrolysis hepatic necrosis. postural hypotension, possible exac- fatal outcome have been reported rarely (less than one per million prescriptions) in patients receiving ciprofloxacin erbation of myasthenia gravis, confusion dysphasia, nystagmus, pseudomembranous colitis. dyspepsia, flatulence. along with other drugs. The possibility that these reactions were related to ciprofloxacin cannot be excluded and constipation Also reported were agranulocytosis; elevation of serum triglycerides. serum cholesterol. blood Ciprofloxacin should be discontinued at the first appearance of a skin rash or any sign of other hypersensitivity glucose. serum potassium: prolongation of prothrombin time: albuminuria candiduria vaginal candidiasis and renal reaction calculi (SEE PRECAUTIONS). Crystals of ciprofloxacin have been observed rarely in the urine of human subjects but more frequently in the urine Adverse Laboratory Changes: Changes in laboratory parameters listed as adverse events without regard to drug of laboratory animals (SEE ANIMAL PHARMACOLOGY SECTION IN FULL PRESCRIBING INFORMATION). Crystalluria relationship related to ciprofloxacin has been reported only rarely in man, because human urine is usually acidic Patients receiving Hepatic-Elevations of ALT (SGPT) 9%) AST (SGOT) (1 7%) alkaline phosphatase (0 8%). LDH 10 4%) ciprofloxacin should be well hydrated and alkalinity of the urine should be avoided The recommended daily dose serum bilirubin 3%) should not be exceeded Cholestatic jaundice has been reported Alteration of the dosage regimen is necessary for patients with impairment of renal function (SEE DOSAGE AND Hematologic-Eosinophilia (0 6%). leukopenia (0 4%), decreased blood platelets (0 1%). elevated blood ADMINISTRATION). platelets (0 1%). pancytopenia 10 1%) As with any potent drug, periodic assessment of organ system functions, including renal hepatic, and hema- Elevations of Serum creatinine (1 1%). BUN (0 9%) topoietic function. is advisable during prolonged therapy CRYSTALLURIA CYLINDRURIA, AND HEMATURIA HAVE BEEN REPORTED Drug Interactions: As with other quinolones, concurrent administration of ciprofloxacin with theophylline may lead to Other changes occurring in less than 0 1% of courses were Elevation of serum gammagiutamy ansferase, elevation elevated plasma concentrations of theophylline and prolongation of its elimination half-life This may result in of serum amylase, reduction in blood glucose elevated uric acid. decrease in hemoglobin, anemia. bleeding increased risk of theophylline-related adverse reactions. If concomitant use cannot be avoided plasma levels of diathesis increase in blood monocytes and leukocytosis theophylline should be monitored and dosage adjustments made as appropriate OVERDOSAGE Quinolones, including ciprofloxacin, have also been shown to interfere with the metabolism of caffeine. This may Information on overdosage in humans is not available In the event of acute overdosage. the stomach should be lead to reduced clearance of caffeine and a prolongation of its plasma half-life emptied by inducing vomiting or by gastric lavage The patient should be carefully observed and given supportive Antacids containing magnesium hydroxide or aluminum hydroxide may interfere with the absorption of ciproflox- treatment Adequate hydration must be maintained Only a small amount of ciproflexacin 10%) is removed from acin resulting in serum and urine levels lower than desired: concurrent administration of these agents with the body after hemodialysis or peritoneal dialysis ciprofloxacin should be avoided DOSAGE AND ADMINISTRATION Concomitant administration of the nonsteroidal anti-inflammatory drug fenbufen with a quinoione has been reported to increase the risk of CNS stimulation and convulsive seizures. The usual adult dosage for patients with urinary tract infections is 250 mg every 12 hours. For patients with Probenecid interferes with the renal tubular secretion of ciproflexacin and produces an increase in the level of complicated infections caused by organisms not highly susceptible 500 mg may be administered every 12 hours ciprofloxacin in the serum. This should be considered if patients are receiving both drugs concomitantly Lower respiratory tract infections skin and skin structure infections and bone and joint infections may be treated As with other broad-spectrum antibiotics. prolonged use of ciprofloxacin may result in overgrowth of nonsuscep- with 500 mg every 12 hours For more severe or complicated infections a dosage of 750 mg may be given every 12 tible organisms Repeated evaluation of the patient's condition and microbial susceptibility testing is essential If hours superinfection occurs during therapy, appropriate measures should be taken. The recommended dosage for infectious diarrhea is 500 mg every 12 hours Information for Patients: Patients should be advised that ciprofloxacin may be taken with or without meals The In patients with renal impairment, some modification of dosage is recommended (SEE DOSAGE AND ADMINIS preferred time of dosing is two hours after a meal. Patients should also be advised to drink fluids liberally and not take TRATION SECTION IN FULL PRESCRIBING INFORMATION) HOW SUPPLIED antacids containing magnesium or aluminum Patients should be advised that ciprofloxacin may be associated with hypersensitivity reactions even following a Cipro* (ciprofloxacin HCI/Miles) is available as tablets of 250 mg. 500 mg. and 750 mg in bottles of 50, and in Unit- single dose, and to discontinue the drug at the first sign of a skin rash or other allergic reaction Dose packages of 100 (SEE FULL PRESCRIBING INFORMATION FOR COMPLETE SCRIPTION) Ciprofloxacin may cause dizziness or lightheadedness; therefore patients should know now they react to this drug References: 1. Data on file. Miles Inc Pharmaceutical Division 2. Barry AL Jones RN Thornsberry before they operate an automobile or machinery or engage in activities requiring mental alertness or coordination Patients should be advised that ciprofloxacin may increase the effects of theophylline and caffeine C et al Antibacterial activities of ciprofloxacin, norfloxacin. oxolinic acid, cinoxacin, and nalidixic Carcinogenesis, Mutagenesis, Impairment of Fertility: Eight in vitro mutagenicity tests have been conducted with acid. Antimicrob Agents Chemother 1984 25 633-637 3. Guimaraes MA. Noone P The comparative in-vitro activity of norfloxacin, ciprofloxacin, enoxacin and nalidixic acid against 423 ciprofloxacin and the test results are listed below: Salmonella/Microsome Test (Negative) strains of gram-negative rods and staphylococci isolated from infected hospitalised patients J Antimicrob Chemother 1986;17:63-67 4. Van Caekenberghe DL, Pattyn SR In vitro activity of E. coli DNA Repair Assay (Negative) Mouse Lymphoma Cell Forward Mutation Assay (Positive) ciprofloxacin compared with those of other new fluorinated piperazinyl-substituted quinolone Chinese Hamster V79 Cell HGPRT Test (Negative) derivatives Antimicrob Agents Chemother 1984 25 518-521 Syrian Hamster Embryo Cell Transformation Assay (Negative) Saccharomyces cerevisiae Point Mutation Assay (Negative) Saccharomyces cerevisiae Mitotic Crossover and Gene Conversion Assay (Negative) Rat Hepatocyte DNA Repair Assay (Positive) Thus. two of the eight tests were positive, but the results of the following three in VIVO test systems gave negative For further information, contact the Miles Information Service: results: Rat Hepatocyte DNA Repair Assay 1-800-642-4776. In VA, call collect: 703-391-7888. Micronucleus Test (Mice) Dominant Lethal Test (Mice) Long-term carcinogenicity studies in rats and mice have been completed. After daily oral dosing for up to 2 years. COMMITTED TO THERAPEUTIC EFFICIENCY there is no evidence that ciprofloxacin had any carcinogenic or tumorigenic effects in these species. Miles Inc. Pregnancy-Pregnancy Category C: Reproduction studies have been performed in rats and mice at doses up to 6 Pharmaceutical Division times the usual daily human dose and have revealed no evidence of impaired fertility or harm to the fetus due to 400 Morgan Lane ciprofloxacin In rabbits as with most antimicrobial agents, ciprofloxacin (30 and 100 mg/kg orally) produced MILES West Haven, CT 06516 gastrointestinal disturbances resulting in maternal weight loss and an increased incidence of abortion No terato- genicity was observed at either dose After intravenous administration, at doses up to 20 mg/kg, no maternal toxicity o October 1990. Miles Inc. Pharmaceutical Division C09280 MIL-6172 FL YING DOC LARGE MEDICAL PRACTICE AVAILABLE. FLYING LESSONS INCLUDED. Not every doctor gets around at over twice the speed of sound. But if you qualify to be a Flight Surgeon, that's the kind of excitement that awaits you as a Navy Physician. Other qualified physicians can operate out of Europe, the Caribbean or the Orient. Still others can study fields seldom found in civilian practice, like undersea medicine. All Navy Physicians enjoy an attractive benefits package: No overhead, mal- practice protection, 30 days Navy physicians are stationed in some of the finest medical facilities in the world. paid vacation and more. Most important, though, is the pride and respect that comes from wearing a Navy Officer uniform. Talk to a Navy Medical Programs Officer today. Or call 1-800-327-NAVY. Then get ready to make your move. NAVY Because in today's Navy, you only go Being a Navy physician gives you the opportunity to travel YOU AND THE NAVY. around the world with your family. one way: Full speed ahead. FULL SPEED AHEAD. 2521 HOW TO DESTROY AN WITHOUT ENDANGER ENTIRE POPULATION ING THIS SPECIES. For years, the most effective treatment for scabies infestations has also been potentially toxic to children. Until now. Elimite™ Cream is the first and only available scabicide with a 5% permethrin formulation that works safely and effectively.* Studies involving over 520 patients concluded that Elimite Cream offers highly effective efficacy after one application, with infestation cure rates in excess of 90%. 1,2 Elimite Cream was also highly successful in resistant cases where Kwell® (lindane) 1% Cream had failed. 3,4,5 More importantly, it works without the potential threat of CNS toxicity which may be associated with lindane overexposure. 1,6 You can assure parents that Elimite Cream has been safely evaluated on infants as young as two months old. 7,8 Elimite Cream offers a convenient, one-time application that is odorless and doesn't stain. To top it off, Elimite Cream spreads on like a lotion, and washes out of the scalp as easily as shampoo. For effective treatment from head to toe, prescribe Elimite Cream. Call Herbert Laboratories at 1-800-347-4500 for more information today. And begin eliminating the potential danger of eliminating scabies. ELIMITE TM (permethrin) 5% Cream Available in a 60 g tube *Itching, mild burning and/or stinging may occur after application of Elimite Cream. Herbert Laboratories Herbert Laboratories, A Division of Allergan, Inc., Irvine, CA 92713 © 1991 Allergan, Inc. Kwell® is a registered trademark of Reed & Carnrick. See next page for brief prescribing information and references. ELIMITE TM Cream (permethrin) 5% INDICATIONS AND USAGE: Elimite (permethrin) 5% Cream is indicated for the single-application treatment of infestation with Sarcoptes scabiei (scabies). CONTRAINDICATIONS: Elimite is contraindicated in patients with known hypersensitivity to any of its components, to any synthetic pyrethroid, or pyrethrin. WARNINGS: If hypersensitivity to Elimite occurs, discontinue use. PRECAUTIONS: General: Scabies infestation is often accompanied by pruritus, edema and erythema. Treatment with Elimite may temporarily exacerbate these conditions. Information for patients: Patients with scabies should be advised that itching, mild burning and/or stinging may occur after application of Elimite. In clinical trials approximately 75% of patients treated with Elimite who continued to manifest pruritus at 2 weeks had cessation by 4 weeks. If irritation persists, they should consult their physician. Elimite may be very mildly irritating to the eyes. Patients should be advised to avoid contact with eyes during application and to flush with water immediately if Elimite gets in the eyes. Carcinogenesis, mutagenesis, impairment of fertility: Six carcinogenicity bioassays were evaluated with permethrin, three each in rats and mice. No tumorigenicity was seen in the rat studies. However, species-specific increases in pulmonary adenomas, a common benign tumor of mice of high spontaneous background incidence, were seen in the Guilt three mouse studies. In one of these studies there was an increased incidence of pulmonary alveolar-cell carcinomas and benign liver adenomas only in female mice when permethrin was given in their food at a concentration of 5000 ppm. Mutagenicity assays, which give useful correlative data for interpreting results from carcinogenicity bioassays in rodents, were negative. Permethrin showed no evidence of mutagenic by Association potential in a battery of in vitro and in vivo genetic toxicity studies. Permethrin did not have any adverse effect on reproductive function at a dose of 180 mg/kg/day orally in a three-generation rat study. Pregnancy: teratogenic effects: Pregnancy Category B: Reproduction studies have been performed in mice, rats, and rabbits (200 to 400 mg/kg/day orally) and have revealed no evidence of impaired fertility or harm to the fetus due to Collective action by independently practicing permethrin. There are, however, no adequate and well-controlled studies in physicians can violate U.S. antitrust laws unless pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy physicians proceed very cautiously. only if clearly needed. Nursing mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the evidence for tumorigenic potential of permethrin in Case in point: animal studies, consideration should be given to discontinuing nursing temporarily or withholding the drug while the mother is nursing. Pediatric use: Elimite is safe and effective in children two months of age and older. At a recent medical society meeting, during Safety and effectiveness in children less than two months of age have not been established. ADVERSE REACTIONS: In clinical trials, generally mild the discussion of a proposed HMO agreement, and transient burning and stinging followed application with Elimite in 10% several doctors said that they would not par- of patients and was associated with the severity of infestation. Pruritus was reported in 7% of patients at various times post-application. Erythema, ticipate in the plan unless the payor increased numbness, tingling, and rash were reported in 1 to 2% or less of patients (see PRECAUTIONS: General). OVERDOSAGE: No instance of accidental reimbursement. If a substantial number of ingestion of Elimite has been reported. If ingested, gastric lavage and general supportive measures should be employed. DOSAGE AND physicians later declined to participate in the ADMINISTRATION: Adults and children: Thoroughly massage Elimite into HMO, the medical society and its members the skin from the head to the soles of the feet. Scabies rarely infests the scalp of adults, although the hairline, neck, temple, and forehead may be could be sued, and a jury could find them infested in infants and geriatric patients. Usually 30 grams is sufficient for an average adult. The cream should be removed by washing (shower or guilty of a group boycott in violation of U.S. bath) after 8 to 14 hours. Infants should be treated on the scalp, temple and antitrust laws. forehead. ONE APPLICATION IS CURATIVE. Patients may experience persistent pruritus after treatment. This is rarely a sign of treatment failure and is not an indication for retreatment. This may be the most important book you'll ever read: Manufactured for Herbert Laboratories Collective Negotiation and Antitrust A Division of Allergan, Inc. Irvine, CA 92713, U.S.A. A Guide for Physicians by Burroughs Wellcome Co. Research Triangle Park, NC 27709 The American Medical Association, Office of the General Counsel, has published this book to help you avoid antitrust pitfalls and improve Herbert Laboratories Herbert Laboratories your ability to bargain effectively with payors. A Division of Allergan, Inc. Irvine, CA 92713 ©1991 Allergan, Inc. To Order, Call Today: 1-800-621-8335 References: 1. Schultz M. Comparative study of 5% permethrin cream and Price: $5.00 (AMA Members) 1% lindane lotion for the treatment of scabies. Arch Dermatol 1990 Feb;126:167-170. $7.50 (Non-members) 2. Taplin D, Meinking TL. Scabies, lice and fungal infections. Primary Care 1989 Sept;16(3):555. 3. Taplin D et al. Permethrin 5% dermal cream: A new treatment for scabies. J Am Acad Dermatol 1986 Nov; 15:995-1001. 4. Yonkosky D et al. Scabies in nursing homes: an eradication program with M permethrin 5% cream. J Am Acad Dermatol 1990;23(6):1133-1136. 5. Taplin D, Meinking TL. Pyrethrins and pyrethroids in dermatology. Arch Derm 1990 Feb; 126:213-221. 6. Davies JE, Dedhia HV, Morgade C et al. Lindane poisonings. Arch Dermatol 1983;119:142-144. ASSOCIATION AMERICAN MEDICAL 7. Taplin D et al. Comparison of crotamiton 10% cream (Eurax) and permethrin 5% cream (Elimite) for the treatment of scabies in children. Pediatric Dermatol 1990; 7(1):67-73. 8. Taplin D, Meinking TL. Infestations. In: Schachner LA and Hansen RC, American Medical Association eds. Pediatric Dermatology. Vol 2. New York, Edinburgh, London, Melbourne, Churchill Livingstone:1988;1465-1515. 2524 Expanding Medicare and Employer Plans to Achieve Universal Health Insurance Karen Davis, PhD This article presents a proposal for expanding Medicare and employer-based establishing common provider payment health insurance plans to achieve universal health insurance. Under this pro- methods applicable to both Medicare posed health care financing system, employers would provide basic health and employer plans. It would be fi- insurance coverage to workers and dependents, or pay a payroll tax contribution nanced through a combination of em- toward the cost of their coverage under Medicare. States would have the option ployer and individual premium contri- of buying all Medicaid beneficiaries and other poor individuals into Medicare by butions, payroll taxes, personal income taxes, and other general tax revenues. paying the Medicare premiums and cost sharing. Other uninsured individuals would be automatically covered by Medicare. Employer plans would incorporate RATIONALE Medicare's provider payment methods. This proposal would result in incremen- The strongest elements of the current tal federal governmental outlays on the order of $25 billion annually. These new US health financing system are the federal budgetary costs would be met through a combination of premiums, Medicare program and health insurance employer payroll tax, income tax, and general tax revenues. The principal provided through large employer-based advantage of this plan is that it draws on the strengths of the current system while plans. Both are popular with beneficia- simplifying the benefit and provider payment structure and instituting innovations ries and have a proven record of admin- to promote efficiency. istrative efficiency with a low ratio of (JAMA. 1991;265:2525-2528) administrative expenses to benefits. Medicare has adopted new methods of paying hospitals and physicians that provide incentives for provider efficien- THE UNITED STATES has a mixed alized nation. Of greatest concern, an cy, simplify administration for both the public-private system of financing estimated 37 million uninsured people program and providers, improve the eq- health care. In 1988, of 244 million are vulnerable to receiving inadequate uity of payment among providers, and Americans, 13% were covered by Medi- health care in the event of illness or give the federal government an en- care, 6% by Medicaid, 57% by employer injury and are exposed to the risk of hanced ability to moderate the histori- health plans, 9% by individual insurance severe financial hardship from health cal rates of spending growth. Many or other sources, and 15% were unin- care bills.2⁴ large employer plans have been innova- sured.¹ This patchwork approach to This article presents a plan to cover tive in the establishment of incentives health insurance coverage, while it the entire US population by building for employees to join lower-cost health serves some Americans well, contrib- on the two strongest elements of maintenance organizations and other utes to a complex, costly health care the current system-employer-pro- managed care plans. system. The United States spends 12% vided health insurance and the Medi- The Medicaid program is an impor- of its gross national product on health care program, which currently covers tant source of health financing for the care-far more than any other industri- elderly and disabled persons-while in- poor and has been instrumental in im- stituting a new universal provider pay- proving access to health care for many ment system to control rising costs. of the nation's poor. 7-9 It is the only sig- This plan would achieve greater effi- nificant source of financing for long- From the Department of Health Policy and Manage- ciency and simplicity by establishing a term care-with over 40% of Medicaid ment, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Md. common basic benefit package under expenditures devoted to nursing home Reprints not available. both Medicare and employer plans, and care. However, the program has a num- JAMA, May 15, 1991 Vol 265, No. 19 Expanding Medicare and Employer Plans-Davis 2525 ber of limitations. Medicaid provider 20% would apply to all services other States would be responsible for sharing payment rates are clearly substandard. than hospital care. Cost sharing would with the federal government the cost of The program is administratively com- be limited to $1500 for an individual, or the Medicare Part B premium (current- plex, causing many eligible people to fail $3000 for a family annually. ly $32 monthly), deductibles, and coin- to participate. surance on covered services. The effect The most unsatisfactory sources of Employer Responsibilities of this provision is to shift most of the insurance coverage are individual insur- Employers would be required to con- cost of hospital and physician services ance plans and small group insurance. tribute toward the health insurance for Medicaid beneficiaries to the federal Such plans have high administrative coverage of full-time and part-time (de- government, and nearly all states could costs, charge high premiums, exclude fined as at least 10 hours per week) be expected to do so. In addition, states individuals who are major health risks, workers and dependents. Since all em- could elect to supplement the Medicare and exclude coverage for preexisting ployers would be subject to this require- benefit package, covering prescription conditions. ment, working spouses would be cov- drugs, dental care, and other optional Building on the strongest parts of the ered under their own employer's plan. services with full state funding. current US health financing system Employer coverage under private The federal government would con- would have several advantages. With plans would be required to cover bene- tinue to share in the cost of long-term an existing administrative structure, fits at least as comprehensive as the care services for Medicaid beneficiaries expanded coverage could be implement- Medicare benefit package. Employers according to the current federal-state ed relatively quickly with minimal dis- could choose to provide benefits beyond matching rate. Reform of long-term ruption of current coverage. Further, this benefit package, without penalty to care financing is also an important issue by building on current programs rather employers or workers. for the national health policy agenda, than replacing them, current revenue Employers would be required to con- but is not addressed herein. It adds sig- sources would be maintained. Any new tribute at least 6% of employee earnings nificantly to the cost of any health insur- taxes or other revenues could be tar- on average toward private plan cover- ance reform proposal, and is, in my geted for care of the uninsured, rather age, not to exceed the cost of the basic view, best addressed separately on its than, for example, requiring major tax benefit plan. Employees would be re- own merits. increases to replace existing private sponsible for the remainder of the pre- The Medicare provider payment coverage. mium, but could negotiate with employ- rates for hospitals, physicians, and oth- ers to cover a higher percentage. er providers would apply to services BASIC STRUCTURE Alternatively, employers could meet provided to low-income beneficiaries All employers would be required to this obligation by paying a 6% payroll bought into Medicare coverage by the provide basic health insurance coverage tax to Medicare, resulting in coverage of states. Physicians would not be permit- to full-time and part-time workers and workers and dependents under Medi- ted to charge low-income beneficiaries dependents, or pay a payroll tax contri- care. Families bought into coverage un- fees in excess of the Medicare allowable bution toward the cost of their coverage der Medicare by employers would also fees. under Medicare. Required employer fi- contribute 2% of their family income to- nancial obligations under either private ward coverage. Contributions to health Remaining Uninsured insurance or Medicare would be limited coverage under either private plans or An estimated 5 to 8 million nonpoor to 6% of workers' wages. This would Medicare for low-income families would individuals would remain uninsured af- expand coverage to two thirds of the be offset by an increase in the earned ter expansion of employer coverage to uninsured who are members of working income tax credit to ensure that such all working families and Medicaid buy- families. States would be given the op- coverage would be affordable for low- in to Medicare of all poor individuals. tion of buying all current Medicaid bene- wage workers. Some of these individuals are early re- ficiaries and others below the poverty tirees who do not have retiree health income level into Medicare, shifting State Medicaid Plans benefits; some are disabled individuals most of the cost of basic hospital and States would be given the option of who have not met the 2-year waiting physician benefits to the federal gov- buying all Medicaid beneficiaries and period for Medicare coverage." ernment. The remaining uninsured other individuals below the federal pov- All remaining uninsured individuals would be covered under Medicare, and erty income level into Medicare. Cur- would be automatically covered under would be assessed an income-related rently, states are required to buy Medi- Medicare. They would be assessed a tax premium through the income tax care coverage for all elderly and equal to 2% of their income, prorated system. disabled Medicare beneficiaries with in- over the year for any portion of the year comes below the federal poverty level, during which the individual was not cov- Benefits and recent legislation will require Med- ered by private insurance. This would The current Medicare benefit pack- icaid programs to pay the Medicare pre- guarantee that all individuals who fail to age would be expanded to include pre- miums for those with incomes up to be covered under an employer plan, an ventive care for pregnant women and 120% of the federal poverty level. In individual health insurance plan, or a children, in addition to the current ben- addition, under recent legislation states state Medicare buy-in plan would be efit package of hospital services, physi- will be required to provide Medicaid protected from the risk of financial ca- cian services, limited home care and coverage to all children up to age 18 tastrophe in the event of a serious ill- nursing home care, limited mental years in families with incomes below the ness or injury. health services, and limited adult pre- federal poverty level. Medicare Beneficiaries ventive services. The cost-sharing Under the proposal, states would be structure of Medicare would be revised given the option of enrolling all Medic- Medicare beneficiaries would experi- to include a maximum $250 per person, aid beneficiaries in Medicare. However, ence some changes under the plan. The or $500 per family deductible-rather states electing this option would be re- cost-sharing structure would be modi- than separate deductibles for hospital quired to extend this option to all unin- fied to include a single deductible of $250 and physician services. A coinsurance of sured poor adults as well as children. per person for all services, rather than 2526 JAMA, May 15, 1991 265, No. 19 Expanding Medicare and Employer Plans-Davis separate hospital and physician deduct- Provider Payment and the proposal, a rough estimate can be ibles. A ceiling on out-of-pocket ex- System Reform obtained by drawing on the work of the penses of $1500 per person would be Employer plans would incorporate Pepper Commission." The benefits and established. On average, beneficiary Medicare's provider payment methods. coverage of the proposal are quite simi- cost-sharing burdens could be expected Specifically, physicians would be paid lar to the Pepper proposal, although the to decline, especially for those who have according to the Medicare Fee Schedule sources of financing, cost-containment catastrophic illnesses or injuries. for all services, and a maximum limit on methods including universal provider balance billing would be set on all ser- payment, role of private insurance, and Financing vices similar to that in the Medicare administrative mechanisms differ. Like The current Medicare Trust Funds program. Employers electing to pay the the Pepper plan, it can be expected that would be replaced with two new trust balance bills for workers and depen- the incremental federal governmental funds: the Medicare Elderly and Dis- dents would be permitted to do so. outlays will be on the order of $25 billion abled Beneficiaries Trust Fund and the The Medicare Fee Schedule would re- annually (my estimate). These costs Medicare Employed Families and Indi- sult in lower physician payments than is would be somewhat lower given the ex- viduals Trust Fund. Current Medicare currently the case in some private em- pansions of Medicaid that have occurred beneficiaries services would be financed ployer plans. Physicians would receive since the cost of the Pepper proposal by revenue flows into the Medicare El- higher payments for Medicaid and unin- was estimated. The cost-containment derly and Disabled Beneficiaries Trust sured patients. This would provide great- mechanisms set forth may also result in Fund. Newly covered Medicare benefi- er equity to physicians who currently lower costs over time. ciaries, including those bought in by em- provide a disproportionate share of care The new federal budgetary costs ployer contributions and by state Med- to low-income patients, and expand avail- would be met through a combination of icaid plans, would be covered under the ability of care to such patients. employer payroll tax contributions set Medicare Employed Families and Indi- The Medicare Volume Performance at 6% of earnings for those newly cov- viduals Trust Fund. Standard that now establishes a target ered under Medicare and individual con- The current financing of care for the for growth in expenditures for physician tributions set at 2% of earnings for those elderly and disabled would be modified services under Medicare would be modi- covered under Medicare. Any remain- somewhat. Payroll tax contributions of fied to include employer plans. This eco- ing revenues could be met either 1.45% of earnings up to for em- nomic incentive to control unnecessary through a 2% income tax surcharge on ployers and employees would continue growth in the volume of services would be all tax-paying households or the estab- to be assessed and would flow into the supplemented by the development of ap- lishment of a new upper income tax Medicare Elderly and Disabled Benefi- propriateness guidelines and expanded bracket of 38%. ciaries Trust Fund. The current Medi- research on effectiveness of medical pro- COMMENT care Part B flat premium would be re- cedures and treatment. placed by a premium set at 2% of family Hospitals would be paid a flat rate for The principal advantage of the plan is income, not to exceed the full actuarial the care of inpatients covered under em- that it is a feasible approach that draws value of Medicare. Revenues from this ployer plans based on the diagnosis re- on the strengths of the current system income-related premium would be ap- lated group prospective payment sys- while simplifying the benefit and pro- proximately equal to current Part B tem. Hospitals would not be permitted vider payment structure and instituting premium receipts, although the distri- to charge patients over and above the innovations to promote efficiency. It bution of the financial burden of the pre- allowed rate. Again, while Medicare minimizes the need for additional feder- mium would clearly be shifted to higher- rates are lower than in some employer al outlays, spreads the financial burden income Medicare beneficiaries. The plans, bad debts for care of the unin- of health spending more equitably premium would be collected through sured and low payments by Medicaid among employers and states, and the income tax system, and forgiven for would be eliminated under the plan. makes health insurance more affordable anyone with no net tax liability. The Beneficiaries enrolled in both Medi- to small businesses, self-employed, and premium would no longer be voluntary, care and employer plans would be given nonworking individuals. but required of all Medicare beneficia- the option of enrolling in health mainte- The plan achieves greater equity ries. General tax revenues would con- nance organizations or other managed within the health care system by reduc- tinue to subsidize care for elderly and care plans. Employers would be per- ing the fiscal burden of hospitals, physi- disabled beneficiaries, at a rate equiva- mitted to pay a higher percentage of cians, and primary care centers provid- lent to the current general tax revenue the premium, reduce cost sharing, or ing charity care to the uninsured and contribution to Part B of Medicare. otherwise provide financial incentives contributes to their financial survival. Financing of the Medicare Employed to workers and dependents to enroll It protects all Americans from the finan- Families and Individuals Trust Fund in more cost-effective managed care cial hardship of health care bills, and it would be based on the 6% of payroll plans. However, the current practice by helps get all children off to a healthy contributions by employers and 2% of which larger employers obtain favor- start in life through comprehensive cov- income contributions of families and in- able price discounts through preferred erage of maternal and infant health dividuals newly covered under Medi- provider organizations would no longer care. care. States would contribute the state be permitted. Instead preferred provid- It builds on the existing administra- share of Medicare Part B premiums and er organizations would be required to tive system for employer-provided cost sharing for Medicaid and other poor compete on the basis of the effective- health insurance and Medicare and, beneficiaries based on the current state ness of their utilization review and other most important, realizes savings from matching rate under Medicaid. Federal managed care techniques. lower administrative costs of these general tax revenues would be used to plans. provide any additional subsidies re- COST The combination of a universal pro- quired to cover the remaining cost of vider payment system, coupled with ex- employed families and nonworking While careful cost analysis would be penditure constraints and incentives for individuals. required to estimate the fiscal impact of managed care, should greatly improve JAMA, May 15, 1991 265, No. 19 Expanding Medicare and Employer Plans-Davis 2527 the ability of government and employ- avoid loss of enrollees to Medicare. costly health system that subjects many ers to constrain rising health care costs. However, it can be expected that the of its most vulnerable citizens to inade- It preserves pluralism in the health sys- Medicare alternative will be relatively quate health care. It is hoped that this tem, while permitting effective cost more attractive to low-wage employers, article will contribute to shaping a con- containment through a unified payer ap- groups with greater than average sensus for change. proach to setting physician and hospital health risk, and small firms that do not payment rates similar to those of other wish to search for a less costly private References industrialized nations. plan. 1. Overview of Entitlement Programs: 1990 Green This approach has a minimal disrup- The tendency of low-wage employers Book. Washington, DC: US House of Representa- tive economic impact and is likely to to seek Medicare coverage, however, tives, Committee on Ways and Means; 1990. have a negligible impact on employment can be viewed as an advantage. It 2. Davis K. Availability of medical care and its in small firms, with some expansion of should help increase the stability of cov- financing. In: Rogers DE, ed. Doctoring America. Baltimore, Md: The Johns Hopkins School of Medi- jobs in the health sector. Its design min- erage of low-income individuals as they cine; 1990. imizes any inflationary impact on the gain employment and leave welfare. 3. Freeman HE, Blendon RJ, Aiken L, Sudman S, health sector, while making American Their coverage under state purchase of Mullimix C, Corey C. Americans report on their products more competitive in interna- Medicare will continue as employer pur- access to health care. Health Aff. 1987;6:6-18. 4. Blendon RJ. What should be done about the tional markets through effective cost chase of Medicare. uninsured poor? JAMA. 1988;260:3176-3177. controls and more equitable sharing of The option of purchasing Medicare 5. Ginsburg PB, LeRoy LB, Hammons GT. Medi- costs among employers. should also reduce the extent of varia- care physician payment reform. Health Aff. The plan differs from the plan ad- tion in experience-rated premiums 1990;9:178-188. 6. Davis K, Anderson GF, Rowland D, Steinberg vanced by the Pepper Commission and among employer private insurance EP. Health Care Cost Containment. Baltimore, other mixed public-private plans in that plans, by permitting high-risk groups to Md: The Johns Hopkins Press; 1990. it does not stress reform of the private choose Medicare coverage. Dumping in- 7. Davis K, Rowland R. Financing health care for health insurance market-such as re- dividuals identified as poor risks on the poor: contribution of health services research. In: Eli Ginzberg, ed. Health Services Research: quiring community-rating, prohibit- Medicare should be mitigated by the Key to Health Policy. Cambridge, Mass: Harvard ing the exclusion of preexisting con- requirement that an employer make an University Press; 1991:93-125. ditions, or establishing risk-sharing all-or-nothing decision to cover employ- 8. Rogers DE, Blendon RJ, Moloney TW. Who pools. While these measures are com- ees under Medicare. Persons deemed needs Medicaid? N Engl J Med. 1982;307:13-18. 9. Davis K. National Health Insurance: Benefits, mendable and perhaps worthy of trial, bad risks could not be singled out for Costs, and Consequences. Washington, DC: The they are working against the economic public plan coverage. Medicare cover- Brookings Institution; 1975. incentives insurers have to avoid bad age, however, could be expected to be 10. Davis K. National health insurance: a proposal. risks and are likely to be circumvented attractive to early retirees with health Am Econ Rev. 1989;79:349-352. 11. Davis K. Uninsured older adults: the need for a through imaginative marketing prac- problems who do not have employer re- Medicare buy-in option. In: Health Insurance Op- tices. tiree health benefits or who cannot pur- tions: Expanding Coverage Under Medicare and Rather, the proposal gives all em- chase private insurance individually at Other Public Health Insurance Programs. Wash- ployers and nonworking individuals the an attractive premium. Medicare be- ington, DC: US House of Representatives, Com- mittee on Ways and Means; 1990. option of coverage under Medicare, comes, in effect, the mechanism for 12. Davis K, Rowland D. Medicare Policy: New with its administrative efficiency and pooling the cost of many high-risk per- Directions for Health and Long-term Care. Balti- strong cost-containment provisions. sons, with necessary subsidies provided more, Md: The Johns Hopkins Press; 1986. This should provide an incentive to pri- by general tax revenues. 13. US Bipartisan Commission on Comprehensive Health Care. A Call for Action. Washington, DC: vate insurers to offer plans with good The United States cannot afford to The Pepper Commission on Comprehensive Health benefits at competitive premiums to continue on its present course with a Care; 1990. 2528 JAMA, May 15, 1991 Vol 265, No. 19 Expanding Medicare and Employer Plans A Framework for Reform of the US Health Care Financing and Provision System The Kansas Employer Coalition on Health, Task Force on Long-term Solutions REPRESENTING 100 businesses, in- role in health care spending. achieving control of costs, access, and surers, providers and other employers Health care observers generally con- quality. throughout Kansas, the Kansas Em- cede that market forces of the 1980s Proposals for system reform ployer Coalition on Health, Inc is the have failed to deal successfully and per- should minimize reliance on regulatory state's primary voice for employers in manently with the problems of cost, ac- controls, consistent with goals for costs, matters of health policy. cess, and quality. access, and quality. In 1987 the coalition's board resolved Agreement grew within the coalition to supply private sector leadership to that the problems of cost, access, and RECOMMENDATIONS AND solve the problem of large numbers of quality are interrelated. Further, it be- RATIONALE uninsured Americans. When an internal came apparent that nothing less than a 1. Establish a system in which each committee presented a universal access comprehensive restructuring of the sys- citizen or citizen's family not eligible for model, the board returned it to the com- tem is required to solve the problems. Medicare, subscribes either to his or her mittee with instructions to include pro- Simply expanding the current system employer's health plan or, by default, to visions for cost containment. In July and amplifying present cost-contain- a publicly sponsored plan. 1989 the board endorsed the principles ment techniques would likely prove The American public perceives health and general strategies of the framework inadequate. care as fundamental to the productivity, that follows. Finding no acceptable blueprint for independence, and well-being of the cit- reform among domestic proposals or izenry. It follows that, to secure such a BACKGROUND foreign systems, the coalition has cre- basic good, the public bears a responsi- The present methods of funding and ated a mosaic of principles and rec- bility to ensure access to a reasonable providing health care throughout most ommendations. level of health care for all citizens, re- of the United States (including Kansas) PRINCIPLES gardless of economic status. Those who have allowed or contributed to the minimize the responsibility of society to emergence of several serious problems: Each citizen or citizen's family has individuals in this regard still tend to Health care costs have increased at a responsibility to secure financial pro- concede the value to society of providing an alarming rate throughout the 1980s, tection against major health care costs basic medical treatment to all individ- far outstripping the overall inflation and should participate in a comprehen- uals in order to prevent expensive rate and doubling approximately every sive plan of health insurance. emergency care. 6 years (Washington Post. January 8, Each citizen has a responsibility, For these reasons, a key tenet of this 1989). means permitting, to share in the cost of framework is to enroll each citizen in a As many as 500 000 Kansans¹ (21%) his or her insurance plan. broad plan of health insurance cover- and over 30 million Americans² are with- Each citizen has a responsibility, age. Each individual or family would be out any medical insurance. Besides means permitting, to share in the cost of expected to show evidence of health in- causing delayed and neglected access to every episode of medical care. surance (perhaps an accompanying tax needed care, such lack of coverage leads Because health care is fundamental return). Failure to do SO would trigger a to uncompensated services by provid- to the productivity, independence, and special tax to help support a publicly ers and an undesirable level of cost shift- well-being of the citizenry, the public sponsored plan, in which that person ing to paying patients. has a responsibility to ensure that basic would be enrolled by default. Morbidity and mortality statistics health care is available to its members, Individuals and dependents who have for the United States are unenviable regardless of economic status. access to a qualifying employer-spon- compared with those of other developed The insurance system should sored plan would be required by law to countries, despite this country's leading spread the risks for medical expenses enroll in such a plan. across the widest practical base, thus From the Kansas Employer Coalition on Health, Inc, In order to apply cost containment Topeka, Kan. Members of the Kansas Employer Coali- ensuring that no individual or group (discussed below) across a broad range tion on Health, Task Force on Long-term Solutions are bears a disproportionate exposure. of medical services, the coverage must listed at the end of the article. Reprint requests to the Kansas Employer Coalition on Proposals for system reform have corresponding breadth. Failing to Health, Inc, 1271 Harrison, Topeka, KS 66612 (James should build on current structures to a make the coverage broad simply invites P. Schwartz, Jr). maximum extent consistent with continued escalation of costs for uncov- JAMA, May 15, 1991 Vol 265, No. 19 Reform of US Health Care System-Kansas Employer Coalition 2529 ered services. determines a single maximum annual market share between the networks. Thus, it is recommended that the percentage of premium increase (or tax- Most likely, such rate regulation minimum breadth of coverage be simi- ation increase in the case of the publicly would force a consolidation of the health lar to that of the HMO Act of 1973 (sec- sponsored plan) for all health insurance insurance industry from hundreds to a tion 1122 of the Social Security Act) or plans. small number that can develop the capa- Medicare. The concept of a budget is fundamen- bility to manage costs. Indeed, insurers One may well question the appropri- tal to health care cost containment.⁶ An may eventually become the financing ateness and utility of having employers expeditious way to achieve a budget and marketing arms of the health care sponsor health plans. From a practical without inviting the government to as- provision system. standpoint, however, an evolutionary sign roles and apportion resources is to Implementing this requirement on a approach to achieving universal cover- require the state or federal government national scale would preclude insurers age seems advisable, building on exist- to determine a single maximum annual from boycotting individual states. The ing employer-insurance relationships. percentage of premium increase (or tax- challenge to insurers would thus be to Thus, it is recommended that employ- ation increase in the case of the publicly find an efficient niche within a consoli- ers have an option either to provide cov- sponsored plan) for all health insurance dated market. Failing that, the likely erage or to pay a tax to help support a plans. alternative would be a highly regulated publicly sponsored plan. The federal government would deter- single-payer system. Individuals would be required to help mine the rate by a formula closely track- It might be argued that if insurers are support their plan participation through ing the consumer price index. The rea- unable or unwilling to manage the de- either premium sharing (in the case of son for not limiting the increases strictly gree of risk associated with these rec- employer-sponsored plans) or taxation to the consumer price index is that some ommendations, it may be time for busi- (in the case of the publicly sponsored latitude may be needed to fund general ness, government, or both to decide plan). medical research and research on proto- that such third parties are obsolete. Currently, many uninsured individ- cols (see recommendation 3), to fund Given a fair chance, rate regulation uals could afford to pay some fraction of improved technology, and to reflect may be expected to reduce the adminis- the cost of insurance. Instead, under the changes in the injury and illness pat- trative overhead associated with the present system, their large medical ex- terns of society. present, fragmented system. In addi- penses must be shifted to the insured A separate pool made up of all insur- tion, this strategy creates incentives to population. Thus, by requiring individ- ance carriers could be created to fund apply provider compensation methods ual participation (means permitting) in widespread catastrophes or unpredict- that reward cost-effective behavior. the cost of insurance, costs would be able epidemics. This pool, similar to cur- For example, fee-for-service plans spread more equitably among those rent "guarantee funds," would also pro- would likely give way to plans that pay who are able to bear them. Moreover, a tect against insolvency on the part of providers by salary, per patient, or per requirement for individual premium individual insurers. case. Where fees are paid, fee schedules sharing would make patients more cog- This requirement for limiting in- and expenditure targets would be nizant of costs and, presumably, wiser creases in insurance rates establishes, employed. purchasers of care. in essence, a budget for the system. A politically attractive aspect of this Detailed funding schemes that satisfy Experience has taught that, when the strategy is that it encourages desirable these requirements have been articu- health care system is constrained in a economic changes simply by limiting the lated by the National Leadership Com- particular direction, it tends to bulge amount of funds available for care. The mission on Health Care,⁸ Enthoven and out in another direction. Thus, by estab- market will then attend to realignment, Kronick, and the Pepper Commission.5 lishing a budget for the entire system, without need for sweeping government The operation of the publicly spon- expansion of the system may be intervention. sored plan could be contracted to pri- controlled. 3. Quality of health care services will vate insurance carriers or to private fis- The effect of limiting rate increases be ensured through government moni- cal intermediaries for administrative would be to place insurers at risk for toring and establishment of publicly services. Failing successful private increasing costs. Thus, insurers would sponsored research on medical proto- management, the plan could be adminis- have a powerful incentive to control cols. tered directly by the government. In costs. A natural reaction by insurers When cost containment is discussed, any case, state Medicaid programs would be to form tightly integrated providers often warn of the possibility could be folded into the public plan. managed-care alliances with providers that quality will suffer. To guard Taxes on individuals for the publicly in order to share the financial risk with against deteriorating quality, it is rec- sponsored plan would reflect income those providers. Insurers and their pro- ommended that the government moni- (and perhaps asset) level, probably with vider allies would have a strong incen- tor the quality of medical services and some realistic cap on taxable amount. tive to apply careful cost-benefit judg- make reports available to the public. In In all likelihood, existing forces will ments to such matters as capital addition, a portion of the taxes on em- maintain a strong commitment by em- expansion, preference among treat- ployers, insurers, and individuals ployers to providing health care cover- ment locations and modalities, length of should be earmarked for research on age. Those forces include the need to confinement, and selection of materials medical protocols. The reason for this attract labor by offering a contribution and subcontractors. Providers who last item is the wide variation in practice to insurance premiums, as well as tax failed to help the plan stay within bud- styles, unsupported by evidence of dif- deductibility of those contributions. In get would be less attractive to plan fering effectiveness or outcomes.⁷ Re- addition, employers would be free to sponsors. search on protocols would help clarify offer private, supplemental insurance Incentives for insurers to profit by some of the "gray areas" in medicine and for conditions not covered in the basic downgrading quality of care would be raise some of the art to the level of plan. offset by public dissemination of quality science. 2. Establish a mechanism by which comparisons among providers (see rec- 4. Reestablish community rating as a the state (or the federal government) ommendation 3) and by competition for basis for determining premiums. 2530 JAMA, May 15, 1991 265, No. 19 Reform of US Health Care System-Kansas Employer Coalition The health insurance industry began be offset by savings from the cost-con- tion, it is recommended that the govern- with the concept that costs should be tainment scheme in recommendation 2. ment take strong measures to reform spread among many people, SO that no 5. Adopt a policy that all health care the tort system in a more cost-conscious individual would risk financial devasta- plans must, within capacity limits, ac- direction. tion from health care expenses. Early cept any applying employer group or Because the recommended provisions insurance plans charged the same rate association of employer groups. are, compared with other reform strate- for all groups within a given community. Some groups presently encounter an gies, friendly to existing arrangements, This practice became known as commu- extreme form of experience rating-not the government should inform the pub- nity rating. by premium levels, but by exclusion at lic that, if the approach fails, it will im- Eventually some groups discovered any price. There is currently much fi- plement a single-payer system. that through good fortune their mem- nancial pressure on insurers to skim the bers were unusually healthy and so healthiest risks from the available popu- CONCLUSIONS needed less care than those of other lation. Thus, it is commonplace for in- Our recommendations are intended groups. They found insurance carriers surers to refuse to write coverage for to constitute a politically moderate ap- who would rate them according to their groups with high claims histories or to proach, with roles and trade-offs for exceptionally low-cost experience. cancel groups that develop such re- all current participants. Competitive Having lost these low-cost members, cords. The effect of such practices is to forces are supported by leaving the pri- the remaining plans quickly found their segregate the ill from the healthy, mary funding and provision systems in costs per beneficiary much higher and which benefits the able at the expense of the private sector and by establishing SO needed to raise premiums. the unfortunate. For the same reasons an overall budget. Regulation is in- This trend of splitting the healthy presented for recommendation 4, it is voked to bring about universality of cov- from the unhealthy has continued until recommended that insurers be required erage, explicit containment of costs, the cost of insurance for some less to accept any employer-based group (or and preservation of quality. healthy groups has become unafforda- association of employer groups) that Although these elements are certain- ble. Even seemingly innocuous prac- applies. ly amenable to modification, they are tices such as rating groups by age and 6. Adopt a policy that each patient or deemed by the authors to be hung in fair sex may effectively shift costs toward patient's family, means permitting, and delicate balance. Modifications will the most needy. The offering of multiple shall pay some fee for every episode of necessarily alter the balance of trade- options within groups has further ag- care, up to an established out-of-pocket offs and the likelihood of acceptance by gravated this situation. Worse yet, maximum. various groups. Likewise, the recom- some groups have resorted to question- It is generally agreed that efforts to mendations are presented not as a sun- able practices like excluding seriously ill contain the overall costs of health care dry assortment of "quick fixes," but members from the plan to keep costs in must address demand by individuals. rather as a cohesive structure with val- line. The first RAND Corporation study ue greater than the sum of its parts. If one accepts the premise that the showed that medical services perceived public has a responsibility to ensure its Members of the Kansas Employer Coalition on as "free" tend to be utilized at a greater Health, Task Force on Long-term Solutions are as members a reasonable level of care, re- rate than those that bear some cost to follows: James P. Schwartz, Jr, Consulting Direc- gardless of economic status, then it fol- the recipient. Thus, it is recommended tor, Kansas Employer Coalition on Health, Inc, lows that systemic reform must restore that each patient, means permitting, Topeka, Kan; Melissa Levy Hungerford, Kansas Hospital Association, Topeka, Kan; John Knack, the practice of well people shouldering pay some fraction of the cost of each Blue Cross/Blue Shield of Kansas, Topeka, Kan; the financial burden imposed on the ill episode of care. An annual limit could be Thomas M. Palace, Savings League Services Inc, and aged. Experience rating, by con- placed on the amount of this expense. Topeka, Kan; Thomas Plumberg, Hill's Pet Prod- trast, tends to shift costs to the ill, in- 7. Establish ancillary activities by ucts, Topeka, Kan; Walter D. Rogers, Family Health Plan, Newton, Kan; James Slover, RN, jured, and aging-often the people least the federal government. Healthcheck, Inc, Topeka, Kan. able to cope with such demands. To provide a context for reform, the Thus, it is recommended that insur- government should provide leadership References ers be required to adopt community rat- to develop health care policy on a nation- 1. Kansas Commission on Access to Services for ing, meaning a single set of rates based al, regional, and state level. the Medically Indigent and Homeless. Report and only on dependent status and the broad- Since prevention is the best medicine Recommendations on Access to Services for the est practical geographic basis. and education is the key to prevention, Medically Indigent and Homeless. Topeka, Kan: In order to maintain incentives for the government should provide im- Kansas Dept of Legislative Research; 1989:4. 2. Moyer ME. A revised look at the number of promoting healthy life-styles among proved health education services to the uninsured Americans. Health Aff. 1989;8(2):102- plan members, allowance would be public. 110. made for rate adjustment by life-style Because of the requirement in this 3. National Leadership Commission on Health characteristics, eg, not smoking, use of framework for every citizen to carry Care. For the Health of a Nation. Ann Arbor, Mich: Health Administration Press; 1989. safety belts, and maintenance of safe coverage, some entity (probably the 4. Enthoven A, Kronick R. A consumer-choice blood pressure. Determining the proper government) must establish a minimum health plan for the 1990s. N Engl J Med. 1989; extent of these adjustments will require level of benefits that meets the intent of 320:29-37. further analysis. the law. 5. US Bipartisan Commission on Comprehensive Health Care. A Call for Action. Washington, DC: To fully realize the system-wide The proposed approach is expected to The Pepper Commission on Comprehensive Health benefits of community rating, the abili- provide strong incentives for providers Care; 1990. ty of individual companies to splinter off to participate. If, however, lack of par- 6. Brown LD, McLaughlin C. Constraining costs from the community and pay only for ticipation becomes a problem, then at the community level. Health Aff. 1990;9:5-28. 7. Wennberg J, Gittelsohn A. Variations in medi- preferred risks would have to be mini- some regulation may be contemplated cal care among small areas. Sci Am. 1982;246:120- mized. Thus, it is contemplated that to require reimbursement through plan 133. self-insured plans might best be gradu- sponsors. 8. Duan N, Keeler EB, Leibowitz A, Marquis MS. ally phased out. This sacrifice on the Because of the pressures for medical Health insurance and the demand for medical care: evidence from a randomized experiment. Am Econ part of self-insured firms is intended to inflation caused by malpractice litiga- Rev. 1987;77:251-277. JAMA, May 15, 1991-Vol 265, No. 19 Reform of US Health Care System-Kansas Employer Coalition 2531 Universal Health Insurance Through Incentives Reform Alain C. Enthoven, PhD, Richard Kronick, PhD Roughly 35 million Americans have no health care coverage. Health care tem pays providers more for doing expenditures are out of control. The problems of access and cost are inextricably more, whether or not more is appropri- related. Important correctable causes include cost-unconscious demand, a ate. ("Open ended" means that no bud- system not organized for quality and economy, market failure, and public funds get is set in advance within which the not distributed equitably or effectively to motivate widespread coverage. We job must be done.) Once insured, con- sumers are not cost conscious. Deduct- propose Public Sponsor agencies to offer subsidized coverage to those other- ibles and coinsurance at the point of ser- wise uninsured, mandated employer-provided health insurance, premium con- vice have little or no effect on most tributions from all employers and employees, a limit on tax-free employer contri- spending, which is on sick people who butions to employee health insurance, and "managed competition." Our have exceeded their out-of-pocket proposed new government revenues equal proposed new outlays. We believe spending limits. "Free choice of provid- our proposal will work because efficient managed care does exist and can er insurance" blocks cost consciousness provide satisfactory care for a cost far below that of the traditional fee-for-service on the demand side by depriving the third-party payment system. Presented with an opportunity to make an economi- insurer of bargaining power. This ap- cally responsible choice, people choose value for money; the dynamic created proach is rapidly yielding in the market- by these individual choices will give providers strong incentives to render high- place to preferred provider insurance. quality, economical care. We believe that providers will respond to these In its present forms, preferred provider insurance helps to regulate price but is incentives. not yet very effective in controlling the (JAMA. 1991;265:2532-2536) volume of services. Medicare, Medic- aid, and the subsidies to employer-pro- vided health care coverage built into the income and payroll tax laws are all open THE PARADOX OF ing conditions, or that may be lost if ended and encourage decisions in favor EXCESS AND they become seriously ill. The American of more costly care. These incentives DEPRIVATION health care financing and delivery sys- are reinforced by a medical culture that AMERICAN national health expendi- tem is becoming increasingly unsatis- esteems use of the most advanced tech- tures are now about 13% of the gross factory and cannot be sustained. Com- nology, high patient expectations, and national product, up from 9.1% in 1980, prehensive reform is urgently needed. the threat of malpractice litigation if and they are projected to reach 15% by these expectations are not met. DIAGNOSIS 2000, far more than in any other coun- Contrary to a widespread impres- try. These expenditures are straining The etiology of this worsening para- sion, America has not yet tried competi- public finances at all levels of govern- dox is extremely complex; many factors tion of alternative health care financing ment. At the same time, roughly 35 mil- enter in. Some factors we would not and delivery plans, using the term in the lion Americans have no health care cov- change if we could (eg, advancing medi- normal economic sense, ie, price compe- erage at all, public or private, and the cal technology, people living longer). tition to serve cost-conscious purchas- number appears to be rising. Millions We emphasize factors that are impor- ers. When there is price competition, more have inadequate insurance that tant and correctable. the purchaser who chooses the more ex- leaves them vulnerable to large ex- First, our health care financing and pensive product pays the full difference penses, that excludes care of preexist- delivery system contains more incen- in price and is thus motivated to seek tives to spend than to not spend. It is value for money. However, in offering based on cost-unconscious demand. health care coverage to employees, From the Graduate School of Business, Stanford (Calif) University (Dr Enthoven); and the Department of Key decision makers have little or no most employers provide a larger subsi- Community and Family Medicine, University of Califor- incentive to seek value for money in dy to the FFS system than to health nia, San Diego (Dr Kronick). health care purchases. The dominant maintenance organizations (HMOs), Reprint requests to Graduate School of Business, Stanford University, Stanford, CA 94305 (Dr Enthoven). open-ended fee-for-service (FFS) sys- thereby destroying the incentive for 2532 JAMA, May 15, 1991 265, No. 19 Universal Health Insurance-Enthoven & Kronick consumers and providers to choose the outcome data today. The FFS system average incomes, many of whom would economical alternative. Many employ- often pays more to poor performers who have bought at least catastrophic ex- ers offer no choice but FFS coverage.8,9 have high rates of complications than to pense protection without the tax subsi- Others offer choices but pay the whole good performers who solve patients' dy, while little went to households with premium, whichever choice the employ- medical problems quickly and economi- below-average incomes, people whose ee makes. In such a case, the HMO has cally. High-quality performers are not decisions to insure could be substantial- no incentive to hold down its premium; rewarded, because of the payment sys- ly affected by such subsidies. The sys- it is better off to charge more and use tem and because employers and con- tem works backwards: the most power- the money to improve service. In many sumers do not have the data to identify ful incentives to insure go to those in the other cases, employers offer a choice of them. highest income tax brackets. From a tax plan, but the employer pays 80% or 90% There are too many beds and too effectiveness point of view, it should be of the premium or all but some fixed many specialists in relation to the num- the reverse. Government-provided sub- amount, whichever plan the employee ber of primary care physicians. A high- sidies should give everyone strong in- chooses. In all these cases, the effect is quality cost-effective system would centives to purchase coverage and to that the employer pays more on behalf carefully match the numbers and types choose economically. of the more costly system and deprives of physicians retained and other re- In brief, powerful incentives that the efficient alternatives of the opportu- sources to the needs of the population shape behavior in the health care sys- nity to attract more customers by cut- served SO that each specialist and sub- tem and that influence the distribution ting cost and price. specialist would be busy seeing just the of services point the system in the The rational policy from an economic type of patient she or he was trained to wrong direction: services too costly for point of view would be for employers to treat. We have a proliferation of costly those who are covered, and the exclu- structure health plan offerings to em- specialized services that are underuti- sion of millions from any coverage at all. ployees so that those who choose the lized. For example, in 1986, more than less costly plans get to keep the full OUR PROPOSAL one third of the hospitals in California savings. Several factors discourage doing open-heart surgery performed We propose a set of public policies and them from doing this. Employers be- fewer than 150 operations, the mini- institutions designed to give everyone came committed to paying the price of mum annual volume recommended by access to a subsidized but responsible the FFS plan in the 1960s and 1970s, the American College of Surgeons (Los choice of efficient, managed care (HMO, when costs were much lower and HMOs Angeles Times. December 27, 1988:3). preferred provider insurance plans, were few. Now this commitment is hard The third major problem area is "mar- etc). 11,12 We propose comprehensive re- to break. When an employment group ket failure." The market for health in- form of the economic incentives that considers more costly and less costly surance does not naturally produce re- drive the system. We propose cost-con- health plans, it knows that government sults that are fair or efficient. It is scious informed consumer and employer will pay about one third of the extra cost plagued by problems of biased risk se- (or other sponsor) choice of managed of the more costly plan through tax re- lection, market segmentation, inade- care SO that plans competing to serve mission. Labor unions see management quate information, "free riders," and such purchasers will have strong incen- commitment to full payment of costs of the like. 10 Insurers profit most by avoid- tives to give value for money. We also the open-ended system as a precious ing coverage of those who need it most. propose a strategy of managed competi- bargaining prize. There is a need for The insurance market for small employ- tion to be executed by large employers collective action. If one employer at- ment groups is breaking down as small and public sponsors (explained below), tempts to convert to cost-conscious em- employers find insurance unavailable or designed to reward with more subscrib- ployee choice while other employers re- unaffordable, especially if a group mem- ers those health care financing and de- main with the employer-pay-all system, ber has a costly medical condition. Most livery plans that offer high-quality care the employer will get disgruntled em- employment groups are too small for at relatively low cost. The goal of these ployees in the short run but no re- risk spreading or economical purchase policies would be the gradual transfor- formed, cost-effective health care sys- of health insurance. Systematic action mation of the health care financing and tem in the long run. For the latter to by large collective purchasers is needed delivery system, through voluntary pri- happen, most employers in a geographic to manage competition to reward pro- vate action, into an array of managed area must convert to cost-conscious viders of high-quality economical care care plans, each competing to attract choice. and to make affordable coverage avail- providers and subscribers by finding The second major problem is that our able to individuals and small groups. ways to improve the quality of care and present health care financing and deliv- Fourth, public funds are not distrib- service while cutting costs. We propose ery system is not organized for quality uted equitably or effectively to moti- restructuring the tax subsidies to cre- and economy. One of the main drives in vate widespread coverage. The unlim- ate incentives to cover the uninsured the present system is for each specialist ited exclusion of employer health and to encourage the insured to be cost to exercise his or her specialty, not to benefit contributions from the taxable conscious in their choice of plan. We produce desired outcomes at reasonable incomes of employees is the second- propose the creation of public institu- cost. In a system designed for quality largest federal government health care tions to broker and market subsidized and economy, managed care organiza- "expenditure," trailing only expendi- coverage for all who do not obtain it tions would attract the responsible par- tures for the Medicare program. While through large employers. We favor sub- ticipation of physicians who would un- providing incentives for the well-cov- stantial public investments in outcomes derstand that, ultimately, their ered well-to-do to choose even more and effectiveness research to improve patients bear the costs of care, and they generous coverage, this provision does the information base for medical prac- would accept the need for an economical little or nothing for those (mainly lower- tice and consumer/employer choice. practice style. Data would be gathered income) people without employer-pro- on outcomes, treatments, and resource vided coverage. Most of the $46 billion Public Sponsor Agencies use, and providers would base clinical the federal budget lost to this tax break The Public Sponsor, a quasi-public decisions on such data. We have few in 1990 went to households with above- agency (like the Federal Reserve) in JAMA, May 15, 265, No. 19 Universal Health Insurance-Enthoven & Kronick 2533 each state, would contract with a num- one of the group gets sick, the group for use by Public Sponsors in offering ber of private-sector health care financ- pays the cost. Some employers and em- subsidized coverage to persons without ing and delivery plans typical of those ployees do not include health care in the employment-based coverage. offered to the employed population and package. The effect is irresponsible be- This tax would be at the federal level would offer subsidized enrollment to all havior; if an employee becomes serious- because individual states might be de- those who do not have employment- ly ill, these employers and employees terred from levying such a tax by em- based coverage. Except in the case of count on someone else to pay. They are ployer threats to move to a state with- the poor, the Public Sponsor would con- taking a "free ride." It is hard to justify out the tax. tribute a fixed amount equal to 80% of raising taxes on the insured to pay for Limit on Tax-Free the cost of the average plan that just coverage for the employed uninsured Employer Contributions meets federal standards. The enrollee unless those uninsured are required to would pay the rest. (The 80% level was contribute their fair share. We propose that Congress change the chosen to balance two incentives. First, The existence of Public Sponsors income and payroll tax laws to limit the we wanted the subsidy level to be low would give all employers access to tax-free employer contribution to 80% enough SO that there would be room for large-scale efficient health care cover- of the average price of a comprehensive efficient plans to compete by lowering age arrangements. However, in the ab- plan meeting federal standards. The av- prices and taking subscribers away sence of corrective action, the availabil- erage price of a qualified health plan in from inefficient plans. Second, we ity of subsidized coverage for uninsured 1991 might be roughly $290 per family wanted the subsidy to be high enough so individuals would create an incentive per month. As a condition of tax exemp- that the purchase of health insurance for employers to drop coverage of their tion, employer health plans would be would appear very attractive even to employees. This would create addition- required to use fixed-dollar defined con- those who expect to have no medical al expense for the Public Sponsor with- tributions, independent of employee expenses.) To the enrollee, the Public out compensating revenue. To prevent choice of plan, not to exceed the limit, SO Sponsor would look like the employee this, our proposal requires employers to that people who choose more costly benefits office. cover their full-time employees (em- health care plans must do so with their In the case of the poor, we propose ployers would make a defined contribu- own money, not with that of the taxpay- additional subsidies. People at or below tion equal to 80% of the cost of an aver- er or employer. the poverty line would be able to choose age plan meeting federal standards and The purposes of this measure are two- any health plan with a premium at or would offer a choice of health plans fold. First, it would save the federal below the average and have it fully paid. meeting federal standards). budget some $11.2 billion in 1988 dol- For people with incomes between 100% lars. This money could be used to help and 150% of the poverty line, we pro- Premium Contributions From finance subsidies for the uninsured com- pose public sharing of the premium con- All Employers and Employees parable to those received by the em- tribution on a sliding scale related to Many people who are self-employed, ployed insured. Second, making people income. who have part-time or seasonal work, or cost conscious would help enlist all em- Public Sponsors would also act as col- who are retired and under age 65 years ployed Americans in a search for value lective purchasing agents for small em- do not have enough attachment to one for money in health care, would stimu- ployers who wished to take advantage employer to justify requiring the em- late the development of cost-effective of economies of scale and of the ability of ployer to provide coverage. Thus, an care, and would create a market for Public Sponsors to spread and manage employer mandate for full-time employ- cost-effective managed care. Thus, this risk. Small employers could obtain cov- ees would leave out millions of people. tax reform is defensible on grounds of erage for their groups by payment of a Moreover, in the absence of corrective both equity and efficiency. maximum of 8% of their payroll. action, a requirement that employers Today, a substantial part of the mon- Budget Neutrality cover full-time employees creates a ey required to pay for care of the unin- powerful incentive to use part-time The Congressional Budget Office has sured comes from more or less broadly employees. estimated the effects of our proposal on based state and local sources, including We propose that employers be re- coverage, costs, and the federal budget employers' payments to private hospi- quired to pay an 8% payroll tax on the and has found that our proposed new tals for bad debt or free care and direct first $22 500 of the wages and salaries of revenues would equal the added out- appropriations from state and local gov- part-time and seasonal employees, un- lays." We have not done a state-by- ernments to acute-care hospitals. In our less the employer covered the employee state analysis, but, in the aggregate, proposal, federal funds (the sources of with a health insurance plan meeting required state and local contributions which are described below) would be the federal standards. Self-employed per- appear to approximately equal outlays main source of support for the Public sons, early retirees, and everyone else for care of the uninsured. Sponsors. These funds would be supple- not covered through employment would mented by funds from state and local be required to contribute through the Managed Competition sources. income tax system. An 8% tax would The market for health insurance does apply to adjusted gross income up to an not naturally produce results that are Mandated Employer-Provided income ceiling related to the size of the fair or efficient. It is plagued by prob- Health Insurance household. The ceiling would be calcu- lems of biased risk selection, market For better or worse, we have an em- lated to ensure that households with segmentation, inadequate information, ployment-based system of health insur- sufficient income paid for approximate- etc. In fact, the market for health insur- ance for most people under age 65 years. ly the total subsidy that would be made ance cannot work at the individual level. It can be modified gradually but not available to them through the Public To counteract these problems, large replaced overnight. Most employers Sponsor. employers and Public Sponsors must and employees agree that health care The proceeds of these taxes would be structure and manage the demand side will be included in the compensation paid by the federal government to the of this market. They must act as intelli- package. This is responsible behavior; if states, on a per-person-covered basis, gent, active, collective purchasing 2534 JAMA, May 15, 1991 265, No. 19 Universal Health Insurance-Enthover & Kronick agents and manage a process of in- plan along these lines can be made to We have been asked, "Why, if non- formed cost-conscious consumer choice work rests on two propositions. profit HMOs are so much more efficient of "managed care" plans to reward pro- First, efficiently managed care does and desirable, have they failed to grow viders of high-quality economical care. exist. It is possible to improve economic except very modestly?" In times past, Tools of effectively managed competi- performance substantially over the non- legal and professional barriers were im- tion include the annual open-enrollment selective FFS, solo practice, third-par- portant, including illegal restraints of process; full employee consciousness of ty intermediary model. The best docu- trade.² In recent years, the main inhibi- premium differences; a standardized mented example was a randomized tor of the growth of HMOs has been the benefit package within each sponsored comparison of per capita resource use employer contribution policies we have group; risk-adjusted sponsor contribu- between Group Health Cooperative of discussed; that is, most employers do tions, so that a plan that attracts pre- Puget Sound and traditional third-party not structure their health plan offerings dictably sicker people is compensated; insurance and FFS providers in Seattle, in such a way that the employee who monitoring disenrollments; surveil- Wash, in the Health Insurance Experi- chooses the most economical plan gets lance; ongoing quality measurement; ment of the RAND Corp.¹⁶ Group to keep the savings. Nevertheless, and improved consumer information. Health Cooperative of Puget Sound some nonprofit HMOs have been grow- Outcomes Management and cared for its assigned patients at a cost ing rapidly; through the 1980s, Harvard Effectiveness Research about 28% lower than that in the FFS Community Health Plan averaged sector, resulting in essentially equal As Ellwood¹⁴ and Roper et al¹⁵ have membership growth of more than 11% health outcomes and overall patient sat- per year, and the Kaiser-Permanente pointed out, there is a poverty of rele- isfaction about 95% as high. Satisfaction Medical Care Program averaged 5.2% vant data linking outcomes, treat- with interpersonal aspects of care and growth on a much larger base. Howev- ments, and resource use. Although such technical quality was 98% as high as in er, the success of our proposal does not data are costly to gather, they consti- the FFS sector. 17,18 Group Health Coop- depend only on nonprofit HMOs. Other tute a public good, and their production erative of Puget Sound accomplished forms of cost-effective managed care ought to be publicly mandated and sup- this without much cost-conscious de- ported. Combined with the incentives may do the job. What we propose is a mand and without any significant com- built into our proposal, such data could restructured market system in which peting organized system. One wonders the efficient prosper and the inefficient be of great value to providers and pa- how much better they might have done must improve or fail. tients seeking more effective and less if there had been several such organiza- costly treatments. Without incentives tions competing to serve cost-conscious COMPREHENSIVE REFORM THAT for efficiency, such data are likely to consumers. Other nonrandomized stud- RELIES ON INCENTIVES IS have little impact on health care costs. ies have produced similar results. PREFERABLE TO DIRECT Mutually Supportive Components Many physicians and patients may GOVERNMENT CONTROLS Some components of our proposal prefer practice styles other than pre- One alternative to the system we have been proposed individually. How- paid group practice. We do not have have proposed is a system like Cana- ever, they would be much more effec- similar experimental evidence on the da's, in which the government is the sole tive as parts of an integrated, compre- economic performance of independent payer for physician and hospital ser- hensive reform program than they practice associations and preferred pro- vices. While Canada's system has evi- would be alone. Consider, for example, vider insurance plans. However, we dent strengths, there would be major a law that employers must cover their have observed wide variation in the per- difficulties in successfully adopting or full-time employees. Alone, this law formance of providers. For example, in implementing it in the United States. would leave out people who are not em- Los Angeles, Calif, in 1986, one hospital First, it would require a political sea ployed on a full-time basis and their de- performed 44 coronary artery bypass change to adopt such a system here. A pendents- 12 million people. Without a grafts with an 11.4% death rate and me- tax increase of approximately $250 bil- payroll tax on uninsured employees, dian charges of $59 000, while another lion per year would be required, the employers would have a strong incen- hospital performed 770 coronary artery intense opposition of insurers and many tive to escape the mandate by using bypass grafts with a 3.8% death rate provider groups would need to be over- part-time employees. Without Public and median charges of $16 000 (Los An- come, and the concerns of many employ- Sponsors, the law would not address the geles Times. July 24, 1988:3). Some ers and citizens about the effects of such problem of availability of affordable managed care plans would find ways of a system on access and quality would coverage for small employers. Without selecting economical providers of high need to be allayed. In the era in which the limit on tax-free employer contribu- quality and would channel business to the Berlin wall has been torn down, one tions, the law would not address the them, improving quality and cutting must be cautious about branding any need for a cost-containment strategy. costs substantially. proposal as politically infeasible, but it We recognize the propensity of the Second, people do choose value for is difficult to imagine a politician win- American political system to seek mini- money. Our limited experience with ning election on a platform including an mal, incremental change. Some compo- even attenuated price competition in extremely large tax increase. Second, nents of our proposal would be viable employment groups such as federal em- government regulatory processes tend and helpful on their own. However, we ployees, California state employees, to freeze industries and often penalize believe that effective solution of the and Stanford University suggests that, efficiency. The Canadian system is not problems of access and cost requires a over time, people do migrate to cost- as frozen as it might be because proximi- comprehensive strategy, and the merits effective systems. A recent study of ty to the United States exposes Canadi- of the combined package exceed the health plan choice in the Twin Cities, ans to our innovations. If American merits of the individual components. Minnesota, area found that employees' medical care were also entirely financed WILL IT WORK? decisions are quite sensitive to health and regulated by the government, the plan prices. 20,21 This accords with gener- negative effects of regulation would Our confidence that a reasonably ally accepted principles of economic likely loom larger. well-managed comprehensive reform behavior. A second alternative would be to JAMA, May 15, 265, No. 19 Universal Health Insurance-Enthoven & Kronick 2535 leave the financing of health insurance cost containment is the development of shakedown, there would be relatively for the employed population in the pri- practice guidelines and the application few managed care organizations in each vate sector but to have the government of these guidelines to eliminate the inef- geographic area. Everyone would get regulate physician and hospital prices fective practices that exist in our medi- coverage through large group arrange- for all payers. It is possible to imagine a cal care system today. While we strong- ments. Eligibility determination would political compromise in which such a ly support the development of better be simple in a system of universal cover- system could be adopted-in the midst outcomes data and practice guidelines, age. Today, the best managed care or- of a recession, providers might agree to in the absence of change in the financial ganizations do not bill patients for ser- accept all payer price controls in ex- incentives created by the FFS system, vices. Providers are paid by health change for an employer mandate, and such guidelines will do little either to plans in simplified ways using prospec- employers might acquiesce to a man- control costs or to lead to improvements tive payments for global units of care. In date in exchange for price controls-but in efficiency. For guideline develop- a system with relatively few managed it is hard to imagine that such a regula- ment to succeed, medical care would care organizations competing to serve tory structure could be effective over have to be much more of a science and competent sponsors and cost-conscious time in promoting quality or economy. much less of an art than it is likely to be consumers, payers would not have to Such price controls would be met by at any time in the foreseeable future. attempt to micromanage the delivery of continuing provider efforts to circum- Finally, administrative costs in the care because providers would be at risk. vent and modify them. Providers would present system are high and increas- Administrative costs and the "hassle lobby for adjustments and exceptions ing. These costs arise from many factor" would be much lower than they deemed to enhance equity, increasing causes: the multiplicity of payers, each are today. However, the most impor- the complexity of the regulations and with its own forms, processes, and data tant economies would be in the effective the incentives for those who were not requirements; the high marketing costs organization of the process of care itself. favored to seek favor. Congress would associated with the coverage of individ- Over time, we would expect slowed have created a rich new barrel of pork to uals and small groups; the costs of deter- growth in the price of the average reward electoral supporters and con- mining eligibility for coverage in a sys- health plan and continuing improve- tributors-an especially attractive tem in which millions have no coverage; ments in efficiency comparable to those source, because price increases for pri- the costs of billing patients for covered in other competitive industries. vate sector rates could be granted with- services; the costs of payers attempting out requiring a tax increase. to determine whether services were ac- The authors gratefully acknowledge support Furthermore, such a system does not tually provided and were appropriate; from the Robert Wood Johnson Foundation, contain incentives to shift medical care and others. We believe administrative Princeton, NJ, and the Henry J. Kaiser Family Foundation, Menlo Park, Calif. resources from less productive to more costs would be greatly reduced under productive uses. The current mantra in our proposal. After a competitive References 1. Office of the Actuary, Health Care Financing sponsored health benefits. Milbank Q. 1987;65:521- N Engl J Med. 1984;310:1505-1510. Administration. National health expenditures, 542. 17. Davies AR, Ware JE, Brook RH, Peterson JR, 1986-2000. Health Care Financ Rev. Summer 9. Foster Higgins Health Care Benefits Survey. Newhouse JP. Consumer acceptance of prepaid and 1987;8:1-36. Managed Care Plans. New York, NY: Foster Hig- fee-for-service medical care: results from a random- 2. Schieber GJ, Poullier JP. Recent trends in inter- gins; 1989. ized controlled trial. Health Serv Res. 1986;23:429- national health care spending. Health Aff. Fall 10. Enthoven A. Theory and Practice of Managed 452. 1987;6:105-112. Competition in Health Care Finance. Amsterdam, 18. Sloss, EM, Keeler EB, Brook RH, Operskalski 3. 1991 US Industrial Outlook. Washington, DC: the Netherlands: Elsevier Science Publishers; BH, Goldberg GA, Newhouse JP. Effect of a health US Dept of Commerce; 1991. 1988. maintenance organization on physiologic health. 4. Kronick R. The Slippery Slope of Health Care 11. Enthoven A, Kronick R. A consumer choice Ann Intern Med. 1987;106:130-138. Finance: Business, Hospitals, and Health Care for health plan for the 1990s: universal health insur- 19. Luft HS. How do health-maintenance organi- the Poor in Massachusetts. Rochester, NY: Uni- ance in a system designed to promote quality and zations achieve their 'savings?' rhetoric and evi- versity of Rochester; 1990. Thesis. economy, I. N Engl J Med. 1989;320:29-37. dence. N Engl J Med. 1978;298;1336-1343. 5. Wilensky GR. Filling the gaps in health insur- 12. Enthoven A, Kronick R. A consumer choice 20. Feldman R, Dowd B, Finch M, Cassou S. Em- ance: impact on competition. Health Aff. Summer health plan for the 1990s: universal health insur- ployee-Based Health Insurance. Rockville, Md: 1988;7:133-149. ance in a system designed to promote quality and National Center for Health Services Research; 6. Ries P. Health care coverage by age, sex, race, economy, II. N Engl J Med. 1989;320:94-101. 1989. US Dept of Health and Human Services pub- and family income: United States, 1986. In: Ad- 13. Long S, Rodgers J. Enthoven-Kronick Plan lication PHS 89-3434. vance Data From Vital and Health Statistics of the for Universal Health Insurance. Washington, DC: 21. Feldman R, Finch M, Dowd B, Cassou S. The National Center for Health Statistics: No. 139. Congressional Budget Office; 1988. demand for employment-based health insurance Hyattsville, Md: Public Health Service; 1987. US 14. Ellwood PM. Outcomes management: a tech- plans. J Hum Res. 1989;24:115-142. Dept of Health and Human Services publication nology of patient experience. N Engl J Med. 22. Weller CD. 'Free choice' as a restraint of trade PHS 87-1250. 1988;318:1549-1556. in American health care delivery and insurance. 7. Health Insurance and the Uninsured: Back- 15. Roper WL, Winkenwerder W, Hackbarth GM, Iowa Law Rev. 1984;69:1351-1392. ground Data and Analysis. Washington, DC: Con- Krakauer H. Effectiveness in health care. N Engl J 23. Himmelstein DU, Woolhandler S. Cost with- gressional Research Service, Library of Congress; Med. 1988;319:1197-1202. out benefit: administrative waste in US health care. 1988. 16. Manning WG, Leibowitz A, Goldberg GA, N Engl J Med. 1986;314:441-445. 8. Jensen GA, Morrisey MA, Marcus JW. Cost Rogers WH, Newhouse JP. A controlled trial of the sharing and the changing pattern of employer- effect of a prepaid group practice on use of services. 2536 JAMA, May 15, 1991 265, No. 19 Universal Health Insurance-Enthoven & Kronick An American Approach to Health System Reform John Holahan, PhD; Marilyn Moon, PhD; W. Pete Welch, PhD; Stephen Zuckerman, PhD THE MAJOR problems in the United sector insurance administered at the But they would be on-budget and highly States' health care system today are the provincial level. Like the United visible. The second problem is that the large number of uninsured Americans, States, Canada retains private sector US health insurance industry would be the high and rising costs of the system, provision of services. Unlike the United eliminated, or largely so. Insurance and the system's administrative com- States, there is no cost-sharing and phy- firms could continue to be agents to pro- plexity. With over 32 million Americans sicians are not generally permitted to cess claims, but they would no longer lacking health insurance at any time and bill in excess of the provincial fee sched- underwrite. Therefore, they would be 63 million Americans lacking health in- ules. The provinces constitute the sin- likely to exercise strong political opposi- surance at some point during a recent gle payer, with substantial monopsony tion to a Canadian-style system. The 28-month period, the problem of being power in negotiating budgets with hos- third problem is that the Canadian sys- uninsured is faced by a large percentage pitals and fee schedules for physicians. tem is probably too egalitarian for the of the population. 1-5 Despite this lack of They also control the availability of new United States. The degree of equity in coverage, the United States spends health technologies. The system is fi- the Canadian system is probably not more on health care, per capita and as a nanced in part by federal contributions acceptable to Americans. The rich are percentage of gross national product to the provinces. Before 1977, the feder- not likely to want to be treated the same (GNP), than any other country. In addi- al contribution represented half of the as the poor, again resulting in a group tion, we also have one of the highest cost of the system. Since then, the in- strongly opposed to this type of reform. rates of increase-over 4% per year af- crease in the federal contribution has Finally, there is no consensus on how to ter adjusting for inflation. 6.7 Finally, it is been tied to the growth in the Canadian contain the cost of the system. Many estimated that the annual administra- GNP, causing it to drop to about 45% by Americans do not believe that a single- tive expenses borne by insurance com- the late 1980s. If provinces are unable to payer, rate-setting system is desirable panies, physicians, hospitals, and other control the growth in costs, they will or absolutely essential to efforts to con- providers are about $80 billion, or 1.5% increasingly bear more of the burden of trol costs. of GNP.⁸ This does not include the ad- financing the system. This gives them ministrative burdens faced by employ- strong incentives to control the growth THE PEPPER COMMISSION ers who must choose among plans and in expenditures. PROPOSAL the efforts of individuals who must file The Canadian system has a number of claims. important strengths. No Canadian is The Pepper Commission's proposal of Although most would agree that without health insurance. There is equi- March 1990 went a long way toward these are serious problems, there is no ty across income groups. The poor are providing a structure that could reform consensus on what should be done. treated as well as the rich. In addition, the US health care system. The Com- Some look to the Canadian system as a the costs of the Canadian system are mission proposed that all employers model for reform. The Pepper Commis- under control. Growth rates of the sys- with more than 100 employees provide sion developed the most visible policy tem's cost are approximately those of health insurance or pay a payroll tax. proposal that would build on existing the GNP. And finally, the administra- Eventually all employers would be re- American institutions. 10 We use ele- tive costs of the system are low. It is quired to do so. If employers choose to ments of both the Canadian system and estimated that the United States would pay the tax, this would enroll their em- the Pepper Commission proposal to de- save about $30 billion, or 0.5% of GNP, ployees in a federally administered pub- sign a reform option that would signifi- if it had the administrative costs of the lic plan. The proposal included reform of cantly expand insurance coverage and Canadian system.¹² the private insurance market that control costs with policies that are polit- Although the Canadian system is at- would eliminate experience rating and ically acceptable. This article is drawn tractive from many points of view, there other practices that make it difficult for from a report that presents a broad are serious problems that make it un- some employers to obtain coverage at overview of reform issues and options.¹¹ likely to be adopted in the United reasonable costs. The Pepper Commis- States. First, taxes are higher than is THE CANADIAN SYSTEM sion proposal would also eliminate Med- politically feasible in the United States. icaid, putting those now served by Med- The Canadian system offers universal It is estimated that the Canadian sys- icaid and those whose employers pay coverage to all citizens through public tem would mean $250 billion of new tax- the payroll tax into a single public plan. es. These are not new resources for the The proposal would essentially leave From The Urban Institute, Washington, DC. health care system; they would largely Medicare as it is. Reprint requests to Director, Health Policy Center, The Urban Institute, 2100 M St NW, Washington, DC replace private insurance payments or The major weakness is that the Pep- 20037 (Dr Holahan). individuals' out-of-pocket payments. per Commission provided for only limit- JAMA, May 15, 1991 Vol 265, No. 19 Health System Reform-Holahan et al 2537 ed cost-containment efforts. Essential- Some alternatives involve fostering Our proposal differs from the Pepper ly, by covering the poor and near-poor more effective competition among pro- Commission's in that we would provide at the federal level, Medicare policies viders. These approaches to lowering for more generous subsidies to the poor for payment to hospitals and physicians costs reflect Americans' preference for and near-poor. One result would be that would be expanded to apply to a broader using choice and the marketplace in- more of the nonelderly population segment of the population. While this is stead of government intervention. One would be in the public plans. Our ap- a step in the right direction, there are no market approach to cost control is called proach would also provide for stronger cost-containment provisions that would "managed competition." Managed cost-containment incentives than does affect the rest of the population. The competition begins with caps on the tax the Pepper Commission and would al- Commission's decision not to back a sin- deductibility of employer contributions low a range of approaches. gle, clearly defined cost-containment to employee health insurance premiums In the same way that the Canadian strategy reflects fundamental disagree- to make consumers more sensitive to system relies on provinces for adminis- ments over what policies will work and costs. It then seeks to control costs tration and to ultimately bear the risk of can be implemented in this country. through competition among multiple, rapidly growing costs, we would rely on However, proposals that do not consid- managed care arrangements, eg, health the states. As in Canada, federal contri- er cost containment ignore one of the maintenance organizations, indepen- butions to the public plans would be tied driving forces for reform of health care dent practice associations, and pre- to the growth in GNP. Our proposal in the United States today. ferred provider organizations, with con- differs from the Canadian system in that sumers able to choose those programs we would retain a large role for the pri- COST-CONTAINMENT that offer the most for the money. The vate sector. APPROACHES assumption is that such competition The first component of our proposal is would lower costs to the point where that Medicare would be unchanged. Although there is evidence that rate traditional indemnity arrangements Medicare is the major health insurance setting does contain costs in specific sec- would no longer be competitive. The program for aged and disabled Social tors (eg, hospitals and nursing homes), competition among the remaining man- Security recipients; it is administered there are few, if any, American tests of aged care organizations would give the federally and has uniform national poli- broader cost-containment initiatives. system control over provider payment cies. The program is well established Therefore, we believe that allowing for rates and volume. and highly popular. There is little to be diversity in this area is essential. The negative side of competition gained from altering its structure. Greater patient cost-sharing (either arises when providers seek ways to Medicare, however, does face major fi- through deductibles or copayments) is screen out people who need expensive nancial problems over the coming often advocated by those who believe health care, thereby voiding the bene- years. It will be necessary to continue to that the volume of services provided is fits of price competition. They may offer develop the cost-containment strate- excessive because Americans do not lower costs, but only by leaving the care gies that Medicare has already begun. have to pay enough of the cost at the of costly patients to others. A second The second component is a pay or play point of service. However, most other problem is implicit in the belief that, scheme-requiring employers to either industrialized countries do not rely given full information about plan quality provide health insurance to their work- heavily on cost sharing as a mechanism and costs, consumers will opt for the ers or pay a tax. All but extremely small for cost containment even though they low-cost alternative once the in-kind tax firms would be required to participate in have had uniformly better experience in subsidies are reduced. There is little this system. The objective would be to controlling costs than the United evidence to suggest how much consum- cover all firms where administratively States. ers might be willing to pay to keep their practical. One possibility would include Others believe that cost containment current health insurance arrangements all employers now paying the FICA requires government regulation of the in place rather than pick the low-cost (Federal Insurance Contributions Act) provider side of the market. One regula- option. Yet, if most people select their tax; this would then include employers tory approach is to subject all providers present high-cost plans-because of with even one employee. to the same rate-setting system, re- perceived access and/or quality advan- Employers would be required to pro- gardless of whether there is one payer tages-despite having to bear the costs vide health insurance meeting minimum or multiple payers. (West Germany has directly, the lower-cost plans would not standards in terms of benefits, with leg- been an example of a system with multi- flourish. islatively established maximum deduct- ple payers but a single set of rules.) ibles and coinsurance; employers would Such a strategy generally relies on the AN AMERICAN APPROACH be required to pay at least 75% of the government to control prices paid to cost of this coverage. (ERISA [Employ- hospitals, physicians, and other provid- Our proposal builds on many of the ee Retirement Income Security Act] ers and to put volume limits on services. ideas proposed by the Pepper Commis- rules would have to be modified to en- Regulation could also be used to control sion as well as important elements of the sure that these and other provisions of the rate of diffusion of technological in- Canadian system. Like the Pepper this plan apply to firms who choose to novations. The strength of this ap- Commission, we propose that universal self-insure.) Employers could offer proach is that it introduces a de facto coverage be achieved through a combi- more generous plans, but the difference monopsonist-t rate setter-to coun- nation of both private and public sector in actuarial value between the offered terbalance health care providers, often expansion. We would also require em- plan and the required benefits would be viewed as having some monopoly power ployers to provide health insurance or to treated as taxable income. Employees over health care decisions. However, if pay a payroll tax. These revenues, as would be required to purchase insur- the regulator is highly effective at con- well as other subsidies, would be used to ance for themselves and their families if trolling the expansion of health care finance a public backup program to cov- it is offered by the employer; individuals spending, new and potentially benefi- er the remainder of the population. We with incomes below certain specified cial technologies may be introduced would also propose similar reforms of levels would have the costs of insurance more slowly. the insurance industry. subsidized by the state. 2538 JAMA, May 15, 1991 265, No. 19 Health System Reform-Holahan et al Most basic acute care services includ- ance on the political process results in chased health insurance, out-of-pocket ing cost-effective preventive services inadequate access for public-plan enroll- expenses, or uncompensated care. Sec- would be covered; prescription drugs ees, some minimum standards for pro- ond, the more important cost issue is the would be excluded at least initially. De- vider reimbursement and utilization growth in health expenditures over ductibles would be approximately $200 control may be necessary. Our concern, time. The savings from gaining control per person and $500 per family, with however, is that overly rigid require- over expenditure growth, as has hap- coinsurance of 20% up to catastrophic ments will limit state flexibility in the pened in other industrialized nations, limits of approximately $1500 per indi- design of cost-containment strategies. could swamp the additional first-year vidual and $3000 per family. Individuals Firms with relatively healthy, highly budget costs of our proposal. and families below certain income levels paid employees would probably choose could be exempt from cost sharing or to offer a private plan. Firms with large STATES AND COST have lower stop-loss limits. numbers of low-wage or part-time em- CONTAINMENT Firms not wishing to provide such ployees, or with disproportionate num- policies would be required to make a bers of older workers or individuals in An essential feature of our approach contribution approximately equal to the poor health, would probably choose to to controlling cost growth is that the national average percentage of payroll pay the tax. Because health care costs annual percentage increase in the feder- now devoted to health insurance (about and, thus, private insurance premiums al contribution to the states will be equal 7.0%) in the form of a tax on payroll. will be high (or low) in the same markets to the growth in nominal GNP, as in (Firms could choose to offer a private where payrolls tend to be high (or low), Canada. (Because the kinds of individ- plan for full-time workers and to pay the there should not be major geographic uals who will shift into the public plan tax for part-time workers but otherwise differences in incentives to choose the may incur more costs than expected as a must choose one approach for all em- public plan. result of unpredicted adverse selection, ployees.) States would be required to The public program that replaces federal contributions may need to grow use these payroll tax revenues to estab- Medicaid would therefore cover three somewhat faster than GNP during an lish new backup public health insurance types of persons: (1) workers whose em- initial phase-in period.) The federal con- programs. These new programs would ployers pay the tax, (2) the poor, and (3) tribution would initially vary from 50% provide insurance for workers whose workers and nonworkers who buy into to 75% of the cost of subsidizing the employers choose to pay the tax and the public plan. The program would be public program, with the federal contri- would also replace Medicaid for persons financed by the tax on employers, by bution varying inversely with state per not in the work force. The new public limitations on the deductibility of em- capita income and directly with the programs would provide coverage to all ployer health insurance contributions, number of persons in poverty. The fed- nonworking individuals and their fam- by beneficiary contributions, and by eral government's contribution would ilies with incomes below poverty at no federal and state subsidies. be about 60% of the total cost, on aver- cost to the individual or the families. This proposal has some important age. The federal contribution could be Individuals and families with incomes features in common with the Pepper financed by an earmarked tax such as a between 100% and 250% of the poverty Commission plan; thus, the cost esti- national sales tax or a payroll tax. Al- line would be permitted to purchase this mates for the Pepper proposal ($24 bil- though it is not essential that the federal insurance on a sliding scale. Those with lion) offer some guidance as to the cost tax be earmarked, the federal contribu- higher incomes could buy into the public of our approach. Because our proposal tion rate does need to increase in step plan at the full community-rated cost. would cover approximately 35% of the with inflation and long-term real Once affordable coverage is offered to nonelderly population in the public plan, growth in the economy. It is also impor- all individuals, enrollment could be re- it would mean higher federal and state tant that a mechanism be established to quired SO that everyone contributes to taxes beyond the payroll taxes (relative protect states from short-term declines the cost of their health care. to the Pepper plan). The cost of subsi- in income during periods of economic The tax would be set (and, probably, dizing nonworkers and dependents be- downturn. adjusted over time) at a rate that would low 250% of the poverty line (including The effect of these provisions is that if result in a large minority of employers the cost of increasing reimbursement increases in health care costs exceed the choosing to pay it rather than provide rates for current Medicaid beneficia- rate of growth in GNP, states would, by private insurance. (The exact rate that ries) and the cost of subsidizing workers design, bear an increasingly large bur- would yield the desired mix of private- whose employers choose to pay the tax den. The objective, in addition to shar- and public-plan enrollees would depend would both be somewhat higher than in ing the burden of financing the system on the cost of the mandated plan and the the Pepper Commission proposal. Off- between both the federal and state gov- distribution of payroll expenses across setting these costs is the increase in ernments, is to provide strong incen- firms.) A relatively large public pro- federal (and possibly state) tax reve- tives for states to control costs. States gram, eg, containing about one third of nues from the limitations on deductibil- could, of course, lobby to have the feder- the nonelderly, would ensure the estab- ity of health insurance premiums (lower al contribution rate increased. lishment of payment rates and other tax expenditures). States, therefore, would have a major policies that would result in a degree of Estimation of these costs, as well as role in our proposed scheme. They access acceptable to voters, many of costs of all other "pay or play" propos- would gain a large influx of federal reve- whom would also be program partici- als, including the Pepper Commission's, nues that would finance much of the cost pants. We would prefer to rely on the is complicated because of the lack of of covering the currently uninsured. In political power that a sizable number of good data on the distribution of payroll exchange, they would both administer public-plan enrollees would provide to expenses across firms. With regard to the public plan and have major responsi- ensure that adequate minimum stan- these cost estimates, however, two is- bilities for cost containment. Their suc- dards of quality and access are estab- sues merit serious attention. First, cess in developing strategies for cost lished. The alternative would be de- much of the public cost is offset by ex- containment would affect not only the tailed federal rules and regulations for penses that would not be borne else- cost of the public sector plan, and thus state-administered programs. If reli- where in the system, eg, privately pur- state tax contributions, but also the cost JAMA, May 15, 1991 265, No. 19 Health System Reform-Holahan et al 2539 of those who are insured privately in the tion ages. Relieving states of this bur- than under conventional mandates and state. den may make the added responsibil- less than under proposals with higher States would have the freedom to ities for administering the acute care tax rates. Second, some states may not choose among a variety of strategies for system significantly more acceptable. want the responsibility we envision or cost containment. We have argued that Federalizing long-term care would also have the capacity to carry it out. But this freedom is essential because there facilitate the coordination of Medicare several Canadian provinces are rela- are fundamental disagreements on how and Medicaid policies toward nursing tively small and are able to perform the the system's costs should be contained; homes and home health care. same administrative functions within much of the disagreement exists across the Canadian national health system. In regional lines. For example, states SUMMARY addition, since the federal government could choose to rely on managed compe- In terms of the major objectives one would continue to administer the Medi- tition, ie, allowing private insurance would have for health system reform, care program, states would have the entities (eg, preferred provider organi- this plan makes the following choices: option of tying their policies for hospital zations, health maintenance organiza- 1. It would cover everyone, through and physician payment and utilization tions) to compete to control costs. This Medicare (the elderly), employer-based control to those of Medicare. Finally, could include permitting the public pro- coverage (some workers and depen- the proposal would require new tax rev- grams to buy individuals into private dents), or a state-level public program enues. Some of this replaces funds spent insurance arrangements or health main- that would replace Medicaid (the poor, at the local level to finance public hospi- tenance organizations. Alternatively, unemployed, and other workers and tal deficits and to reduce uncompensat- states could choose to use some form of dependents). ed care in other hospitals. Some of it all-payer rate setting to control both 2. There would be a standard mini- would also replace expenditures borne price and volume of care. These regula- mum package of required benefits for by corporations in purchasing private tions would be applied to both public- employer-based and public programs, health insurance plans and some of the and private-sector plans. They could with legislative requirements on maxi- insurance premiums borne by individ- also choose to limit coverage to cost- mum cost-sharing. Choice of provider uals privately. There would, nonethe- effective procedures along lines that might be restricted in some states. less, be a visible increase in taxes at the have recently been proposed in Oregon. 3. Administration of the private pro- federal and state levels. But it seems a States would also have Medicare poli- grams would be the responsibility, as modest price to pay for resolving the cies available as a possible model. The now, of the employers and/or insurance problem of the uninsured and for gain- key element is that states bear a mea- companies. Administration of the public ing control over the growth in costs that sure of financial risk for failure. program would be the responsibility of now seems endemic to the US health The incentives for cost containment the states, with the objective of maxi- care system. extend beyond the states' risk for ex- mizing responsiveness to local needs References cess growth in the costs of the care of and conditions. 1. Monheit A, Short P. Mandatory health cover- public-plan enrollees. States have in- 4. It would control costs through giv- age. Health Aff. Winter 1989;8:22-39. centives to be concerned with the ing the states a substantial financial 2. Moyer E. A revised look at the number of unin- growth in costs of private plans as well. stake in ensuring that the public pro- sured Americans. Health Aff. Summer 1989;8:102- 110. If private insurance premiums increase gram costs did not grow faster than 3. Swartz K. The Medically Uninsured: Special as a percentage of payroll, the number nominal GNP. State control would also Focus on Workers. Washington, DC: The Urban of enrollees in the public plan will grow, allow the testing of different mecha- Institute; July 1989. increasing the need for state (and feder- nisms for cost control, with the ultimate 4. Zedlweski SR. Expanding the Employer-Pro- al) subsidies. In addition, the private objective of identifying the most effec- vided Health Insurance System: Effects on Work- ers and Their Employers. Washington, DC: The insurance industry needs to control the tive cost-containment strategies. Urban Institute. In press. growth in health care costs and thus 5. The cost would be borne by em- 5. Nelson C, Short K. Health Insurance Coverage premiums, because failure to do SO will ployers, employees, and taxpayers. 1986-1988. Washington, DC: Bureau of the Census, mean loss of market share and an in- Employers would be protected from ex- US Dept of Commerce: March 1990. Current Popu- lation Reports, Household Economic Studies, Se- crease in public-plan enrollment. Final- orbitant costs by being allowed the op- ries P-70, No. 17. ly, because insurance reforms should tion of paying into a public plan rather 6. Schieler GJ, Poulier J-P. International compari- limit risk-selection opportunities, cost than providing health insurance them- sons of health care expenditures. Health Care Fin- control must come through controlling selves. The poor and unemployed would anc Rev. 1989 Annual Supplement:1-8. 7. Poulier J-P. Health care expenditure and other provider payments and increased ad- be protected by having their coverage data. Health Care Financ Rev. Summer 1990; ministrative efficiency. under the public program subsidized on 11:159-167. The increase in costs at the state level a sliding scale. 8. Himmelstein DU, Woolhandler S. Cost without would be a relatively large financial bur- 6. The political feasibility test would benefit: administrative waste in U.S. health care. N Engl J Med. 1986;314:441-445. den for many of them. One way to allevi- be met by retaining a major role for 9. Himmelstein DU, Woolhandler S. A national ate this burden would be to federalize insurance companies and by retaining health program for the United States. N Engl J the long-term-care component of the the role of employer-based coverage- Med. 1989;320:102-108. Medicaid program. This would provide thus reducing the tax increase needed to 10. The Pepper Commission (US Bipartisan Com- mission on Comprehensive Health Care). A Call for approximately $14.5 billion of fiscal re- ensure universal coverage. By allowing Action: Final Report. Washington, DC: US Gov- lief to states in 1990 dollars. (Although flexibility in design of cost-containment ernment Printing Office; September 1990. this is approximately the same amount strategy, some of the controversy over 11. Balancing Access, Costs, and Politics: The as the increase in states' costs for the this issue would also be deflected. American Context for Health System Reform. Washington, DC: The Urban Institute. In press. expansion of acute care, there would be Our proposal is also not without prob- Urban Institute report 91-6. gainers and losers among individual lems. First, our approach would still 12. Evans RG, Lomas J, Barer ML, et al. Control- states. These may need to be ad- have adverse effects on the profitability ling health expenditures-th Canadian reality. N dressed.) Long-term care is a large bur- of small businesses and on the employ- Engl J Med. 1989;320:571-577. 13. Enthoven A, Kronick R. A consumer choice den for states, and one that will grow ment prospects for low-wage workers- health plan for the 1990s. N Engl J Med. substantially over time as the popula- although these effects would be less 1989;320:29-37, 94-101. 2540 JAMA, May 15, 1991 265, No. 19 Health System Reform-Holahan et al A Tax Reform Strategy to Deal With the Uninsured Stuart M. Butler, PhD The high level of uninsurance in the United States is due in large measure to the the uninsured (those lacking private in- tax treatment of health care, which is based on the tax exclusion for company- surance or eligibility for public pro- provided plans. Correcting the perverse incentives for providers and patients grams) are workers or the dependents resulting from this tax treatment is the crucial step to creating a national health of workers, concentrated heavily care system that is affordable and efficient. The Heritage Foundation proposal among lower-paid employees.² More- calls for the elimination of the current tax exclusion and its replacement with a over, a company-provided plan does not have to contain any specific features, system of refundable tax credits for the purchase of health insurance and such as preventive medical care, family medical services. coverage, or catastrophic protection, to (JAMA. 1991;265:2541-2544) be eligible for the tax exclusion. So it is not unusual to find workers with a very ALMOST 90% of Americans say that coverage as a fringe benefit because expensive plan paying for all routine fundamental changes are needed in the such plans are excludable without limit dental care, and yet lacking catastroph- nation's health care system. Dissatis- from the employee's taxable income. ic protection. faction centers on the shortcomings of While limited tax relief is also available 2. Job mobility disincentives. job health insurance.¹ One of the most pro- to the self-employed and those incur- change of any kind, whether voluntary nounced deficiencies of this system, of ring unusually heavy medical costs, for or forced, usually requires a family to course, is that as many as 37 million most Americans the company plan is the change its insurer because coverage is Americans lack health insurance. only way of receiving a tax break for employer-based. This often means wait- Policymakers tend to assume that the medical costs. ing periods and preexisting condition only way to correct the problem is to The tax exclusion for company-based clauses in the new plan, and possibly construct a national health care system plans undoubtedly has encouraged the some change in benefits that the family in which tighter regulation is used both spread of health insurance and eased the would not have freely chosen. For fam- to control providers and to constrain the financial worries of millions of families. ilies with severe health problems this appetites of consumers. Whether such But it is also a major cause of uninsur- can mean that moving to a better job is policymakers favor a government-run ance and rapidly escalating health costs. impossible, and a layoff can be a Canadian-style system, or one requir- There are three reasons for this: disaster. ing employers to provide universal ac- 1. Inequity in tax assistance. A tax 3. Inflationary pressure.-Wi cess to health insurance, the assump- exclusion provides the employee with health care largely paid for by the em- tion is that normal consumer choice tax relief from all taxes (including pay- ployer (completely SO in the case of first within free and open markets can have roll tax) at his or her marginal tax brack- dollar coverage, which covers all costs), no major role. This assumption is erro- et. Thus, the tax benefit is highest for an employee has little or no incentive to neous. Policymakers should recognize employees in the highest bracket with be economical when seeking services. If that the deficiencies in today's US the most expensive health plans. A the employee does try to economize, it is health care system are due in large part highly paid executive can easily receive the employer who normally will gain the to powerful and perverse incentives re- a tax subsidy worth over 40% of the cost vast bulk of the savings (assuming the sulting from the current tax treatment of a generous package, when state and annual deductible has been exceeded). of health care. By correcting those in- local tax relief is considered. Mean- Knowing that the patient has little in- centives it would be possible to con- while, an employee in the same firm, centive to economize, physicians and struct a system based on consumer- with children, making $10 000, may be hospitals also have little incentive to driven markets, in which the problem of below the tax threshold and receive no hold down costs. Providing the per- uninsurance is solved and resources are income tax break at all. Worse still is the ceived value of a service is greater than used more efficiently with little or no individual who has no company plan, or the copayment-if any-faced by the increase in government expenditures. a plan not covering his or her family. patient, the patient will have no cause to HOW THE TAX SYSTEM This person normally must pay in after- challenge the price charged the insurer LEADS TO UNINSURANCE tax dollars for his or her family's insur- and ultimately the employer. The vast majority of American fam- ance or out-of-pocket medical expenses. This lack of concern for price is, of ilies receive medical insurance through Thus, the tax code gives virtually no course, a recipe for inflation. This in their employer. The tax code strongly help to Americans at the bottom of the turn adds to the number and plight of encourages such employer-provided income ladder who are not covered by the uninsured. Rising costs force more company plans, while it can mean thou- companies to reduce coverage or drop From The Heritage Foundation, Washington, DC. sands of dollars in tax subsidies for high- dependents from plans. The annual sur- Reprint requests to The Heritage Foundation, 214 Massachusetts Ave NE, Washington, DC 20002 (Dr er-paid individuals. It is little wonder vey of corporate health insurance con- Butler). that approximately three quarters of ducted by the New York City benefits JAMA, May 15, 1991 265, No. 19 Tax Reform Strategy for the Uninsured-Butler 2541 consulting firm of A. Foster Higgins & their money. catastrophic stop-loss insurance (which Co, for instance, found employees fac- The Heritage Foundation proposal limits out-of-pocket costs to a fixed dol- ing an average increase of $20 per calls for two principal steps: lar amount), hospital and physician cov- month in 1990 for their share of family 1. Replace today's tax exclusion with erage for all family members, and rou- health plan costs, and more firms en- a new system of refundable tax credits tine preventive care. The out-of-pocket couraging employees to accept restric- for health expenses. The current tax deductible and copayment in the health tions on their choices of medical care exclusion for company-provided health plan could not normally exceed 10% of (Wall Street Journal. January 29, benefits would be phased out over sev- adjusted gross income. Health plans 1991:B1). Higher insurance rates cause eral years. Any health package received would be required to offer a series of more families without company plans to by a worker would be included as tax- premiums, based on different out-of- forgo insurance while facing higher out- able income on the employee's W2 tax pocket costs, and consumers would be of-pocket costs. form. If a company were to discontinue required to choose a plan meeting at or scale back its health plan, it would least the 10% requirements. While this HOW A MARKET-BASED have to add the cash value of the re- would mean lower-income families typi- NATIONAL HEALTH CARE duced benefits to employee paychecks. cally would face higher premiums, re- SYSTEM WOULD WORK Over the same period, however, a new flecting the out-of-pocket limit, this in Proposals that would mandate em- system of tax credits in the personal tax turn would be offset by the larger tax ployers to provide insurance for em- code would be introduced for family credit available to them. ployees and their families or pay a pay- health care costs (out-of-pocket costs, The federal government would in roll tax for public insurance (so-called insurance premiums, and prepaid turn guarantee to make it financially play-or-pay proposals) simply would plans). These credits would be "above- possible for each household to discharge force all employers into today's flawed the-line," meaning they would be avail- this legal responsibility in one of the system. The result would be higher la- able to those who do not itemize deduc- following two ways: through the system bor costs and fewer employment oppor- tions on their tax returns. They would of refundable tax credits or by granting tunities for workers whose low skills also be "refundable." This means that if access to Medicaid or Medicare. Thus and whose insurance or health payroll the total credit exceeded the family's under The Heritage Foundation pro- tax costs would be high compared with tax liability, the Internal Revenue Ser- posal, all Americans would have at least their output. In addition, if employers vice would remit the difference. a basic package of medical care, paid for were prohibited from reducing benefits The size of the credit (in percentage by themselves or by the federal or coverage, they would resort to even terms) would depend on the family's to- government. tighter controls over the most basic tal annual health care spending com- This two-pronged market strategy health care decisions of American fam- pared with its income; the higher that would have significant effects on the ilies. A Canadian-style system similarly ratio, the higher the percentage credit. American health care system. First, it would use regulation rather than mar- Thus, a typical family incurring insur- would guarantee basic health coverage kets to determine access and to allocate ance and direct medical costs (including to all Americans, irrespective of their resources. As we now see in the Canadi- any employer-paid benefits) equal to place of employment-or whether they an system, just as with its forerunner 10% of its annual income, might be eligi- were employed at all. the British National Health Service, re- ble for a 20% credit. If that same family Second, government help to offset moving market prices as the primary faced unusually high costs, eg, 30% of medical costs would be based on medical regulator of demand leads to chronic income, the credit might rise to 50%. expenses as a proportion of income, not overdemand when compared with sup- Higher costs would mean a still larger on the family's marginal tax rate. Thus a ply and to waiting lines and shortages. percentage credit, such that the actual part-time employee of Joe's Bar and The alternative to such systems costs to the family, net of the tax credit, Grill would be eligible for exactly the based on curbing consumer choice and would be manageable. Similarly, if the same structure of tax help as a senior expanding regulation, which implicitly family's annual costs were low com- executive with Megacorp Inc, but the remove consumer-driven markets from pared with its income, the percentage part-time employee-or the chronically health care, is to address the perverse credit would be lower than 20%, and sick individual-would receive more incentives that lead to today's short- perhaps phased out entirely above a cer- cash help by virtue of his or her income comings, and to construct a system tain income. The credit would be de- and likely medical expenses. based on an active consumer-driven signed to ensure that these net costs Third, the credit system would intro- market. Such a system has been devel- would not normally exceed 10% of fam- duce a powerful tool to curb rising oped by The Heritage Foundation. ily income. By comparison, the most health care costs, since families would The Heritage Foundation proposal is comprehensive analysis of family health have a strong incentive to seek the best based on a reform of the tax treatment expenditures currently available, based value for their money in their health of health care, designed to achieve two on the National Medical Care Expendi- care decisions and to avoid overutiliza- goals. First, by changing the structure ture Survey of 1977, showed that out-of- tion. One reason for this is that the indi- of existing tax relief, it would provide pocket premium and direct service ex- vidual purchaser of insurance or ser- more help to the uninsured to obtain penses averaged 10.1% of family income vices would keep any savings (net of the health care and insurance, and less to for families earning less than $12 000 credit) gained through prudent buying, those who do not need generous tax sub- per annum, falling to 2.5% for families rather than these savings going to the sidies. The available pool of forgone tax earning more than $20 000.⁷ employer. This incentive would be revenues at the federal level alone is 2. Establish a "Health Care Social strongest for those eligible for only a estimated by the Congressional Budget Contract. Under this "social con- small credit (generally the more healthy Office to be worth $48 billion in 1991. tract," each head of household would be and affluent buyers), and weakest for Second, the new structure of tax relief required, by law, to enroll all family those eligible for a large credit. Another would provide stronger incentives for members in a health plan containing at reason is that an employee no longer consumers to challenge provider costs least a federally prescribed basic pack- would effectively be locked into the plan and to seek the best insurance value for age of features. These would include provided through the employer. Thus, 2542 JAMA, May 15, 1991 Vol 265, No. 19 Tax Reform Strategy for the Uninsured-Butler the employee could "shop around" for a Revenue Estimates of Options for Limiting the Tax Exclusion for Company-Based Health Plans and plan with the necessary services at the Introducing a Credit in the Personal Code* best price. That in turn would intensify 1991 1992 1993 1994 1995 competition among insurers and service Monthly limit on exclusiont providers. A family might choose more $400 for families/$160 for individuals services that their company plan used to Total receipts, $ in billions 1.5 3.1 4.5 6.7 9.6 offer. Or it might mean fewer extra ser- Affected recipients, % 15 16 19 22 26 vices, if a healthy employee had been $300 for families/$120 for individuals Total receipts, $ in billions 5.4 10.1 13.6 18.4 23.6 overinsured, leaving the family with ex- Affected recipients, % 32 35 39 40 42 tra cash income. Annual refundable credit Fourth, the consumer-driven model $200 per individual, up to $600 per household would drastically reduce the need for Total cost, $ in billions -0.4 -6.1 -6.6 -7.3 -7.8 expensive administrative regulation by Permanent 25% deduction for self-employed, $ in billions -0.2 -0.4 -0.5 -0.5 -0.6 insurers and employers. Most critics of the current US health care system point *Estimates assume that contributions to cafeteria plans for health care will be included in the computation of employer contributions. Data from Department of the Treasury, Office of Tax Analysis.¹⁰ out, correctly, that it is probably the tThe monthly exclusion limit and the value of the refundable credit for 1991 and beyond are indexed by the most bureaucratized and administra- consumer price index for all items. #The refundable credit is available to persons who do not have employer-provided insurance or public health tively top-heavy of systems.⁸ This did insurance. not just "happen." In the rest of the US economy, consumer choices based on real prices spur efficiency and force pro- ditional $89.4 billion in net additional tives in The Heritage Foundation pro- viders to compete by streamlining over- income and payroll taxes over 5 years.⁶ posal would reduce pressure for medi- head costs. But in health care provision, This means that the basic 20% credit cally unnecessary state mandates on the actual cost of services is largely ir- considered by the Congressional Bud- insurers. Such mandates are a signifi- relevant to consumer decisions. Thus, get Office could be expanded by addi- cant factor in rising insurance costs. the immediate payers of medical bills- tional credits in the amount of nearly Moreover, according to a statistical insurers and employers-have been $18 billion per year and still remain bud- study by Goodman and Musgrave," as forced to install a system of administra- get neutral. The US Treasury has ana- many as 9.3 million Americans lack tive controls and paperwork in an effort lyzed a limited version of a plan similar health insurance specifically because of to allocate resources reasonably effi- to The Heritage Foundation proposal. the additional costs due to mandates. ciently in spite of consumer demands. If the monthly exclusion for company- With families paying directly for insur- Consumer choice is a far more effective provided plans were capped at $400 per ance, rather than these costs being "hid- method of regulating prices and encour- family ($160 per individual), the trea- den" in company plans, there would be aging efficiency. It does not require a sury estimates that the extra revenue far less voter acceptance of pressure vast superstructure of resource plan- would, by 1995, finance an annual re- from provider groups to add new ser- ners trying to manage consumers. It is fundable credit of $200 per individual vices to state mandates. The same polit- the individual decisions of consumers (up to $600 per family) for families lack- ical dynamic would help offset provid- themselves that achieve an efficient ing company plans. If the monthly cap ers' lobbying at the federal level to system. were placed at $300 per family ($120 per expand the legally required basic Fifth, a tax system allowing Ameri- individual), the credit would still leave package. cans to select from a full range of com- the treasury with a net annual surplus of There are a number of understand- peting plans would end most of the em- $15.8 billion by 1995. This financial able concerns about such a consumer- ployment mobility problems plaguing cushion would permit more generous driven system based on individual today's system (and inherent in employ- credits to needy families and finance the choice of a medical plan, including the er-mandated proposals) because a fam- refundable credits envisioned in The following: ily would not change plans merely be- Heritage Foundation proposal. A sum- 1. Can average Americans really cause the head of the household changed mary of the treasury's estimates is pro- make informed choices about health jobs. Moreover, because the employer vided in the Table.9 care?-The more informed and techni- would not be responsible for providing Seventh, the tax credit system would cally sophisticated a consumer is, the health coverage under The Heritage reduce Medicaid and welfare costs. more likely he or she is to make sound Foundation proposal, there would not Since The Heritage Foundation propos- decisions regarding a medical plan. But be an incentive for firms to avoid hiring al includes a system of refundable tax there are two reasons why individuals individuals who would pose high insur- credits for lower-income individuals, it with little medical knowledge can be ance costs-another major drawback of would eliminate the current disincen- confident buyers in the system envi- mandated-benefits schemes. tive for many welfare recipients receiv- sioned under The Heritage Foundation Sixth, reforming the tax code would ing Medicaid to take a job with few or no proposal. allow the uninsured to be protected at a medical benefits. The Medicaid pro- The first is that any comprehensive far lower cost to the government than gram would be retained under The Her- plan would, under federal law, have to other approaches. Indeed, it might well itage Foundation proposal as an inte- include at least the basic set of services. be accomplished without any net in- gral part of the welfare system. The second reason is that a system crease in the federal deficit. The Con- Subsidized risk pools and similar state- based on individual buyers does not in gressional Budget Office estimates that based innovative strategies would also any way rule out the formation of group if the current tax exclusion for compa- be encouraged as a safety net to deal buyers. Indeed, most individuals proba- ny-based plans were ended and re- with unusual situations," although the bly would join groups, both to gain bar- placed with a flat 20% income tax credit number of uninsurable Americans gaining power as organized buyers, and for insurance costs up to $250 per month would decline under the proposal (see to delegate detailed purchasing deci- for families ($100 for individuals), the below). sions to an organization they trusted. federal government would collect an ad- Eighth, the strong consumer incen- Such groups would negotiate plans with JAMA, May 15, 1991 265, No. 19 Tax Reform Strategy for the Uninsured-Butler 2543 providers and insurers on behalf of their itage Foundation proposal, however, Moreover, the idea of individual tax members, much as companies do today. realistic premiums could in many in- credits to help certain categories of The important difference is that con- stances be charged and paid. Americans to purchase medical insur- sumers would be able to choose a buyer 3. Would a tax credit system be diffi- ance or services is not new or unique to group they really trusted and still ob- cult for the consumer to operate?-En The Heritage Foundation proposal. The tain tax benefits; today they are effec- ployees would instruct the payroll de- 1991 budget passed by Congress in Oc- tively restricted to a group organized by partment of their employer to adjust tober 1990, for instance, contains a new their employer. their withholding to reflect their antici- program granting a 50% refundable tax Various groups can be imagined par- pated credit. If the employee was eligi- credit for low-income families purchas- ticipating in a system like The Heritage ble for a refundable credit, that credit ing insurance to cover children not cov- Foundation proposal. A trade union, a would be added to the paycheck each ered under company plans. professional organization, or a state pay period. At the end of the year the Capping or limiting the exclusion of farm bureau might manage a plan on total credit would be adjusted when the company plans also is not a new idea. It behalf of its members. Churches, uni- family filed its tax return. was routinely proposed as a deficit re- versity alumni groups, and school asso- Variants of this basic mechanism duction measure during the Reagan ad- ciations also might act as brokers. Other would deal with most potential difficul- ministration. It made little headway groups might comprise those who suffer ties. If anticipated costs were to rise then because workers saw no advantage from particular ailments, such as dia- unexpectedly, the employee could in supporting such a measure. Blending betics, who would be seeking the most change the number of exemptions a phaseout of the exclusion with a new economical plans supplying additional claimed (as an individual would do if he system of tax credits leads to a very specialized services. The Heritage or she were to take on a larger mortgage different political equation, however, Foundation proposal, unlike the man- for a home). If the individual became since millions of employees would gain dated benefits approach, would make it unemployed, or a sudden outlay exceed- from such an exchange, including many very easy for these specialized plans to ed the family's immediate ability to pay, workers currently with generous plans. develop. despite catastrophic protection, federal In today's climate of deficit reduction 2. Wouldn't adverse selection under- regulations could require providers to and concern about rising unemploy- mine The Heritage Foundation propos- wait for payment until the appropriate ment, a "balanced budget" proposal Active consumer choice is consid- refundable credit was processed by the that does not mean huge new federal ered the key to the workings of other Internal Revenue Service. In addition, outlays or additional payroll costs for segments of the economy. In the health to ensure regular premium payments, a business has a distinct attraction. sector it is usually deemed adverse. The requirement could be placed on larger reason for this is that the principal employers to make a payroll deduction References method we use to subsidize working on behalf of their employees and to re- Americans facing high medical costs is mit it to the insurance company chosen 1. Blendon RB, Leitman R, Morrison I, Donelan K. Satisfaction with health systems in ten coun- equal premiums for company-based by the employee, as many firms cur- tries. Health Aff. 1990;9(2):185-192. group plans. In this way the healthy rently do for 401K savings plans. 2. Short P, Cornelius L, Goldstone D. Health in- subsidize the unhealthy. Naturally, a The primary tool to assure compli- surance of minorities in the United States. J Health problem immediately arises if healthy ance with the mandate for families Care Poor Underserved. 1990;1(1):15-16. 3. Walker M. Why Canada's health care system is consumers are permitted to opt out of would be to require proof of basic insur- no cure for America's ills. Heritage Found Int the group and choose a lower-cost plan ance to be attached to the annual tax Briefing; no. 19. reflecting their better health risk. return. Insurance companies or health 4. Globerman S, Hoye L. Waiting Your Turn: Hence, elaborate steps are included in plans providing the basic comprehen- Hospital Waiting Lists in Canada. Vancouver, British Columbia: Fraser Institute; 1990. managed care proposals to restrict or sive package would be required to send 5. Butler S, Haislmaier E, eds. A National Health guide consumer choices.¹ enrollees a statement indicating the pe- System for America. Washington, DC: The Heri- The Heritage Foundation proposal riod of coverage (if an employee tage Foundation; 1989. avoids this problem by cross-subsidiz- switched companies, the statement 6. Reducing the Deficit: Spending and Revenue Options, Part II. Washington, DC: Congressional ing through the tax code, rather than would indicate the change). There Budget Office; 1990:143-146. through premium setting. Under The would be fines for families failing to in- 7. National Center for Health Services Research Heritage Foundation proposal there clude proof of insurance with their tax and Health Care Assessment. A summary of ex- would indeed be a tendency for healthy return. While some families would still penditures and sources of payment for personal health services from the National Medical Care individuals to purchase lower-priced evade the requirement, just as some Expenditure Survey. In: National Health Care plans, leaving higher-risk individuals to evade taxes, this system would reduce Expenditures Study, Data Preview 24. Washing- face steeper premiums. But the higher- the problem to an acceptable level. ton, DC: US Dept of Health and Human Services; risk consumers would receive large 1987:Table 12. CONCLUSION 8. Himmelstein DU, Woolhandler S. Cost without credits to offset the higher costs, benefit: administrative waste in US health care. N financed by US Treasury savings A structural change of this kind might Engl J Med. 1986;314:441-445. achieved from lower revenue losses on seem politically unrealistic, but there 9. Department of the Treasury, Office of Tax Anal- the leaner plans chosen by healthy indi- are several reasons to believe other- ysis. Financing Health and Long-term Care. Washington, DC: US Dept of the Treasury; viduals. This method of cross-subsidy is wise. It is certainly less radical than 1990:88. not just more precise and consistent, replacing the entire system with a Ca- 10. Wasley T. Health care for the poor, unem- and less expensive to the taxpayer, than nadian-style system. It can also be in- ployed, and high-risk. In: Butler S, Haislmaier E, the necessarily wide variations in subsi- troduced gradually. A specific credit to eds. A National Health System for America. Washington, DC: The Heritage Foundation; dy levels with company groups. It cover one segment of the uninsured, for 1989:91-119. would also reduce the problem of unin- instance, could be paid for with a modest 11. GoodmanJ, Musgrave G. Freedom of Choice in surable individuals. Today such individ- cap on the current exclusion. When con- Health Insurance. Dallas, Tex: National Center for uals cannot be insured except at rates sumers and insurers had grown accus- Policy Analysis; 1988. 12. Enthoven A, Kronick R. A consumer-choice they or their employer cannot afford. tomed to that change, the credit could health plan for the 1990s. N Engl J Med. With the sliding scale credit in The Her- be expanded and the cap reduced. 1989;320:29-37, 94-101. 2544 JAMA, May 15, 1991 265, No. 19 Tax Reform Strategy for the Uninsured-Butler The 'USHealth Act' Comprehensive Reform for a Caring America Rep Edward R. Roybal MUCH to the credit of THE JOURNAL wife faces many expensive years in a sive reform can take many forms. Com- and its editors, this in-depth discussion nursing home. Finally, uninsured and pared with the early 1980s, many is significant in its timeliness. It should underinsured Americans include the alternative solutions are now available be a precursor to action. Having just couple in their 70s who have lived just and are being advanced by congressio- passed the largest federal deficit reduc- above "poverty" all their lives and who nal leaders, coalitions, and experts. The tion package in the history of this na- now can barely afford needed medical most recent and prominent proposal tion, the federal government is in a posi- care for even one of them. As a result, was the plan laid out by the "Pepper tion to tackle the societal problems that the husband gets only minimal care and Commission," a bold plan that would have seemed SO intractable for so long. the wife goes without care. These are effectively extend health and long-term One of the most intractable problems Americans we should care about; as a care protection to all Americans. has been caring for the health of the nation, we are failing them. Although the commission's recom- uninsured and underinsured, the theme As shown by the lives of these Ameri- mendations may not be the "perfect so- of this issue of THE JOURNAL. As this cans, we are confronted with a some- lution," they may just be the "perfect issue makes its way to hundreds of thou- what tattered and increasingly unaf- compromise solution," and they do take sands of key decision makers in and out- fordable and unsustainable health care us far on the journey toward a healthy side of the medical community, it is cru- system. In some ways this is the best and caring America. While I support the cial that ever larger portions of that system and in some ways it is the worst commission plan and am willing to sup- community become actively committed system, but in almost all ways it is un- port several of the other major compre- to comprehensive reform and to helping fair, incomplete, and inadequate. hensive reform proposals, I believe that ensure that the terms "uninsured and Although we have a somewhat tat- some plans to care for the American underinsured Americans" will be re- tered system, there are very powerful people are more effective and affordable moved from the American health care forces in health and long-term care than others. The "USHealth Act" is one vocabulary. pushing us toward change while pulling of them. THE ENVIRONMENT us in different directions. The most FOR CHANGE powerful force is the rapid escalation of THE 'USHEALTH' SOLUTION health and long-term care costs. On the I first proposed the USHealth Act Why this great need for change? It is one hand, any solution dealing with ac- (HR 2980 in the 101st Congress) in 1986, because of who these Americans are, cess becomes more expensive unless when almost no comprehensive reform the number of people at risk, and the there is a very strong cost-containment proposals were being considered. The nature of their plight. Uninsured and program. On the other hand, the in- USHealth Act was designed to help re- underinsured Americans include, as one creasing unaffordability of health and start the debate on health care reform example, the young working family long-term care for even the middle class and to incorporate the knowledge lacking adequate insurance. This may creates pressure for a broad-based solu- gained since the late 1970s. not stop them from getting care for the tion. Will we let those forces drive us, or What is USHealth? If enacted, children, often in an emergency depart- will we assert leadership and channel the USHealth program provides cata- ment, but it inhibits the parents from those forces to develop a comprehensive strophic and basic health protection for getting care. This same young family health and long-term care system pro- all Americans regardless of age, in- lives in fear of being impoverished if hit tecting all Americans? come, or illness. It offers an affordable by a catastrophic and expensive illness. As we move into the 1990s and, as American alternative to the current We also should consider the middle-in- noted above, having just enacted a 5- health care system by constraining come family whose brain-injured teen- year, $500 billion dollar federal deficit health care cost increases, as Canada age daughter faces years of rehabilita- reduction plan, there is no doubt that has done with great success for over a tion and thousands of dollars in medical America and its leaders face new fiscal decade. The program provides all bills each month for the foreseeable fu- realities. To the extent that the deficit Americans with broad health insurance ture. Also, we need to think about the reduction plan fails and federal deficits protection, including coverage for basic middle-aged man whose grandparent worsen, the policy climate also worsens. health and long-term care and special and parent suffered from Alzheimer's If the deficit reduction plan works, the safeguards for catastrophic illnesses, disease. Not only does he carry the bur- policy climate improves. In either case, such as Alzheimer's disease. In addi- den of their care but he fears having having faced up to the fiscal realities, tion, the program provides assurances Alzheimer's disease himself. Then there the federal government is in a better that health care quality will be main- is the couple in their early 60s whose position than it has been for the past tained or improved. retirement plans are in jeopardy as the 5 years to realign its priorities and ad- Congressman Roybal (D, Calif) is the chairman of the dress the larger unresolved issues on a Organization US House Select Committee on Aging. pay-as-you-go basis. Reprint requests to Select Committee on Aging, US Under my proposal, the program House of Representatives, Room 712, HOB Annex #1, Within this environment and oppor- is managed by the USHealth Adminis- Washington, DC 20515 (Rep Roybal). tunity for change, action on comprehen- tration, which replaces the current JAMA, May 15, 1991 265, No. 19 The 'USHealth Roybal 2545 Health Care Financing Administration fordable. For the first time, total na- containment should keep in mind that (HCFA). The USHealth Administra- tional health and long-term care costs this nation's health and long-term care tion is treated as an independent agency are capped at 13% of the nation's gross expenditures are projected to easily ex- whose funding is considered "off bud- national product (GNP). Under that ceed 13% of GNP by the year 2000, but get" for most federal purposes. ceiling is a second ceiling on long-term without resolving the crisis facing peo- USHealth changes the system of care costs set at 1.1% of GNP; this sec- ple with catastrophic illnesses and peo- health insurance in this country by con- ond ceiling is indexed to changes in the ple without adequate health insurance solidating Medicare, Medicaid, and pri- population's severity of illness, assis- protection. Establishing a fair cost-con- vate insurance into a single insurance tance with daily living (ADL) levels, tainment program that treats everyone system. This system is funded by cost and cognitive impairment levels. While equally and setting a national health and sharing, employer contributions, state USHealth places a cap on total expendi- long-term care expenditure cap is a fair revenues, federal excise and income tures by law, it also allows for that legis- trade-off if we can secure comprehen- taxes, and beneficiary premiums. At lated cap to be changed if the American sive protection for all Americans. the same time, it expands the existing public and its representatives decide to In the interest of making people role of insurance companies through do SO after weighing the tax and health aware of the cost of health care, benefi- contracts for a much larger volume of consequences against each other. ciaries are required to share some of the bill processing and review, especially As should always be the case, expen- cost. For medical and skilled nursing since the program covers, for the first ditures for improving health care must care, beneficiaries are required to pay time, millions of long-term care recipi- be considered in the context of expendi- coinsurance of 20%. For nonskilled ents and over 30 million uninsured per- tures for competing social needs. Com- long-term care, beneficiaries are re- sons. This partnership with the nation's prehensive models such as USHealth do quired to pay coinsurance of 25%. To insurance industry protects the finan- just that. The expenditure cap of 13% of protect people against very expensive, cial viability of insurance companies GNP represents a modest increase from catastrophic, and short-term illnesses, while ensuring comprehensive cover- where we are today but is lower than this cost sharing is limited to no more age for every American. where the expenditure cap will be at the than $600 per person (indexed to per The design is straightforward and turn of the century. Again, the Ameri- capita GNP) per year for medical and builds on the ever-growing knowledge can public and its representatives will skilled nursing home and home health and experience base of the Medicare have a full debate and will decide wheth- care. For long-term illnesses needing program as well as the experience with er 13% is too high or too low in the nonskilled long-term care, there is a both private insurance and the federal- context of other national needs. Today, separate cost-sharing limit of $1000 per state Medicaid program. USHealth there is much less opportunity to have person per year (indexed to per capita takes the current Medicare program as that debate, and health care continues GNP). Cost sharing is optional for quali- its foundation, with the following provi- to absorb ever-larger portions of GNP. fied health maintenance organizations sions: It extends protection to all Amer- Under the current system, total na- (HMOs), as under the current Medicare icans regardless of age or income. It tional health expenditures are esti- program. Poor people who have in- expands coverage to include long-term mated to reach about $1 trillion in 1996. comes less than 100% of poverty and care and essential health care not cur- Under USHealth, total expenditures people who spend down into poverty are rently covered by Medicare. It uses the would be capped at 13% of the GNP, and virtually exempt from any cost sharing. developing quality assurance system. It the expenditure cap under USHealth in 1996 is also estimated to be about Covered Care brings to bear the evolving cost-con- tainment effort. In effect, the Medicare $1 trillion. USHealth covers a broad range of card of today becomes the USHealth Health care providers are paid pro- preventive, short-term care, and long- card of tomorrow, and every American spectively set fees based on such Medi- term care (both skilled and custodial) (both citizens and permanent residents) care models as diagnostic related services. In deciding what care should would have one. groups (DRGs) and resource-based rel- be covered, we examined benefits cov- While today's Medicare program is ative value scales (RBRVSs). As in the ered by Medicare, Medicaid, and pri- certainly not perfect, in my opinion it RBRVS system, such fees would be de- vate insurance programs. We also at- outperforms the alternatives, whether veloped in consultation with represen- tempted to determine what services, they be the federal-state Medicaid pro- tatives of health care providers. These for example, prevention services, it gram or the best of the private insur- fees are indexed to our nation's ability to makes sense to cover when the insur- ance firms. To cite one example, Medi- pay as measured by increases in per ance program is responsible for short- care returns a much higher ratio of capita GNP. As with today's Medicare and long-term care for the whole nation benefit dollars for every premium or tax and Medicaid programs and private in- and for the entire life span. Finally, we dollar collected than do private insur- surance, the volume and intensity of took into account those services that ance firms. The imperfections in Medi- health care services under this program were most critical in preventing both care can be fixed if there is a commit- must also be addressed. If these prob- financial and emotional devastation re- ment to doing so and if all Americans lems are solved, the combination of the sulting from catastrophic short- or long- have a solid stake in it. Both will exist if expenditure cap and the fee system un- term illnesses. As a result, the decision every American is both a beneficiary der the USHealth program will result in was made to cover a broad range of and a financier of USHealth, the succes- fair treatment of health care providers health and long-term care services and sor to Medicare. and appropriate access to needed and make them subject to tight utilization quality health care. Also, under this review and an overall national expendi- Cost Containment program, each state does have the op- ture cap. As the debates of the last two decades tion of setting up an alternative pay- Under this program, the basic health have convinced us all, cost containment ment system as long as it performs as and long-term care benefits include is essential to the political and financial well as the federal system. standard Medicare-covered services as viability of any comprehensive solution. Those who are concerned about such well as the following: inpatient and psy- USHealth is fiscally responsible and af- an all-encompassing approach to cost chiatric hospital services, medical and 2546 JAMA, May 15, 1991 265, No. 19 The 'USHealth Roybal other health services, comprehensive managed through a care management sumer access through "hotlines" and outpatient rehabilitation facility ser- system that ensures that beneficiaries consumer advisory boards, by estab- vices, health care services provided by a receive the care they need and that tax- lishing a national quality assurance rural medical care access facility, ex- payers will not face increases in costs council, and by improving methods for tended care and nursing facility ser- beyond increases in their ability to pay. monitoring and assuring the quality of vices, skilled home health services, hos- Furthermore, the bill's long-term care care. Quality assurance protection is ex- pice services, alcohol and drug abuse benefits and care management are flexi- tended and applies to all care, settings, rehabilitation, and outpatient mental ble to best match beneficiary needs providers, and patients covered by the health services (including community and promote beneficiary independence. program. As was the case with the cost- mental health centers and state-autho- This last point is critical to a long-term containment program, states have the rized services provided by a clinical psy- care program that addresses the needs option to develop their own quality as- chologist, clinical social worker, or psy- of both the patient with Alzheimer's dis- surance program as long as it performs chiatric nurse-specialist). ease with major cognitive impairment as well as the federal program. In addition to the services traditional- and the young adult with major dis- Building on recent changes in Medi- ly covered by Medicare, medical and abling conditions and no cognitive care and recent reports by organiza- other health services are expanded to impairment. tions such the National Institute of include nurse-practitioner and clinical Medicine, the quality assurance pro- nurse-specialist services; Early and Pe- Provider, Patient, and gram will need to continue to undergo riodic Screening, Diagnosis, and Treat- Program Relationship change in future years. As our knowl- ment (EPSDT) programs for those un- While applauding the comprehensive edge base grows with respect to mea- der age 21 years; family planning for benefit structure of this program, many suring and assuring quality, our ap- individuals of childbearing age; private- health care providers will likely be un- proach to quality assurance will also duty nursing services; physical therapy; easy at the prospect of Medicare being have to change. USHealth creates the occupational therapy; speech and lan- the primary payer and at the potential "vessel" for an evolving quality assur- guage therapy; audiology; and other intrusions into patient care. These con- ance program without binding us to cur- medical or remedial care recognized un- cerns, however, need to be put in per- rent approaches. For example, on der state law and specified by the spective. Whether or not USHealth the issue of outcome measures, the USHealth program. The program also becomes the plan of choice, the relation- USHealth quality assurance program covers physical checkups, health ship between health care provider and intends to use current approaches while screening, immunizations, health risk payer will be much the same. It will recognizing the difficulty of moving to reduction, and other preventive ser- always be difficult to strike a balance outcome-oriented quality assurance. vices. As would have been the case un- among the interests of the health care Because USHealth is a national pro- der the now-repealed Medicare Cata- provider, the patient, and the payer, gram, outcome measures of the soci- strophic Coverage Act, prescription who may be the patient or a third party. ety's health as a whole as well as of drugs are covered after an annual de- As with Medicare and Medicaid, private subgroups within our society have di- ductible of $100. Dental services (in- insurers no longer have the luxury of rect significance. Furthermore, in the cluding dentures) and eyeglasses are to letting health care providers operate context of a national health program, be added before the year 2000 unless without some review and restraint. Un- quality assurance can help monitor the total USHealth program expenditures der the USHealth Act there is a com- impact of cost containment and signal exceed the national health expenditure mon interest in eliminating unnecessary when cost containment is having a sig- cap. burdens on both health care providers nificant negative effect on quality and With respect to long-term care, bene- and patients. access. fits are covered for chronically ill indi- Through its benefit, payment, and viduals, including those with at least quality assurance structure, the pro- Financing two age-appropriate ADLs or a similar gram tries to make critically needed Although the question of financing level of cognitive impairment. Long- improvements without disrupting the appears last in this report, it is first term care benefits include care manage- essential professional and personal rela- in policymakers' minds. Since the ment services; nursing care; homema- tionship between individual patients USHealth Act was first introduced in ker/home health aide services; physical, and their health care providers. Patient 1986, it has always used a pay-as-you-go occupational, speech, respiratory, and and health care provider "freedom of approach. Financing is derived from corrective therapy; patient and care choice" is preserved. Patients are free three mechanisms: revenues, cost con- giver education, training, and counsel- to continue their relationship with their tainment, and savings associated with ing; medical social services; day health existing physician or hospital and are using the Medicare model. Savings are care; respite care (minimum of 120 free to choose among fee-for-service or generated by using the Medicare model, hours per year if eligible); nursing facili- capitation providers. Health care pro- which has a history of returning signifi- ty services (as under the current Medic- viders, such as public providers and pri- cantly more in benefits than a private aid program); medical supplies; and lim- vate profit and not-for-profit providers, insurance model, generally over 95 ited transportation. Other long-term are included in the program. cents for every tax or premium dollar care services, including personal care, may be covered if authorized by the care Quality Assurance invested. By some estimates, following the Medicare model alone could save the management agency and if total costs do Continuing a growing national com- nation as much as $30 billion per year. not exceed the expected cost. mitment to quality assurance, There are also savings generated by Compared with almost all other com- USHealth upgrades and extends the the cost-containment system instituted prehensive reform packages, with the current Medicare quality assurance sys- under this program. The key elements exception of the Pepper Commission's, tem. The current Medicare system is of this cost-containment system are the this program has a carefully articulated upgraded by making quality assurance indexed and prospective fee-based pay- system providing long-term care pro- the highest priority for peer review or- ment system and the national expendi- tection. Long-term care benefits are ganizations (PROs), by increasing con- ture cap of 12% or 13% of GNP. De- JAMA, May 15, 1991 265, No. 19 The 'USHealth Act'-Roybal 2547 signed to slowly, methodically, and underinsured Americans. There are surance, and the general public are carefully reduce health and long-term two key questions: Is there sufficient driving us to action and will force com- care costs over several years, this mea- commitment? What criteria should be mitment upon us even if we cannot find sure produces significant savings with- used to select a solution? it on our own. Inaction will only result in out subjecting health care providers to In selecting a solution and its financ- an incomplete, inadequate, and unfair the uncertainties of current cost-con- ing, it is important to keep in mind that health care system that we cannot af- tainment systems or sharply fluctuating all funding comes from the same source, ford as individuals or as a nation. shifts in payments from year to year. the pockets of the American people, However, cost considerations should Although these savings make a sub- even though payment may be made not be the only source for creating com- stantial contribution to covering the through premiums, deferred wages mitment. Commitment should also cost of the program, revenues are need- (through employers), or taxes or out of come from our deep concern for the ed to sustain it. The program begins pocket. The criteria for selecting a par- plight of a large number of Americans with the funding base for health care ticular solution should be based on the without any health insurance cover- under the existing system. First, bene- most efficient and effective way to use age-31 to 37 million people are unin- ficiaries are generally required to par- the American people's dollars to meet sured today. The fundamental right of ticipate in cost sharing, just as most the American people's health and long- every American to necessary health people do today, whether they are cov- term care needs. care cannot and should not be denied. ered by the Medicare program or by As for whether the focus should be on Beyond the problem of the uninsured, private insurance. Exceptions are al- piecemeal or partial solutions or a com- commitment should come from our fears lowed for enrollees in HMOs, and pro- prehensive solution, there should be lit- of being underinsured; in other words, tections are provided for the poor and tle doubt as to what is needed. The pas- having inadequate coverage for prima- near poor. sage and subsequent repeal of the ry, short-term, and long-term care. Second, revenues from the existing Medicare Catastrophic Coverage Act More and more of our younger and older Medicare payroll tax and a premium ap- demonstrated that piecemeal and par- families are likely to be working for em- proximating the Medicare part B premi- tial reforms are fraught with perils. ployers who provide only minimal cov- um are shifted into the USHealth Trust While comprehensive reform poses erage for short-term care. With respect Fund. The amount of revenue from the problems of its own, a broad-based to long-term care, over 200 million payroll tax is increased by removing the problem exists, and only a broad-based Americans of all ages are without long- current wage cap, making higher-in- solution will provide the full health and term care protection-either public or come wage earners pay the payroll tax long-term care protection Americans private-and are at major risk of finan- on all their wage income. Third, with desperately require. cial disaster if hit by a catastrophic, respect to existing Medicaid funding, a When considering alternative pro- chronic illness. state that wants its citizens to be part of posals in the search for a comprehensive As the public opinion polls have this program is required to pay an solution, a "true" solution must meet shown time after time, Americans feel it amount that covers about half the cost of certain criteria: is unacceptable that those underinsured caring for the state's poor. This amount It must protect the uninsured. for long-term care face not only the is adjusted, as in the current Medicaid It must protect working families tragedy of severe long-term care illness program, to account for the relative that are underinsured for basic, cata- but also a second tragedy-a financial wealth of different states. strophic, and long-term health care. disaster that strikes both young and old. A fourth revenue source is an employ- It must protect people who are un- Just as strongly, Americans also feel it er tax similar to what employers would derinsured for catastrophic short-term is unacceptable that any Americans be be paying for private insurance under care costs. uninsured and left to face an acute ill- the current system. The employer tax is It must protect people who are un- ness without the resources to retain a tax on total compensation and is de- derinsured for catastrophic long-term their dignity and pay for the care. signed to produce total revenues ap- care costs. Even in these years of tight federal proximating the proportion that em- It must contain health care costs budgets, this nation cannot afford to ployers in the aggregate are paying for everyone (consumers, employers, stop short of fully ensuring care for all today through private insurance. and the government). Americans. With leadership from the Finally, the fifth revenue source for It must ensure quality health care public, the Congress, and the adminis- the program is a special dedicated for everyone. tration, this nation must make the com- USHealth tax, a surcharge that would It must be fully financed now and mitment and have sufficient political be applied to existing corporate and in- for the foreseeable future. will to carry through on that com- dividual tax liability for all taxpayers. USHealth is not the only proposal mitment. To set the level of the surcharge, an that fully meets these criteria. Another If the commitment and the will are estimate is made of the total national proposal clearly deserving consider- sufficient, then it is time to join our cost of the program and the total reve- ation is that of the Pepper Commission, efforts, consider all the alternative solu- nues from the sources listed above. The which comes very close to meeting these tions, make our decision, and get going surcharge rate is set at a level to pro- criteria. on the task of building a health and long- duce revenues to cover the difference With good alternatives in hand, the term care system of which the United between costs and other revenues and remaining question is whether or not States can be proud. USHealth is one to ensure the continued solvency of the there is sufficient commitment to actu- solution, a comprehensive federal pro- USHealth program. ally carry out a comprehensive and com- gram with full and free participation by plete solution. In my view, we have no the private and public sectors. It is built COMMITMENT TO AND choice. on the belief that this nation can and CRITERIA FOR A SOLUTION The escalating costs and the increas- should protect and care for the unin- Fortunately, there is no shortage of ing unaffordability of health and long- sured and underinsured. options to ensure care for uninsured and term care for government, private in- 2548 JAMA, May 15, 1991 Vol 265, No. 19 The 'USHealth Act'-Roybal Liberal Benefits, Conservative Spending The Physicians for a National Health Program Proposal Kevin Grumbach, MD; Thomas Bodenheimer, MD, MPH; David U. Himmelstein, MD; Steffie Woolhandler, MD, MPH The Physicians for a National Health Program proposes to cover all Americans ministrative savings without adding under a single, comprehensive public insurance program without copayments or new costs to the overall health care bud- deductibles and with free choice of provider. Such a national health program get and would establish effective mech- could reap tens of billions of dollars in administrative savings in the initial years, anisms for long-term cost control. Al- enough to fund generous increases in health care services not only for the though consolidation of purchasing uninsured, but for the underinsured as well. We delineate a transitional national power in a public agency may cause ap- prehension among some physicians, the health program budget that would hold overall health spending at current levels program could free them from the myri- while accommodating increases in hospital and physician utilization. Future ad administrative intrusions that cur- national health program spending would be indexed to the growth in gross rently plague the practice of medicine. national product adjusted for demographic, epidemiologic, and technologic shifts. Financing for the national health program would transfer funds into the STRUCTURE OF THE NHP public program without disrupting the general pattern of current revenue We have previously described the de- sources. We suggest a funding package that would augment existing govern- sign of the NHP in some detail. 7,8 It ment health spending with earmarked health care taxes. Because these new would create a single insurer in each taxes would replace employer-employee insurance premiums and substantial state, locally controlled but subject to portions of current out-of-pocket expenditures, they would not increase health stringent national standards. States costs for the average American. could experiment with the precise structure of the single insurer. Some (JAMA. 1991;265:2549-2554) may place it within a government agen- cy, while others may choose a commis- THE AMERICAN approach to financ- ments of familiar regimens: larger doses sion elected by the citizens or appointed ing health care has gone awry. From of employment-based insurance and by provider and consumer interests. physicians to patients, from The Heri- greater infusions of public funds to ex- Everyone would be fully insured for tage Foundation to the AFL-CIO, there pand Medicaid or to subsidize risk pools all medically necessary services includ- is agreement that the system needs re- for the uninsured. 1-4 Because such mea- ing prescription drugs and long-term form. But what kind of reform? Al- sures do not confront the interdepen- care. Private insurance duplicating though all concur that the system is dent problems of rising costs and declin- NHP coverage would be proscribed, as ailing, proposals diverge in their thera- ing access, they cannot ensure health would patient copayments and deduct- peutic approach. Many advocate adjust- services to all at a cost the nation can ibles. Physicians and hospitals would afford. A lasting remedy requires basic not bill patients directly for covered ser- From Physicians for a National Health Program, Cam- restructuring of the way we pay for vices. Hospitals, nursing homes, and bridge, Mass (Drs Grumbach, Bodenheimer, Himmel- care.⁵,⁶ clinics would receive a global budget to stein, and Woolhandler); the Institute for Health Policy Studies (Dr Grumbach) and the Department of Family The Physicians for a National Health cover operating expenses, annually ne- and Community Medicine, University of California, San Program plan would cover all Ameri- gotiated with the state health plan- Francisco (Drs Grumbach and Bodenheimer); the De- cans under a publicly administered, tax- based on past expenditures, previous partment of Medicine, the Cambridge (Mass) Hospital and Harvard Medical School (Drs Himmelstein and financed national health program financial and clinical performance, pro- Woolhandler); and the Public Citizen Health Research (NHP). A single public payer would re- jected changes in cost and use, and pro- Group, Washington, DC (Dr Himmelstein). Dr Grum- place the present array of more than posed new and innovative programs. bach is a Pew Health Policy Fellow. Reprint requests to Physicians for a National Health 1500 private insurers, Medicaid, and Itemized patient-specific hospital bills Program, 1493 Cambridge St, Cambridge, MA 02139 Medicare. A unitary program could ini- would become an extinct species. No (Dr Grumbach). tially pay for expanded care out of ad- part of the operating budget could be JAMA, May 15, 1991 265, No. 19 Physicians for a National Health Program-Grumbach et al 2549 diverted for hospital expansion, profit, among those currently insured? The Table .-Personal Health Care Costs for 1991, marketing, or major capital acquisi- RAND Health Insurance Experiment Excluding Nursing Home Care, With and Without a tions. Capital expenditures approved found that costs for persons assigned to National Health Program (NHP), in Billions of Dollars* by a local planning process would be a plan with no cost sharing were approx- funded through appropriations distinct imately 15% higher than the age-adjust- Current from operating budgets. ed, per capita health care expenditures NHP Policies Fee-for-service practitioners would for the United States as a whole. 11 How- "Baseline" conditions 567 567 submit all claims to the state health New costs for previously uninsured 12 ever, a more natural experiment, a Discount for 11.2% hospital plan. Physician representatives (proba- study before and after the implementa- administrative savings (31) bly state medical societies) and state tion of an NHP in Quebec, failed to de- Discount for 6.25% physician administrative savings (9) plans would negotiate a fee schedule for tect the overall utilization surge pre- Subtotal: Personal Health Care 539 567 physician services. The effort and ex- dicted by the RAND experiment. 12,13 Insurance administration and profits 8t 35# pense of billing would be trivial: stamp Although the use of physician services Total Personal Health Care Plus the patient's NHP card on a billing in Quebec rose among those with lower Insurance Overhead 547 602 form, check a diagnosis and procedure incomes, the increase was counterbal- *This assumes Canadian-level administrative effi- code, send in all bills once a week, and anced by a decrease in utilization among ciency and changes in utilization only among the receive full payment for virtually all ser- the affluent. The net effect was conver- previously uninsured. vices-with an extra payment for any gence of utilization rates (adjusted for 11.4% of personal health care expenditures. #This is the amount estimated by the Health Care bill not paid within 30 days. Gone would health status) among income groups, Financing Administration. be the massive accounts receivables and with no change in the overall rate. the elaborate billing apparatus that now Would an across-the-board increase beleaguer private physicians. Alterna- in utilization be desirable? In the RAND trative savings in physician expendi- tively, physicians could elect to work on experiment, lower-income patients tures is more difficult. Although prac- a salaried basis for globally budgeted with medical problems who received tice expenses are 49% of physician gross hospitals or clinics, or in health mainte- free care had better outcomes than income in the United States and only nance organizations capitated for all those in cost-sharing plans. At the 36% in Canada,20,21 it is uncertain how nonhospital services. same time, many medical services cur- much of this difference is due to billing rently provided are of no or of extreme- costs. Malpractice costs for US physi- COSTS OF THE NHP ly marginal benefit, 15-17 and it is not the cians, for example, are higher than To estimate total costs, we start by intent of the NHP to inject an additional those in Canada. We therefore extrapo- using the Health Care Financing Ad- bolus of such unnecessary care into the lated billing cost data from a recent ministration's projection of 1991 costs health care system. American Medical Association survey under current policies as our "baseline" All these factors make it difficult to to project minimum expected adminis- figure. The Health Care Financing Ad- predict the level of overall utilization trative savings in physician expendi- ministration estimates that $567 billion that would result from the NHP. For tures. The average physician spent ap- will be spent on personal health care this analysis, we have added on the full proximately $14500 in 1988 billing services and products in 1991, excluding $12.2 billion cost of bringing utilization Medicare and Blue Shield alone, repre- nursing home costs and insurance over- rates of the uninsured up to those of the senting 5.5% of gross physician income. head and profits (Table 1).⁹ (Although insured. We will discuss in the "Budget- In addition, physicians spent approxi- long-term care is covered by the NHP, ing Under the NHP" section below how mately .75% of their own professional we have omitted these costs to permit the NHP budget could also accommo- time on billing-related activities for comparison with other acute care date increases in utilization among the these claims. (The survey did not mea- proposals.) currently insured. sure the costs of billing other third par- Universal coverage should increase ties or patients and therefore yields a the use of health services by the unin- Savings of the NHP low estimate of physician billing costs.) sured. According to the Lewin/ICF The administrative efficiencies of a We liberally estimate that physician Health Benefits Simulation Model, ap- single-payer NHP offer the opportunity billing expenses in Canada are 1% of proximately $36 billion of the $567 bil- for large savings during the implemen- physician costs and that Canadian phy- lion in 1991 spending projected under tation of the program.¹⁸ Providers sicians spend at the most 1% of their current policies will be accounted for by would be relieved of much of the ex- time on billing (D. Peachey, MD, Ontar- care for the uninsured, including free pense of screening for eligibility, pre- io Medical Association, written commu- care at public hospitals, uncompensated paring detailed bills for multiple payers, nication, June 1990). In sum, US billing care at private facilities cross-subsi- responding to cumbersome utilization costs for physician time and practice ex- dized by insurance revenues, and ser- review procedures, and marketing their penses are at least 8.25% of total physi- vices purchased out-of-pocket. The services. In 1987, California hospitals cian expenditures in contrast to at most Lewin/ICF model estimates that an ad- devoted 20.2% of revenues to adminis- 2% of Canadian physician costs. An ditional $12.2 billion would be required trative functions,¹⁹ in contrast to 9.0% NHP functioning at Canadian-level ad- to increase the utilization by the unin- spent by Canadian hospitals (L. ministrative efficiency could save at sured to levels commensurate with Raymer, Health and Welfare Canada, least 6.25% of physician costs. Most of those of the insured (Needleman et al¹⁰ written communication, April 1990). these savings can be realized rapidly. In and J. Sheils, oral communication, Octo- (These figures exclude malpractice pre- the private practice of one of the authors ber 1990). mium costs and administrative person- (T. B.), for example, the change to a The NHP will not only assist the unin- nel in clinical departments such as nurs- single payer would allow an immediate sured, but will also cover services (eg, ing.) The 11.2% difference is reduction in office payroll of 18%. preventive) and payments (eg, deduct- attributable to Canada's simplified hos- Administrative savings to hospitals ibles) that many insurers currently ex- pital payment method, a method we and physicians function as price dis- clude. Would this more extensive cover- propose for the United States. counts when calculating costs. For ex- age "induce" a surge of utilization Determining the potential adminis- ample, if physicians could lower their 2550 JAMA, May 15, 1991 265, No. 19 Physicians for a National Health Program-Grumbach et al overhead by 6.25% of gross income by projected "baseline" 1991 level of $273 Table 2.-National Health Program (NHP) Budget, trimming billing expenses, fees could be billion (Table 2), though some individual by Category of Expenditure, in Billions of Dollars lowered by 6.25% and physicians would hospitals' budgets might be adjusted to Current still earn the same net income for the reflect past underfunding or large oper- Category NHP Policies* same volume of services. We therefore ating surpluses. On average, a hospital Hospital 273 273 estimated the minimum potential ad- able to achieve full administrative sav- Physician 154 145 Othert 149 149 ministrative savings in hospital and ings would have 11.2% of its budget to Insurance administration and profits 8 35 physician expenditures to be $40 billion devote to more or better clinical ser- Subtotal 584 602 by discounting projected hospital and New health initiatives vices. Billing personnel could be trans- and transition costs 18 0 physician costs by 11.2% and 6.25%, re- ferred to clinical departments to per- Total Budget 602 602 spectively (Table 1). form clerical duties, freeing up nurses Additional savings accrue from the for bedside care. Hospitals unable to *These are Health Care Financing Administration projections.⁹ reduced administrative "load factor" of realize immediate administrative sav- t"Other" includes drugs, dental and other profes- a public plan. In 1987, the cost of public ings would not be penalized in the short sional services, and so forth. and private insurance overhead and run. However, in the longer run, the profits expressed as a percent of person- single payer within each state would al health care expenditures was 5.9% in evaluate hospitals' clinical performance must specify a revenue package. Al- the United States and only 1.4% in Can- and efficiency and modify budgets, tak- though the NHP would not result in a ada. 9,23 If our NHP operated with the ing account of these hospital quality net increase in total health care expen- efficiency of Canada's, the administra- measures as well as community needs. ditures, it would produce a major shift tion of health insurance would cost $8 The Canadian experience demonstrates in payment sources toward government billion, less than one quarter the $35 that such a budgeting process need not and away from private insurance and billion projected by the Health Care Fi- be cumbersome or expensive, consum- out-of-pocket payments. We emphasize nancing Administration in 1991. ing less than $2 per capita in British that the average individual and busi- As indicated in Table 1, the net cost of Columbia (D. Cunningham, British Co- ness would not pay more for health care personal health care and insurance lumbia Ministry of Health, written com- under the NHP but would pay taxes overhead for universal coverage under munication, July 1990). that take the place of, but do not exceed, the NHP, including expanded services Prospective budgeting of physician current premium payments and out-of- for the previously uninsured, would be services under fee-for-service methods pocket costs. Moreover, with the single at most $547 billion if the system oper- would require expenditure targets or payer's capacity to control inflation, in- ated with the administrative efficiency caps. On average, fees would be set at dividuals and businesses should soon of the Canadian system. This is $55 bil- 6.25% below current levels, reflecting enjoy reductions in the rate of increase lion less than the $602 billion that will be expected administrative savings to phy- of their health care costs. spent in 1991 under current policies that sicians. The expenditure target, howev- What principle should underlie the exclude approximately 35 million er, could be set at $154 billion, 6% above choice of revenue sources? Health care Americans. the "baseline" projected level for 1991 is only one factor-sometimes a minor (Table 2). This would allow physician one-in the promotion and preservation Budgeting Under the NHP payments to accommodate a net utiliza- of health. Poverty, racial oppression, We do not propose reducing the tion increase of up to 12.25%, sufficient substance abuse, lack of education, lack health care budget by $55 billion under to satisfy increased demand by the unin- of exercise, overnutrition and undernu- the NHP. As noted above, we are un- sured and underinsured, while allowing trition, and occupational and environ- certain how utilization patterns might a net increase in physician income of 6%. mental hazards all damage health. Some respond to universal, first-dollar insur- A utilization increase above 12.25% of these factors can be influenced by ance coverage. Nor can we be complete- would trigger a compensatory decrease society's revenue-generating mecha- ly confident that hospitals and physi- in fees to keep expenditures within the nisms. For example, raising excise tax- cians will immediately shed their excess budget target. Such a plan allows for es on cigarettes and alcohol reduces administrative poundage and assume control of costs with a minimum of the their consumption and thereby im- the leaner proportions possible under a administrative waste or encumbrances proves health, particularly among teen- simplified payment system. We there- of our current utilization review mecha- agers and the poor. 25 On the other hand, fore propose the following budgetary nisms. burdening low-income families with strategy for the NHP: We would set the Summing the aggregate hospital op- high payments (whether taxes, premi- overall health care budget for the erating budget of $273 billion, the physi- ums, or out-of-pocket dollars) reduces NHP's initial year at the amount pro- cian budget of $154 billion, and the other their disposable income and amplifies jected under current policies ($602 bil- categories of personal health care the ill effects of poverty. In contrast, a lion if implemented in 1991). To keep spending and administration would still system of taxes and other payments expenditures within this target, we leave total expenditures $18 billion be- that reduces the burden on low-income would rely on the ability of a single pay- low our proposed $602 billion budget families without impeding job formation er to allocate and enforce prospective (Table 2). The $18 billion balance could may ameliorate poverty's health conse- budgets for physician and hospital ser- be used for start-up costs for the NHP, quences. Thus, funding mechanisms can vices. These budgets would challenge job training and placement programs be "healthy" or "unhealthy." providers to extract administrative sav- for displaced administrative personnel, Health care financing in the United ings and redirect resources into patient improved long-term care, and revital- States is markedly regressive and care for the underserved. The budget ized public health programs. hence unhealthy. The bottom income would allow a range of utilization re- decile receives 1.3% of total income but sponses among patients and physicians. FINANCING THE NHP pays 3.9% of health costs, while the top For example, the NHP could set total Health insurance proposals are fre- income decile receives 33.8% of income hospital operating budgets at the quently shipwrecked on the shoals of and pays only 21.7% of health costs. By Health Care Financing Administration their financing; any serious proposal comparison, in Britain the bottom decile JAMA, May 15, 1991 Vol 265, No. 19 Physicians for a National Health Program-Grumbach et al 2551 Table 3.-Public Plan's Share of 1991 Personal Health Care Expenditures Under National Health Program (NHP), in Billions of Dollars Current Policies NHP Total % Covered NHP $602 $602 Service Cost by NHP Cost Hospital 273 96* 262 Physician 154 91* 140 Other 149 55t 82 New health initiatives and transition costs 18 100 18 $259 $228 Administration 8 85t 7 Total 602 85 509+ *These figures are based on the public share of spending for these services in Canada. The shares are $157 $157 less than 100% because certain services, such as cosmetic surgery, life insurance examinations, and private room surcharges, are not covered benefits.2⁴ $93 tThese figures are based on our "best guess" esti- mate, since the NHP will provide more extensive $186 coverage of nonhospital and nonphysician services than do the Canadian provincial plans. Nonprescription $124 drugs are an example of a product in the "other" category that will not be covered. #A total of $93 billion of personal health care expen- ditures uncovered by the NHP remain as out-of-pocket and individual private insurance premium costs. General Taxes Employment - Base receives 2.3% of income and pays 1.7% of health costs, while the top decile re- Out-of-Pocket and New Earmarked ceives 24.9% of income and pays 25.6% Individual Premiums Taxes of costs.26 Any departure from the exist- ing configuration of US health care funding should reverse the current un- healthy pattern. Revenue sources. Figures are in billions of 1991 dollars. NHP indicates national health program. We estimate that public expenditures will account for 85% of health spending under the NHP, requiring $509 billion in revenues for 1991 (Table 3). We will and employees currently pay almost 2% Payments by Individuals discuss these revenues in three catego- of total payroll for Medicare-related So- The third major source of health fi- ries: (1) payroll taxes, (2) general gov- cial Security taxes and approximately nancing consists of payments by indi- ernment revenues, and (3) payments by 10% for private health insurance-a viduals; these payments currently ac- individuals (Figure). combined health-related payroll tax of count for 31% of health expenditures 13%. 29,31,32 Using Department of Com- (5% in individual insurance premiums, Payroll Taxes merce figures, we project that under 24% in out-of-pocket payments, 1% in Employer-employee payments for the NHP, an average tax rate of 9% for Medicare premiums, and 1% in other group health insurance (31% of personal medium and large employers, with an private funds). 27,29 They are the least health expenditures [excluding nurs- average 2% rate for employees, and half healthy revenues because they burden ing-home care]²⁷) are, in essence, a pay- these rates for businesses with fewer lower-income families far more than roll tax,28 with the money going to an than 20 employees, would raise $228 bil- they do the affluent. To the extent that insurance company or a self-insured lion in revenues. These precise tax they pay for services covered under the fund rather than to the government. rates are only initial suggestions and NHP, they will disappear. Social Security payments for Medicare must be negotiated with the affected We propose replacing the majority of (12% of health expenditures are also parties. individual payments with "healthier" a payroll tax. It is logical to combine revenues-taxes that reduce income these two sources of financing, which General Government Revenues disparities and discourage the use of together account for 43% of health ex- Twenty-six percent of personal harmful and polluting substances. The penditures. To minimize economic dis- health expenditures (excluding nurs- following measures, according to a Con- ruption, we propose that a similar pro- ing-home care) comes from non-Social gressional Budget Office study,⁸ would portion of the NHP be funded by payroll Security governmental revenues at the generate $124 billion per year and could tax. federal, state, and local levels. 27,29 Of this be considered as NHP tax revenue The regressive nature of a payroll tax total, 51% comes from individual income sources: (1) a new federal income tax makes it a less-than-healthy revenue taxes, 12% from property taxes, 12% bracket of 38% for families with income source; the employer share is often from sales taxes, 12% from corporation higher than $170 000, (2) a cap on mort- shifted to employees as lower wages or income taxes, 5% from gasoline, tobac- gage interest deductions for luxury to consumers as higher prices. It co, and alcohol taxes, and 8% from other homes, (3) a 0.5% tax on transfer of should be made more progressive by sources. Although some of these reve- securities, (4) an increase in energy tax- reducing the employee share for lower- nue sources are unhealthy, we propose es to encourage energy conservation wage employees, by raising the employ- leaving them intact, adhering to the and reduce pollution, (5) an increase in ee share for high-income employees (eg, principle that implementing the NHP excise taxes on cigarettes to 32 cents eliminating the current Social Security should not demand radical economic re- per pack and on alcohol to 25 cents per cap), and by reducing the employer structuring. These revenues would gen- ounce, (6) an excise tax on sources of air share for small business. Employers erate $157 billion for the NHP in 1991. 9,29 and water pollutants, and (7) a tax on 2552 JAMA, May 15, 1991 265, No. 19 Physicians for a National Health Program-Grumbach et al fossil fuels to reduce carbon dioxide The administrative cost reductions other nation. Deploying our greater re- emissions. Although some of these tax- during the NHP's initial phase are not, sources with Canadian efficiency would es are regressive, their overall effects as some have argued, only a one-time permit increases in utilization and im- are health promoting. saving.⁸⁷ Whether in Canada or New provements in technology without sky- To summarize, the NHP would fund Zealand, Sweden or Britain, single-pay- rocketing costs. Compared with Ameri- approximately 38% of health expendi- er systems have stabilized costs in the cans, Canadians do, in fact, get more tures from a payroll tax similar to cur- past decade, while US health care infla- health care for their health care dollar. rent payroll expenses for Medicare and tion has been impervious to the most About half of the cost differential be- health insurance premiums; 26% from earnest attempts to control costs. tween the two nations is squandered on existing federal, state, and local reve- Economist Robert Evans⁴¹ has conclud- insurance overhead and paper push- nues; and 21% from new, healthy feder- ed that "universality of coverage and ing. Stanford economist Victor al tax revenues that would largely sole-source funding are, as far as we Fuchs has concluded that "the quanti- supplant current out-of-pocket expendi- know now, preconditions for cost ty of [physician] services per capita is tures. Fifteen percent of expenditures control." much higher in Canada than in the Unit- would remain out-of-pocket (Figure). Global expenditure control can also ed States the data firmly reject the A majority of Americans would ac- enhance clinical freedom. Under the mi- view that Canadians save money by de- cept this type of tax package if it were cromanagement model of cost contain- livering fewer services." earmarked for health care and placed in ment, each of the multiple payers, lack- Health financing reforms unable to a health care trust fund. A 1990 poll ing global budgetary levers, resorts to extract administrative savings inevita- found that 72% would support an NHP intrusive patient-by-patient utilization bly impose added costs for expanded even if it required a tax increase; how- review.²⁴ Such day-to-day interference services. Employer mandate proposals ever, only 22% would pay more than in medical practice is minimized in sin- (eg, the Pepper Commission Plan,¹ the $200 extra per year.⁸⁶ Our proposal gle-payer systems.40 As John Wenn- American Medical Association's Health would not increase the sums paid for berg¹⁶ recently observed: Access America plan,⁸ the National health care by low- and middle-income The key to the preservation of fee-for-service Leadership Commission's proposal,² groups. It is designed to minimize win- markets, as the Canadians seem to recog- and Massachusetts' Universal Health ners and losers, aside from the private nize, is not the micromanagement of the doc- Care Law [New York Times. April 11, health insurance industry. tor-patient relationship but the management 1991:A1]) would leave existing insur- Two additional principles should be of capacity and budget. The American prob- ance in place while expanding public incorporated in NHP funding. Per capi- lem is to find the will to set the supply ther- programs for the unemployed and re- ta health spending should be equalized mostat somewhere within reason. quiring employers to insure their work- throughout the nation, with federal The NHP would benefit most Ameri- ers. None of these plans offer improved funds transferred to states under for- cans, though a few powerful interest coverage for those currently insured, mulas adjusted for age, income levels, groups would suffer. It would virtually nor do they offer new cost control mech- health status, wage, and other input eliminate financial barriers to care for anisms. Hence high initial costs presage costs. Finally, to protect the NHP from those who are currently uninsured and continuing inflation or far more strin- annual budgetary debacles in Washing- underinsured, ensure patients a free gent and intrusive micromanagement- ton, DC, it must be an entitlement pro- choice of providers, ensure physicians a probably both. Modifications of the em- gram with a statutory expenditure floor free choice of practice settings, diminish ployer mandate approach (eg, the as well as a ceiling. In contrast to enti- bureaucratic interference in clinical de- UNYCare proposal in New York tlement programs restricted to poor cision making, stabilize health spend- State) that attempt to meld the cost families, the NHP would embrace the ing, and reduce the growing burden of containment features of a single-payer entire population and could thus com- health care costs for many individuals system with a continuing role for pri- mand the level of support enjoyed by and employers. Small-business owners vate insurance also eschew most admin- Social Security. Adequate increases in who do not currently cover their em- istrative savings, compromising the NHP funding (based on such factors as ployees would face modest cost in- ability of such measures to expand ac- aging of the population, epidemics, ad- creases, though far less than mandated cess without raising costs. vances in medical technology, and infla- by most alternative proposals. The There is slim evidence that Enthoven tion) must be mandated by law. As sug- health insurance industry would feel the and Kronick's⁴⁶ "managed competition" gested in our original NHP proposal,⁷ an greatest impact. Indeed, most of the plan-featuring competing managed expanded program of technology as- extra funds needed to expand care care insurers and higher patient copay- sessment would help guide budgetary would come from eliminating the over- ments-can hold costs in check. Does allocations. head and profits of insurance companies forcing consumers to bear premium COMMENT and from abolishing the billing appara- costs for higher-priced plans hold down tus necessary to apportion costs among overall costs or simply segregate the In health insurance, as in many things the various plans. Job retraining pro- market based on ability to pay? Do low- in life, simplicity is a virtue. The NHP's grams for displaced administrative and cost plans provide care more efficiently approach to universal access is simple: clerical personnel would be essential. or simply market themselves more ef- every American automatically qualifies Although few dispute the ability of fectively to lower-risk subscribers? Is for equal, comprehensive health insur- the NHP to provide universal coverage the rubric "Consumer Choice Health ance under a unitary public plan. The and control costs, critics have raised the Plan" appropriate for a system likely to economic premises of the NHP are also specter of rationing, pointing to queues lock the vast majority of patients and simple: funnel all third-party payments for some high technology services in physicians into closed panel health through a single payer, thereby saving Canada. We do not advocate cutting maintenance organizations run by in- billions of dollars in administrative costs US health spending to Canadian levels. surance companies? The ultimate vision and achieving cost containment through Even with a slower rate of growth un- of managed competition-a landscape global controls rather than minute bu- der the NHP, US health expenditures dominated by a limited number of huge reaucratic scrutiny. will remain well above those of any health maintenance organizations man- JAMA, May 15, 1991 Vol 265, No. 19 Physicians for a National Health Program-Grumbach et al 2553 aging salaried physicians-is a more reasonable level. Once a structure is in sources should we devote to health radical departure from the current place for meeting these basic concerns, care? How shall we reduce the toll now health care scene than the NHP. the medical profession and society as a extracted by poverty, ignorance, and The objectives of the NHP are simple: whole can move on to the more compli- addictions? By implementing a national (1) to minimize financial barriers to ap- cated questions: Which health services health program, we can turn and face propriate medical care, (2) to distribute truly improve the quality of life? What the challenges ahead. costs fairly, and (3) to contain costs at a share of our human and material re- References 1. US Bipartisan Commission on Comprehensive J Med. 1990;323:1202-1204. of Commerce; 1990. Health Care. A Call for Action. Washington, DC: 17. Chassin MR, Kosecoff J, Park RE, et al. Does 34. Bureau of the Census. Quarterly Summary of The Pepper Commission on Comprehensive Health inappropriate use explain geographic variations in Federal, State, and Local Tax Revenue, July-Sep- Care; 1990. the use of health care services? JAMA. tember 1989. Washington, DC: US Dept of Com- 2. National Leadership Commission on Health 1987;258:2533-2537. merce; 1990. Care. For the Health of a Nation. Ann Arbor, Mich: 18. Himmelstein D, Woolhandler S. Cost without 35. Congressional Budget Office. Reducing the Health Administration Press; 1989. benefit: administrative waste in US health care. N Deficit: Spending and Revenue Options. Washing- 3. Health Access America. Chicago, Ill: American Engl J Med. 1986;314:441-445. ton, DC: The Congress of the United States; 1990. Medical Association; 1990. 19. Aggregate Hospital Financial Data for Cali- 36. Blendon RJ, Donelan K. The public and the 4. Kennedy E. Senate Bill S.768. November 20, fornia: Report Periods Ending June 30, 1987-June emerging debate over national health insurance. N 1989. 29, 1988. Sacramento: California Health Facilities Engl J Med. 1990;323:208-212. 5. Woolhandler S, Himmelstein DU. Resolving the Commission; 1989. 37. Aaron H, Schwartz WG. Rationing health care: cost/access conflict: the case for a national health 20. Gonzalez ML, Emmons DW. Socioeconomic the choice before us. Science. 1990;247:418-422. program. J Gen Intern Med. 1989;4:54-60. Characteristics of Medical Practice. Chicago, Ill: 38. International comparisons of health care fi- 6. Grumbach K. National health insurance in American Medical Association; 1988. nancing and delivery: data and perspectives. America: can we practice with it? can we practice 21. Iglehart J. Canada's health system faces its Health Care Financing Rev. 1989; 10(suppl):1-196. without it? West J Med. 1989;151:210-216. problems. N Engl J Med. 1990;322:562-568. 39. Pfaff M. Differences in health care spending 7. Himmelstein DU, Woolhandler S. A national 22. American Medical Association. The adminis- across countries: statistical evidence. J Health Po- health program for the United States: a physicians' trative burden of health insurance on physicians. lit Policy Law. 1990;15:1-24. proposal. N Engl J Med. 1989;320:102-108. Socioeconomic Monitoring Survey Rep. 1989;3:2-4. 40. Evans RG, Lomas J, Barer ML, et al. Control- 8. Woolhandler S, Himmelstein DU. A national 23. National Health Expenditures. Ottawa, On- ling health expenditures: the Canadian reality. N health program: a northern light at the end of the tario: Health and Welfare Canada; 1990. Engl J Med. 1989;320:571-577. tunnel. JAMA. 1989;262:2136-2137. 24. Grumbach K, Bodenheimer T. Reins or fences? 41. Evans RG. Accessible, acceptable, and afford- 9. Health Care Financing Administration. Nation- a physician's view of cost containment. Health Aff. able: financing health care in Canada. In: The 1990 al health expenditures: 1986-2000. Health Care Fi- 1990;9(4):120-126. Richard and Hinda Rosenthal Lectures. Washing- nancing Rev. 1987;8(4):1-36. 25. Last JM. Controlling the smoking epidemic. ton, DC: Institute of Medicine; 1990:7-47. 10. Needleman J, Arnold J, Sheils J, Lewin LS. Am J Prev Med. 1985;1:1-3. 42. Board of Trustees, American Medical Associa- The Health Care Financing System and the Unin- 26. Wagstaff A, Van Doorslaer E, Paci P. Equity tion. Study of the Canadian Health Care System. sured. Washington, DC: Lewin/ICF; 1990. in the finance and delivery of health care: some Chicago, Ill: American Medical Association; 1989. 11. Newhouse JP, Manning WG, Morris CN, et al. tentative cross-country comparisons. Oxford Rev Report V(A-89). Some interim results from a controlled trial of cost Econ Policy. 1989;5:89-112. 43. Evans RG. Split vision: interpreting cross-bor- sharing in health insurance. N Engl J Med. 27. Levit KR, Freeland MS, Waldo DR. National der differences in health spending. Health Aff. 1981;305:1501-1507. health care spending trends: 1988. Health Aff. 1988;7(4):17-24. 12. Enterline PE, Salter V, McDonald AD, Mc- 44. Fuchs VR, Hahn JS. How does Canada do it? a Donald JC. The distribution of medical services 28. Reinhardt UE. Health insurance for the na- comparison of expenditures for physicians' services before and after 'free' medical care: the Quebec tion's poor. Health Aff. 1987;6(1):101-112. in the United States and Canada. N Engl J Med. experience. N Engl J Med. 1973;289:1174-1178. 29. Levit KR, Freeland MS, Waldo DR. Health 1990;323:884-890. 13. McDonald AD, McDonald JC, Salter V, Enter- spending and ability to pay: business, individuals, 45. Beauchamp DE, Rouse RL. Universal New line P. Effects of Quebec Medicare on physician and government. Health Care Financing York Health Care: a single-payer strategy linking consultation for selected symptoms. N Engl J Med. Rev. 1989;10(3):1-11. cost control and universal access. N Engl J Med. 1974;291:649-652. 30. Pechman JA. Federal Tax Policy. Washing- 1990;323:640-644. 14. Brook RH, Ware JE Jr, Rogers WH, et al. ton, DC: The Brookings Institution; 1987. 46. Enthoven A, Kronick R. A consumer choice Does free care improve adults' health? results from 31. Bergthold LA. Purchasing Power in Health. health plan for the 1990s: universal health insur- a randomized controlled trial. N Engl J Med. 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Washington, DC: US Dept 2554 JAMA, May 15, 1991 265, No. 19 Physicians for a National Health Program-Grumbach et al The Health Security Partnership A Federal-State Universal Insurance and Cost-Containment Program Rashi Fein, PhD The Health Security Partnership attempts to assure (1) that all Americans have expenditure control without insurance insurance coverage for a set of comprehensive health care benefits, (2) that cost- protection-surely, in the long run, containment issues are addressed in a manner that does not impinge negatively such controls would not be perceived as on the quality of care, and (3) that provider freedom to deliver appropriate clinical impinging equitably on all population care is strengthened. It assigns important responsibilities to the federal govern- groups (and in fact would not do so), ment (eg, specification of benefits, review of proposed state health care bud- leading to pressures to ease cost con- trols to expand access. Furthermore, in gets), while permitting states to select, develop, and administer specific program both cases, providers would be criti- design features they deem appropriate (eg, states could build on and expand the cized for presumed failure to provide existing health system infrastructure, including private insurance, and/or extend services to all and/or to control costs. the role of tax-supported programs). It is estimated that in its first year the Thus, we must develop a comprehen- program would add about 5% to America's health expenditures, but within a few sive program. This should not surprise years, cost-containment efforts and administrative efficiencies would reduce us; one of the important lessons of the overall expenditures below what they otherwise would be. last quarter century is that the various (JAMA. 1991;265:2555-2558) parts of the health care sector are inter- related. It is reasonable to suggest that, the more broad and comprehensive the approach, the greater the opportunities PATIENTS, providers, and private health care expenditures without im- for individuals and organizations with and public payers who encounter the pinging negatively on quality. As an im- differing priorities to negotiate their American health care system face in- portant corollary, it eschews the micro- differences. Without a broad agenda creasing difficulties. The Health Securi- management of clinical care and affords that enables the kinds of compromise ty Partnership, developed by a multi- providers and patients greater freedom that might provide some "gains" for disciplinary technical committee of the in exercising clinical choices. each of the many participants in the Committee for National Health Insur- Some may consider it unnecessary to health sector, the historical gridlock ance, attempts to deal with a number of address these multiple goals at the same will continue. those problems. It specifically address- time and within the same program. I Although the Health Security Part- es the issue of equitable access for the believe that we cannot solve either the nership proposal is very detailed and uninsured and underinsured and estab- access or the cost problem by itself. The has been "translated" into legislative lishes mechanisms to make certain that enactment of legislation to attain one language, space constraints require all Americans have insurance for a set of goal (but not both) would prove to be an that this presentation be limited to the core benefits. It specifically addresses unstable "solution." The reader need salient features and descriptors. Before the issue of expenditure control and es- only consider what would happen to ac- explaining the proposal, I note that, al- tablishes mechanisms to help contain cess without expenditure control- though it is not presented in this review, surely history suggests the outcome the proposal has a phased long-term- would be cutbacks in coverage and care component. I also note that the From the Department of Social Medicine, Harvard benefits, increased emphasis on "utili- proposal does not fold in Medicare (until Medical School, Boston, Mass. zation review," and stronger efforts to Reprint requests to Department of Social Medicine, 5 years have elapsed and the program Harvard Medical School, 643 Huntington Ave, Boston, control the behavior of individual pa- has demonstrated its administrative MA 02115 (Dr Fein). tients and providers. Similarly, imagine and operational effectiveness). JAMA, May 15, 1991 Vol 265, No. 19 Health Security Partnership-Fein 2555 LEVEL OF ADMINISTRATIVE differences and cyclical variations in This assistance, which would increase RESPONSIBILITY state economies, fiscal resources, and over time but at a rate not to exceed the The plan calls for a partnership be- health care needs. Such formulas would growth in the gross national product, tween the federal government and the also have to take account of existing would encompass (and add to) existing various states. It is reasonable to ask differences among the states in health funding for medical care services now why a group of individuals who, in earli- care prices and costs, although this provided under Medicaid and various er years, looked to the federal govern- should be done in a manner that, over a other federal and federal/state health ment to develop and administer pro- period of time, would help reduce these service programs. The federal govern- grams designed to address national variations. We expect that, as the vari- ment would undertake technology as- health care and insurance problems ous states learned from each other's ex- sessment and the study of treatment have shifted to the concept of a partner- periences, health systems would gradu- effectiveness and would disseminate ship with specific responsibilities dele- ally converge. Even so, a state-based the findings for review and action by the gated to various levels of government. program does imply that existing com- states. Given the potential variation in state plexities now faced by national employ- State governments would design and programs and in state administrative ers would not be fully eliminated. Our administer their own programs. They capacities, why risk horizontal in- judgment is that the gains of state would decide on mechanisms to assure equities for residents in different administration far outweigh these enrollment of individuals and families jurisdictions? difficulties. and to generate the requisite funds. A I believe the answer can be general- majority of states would probably de- FEDERAL AND STATE ized and should help guide the develop- velop programs that would mandate ment of any plan. Today's health care RESPONSIBILITIES employers to contribute to health insur- system is very different from the one The proposal provides a precise out- ance for their employees (with appro- that existed as recently as the early or lining of governmental responsibilities priate subsidies for part-time employ- even late 1970s, when universal health and allows freedom for individual states ees and small and low-income insurance was most recently discussed to meet their responsibilities through employers) and that would reach other actively. Today's state health care de- mechanisms and measures they deem uninsured and underinsured individuals livery systems are much more hetero- appropriate. Although this means that with new insurance programs spon- geneous (eg, there is greater variation states will have the freedom to make sored by the state and funded through in the proportion of residents enrolled in mistakes, it also means that the nation state tax mechanisms. I stress the word prepaid group practices, independent will have a "diversified portfolio" of pro- insurance, for the plan does not rely on practice associations, and preferred grams, reducing the risk of widespread an expansion of Medicaid (indeed, ex- provider organizations). As a conse- error. Because there are likely to be cept for long-term care, Medicaid would quence, it is appropriate that different many different programs, it is impossi- be subsumed under the partnership) or parts of the country structure payment, ble to describe how the program will the support or creation of programs to enrollment, and cost-containment work. Nevertheless, it is possible to fund uncompensated care. Rather, the mechanisms differently to suit their de- suggest what the typical state approach Health Security Partnership is de- mographic and economic conditions and might be and how it would operate. signed to provide financial protection to the organization of their health sectors. The federal government would define enrolled individuals and full payment to In addition, the committee believed the basic or core benefits that would providers through insurance, encourag- that population groups residing in dif- apply to all the states. This would pro- ing health care providers to treat all ferent parts of the nation and with dif- vide equity among the states and would citizens the same, regardless of income. ferent cultural traditions should have eliminate interstate competition (indi- Because legislators seem to be averse mechanisms to directly influence the vidual states would be permitted to add to shifting private financing to govern- priorities of the health system they en- benefits to the core). The proposal has mental budgets via increased taxes, at counter. Furthermore, some states carefully defined these benefits, which the outset, it is likely that most states have developed strong administrative include necessary medical services pro- would opt for mandating and "gap fill- competence on matters such as enroll- vided by physicians and hospitals, in- ing." Nevertheless, the proposal does ment, rate setting, and cost contain- hospital drugs, and preventive ser- permit states to use taxes as well as ment. Those capacities should be used. vices. Federal authorities would certify premiums as a funding source. It would Finally, we have placed major responsi- that a state has 95% of its residents be advantageous if a number of states bilities at the state level because we enrolled in private or public health in- were to do so, providing information on agree with Justice Brandeis' view that surance programs that provide the de- possible efficiency gains and dollar the states should serve as the nation's fined benefits. States would have to cov- savings. experimental laboratories.¹ There is er their residents even when they were The plan permits state political and merit in providing the opportunity to out of state and would have to meet a legislative processes to determine the learn from the different experiences of limited number of additional criteria roles that insurance companies would the various states. Our plan reflects the that relate to such matters as maximum play in underwriting and as fiscal inter- view that, like politics, health care ser- limits for individual cost sharing, adop- mediaries, the level (within an upper vices are local, and both citizenship and tion of approved cost-containment pro- limit) of cost sharing, the specific fee medical care are enhanced by bringing grams, and development of state health structure for physician payment, and decisions closer to the people. care budgets. In general, states would prospective budgets for institutional We believe these are compelling ar- remain free to implement state-devel- providers. Even so, the need for equita- guments. Nevertheless, we recognize oped programs, and federal certifica- ble treatment for all Americans and the that, compared with a purely federal tion would not require that states adopt imperatives of cost containment neces- program, a state-based approach does a federally prescribed approach. When sitate a limited number of national stan- entail additional complexity-attaining the state program has been certified, dards or requirements. These include interstate equity requires that federal the state would receive federal financial (1) the adoption of state health budgets, financial assistance formulas adjust for assistance at a predetermined level. with federal review; (2) the determina- 2556 JAMA, May 15, 1991 265, No. 19 Health Security Partnership-Fein tion of insurance premiums, if any, on present, as subscribers with a particu- abled while erecting a program without the basis of community rather than ex- lar insurer they felt would administer deductibles and coinsurance for the pop- perience rating; (3) a ban on balance the dollars that flow in their behalf effi- ulation under 65 years. Equity consid- billing; and (4) an emphasis on consumer ciently, enabling program savings and erations nonetheless impelled us to cir- participation in policy development as possible additional benefits or reduc- cumscribe the extent of cost sharing and well as on adequate grievance proce- tions in cost sharing. In turn, funds in limit its potential unfavorable impact. dures for patients and providers. I support of individual or group subscrib- We set annual limits on individual ($200) stress the importance of the move from ers would flow from the single agency to and family ($500) deductibles, on co- experience rating, and, perforce, from the designated insurers or delivery sys- insurance rates (20%), and on total out- self-insurance. Without the adoption of tems on a capitated basis, adjusted pri- of-pocket expenditures ($2500 per fam- a broad community perspective, rapid marily by age and gender. The develop- ily). Furthermore, patient payments advances in testing procedures, en- ment of more reliable data than are would be eliminated for persons below abling increasingly refined estimates of currently available would also make it the poverty line as well as for prenatal an individual's future need for health possible to adjust the capitation rate for and postnatal and well-baby care ser- care, will lead to increases in employ- other influences on anticipated medical vices provided to individuals in families ment discrimination as employers and expenditures, reducing the incentive to with incomes below 150% of poverty. employees seek to distance themselves dump subscribers who are viewed as from potential high utilizers. poor health care risks. COST CONTAINMENT Three important benefits are associ- The plan attempts to constrain the THE ROLE OF PRIVATE INSURANCE ated with the extra step in the flow of escalation of health expenditures The Health Security Partnership per- funds. (1) No insurer or deliverer of care through various mechanisms: the adop- mits individual states to determine the would know the source or mix of private tion of national and state health care role they deem appropriate for private or government-assisted funding on be- budgets- measure that will require ex insurance and to use private insurers half of an individual subscriber or family ante consideration of levels of spending, (and, indeed, even to expand their role). unit. (2) All funds would be commingled, trade-offs, and willingness to pay; pro- It is likely that in most states insurers and this could become part of the mecha- spective negotiated budget payment for would retain their present role as fiscal nism for raising funds in support of sub- institutional providers; adoption of ne- agents (although there is likely to be a sidies for individuals who could not pay gotiated, resource-based relative value decline in the number of companies op- or whose employer could not pay the full fee levels; continued expansion of capi- erating within a state as well as in insur- costs of health insurance. (3) This struc- tated payment systems; savings on ad- ance marketing expenditures). Com- ture makes possible a more precise ministrative costs associated with mar- petitive advantages would accrue to tracking of the size and sources of total keting, enrollment, claims handling, those insurers that developed and spon- health care expenditures within a state, and reimbursement; and expansion of sored managed care programs and capi- a requirement for careful budgeting. federal and state efforts in the areas of tated health care delivery systems, in- We believe that, in a system based on technology and treatment effective- creasing their ability to restrain outlays community rating, it is useful to permit ness. As a consequence of these features and stay within their budgets. Individ- collectively bargained premium dollars and of the limits on annual increases in ual states can be expected to standard- to follow groups of employees. The shar- the federal contribution, health expen- ize claim and payment procedures to ing of savings associated with efficien- ditures within a state could continue to provide relief for patients and physi- cies in delivery of care would encourage increase rapidly and as a percentage of cians (as well as other care providers) individuals and their employers to con- the gross national product only if the from the present process, which can be tinue efforts to reduce the need for electorate and its representatives made onerous, time-consuming, costly, com- health care interventions and to reduce a deliberate decision that they favored plex, and confusing. The combination of the costs of care. This design would re- and were prepared to pay for such in- a state health care budget, continued place today's efforts at cost shifting with creases. We expect the need for explicit movement to capitated funding and sim- incentives stressing occupational safety decisions to help restrain costs. ilar fixed-budget arrangements, and ne- and health, prevention and wellness gotiated fee schedules and prospective programs, and research to assure "val- REQUISITE FUNDS payment systems will create a new envi- ue for money" as well as earlier augmen- Under the Health Care Partnership, ronment within which health insurers tation of phased long-term-care bene- new funds would be required to finance will function. This environment is de- fits and reductions in cost sharing. care for persons who would receive signed to increase system efficiency. The plan does not require the elimina- more care than at present (existing hos- Given increased governmental concern tion of deductibles or coinsurance. pital and ambulatory utilization pat- with quality and efficacy of treatment, While the committee did not view cost terns by the uninsured and underin- more attention will be directed to "buy- sharing as an important contributor to sured must be taken into account). ing" than "paying for" care. Those who cost-containment efforts and agreed Furthermore, these new demands may finance care should do more than simply that cost sharing added complexity and add inflationary pressures to parts of write checks and pay bills; they should administrative costs (while impinging the system because, although the nation adopt a buyer's philosophy and ask negatively on equity), we left cost-shar- has enough physicians and hospital whether the bill (and the associated pro- ing decisions to the states. We recog- beds, services are delivered not nation- cedure) has merit and is justified. nized that eliminating cost sharing ally but locally. Over time, savings on FINANCING would require shifting considerable administrative expenditures and as a sums from individual subscribers to consequence of cost-containment ef- Federal, state, tax, and premium premiums or taxes. It would also add forts would offset new service costs and funds would flow into a single state- considerably to the revenues needed for inflationary price increases for existing designated agency. In states that retain the Medicare program (since it would services. Projections of expenditures, private insurers to administer claims, hardly make sense to retain cost sharing therefore, are heavily dependent on as- individuals or groups would enroll, as at for those over 65 years and for the dis- sumptions about the willingness of gov- JAMA, May 15, 1991 265, No. 19 Health Security Partnership-Fein 2557 ernment negotiators to engage in hard lar amounts would be altered in states and flexible program. Furthermore, bargaining. Cost-containment efforts that adopted a comprehensive tax- only a comprehensive approach will would likely be more vigorous and effec- based financing mechanism. help physicians and other care givers tive if providers attempted to capture Future increases in expenditures regain important aspects of clinical free- large increases in income, particularly if would be moderated by cost-contain- dom and remove themselves from a role these increases in income were associ- ment efforts and would be offset, in they do not seek and that is inappropri- ated with "windfall" inflationary price part, by administrative savings. As a ate to their profession: that of gatekeep- increases. consequence, after a one-time jump, the er and resource allocator, whose clinical The committee estimates that imple- expenditure trend line would flatten out decisions are guided by insurance cov- menting the suggested federal defini- and diverge from present trends. After erage and ability to pay rather than by tion of core benefits would lead to an a few years the nation would be spend- medical need. increase of about 5% in US personal ing less than would otherwise be the 3. A number of states are consider- health care expenditures in the pro- case. The powerful impact of reductions ing or developing legislation to address gram's first year. This derives from a in the rate of increase in personal health universal access issues. Since it will not 6% increase in hospital care (but, be- expenditures is illustrated by the obser- be possible for all states to "go it alone," cause marginal costs are less than aver- vation that, if the present trend were federal legislation is required if the goal age costs, a smaller percentage increase lowered by 3 percentage points, annual of universal coverage for all Americans in hospital revenues) and a 15% increase savings would be $18 billion to $21 bil- is to be attained. Nevertheless, state in physician services (associated with a lion, implying a "crossover" in only 2 efforts and programs will increase the 10% increase in physician incomes). years. Even a modest reduction of 1 probability of federal action. This would add $30 billion to $35 billion percentage point would imply that, 4. The American political process is in health care expenditures. Of course, within a decade, the nation would be one of compromise. The Health Securi- it is impossible to be more precise, be- spending less than if present trends con- ty Partnership proposal fits within that cause the various states would be free to tinue unchanged. process. It relies on state efforts, assur- design their own enrollment and financ- In assessing the Health Security ing both compromise and diversity. ing programs. Partnership proposal, four important Furthermore, it has a number of parts The committee suggests that one considerations should be kept in mind. and characteristics that can be altered third of this increase (about $10 billion) 1. America's health care financing is without jeopardizing the integrity of come from the federal government, one changing and will continue to do so. Our the program. It is not a "take it or leave third from state governments, and one choice is whether to adopt programs it" program. It recognizes existing rela- third from private sector contributions that help the nation attain a set of inter- tionships and the existing health care to the purchase of health insurance. The related goals or to intervene on an ad financing infrastructure. It also recog- federal contribution could come from hoc, emergency, and crisis basis as the nizes political forces and attempts to any of a number of special taxes or com- insurance system continues to come develop a "realistic" program. Those binations of taxes (eg, excise taxes, apart and as expenditures continue to who read the current scene differently "sin" taxes, payroll taxes, or income-tax escalate. Anything less than a compre- are invited to offer their comments and surcharges). State contributions would hensive approach is not likely to be modifications. likely rely on expansion of traditional effective. state sources of revenue. Depending on 2. It is necessary to address univer- Reference the nature of the state program, private sal coverage and expenditure control at 1. Urofsky MI. Louis D Brandeis and the Progres- costs would be met through premiums the same time. Only in this way can we sive Tradition. Boston, Mass: Little Brown & Co or taxes. The ratios and associated dol- achieve a politically stable but evolving Inc; 1981. 2558 JAMA, May 15, 1991 265, No. 19 Health Security Partnership-Fein Beyond Universal Health Insurance to Effective Health Care Eli Ginzberg, PhD, Miriam Ostow, MA NO ONE, least of all an economist, partment is mandated to treat as well as practitioners and voluntary hospitals. needs to be persuaded that people who those whose care is discretionary, de- Although it was widely believed that lack money or health insurance are like- pending on the availability of resources. Medicaid would be a first step for the ly to encounter difficulties in obtaining The ease of access and the quality of poor to gain access to mainstream medi- essential health care services. On the treatment received by veterans with cine, that expectation has not been other hand, the economist has an obliga- preferred eligibility depend on such borne out. On the positive side, succes- tion to explain that the adoption of a considerations as the location of the vet- sive surveys conducted by The Robert system of universal coverage will not, erans' hospital nearest to their place of Wood Johnson Foundation (Princeton, ipso facto, translate into assured access residence and whether the hospital is NJ) in the years 1976, 1982, and 1986 for essential, much less optimal, health affiliated with a medical school that has found that the new financing efforts con- care for those who are currently disad- assumed principal responsibility for the tributed a great deal to increasing the vantaged. The reasons that universal operation of its professional services.¹ number and range of health services coverage will not necessarily guarantee For many decades New York City has available to the poor and the uninsured.⁸ effective services to all are embedded in operated a major health and hospital However, there are important nega- the nature and characteristics of the system with a current budget of about tives that should be identified in the health care system. $2.5 billion that has been committed to context of the resurgent belief that fi- In developing this argument and its providing care to everyone, regardless nancial reform by itself, possibly at last policy implications, we will undertake a of ability to pay. Accordingly, New in the form of universal coverage, will threefold analysis, including (1) a selec- Yorkers may be said to have had "uni- result in access to effective health care tive review of health care financing re- versal coverage" for almost a century. for all. The following have been some of forms in the United States, (2) an expli- Consider, however, the following quo- the principal shortfalls of Medicaid in cation of nonfinancial barriers to tation from a recent report of the state fulfilling the expectations of its effective health care, and (3) a delinea- comptroller: proponents: tion of the range of interim policy inter- HHC [the Health and Hospitals Corporation Despite the willingness of the feder- ventions required to lower the barriers of New York] is faced with severely over- al government to cover up to 78% of the to access. crowded conditions stemming from signifi- Medicaid costs of low-income states, cant increases in AIDS, psychiatric, and many states have resisted the incen- LESSONS FROM HISTORY drug-abuse patients; a lack of available dis- tive. From the mid-1970s to the mid- The first large-scale governmental charge options for patients occupying acute 1980s, the proportion of poor persons reform of the US health care system in care beds unnecessarily; and bed closings due covered declined from two of three to the post-World War II era involved the to shortages of key staff such as nurses and social workers.² two of five, with some reversal in the radical restructuring of the medical ser- last years as Congress has forced the vices of the Veterans Administration, The most ambitious financial reform states to expand coverage for pregnant now renamed the Department of Veter- that the nation has undertaken dates women and young children.⁴ ans Affairs. In recent years, the De- from 1965 when Congress passed Medi- Faced with steeply rising Medicaid partment of Veterans Affairs, the care and Medicaid with the intention of costs, various states have arbitrarily nation's largest medical system, con- ensuring broad access to care for the limited the number of physician visits, sisting of about 170 hospitals and signifi- elderly and the categorical poor (recipi- days of hospitalization, and number of cant numbers of adjunct facilities in- ents of Aid to Families with Dependent prescriptions for which they provide re- cluding ambulatory care clinics and Children). What does the subsequent imbursement. In many states, reim- nursing homes that provide long-term record reveal? Unquestionably, the bursement rates for physician visits and care, has been operating at an annual large-scale infusion of federal, state, payment for hospital care have been set budget in the $10 billion range. Con- and, in the case of Medicaid, some local SO low that a large segment of the pro- gress has stipulated the categories of governmental funds resulted in much vider community has avoided accepting patients that the Veterans Affairs De- improved access of the elderly and the Medicaid patients or has severely limit- poor to both short-term inpatient care ed the number of Medicaid recipients From the Eisenhower Center for the Conservation of and ambulatory services. Furthermore, treated. Human Resources, Columbia University, New York, NY. with the passage of Medicare, most of Reprint requests to the Eisenhower Center for the Medicare came closer to fulfilling the Conservation of Human Resources, Columbia Universi- the elderly were able to turn for their expectations of its advocates and the ty, New York, NY 10027 (Dr Ginzberg). short-term care needs to mainstream legislators who passed the program, but JAMA, May 15, 1991 - Vol 265, No. 19 Beyond Universal Health Insurance-Ginzberg & Ostow 2559 it too revealed discrepancies between bulk, of their medical care from emer- tals and clinics for fear that routine re- financing reform and effective access gency departments, clinics, and inpa- cord keeping may result in their detec- that are worth noting: no one contem- tient services of public hospitals, the tion. Although universal coverage plated that over 70% of Medicare enroll- vast majority of which are seriously would make it easier for many members ees would resort to supplemental pri- strained with respect to capacity, staff, of these groups to seek and obtain effec- vate insurance (Medigap) to improve and equipment. Even with the introduc- tive health services, language handi- their coverage. Nor did Congress antic- tion of universal coverage, it is likely caps and the threat of deportation will ipate that Medicare enrollees would that most of these low-income individ- continue to inhibit their use of the health balk at covering half of the premium uals will continue to seek and obtain care system. costs for Medicare B, placing an unex- care from these neighborhood institu- These barriers, separate and distinct pected new burden on federal financing. tions. At the same time, it is not likely from the issue of financing, are among In 1988, Congress sought belatedly to that enhanced coverage would enable those that need to be addressed if the relieve the elderly of some of the cata- most of the public hospitals to remedy implicit promise that universal cover- strophic costs of hospital care and pre- the pressures and inefficiencies under age will provide effective access is to be scription drugs through Medicare, only which they have long been operating in realized. to have to rescind the amendments a the near or middle term. year later in the face of a voter revolt INTERIM TARGETS TO EXPAND against the higher premiums and taxes Teaching Hospitals ACCESS that these reforms entailed. During the first half of this century- The analysis thus far has emphasized The burden of this review under- scores that even large-scale financing and throughout most of the preceding the powerful barriers that impair access century-large urban teaching hospi- to basic medical care for various individ- reforms aimed at increasing coverage tals were a primary source of ambula- uals and groups, even in the presence of do not automatically translate into broadened access and improved ser- tory and inpatient care for the poor and private or public insurance. The barri- vices. After some years, federal and near poor. There was an implicit quid ers are that much greater for the ap- pro quo between the teaching hospital proximately 32 million persons who are state governments often encounter and its patients. Medical students, in- uninsured. In sum, our pluralistic budgetary stringencies that impel them terns, residents, and fellows could learn health care system is failing in greater to retrench in covering costs, to decerti- fy persons who had previously been en- the art of medicine only through prac- or lesser degree to meet the basic needs rolled, and to place limitations on eligi- tice and it was the poor who provided for effective medical care of about one bility and benefits. The lessons clinical experience for the novice. In re- third of the American people-th unin- extracted from the experience of earlier cent decades the role of the poor in the sured, the underinsured, and the under- health care reforms should not be over- learning process has diminished, al- served Medicaid population. though it has not disappeared. Other The recent report of the Pepper Com- looked in the debate over the new agen- things, however, have changed; the mission on Comprehensive Health Care da item known as universal coverage. emergency department, with a cost of concluded that the federal government $140 or more per visit, is not a desirable could not take the lead to establish a NONFINANCIAL BARRIERS TO ACCESS site for the poor to receive ambulatory system of national health insurance cov- care. Some acute care hospitals are erage for the entire population since the This section illuminates a number of forced to retain patients, usually at a estimated cost to the government would cultural, demographic, geographic, and institutional factors that adversely af- high per diem cost, because there is nei- be $200 billion annually. The difficulties fect access, even in the case of individ- ther an available nursing home bed nor a that the Bush administration and the suitable home to which they can be dis- Congress encountered in 1990 in writ- uals who have reasonable coverage or charged. It is hard to see how universal ing and enacting a long overdue 5-year the means to purchase it. coverage would resolve these institu- deficit reduction act (which probably Physician Practice Preferences tional "non-fits." grossly underestimated the size of the deficit) must be the point of departure Access to medical care implies access Immigrant Status and Language for any proposals for health care reform to physicians. However, it has long been Barriers that are put forward in 1991. In the near evident that most physicians are reluc- term, no significant additional financing tant to practice among the poor, the Medical care characteristically re- can be expected from the federal geographically isolated, and minorities. quires an interaction between the pa- government. Recent studies of the health care system tient seeking care and the physician or Although Congress, in the face of in the nation's four largest metropolitan other care giver. The United States has strong opposition from the National centers have revealed a 10-fold or great- been admitting approximately a million Governors' Association, mandated ex- er differential in the proportion of physi- legal immigrants, refugees, and illegal panded coverage in 1990 for pregnant cians to population between more afflu- aliens every year for the last decade and women and children by the Medicaid ent areas and low-income, minority the inflow will increase in the years program, no large-scale federal initia- neighborhoods.⁵ Within such a profes- ahead. A high proportion of these new- tives appear likely. There are some fed- sional culture, there is little reason for comers take up residence in coastal cit- eral and state proposals under consider- confidence that universal coverage by ies in the West, the South, and the East, ation to provide coverage for the itself would effect an appreciable redis- although increasing numbers are also uninsured working population through tribution of the physician supply that relocating to cities in the interior, such employer mandates (with some state would significantly improve access for as Chicago, Ill. participation), but the odds are that underserved populations. Most of the immigrants do not, at none of the proposals will be enacted. least initially, understand, speak, or This suggests that any additional fund- Stressed Public Hospitals read English; others have entered the ing for medical care must be sought A large proportion of the urban poor country illegally and generally avoid from individuals and households, out-of- and the uninsured obtain all, or the contact with institutions such as hospi- pocket or through payment of additional 2560 JAMA, May 15, 1991-Vol 265, No. 19 Beyond Universal Health Insurance-Ginzberg & Ostow "sin," income, or other taxes. Subsidized Coverage for the tic decline from its peak of $79.5 million The point could be made that an im- Near Poor in 1980. In 1989, the National Health portant source of potential funding has been overlooked: reform of the extant Some state experiments are under Service Corps placed in practice sites way to permit persons with incomes be- 215 scholars who had completed their system of medical care provision to re- tween 100% and 200% of the federal training and about 160 physician benefi- duce its excessive administrative and poverty level to buy into Medicaid. ciaries of the loan forgiveness program. malpractice costs and the elimination of Since the federal government covers on However, in 1991 the pipeline will have many unnecessary and ineffective the average 55% of state Medicaid out- been exhausted and virtually no Nation- treatments. It has been estimated that lays, and in low-income states as much al Health Service Corps scholars will be the combined total savings from such as 78%, we urge the adoption of pro- available for service. In light of the exis- reforms could amount to as much as $100 to $150 billion annually. In the gram models that, after critical assess- tence in the United States of 2000 un- ment, have been found to be effective. derserved areas and a requirement of present context it is essential to note This would represent, at the optimum, 4100 physicians in both public and pri- that although substantial savings might an addition of some 18 million people. At vate settings (in 1989, the Public Health be recoverable over time, they cannot an average expenditure of $2319 per re- Service sought over 1000 National be spent until they have been recov- cipient (fiscal year 1989), the estimated Health Service Corps graduates to fill ered, and the lead time for implement- gross cost would be $42 billion, but the vacancies), we urge early congressional ing practice guidelines is likely to be of net cost would be considerably less.9 approval of the substantial expansion of the order of a decade of intensive out- the program as well as action to extend comes research.⁸ Private Sector Catastrophic state debt forgiveness programs. It If one looks forward to their early Insurance Policies should be noted that the section 330 implementation, all proposals for large- community health centers depend scale health care reform must be predi- Almost 30% of the presently unin- heavily on the above for their physician cated on the foregoing pessimistic sured population are younger, em- staffing." appraisal of the financing outlook. Nev- ployed persons, most of whom work for ertheless, it would be shortsighted to small employers or for themselves and State Subsidies for Uncompensated assume that the present frozen environ- earn in excess of 200% of the federal Care ment for health reform, as well as for poverty level. The insurance industry, Medicare currently assists hospitals other public social policy initiatives, will if freed from state mandates by an that provide a large volume of uncom- not ultimately thaw. The United States amendment to the Employee Retire- pensated care through disproportionate continues to have both the highest per ment Income Security Act, should be share adjustments, special reimburse- capita standard of living and the lowest able to offer a catastrophic policy for ments for sole service hospitals, and re- per capita tax rate of any advanced na- individuals for around $1000 per annum, cently increased reimbursements for tion with the exception of Japan. How- perhaps less. Early action to move to- rural hospitals. We recommend that ever, it will take time before Americans ward this goal is indicated. more states follow the practice of New reach a consensus that low taxes are not York, New Jersey, Florida, and Cali- necessarily the best assurance of con- Expansion of the Federal Community fornia in creating a statewide pool for tinuing national prosperity and pro- Health Center Program reimbursing hospitals that provide dis- gress. Hence, we present the following Between 1980 and 1990 the federal proportionate amounts of uncompensat- modest proposals for health reform, not because more ambitious goals could not government maintained a reasonably ed care. They can do so by levying be formulated or are not desirable, but constant level of funding for community special sin taxes as in the case of Califor- because we believe that even these health centers under the Department of nia, by a tax on insurance premiums or Health and Human Services Communi- hospital revenues, or by some combina- modest proposals will prove difficult to ty-Migrant Health Centers program tion of both. Since the total amount of implement in the near term. (Public Health Service Act, section uncompensated hospital care is approxi- The Expansion of Medicaid 330). In fiscal year 1990, this amounted mately $13 billion annually, and since to $459 million and supported 527 cen- Medicare's contribution toward meet- ters. We recommend that the Con- ing this deficit is considerable, state Despite the resistance of the state governors, we believe that Congress gress expand this relatively inexpen- subsidies to help cover the remainder should continue to enact, as it has since sive program, which, in the areas where should be manageable." it exists, helps to compensate for the The foregoing six recommendations 1984, mandates and incentives for the severe dearth, if not absence, of prima- are avowedly modest. They are aimed states to enlarge Medicaid coverage. In the last 6 years this effort has resulted ry care services. at extending coverage for the unin- sured, providing improved primary in adding approximately 900 000 per- Expansion of the National Health care services for the underserved rural sons to the rolls. Despite federal and Service Corps and State Educational and urban populations, and helping to state fiscal constraints, we urge, at a Debt Forgiveness Programs ensure that vulnerable hospitals, par- minimum, that the present rate of ex- ticularly hard-pressed public hospitals, pansion be continued and that, as the As part of his budget proposal for have the essential financial resources to political and economic environment be- 1991, Secretary Sullivan of the Depart- continue to operate. We are aware that comes more favorable, Congress accel- ment of Health and Human Services has these proposals to expand coverage do erate the enrollment of all persons be- included funds to revive the National not address the substantial variability low the federal poverty standard. This Health Service Corps scholarship and among the states in the scope and quali- policy change has been recommended loan forgiveness programs that were al- ty of their health care services. Some- by the American Medical Association, located just $3 million in 1990, primarily day, the United States will have to face the Blue Cross and Blue Shield Associa- for scholarships to medical students, up to more fundamental reforms to en- tion, and the Health Insurance Associa- and loan repayment for physicians (fed- sure that all people have access to essen- tion of America. eral and state). This represented a dras- tial health care in a system where the JAMA, May 15, 1991 265, No. 19 Beyond Universal Health Insurance-Ginzberg & Ostow 2561 costs of health care do not outpace the form is the preoccupation of the public 3. The Robert Wood Johnson Foundation. Access growth and productivity of the with educational reform, drug control, to Health Care in the United States: Results of a 1986 Survey. Princeton, NJ: The Robert Wood economy. crime reduction, environmental issues Johnson Foundation; 1987. Special Report No. 2. CONCLUDING OBSERVATIONS and-not to be overlooked-the conse- 4. Statistical Abstract of the United States, 1990. quences following the successful prose- Washington, DC: US Bureau of the Census; 1990. This article has been written not by cution of the war against Iraq. 5. Ginzberg E, Berliner HB, Ostow M. Changing way of ideological opposition to the de- US Health Care: A Study of Four Metropolitan Faced with insurmountable obstacles velopment of a system of universal Areas. Boulder, Colo: Westview Press. In press. to the early establishment of universal 6. Ginzberg E. Access to health care for Hispanics. health care coverage for the United health care coverage, the United States JAMA. 1991;265:238-241. States, but rather as an exposition- should use the next years to experiment 7. US Bipartisan Commission on Comprehensive selective, not exhaustive-of the range Health Care. A Call for Action. Washington, DC: with removing discrete barriers that of factors that will continue to impede The Pepper Commission on Comprehensive Health currently impair the access of many mil- Care; 1990. access to effective care for a significant lions of Americans to proper medical 8. Ellwood PM. Shattuck Lecture: outcomes man- segment of the population, even with care. Such experimentation should con- agement: a technology of patient experience. N the institution of universal coverage. It Engl J Med. 1988;318:1549-1556. tribute to designing a more effective is at the same time skeptical of the likeli- 9. Health Care Financing Administration, Divi- system of universal coverage, if and sion of Medicaid Statistics. State Medicaid Statisti- hood of early action toward a scheme of when the opportunity arises. cal Report. Baltimore, Md: US Dept of Health and universal insurance at the federal or Human Services; 1989. HCFA publication 2082. federal-state level, or at the govern- References 10. Omnibus Budget Reconciliation Act 1990. PL mental-private sector level, in view of 101-239. December 19, 1989. 1. Ginzberg E. The VA in a vise: an outside observ- 11. US General Accounting Office. National the resistance of the American people to er spells out the social and economic realities ahead. Health Service Corps: Program Unable to Meet further large-scale taxation and the per- VA Practitioner. 1989;6:39-46. Need for Physicians in Underserved Areas. Wash- ilous budgetary situation of the federal 2. State of New York. Review of the Financial ington, DC: US General Accounting Office; August government and most state govern- Plan for the New York City Health and Hospitals 10, 1990. Publication GAO/HRD-90-128. Corporation for Fiscal Years 1991 Through 1994. 12. Office of National Cost Estimates. National ments. Perhaps the most powerful de- Albany, NY: Office of the State Comptroller; July health expenditures, 1988. Health Care Fin Rev. terrent to early large-scale health re- 3, 1990. Report 7-91. 1990;11(4):1-41. 2562 JAMA, May 15, 1991 Vol 265, No. 19 Beyond Universal Health Insurance-Ginzberg & Ostow Editorials Caring for the Uninsured Choices for Reform These recent events provide the impetus for this theme issue their employers, for the purchase of private insurance; and of THE JOURNAL: (1) Government reports show a 24% in- (4) an all-government insurance system. crease in the last decade in the total number of uninsured Table 2 displays the proposals grouped into these four people and a 40% increase in the number of uninsured chil- categories in a way that facilitates comparison. Although this dren.¹⁴ Most uninsured children are part of a family with a summary masks some innovative features of individual pro- working adult. (2) Recent studies have found that, despite posals, it highlights the broad similarities. Each proposal considerable amounts of uncompensated care provided by shares the goal of achieving near-universal access to care hospitals and physicians, Americans without health insurance through improved insurance coverage of the population; it is face major barriers to the receipt of needed health services. the means to achieve this that separate them. Although they suffer from higher rates of ill health than the We expect this framework to promote a better understand- insured population, the uninsured report fewer hospitaliza- ing of the choices available to us as a nation to address the tions and fewer visits to a physician, shorter hospital stays, problem of access to care, and ultimately to aid in finding a and fewer discretionary inpatient hospital treatments and consensus on some acceptable, uniquely American approach tests, at higher cost. The uninsured also experience higher to reform. Before the publication of this issue of THE JOUR- mortality rates when hospitalized than persons with health NAL, a series of national opinion surveys asked a random insurance coverage who have similar medical diagnoses.611 sample of the general public, corporate executives, and labor (3) There is evidence of growing public dissatisfaction with union leaders about their preference for two of the four types our inability to resolve this serious problem, and there are of proposals presented herein (Table 3). The findings indi- signs of a broad consensus that some type of major reform is cate that, although most people favored some type of univer- now required. sal plan, there was no majority supporting either approach. On one hand, current opinion survey findings show that This lack of agreement on any specific plan is similar to the Americans are relatively well satisfied with the medical care they receive personally compared, for example, with citizens Table -Public Satisfaction With Health Care System and With Own Medical of Canada, Great Britain, or (West) Germany. However, Care in Four Nations* growing public concern over access to care for the uninsured Very Satisfied Satisfied With and sharply rising costs have led Americans to be much less With Own and Current Health satisfied with the overall workings of our health care system Country Family's Care, % Care System,t % (Table 1). 12,13 United States 55 10 In addition, as shown in the Figure, increased awareness of Canada 60 56 Great Britain 39 27 and experience with these problems have led the public, (West) Germany 45 41 corporate executives, and labor union leaders to support some form of universal insurance coverage, even if it means *From the Harvard Community Health Plan and Louis Harris & Associates. an increase in taxes. 14,15 tBelieved that only minor changes were needed. These factors led the editors of THE JOURNAL to ask read- ers last August to propose major options to resolve this Support for universal health insurance coverage, even if it means an increase in taxes, among the general public, corporate executives, and labor union leaders. problem.¹⁶ Eighty authors or groups of authors from a variety Asterisk indicates that there were minor wording differences in the question of professional backgrounds submitted proposals for needed asked of the general public (from public opinion polls conducted by the Metropol- reforms. This issue of THE JOURNAL is an attempt to include itan Life Insurance Company and Louis Harris & Associates and by the Los Angeles Times in one place most of the major approaches to this problem at the national level. (Additional national proposals have ap- peared in recent issues, 17-20 and state proposals will appear in 100 92% subsequent issues.) After rigorous peer review, 13 definitive proposals were selected from among the many thoughtful 80 72% ones submitted. These proposals follow one of four approach- gram, with the government insuring nonworkers and the poor; (2) a plan that requires employers to provide their Support for Universal Health 67% es: (1) a compulsory, employer-based private insurance pro- Insurance Coverage, % 60 40 employees with health insurance or pay a tax, with the gov- ernment insuring nonworkers and the poor; (3) a program of 20 income-related tax credits for individuals, independent of 0 From the Department of Health Policy and Management, Harvard School of Public Public* Corporate Labor Union Health, Boston, Mass. Executives Leaders Reprint requests to Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (Dr Blendon). JAMA, May 15, 1991 Vol 265, No. 19 Editorials 2563 Table Proposals for Reform in This Issue of THE JOURNAL* Cost Containment/ Provider Other Distinctive Author of Proposal Coverage Administration Financing Reimbursement Features TYPE I: COMPULSORY PRIVATE INSURANCE THROUGH EMPLOYERS, WITH GOVERNMENT INSURING NONWORKERS AND THE POOR Kirkman-Liff Universal Private: insurers offer Employer/employee Copayments/cost sharing; Copies some features of community-rated premium sharing; managed care optional; German and Dutch plans federal government reimbursement systems; LTC benefits Government: pays employer share negotiated between unmentioned Medicare/Medicaid of premium for provider and payer enrollees get nonworkers representatives vouchers to buy private insurance Todd et al (American Nearly universal; Private: insurers offer No change Changes tax treatment of Adds private LTC Medical Association) excludes nonpoor private plans or employee benefits; benefits and expands nonworkers state risk pool for health promotion; Medicaid; uninsurable and repeals state-mandated catastrophic others benefits; seeks coverage; reforms Government: reduction in Medicare trust fund unchanged administrative costs; improves Medicaid reimbursement levels; private insurance unchanged Rockefeller (Pepper Universal Private: insurers offer Employer/employee Encourages use of Insurance reform; Commission) private plans premium sharing; managed care; cost universal coverage of Government: existing government sharing; improves LTC replaces Medicaid sources plus new consumers' knowledge; with new program taxes malpractice reform; for poor public program pays nonworkers, and Medicare rates; private self-employed, insurance unchanged with buy-in option for employed Bronow et al (Physicians Nearly universal; Private: community- Employer/employee High cost sharing; Adds public-private LTC Who Care) excludes nonpoor rated insurance premium sharing plus reimbursement coverage and nonworkers plans with high individual medical unchanged catastrophic coverage deductibles savings accounts; Government: government expanded unchanged Medicaid coverage Nutter et al (Medical Nearly universal; Private: insurance Employer/employee All-payer, prospective Eliminates deductibility Schools Section, excludes nonpoor plus insurance risk premium sharing; payment for hospital of employer American Medical nonworkers pools employment-based and professional contributions; adds Association) Government: tax to cover new services LTC and catastrophic expanded Medicaid costs; coverage to Medicare Medicaid coverage elderly pay for Medicare expansion TYPE II: LAW REQUIRING EMPLOYERS TO PROVIDE PRIVATE INSURANCE TO EMPLOYEES OR PAY EQUIVALENT TAX, WITH GOVERNMENT INSURING NONWORKERS AND THE POOR Davis Universal Private: insurers offer Employer/employee All payers adopt Medicare Allows states to buy private plans premium sharing or rates and volume Medicaid enrollees Government: employer payroll tax; performance standards into Medicare; LTC Medicare income tax; general for hospitals and expansion optional for coverage for all revenues physicians states others Schwartz (Kansas Universal Private: insurers offer Employer/employee Malpractice reform; Insurers join Employer Coalition on private plans premium sharing; tax increased cost sharing; reinsurance pools Health) Government: on individuals in pool; health promotion; regional public general revenue insurance price sponsors and increases tied to Medicare Consumer Price Index, with government adjustments; mandatory community rating of insurance Enthoven and Kronick Universal Private insurance, Employer/employee Increased cost sharing; Emphasizes managed Medicare, and premium sharing: market forces growing care delivery public sponsors for other sources from competing systems; no change all others unchanged managed care plans; in LTC benefits changes the tax deductibility of employer health benefits Holahan et al Universal New federal-state Employer/employee Federal share of health Federalizes LTC program for premium sharing or expenditures tied to benefits; cost anyone not tax; existing and new growth in GNP; states containment left to covered by an state and federal tax have strong cost- the states; eliminates employer or revenue containment incentives; Medicaid Medicare tax deductibility of benefits limited to standard benefit package; reimbursement unchanged TYPE III: TAX CREDIT FOR PURCHASE OF PRIVATE INSURANCE Butler (Heritage Universal Individuals purchase Individual payment for Changes in tax treatment Purchase of LTC Foundation) private coverage all premiums or care; of health benefits to coverage at discretion from competing government pays for discourage of individuals insurers poor overinsuring and independent of overuse; employers; reimbursement Medicare/Medicaid unchanged beneficiaries get vouchers TYPE IV: ALL-GOVERNMENT INSURANCE SYSTEM Roybal (USHealth Act) Universal Single insurance Same sources of Prospective payment, Adds broad range of system run by new revenue to be paid with total budget cap of health and LTC agency; role for into single account 12% to 13% of GNP; all benefits private insurers reimbursement based on Medicare rules Grumbach et al Universal Public administrator Payroll tax; existing Annual hospital budget Each state determines (Physicians for a replaces Medicare, government revenue negotiated with state who runs the plan; no National Health Medicaid, and sources; new taxes plan based on past copayments and Program) private insurance expenditures, deductibles; LTC fully performance, and cost covered and use projections; physicians paid on negotiated fee schedule Fein (Committee for Universal States have much Federal and state taxes State and national health Encourages state National Health flexibility with and premiums paid care budgets; experimentation; LTC Insurance) federally specified into single state negotiated payments to benefits unchanged benefits and agency; agency pays insitutional providers; budget oversight insurers or providers negotiated physician on capitated basis; fee schedule; federal contribution expansion of capitated increases based on systems; consolidated growth in GNP administration; government review of technology and treatment effectiveness; administrative savings *LTC indicates long-term care; GNP, gross national product. Table 3. Preferences for Universal Health Insurance Systems* Rockville, Md: Public Health Service; 1990. US Dept of Health and Human Services publication PHS 90-3469. National Medical Expenditure Survey Data Corporate Labor Union Summary 2. System Option Executives, % Leaders, % Public, % 3. Cunningham P, Monheit A. Insuring the children: a decade of change. Health Favor an all-government national Aff. Winter 1990;9:76-90. health plan 27 58 46 4. Congressional Research Service. Health Insurance and the Uninsured: Favor a compulsory private insurance Background Data and Analysis. Washington, DC: US Library of Congress; plan, with government providing for 1988:229-230. Publication EPW 88-537. the unemployed 35 28 33 5. Davis K, Rowland D. Uninsured and underserved: inequalities in health care Favor no change in the present system 35 10 19 in the United States. Milbank Q. 1983:61:160-163. 6. Freeman H, Blendon R, Aiken L, Sudman S, Mullinex C, Corey C. Ameri- *From Louis Harris & Associates Inc.17 cans report on their access to health care. Health Aff. Spring 1987;6:13-14. 7. Blendon R, Aiken L, Freeman H, Kirkman-Liff B, Murphy J. Uncompen- sated care by hospitals or public insurance for the poor: does it make a differ- ence? N Engl J Med. 1986;314:1160-1163. 8. Wenneker MB, Weissman JS, Epstein AM. The association of payer with dilemma faced in the 1970s. During the early part of that utilization of cardiac procedures in Massachusetts. JAMA. 1990;264:1255-1260. 9. Weissman J, Epstein AM. Case mix and resource utilization by uninsured decade, more than a dozen initiatives for universal health hospital patients in the Boston metropolitan area. JAMA. 1989;261:3572-3576. coverage were introduced in Congress. However, leaders of 10. Aday L, Fleming G, Andersen R. Access to Medical Care in the US: Who key groups and the public were unable to reach agreement on Has It, Who Doesn't? Chicago, Ill: Pluribus Press; 1984. 11. Hadley J, Steinberg EP, Feder J. Comparison of uninsured and privately any single approach to reform. Because the problem of insured hospital patients: condition on admission, resource use, and outcome. adequately caring for the uninsured has been worsening, we JAMA. 1991;265:374-379. 12. Blendon R, Leitman R, Morrison I, Donelan K. Satisfaction with health hope that the discussion generated by this theme issue will systems in 10 nations. Health Aff. Summer 1990;9:185-192. make it easier to reach a national consensus. 13. Comparing Health Systems: Health Service Satisfaction in Six Countries. When considering the various proposals, it is important to Boston, Mass: Harvard Community Health Plan and Louis Harris & Asso- ciates; 1990. keep in mind the caveat raised by Ginzberg and Ostow²⁵ in 14. Taylor H, Leitman R. Trade-offs and Choices: Health Policy Options for the their article in this issue. Even if we do enact a universal 1990s. New York, NY: Metropolitan Life Insurance Company and Louis Harris health care plan, we will need additional solutions to "the & Associates; 1990. Study 902026. 15. Health Care in the United States. Storrs, Conn: Roper Center for Public range of [nonfinancial] factors that will continue to impede Opinion Research and the Los Angeles Times; 1990. Poll 212. access to effective care for a significant segment of the 16. Lundberg GD, Blendon RJ. A special JAMA theme issue on caring for the uninsured and the underinsured. JAMA. 1990;264:739. population." 17. Kleinman LC. Health care in crisis: a proposed role for the individual Robert J. Blendon, ScD physician as advocate. JAMA. 1991;265:1991-1992. Jennifer N. Edwards, MHS 18. Moore GT. Let's provide primary care to all uninsured Americans-now! JAMA. 1991;265:2108-2109. 19. Daniels N. Is the Oregon rationing plan fair? JAMA. 1991;265:2232-2235. Dr Blendon is a non-stock-holding director of AMEV Holdings Inc, in New 20. Gleicher N. Expansion of health care to the uninsured and underinsured York, NY, a Dutch-American firm that owns 12 US companies, two of which are has to be cost-neutral. JAMA. 1991;265:2388-2390. in the insurance business. Both authors are collaborators with Louis Harris & 21. Health Care Poll. Storrs, Conn: Roper Center for Public Opinion Research Associates in a number of surveys, polls, and publications. Financial support and Louis Harris & Associates; 1990. from this activity, given through Harvard University, provides partial support 22. Blendon R, Donelan K. The public and the emerging debate over national for their current salaries. health insurance. N Engl J Med. 1990;323:208-212. 23. Etheredge L. Universal health insurance: Lessons of the 1970's, prospects 1. Walden D, Wilensky G, Kasper J. Changes in Health Insurance Status: Full for the 1990's. Front Health Serv Manage. Winter 1990;6:3-35. Year and Part Year Coverage: Data Preview 21. Rockville, Md: National Center 24. Waldman S. National Health Insurance Proposals. Washington, DC: So- for Health Services Research; 1985. US Dept of Health and Human Services cial Security Administration; 1974:21-44. Publication SSA7-11902. publication PHS 85-3377. 25. Ginzberg E, Ostow M. Beyond universal health insurance to effective 2. Short P. Estimates of the Uninsured Population, Calendar Year 1987. health care. JAMA. 1991;265:2559-2562. JAMA, May 15, 1991 - Vol 265, No. 19 Editorials 2565 National Health Care Reform An Aura of Inevitability Is Upon Us "With malice toward none; with charity for all. So spoke editorial in JAMA between Thanksgiving and Christmas in Abraham Lincoln in his second Inaugural Address, recogniz- 1988 and again in 1989. Among the eight other articles that ing that he had no political consensus regarding either the appeared in that column was one by then-AMA President, constitutionality of states' seceding or the morality of slav- James E. Davis, MD,⁵ who made service by physicians with- ery's being abolished. Nonetheless, he knew what was right out expectation of compensation the theme of his 1988-1989 and was able, through persuasive, often inspiring rhetoric, to presidency. A column by Dr Eric Muñoz⁶ on the Hispanic poor conclude a bloody and divisive civil war and constitute the spawned the 1991 JAMA theme issue dedicated to Hispanic foundation for this great democracy. health.⁷ Emily Friedman's® "The Torturer's Horse," perhaps Yet, access to basic medical care for all of our inhabitants is more than any other piece, sparked today's theme of "Caring still not a reality in this country. There are many reasons for for the Uninsured and Underinsured." Robert J. Blendon's® this, not the least of which is long-standing, systematic, insti- "What Should Be Done About the Uninsured Poor?" posi- tutionalized racial discrimination. The major studies of health tioned him to coedit this issue. And AMA President C. John care maldistribution reinforce this statement with hard data, Tupper's¹⁰ Inaugural Address launched his year-long cam- especially with regard to blacks and Hispanics. 1,2 It is not a paign "Health Access America." coincidence that the United States of America and the Repub- When it became clear about a year ago that our worsening lic of South Africa-the only two developed, industrialized crises of access and cost of health care in the United States countries that do not have a national health policy ensuring extended to far more than the poor, we decided with the that all citizens have access to basic health care-also are the editors of the AMA specialty journals that all 10 of the AMA only two such countries that have within their borders sub- scientific journals would focus on this question in May 1991. 11 stantial numbers of underserved people who are different Fifty-two articles on this subject are also appearing concur- ethnically from the controlling group. rently in the nine specialty journals, and they will be bound as When we look at health care access, we are especially looking a companion compendium. at the results of these disparities. The problem is manifested in a The new "Caring" column began on April 17, 1991, with an higher percentage of people who are black and Hispanic being essay by Lawrence Kleinman, MD," of UCLA that challenges unemployed and thus having less employment-related health physicians to dedicate themselves to making positive change insurance and in a higher percentage of blacks and Hispanics happen. A week later, Gordon Moore, MD,¹ of Harvard noted being in low-level or part-time employment that provides fewer that a complete solution to the problem may not be rapidly health insurance opportunities. Medicaid coverage by poverty- forthcoming; so we should solve the problem of access to line demarcations and physician payments are the lowest in primary care now on a priority basis. On May 1, Norman many states that have the largest population of blacks; main- Daniels, PhD,¹⁴ of Tufts analyzed the philosophical base of the stream private medicine, particularly in large cities such as our bold Oregon rationing experiment. And on May 8, Norbert nation's capital, has turned its back on the poor; most physicians Gleicher, MD,¹⁵ of Chicago pointed the way for providing refuse even to see such patients (David Hilfiker, MD, oral essential health care for all of our people with no increased communication, February 6, 1991). cost to the total economy. He showed how we could achieve Although there may be consensus that our society must this goal by redirecting funding away from unnecessary pa- provide basic medical/health care for all of our people, we seem tient luxuries and from profiteering by those with vested self- not to be close to a consensus on how to do it. Virtually all interests in our medical affluence complex. comprehensive health care proposals involve major legislation Blendon and Edwards¹⁶ have summarized the 13 broad- of some sort. Since consensus means "general agreement or based articles appearing in this issue. These proposals repre- unanimity; group solidarity in sentiment or belief," it is unlikely sent the political and economic spectrum, from the far left to that, either as a society or as a profession, we will ever reach a the far right, from Atlantic to Pacific, from urban to rural true consensus on how to proceed, so we must not wait for one. settings, from academia, from labor, from consumers, from To pass federal legislation requires only a simple majority in government, and from organized medicine. Extraordinarily both houses of Congress plus presidential approval. diverse in concept, the proposals all share a common thread- Let us do our part to end this last health-related carryover a serious intention to find a way to meet our professional and from antebellum days and provide equal opportunities for societal responsibilities of caring well for the basic health of all health for all of our people, thus continuing to carry out of our people. Subsequent JAMA articles will appear in the Lincoln's agenda. Caring column, detailing individual state, local, and national proposals and the databases from which they arise. JOURNAL Initiatives De Facto Rationing Our JAMA column "Caring for the Poor" began December Since virtually no one is completely healthy on any day, the 4, 1987, with Hilfiker's® inspiring essay "Unconscious on a potential use of medical resources is endless. There will never Corner," adjacent to the editorial "Fifty Hours for the Poor." be enough providers or enough money to give all possible care The editorial was coauthored by Larry Bodine, then editor of to everybody. Thus, care is rationed every day but in irratio- the American Bar Association journal, and myself and ran nal ways. How do we currently ration? concurrently in JAMA and the ABA Journal. We reran the By access control through pricing that does not discrimi- nate between needed and effective medical care and unneed- Reprint requests to Scientific Publications Group, American Medical Association, 515 N State St, Chicago, IL 60610 (Dr Lundberg). ed or ineffective care. 2566 JAMA, May 15, 1991 Vol 265, No. 19 Editorials By not providing sufficient resources for disease preven- high deductibles and copayments to increase patient re- tion, which results in unwanted teenage pregnancies, wide- straint in demanding care spread initiation of tobacco addiction, and rampant sexually pre-use approval for expensive technology, depending transmitted diseases. upon safety, efficacy, and cost-effectiveness By insufficient transportation to appropriate facilities a maximum percentage of GNP for health capped by law that affects rural and inner-city residents alike. overall national or state medical expense caps By absolute and relative shortages of organs for trans- expenditure targets plantation that lead to unnecessary deaths. diagnosis related groups for all hospitals and payers By major variations in practice patterns between geo- Resource-Based Relative Value Scale payment for phy- graphic areas without meaningful outcome differences, dem- sicians from all payers onstrating a waste of resources. limitation of number and types of physicians By differing payment approval policies that function un- marketplace competition with strictly managed care. der widely varied rules and institutionalize such variations. We Can Succeed By accepting social class membership as a determinant of In the past several months, this country demonstrated once whether patients can or cannot pay. again that it is capable of addressing a serious national crisis Through ignorance about the availability and desirability and succeeding brilliantly in meeting its objectives. I refer to of effective preventive and treatment services. the 42-day air and 100-hour air-land war for the liberation of By language and cultural barriers that exclude Hispanics Kuwait. Why did we succeed? We had the knowledge, the and blacks from appropriate access. resources, the skills, the time, clear-cut objectives, a belief By not training sufficient numbers of health profession- that the foe was morally reprehensible, a narrow but decisive als from minority backgrounds. political margin, and, as with Abraham Lincoln and the War By training insufficient numbers of primary care physi- Between the States, we had the national will, the result in cians and excessive numbers of specialist technocrats. large part of presidential leadership. Health care rationing, then, is both inevitable and perva- If the Iron Curtain can be lifted, the Warsaw Pact dis- sive. But we need to begin rationing rationally. solved, and East and West Germany politically reunited, all Cost Control as the Political 'Litmus Test' quite rapidly, because it was the right thing to do and the time Recent AMA-sponsored surveys demonstrate that neither had come-surely we in this rich and successful country can the American people nor American physicians consider quali- manage to provide basic medical care because it too is the ty to be the main problem facing medical/health care in the right thing to do, and the time has come. A long-term crying United States; rather, they name cost as the first concern, need has developed into a national moral imperative and now and access as the second. Because the opinion that costs are a into a pragmatic necessity as well. huge medical problem is strongly held by leaders of industry, An aura of inevitability is upon us. It is no longer acceptable labor, and government, as well as by physicians and the morally, ethically, or economically for so many of our people general public, and because of concerns about whether Amer- to be medically uninsured or seriously underinsured. We can icans are receiving appropriate value for money spent, I do solve this problem. We have the knowledge and the re- not believe that meaningful health care reform will come sources, the skills, the time, and the moral prescience. We about unless it is tied to some form of cost control. need only clear-cut objectives and proper organization of our The cost increases in medical care since 1955 that have resources. Have we now the national will and leadership? taken a progressively higher percentage of the gross national George D. Lundberg, MD product (GNP) can generally be ascribed to: 1. Treviño FM, Moyer ME, Valdez RB, Stroup-Benham CA. Health insurance economic inflation coverage and utilization of health services by Mexican Americans, mainland increased number of elderly persons Puerto Ricans, and Cuban Americans. JAMA. 1991;265:233-237. 2. Wenneker MB, Epstein AM. Racial inequalities in the use of procedures for increased number of surviving tiny neonates patients with ischemic heart disease in Massachusetts. JAMA. 1989;261: new technology 253-257. professional liability 3. Hilfiker D. Unconscious on the corner. JAMA. 1987;258:3155-3156. 4. Lundberg GD, Bodine L. Fifty hours for the poor. JAMA. 1987;258:3157. inappropriate uses of diagnostic or therapeutic 5. Davis JE. National initiatives for care of the medically needy. JAMA. procedures 1988;259:3171-3173. increased number of health care providers 6. Muñoz E. Caring for the Hispanie poor: a growing segment of American society. JAMA. 1988;260:2711-2712. heightened societal and/or personal expectations. 7. Hispanic health. JAMA. 1991;265(theme issue):161-296. Because of the steepness of the slope and the huge expendi- 8. Friedman E. The torturer's horse. JAMA. 1989;261:1481-1482. 9. Blendon RJ. What should be done about the uninsured poor? JAMA. tures involved, a substantial segment of our society, especial- 1988;260:3176-3177. ly leaders of businesses, both large and small, is becoming 10. Tupper CJ. Dreams, dollars, and deeds: the sacred fire and Health Access frantic about rising health care costs. In national (and ratio- America. JAMA. 1990;264:1150-1151. 11. Lundberg GD, Blendon RJ. A special JAMA theme issue on caring for the nal) health care reform, successful cost containment will be uninsured and underinsured. JAMA. 1990;264:739. both the political "litmus test" and the gateway to universal 12. Kleinman L. Health care in crisis: a proposed role for the individual physician as advocate. JAMA. 1991;265:1991-1992. access. 13. Moore GT. Let's provide primary care to all uninsured Americans-now! Many proposals in this theme issue address the problem of JAMA. 1991;265:2108-2109. costs; several incorporate methods of control. Controls could 14. Daniels N. Is the Oregon rationing plan fair? JAMA. 1991;265:2232-2235. include: 15. Gleicher N. Expansion of health care to the uninsured and underinsured has to be cost-neutral. JAMA. 1991;265:2388-2390. education of physicians and the public about proper ap- 16. Blendon RJ, Edwards JN. Caring for the uninsured: choices for reform. plication of clinical guidelines or parameters JAMA. 1991;265:2563-2565. 17. Harvey LK. AMA Survey of Public and Physicians' Opinions on Health increased use of patient choices for spending options Care Issues. Chicago, Ill: American Medical Association; 1990 and 1991. JAMA, May 15, 1991 Vol 265, No. 19 Editorials 2567 ROCHE MEDICAL DIRECTOR'S PAGE Bruce H. Medd, M.D., Associate Vice President and Director, Professional Services Managing the Benzodiazepine-Dependent Patient Since their introduction almost three decades ago, the benzodiazepines have become one of These experts agreed that:2 the most widely prescribed group of drugs in the the physician must evaluate a number of history of medicine. Despite periodic trends to behavioral and clinical features and their criticize the broad use of the benzodiazepines, time course to distinguish benzodiazepine- their popularity seems to be well deserved, when dependent patients from those patients with one considers the many thousands of references chronic anxiety who may be suffering from a in the worldwide medical literature that clearly return of their symptoms. reflect the significant benefits realized with some patients should not be withdrawn these agents. In addition to their more familiar from therapy even if they show signs of applications in anxiety, insomnia and dependence. Careful evaluation of the patient preoperative sedation, administration of the should always precede any attempt at benzodiazepines extends to certain life-saving withdrawal. uses as well (i.e., control of the muscle spasms while there are many methods available of tetanus and other conditions often seen in for the safe and effective withdrawal of the certain Third World countries). benzodiazepine-dependent patient, gradual reductions in dosage in an outpatient setting is The potential for abuse and the occurrence preferred in uncomplicated cases. of dependence during benzodiazepine therapy continued management of the patient has prompted numerous studies and reports. withdrawn successfully is essential to reduce Although physiologic dependence can develop the patient's risk of relapsing into drug in some patients, available evidence does not dependency. Of course, the importance of appear to support the wide occurrence of abuse support from the patient's family and friends in the general population.¹ However, it is critically during and after the withdrawal period cannot important that health care professionals be be stressed enough. able to recognize and treat benzodiazepine dependence when it occurs. To assist physicians References in this effort, a workshop was held in Basle, 1. Woods JH, Katz JL, Winger G: Use and abuse of Switzerland, in September of 1987. Experts benzodiazepines: Issues relevant to prescribing. JAMA. gathered there to evaluate their experiences 1988;260(23):3476-3479. and establish guidelines for managing 2. Marks J: Techniques of benzodiazepine withdrawal in clinical practice: A consensus workshop report. Med Toxicol benzodiazepine-dependent patients.² Adverse Drug Exp. 1988;3(4):324-333. If you would like more information on the management of benzodiazepine-dependent patients, ask your Roche representative or write to me: Bruce H. Medd, M.D., Associate Vice President and Director, Professional Services, Roche Laboratories, a division of Hoffmann-La Roche Inc., Nutley, New Jersey 07110. Roche Laboratories ROCHE a division of Hoffmann-La Roche Inc. 340 Kingsland Street Nutley, New Jersey 07110-1199 Zestril* (lisinopril) ZESTRIL® Lisinopril was not mutagenic in the Ames microbial mutagen test with or without metabolic activation It was also negative in forward mutation assay using Chinese hamster lung cells Lisinopril did not produce single strand DNA breaks in an in vitro (LISINOPRIL) alkaline elution rat hepatocyte assay. In addition, lisinopril did not produce increases in chromosomal aberrations in an in vitro test in Chinese hamster ovary cells or in an in vivo study in mouse bone marrow There were no adverse effects on reproductive performance in male and female rats treated with up to 300 mg/kg/day of lisinopril Pregnancy: Pregnancy Category D. See WARNINGS, Fetal/Neonatal Morbidity and Mortality. (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE INSERT.) Nursing Mothers: Milk of lactating rats contains radioactivity following administration of "C lisinopril, It is not known whether INDICATIONS AND USAGE: ZESTRIL is indicated for the treatment of hypertension. It may be used alone as initial therapy or this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when ZESTRIL is given to nursing mother. concomitantly with other classes of antihypertensive agents. Pediatric Use: Safety and effectiveness in children have not been established In using ZESTRIL, consideration should be given to the fact that another angiotensin converting enzyme inhibitor, captopril, has caused agranulocytosis, particularly in patients with renal impairment or collagen vascular disease, and that available data are ADVERSE REACTIONS: ZESTRIL has been found to be generally well tolerated in controlled clinical trials involving 2003 insufficient to show that ZESTRIL does not have a similar risk. (See WARNINGS.) patients and subjects CONTRAINDICATIONS: is contraindicated in patients who are hypersensitive to this product and in patients with a history The most frequent clinical adverse experiences in controlled trials with ZESTRIL were dizziness 3%), headache (5.3%), fatigue diarrhea upper respiratory symptoms .0%), and cough (2.9%), all of which were more frequent than in of angioedema related to previous treatment with an angiotensin converting enzyme inhibitor placebo-treated patients. For the most part, adverse experiences were mild and transient in nature. Discontinuation of therapy WARNINGS: Angioedema: Angioedema of the face, extremities. lips, tongue, glottis and/or larynx has been reported in patients was required in 6.0% of patients. In clinical trials, the overall frequency of adverse experiences could not be related to total daily treated with angiotensin converting enzyme inhibitors, including ZESTRIL In such cases, ZESTRIL should be promptly dosage within the recommended therapeutic dosage range. discontinued and appropriate therapy and monitoring should be provided until complete and sustained resolution of signs and For adverse experiences which occurred in more than 1% of patients and subjects treated with ZESTRIL or ZESTRIL plus symptoms has occurred. In instances where swelling has been confined to the face and lips the condition has generally resolved hydrochlorothiazide in controlled clinical trials, comparative incidence data are listed in the table below. without treatment, although antihistamines have been useful in relieving symptoms. Angioedema associated with laryngeal edema Percent of Patients in Controlled Studies may be fatal. Where there is involvement of the tongue, glottis or larynx likely to cause airway obstruction, appropriate ZESTRIL/ therapy. eg, subcutaneous epinephrine solution 1:1000 mL to 0.5 mL) and/or measures necessary to ensure a patent ZESTRIL Hydrochlorothiazide Placebo airway should be promptly provided. (See ADVERSE REACTIONS.) (n=2003t) (n=644) (n=207) Hypotension: Excessive hypotension was rarely seen in uncomplicated hypertensive patients but is a possible consequence of Incidence Incidence Incidence the use with ZESTRIL in salt/volume-depleted persons, such as those treated vigorously with diuretics or patients on dialysis. (See (discontinuation) (discontinuation) PRECAUTIONS, Drug Interactions and ADVERSE REACTIONS. In patients with severe congestive heart failure, with or without associated renal insufficiency, excessive hypotension has been observed and may be associated with oliguria and/or progressive Dizziness 6.3 (0.6) (0.9) 1.9 azotemia, and rarely with acute renal failure and/or death. Because of the potential fall in blood pressure in these patients, therapy Headache 5.3 (0.2) 4,3 (0.5) 1.9 should be started under very close medical supervision. Such patients should be followed closely for the first two weeks of Fatigue 3.3 (0.2) 3.9 (0.5) 1.0 treatment and whenever the dose of ZESTRIL and/or diuretic is increased. Similar considerations apply to patients with ischemic Diarrhea 3.2 (0.3) 2.6 (0.3) 2.4 heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or Upper Respiratory Symptoms 3.0 (0.0) 4.5 (0.0) 0.0 cerebrovascular accident. Cough 2.9 (0.4) 4.5 (0.8) 1.0 If hypotension occurs. the patient should be placed in supine position and if necessary, receive an intravenous infusion of Nausea 2.3 (0.3) 2.5 (0.2) 2.4 normal saline. A transient hypotensive response is not contraindication to further doses which usually can be given without Hypotension 1.8 (0.8) 1.6 (0.5) 0.5 difficulty once the blood pressure has increased after volume expansion Rash 1.5 (0.4) 1.6 (0.2) 0.5 Neutropenia/Agranulocytosis: Another angiotensin converting enzyme inhibitor, captopril, has been shown to cause Orthostatic Effects 1.4 (0.0) 3.4 (0.2) 1.0 agranulocytosis and bone marrow depression, rarely in uncomplicated patients but more frequently in patients with renal Asthenia 1.3 (0.4) 2.0 (0.2) 1.0 impairment especially if they also have collagen vascular disease. Available data from clinical trials of ZESTRIL are insufficient to Chest Pain 1.3 (0.1) 1.2 (0.2) 1.4 show that ZESTRIL does not cause agranulocytosis at similar rates. Marketing experience has revealed rare cases of neutropenia Vomiting 1.3 (0.2) 1.4 (0.0) 0.5 and bone marrow depression in which a causal relationship to lisinopril cannot be excluded Periodic monitoring of white blood Dyspnea 1.1 (0.0) 0.5 (0.2) 1.4 cell counts in patients with collagen vascular disease and renal disease should be considered. Dyspepsia 1.0 (0.0) 1.9 (0.0) 0.0 Fetal/Neonatal Morbidity and Mortality: ACE inhibitors, including ZESTRIL, can cause fetal and neonatal morbidity and Paresthesia 0.8 (0.0) 2.0 (0.2) 0.0 mortality when administered to pregnant women. Impotence 0.7 (0.2) 1.6 (0.3) 0.0 Lisinopril crosses the human placenta. When ACE inhibitors have been used during the second and third trimesters of Muscle Cramps 0.6 (0.0) 2.8 (0.6) 0.5 prégnancy, there have been reports of hypotension, renal failure, skull hypoplasia, and/or death in the newborn. Oligohydramnios Back Pain 0.5 (0.0) 1.1 (0.0) 1.4 has also been reported, presumably representing decreased renal function in the fetus: limb contractures, craniofacial deformities, Nasal Congestion 0.3 (0.0) 1.2 (0.0) 0.0 hypoplastic lung development and intrauterine growth retardation have been reported in association with oligohydramnios. Decreased Libido 0.2 (0.1) 1.2 (0.0) 0.0 Patients who do require ACE inhibitors during the second and third trimesters of pregnancy should be apprised of the potential Vertigo 0.1 (0.0) 1.1 (0.2) 0.0 hazards to the fetus, and frequent ultrasound examinations should be performed to look for oligohydramnios. If oligohydramnios Includes 420 patients treated for congestive heart failure who were receiving concomitant digitalis and/or diuretic therapy. is observed. ZESTRIL should be discontinued unless it is considered life-saving for the mother Clinical adverse experiences occurring in to 1.0% of patients in the controlled trials and rarer, serious, possibly Other potential risks to the fetus/neonate exposed to ACE inhibitors include: intrauterine growth retardation. prematurity, drug related events reported in uncontrolled studies or marketing experience are listed below and, within each category, are patent ductus arteriosus: fetal death has also been reported. It is not clear, however, whether these reported events are in order of decreasing severity. related to ACE inhibition or the underlying maternal disease. It is not known whether exposure limited to the first trimester can adversely affect fetal outcome. BODY AS A WHOLE: Chest discomfort, fever, flushing, malaise Infants exposed in utero to ACE inhibitors should be closely monitored for hypotension, oliguria, and hyperkalemia. If oliguria CARDIOVASCULAR: Myocardial infarction or cerebrovascular accident, possibly secondary to excessive hypotension in occurs, attention should be directed toward support of blood pressure and renal perfusion. high risk patients (see WARNINGS, Hypotension): angina pectoris, orthostatic hypotension, rhythm disturbances. Another ACE inhibitor, enalapril, has been removed from the neonatal circulation by peritoneal dialysis and theoretically may be tachycardia, peripheral edema, vasculitis, palpitation removed by exchange transfusion, although there is no experience with the latter procedure. There is no experience with either of DIGESTIVE: Pancreatitis, hepatitis (hepatocellular or cholestatic jaundice), abdominal pain, anorexia, constipation, these procedures for removing lisinopril or other ACE inhibitors from the neonatal circulation flatulence, dry mouth Lisinopril was not teratogenic in mice treated on days of gestation with up to mg/kg/day (625 times the maximum METABOLISM: Gout recommended human dose) There was an increase in fetal resorptions at doses down to mg/kg: at doses of mg/kg this was Joint pain, shoulder pain. prevented by saline supplementation. There was no fetotoxicity or teratogenicity in rats treated with up to mg/kg/day (188 times the NERVOUS SYSTEM/PSYCHIATRIC: Depression, somnolence, insomnia, stroke, nervousness, confusion. maximum recommended dose) of lisinopril at of gestation. In rats receiving lisinopril from day 15 of gestation through day 21 RESPIRATORY SYSTEM Bronchitis, sinusitis, pharyngeal pain. postpartum, there was an increased incidence in deaths on days 2-7 postpartum and lower average body weight of pups on day 21 SKIN: Urticaria, pruritus, diaphoresis. postpartum. The increase in pup deaths and decrease in pup weight did not occur with maternal saline supplementation. SPECIAL SENSES: Blurred vision Lisinopril. at doses up to mg/kg/day, was not teratogenic when given throughout the organogenic period in saline UROGENITAL Oliguria, progressive azotemia, acute renal failure, urinary tract infection supplemented rabbits Saline supplementation (physiologic saline in place of tap water) was used to eliminate maternotoxic A symptom complex has been reported which may include positive ANA, an elevated erythrocyte sedimentation rate, effects and enable evaluation of the teratogenic potential at the highest possible dosage level. The rabbit has been shown to be arthralgia/arthritis, myalgia and fever. extremely sensitive to angiotensin converting enzyme inhibitors (captopril and enalapril) with maternal and fetotoxic effects ANGIOEDEMA: Angioedema has been reported in patients receiving ZESTRIL Angioedema associated with apparent at or below the recommended therapeutic dosage levels in man. laryngeal edema may be fatal. If angioedema of the face, extremities, lips, tongue, glottis and/or larynx occurs, treatment Fetotoxicity was demonstrated in rabbits by an increased incidence of fetal resorptions at an oral dose of lisinopril of mg/kg/ with ZESTRIL should be discontinued and appropriate therapy instituted immediately. (See WARNINGS.) day and by an increased incidence of incomplete ossification at the lowest dose tested mg/kg/day). A single intravenous dose HYPOTENSION: In hypertensive patients, hypotension occurred in 1.2% and syncope occurred in of patients. of 15 mg/kg of lisinopril administered to pregnant rabbits on gestation days 16, or 26 resulted in 88% to 100% fetal death Hypotension or syncope was a cause of discontinuation of therapy in 0.5% of hypertensive patients. (See WARNINGS.) If ZESTRIL is used during pregnancy or if the patient becomes pregnant while taking ZESTRIL, the patient should be in patients with congestive heart failure, hypotension occurred in 5.0% and syncope occurred in 1.0% of patients. These apprised of the potential hazards to the fetus. adverse experiences were causes for discontinuation of therapy in 1.3% of these patients. PRECAUTIONS: General: Impaired Renal Function: a consequence of inhibiting the renin-angiotensin-aldosterone Fetal/Neonatal Morbidity and Mortality: In infants exposed in utero to ACE inhibitors the following adverse experiences have system, changes in renal function may be anticipated in susceptible individuals. In patients with severe congestive heart been reported: Fetal and neonatal death, renal failure, hypoplastic lung development, hypotension, hyperkalemia, skull hypoplasia, failure whose renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with limb contractures, craniofacial deformities, intrauterine growth retardation, prematurity and patent ductus arteriosus. (See angiotensin converting enzyme inhibitors, including ZESTRIL, may be associated with oliguria and/or progressive azotemia WARNINGS Fetal/Neonatal Morbidity Mortality.) and rarely with acute renal failure and/or death. Clinical Laboratory Test Findings: Serum Electrolytes: Hyperkalemia. (See PRECAUTIONS.) in hypertensive patients with unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and serum Creatinine, Blood Urea Nitrogen: Minor increases in blood urea nitrogen and serum creatinine, reversible upon discontinuation creatinine may occur. Experience with another angiotensin converting enzyme inhibitor suggests that these increases are of therapy, were observed in about 2.0% of patients with essential hypertension treated with ZESTRIL alone Increases were more usually reversible upon discontinuation of ZESTRIL and/or diuretic therapy. In such patients, renal function should be common in patients receiving concomitant diuretics and in patients with renal artery stenosis. (See PRECAUTIONS.) Reversible monitored during the first few weeks of therapy. minor increases in blood urea nitrogen serum creatinine were observed in approximately of patients with congestive heart Some hypertensive patients with no apparent preexisting renal vascular disease have developed increases in blood urea failure on concomitant diuretic therapy Frequently these abnormalities resolved when the dosage of the diuretic was decreased. nitrogen and serum creatinine, usually minor and transient especially when ZESTRIL has been given concomitantly with Hemoglobin and Hematocrit: Small decreases in hemoglobin and hematocrit (mean decreases of approximately and diuretic This is more likely to occur in patients with preexisting renal impairment. Dosage reduction of ZESTRIL and/or 1.3 vol%, respectively) occurred frequently in patients treated with ZESTRIL but were rarely of clinical importance in patients discontinuation of the diuretic may be required without some other cause of anemia. In clinical trials, less than of patients discontinued therapy due to anemia. Evaluation of the hypertensive patient should always include assessment of renal function. (See DOSAGE AND ADMINISTRATION.) Other (Causal Relationship Unknown): Rarely, elevations of liver enzymes and/or serum bilirubin have occurred In marketing Hyperkalemia: clinical trials hyperkalemia (serum potassium greater than mEq/L) occurred in approximately 2.2% of experience, rare cases of neutropenia and bone marrow depression have been reported. hypertensive patients and 4.0% of patients with congestive heart failure. In most cases these were isolated values which resolved Overall, 2.0% of patients discontinued therapy due to laboratory adverse experiences, principally elevations in blood urea despite continued therapy. Hyperkalemia was a cause of discontinuation of therapy in approximately of hypertensive nitrogen (0.6%), serum creatinine (0.5%) and serum potassium (0.4%). patients factors for the development of hyperkalemia include renal insufficiency, diabetes mellitus, and the concomitant use of potassium-sparing diuretics, potassium supplements and/or potassium-containing salt substitutes, which should be used DOSAGE AND ADMINISTRATION: Initial Therapy: In patients with uncomplicated essential hypertension not on diuretic therapy. cautiously, if at all, with ZESTRIL (See Drug Interactions.) the recommended initial dose is 10 mg once day. Dosage should be adjusted according to blood pressure response. The usual Cough: Cough has been reported with the use of ACE inhibitors. Characteristically, the cough is nonproductive, persistent and resolves dosage range is 20-40 mg per day administered single daily dose. The antihypertensive effect may diminish toward the end of after discontinuation of therapy. ACE inhibitor-induced cough should be considered as part the differential diagnosis of cough. the dosing interval regardless of the administered dose, but most commonly a dose of 10 mg daily. This can be evaluated by Surgery/Anesthesia: In patients undergoing major surgery or during anesthesia with agents that produce hypotension, measuring blood pressure just prior to dosing to determine whether satisfactory control is being maintained for 24 hours. is ZESTRIL may block angiotensin II formation secondary to compensatory renin release If hypotension occurs and is considered to not, an increase in dose should be considered Doses up to 80 mg have been used but do not appear to give greater effect If blood be due to this mechanism it can be corrected by volume expansion pressure is not controlled with ZESTRIL alone, a low dose of diuretic may be added Hydrochlorothiazide, has been Information for Patients: Angioedema: Angioedema, including laryngeal edema, may occur especially following the first dose shown to provide an additive effect. After the addition of diuretic, it may be possible to reduce the dose of ZESTRIL of ZESTRIL Patients should be so advised and told to report immediately any signs or symptoms suggesting angioedema Diuretic Treated Patients: In hypertensive patients who are currently being treated with a diuretic, symptomatic hypotension (swelling of face, extremities, eyes, lips, tongue, difficulty in swallowing or breathing) and to take no more drug until they have occur occasionally following the initial dose of ZESTRIL The diuretic should be discontinued, if possible, for two to three consulted with the prescribing physician days before beginning therapy with ZESTRIL to reduce the likelihood of hypotension. (See WARNINGS.) The dosage of ZESTRIL Symptomatic Hypotension: Patients should be cautioned to report light-headedness especially during the first few days of therapy. should be adjusted according to blood pressure response. If the patient's blood pressure is not controlled with ZESTRIL alone, actual syncope occurs, the patient should be told to discontinue the drug until they have consulted with the prescribing physician. diuretic therapy may be resumed as described above All patients should be cautioned that excessive perspiration and dehydration may lead to an excessive fall in blood pressure If the diuretic cannot be discontinued, an initial dose of mg should be used under medical supervision for at least two hours because of reduction in fluid volume. Other causes of volume depletion such as vomiting or diarrhea may also lead to a fall in and until blood pressure has stabilized for at least an additional hour. (See WARNINGS and PRECAUTIONS, Drug Interactions.) blood pressure; patients should be advised to consult with their physician Concomitant administration of ZESTRIL with potassium supplements, potassium salt substitutes, or potassium-sparing Hyperkalemia: Patients should be told not to use salt substitutes containing potassium without consulting their physician. diuretics may lead to increases of serum potassium. (See PRECAUTIONS.) Neutropenia: Patients should be told to report promptly any indication of infection (eg. sore throat, fever) which may be Use in Elderly: In general, blood pressure response and adverse experiences were similar in younger and older patients given sign of neutropenia. similar doses of ZESTRIL Pharmacokinetic studies, however, indicate that maximum blood levels and area under the plasma NOTE: As with many other drugs, certain advice to patients being treated with ZESTRIL is warranted. This information is concentration time curve (AUC) are doubled in older patients so that dosage adjustments should be made with particular caution. intended to aid in the safe and effective use of this medication It is not disclosure of all possible adverse or intended effects Dosage Adjustment in Renal Impairment: The usual dose of ZESTRIL (10 mg) is recommended for patients with creatinine clearance mL/min (serum creatinine of up to approximately mg/dL). For patients with creatinine clearance ≥ 10 mL/min DRUG INTERACTIONS: Hypotension Patients on Diuretic Therapy: Patients on diuretics and especially those in whom diuretic 30 mL/min (serum creatinine mg/dL), the first dose is mg once daily For patients with creatinine clearance 10 mL/min therapy was recently instituted, may occasionally experience an excessive reduction of blood pressure after initiation of therapy (usually OR hemodialysis) the recommended initial dose is 2.5 The dosage may be titrated upward until blood pressure is with ZESTRIL The possibility of hypotensive effects with ZESTRIL can be minimized by either discontinuing the diuretic or controlled or to maximum of 40 mg daily. increasing the salt intake prior to initiation of treatment with ZESTRIL If is necessary to continue the diuretic, initiate therapy Creatinine Clearance Initial Dose with ZESTRIL at dose of 5 mg daily, and provide close medical supervision after the initial dose for at least two hours and until Renal Status mL/min mg/day blood pressure has stabilized for at least an additional hour. (See WARNINGS, and DOSAGE AND ADMINISTRATION.) When Normal Renal Function to Mild Impairment >30 diuretic is added to the therapy of patient receiving ZESTRIL, an additional antihypertensive effect is usually observed. Studies 10 with ACE inhibitors in combination with diuretics indicate that the dose of the ACE inhibitor can be reduced when it is given with Moderate to Severe Impairment 5 diuretic (See DOSAGE AND ADMINISTRATION.) Dialysis Patients <10 2.5: Indomethacin: In study in patients with mild to moderate hypertension where the antihypertensive effects of ZESTRIL Dosage or dosing interval should be adjusted depending on the blood pressure response alone were compared to ZESTRIL given concomitantly with indomethacin, the use of indomethacin was associated with a reduced HOW SUPPLIED effect. although the difference between the two regimens was not significant. Other Agents: ZESTRIL has been used concomitantly with nitrates and/or digoxin without evidence of clinically significant 5 mg Tablets (NDC 0038-0130) pink, round, biconvex, uncoated scored tablets identified "ZESTRIL 5" debossed on one side, adverse interactions No clinically important pharmacokinetic interactions occurred when ZESTRIL was used concomitantly with and "130" debossed and scored on the other side are supplied in bottles of 100 tablets and unit dose packages of 100 tablets propranolol or hydrochlorothiazide. The presence of food in the stomach does not alter the bioavailability of ZESTRIL 10 mg Tablets (NDC 0038-0131) pink, round, biconvex, uncoated tablets identified "ZESTRIL 10" debossed on one side, and Agents Increasing Serum Potassium: ZESTRIL attenuates potassium loss caused by thiazide-type diuretics. Use of ZESTRIL "131" debossed on the are supplied in bottles of 100 tablets and unit dose packages of 100 tablets. with potassium-sparing diuretics (eg. spironolactone, triamterene or amiloride), potassium supplements, or salt 20 mg Tablets (NDC 0038-0132) red. round, biconvex, uncoated tablets identified "ZESTRIL 20" debossed on one side, and substitutes may lead to significant increases in serum potassium. Therefore, if concomitant use of these agents is indicated "132" debossed on the other side are supplied in bottles of 100 tablets and unit dose packages of 100 tablets. because of demonstrated hypokalemia, they should be used with caution and with frequent monitoring of serum potassium. Lithium: Lithium toxicity has been reported in patients receiving lithium with drugs which cause elimination of sodium, 40 mg Tablets (NDC 0038-0134) yellow, round, biconvex, uncoated tablets identified "ZESTRIL 40" debossed on one side, and including ACE inhibitors Lithium toxicity was usually reversible upon discontinuation of both drugs. It is recommended that "134" debossed on the other side are supplied in bottles of 100 tablets and unit dose packages of 100 tablets serum lithium levels be monitored frequently if ZESTRIL is administered concomitantly with lithium. Store at room temperature. Protect from moisture, freezing and excessive heat. Dispense in a tight container. Carcinogenesis, Mutagenesis, Impairment of Fertility: There was no evidence of tumorigenic effect when lisinopril was Rev /01/91 administered for 105 weeks to male and female rats at doses up to 90 mg/kg/day (about 56 times* the maximum recommended daily human dose) or when lisinopril was administered for 92 weeks to (male and female) mice at doses up to 135 mg/kg/day STUART PHARMACEUTICALS (about 84 times* the maximum recommended daily human dose). A business unit of ICI Americas Inc. *Based on patient weight of 50 Wilmington, Delaware 19897 USA 2569 Fast, powerful relief for pain/inflammation. Sprains & Strains Helps trauma patients get back to work faster.¹ No oral analgesic works faster-onset of Fast Relief. Fast Recovery. pain relief may occur as fast as 20 minutes Pain relief as powerful as the codeine com- binations and propoxyphene napsylate² Anaprox 550 MG TABLETS ® DS Potent anti-inflammatory effect helps pro- mote return to full function by reducing (NAPROXEN SODIUM) swelling and inflammation 1. Ogilvie-Harris DJ, et al: Prostaglandin inhibition and the rate of recovery after arthroscopic meniscectomy. J Bone Joint Surg 1985;67-B:567-571. 2. Scoren RD, et al: Pain following periodontal surgery: Treatment with a non- narcotic analgesic compared with two codeine combinations. Curr Ther Res 1987;42:463-471. For brief summary of prescribing information, please see next page. SYNTEX SYNTE X PUERTO RICO INC HUMACAO PR 00661 1990 Syntex Puerto Rico, Inc. 811-H2-386-90 Brief Summary: Contraindications: Patients who have had allergic reactions to NAPROSYN, ANAPROX or ANAPROX DS or in whom aspirin or other NSAIDs induce the syn- drome of asthma, rhinitis, and nasal polyps. Because anaphylactic reactions usu- ally occur in patients with a history of such reactions, question patients for asthma, nasal polyps, urticaria, and hypotension associated with NSAIDs before Announcements starting therapy. If such symptoms occur, discontinue the drug. Warnings: Serious GI toxicity such as bleeding, ulceration, and perforation, can occur at any time, with or without warning symptoms, in patients treated chroni- cally with NSAIDs. Remain alert for ulceration and bleeding even in the absence of previous GI tract symptoms. In clinical trials, symptomatic upper GI ulcers, gross bleeding or perforation occur in about 1% of patients treated for 3-6 months, and in about 2-4% of patients treated for one year. Inform patients of signs and/or symptoms of serious GI toxicity and what steps to take if they occur. Studies have not identified any subset of patients not at risk of developing peptic ulceration and bleeding. Except for a prior history of serious GI events and other risk factors associated with peptic ulcer disease, such as alcoholism, smoking, etc., no risk factors (e.g., age, sex) have been associated with increased risk. Elderly or debilitated patients seem to tolerate ulceration or bleeding less well American Heart Association for Research in Disease Prevention, and most spontaneous reports of fatal GI events are in this population. In consid- 1000 Welch Rd, Palo Alto, CA 94304- ering the use of relatively large doses (within the recommended dosage range), sufficient benefit should be anticipated to offset the potential increased risk of The American Heart Association is 1885. Deadline for submission of papers GI toxicity. Precautions: DO NOT GIVE NAPROSYN® (NAPROXEN) CONCOMITANTLY WITH making available reprints of an article is October 21, 1991. ANAPROX® OR ANAPROX® DS (NAPROXEN SODIUM) SINCE THEY CIRCULATE IN entitled "Guidelines for Treatment of PLASMA AS THE NAPROXEN ANION. Acute interstitial nephritis with hematuria, proteinuria, and nephrotic syndrome has been reported Patients with impaired Acute Myocardial Infarction," pub- European Medical Partnerships renal function. heart failure, liver dysfunction, patients taking diuretics, and the elderly are at greater risk of overt renal decompensation. If this occurs, discon- lished simultaneously by the American Sought: US AID tinue the drug. Use with caution and monitor serum creatinine and/or creatinine Academy of Cardiology and the Ameri- clearance in patients with significantly impaired renal function. Use caution in can Heart Association in the August The US Agency for International De- patients with baseline creatinine clearance less than 20 ml/minute. Use the low- est effective dose in the elderly or in patients with chronic alcoholic liver disease 1990 issues of Circulation and the Jour- velopment (US AID) is soliciting pro- or cirrhosis. Borderline elevations of liver tests may occur in up to 15% of patients. Elevations of SGPT or SGOT occurred in controlled trials in less than 1% nal of the American College of Cardi- posals for partnerships between medi- of patients. Severe hepatic reactions, including jaundice and fatal hepatitis, have been reported rarely. If liver disease develops or if systemic manifestations occur ology. cal facilities in the United States and (e.g., eosinophilia or rash), discontinue therapy. If steroid dosage is reduced or eliminated during therapy, do so slowly and observe patients closely for adverse Up to five copies are available free of those in Central and Eastern Europe. effects, including adrenal insufficiency and exacerbation of arthritis symptoms. charge. Additional copies can be pur- Up to 10 grants are expected to be Determine hemoglobin values periodically for patients with initial values of 10 chased for $1 per copy. Send requests to awarded by US AID in support of such grams or less who receive long-term therapy. Peripheral edema has been reported. For patients with restricted sodium intake, note that each tablet con- tains approximately 25 or 50mg(1 or 2mEq) sodium. Use with caution in patients Eleanor A. Sanders, Manager of Scien- partnerships during 1991. It also is ex- with fluid retention, hypertension or heart failure. The drug may reduce fever and tific Statements, American Heart Asso- pected that grants will range between inflammation, diminishing their diagnostic value. Conduct ophthalmic studies if ciation, 7320 Greenville Ave, Dallas, $1.5 and $2.5 million and will be extend- any change or disturbance in vision occurs. Information for Patients: Side effects can cause discomfort and, rarely, more serious side effects, such as GI TX 75231. ed from 2 to 3 years. bleeding, may result in hospitalization and even fatal outcomes. Physicians may wish to discuss with patients potential risks and benefits of NSAIDs, particularly Applications are welcomed from com- when they are used for less serious conditions where treatment without NSAIDs may be acceptable. Patients should use caution for activities requiring alertness Award for Best Paper on munity and municipal hospitals, univer- if they experience drowsiness, dizziness, vertigo or depression during therapy. Laboratory Tests: Because serious GI tract ulceration and bleeding can occur Preventive Medicine sity teaching hospitals or tertiary without warning symptoms, follow chronically treated patients and inform them health care facilities, and for-profit and of the importance of the follow Drug Interactions: Use caution when giving The American Journal of Preventive non-profit institutions. concomitantly with coumarin-typ anticoagulants; a hydantoin, sulfonamide or sulfonylurea; furosemide; lithium; beta blockers; probenecid; or methotrexate. Medicine and the Ulrich and Ruth Priority areas of assistance are car- Drug/Laboratory Test Interactions: May decrease platelet aggregation and Frank Foundation for International diovascular and cerebrovascular dis- prolong bleeding time or increase urinary values for ketogenic steroids. Tempo- rarily stop therapy for 72 hours before adrenal function tests. May interfere with Health announce an award for the best eases, cancer, pediatric trauma, emer- urinary assays of 5HIAA. Carcinogenesis: A 2-year rat study showed no evi- dence of carcinogenicity. Pregnancy: Category B. Do not use during pregnancy papers on the topic of preventive gency medical systems, and medical unless clearly needed Avoid use during late pregnancy. Nursing Mothers: Avoid use. Pediatric Use: Single doses of 2.5-5 mg/kg (as naproxen suspension), with medicine. effects of environmental pollution. total daily dose not exceeding 15 mg/kg/day, are safe in children over 2 years One award will be made in each cate- Partnership activities might include of age. Adverse Reactions: In a study, GI reactions were more frequent and severe in gory (to a resident in any specialty, a training, utilization and outcome re- rheumatoid arthritis patients on 1650 mg/day naproxen sodium than in those on 825 mg/day. In children with juvenile arthritis, rash and prolonged bleeding medical student from any accredited search, diagnostic and treatment im- times were more frequent, GI and CNS reactions about the same, and other reac- school of medicine or osteopathy, and a provements, and outpatient prevention tions less frequent than in adults. Incidence Greater Than 1%, Probable Causal Relationship: Gl: The most frequent complaints related to the GI tract: constipa- graduate student in public health from programs. Target countries are Poland, tion.* heartburn,* abdominal pain,* nausea,* dyspepsia, diarrhea, stomatitis. CNS: headache.* dizziness,* drowsiness,* light headedness, vertigo. Dermatologic: any public health program that is part of Hungary, Czechoslovakia, Yugoslavia, itching (pruritus),* skin eruptions,* ecchymoses,* sweating, purpura. Special an accredited medical school). There Bulgaria, and Romania. Partnerships Senses: tinnitus.* hearing disturbances, visual disturbances. Cardiovascular: edema,* dyspnea,* palpitations. General: thirst. *Incidence of reported reaction will be a total of three cash awards: first will focus on a single area of medical 3%-9%. Where unmarked, incidence less than 3%. Incidence Less Than 1% Probable Causal Relationship: GI: abnormal liver function tests, colitis, GI bleed- prize is $1000; second prize, $500; and assistance in a single country. ing and/or perforation, hematemesis, jaundice, melena, peptic ulceration with third prize, $250. To obtain a copy of Request for Appli- bleeding and/or perforation, vomiting. Renal: glomerular nephritis, hematuria, hyperkalemia, interstitial nephritis, nephrotic syndrome, renal disease, renal fail- The American Journal of Preventive cation Number OS/EE/91-009, send a ure, renal papillary necrosis. Hematologic: agranulocytosis, eosinophilia, granulo- cytopenia, leukopenia, thrombocytopenia. CNS: depression, dream Medicine will publish abstracts from all written request with two self-ad- abnormalities, inability to concentrate, insomnia, malaise, myalgia and muscle three prize-winning papers and will con- dressed mailing labels to The Agency weakness. Dermatologic: alopecia, photosensitive dermatitis, skin rashes. Spe- cial Senses: hearing impairment. Cardiovascular: congestive heart failure. Respi- sider publishing (after editorial review) for International Development, Office ratory: eosinophilic pneumonitis. General: anaphylactoid reactions, menstrual disorders, pyrexia (chills and fever). Causal Relationship Unknown: Hematologic: additional text from all papers. Any pre- of Procurement, Overseas Division, aplastic anemia, hemolytic anemia. CNS: aseptic meningitis, cognitive dysfunc- vention-oriented topic will be consid- Room 1583, SA-14, Washington, DC tion. Dermatologic: epidermal necrolysis, erythema multiforme, photosensitivity reactions resembling porphyria cutanea tarda and epidermolysis bullosa, ered for prizes (especially, although not 20523-1420; attention: Mr James Loy; Stevens-Johnson syndrome, urticaria. GI: non-peptic GI ulceration, ulcerative stomatitis. Cardiovascular: vasculitis. General: angioneurotic edema, hyper- exclusively, papers on the environment telephone (703) 875-1041. glycemia, hypoglycemia. and on overpopulation). Awardees will Please indicate in your request the Overdosage: May have drowsiness, heartburn, indigestion, nausea, vomiting. A few patients have had seizures. Empty stomach and use usual supportive meas- be honored at the Prevention '92 Central or Eastern European country ures. In animals 0.5g/kg of activated charcoal reduced plasma levels of naproxen. conference. Dosage and Administration for Mild to Moderate Pain, Dysmenorrhea and of priority interest to your institution; Acute Tendinitis and Bursitis: Recommended starting dose is 550 mg, fol- For further information, write to Eri- US AID will share this information with lowed by 275 mg every 6 to 8 hours. Total daily dose should not exceed 1375 mg. Dosage and Administration for Rheumatoid Arthritis, Osteoarthritis and ca Frank, MD, MPH, Stanford Center other requestors unless directed not to. Ankylosing Spondylitis: Recommended dose in adults is 275 mg or 550 mg twice daily. In patients who tolerate lower doses well, the dose may be increased to 1650 mg per day for limited periods when a higher level of -inflammatory/ analgesic activity is required At this dosage, physicians should observe suffi- cient increased clinical benefits to offset potential increased risk. Caution: Federal law prohibits dispensing without prescription. See package insert for full Prescribing Information. Revised 9/90 #33 SYNTEX Anaprox 550 MG TABLETS DS SYNTEX PUERTO RICO INC HUMACAO PR 00661 (NAPROXEN SODIUM) © 1990 Syntex Puerto Rico, Inc. 2572 At Large With Dennis L. Breo HHS Secretary Louis Sullivan speaks out for improved health N ext month, Louis W. Sullivan, deliver that commencement address to deficiencies, and the effect of alcohol on MD, the Secretary of Health and residents of the rural Georgia town blood cells. Human Services, will return to his where he was born. He will also come In 1975, however, he made a quantum hometown of Blakely, Ga, a rural town home with the imposing credentials of a leap by returning home to become the of 1100 in the southwestern corner of respected medical academician and re- founding dean and director of the Medi- the state, to address the graduating searcher, former medical school dean cal Education Program at his alma ma- high school class. and president, and, now, controversial ter, Morehouse College. It will be a sweet moment for the 57- federal Cabinet officer. During the next 10 years, Sullivan year-old physician and Cabinet mem- transformed the dream into reality by ber. Sullivan himself never attended From academics to politics converting a program operating out of the high school because he grew up in an Sullivan got to HHS in a roundabout two trailers into a fully accredited 4- area where blacks were occasionally fashion and took over this uniquely po- year medical school that awarded the lynched and during an era when blacks litical position on the strength of his MD degree to its first 16 graduates in were always forced to go to segregated personal drive and academic and per- 1985. Along the way, Sullivan became schools. sonal qualifications, not political IOUs. dean and president of the new medical Things have improved in Blakely After graduating magna cum laude school and developed a reputation, ac- over the years, but Sullivan's parents from Atlanta's Morehouse College in cording to published profiles, for great wanted him to have a better education 1954 and earning his medical degree, expectations and "a great big ego." than the meager offerings provided in cum laude, from Boston University in By the time he resigned in 1989 as his hometown back in the 1940s. He and 1958, Sullivan completed his internship president of the Morehouse School of his older brother, Walter, were sent to (1958-1959) and residency (1959-1960) in Medicine, he was, according to a profile live with relatives in Atlanta, where internal medicine at the New York Hos- in the Washington Post, "demanding- they completed junior high and Booker pital-Cornell Medical Center. After a and getting-$200,000 a year, and that T. Washington High School. fellowship in pathology (1960-1961) at represented a scaled-back demand." Sullivan's mother was a schoolteach- Massachusetts General Hospital, he be- Most observers, the newspaper report- er who insisted on a solid education for came a fellow in hematology at the ed, believed he was well worth it. Typi- her sons, and his father, an insurance Thorndike Memorial Research Labora- cally, he was described as a "driven salesman and undertaker, was a hard- tories of Harvard Medical School at Bos- workaholic." working man who helped form a chapter ton City Hospital. He was also an in- The opportunity to run HHS, the of the National Association for the Ad- structor of medicine at Harvard Medical newspaper reported, grew out of Sulli- vancement of Colored People. His fa- School from 1963 to 1964 and an assis- van's friendship with President George ther joined the NAACP for self-protec- tant professor of medicine at the New Bush and Mrs Barbara Bush, a friend- tion from marauding racists, Sullivan Jersey College of Medicine from 1964 to ship that developed because of Sulli- recalls. The father also "never took a 1966. van's patience, persistence-and politi- day of vacation in his life," according to In 1966, he began his ascent up the cal instincts. his son. academic medicine ladder by signing on Realizing the potential political sym- From the start, the future Dr Sulli- as codirector of hematology at the Bos- bolism, Sullivan had been after then- van knew that he was on a mission. ton University Medical Center. "My President Ronald Reagan to come down "I knew that I wanted to be a doctor only goal was to become chairman of a and help dedicate his new medical from the time I was about 5 years old," department of medicine before I was school, but again and again he was re- Sullivan told this reporter during a re- 45," he recalls. buffed. He continued his requests, how- cent interview in his majestic office in From 1966 to 1975, his rise was re- ever, until then-Vice President Bush the Hubert H. Humphrey Building near lentless, as he became, successively, as- was dispatched to Atlanta in 1985 to Capitol Hill in Washington, DC. He sistant professor of medicine, associate christen the new school's first building. added, though, with the hearty chuckle professor, and professor. From 1972 to That visit led to a friendship, Mrs Bush that is his trademark, "I always thought 1975, he also was the project director of joined the medical school's board, and, that I would be a family physician prac- the Boston Sickle Cell Center and direc- on March 10, 1989, Sullivan was sworn ticing in a rural area like Blakely. In tor of hematology at Boston City Hospi- in as secretary of HHS. that sense, my entire medical career has tal. The study of blood disorders was his Sullivan is the second black (following gone awry." passion, and he made original research Patricia Harris) and second physician Awry, indeed. It will be with an ac- contributions toward the understand- (following Otis Bowen, MD) to run quired Boston accent that Sullivan will ing of sickle cell anemia, vitamin B₁₂ HHS, but he is the only HHS secretary JAMA, May 15, 1991 Vol 265, No. 19 At Large 2573 who actually once had a research grant from the National Institutes of Health (NIH), the research arm of HHS. As HHS secretary, Sullivan is in charge of an enormous budget that is the fourth highest in the world-sur- passed only by the budgets of the entire governments of the United States, Sovi- et Union, and Japan. The HHS annual budget is $425 billion, and it commands a staff of 118 000. His empire includes the Social Security Administration, US Public Health Service, Health Care Fi- nancing Administration (which funds Medicare and Medicaid), and a grab bag of both public assistance and human de- velopment programs. Almost 95% of all moneys paid out by HHS are for fixed entitlement programs. Sullivan came to Washington to run this elephantine operation as a political outsider, but during the past 2 years he has stirred things up with his strong views on changing unhealthy life-style habits like drinking and smoking, im- proving access to care, and reducing its cost. He will work hard for his beliefs. "My beloved mentor and role model," he said, "is the late Dr Benjamin Elijah Mays. He was the son of slaves and he had to teach himself how to read and write and, yet, he earned a PhD from the University of Chicago. He was pres- ident of Morehouse College from 1940 to 1967, and he used to talk to his students Photo: Anna Ng for JAMA every Monday morning. "He impressed upon us that it was not the outside environment that would de- Dr Louis Sullivan, shown here in his Washington, DC, office, has traveled the nation, calling for a new "culture termine our success, or lack of success, of character." but, rather, the inner environment of the quality of our discipline, our work his arguments. accident deaths every year, 40% of the habits, our service to others, and the "Everything we do here can be drownings, and is the leading cause of strength of the dreams in our hearts. He summed in one word," Sullivan says, cirrhosis of the liver, which is the ninth taught us to work hard for our beliefs "and that word is 'family.' Almost all of leading cause of death in the US. Alco- and to make sure that our qualifications our 250 programs are designed to help hol also is linked to our high rates of were SO solid that we would 'have' to be the family, to keep the family together, homicides, suicides, and violence." considered for any position that we or to substitute for the breakdown of the The HHS secretary recently pro- might seek and that, if unsuccessful, it family. That's why I am calling for a new voked headlines when he called for a would not be for lack of qualifications." culture of character and personal boycott of tobacco-sponsored sports This is Sullivan's credo, and, as HHS responsibility." events, but he is sticking to his guns. chief, he has articulated three broad It is a challenging goal. "Smoking is our No. 1 preventable themes: the development of a new "cul- "Every 60 seconds, a baby is born to a cause of death," he says. "The toll from ture of character," by which he means a teen-aged mother," Sullivan notes, smoking is 390 000 deaths a year, in- new emphasis on prevention and per- "and 20% of all white babies, 30% of all cluding 87% of all deaths from lung can- sonal responsibility for changing un- Hispanic babies, and 70% of all black cer, 21% of all deaths from heart dis- healthy life-styles; the widening of ac- babies will be raised in single-parent ease, and 30% of all deaths from cancer. cess to care to meet the "morally homes. This usually begins a cycle of Smoking is also to blame for 20% to 30% appropriate" goal of providing needed poverty and poor health. The leading of all low-birth-weight babies. This medical care to all Americans; and to cause of death among young blacks 15 to habit costs the nation $52 billion a year hold down the rapid rise in the cost of 19 is homicide-blacks killing blacks- in death and disability." medical care. and this is usually linked to the break- Sullivan also singles out improper di- He is a gracious man who speaks in a down of the black family and the lack of ets and lack of exercise as among the smoothly modulated and Eastern- proper male role models." behavioral and life-style factors that accented voice, occasionally punctuated He is also a strong critic of this na- have put Americans on a path toward by a large-sized laugh. Whatever the tion's drinking and smoking habits. "Al- poor health. question, he tends to begin, "Roight, cohol costs us $70 billion a year," he He concludes, "We have come to view roight and then proceed to make says. "It causes half of the 30 000 auto (Continued on p 2576.) 2574 JAMA, May 15, 1991 Vol 265, No. 19 At Large R SUPRAX efixime/Lederle Suspension & Tablets Lederle Lederle Laboratories A Division of American Cyanamid Company Wayne, New Jersey 07470 Under License of Fujisawa Pharmaceutical Co., Ltd. Lederle Laboratories 3143-1 Osaka, Japan (Continued from p 2574.) tem does not work for all Americans. health insurance; reducing the cost of medicine as a safety net, as a fix-it shop The figures can be argued, whether professional liability and "defensive for our sloppy life-styles, and this can- there are 37 million Americans without medicine"; and targeting funds for spe- not be sustained. During this century, adequate health insurance or 33 million cific programs, such as a campaign to medicine has managed to eliminate the or 31 million, but, clearly, any number reduce infant mortality. infectious and vitamin-deficiency dis- in the millions is unacceptable. This summer marks the 25th anniver- eases that used to cause most deaths. "In 1990, the nation spent $650 billion sary of Medicare and Medicaid, the two The exceptions, of course, are viral dis- on health care, or 12% of our gross na- giant government programs that have eases, like AIDS. Our remaining chal- tional product. This represents $2600 expanded access to medical care, lenge is to better manage chronic dis- for every man, woman, and child in the though at a very high cost. "On bal- eases that build over a lifetime, and the nation, and it ought to be enough to ance," Sullivan says, "the programs are individual patient holds one key to provide access for all. Yet, it is not, and a plus, with Medicare more so and Med- achieving this goal-following a healthy as costs rise, and as de facto rationing icaid more a mosaic of widely varying life-style." increases, then all of the uninsured state plans." The secretary practices what he and insured alike-will get less medical The HHS secretary added that while preaches. He neither smokes nor care." he is sympathetic to physician com- drinks, bypasses red meat in favor of The problem, Sullivan emphasizes, is plaints and frustration over Medicare's chicken and seafood, and works out reg- not SO much lack of health insurance as "hassle factor" and paper chase, he is ularly at a fitness center. He also makes lack of access to needed care. "Money also mindful of ineffective or unproven time for a daily long walk with his wife of alone will not solve the problem," he medical care and the big moneys paid by 33 years, Ginger (so named after her emphasizes, going SO far as to suggest, Medicare to physicians. favorite drink, ginger ale). The Sulli- "Research into the appropriateness and He elaborates, "A former Harvard vans are known as a straight-arrow cou- outcome of medical treatments indi- Medical School dean once told the grad- ple who are regularly seen holding cates that even those with virtually un- uating medical class, 'Half of what we hands at Washington social events. Sul- limited financial access do not always have taught you is wrong. Unfortunate- livan's only vice, it appears, is his work- get the care they need." ly, we do not know which half!' aholic ways. Turning to the problem of uninsur- "Well, we all have heard estimates He wants MDs to take a bigger role in ance, the HHS secretary says, "The such as that 20% or more of hospital preventive medicine and intends to ac- problem is usually not that the patients days may be unnecessary, that 50% of complish this by "emphasizing preven- are poor, but that their employers do prescribed antibiotics are probably un- tion in medical school; by changing reim- not offer health insurance, usually be- needed or misused, and that too many bursement policies to pay physicians cause the employers themselves cannot coronary artery bypass grafts lack clear more for preventive services and prima- afford to do so." medical justification. The best we can ry care; and by persuading MDs to work The HHS estimates that one third of say is that the number and cost of pa- closer with allied health professionals all uninsured are the so-called working tient care procedures and interventions and corporate America to promote well- poor who have jobs and income above undertaken by physicians and other ness programs." the poverty line but either are not pro- health care providers that are of un- When it comes to improving access to vided health insurance by their employ- proven medical necessity and effective- and lowering the cost of medical care, ers or cannot afford health insurance; ness are unknown but substantial. the secretary faces a challenge at least that another third, usually unemployed, Physicians are 'entitled,' too as great as persuading Americans to have income below the poverty line and "Also, Medicare Part B-the part adopt healthier life-styles. Indeed, cyn- are dependent upon Medicaid and chari- that pays for physician services-has ics have suggested that the Bush Ad- ty care; and that the final third have grown from $8 billion in 1980 to $31 ministration and Secretary Sullivan are adequate income but either elect not to billion in 1990, making it the fastest- emphasizing prevention and personal buy health insurance or are barred by growing entitlement program in the responsibility for health precisely be- preexisting medical conditions. federal government. At this rate of in- cause they do not have any solutions to Sullivan concludes, "National health crease, payments to physicians would the thornier problems of access and insurance is not the answer, but we by the year 2005 outrun payments to cost. must do more as a nation to meet the Social Security beneficiaries!" Best care, but not for all needs of those without access to care." This cannot happen, he adds. Possible Sullivan says that the Administra- In general, he believes the answer lies solutions, the secretary says, are the tion's formal health policy proposals are in a significant reform of this nation's physician payment reform proposals still under development. In the mean- existing web of group health insurance currently under debate and a new em- time, he has been traveling across the plans-our complex system of cross- phasis on research into the effective- country carrying on a dialogue with subsidies. The haves (those who remain ness of various medical procedures and physicians and policymakers and using healthy while paying insurance premi- their outcomes. These, like the others, his office as a bully pulpit to express his ums and/or who can pay the going rate are tough issues. views. for needed care) will continue to subsi- So, the secretary is asked, what does "In America," he says, "we have the dize the have-nots. he really think of this new twist in a best-trained physicians in the world. Proposals under consideration, he career that went awry? We also have the best biomedical re- says, are reimbursement incentives to He laughs long and loudly. "I've nev- search facilities, and spend the most emphasize primary care over high-tech er been so busy in my life," he con- money on medical care. We must never specialized care; taxing the employee cludes. "I have strong feelings, and I'm forget what American medicine has ac- health benefits provided by employers going to work hard for my beliefs. Gen- complished-the end of childhood dis- and using the estimated $58 billion in erally, I'm quite encouraged and opti- eases like measles and polio, the advent tax savings to pay for care of the poor; mistic. of miracle drugs and organ transplants. reforming the market SO that small em- "This job is all that I hoped for-and "The problem is that this superb sys- ployers of 25 or fewer can compete for more." 2576 JAMA, May 15, 1991 265, No. 19 At Large AVAILABLE SOON An Unforgettable Approach To Antihypertensive Therapy TM ALTACE Please see brief summary of prescribing information on following page. TM converting enzyme inhibitor suggests that these increases are usually reversible Pediatric Use: Safety and effectiveness in children has not been established ALTACE upon discontinuation of ALTACE and/or diuretic therapy. In such patients renal ADVERSE REACTIONS: ALTACE has been evaluated for safety in over 4,000 function should be monitored during the first few weeks of therapy. Some patients with hypertension; of these, 1,230 patients were studied in US controlled hypertensive patients with no apparent pre-existing renal vascular disease have trials, and 1,107 were studied in foreign controlled trials. Almost 700 of these developed increases in blood urea nitrogen and serum creatinine, usually minor patients were treated for at least one year. The overall incidence of reported and transient, especially when ALTACE has been given concomitantly with a adverse events was similar in ALTACE and placebo patients. The most frequent diuretic This is more likely to occur in patients with pre-existing renal impair- clinical side effects (possibly or probably related to study drug) reported by BRIEF SUMMARY ment Dosage reduction of ALTACE and/or discontinuation of the diuretic may be patients receiving ALTACE in US placebo-controlled trials were: headache required. Evaluation of the hypertensive patient should always include ALTACE is available in potencies of 1.25 mg. 2.5 mg. 5 mg. and 10 mg in color- assessment of renal function. (5.4%), "dizziness" (2.2%) and fatigue or asthenia (2.0%), but only the last was coded, hard gelatin capsules. more common in ALTACE patients than in patients given placebo. Generally, the Hyperkalemia: In clinical trials, hyperkalemia (serum potassium greater than 5.7 side effects were mild and transient, and there was no relation to total dosage INDICATIONS AND USAGE: ALTACE is indicated for the treatment of hyper- mEq/L) occurred in approximately 1% of hypertensive patients receiving ALTACE. within the range of 1.25 to 20 mg. Discontinuation of therapy because of a side tension. It may be used alone or in combination with thiazide diuretics. in most cases, these were isolated values, which resolved despite continued effect was required in approximately 3% of US patients treated with ALTACE. The In using ALTACE, consideration should be given to the fact that another therapy. None of these patients was discontinued from the trials because of most common reasons for discontinuation were: cough (1.0%), "dizziness" angiotensin converting enzyme inhibitor, captopril, has caused agranulocytosis, hyperkalemia. Risk factors for the development of hyperkalemia include renal (0.5%), and impotence (0.4%). particularly in patients with renal impairment or collagen-vascular disease. insufficiency, diabetes mellitus, and the concomitant use of potassium-sparing The side effects considered possibly or probably related to study drug that Available data are insufficient to show that ALTACE does not have a similar risk. diuretics, potassium supplements, and/or potassium-containing salt substitutes, occurred in US placebo-controlled trials in more than 1% of patients treated with (See WARNINGS.) which should be used cautiously. if at all, with ALTACE (See DRUG ALTACE are shown below. CONTRAINDICATIONS: ALTACE is contraindicated in patients who are hyper- INTERACTIONS.) PATIENTS IN US PLACEBO CONTROLLED STUDIES sensitive to this product and in patients with history of angioneurotic edema. Impaired Liver Function: Since ramipril is primarily metabolized by hepatic Altace Placebo WARNINGS: Angioedema: Angioedema of the face, extremities, lips, tongue, esterases to its active moiety, ramiprilat, patients with impaired liver function (N = 651) (N=286) glottis, and larynx has been reported in patients treated with angiotensin convert- could develop markedly elevated plasma levels of ramipril. No formal pharma- ing enzyme inhibitors. Angioedema associated with laryngeal edema can be fatal. cokinetic studies have been carried out in hypertensive patients with impaired n. % n % If laryngeal stridor or angioedema of the face, tongue, or glottis occurs, treatment liver function. Headache 35 5.4 17 5.9 with ALTACE should be discontinued and appropriate therapy instituted immedi- Surgery/Anesthesia: In patients undergoing surgery or during anesthesia with "Dizziness" 14 2.2 9 3.1 ately. Where there is involvement of the tongue, glottis, or larynx, agents that produce hypotension, ramipril may block angiotensin II formation that likely to cause airway obstruction, appropriate therapy, e.g., subcuta- would otherwise occur secondary to compensatory renin release. Hypotension Asthenia (Fatigue) 13 2.0 2 0.7 neous epinephrine solution 1:1,000 (0.3 ml to 0.5 ml) should be that occurs as a result of this mechanism can be corrected by volume expansion. Nausea/Vomiting 7 1.1 3 1.0 promptly administered. (See ADVERSE REACTIONS.) Information for Patients: Angioedema: Angioedema, including laryngeal In placebo-controlled trials, there was also an excess of upper respiratory Hypotension: ALTACE can cause symptomatic hypotension, after either the edema, can occur with treatment with ACE inhibitors, especially following the first infection and flu syndrome in the ramipril group. As these studies were carried initial dose or a later dose when the dosage has been increased. Like other ACE dose. Patients should be so advised and told to report immediately any signs or out before the relationship of cough to ACE inhibitors was recognized, some of inhibitors, ramipril has been only rarely associated with hypotension in symptoms suggesting angioedema (swelling of face, eyes, lips, tongue, or these events may represent ramipril-induced cough. In a later 1-year study, uncomplicated hypertensive patients. Symptomatic hypotension is most likely to difficulty in breathing) and to take no more drug until they have consulted with the increased cough was seen in almost 12% of ramipril patients, with about 4% of occur in patients who have been volume- and/or salt-depleted as a result of prescribing physician. these patients requiring discontinuation of treatment. Other adverse experiences prolonged diuretic therapy, dietary salt restriction, dialysis, diarrhea, or vomit- ing. Volume and/or salt depletion should be corrected before initiating therapy Symptomatic Hypotension: Patients should be cautioned that lightheadedness reported in controlled clinical trials (in less than 1% of ramipril patients). or rarer with ALTACE can occur, especially during the first days of therapy. and it should be reported events seen in postmarketing experience, include the following (In some, a In patients with congestive heart failure, with or without associated renal Patients should be told that if syncope occurs, ALTACE (ramipril) should be causal relationship to drug use is uncertain.): insufficiency. ACE inhibitor therapy may cause excessive hypotension, which discontinued until the physician has been consulted. Cardiovascular: Symptomatic hypotension (reported in 0.5% of patients in US may be associated with oliguria or azotemia and, rarely, with acute renal failure All patients should be cautioned that inadequate fluid intake or excessive trials) (see PRECAUTIONS and WARNINGS), syncope (not reported in US trials), and death. In such patients, ALTACE therapy should be started under close perspiration, diarrhea, or vomiting can lead to an excessive fall in blood pressure, angina pectoris, arrhythmia, chest pain, palpitations, and myocardial infarction. medical supervision: they should be followed closely for the first 2 weeks of with the same consequences of lightheadedness and possible syncope. Renal: Some hypertensive patients with no apparent pre-existing renal disease treatment and whenever the dose of ramipril or diuretic is increased. Hyperkalemia: Patients should be told not to use salt substitutes containing have developed minor, usually transient, increases in blood urea nitrogen and If hypotension occurs, the patient should be placed in a supine position and, potassium without consulting their physician. serum creatinine when taking ALTACE, particularly when ALTACE was given if necessary. treated with intravenous infusion of physiological saline. ALTACE treatment usually can be continued following restoration of blood pressure and Neutropenia: Patients should be told to promptly report any indication of concomitantly with a diuretic. (See WARNINGS.) volume. infection (e.g., sore throat, fever). which could be a sign of neutropenia. Angioneurotic Edema: Angioneurotic edema has been reported in 0.3% of Drug Interactions: With Diuretics: Patients on diuretics, especially those in patients in US clinical trials. (See WARNINGS.) Neutropenia/Agranuloytosi Another angiotensin converting enzyme in- hibitor, captopril, has been shown to cause agranulocytosis and bone marrow whom diuretic therapy was recently instituted, may occasionally experience an Cough: A tickling. dry, persistent, nonproductive cough has been reported with depression, rarely in uncomplicated patients, but more frequently in patients with excessive reduction of blood pressure after initiation of therapy with ALTACE the use of ACE inhibitors. Approximately 1% of patients treated with ALTACE renal impairment, especially if they also have a collagen-vascular disease such The possibility of hypotensive effects with ALTACE can be minimized by either have required discontinuation because of cough. The cough disappears shortly discontinuing the diuretic or increasing the salt intake prior to initiation of after discontinuation of treatment. as systemic lupus erythematosus or scleroderma. Available data from clinical trials of ramipril are insufficient to show that ramipril does not cause treatment with ALTACE. If this is not possible, the starting dose should be Gastrointestinal: Abdominal pain (sometimes with enzyme changes suggesting agranulocytosis at similar rates. Monitoring of white blood cell counts should be reduced. pancreatitis). anorexia, constipation, diarrhea, dry mouth, dyspepsia, dysphagia, considered in patients with collagen-vascular disease, especially if the disease is With Potassium Supplements and Potassium-Sparing Diuretics: ALTACE can gastroenteritis, nausea, increased salivation, taste disturbance, and vomiting. associated with impaired renal function. attenuate potassium loss caused by thiazide diuretics. Potassium-sparing Dermatologic: Apparent hypersensitivity reactions (manifested by dermatitis, Fetal/Neonatal Morbidity and Mortality: ACE inhibitors can cause fetal and diuretics (spironolactone, amiloride, triamterene, and others) or potassium pruritis. or rash, with or without fever). photosensitivity. and purpura. neonatal morbidity and mortality when administered to pregnant women. supplements can increase the risk of hyperkalemia. Therefore, if concomitant use When ACE inhibitors have been used during the second and third trimesters of such agents is indicated, they should be given with caution, and the patient's Neurologic and Psychiatric: Anxiety, amnesia, convulsions, depression, hearing of pregnancy, there have been reports of neonatal hypotension, renal failure, skull serum potassium should be monitored frequently. loss, insomnia, nervousness, neuralgia, neuropathy, paresthesia, somnolence, tinnitus, tremor, vertigo, and vision disturbances. hypoplasia, and death. Oligohydramnios has also been reported, presumably With Lithium: Increased serum lithium levels and symptoms of lithium toxicity resulting from decreased fetal renal function: oligohydramnios has been associ- have been reported in patients receiving ACE inhibitors during therapy with Other: arthralgia, arthritis, dyspnea, edema, epistaxis, impotence, increased ated with fetal limb contractures, craniofacial malformations, hypoplastic lung lithium. These drugs should be coadministered with caution, and frequent sweating, malaise, myalgia, and weight gain. development, and intrauterine growth retardation. Prematurity and patent ductus monitoring of serum lithium levels is recommended. If a diuretic is also used, the Clinical Laboratory Test Findings: Creatinine and Blood Urea Nitrogen: arteriosus have been reported, although it is not clear whether these occurrences risk of lithium toxicity may be increased. Increases in creatinine levels occurred in 1.2% of patients receiving ALTACE were due to the ACE-inhibitor exposure or to the mother's underlying disease. Other: Neither ALTACE nor its metabolites have been found to interact with food, alone, and in 1.5% of patients receiving ALTACE and a diuretic. Increases in It is not known whether exposure limited to the first trimester can adversely digoxin, or antacid. blood urea nitrogen levels occurred in 0.5% of patients receiving ALTACE alone affect fetal outcome and in 3% of patients receiving ALTACE with a diuretic. None of these increases A patient who becomes pregnant while taking ACE inhibitors, or who takes Carcinogenesis, Mutagenesis, Impairment of Fertility: No evidence of a required discontinuation of treatment. Increases in these laboratory values are ACE inhibitors when already pregnant, should be apprised of the potential hazard tumorigenic effect was found when ramipril was given by gavage to rats (up to 500 more likely to occur in patients with renal insufficiency or those pretreated with to her fetus. If she continues to receive ACE inhibitors during the second or third mg/kg/day for 24 months) or to mice (up to 1,000 mg/kg/day for 18 months). a diuretic and, based on experience with other ACE inhibitors, would be expected trimester of pregnancy, frequent ultrasound examinations should be performed to Dosages greatly in excess of those recommended for humans produced hypertro- to be especially likely in patients with renal artery stenosis. (See PRECAUTIONS look for oligohydramnios. When oligohydramnios is found, ACE inhibitors phy of the renal juxtaglomerular apparatus in mice, rats, dogs, and monkeys. No and WARNINGS.) should generally be discontinued mutagenic activity was detected in the Ames test in bacteria, the micronucleus test Since ramipril decreases aldosterone secretion, elevation of serum potas- Infants with histories of in exposure to ACE inhibitors should be closely in mice, unscheduled DNA synthesis in a human cell line, or a forward gene- sium can occur Potassium supplements and potassium-sparing diuretics should observed for hypotension, oliguria, and hypokalemia. If oliguria occurs, attention mutation assay in a Chinese hamster ovary cell line. Several metabolites and be given with caution, and the patient's serum potassium should be monitored should be directed toward support of blood pressure and renal perfusion. degradation products of ramipril were also negative in the Ames test. A study in frequently. (See PRECAUTIONS and WARNINGS.) Ramipril could theoretically be removed from the neonatal circulation by ex- rats with dosages as great as 500 mg/kg/day did not produce adverse effects on change transfusion, but no experience with this procedure has been reported. fertility. Hemoglobin and Hematocrit: Decreases in hemoglobin or hematocrit (a low value Ramipril has been shown to increase the incidence of dilated renal pelvises and a decrease of 5 g/dl or 5% respectively) were rare, occurring in 0.4% of Pregnancy: Pregnancy Category D: See WARNINGS. in rat fetuses, to retard birth weights in mice, and to be toxic to pregnant rabbits patients receiving ALTACE alone and in 1.5% of patients receiving ALTACE plus and pregnant cynomolgus monkeys, but not, in any of these studies, to produce Nursing Mothers: Ingestion of a single 10 mg oral dose of ALTACE resulted in a diuretic. No US patients discontinued treatment because of decreases in terata or to affect fertility, reproductive performance or pregnancy. On a mg/kg undetectable amounts of ramipril and its metabolites in breast milk. However, hemoglobin or hematocrit. basis, the doses used in these studies were 125-2500 times (in rats), 2500 times because multiple doses may produce low milk concentrations that are not Other (causal relationships unknown): Clinically important changes in standard (in mice), more than 12 times (in monkeys). and more than twice (in rabbits) the predictable from single doses, ALTACE should not be administered to nursing laboratory tests were rarely associated with ALTACE administration. Elevations maximum recommended human dose. mothers. of liver enzymes, serum bilirubin, uric acid, and blood glucose have been PRECAUTIONS: General: Impaired Renal Function: As a consequence of Geriatric Use: Of the total number of patients who received ramipril in US reported, as have scattered incidents of leukopenia, eosinophilia, and proteinuria. inhibiting the renin-angiotensinaldoston system, changes in renal function clinical studies of ALTACE 11 0% were 65 and over while 0.2% were 75 and over In US trials, less than 0.2% of patients discontinued treatment for laboratory may be anticipated in susceptible individuals. In patients with severe congestive No overall differences in effectiveness or safety were observed between these abnormalities: all of these were cases of proteinuria or abnormal liver-function tests. heart failure whose renal function may depend on the activity of the renin- patients and younger patients, and other reported clinical experience has not angiotensin-aldosterone system, treatment with angiotensin converting enzyme identified differences in responses between the elderly and younger patients, but OVERDOSAGE: Human overdoses of ramipril have not been reported, but the inhibitors, including ALTACE, may be associated with oliguria and/or progres- greater sensitivity of some older individuals cannot be ruled out. most common manifestation of human ramipril overdosage is likely to be sive azotemia and (rarely) with acute renal failure and/or death. In hypertensive One pharmacokinetic study conducted in hospitalized elderly patients indi- hypotension. Because the hypotensive effect of ramipril is achieved through patients with unilateral or bilateral renal artery stenosis, increases in blood urea cated that peak ramiprilat levels and area under the plasma concentration time vasodilation and effective hypovolemia, it is reasonable to treat ramipril overdose nitrogen and serum creatinine may occur. Experience with another angiotensin curve (AUC) for ramiprilat are higher in older patients. by infusion of normal saline solution. © 1991 HRPI/TUC Q65028 - 391 Hoechst-Roussel Pharmaceuticals Inc. Hoechst D Upjohn The Upjohn Company Kalamazoo, MI 49001, USA Somerville, New Jersey 08876-1258 2578 The name and logo HOECHST are registered trademarks of Hoechst AG ANNOUNCING A GREAT YEAR AHEAD FOR HERPES PATIENTS INDICATED FOR DAILY 1991 THERAPY FOR UP TO ONE YEAR ZOVIRAX (acyclovir)capsules JANUARY FEBRUARY MARCH APRIL SMTWTFS SMTWTFS SMTWTFS SMTWTFS 12345 1 2 1 2 123456 6 7 8 9 10 11 12 3 4 5 6 7 8 9 3456789 7 8 9 10 11 12 13 13 14 15 16 17 18 19 10 11 12 13 14 15 16 10 11 12 13 14 15 16 14 15 16 17 18 19 20 20 21 22 23 24 25 26 17 18 19 20 21 22 23 17 18 19 20 21 22 23 21 22 23 24 25 26 27 27 28 29 30 31 24 25 26 27 28 24 25 26 27 28 29 30 28 29 30 31 MAY JUNE J U L Y AUGUST S M T W T F S SMTWTFS S M T W T F S SMTWTFS 1 2 3 4 1 1 2 3 4 5 6 1 2 3 5 6 7 8 9 10 11 2345678 7 8 9 10 11 12 13 4 5 6 7 8 9 10 12 13 14 15 16 17 18 9 10 11 12 13 14 15 14 15 16 17 18 19 20 11 12 13 14 15 16 17 19 20 21 22 23 24 25 16 17 18 19 20 21 22 21 22 23 24 25 26 27 18 19 20 21 22 23 24 26 27 28 29 30 31 23 24 25 26 27 28 29 28 29 30 31 25 26 27 28 29 30 31 30 SEPTEMBER OCTOBER NOVEMBER D E C E M B E R S M T W T F S S M T W T F S S M T W T F S S M T W T F S 1234567 1 2 3 4 5 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 6 7 8 9 10 11 12 3 4 5 6 7 8 9 8 9 10 11 12 13 14 15 16 17 18 19 20 21 13 14 15 16 17 18 19 10 11 12 13 14 15 16 15 16 17 18 19 20 21 22 23 24 25 26 27 28 20 21 22 23 24 25 26 17 18 19 20 21 22 23 22 23 24 25 26 27 28 29 30 27 28 29 30 31 24 25 26 27 28 29 30 29 30 31 1-YEAR INDICATION FOR DAILY THERAPY Herpes patients can look forward to a great year ahead. Results of a recent clinical study show a lesion-free year for nearly half the patients treated with ZOVIRAX Capsules 400 mg b.i.d.*¹ For all ZOVIRAX Capsule recipients, recurrences during the study year were limited to a mean of 1.8, compared with a mean of 11.4 for placebo recipients.¹ PHARMACY Inc. Daily use was also shown to be well tolerated. And this extended clinical study NEW YORK demonstrated no evidence of cumulative toxicity and no change in acyclovir Dr.SMITH sensitivity.¹,² 6547636 ANA JONES Prescribe daily ZOVIRAX Capsule therapy...and help keep your patients lesion- ake two capsule(s) twice free longer. day *Alternate maintenance regimens range from 200 mg t.i.d. to 200 mg five times daily. tIn a controlled study of 3 years' duration, 45%, 52%, and 63% of patients remained free of ZOVIRAX CAP 200% Quantity 120 CAP BW recurrences in the first, second, and third years, respectively.³ Refill(s) Please see brief summary of prescribing information on adjacent page. ZOVIRAX® (acyclovir)capsules KEEPS HERPES PATIENTS LESION-FREE LONGER+ ZOVIRAX® CAPSULES Because of the possibility that less sensitive virus may be selected in Nausea and/or vomiting occurred in 2 of 287 7%) patients who patients who are receiving acyclovir. all patients should be advised to received placebo. take particular care to avoid potential transmission of virus if active le- Less frequent adverse reactions each of which occurred in 1 of 298 ZOVIRAX® SUSPENSION sions are present while they are on therapy In severely immunocom- patient treatments with orally administered Zovirax (0 3%) included promised patients, the physician should be aware that prolonged or diarrhea, dizziness, anorexia fatigue, edema. skin rash. leg pain. in- repeated courses of acyclovir may result in selection of resistant viruses guinal adenopathy. medication taste and sore throat (ACYCLOVIR) which may not fully respond to continued acyclovir therapy Long-Term Administration: The most frequent adverse reactions reported Drug Interactions: Co-administration of probenecid with intravenous in a clinical trial for the prevention of recurrences with continuous ad- BRIEF SUMMARY acyclovir has been shown to increase the mean half-life and the area ministration of 400 mg (two 200 mg capsules) 2 times daily for 1 year under the concentration-time curve. Urinary excretion and renal in 586 Zovirax - treated patients were: nausea 8%). diarrhea 4%). INDICATIONS AND USAGE: Zovirax Capsules and Suspension are in- clearance were correspondingly reduced. The clinical effects of this headache 9%) and rash (1.7%) The 589 control patients receiv- dicated for the treatment of initial episodes and the management of recur- combination have not been studied ing intermittent treatment of recurrences with Zovirax for 1 year reported rent episodes of genital herpes in certain patients Carcinogenesis, Mutagenesis, Impairment of Fertility: The data pre- diarrhea (2,7%). nausea 4%), headache 2%) and rash (1.5%). Zovirax Capsules and Suspension are also indicated for the acute treat- sented below include references to peak steady state plasma acyclovir The most frequent adverse reactions reported during the second year ment of herpes zoster (shingles). concentrations observed in humans treated with 800 mg given orally by 390 patients who elected to continue daily administration of 400 mg Genital Herpes Infections: The severity of disease is variable depend- 6 times a day (dosing appropriate for treatment of herpes zoster) or 200 (two 200 mg capsules) 2 times daily for 2 years were headache 15%), ing upon the immune status of the patient. the frequency and duration mg given orally 6 times a day (dosing appropriate for treatment of genital rash (1.3%) and paresthesia 8%). Reactions reported by 329 pa- of episodes, and the degree of cutaneous or systemic involvement. These herpes). Plasma drug concentrations in animal studies are expressed tients during the third year include asthenia 2%). paresthesia 2%) factors should determine patient management, which may include as multiples of human exposure to acyclovir at the higher and lower dos- and headache 9%). symptomatic support and counseling only. or the institution of specific ing schedules (see Pharmacokinetics) Herpes Zoster: The most frequent adverse reactions reported during therapy. The physical, emotional and psycho-social difficulties posed Acyclovir was tested in lifetime bioassays in rats and mice at single daily three clinical trials of treatment of herpes zoster (shingles) with 800 by herpes infections as well as the degree of debilitation. particularly doses of up to 450 mg/kg administered by gavage. There was no mg of oral Zovirax 5 times daily for 7 to 10 days in 323 patients were: in immunocompromised patients, are unique for each patient. and the statistically significant difference in the incidence of tumors between malaise (11.5%). nausea (8 0%). headache (5 9%), vomiting (2.5%). physician should determine therapeutic alternatives based on his or treated and control animals. nor did acyclovir shorten the latency of diarrhea (1.5%) and constipation 9%). The 323 placebo recipients her understanding of the individual patient's needs. Thus orally ad- tumors. At 450 mg/kg/day. plasma concentrations were 3 to 6 times reported malaise (11.1%) nausea (11 5%). headache (11 1%). ministered Zovirax is not appropriate in treating all genital herpes in- human levels in the mouse bioassay and 1 to 2 times human levels in vomiting 2.5%), diarrhea 10 3%) and constipation (2.4%) fections. The following guidelines may be useful in weighing the bene- the rat bioassay. fit/risk considerations in specific disease categories: OVERDOSAGE: Precipitation of acyclovir in renal tubules may occur when Acyclovir was tested in two in vitro cell transformation assays. Positive First Episodes (primary and nonprimary infections-commonly known the solubility (2.5 mg/mL in the intratubular fluid is exceeded Renal results were observed at the highest concentration tested (31 to63 times as initial genital herpes): lesions considered to be related to obstruction of renal tubules by human levels) in one system and the resulting morphologically precipitated drug crystals occurred in the following species rats treated Double-blind, placebo-controlled studies have demonstrated that orally transformed cells formed tumors when inoculated into immunosup- pressed. syngeneic. weanling mice Acyclovir was negative (40 to 80 with i.v. and doses of 20 mg/kg/day for 21 and 31 days. respec- administered Zovirax significantly reduced the duration of acute infection (detection of virus in lesions by tissue culture) and lesion healing. The lively, and at S.C. doses of 0 mg/kg/day for 10 days: rabbits at S.C. times human levels) in the other. possibly less sensitive, transforma- and V. doses of 50 mg/kg/day for 13 days: and dogs at i.v. doses of duration of pain and new lesion formation was decreased in some pa- tion assay 100 mg/kg/day for 31 days. A6 hr hemodialysis results in a 60% de- tient groups. The promptness of initiation of therapy and/or the patient's In acute cytogenetic studies, there was an increase. though not sta- prior exposure to Herpes simplex virus may influence the degree of ben- crease in plasma acyclovir concentration Data concerning peritoneal tistically significant. in the incidence of chromosomal damage at max- efit from therapy. Patients with mild disease may derive less benefit than dialysis are incomplete but indicate that this method may be significantly imum tolerated parenteral doses of acyclovir (100 mg/kg) in rats (62 less efficient in removing acyclovir from the blood In the event of acute those with more severe episodes. In patients with extremely severe to 125 times human levels) but not in Chinese hamsters: higher doses renal failure and anuria. the patient may benefit from hemodialysis un- episodes, in which prostration, central nervous system involvement. of 500 and 1000 mg/kg were clastogenic in Chinese hamsters (380 urinary retention or inability to take oral medication require hospitaliza- til renal function is restored (see DOSAGE AND ADMINISTRATION) to 760 times human levels) In addition. no activity was found after 5 tion and more aggressive management. therapy may be best initiated days dosing in a dominant lethal study in mice (36 to 73 times human DOSAGE AND ADMINISTRATION: Treatment of initial genital herpes: with intravenous Zovirax levels). In all 4 microbial assays. no evidence of mutagenicity was 200 mg (one 200 mg capsule or one teaspoonful [5 mL suspension) Recurrent Episodes: observed. Positive results were obtained in of 7 genetic toxicity assays every 4 hours. 5 times daily for 10 days. Double-blind. placebo-controlled studies in patients with frequent recur- using mammalian cells in vitro. In human lymphocytes. a positive re- Chronic suppressive therapy for recurrent disease: 400 mg (two 200 rences (6 or more episodes per year) have shown that orally administered sponse for chromosomal damage was seen at concentrations 150 to 300 mg capsules or two teaspoonfuls [10 mL suspension) 2 times daily Zovirax given daily for 4 months to 3 years prevented or reduced the times the acyclovir plasma levels achieved in man At one locus in mouse for up to 12 months. followed by re-evaluation. See INDICATIONS AND frequency and/or severity of recurrences in greater than 95% of lymphoma cells. mutagenicity was observed at concentrations 250 to USAGE and PRECAUTIONS for considerations on continuation of sup- patients. 500 times human plasma levels. Results in the other five mammalian pressive therapy beyond 12 months Alternative regimens have included In a study of 283 patients who received 400 mg (two 200 mg capsules) cell loci follow at 3 loci in a Chinese hamster ovary cell line. the results doses ranging from 200 mg 3 times daily to 200 mg 5 times daily twice daily for 3 years. 45%: 52% and 63% of patients remained free were inconclusive at concentrations at least 1850 times human levels: Intermittent Therapy: 200 mg (one 200 mg capsule or one teaspoonful of recurrences in the first, second and third years, respectively. Serial at 2 other loci in mouse lymphoma cells. no evidence of mutagenicity [5 mL suspension) every 4 hours. 5 times daily for 5 days Therapy analyses of the 3 month recurrence rates for the 283 patients showed was observed at concentrations at least 1500 times human levels. should be initiated at the earliest sign or symptom (prodrome) of that 71% to 87% were recurrence-free in each quarter. indicating that Acyclovir has not been shown to impair fertility or reproduction in mice recurrence the effects are consistent over time. (450 mg/kg/day. or in rats (25 mg/kg/day. S.C.) In the mouse Acute Treatment of Herpes Zoster: 800 mg (four 200 mg capsules or The frequency and severity of episodes of untreated genital herpes may study plasma levels were 9 to 18 times human levels. while in the rat four teaspoonfuls [20 mL) suspension) every 4 hours orally 5 times daily change over time. After 1 year of therapy, the frequency and severity study they were 8 to 15 times human levels At a higher dose in the rat for 7 to 10 days of the patient's genital herpes infection should be re-evaluated to assess 50mg/kg/day S.C.). there was a statistically significant increase in Patients With Acute or Chronic Renal Impairment: Comprehensive phar- the need for continuation of acyclovir therapy. Re-evaluation will usually post-implantation loss, but no concomitant decrease in litter size In macokinetic studies have been completed following intravenous require a trial off acyclovir to assess the need for reinstitution of sup- female rabbits treated subcutaneously with acyclovir subsequent to acyclovir infusions in patients with renal impairment Based on these pressive therapy. Some patients, such as those with very frequent or mating. there was a statistically significant decrease in implantation studies. dosage adjustments are recommended in the following chart severe episodes before treatment. may warrant uninterrupted suppres- efficiency but no concomitant decrease in litter size at a dose of 50 for genital herpes and herpes zoster indications: sion for more than a year. mg/kg/day (16 to 31 times human levels). No effect upon implanta- Chronic suppressive therapy is most appropriate when, in the judge- tion efficiency was observed when the same dose was administered Normal Dosage Adjusted Dosage Regimen ment of the physician. the benefits of such a regimen outweigh known intravenously (53 to 106 times human levels). In a rat peri- and postnatal Regimen Creatinine Clearance or potential adverse effects. In general. orally administered Zovirax study at 50 mg/kg/day S.C. (11 to 22 times human levels). there was (5x daily) (mL/min/1 73mg Dose (mg) Dosing Interval (hrs) should not be used for the suppression of recurrent disease in mildly a statistically significant decrease in the group mean numbers of cor- affected patients. Unanswered questions concerning the relevance to pora lutea, total implantation sites and live fetuses in the F, generation. 200 mg every >10 200 every 4 hours. 5x daily humans of in vitro mutagenicity studies and reproductive toxicity studies Although not statistically significant, there was also a dose-related de- 4 hours 0.10 in animals given high parenteral doses of acyclovir for short periods (see crease in group mean numbers of live fetuses and implantation sites 200 every 12 hours Carcinogenesis, Mutagenesis, Impairment of Fertility) should be borne at 12 mg/kg/daya and 25 mg/kg/day S.C. The intravenous administra- tion of 100mg/kg/day. a dose known to cause obstructive nephropathy 800 mg every >25 800 every 4 hours 5x daily in mind when designing long-term management for individual patients. Discussion of these issues with patients will provide them the oppor- in rabbits. caused a significant increase in fetal resorptions and a cor- 4 hours 10-25 responding decrease in litter size (plasma levels were not measured). 800 every 8 hours tunity to weigh the potential for toxicity against the severity of their 0-10 disease. Thus, this regimen should be considered only for appropriate However, at a maximum tolerated intravenous dose of 50 mg/kg/day 800 every 12 hours patients with annual re-evaluation. in rabbits (53 to 106 times human levels). no drug-related reproduc- Limited studies have shown that there are certain patients for whom tive effects were observed. For patients who require hemodialysis. the dosing schedule should be adjusted so that a dose is administered after each dialysis. intermittent short-term treatment of recurrent episodes is effective This Intraperitoneal doses of 80 or 320 mg/kg/day acyclovir given to rats approach may be more appropriate than a suppressive regimen in pa- for 6 and 1 months, respectively, caused testicular atrophy. Plasma References: 1. Mertz GJ, Jones CC, Mills J. et al. tients with infrequent recurrences. levels were not measured in the one month study and were to 48 times Immunocompromised patients with recurrent herpes infections can be human levels in the Six month study. Testicular atrophy was persistent Long-term acyclovir suppression of frequently recur- treated with either intermittent or chronic suppressive therapy Clinically through the 4-week postdose recovery phase after 320 mg/kg/day: ring genital herpes simplex virus infection: a mul- significant resistance, although rare, is more likely to be seen with pro- some evidence of recovery of sperm production was evident 30 days ticenter double-blind trial. JAMA. 1988:260:201-206. longed or repeated therapy in severely immunocompromised patients postdose. Intravenous doses of 100 and 200 /kg/day acyclovir given with active lesions. to dogs for 31 days caused aspermatogenesis. At 100 mg/kg/day 2. Mertz GJ, Eron L, Kaufman R, et al. Prolonged con- plasma levels were 47 to times human levels while at 200mg/kg/day tinuous versus intermittent oral acyclovir treatment Herpes Zoster Infections: In double-blind, placebo-controlled study they were 159 to 317 times human levels No testicular abnormalities of 187 normal patients with localized cutaneous zoster infection (93 in normal adults with frequently recurring genital her- were seen in dogs given 50 mg/kg/day V. for one month (21 to 41 times randomized to Zovirax and 94 to placebo). Zovirax (800 mg 5 times daily human levels) and in dogs given 60 mg/kg/day orally for one year (6 pes simplex virus infection. AmJ Med. 1988;85(suppl for 10 days) shortened the times to lesion scabbing, healing and com- to 12 times human levels) 2A):14-19. 3. Data on file, Burroughs Wellcome Co., plete cessation of pain, and reduced the duration of viral shedding and the duration of new lesion formation. Pregnancy: Teratogenic Effects: Pregnancy Category C. Acyclovir was 1990. not teratogenic in the mouse (450 mg/kg/day. p.o.). rabbit (50 In a similar double-blind, placebo-controlled study in 83 normal pa- mg/kg/day. and V. )or in standard tests in the rat (50mg/kg/day. tients with herpes zoster (40 randomized to Zovirax and 43 to placebo). S.C.). hese exposures resulted in plasma levels 9 and 18, 16 and 106. Zovirax (800 mg 5 times daily for 7 days) shortened the times to com- and 11 and 22 times, respectively human levels In a non-standardtest plete lesion scabbing, healing, and cessation of pain, reduced the dura- in rats, there were fetal abnormalities, such as head and tail anomalies, tion of new lesion formation, and reduced the prevalence of localized and maternal toxicity. In this test. rats were given 3 doses of 100 zoster-associated neurologic symptoms (paresthesia, dysesthesia or mg/kg acyclovir on gestation day 10. resulting in plasma levels 63 and hyperesthesia). 125 times human levels There are no adequate and well-controlled CONTRAINDICATIONS: Zovirax Capsules and Suspension are contrain- studies in pregnant women Acyclovir should not be used during dicated for patients who develop hypersensitivity or intolerance to the pregnancy unless the potential benefit justifies the potential risk to the components of the formulations. fetus. Although acyclovir was not teratogenic in standard animal studies, WARNINGS: Zovirax Capsules and Suspension are intended for oral in- the drug 's potential for causing chromosome breaks at high concen- gestion only. tration should be taken into consideration in making this determination. PRECAUTIONS: General: Zovirax has caused decreased spermato- Nursing Mothers: Acyclovir concentrations have been documented in genesis at high parenteral doses in some animals and mutagenesis in breast milk in two women following oral administration of Zovirax and some acute studies at high concentrations of drug (see PRECAUTIONS ranged from to 4. times corresponding plasma levels. These con- centrations would potentially expose the nursing infant to a dose of IMPROVING LIVES THROUGH Carcinogenesis, Mutagenesis, Impairment of Fertility). The recom- mended dosage should not be exceeded (see DOSAGE AND acyclovir up to 0.3 mg/kg/day. Caution should be exercised when ANTIVIRAL RESEARCH ADMINISTRATION). Zovirax is administered to a nursing woman Exposure of Herpes simplex and varicella-zoster isolates to acyclovir Pediatric Use: Safety and effectiveness in children have not been Burroughs Wellcome Co., in vitro can lead to the emergence of less sensitive viruses. The possibility established. Research Triangle Park, of the appearance of less sensitive viruses in man must be borne in mind ADVERSE REACTIONS North Carolina 27709 when treating patients. The relationship between the in vitro sensitivi- Herpes Simplex: Short-Term Administration: The most frequent adverse ty of Herpes simplex or varicella-zoster virus to acyclovir and clinical reactions reported during clinical trials of treatment of genital herpes response to therapy has yet to be established (see CLINICAL with orally administered Zovirax were nausea and vomiting in 8 of Copr. © 1991 Burroughs Wellcome Co. PHARMACOLOGY-Microbiology) 298 patient treatments (2.7%) and headache in 2 of 298 (0.6%). All rights reserved. ZC-Y01615RV January 1991 2580 Obituary Nicholas Edward Davies, MD, 65, was meetings to launch this organization tice Subcommittee, where he worked killed April 5, 1991, in the commuter and, at the time of his death, had in- with the Physician Payment Reform airline crash in Brunswick, Ga, that also volved perhaps 100 people from busi- Commission and testified before Con- claimed the lives of former Senator John ness, industry, government, and socio- gress on matters of Medicare reim- G. Tower and NASA shuttle astronaut logical groups throughout the state. bursement, and was chairman of the Ac- Manley L. Carter, Jr. In January 1990, JAMA published cess to Health Care Committee, where Dr Davies was on "Applying Brakes to the Runaway he was involved in the formulation of the his way to address a American Health Care System: A Pro- Position Paper of the American College regional meeting of posed Agenda," of which Dr Davies was of Physicians. young physicians for senior author. "Universal Access to In addition to his many other accom- the American Col- Health Care in America: A Moral and plishments, Dr Davies served as presi- lege of Physicians. Medical Imperative," an article he also dent of the Georgia Heart Association, As president-elect, coauthored in 1990, ran in Annals of the Southeastern Clinical Club, and the he was to have left Internal Medicine (1990;112:637-639). Atlanta Medical History Society. He Georgia promptly Altogether, Dr Davies was the author of was a member of the American Heart thereafter to be in- more than 50 articles for scientific and Association, the Royal Society of Medi- stalled on April 13 as the president of lay publications. In addition, he served cine, the American Clinical and Clima- the American College of Physicians at on the editorial board of the Annals of tological Association, the Institute of its annual meeting in New Orleans, La. Internal Medicine from 1980 to 1984. Medicine, the American Society of In- Dr Davies was highly visible in his The Medical Association of Atlanta se- ternal Medicine, and the Georgia Soci- profession, both locally and nationally, lected him to be editor of Atlanta Medi- ety of Internal Medicine. He served on perhaps particularly because his consid- cine from 1971 to 1975. His wife-Gar- the American Board of Internal Medi- erable accomplishments were coupled land Hunter Davies, a professor of cine from 1984 to 1990. with a gentle, unassuming personality. English at Georgia State University in Dr Davies was the recipient of a com- His overriding passion of the past few Atlanta-ably assisted him in these edi- mendation medal from the US Air years was access to health care and its torial pursuits. Force. He served as medical adviser to costs. He became increasingly con- Dr Davies graduated from the Uni- the Visiting Nurse Association of Atlan- cerned about a health care system versity of Virginia School of Medicine, ta and was founder and chairman of the where the best health care in the world Charlottesville, in 1952. Following an Friends of the Public Library. He was available to some of the people internship at Cincinnati (Ohio) General served on the United Way Board of while others were virtually ignored. He Hospital and a residency in internal Trustees, the Georgia Council for Inter- decried the gap between the federal medicine at Grady Memorial Hospital in national Visitors, and the Metropolitan poverty level and Medicaid coverage Atlanta, he remained in Atlanta, where Atlanta Community Foundation. Dr and was determined that society must he practiced internal medicine and car- Davies was an avid and excellent tennis find a way to make health care available diology at Piedmont Hospital from 1957 player and a frequent golfer with his to the reported 37 million uninsured, to 1991. He was chairman of the Depart- wife. approximately 900 000 of whom were in ment of Medicine from 1983 to 1990 and In addition to his wife, Garland, of his home state of Georgia. How ironic, a member of the Board of Trustees from Atlanta, Dr Davies is survived by three indeed, that the news of his death co- 1982 to 1990. In 1990, he resigned to children: Nicholas E., Jr, Elizabeth incides with this week's JAMA, a spe- prepare for his duties as president of the Sanders, and Sally Halsey. cial issue dedicated to caring for the American College of Physicians. Dr Davies' buoyant spirit, his contin- uninsured and underinsured. Dr Davies also held the position of uous optimism, and his personal magne- In search of solutions to the problems chairman of the Piedmont Hospital Eth- tism made it easy for him to involve of the uninsured and underinsured, Dr ics Committee. His professional con- others in his many activities that had a Davies became the catalyst in the estab- duct and abiding interest in appropriate positive influence on physicians in Geor- lishment of Georgia Health Decisions, interpersonal relationships-particu- gia and around the nation. He had a modeled after Oregon Health Deci- larly between patients and physicians- spirited sense of humor that mixed well sions. From the beginning, he insisted seemed to make this a natural position with his kindness, compassion, pa- that the role of physicians would be to for him. Dr Davies was perceived by his tience, and cordiality. His untimely spearhead the initiation of this organi- associates as a warm, personable col- death as he approached the peak of his zation, to educate and inform the public league who was constantly active in opportunities to spread his welcome in- of the details of the health care situa- many intellectual, academic, and com- fluences nationwide is agonizing. We at tion, and to interest and train lay people munity affairs. Piedmont Hospital will continue to pro- to carry out the goals of Georgia Health He became a fellow in the American gress, but not nearly as well or as rapid- Decisions, which were oriented toward College of Physicians in 1965, was gov- ly as we would have under his unique providing a package of basic health care ernor for the Georgia section from 1976 leadership. benefits for everyone, initially in Geor- to 1980, was a regent from 1984 to 1990, -Louis H. Felder, MD gia but ultimately throughout the Unit- and was elected president-elect in 1990. ed States. He chaired innumerable He was a member of the Clinical Prac- JAMA, May 15, 1991 265, No. 19 Obituary 2581 Let your patients know they can eat this While fish and chicken are certainly appropriate choices for fat-modified diets, so are lean cuts of today's beef. Lean beef has the high-protein, iron-rich nutrient profile you value-and a fat profile that may surprise you. And when you include the good taste and versatility of beef in your heart- healthy diet recommendations, you're improving the chance that patients will comply better for long-term results. Today, beef cuts are lower in fat According to a national survey of supermarkets, there is on average 27% less trimmable fat on the beef sold in stores today than in the late '70s and early '80s.¹ Since that time, a follow-up survey in 1990 confirms a continued reduction in fat on retail beef.² 3-oz cooked serving of beef tenderloin Skinniest AHA and NCEP guidelines allow Top Round Six Top Loin 153 cals. 176 cals. lean beef 4.2 g fat 8.0 g fat 1.4 g sat. fat Per 3-oz. trimmed 3.1 g sat. fat The American Heart Association and the (after cooking) serving National Cholesterol Education Program have recognized the place for lean beef in a varied, Eye of Round Sirloin Tenderloin Round Tip balanced diet. Both of their dietary guidelines 143 cals. 165 cals. 179 cals. 157 cals. 4.2 g fat 6.1 g fat 8.5 g fat 5.9 g fat recommend up to 6 OZ daily of lean beef and 1.5 g sat. fat 2.4 g sat. fat 3.2 g sat. fat 2.1 g sat. fat meats, poultry, or seafood. 3,4 as well as this. Now when you recommend fat-modified diets, you can assure patients that fish and chicken aren't their only options. Tell them they can enjoy today's lean beef, a delicious and heart- healthy choice. References: 1. Savell JW, et al. National Beef Market Basket Survey. J Anim Sci. In press. 2. Morgan JB, et al. National Beef Tenderness Survey: Meat Research Brief. College Station, TX: Meats and Muscle Biology Section, Department of Animal Science, Texas A & M University; 1990. 3. American Heart Association. Dietary Guidelines for Healthy American Adults. (Document No. 71-1003). Circulation. 1988; 77 (3). 4. National Cholesterol Education Program. Report of the Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Washington, DC: National Institutes of Health; January 1988. NIH publication 88-2925. Recommend Today's Lean Beef Here's how you can help patients enjoy beef that's compatible with a heart-healthy diet: Encourage your patients to purchase lean cuts, A Heart-Healthy Keep portions moderate (about 3 oz, Choice cooked), Remove visible fat before cooking, and Prepare without using any additional fat. ©1991 Beef Industry Council and Beef Board PUBLIC GRANT ANNOUNCEMENT European Medical Partnerships Sought T he U.S. Agency for International Development (A.I.D.), the federal government's agency for management of U.S. foreign assistance, is soliciting proposals for partnerships between medical facilities in the U.S. and those in Central and East Europe. Subject to the availability of funds, A.I.D. expects to award up to ten grants in support of such partnerships during 1991. It is expected that grants will range between $1.5 and $2.5 million and two-to three years. A.I.D. welcomes applications from community and municipal hospitals, university teaching hospitals or tertiary health care facilities and from for-profit or non-profit institutions. Eligible partners may be individual medical facilities, a consortia of medical facilities, or a third party acting on behalf of a group of such facilities. Preference will be given to proposals that demonstrate the maximum allocation of A.I.D. resources to program activities. Participating U.S. medical facilities must be accredited by the Joint Commission on Accreditation of Healthcare Organizations. Priority areas of assistance are cardiovascular and cerebrovascular diseases, cancers, pediatric trauma, emergency medical systems, and medical effects of environmental pollution. Partnership activities might include training, utilization and outcome research, diagnostic and treatment improvements, and outpatient prevention programs. The target countries are Poland, Hungary, Czechoslovakia, Yugoslavia, Bulgaria and Romania. Partnerships are to focus on a single area of medical assistance in a single country. A.I.D. anticipates making Request for Applications Number OS/EE/91-009 available in early April. To obtain a copy, please send a written request with two self-addressed mailing labels to: The Agency for International Development, Office of Procurement, Overseas Division, Rm. 1583, SA-14, Washington, D.C. 20523-1420, Attn: Mr. James Loy (Telephone (703) 875-1041). Please indicate in your request the Central or East European country of priority interest to your institution. A.I.D. will share this information with other requestors unless directed not to do so. Solving one puzzle of patient communications Medicolegal Forms with Legal Analysis Medicolegal Forms with Legal Analysis is the ideal resource for assembling the legal pieces of your physician-patient relations. This newly-revised single volume contains more than 80 sample forms developed by the AMA's Office of the General Counsel, along with discussions explaining the use and structure of the forms and case law citations. Only Medicolegal Forms with Legal Analysis assembles this valuable information so conveniently for adaptation to individual practice situations. M Order your copy today; call toll-free 1-800-621-8335 AMERICAN Order #OP630290 AMA Member $25 Non-member $32 MEDICAL Visa and MasterCard only. American Medical Appropriate state sales tax will be added as applicable. $3.50 will also be added for shipping Association and handling for orders under $35.00 HP011 2584 LANOXIN® TABLETS amount should have no pharmacologic effect upon the intant Nevertheless caution should be exercised when digox (DIGOXIN) in is administered to a nursing woman ADVERSE REACTIONS: The frequency and severity of adverse reactions to digoxin depend on the dose and route of 125 µg (0.125 mg) Scored I.D. Imprint Y3B (yellow) administration as well as on the patient underlying disease or concomitant therapies (see PRECAUTIONS section 250 µg (0.25 mg) Scored I.D. Imprint X3A (white) and Serum Digoxin Concentrations subsection of DOSAGE AND ADMINISTRATION) The overall incidence of adverse 500 µg (0.5 mg) Scored I.D. Imprint T9A (green) reactions has been reported as to 20% with 15 to 20% of them being considered serious (one to four percent of pa tients receiving digoxin) Evidence suggests that the incidence toxicity has decreased since the introduction of the serum digoxin assay and improved standardization of digoxin tablets Cardiac toxicity accounts for about one-half Before using Lanoxin Tablets, the physician should be thoroughly familiar with the basic phar- gastrointestinal disturbances for about one-fourth and CNS and other toxicity for about fourth of these adverse macology of this drug as well as its drug interactions. indications, and usage reactions Adults: Cardiac-Unifocal or multiform ventricular premature contractions especially in bigeminal or trigeminal patterns are DESCRIPTION: Lanoxin is digoxin one of the cardiac (or digitalis) glycosides a closely related group of drugs having the most common arrhythmias associated with digoxin toxicity in adults with heart disease in common specific effects on the myocardium Ventricular tachycardia may result from digitalis toxicity Atrioventricular (AV) dissociation accelerated junctional (nodal) INDICATIONS AND USAGE: rhythm and atrial tachycardia with block are also common arrhythmias caused by digoxin overdosage Heart Failure: The increased diac output resulting from the inotropic action of digoxin ameliorates the disturbances xcessive slowing of the pulse is a clinical sign of digoxin overdosage AV block (Wenckebach) of increasing degree characteristic of heart failure (venous congestion edema. dyspnea. orthopnea and cardiac asthma) may proceed to complete heart block Digoxin is more effective in "low output (pump) failure than in high output heart failure secondary to arteriovenous Note The electrocardiogram is fundamental in determining the presence and nature of these cardiac disturbances fistula. anemia. infection or hyperthyroidism Digoxin may also induce other changes in the ECG (e.g. PR prolongation ST depression) which represent digoxin Digoxin is usually continued after failure IS controlled unless some known precipitating factor is corrected Studies effect and may or may not be associated with digitalis toxicity have shown however that even though hemodynamic effects can be demonstrated in almost all patients correspond. Gastrointestinal-Anorexia. nausea. vomiting and less commonly diarrhea are common early symptoms of overdosage improvement in the signs and symptoms of heart failure is not necessarily apparent Therefore in patients in whom However uncontrolled heart failure may also produce such symptoms Digitalis toxicity very rarely may causeabdominal digoxin may be difficult to regulate or in whom the risk of toxicity may begreat (e.g. patients with unstable renal func- pain and hemorrhagic necrosis of the intestines tion or whose potassium levels tend to fluctuate) cautious withdrawal of digoxin may be considered If digoxin discon CNS-Visual disturbances (blurred yellow vision) headache weakness diz ziness apathy and psychosis can occur tinued the patient should be regularly monitored for chnical evidence of recurrent heart failure Other-Gynecomastia is occasionally observed Maculopapular rash or other skin reactions are rarely observed CONTRAINDICATIONS: Digitalis glycosides are contraindicated in ventricular fibrillation Infants and Children: Toxicity differs from the adult in a number of respects Anorexia nausea vomiting. diarrhea In given patient an untoward effect requiring permanent discontinuation of other digitalis preparations usually con- and CNS disturbances may be present but are rare as initial symptoms in infants Cardiac arrhythmias are more reliable stitutes acontraindication to digoxin Hypersensitivity to digaxin itself is contraindication to its use Allergy to digox- signs of toxicity Digoxin in children may produce any arrhythmia The most commonly encountered are conduction in. though rare does occur It may not extend to all such preparations and another digitalis glycoside may be fried disturbances or supraventricular fachyarrhythmias, such as atrial tachycardia with or without block and junctional with caution (nodal) tachycardia Ventricular arrhythmias are less common Sinus bradycardia may also be a sign of impending digoxin intoxication especially in infants even in the absence of first degree heart block Any rhythmia or atteration WARNINGS: Digitalis alone with other drugs has been used in the treatment of obesity This use of digoxin or other in cardiac conduction that develops in a child taking digoxin should initially be assumed to be a consequence of digox. digitalis glycosides is unwarranted Moreover since they may cause potentially fatal rhythmias or other adverse in intoxication fects. the use of these drugs solely for the treatment of obesity is dangerous Anorexia. nausea vomiting and rhythmias may accompany heart failure or may be indications of digitalis intoxica OVERDOSAGE: tion Clinical evaluation of the cause of these symptoms should be attempted before further digitalis administration Treatment of Arrhythmias Produced by Overdosage: In such circumstances determination of the serum digoxin concentration may be an aid in deciding whether or not Adults: Digoxin should be discontinued until all signs of toxicity are gone Discontinuation may be all that is necessary digitalis toxicity is likely to be present If the possibility of digitalis intoxication cannot be excluded cardiac glycosides it toxic manifestations are not severe and appear only near the expected time for maximum effect of the drug should be temporarily withheld if permitted by the clinical situation Correction of factors that may contribute to toxicity suchas electrolyte disturbances hypoxia acid-base disturbances Patients with renal insufficiency require smaller than isualmaintenance doses of digoxin (see DOSAGE AND ADMINIST and removal of aggravating agents such as catecholamines, should also be considered Potassium salts may be in. TION section) dicated particularly if hypokalemia is present Potassium administration may be dangerous in the setting of massive Heart failure accompanying acute glomerulonephritis requires extreme care in digitalization Relatively low loading digitalis overdosage (see Massive Digitalis Overdosage subsection below) Potassium chloride in divided oral doses and maintenance doses and concomitant use of antihypertensive drugs may be necessary and careful monitoring is totaling 3 to 6 grams of the salt (40 to 80 mEq K for adults may be given provided renal function is adequate (see essential Digoxin should be discontinued as soon as possible below for potassium recommendations in Infants and Children) Patients with severe carditis such as carditis associated with rheumatic fever or viral myocarditis are especially sen When correction of the rrhythmia is urgent and the serum potassium concentration is low or normal potassium should sitive to digoxin-induced disturbances of rhythm be administered travenously in 5% dextrose injection For adults a total of 40 to 80 mEq (diluted to a concentration Newborn display considerable variability in their tolerance to digoxin Premature and immature intants are par of 40 mE per 500 mL may be given at a rate not exceeding 20 mEq per hour or slower if limited by pain due to local ticularly sensitive and dosage must not only be reduced but must individualized according to their degreeof maturity irritation Additional amounts may be given if the rrhythmia is uncontrolled and potassium well tolerated ECG monitoring Note: Digitalis glycosides are an important cause of accidental poisoning in children should be performed to watch for any evidenced potassium toxicity (e peaking of 1 waves) and observe the effect on the arrhythmia The infusion may be stopped when the desired effect is achieved PRECAUTIONS: Note Potassium should not be used and may be dangerous in heart block due to digoxin unless primarily related to General: Digoxin toxicity develops more frequently and lasts longer in patients with renal impairment because of the supraventricular tachycardia decreased excretion of digoxin Therefore it should be anticipated that dosage requirements will be decreased in pa Other agents that have been used for the treatment of digoxin intoxication include lidocaine procainamide propranolol tients with moderate to severe renal disease (see DOSAGE AND ADMINISTR section) Because of the prolonged and phenytoin although use of the latter must be considered experimental In advanced heart block atropine and /or half-life a longer period of time is required to achieve initial or new steady-state concentration in patients with renal temporary ventricular pacing may be beneficial Digibind* Digoxin Immune Fab (Ovine) can be used to reverse potentially impairment than in patients with normal renal function life-threatening digoxin (or digitoxin) intoxication Improvement in signs and symptoms of digitalis toxicity usually in patients with hypokalemia toxicity may occur despite serum digoxin concentrations within the normal range." begins within 1/2 hour of Digibind administration Each 40 mg vial of Digibind will neutralize 0 mg of digoxin which because potassium depletion sensitizes the myocardium to digoxin Therefore it is desirable to maintain normal serum is a usual body store of an adequately digitalized 70 kg patient) potassium levels in patients being treated with digoxin Hypokalemia may result from diuretic amphotericin B or cor Infants and Children: See Adult section for general recommendations for the treatment of arrhythmias produced by ticosteroid therapy. and from dialysis or mechanical suction of gastrointestinal secretions It may also accompany malnutri- overdosage and for cautions regarding the use of potassium tion. diarrhea, prolonged vomiting old age and long-standing heart failure in general rapid changes in serum potassium If a potassium preparation is used to treat toxicity il may be given orally in divided doses totaling 1 to 1 5 mEq K+ or other electrolytes should be avoided and intravenous treatment with potassium should be reserved for special CIP. per kilogram (kg) body weight (1 gram of potassium chloride contains 13 4 mE cumstances as described below (see TREATMENT OF ARRHYTHMIAS PRODUCED BY RDOSAGE section) When correction of the arrhythmia with potassium is urgent approximately 0 5 mEq/kg of potassium per hour may Calcium. particularly when administered rapidly by the intravenous route. may produce serious arrhythmias in digitalized be given intravenously with careful ECG monitoring The intravenous solution of potassium should be dilute enough patients Hypercalcemia from any cause predisposes the patient to digitalis toxicity On the other hand. hypocalcemia to avoid local irritation however, especially in infants care must be taken to avoid intravenous fluid overload can nullity the effects of digoxin in man: thus digoxin may be ineffective until serum calcium is restored to normal DOSAGE AND ADMINISTRATION: Recommended dosages are average values that may require considerable modification These interactions are related to the fact that calcium affects contractility and excitability of the heart in manner similar because of individual sensitivity or associated conditions Diminished renal function is the most important factor re- to digoxin quiring modification of recommended doses typomagnesemia may predispose to digitalis toxicity If low magnesium levels are detected in a patient on digoxin In deciding the dose of digoxin, several factors must be considered replacement therapy should be instituted 1 The disease being treated Atrial arrhythmias may require larger doses than heart failure Quinidine verapamil. and amiodarone cause a rise in serum digoxin concentration with the implication that digitalis 2 The body weight of the patient Doses should be calculated based upon lean or ideal body weight intoxication may result This rise appears to be proportional to the dose The effect is mediated by a reduction in the 3 The patient's renal function preferably evaluated on the basis of creatinine clearance digoxin clearance and in the case of quinidine, decreased volume of distribution as well 4 Age is an important factor in infants and children Certain antibiotics may increase digoxin absorption in patients who convert digoxin to inactive metabolites in the gut 5 Concomitant disease states. drugs or other factors likely to alter the expected clinical response to digoxin (see PRECAU- (see Pharmacokinetics portion of the CLINICAL PHARMACOLOGY section) Recent studies have shown that specific TIONS and Drug Interactions sections) colonic bacteria in lower gastrointestinal convert digoxin to cardioinactive reduction products. thereby reducing its bioavailability Although inactivation of these bacteria by antibiotics is rapid, the serum digoxin concentration will Consult complete product information before prescribing rise at a rate consistent with the elimination half-life of digoxin The magnitude of rise in serum digoxin concentration relates to the extent of bacterial inactivation. and may be as much as two-fold in some cases Patients with acute myocardial infarction or severe pulmonary disease may be unusually sensitive to digoxin-induced disturbances of rhythm Atrial rhythmias associated with hypermetabolic states (e hyperthyroidism) are particularly resistant to digoxin treatment Large doses of digoxin are not recommended as the only treatment of these rhythmias and care must be taken to avoid toxicity if large doses of digoxin are required In hypothyroidism. the digoxin requirements are reduced Digoxin responses in patients with compensated thyroid disease are normal Reduction of digoxin dosagemay be desirable prior to electrical cardioversion to avoid inductions ventricular hythmias but the physician must consider the consequences of rapid increase in ventricular response to atrial fibrillation if digoxin is withheld to 2 days prior to cardioversion If there is a suspicion that digitalis toxicity exists elective cardioversion References: 1. The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with should be delayed If it is not prudent to delay cardioversion the energy level selected should be minimal at first and captopril and digoxin in patients with mild to moderate heart failure. JAMA 1988;259:539-544. carefully increased in an attempt to avoid precipitating ventricular arrhythmias 2. DiBianco R, Shabetai R, Kostuk W, Moran J, Schlant RC, Wright R. A comparison of oral milrinone, Incomplete AV block especially in patients with attacks may progress to advanced or complete heart digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. block if digoxin is given 1989;320:677-683. 3. Guyatt GH, Sullivan MJJ. Fallen EL, et al. A controlled trial of digoxin in congestive In some patients with sinus node disease (i.e. Sick Sinus Syndrome). digoxin may worsen sinus bradycardia or sino heart failure. Am J Cardiol. 1988;61:371-375 4. Gheorghiade M, Hall V, Lakier JB, Goldstein S. atrial block Comparative hemodynamic and neurohormonal effects of intravenous captopril and digoxin and their In patients with Wolff-Parkinson-White Syndrome and atrial fibrillation digoxin can enhance transmission of impulses through the accessory pathway This effect may result in extremely rapid ventricular rates and even ventricular fibrillation combinations in patients with severe heart failure. Am Coll Cardiol 1989;13:134-142 5. Arnold SB, Digoxin may worsen the outflow obstruction in patients with idiopathic hypertrophic subaortic stenosis (IHSS) Unless Byrd RC, Meister W, et al. Long-term digitalis therapy improves left ventricular function in heart failure. cardiac failure is severe. it is doubtful whether digoxin should be employed N Engl J Med. 1980;303;1443-1448. 6. Alicandri C, Fariello R, Boni E, Zaninelli A, Mulesan G. Comparison Patients with chronic constrictive pericarditis may fail to respond to digoxin in addition slowing of the heart rate by of captopril and digoxin in mild to moderate heart failure. Postgrad Med J. 1986;62(suppl 1):170-175. digoxin in some patients may further decrease cardiac output Patients with heart failure from amyloid heart disease or constrictive cardiomyopathies respond poorly to treatment with digoxin Digoxin is not indicated for the treatment of sinus tachycardia unless it is associated with heart failure Digoxin may produce false positive ST-T changes in the electrocardiogram during exercise testing IN THE EARLY TREATMENT OF CHF Intramuscular injection of digoxin is extremely painful and offers no advantages unless other routes of administration are contraindicated Laboratory Tests: Patients receiving digoxin should have their serum electrolytes and renal function (BUN and /or serum creatinine) assessed periodically: the frequency of assessments will depend on the clinical setting For discussion of serum digoxin concentrations. see DOSAGE AND ADMINIST RATION section in the complete prescribing information LANOXIN Drug Interactions: Potassium-depleting corticosteroids and diuretics may be major contributing factors to digitalis toxicity Calcium, particularly if administered rapidly by the intravenous route. may produce serious arrhythmias in digitalized patients Quinidine, verapamil, and amiodarone cause a rise in serum digoxin concentration with the im. plication that digitalis intoxication may result Certain antibiotics increase digoxin absorption in patients who inac- tivate digoxin by bacterial metabolism in the lower intestine so that digitalis intoxication may result Propantheline (digoxin) Tablets and diphenoxylate by decreasing gut motility. may increase digoxin absorption Antacids kaolin-pectin. sulfasalazine, neomycin. cholestyramine and certain anticancer drugs may interfere with intestinal digoxin absorption, resulting in unexpectedly low serum concentrations There have been inconsistent reports regarding the effects of other drugs on the serum digoxin concentration Thyroid administration to a digitalized. hypothyroid patient may increase the dose Unique inotropic requirement of digoxin Concomitant use of digoxin and sympathomimetics increases the risk of cardiac arrhythmias because both enhance ectopic pacemaker activity Succinylcholinemay cause a sudden extrusion of potassium from muscle cells. and may thereby cause arrhythmias in digitalized patients Although B adrenergic blockers or calcium channel blockers and digoxin may be useful in combination to control atrial fibrillation their additive effects on AV node support for the conduction can result in complete heart block Due to the considerable variability of these interactions digoxin dosage should be carefully individualized when pa tients receive coadministered medications Furthermore caution should be exercised when combining digoxin with failing heart. any drug that may cause a significant deterioration in renal function since this may impair the excretion of digoxin Carcinogenesis, Mutagenesis, Impairment of Fertility: There have been no long-term studies performed in animals evaluate carcinogenic potential Pregnancy: Teratogenic Effects: Pregnancy Category C Animal reproduction studies have not been conducted with Burroughs Wellcome Co. digoxin It is also not known whether digoxin can cause tetal harm when administered to a pregnant woman or can Wellcome Research Triangle Park, NC 27709 affect reproduction capacity Digoxin should be given to a pregnant woman only it clearly needed Nursing Mothers: Studies have shown that digoxin concentrations in the mother serum and milk are similar Howev. er, the estimated daily dose to a nursing infant will be far below the usual infant maintenance dose Therefore this Copr. © 1991 Burroughs Wellcome Co. All rights reserved. LN-Y01751 For patients with lactose intolerance DAIRY FOODS COME WITH HIDDEN COSTS ABDOMINAL BLOATING DIARRHEA FLATULENCE CRAMPS HELP PREVENT THEM WITH LACTAID ® Take the unpleasant consequences out of milk and other dairy products with Lactaid ® therapy. In controlled studies with children and adults, Lactaid treatment effectively prevented the gastro- Lactaid lactose reduced intestinal symptoms of lactose lowfatmilk ® intolerance.¹,² References: Lactaid® 1. Medow MS, Thek KD, Newman LJ, Berezin S, Glassman Ha MS, Schwarz SM. AJDC. 1990;144:1261-1264. 2. Rosado JL, Lactaid Solomons NW, Lisker R, et al. Gastroenterology. 1984;87: 1072-1082. milk Lactaid Lactase Supplementation Therapy Marketed by: ONE 100 McNeil Consumer Products Company For dairy foods McNEIL Division of McNeil-PPC. Inc. Fort Washington, PA 19034 USA ©McN, 1991 without discomfort A breakthrough in convenience for the treatment of vaginal candidiasis Now, recommend the first nonprescription cure* for your patients wherever they may be *Gyne-Lotrimin cures most vaginal candidiasis. © 1991, Schering Plough HealthCare Products, Inc. Memphis, TN Gyne-Lotrimin CLOTRIMAZOLE vaginal inserts or cream ® Full prescription strength with nonprescription convenience Proven efficacy comparable to prescription medications. Now, when you diagnose vaginal candidiasis, you can offer patients the same proven clotrimazole efficacy, fast symptom relief, and excellent safety profile you've always depended on for the first time, without a prescription. New convenience when you see her in your office or when you don't. When your patients recognize the classic symptoms of a recurrent infection, your recommendation will ensure Cures most vaginal yeast infections that they get the fast, safe, and effective treatment they need. It's never without Q prescription Now available been this easy-or this cost-effective-to provide effective therapy for Gyne- recurrent vaginal candidiasis. Lotrimin® vaginal inserts Recommend nonprescription Gyne-Lotrimin. Available in 7-day vaginal insert 100 mg or 7-day vaginal cream 1%. Cures most vaginal yeast infections without prescription) Now avaidable Gyne- MOIN Instruct patients to insert one tablet or one applicator full of cream each night for 7 days. Lotrimin® Antifungal vaginal cream GLZ-102 2/91 Printed in USA ONE 45g TUBE VAGNAL CREAM APPLICATOR Day therapy) Recommend Gyne-Lotrimin when you see her when you don't. Schering-Plough Books Ethics, Cost is best for the patient would have to vide people with ineffective or margin- eliminate the former but not the latter. ally effective medical treatment" (p Medicine and Money: A Study of the Role of Be- Part of the problem with the book is 131). They cannot see that even if there neficence in Health Care Cost Containment, by that the authors never really provide a is no good reason to provide ineffective Frank H. Marsh and Mark Yarborough, 171 pp, $39.95, ISBN 0-313-26357-4, St Louis, Mo, Warren clear conceptualization of their key cat- care, doing what is best for the patient H Green Inc, 1990. egory, beneficence. Do they simply still requires providing effective care, mean literally "doing good" no matter even if it is marginal. Only a shift to the No subject in medical ethics is more for whom the good accrues (the stan- principle of justice provides a ground for important today than the moral prob- dard use of the term) or do they mean, eliminating the latter kind of care. Only lems underlying the pressures of cost in more traditional Hippocratic fashion, by abandoning patient-centered benef- containment. Frank H. Marsh and Mark Yarborough have, in a modestly sized doing good for the patient? They seem icence and shifting to justice will such volume, attacked ethics and health care to mean the latter; at several points they care be limited. They come close to say- at its most vulnerable underbelly. Their say SO (pp 32, 74, 98, 129), yet there must ing this when they say, "Justice de- mands that people be granted access to thesis is that "the principle of benefi- be many cases in which it simply does cence [doing good] as structured within not work out that doing the best for the effective care and nothing else." It the physician-patient relationship can patient also happens to do the most good seems it would have been more reason- become a formidable resource to be used for society. They simply do not take se- able to say that while beneficence de- riously the possibility that these two mands (all) effective care, justice would in the struggle against inflationary health care expenditures" (p 5). In fact, goods can conflict. It seems very un- permit eliminating some marginally ef- they claim that the principle, properly likely that doing what is best for the pa- fective care. applied, can produce substantial sav- tient will really solve the cost- We are left with contradictions that containment dilemma. suggest that beneficence alone-a least ings, bringing escalating health care ex- Furthermore, they do not take seri- beneficence as described by Marsh and penditures under control (p 86). They first point to expenditures for ously the possibility that beneficence Yarborough-cannot possibly commit futile care and care that actually does can really conflict with other moral du- the physician to doing what is best for patients more harm than good. Simply ties, including respect for autonomy and the patient and solve the cost- doing what will benefit the patient the promotion of justice. At places (pp containment problem. According to the would actually save money as a fringe 26, 67) they consider autonomy a value authors, "The approach we are endors- served in the name of beneficence, while ing places the responsibility to contain benefit. If that were sufficient savings, Marsh and Yarborough would have at other places they acknowledge that costs squarely on the shoulders of phy- sicians" (p 135), yet "these constraints solved the most difficult medical ethical patients may not know their own inter- must originate, if they are to be accept- problem of the generation. ests (p 76). They seem to affirm contra- able, outside of the medical context. But there is a catch. There are good dictions such as that "the physician can They must be supramedical and im- reasons to believe that, in principle, it seek the good of patients only by con- posed on medicine" (p 152). Perhaps the cannot be enough simply to eliminate sulting them" (p 74) and that "some pa- time has come to look once again at some useless and harmful care. There will al- tients cannot, for a variety of reasons, of the principles that Marsh and Yar- ways be care that is very marginally define their own best interests." borough reject, such as the principle of beneficial and yet very expensive. It Their treatment of the principle of justice. In doing so we could still insist seems not all such care should be pro- justice is unfortunate. They seem to that the clinician be beneficent, but then vided, yet Marsh and Yarborough never think that defenders of egalitarian jus- set societal limits grounded in justice to tell us how it could be eliminated in the tice would require that if a service is pro- solve the cost-containment problem. name of the principle of beneficence. vided to some, it must be provided to all. The authors use interchangeably the The literature is full of sophisticated Robert M. Veatch, PhD Georgetown University terms futile or ineffective care and mar- justice-based arguments showing that, Washington, DC ginally effective care so that they can for example, care could be allocated in Deinstitutionalization claim that because beneficence supports the name of justice among people with removal of ineffective care, it supports the same disease on the basis of age, de- Out of Bedlam: The Truth About Deinstitution- removal of marginally effective care as gree of illness, or many other measures alization, by Ann Braden Johnson, 306 pp, $22.95, ISBN 0-465-05427-7, New York, NY, Basic Books well (p 131). They simply fail to see that of who is worst off. Sometimes the au- Inc, 1990. a clinician really devoted to doing what thors themselves cannot tell if they are Madness in the Streets: How Psychiatry and the grounding their claim in beneficence or Law Abandoned the Mentally III, by Rael Jean Edited by Harriet S. Meyer, MD, Contributing Editor; justice, as in their confusing claim that Isaac and Virginia C. Armat, 436 pp, $24.95, ISBN adviser for software, Robert Hogan, MD, San Diego. "There is no good or just reason to pro- 0-02-915380-8, New York, NY, Free Press, 1990. 2588 JAMA, May 15, 1991 Vol 265, No. 19 Books Out of Bedlam takes a very cynical, In part II, "1970 and Beyond the Af- stitutionalization and the problems that angry look at the mental health system. termath of Deinstitutionalization," the prevent the mental health system from Part I, "How Deinstitutionalization author describes where the seriously working optimally. The weakness of the Supposedly Took Place," begins by de- mentally ill really went, ie, into nursing book is that it is written with SO much scribing how asylums were originally homes, board and care homes, adult cynicism that the good points it raises created to protect the seriously men- care homes, and the like. The lack of reg- may be overlooked because of its tone. tally ill from the stresses of society. This ulation of these facilities made it possi- treatment concept dwindled as case- ble for their clients to become a profit- loads began to overwhelm the system, able commodity. Unfortunately, be- Madness in the Streets is a very im- cause these residences weren't formally portant book because it clearly chroni- causing the state hospitals to have to connected to the mental health system, cles the process that significantly con- move from treatment to custody. Next came the mental hygiene movement, the coordination of care often broke tributed to the seriously mentally ill which was designed to have smaller hos- down, which contributed to the problem having to live on the streets. It provides pitals and community-based aftercare; of the homeless mentally ill. There is a the accurate direction society needs to unfortunately, neither materialized as fair amount of unconstructive criticism correct a serious problem. the prevention of mental illness became about how the current mental health The authors show how the care of the system is large, chaotic, uncoordinated, seriously mentally ill has evolved from a priority. As the deplorable conditions and incoherent and utterly fails in its the shame of poor public mental hospital of state hospitals became known and care to the shame of no care as a result state governments realized they could mission, the ongoing care and treatment of the seriously mentally ill. The author of their being denied hospitalization not afford the care of the seriously men- tally ill, pressure for the federal govern- finally succinetly states what they need: without adequate treatment and sup- a place to live, aggressive outreach, the port in the community. The origins of ment to become involved in mental health care mounted. The author does a ability to be rehospitalized when this transition are traced back to the good job of describing the philosophic needed, reeducation in the myriad skills counterculture and antipsychiatry and political conflicts between the goals of interpersonal life, work to do, ciga- movements, and a fine job is done of rettes and coffee, and real treatment highlighting the major events and peo- of prevention vs care, which caused the free of condescension from therapists ple who gave these movements momen- recommendations of the Joint Commis- they feel they can trust for as long as tum. sion on Mental Illness and Health to be ignored, despite the fact that its report they are needed. She reports on pro- It is revealed how, despite the Joint clearly spelled out the need for grams that work and underscores their Commission of Mental Illness and community-based treatment working common thread, a focus on the transmis- Health's recommendations, community along with smaller hospitals. sion of social skills to promote patients' mental health's goal was to prevent se- In the chapter "May the Sales Force adaptations to society. rious mental illness rather than care for "How the Mental Health System the mentally ill. Little attention was Be With You: Psychotrophic Medica- Works" is covered in part III, and men- paid to where deinstitutionalized pa- tion, the New Magic Bullet," the author tal health is called "big business." Men- tients would live or go for inpatient care. assails how psychotropic medication tal health funding is said to be driven by The book charges that early community was marketed and how it never lived up politics, expediency, and fads. Along mental health center (CMHC) regula- to its claims. She charges that while with the lure of quick fixes, there is frag- tions ignored procedures to aid in treat- medication made patients more man- mentation of the system due to the ab- ment, eg, there was no mandate for ageable, it often became the "sole treat- sence of any organization to oversee CMHCs to interface with state hospi- ment of choice in far too many cases." governmental, voluntary, and private tals. Credit is given to CMHCs for help- In looking at the forces that have practice with an agenda of unifying and ing to develop partial hospitalization, shaped the practice of psychiatry, the interrelating patient services for better psychiatric emergency care, and psychi- author briefly notes the antipsychiatry care. The service provision system is ac- atric beds in general hospitals, but they movement so eloquently described in cused of being full of holes. are castigated for making their major fo- Madness in the Streets by R. J. Isaac Exposing the fact that practitioners cus social activism and counseling and and V. C. Armat, but she really doesn't and policymakers-administrators don't crisis intervention for problems of liv- expound on how this movement caused communicate, the author identifies a ing. a lot of the problems she identifies with major factor in the fragmentation pro- In the section provocatively entitled the current mental health system. She cess. She is very critical of monitoring "The Law Becomes Deranged," the au- does do a creditable job of indicating programs that result in policy on one thors trace the development of the how Medicaid, which gave the disabled level and practice on another level with "mental health bar," which consisted of mentally ill benefits, made it possible for communication between the two levels a group of young lawyers who sought to state hospitals to begin moving mentally forced, artificial, and self-serving. eliminate involuntary commitment as ill patients into nursing homes. And The conclusion is that serious mental their contribution to civil rights. Law Medicaid is blamed for the failure of illness is not the fault of the mental journals began to be filled with unsci- states to develop genuine, community- health system, deinstitutionalization, entific antipsychiatry propaganda, and based alternatives to the institutional or the patient. Deinstitutionalization state hospitals came under attack for care of the seriously mentally ill because has made it clear that many seriously not providing treatment. Faced with of the reimbursement practices that ex- and chronically mentally ill people can laws demanding staffing patterns that clude day treatment, casework, voca- live outside of a total institution and can state budgets couldn't accommodate, tional services, etc. Finally, it is pointed do well under certain circumstances- laws preventing patient labor that had out that nobody built community-based the problem has been putting those cir- reduced state hospital maintenance housing (an essential component needed cumstances in place in the community. costs, and a new law entitling the men- to make deinstitutionalization work) be- The strength of the book is that it has a tally ill to disability benefits (making it cause no organization had the means to lot of relevant information necessary to possible for them to be supported out- pay for it. understand what happened with dein- side of the hospital on the federal rather JAMA, May 15, 265, No. 19 Books 2589 than the state budget), the states began of the book is that it gives a candid Each of chapters 4 through 7, com- to empty and close their hospitals. The bird's-eye view of how the mental health prising the second part of the book, is next step in the process was the estab- system developed into its current em- devoted to an analysis of one specific lishment of the right to refuse treat- barrassing lack of care for the seriously area of medical technology. Typically, ment. Legal roadblocks were estab- mentally ill. The book's weakness is that these chapters (1) evaluate technologi- lished that caused treatment delays, a it's SO strong and impactful that it may cal innovations from a historical per- waste of money on administrative pro- be dismissed as simply a counterpropa- spective, (2) explain how those technol- cedures, and discharge of uncooperative gandist attack against the antipsychia- ogies function in the health care setting, patients. The dangerousness standard try movement. Although the accusa- and then (3) examine the economic and of commitment rather than the need for tions of what has gone wrong and why ethical issues arising from the use of treatment standard made it easier for are quite strong and may be argued each technology. Chapter 4 focuses on patients to enter the criminal justice with, the book is invaluable because it cardiac technology (eg, pacemakers, the system than the mental health system. sets forth the right direction for the cor- artificial heart), chapter 5 deals with An excellent job is done of illustrating rection of the problem. technologies used in the intensive care the scientific proof of the efficacy and Carl C. Bell, MD unit to monitor and sustain cardiopul- safety of psychosurgery, electroconvul- Community Mental Health Council, Inc monary function, chapter 6 examines sive therapy, and psychotropic medica- University of Illinois the use of computers in health care, and School of Medicine tion. Yet the proponents of antipsychi- Jackson Park Hospital chapter 7 deals with medical imaging atry have been able to sway public Chicago procedures. opinion, public policy, and the law The last part of the book consists of a against these effective treatments of single chapter, which deals with eco- psychiatry by using the popular media. Technology and Society nomic and social issues that are not re- Rich stories of real people exemplify the lated to the development of any specific price of not having these treatments Medical Technology and Society: An Interdisci- technology but instead cut across all readily available to the seriously men- plinary Perspective, by Joseph D. Bronzino, Vin- technological innovations discussed in tally ill and the good these treatments cent K. Smith, and Maurice L. Wade (New Liberal part 2. For example, chapter 8 not only have done when given appropriately. Arts Series), 571 pp, with illus, $29.95, ISBN 0-262- 02300-8, Cambridge, Mass, MIT Press, 1990. attempts to determine whether the Model programs that provide work, highly technological nature of modern housing, treatment, and social interac- This book focuses on the economic and medical care dehumanizes patients, but tion are portrayed, but the authors ac- ethical issues associated with the devel- also asks whether preventive medicine curately point out that without compli- opment and use of medical technology. or acute care/rescue medicine should re- ance with drug therapy such programs The text is intended for liberal arts un- ceive higher priority in our society's don't work. dergraduates and all those interested in health care budget. The assertion is made that society has the problems posed by the use of modern Medical Technology and Society is approved of the right to be crazy, and medical technology. Because the text well written and easy to understand. the burden of care has fallen on the fam- targets a general audience, it presup- Furthermore, the text is innovative and ily, with little support forthcoming from poses no specialized knowledge on the possesses a number of strengths, of the hamstrung psychiatric profession. part of its readers. which I shall discuss two. Thus, in the final chapter, the authors First, this is the only medical ethics are specific in stating that community text I know of that takes the time and services are not enough, and a public "technological, economic, and trouble to introduce the reader to the policy prescription is given to correct ethical issues associated with the fundamentals of cost-benefit analysis. the damage the "myth of mental illness" evolution of America's health care Determining the economic costs and has done over the last 30 years. The au- benefits of various courses of action is an thors conclude by observing that the provision system" important factor in arriving at a correct National Alliance for the Mentally Ill moral judgment; consequently, the au- will be most helpful if it breaks its ties thors do their readers a distinct service with those in the antipsychiatry move- The book itself is divided into three when they include the basic techniques ment who seek to obstruct the mental parts. The first consists of three chap- of cost-benefit analysis within their health system in reestablishing access ters and is intended to provide the text. to treatment and proven tools of treat- reader with the basic tools necessary for Second, Medical Technology and So- ment. analyzing the major technological, eco- ciety does a better job than most medical The authors have done their home- nomic, and ethical issues associated ethics texts in providing readers with a work by gathering documents and per- with the evolution of America's health detailed understanding of the moral, sonal interviews with key players that care provision system since the turn of economic, and social issues spawned by support their perception of the dynam- the century. In chapter 1 the authors recent developments in medical technol- ics that led to our current state of mental provide a synoptic overview of the de- ogy. This is SO because the authors take health care. It is an outstanding book for velopment of medical practice and tech- the time to place technological innova- the physician who is seeking to under- nology from earliest recorded history up tions within a historical context and, in stand its development from forces that until the present. Chapter 2 briefly ex- addition, go into some detail to explain shape public policy, while Out of Bed- plores the relationship between innova- how such innovations function within lam tends to focus on what has occurred tions in medical technology and changes the health care setting. For example, to make the mental health system what in the economic policies of the United when the authors discuss the relation- it is today. The book is easy and enjoy- States since 1950. In addition, this chap- ship between modern medicine and the able to read. It is critical of organized ter introduces the reader to the basic possible dehumanization of patient care psychiatry's ability to be a watchdog of techniques of cost-benefit analysis. Fi- (pp 533-549), they clarify the issue with dangerous trends and faults psychiatry nally, chapter 3 serves as an introduc- an enlightening discussion of various for its lack of self-defense. The strength tion to ethical theory. changes medicine has undergone over 2590 JAMA, May 15, 265, No. 19 Books the past 2000 years. Again, before dis- (GDP), and all Canadians can receive government system. This helps the Ca- cussing the economic and ethical issues hospital and physicians' services with no nadian system to control costs through associated with devices such as the ar- charge at time of service. a dual government budget, federal and tificial heart, the authors describe the The differences between the Cana- provincial. fundamental principles of heart action dian and the US health services and The documentary made no mention (pp 137-144). Providing this information health insurance have been documented that the Canadian system forbids the adds greatly to the reader's understand- in an hour-long television program, Bor- sale of private health insurance that ing of how artificial hearts, pacemakers, derline Medicine, narrated by the vet- competes with services already paid for etc, work and also helps to set Medical eran TV reporter Walter Cronkite. The by government insurance, thus en- Technology and Society apart from presentation is even-handed, with com- abling more fiscal control from only two other "traditional" texts in medical eth- mentaries from health services policy sources, the provinces and the federal ics. experts from the United States both fa- government. It is extremely unlikely Despite my admiration for Medical vorably and unfavorably disposed to the that the US Congress would forbid this Technology and Society, I suspect that adoption of the Canadian system in this choice to the American people, even some professors may be reluctant to country. The facts presented are cor- though more fiscal control would be pos- adopt the text for classroom use because rect, such as continuing choice of phy- sible with fewer sources of funding. It is of its narrow focus. Not all problems in sicians and hospitals in Canada as in the plausible to predict, given past experi- biomedical ethics relate directly to United States, the differences in expen- ences with the reluctance to tax our- innovations in medical technology. For diture levels, and the striking differ- selves, that the United States would fi- example, the moral problem of abortion ences in the supply of high-technology nance a reasonably accessible health is not directly and immediately tied to services such as coronary artery bypass service or amenities that people in this technological advance and, as a result, surgery, angioplasty, and other sophis- country would want. What would is not dealt with in Medical Technology ticated diagnostic and treatment tech- emerge is that a rather large minority, and Society. Moreover, there are some nology. Canada creates waiting lists for the upper 40% of income, would also buy issues that are directly tied to these high-technology procedures and private insurance. If Canada continues technological innovation that Medical in some cases sends patients to Detroit to hold its expenditures to 8% of the Technology and Society neglects to and Seattle, as reported in the film. A GDP or even raises expenditures in con- mention, eg, genetic screening and re- particularly graphic part of the docu- stant relation to the GDP, Canada will combinant DNA technology. Given mentary is the live presentation of sev- not be able to maintain a modern health omissions of this sort, some teachers eral patients comparing Canada and the services provision system without using may opt for a medical ethics text United States as to how their treat- the United States as a high-technology broader in scope. ments, from obstetrics to cardiac, were backup. Apart from the above, Medical Tech- managed and paid for. Borderline Medicine is well done and nology and Society may be criticized by worth seeing. Perhaps it can stimulate some ethicists as being slightly biased discussion and debate regarding the against utilitarianism and in favor of "Canada creates waiting lists for questions raised herein. Kantianism. I am not a devotee of util- high-technology procedures and Odin W. Anderson, PhD itarianism, and even I felt that the dis- in some cases sends patients to University of Wisconsin cussion of ethical theories in chapter 3 Detroit and Seattle " Madison unfairly favored Kantianism over utili- tarianism. In my opinion, the strengths of Med- The 37 million or so people in the Ethics, Technology ical Technology and Society far out- United States with no insurance are What Kind of Life: The Limits of Medical weigh its weaknesses, and I would be played up as a serious deficiency in the Progress, by Daniel Callahan, 318 pp, with illus, happy to use the book as a classroom US system and, rightly, as an appalling $19.95, ISBN 0-671-67096-4, New York, NY, Simon text. Also, I would recommend the book example of inequity. Canada seems so & Schuster, 1990. to anyone who has an interest in medical far to have traded less high technology The focus of this work by Daniel Cal- ethics. for more primary care, whereas the lahan is individualism vs the good of the James M. Humber, PhD United States has done the opposite. community as played out on the wards Georgia State University The plight of the uninsured was dis- of American medicine. Atlanta cussed at length as if it was caused by He is concerned about a runaway the plurality of provision systems rather health care caused by the excessive ex- than a lack of a national public policy to pectations and demands of given pa- Government Health Insurance cover them. The government could buy tients to restore and maintain health, an services for the uninsured from the ex- aging population that dominates this Borderline Medicine, by Roger Weisberg, 1 video- isting delivery systems as it does for the claim, and a proliferation of medical sci- cassette, color, 57 minutes, U-matic or VHS, $395, Medicare patients. There are various ence and technology that fuels the pur- rental $75/3 days or $101/5 days, Champaign, III, ways to achieve universal health insur- suit of health but never quite satisfies it. Carle Medical Communications, 1991. ance. The implication of the documen- He warns that if these activities are un- In the face of continuing rising expen- tary seems to be that if the United checked, increasingly we will sacrifice ditures for health services in the United States adopted the Canadian pattern of other important social goods. He ques- States, the government-financed and federal-provincial (state) financing and tions the wisdom of this quest for med- -administered health insurance in Can- administration, it could operate as rea- ical progress and the inordinate place of ada is receiving a great deal of attention sonably effectively as Canada. There is maintaining health in our scale of indi- here. There are two reasons for this: in no mention of the fact that the Canadian vidual and social values. Canada the expenditure for health ser- government forbids private insurance He sees these problems as inade- vices has remained quite constant at 8% companies from competing with the sale quately addressed by developing new or so of the gross domestic product of insurance-for-services covered by the schemes to reorganize health services; JAMA, May 15, 1991-Vol 265, No. 19 Books 2591 by reining in the profits of physicians, mechanisms is not a straight-line engi- His suggested age standard policy in- health care institutions, or manufactur- neering process and cannot be so pre- troduces other issues, such as how to ers of technology; or by the myriad other cisely directed as Callahan would wish. deal with the ethical concerns of families regulatory and cost-cutting devices that Different fields of biologic research have who, seeking to honor the value of grat- are suggested routinely in the medical become increasingly interdependent. itude they bear toward those elders who literature. Neither does he think such For example, research on the acquired nurtured them, would, along with the factors basically cause our health care immunodeficiency syndrome has helped patients themselves, find significant crisis. Rather, he points to values as the us to penetrate biologic puzzles in can- age-restrictive policies that prevented core of the problem, particularly the cul- cer. Discoveries often are unantici- the use of beneficial therapy on them in- tural value of seeking to foster the good pated, and combinations of knowledge tolerable. Further, the concern for dif- of individuals by attempting to meet produce novel extensions. Such a ferences in people, seeing patients as their limitless demand for medical re- bounded research policy as he suggests, unique, has a significance beyond the sources. particularly when directed at basic bi- cultural and moral roots that Callahan His answer to this situation is to place ologic mechanisms, would be difficult, if focuses on. It has origins in the growth boundaries on these aspirations. He at- not impossible, to pursue. of a scientific medicine. It is a common- tempts to define a different moral and " place in medicine that one rarely sees a cultural basis by which to distribute the focus of policy should textbook case. It is the recognition of medical goods than one based on acqui- become a concern for the collective differences in patients that is at the escing to individual needs and claims for health of society " them-particularly the claims of the heart of doing the tasks of doctoring older segment of society with its de- well. The physician classifies patients A second significant proposal is that mand that "aging be fought against." through diagnosis as the first step to of using age as a prominent aspect of set- He argues that the focus of policy seeing what is unique. Medicine begins ting limits on the provision of health should become a concern for the collec- with linking patients but ends by sep- care. It must be noted that he discusses tive health of society through promoting arating them. Its art requires discern- applying other criteria to limit the serv- a healthy environment and preventive ing and treating the untypical. Its ing of individual curative need, such as measures, with regard for the individual groupings reflect shared experience, outcome or efficacy standards, with expressed more in terms of "care rather not common destiny. It is an illusion that which I agree. But the influence of aging than cure," and with basic and not un- and the elderly on health care use is people and the treatment of their ill- limited efforts made to vanquish the ill- quite important for him in defining the nesses are susceptible to rigid standard- ness of the individual, particularly if problem and the solution of the crisis he ization except at establishing their re- that person is very old. Society, he as- discusses. He argues that limits set on lation to general categories such as serts, would be "well justified in the fu- entire groups are less of an assault on a offered by diagnostic sortings. Taking a ture to set an age limit on the public pro- particular patient than denying treat- class of persons as diverse as that ob- vision of expensive, life-extending, ment to that patient for special reasons. tained through the rigid standard of nu- curative healthcare" and to "abandon Patients and physicians, he believes, merical age, and agreeing to treat them the idea of unlimited progress-but not would be more accepting of such cate- without reference to their differences, all progress-on the frontier of individ- gorical standards, and they would be would force physicians to treat partic- ual curative need." easier to carry out and more open to in- ular patients wrongly, set inappropriate By addressing the centrality of cul- spection than decisions based on per- precedents of practice that could extend tural and moral values in the cost ex- sonal standards applied at the bedside in to the treatment of other patients, and pansion of modern medicine, Callahan nonuniform ways. I agree that categor- severely encumber the task of clinical points us in the right direction: policy ical standards have such vantages and work. analyses of national health problems are important to develop and apply in Finally, although the demand on med- have given this inadequate attention. health care. But to place as much sig- icine from the force of individualism is Troublesome, however, are two of his nificance on the use of the categorical great, its pursuit has been vastly central suggestions. One concerns re- standard of age in treating the elderly as significant in galvanizing the creative search policy. Since research is the en- Callahan does, calling it "the main way energies of American society. What gine producing technology, he would of restricting that frontier," is unwise. would be the larger effect on our soci- like research policy structured in a way I question the assumption he makes that ety if individualism was successfully that assigns priorities to the relief of we seek to extend life at any cost as we staunched in respect to health? Since conditions already well understood and grow older. The introduction of the con- limits on it would likely extend into that afflict children and younger adults, cept of the living will in the early 1970s other facets of society, would we be bet- both of which policies would enhance the was an important patient-driven ex- ter off on the whole by having its sig- likelihood of better long-term outcome. pression of a growing view: that extend- nificance diminished? He further would give preference to the ing life is not good if that extension re- This is a challenging book, which needs of already surviving patients. He sults in much suffering and greatly makes a splendid effort to unite moral writes: reduced function. People do not want to and policy analysis and succeeds at We should not, in short, go beyond those be preserved to suffer. Yet, largely be- many levels. Callahan has many good frontiers until we know how to improve life cause of the lack of adequate help in ex- thoughts on rationing and political strat- for those already existing, but poorly, within plaining and constructing living wills, egies to achieve them too numerous to present frontiers. To use a military analogy: today only about 10% of adults have detail in this review. He deals with is- If we are going to conduct a war on various made them. A significant effort by the sues central to our times and tells us diseases, we should not extend our advance medical profession to determine the much that we can learn from, even when beyond our supply lines. preferences for treatment of the re- we disagree with him. I don't agree with this goal and do not maining adult part of the population Stanley J. Reiser, MD, PhD believe that those who do can accom- would be one type of measure needed to The University of Texas plish it. The finding of biologic facts and meet the problems Callahan raises. Health Science Center at Houston 2592 JAMA, May 15, 1991-Vol 265, No. 19 Books LASTYEAR,448 DOCTORS GAVE UP PRIVATE PRACTICE FOR A CHALLENGING NEW CAREER. They didn't give up medicine. They just started practicing it in a more exhilarating environment. An environment that affords them many tangible benefits. Like a diverse practice, unlimited access to medical specialities, and financial security. Plus a lot of intangibles. Like a comfortable lifestyle, an opportunity for worldwide experiences and the respect that goes along with being an Air Force officer. Of course, to enter an environment this rewarding, they did have to give up a few things. Like rent, equipment expenses, malpractice insurance, payrolls and utility bills. Now, you may be intrigued by such a unique opportunity. But like any good medical professional, you'd probably like a complete case history. So call 1-800-423-USAF. Or send your curriculum vitae to Colonel William E. Patterson, United States Air Force/RSH, Randolph Air Force Base, Texas 78150-5421. AIM HIGH. Impaired by peripheral arterial disease. Improved by Trental® (pentoxifylline) Increased blood viscosity is often a result of diminished red blood cell flexibility down- stream of a fixed obstruction.¹ Elevated plasma fibrinogen, as well as elevated red cell and platelet aggregation, contribute to hyperviscosity.1.3 Patients at greatest risk from peripheral arterial disease are usually over 50, smokers, diabetics, hypertensives or present with elevated cholesterol/triglycerides Intermittent claudication is one of several symptoms characteristic of the disease. Trental® (pentoxifylline) reduces blood viscosity,4 improving red cell flexibility,5 decreasing red cell and platelet aggregation, 6,7 and decreasing elevated plasma fibrinogen.⁴ Trental® improves tissue oxygenation. A significant increase in calf muscle pO₂ has been demonstrated in patients with intermittent claudication following a single oral dose.⁸ For best results continue treatment at least 2-3 months. Depending on the severity and previous duration of ischemia, improvement as measured by increased walking dis- tance to claudication may continue over weeks or months. Although some benefit may be seen as early as two to four weeks, therapy of at least two to three months is recommended. Not a vasodilator Not an anticoagulant Not related to aspirin or dipyridamole Trental (pentoxifylline) 400 mg Tablets The only proven-effective agent for intermittent claudication, a symptom of peripheral arterial disease Trental® can improve function and symptoms, but is not intended to replace more definitive therapy, such as surgery. © 1988 by Hoechst-Roussel Pharmaceuticals Inc. Please see references and brief summary of prescribing information on following page. References: 1. Chien S: Determinants of blood viscosity and red cell deformability. (pentoxifylline) tablets, immediate-release Trental® (pentoxifylline) capsules, or the Abstracts: 6, International Symposium on Filterability and Red Blood Cell Deformability, corresponding placebos. The incidence of adverse reactions was higher in the capsule Göteborg, Sweden, Sept 11-13, 1980. 2. Hanss MF: Filtration methods. Abstracts: 16, studies (where dose related increases were seen in digestive and nervous system side International Symposium on Filterability and Red Blood Cell Deformability, Göteborg, effects) than in the tablet studies. Studies with the capsule include domestic experience, Sweden, Sept 11-13, 1980. 3. Lowe GDO, Drummond MM, Forbes CD, et al: Blood and whereas studies with the controlled-release tablets were conducted outside the U.S. plasma viscosity in prediction of venous thrombosis. Abstracts: 77, International Sympo- The table indicates that in the tablet studies few patients discontinued because of sium on Filterability and Red Blood Cell Deformability, Göteborg, Sweden, Sept 11-13, adverse effects. 1980. 4. Müller R: Modification of disturbed flow properties of blood: a promising avenue in the treatment of peripheral vascular diseases. Pharmatherapeutica INCIDENCE (%) OF SIDE EFFECTS 1983; 3(Suppl 1):5-17. 5. Stormer B, Kleinschmidt K, Loose D, et al: Rheological changes Controlled-Release Immediate-Release in the blood of patients with chronic arterial occlusive disease after the administration of Tablets Capsules vasoactive drugs. Curr Med Res Opin 1977;4:588-595. 6. Seiffge D: IRCS Med Sci 1980;8:727. 7. Nenci GG, Gresele P. Agnelli G, et al: Effect of pentoxifylline on platelet Commercially Used only for aggregation. Pharmatherapeutica 1981;2:532-538. 8. Ehrly AM: Effects of orally Available Controlled Clinical Trials administered pentoxifylline on muscular oxygen pressure in patients with intermittent Trental® Placebo Trental® Placebo claudication. IRCS Med Sci 1982;10:401-402. (Numbers of Patients at Risk) (321) (128) (177) (138) Discontinued for Side Effect 3.1 0 9.6 7.2 Trental® (pentoxifylline) Tablets, 400 mg CARDIOVASCULAR SYSTEM A brief summary of the Prescribing Information follows. Angina/Chest Pain 0.3 - 1.1 2.2 Arrhythmia/Palpitation - - 1.7 0.7 INDICATIONS AND USAGE: Flushing - - 2.3 Trental® (pentoxifylline) is indicated for the treatment of patients with intermittent 0.7 claudication on the basis of chronic occlusive arterial disease of the limbs. Trental® (pen- DIGESTIVE SYSTEM toxifylline) can improve function and symptoms but is not intended to replace more Abdominal Discomfort - - 4.0 1.4 definitive therapy, such as surgical bypass, or removal of arterial obstructions when Belching/Flatus/Bloating 0.6 - 9.0 3.6 treating peripheral vascular disease. Diarrhea - - 3.4 2.9 CONTRAINDICATIONS: Dyspepsia 2.8 4.7 9.6 2.9 Trental® (pentoxifylline) should not be used in patients who have previously exhibited Nausea 2.2 0.8 28.8 8.7 intolerance to this product or methylxanthines such as caffeine, theophylline, and Vomiting 1.2 - 4.5 0.7 theobromine. NERVOUS SYSTEM PRECAUTIONS: Agitation/Nervousness - - 1.7 0.7 General: Patients with chronic occlusive arterial disease of the limbs frequently show Dizziness 1.9 3.1 11.9 4.3 other manifestations of arteriosclerotic disease. Trental® (pentoxifylline) has been used Drowsiness - - 1.1 5.8 safely for treatment of peripheral arterial disease in patients with concurrent coronary Headache 1.2 1.6 6.2 5.8 artery and cerebrovascular diseases, but there have been occasional reports of angina, Insomnia - - 2.3 2.2 hypotension, and arrhythmia. Controlled trials do not show that Trental® (pentoxifylline) Tremor 0.3 0.8 - - causes such adverse effects more often than placebo, but, as it is a methylxanthine Blurred Vision - - 2.3 1.4 derivative, it is possible some individuals will experience such responses. Drug Interactions: Although a causal relationship has not been established, there Trental® (pentoxifylline) has been marketed in Europe and elsewhere since 1972. In have been reports of bleeding and/or prolonged prothrombin time in patients treated addition to the above symptoms, the following have been reported spontaneously since with Trental® (pentoxifylline) with and without anticoagulants or platelet aggregation marketing or occurred in other clinical trials with an incidence of less than 1%; the inhibitors. Patients on warfarin should have more frequent monitoring of prothrombin causal relationship was uncertain: times, while patients with other risk factors complicated by hemorrhage (e.g., recent Cardiovascular-dyspnea, edema, hypotension. surgery, peptic ulceration) should have periodic examinations for bleeding including Digestive-anorexia, cholecystitis, constipation, dry mouth/thirst. hematocrit and/or hemoglobin. Trental® (pentoxifylline) has been used concurrently with Nervous-anxiety, confusion. antihypertensive drugs, beta blockers, digitalis, diuretics, antidiabetic agents, and Respiratory- epistaxis, flu-like symptoms, laryngitis, nasal congestion. antiarrhythmics, without observed problems. Small decreases in blood pressure have Skin and Appendages-brittle fingernails, pruritus, rash, urticaria, angioedema. been observed in some patients treated with Trental® (pentoxifylline); periodic systemic Special Senses-blurred vision, conjunctivitis, earache, scotoma. blood pressure monitoring is recommended for patients receiving concomitant antihy- Miscellaneous-bad taste, excessive salivation, leukopenia, malaise, sore pertensive therapy. If indicated, dosage of the antihypertensive agents should be reduced. throat/swollen neck glands, weight change. Carcinogenesis, Mutagenesis and Impairment of Fertility: Long-term studies of A few rare events have been reported spontaneously worldwide since marketing in the carcinogenic potential of pentoxifylline were conducted in mice and rats by dietary 1972. Although they occurred under circumstances in which a causal relationship with administration of the drug at doses up to approximately 24 times (570 mg/kg) the maxi- pentoxifylline could not be established, they are listed to serve as information for physi- mum recommended human daily dose (MRHD) of 24 mg/kg for 18 months in mice and cians: Cardiovascular-angina, arrhythmia, tachycardia; Digestive-hepatitis, jaundice, 18 months in rats with an additional 6 months without drug exposure in the latter. No increased liver enzymes; and Hemic and Lymphatic - serum fibrinogen, carcinogenic potential for pentoxifylline was noted in the mouse study. In the rat study, pancytopenia, aplastic anemia, purpura, thrombocytopenia. there was a statistically significant increase in benign mammary fibroadenomas in OVERDOSAGE: females in the high dose group (24.x MRHD). The relevance of this finding to human Overdosage with Trental® (pentoxifylline) has been reported in children and adults. use is uncertain since this was only a marginal statistically significant increase for a Symptoms appear to be dose related. A report from a poison control center on 44 tumor that is common in aged rats. Pentoxifylline was devoid of mutagenic activity in patients taking overdoses of enteric-coated pentoxifylline tablets noted that symptoms various strains of Salmonella (Ames test) when tested in the presence and absence of usually occurred 4-5 hours after ingestion and lasted about 12 hours. The highest metabolic activation. amount ingested was 80 mg/kg; flushing, hypotension, convulsions, somnolence, loss Pregnancy: Category C. Teratogenic studies have been performed in rats and rabbits at of consciousness, fever, and agitation occurred. All patients recovered. oral doses up to about 25 and 10 times the maximum recommended human daily dose In addition to symptomatic treatment and gastric lavage, special attention must be (MRHD) of 24 mg/kg, respectively. No evidence of fetal malformation was observed. given to supporting respiration, maintaining systemic blood pressure, and controlling Increased resorption was seen in rats at 25 times MRHD. There are, however, no ade- convulsions. Activated charcoal has been used to adsorb pentoxifylline in patients who have overdosed. quate and well controlled studies in pregnant women. Because animal reproduction DOSAGE AND ADMINISTRATION: studies are not always predictive of human response, Trental® (pentoxifylline) should be used during pregnancy only if clearly needed. The usual dosage of Trental® (pentoxifylline) in controlled-release tablet form is one Nursing Mothers: Pentoxifylline and its metabolites are excreted in human milk. tablet (400 mg) three times a day with meals. Because of the potential for tumorigenicity shown for pentoxifylline in rats, a decision While the effect of Trental® (pentoxifylline) may be seen within 2 to 4 weeks, it is recom- should be made whether to discontinue nursing or discontinue the drug, taking into mended that treatment be continued for at least 8 weeks. Efficacy has been demon- account the importance of the drug to the mother. strated in double-blind clinical studies of 6 months duration. Pediatric Use: Safety and effectiveness in children below the age of 18 years have not Digestive and central nervous system side effects are dose related. If patients develop been established. these side effects it is recommended that the dosage be lowered to one tablet twice a ADVERSE REACTIONS: day (800 mg/day). If side effects persist at this lower dosage, the administration of Clinical trials were conducted using either controlled-release Trental® (pentoxifylline) Trental® (pentoxifylline) should be discontinued. Edition 2/88 tablets for up to 60 weeks or immediate-release Trental® (pentoxifylline) capsules for up Trental® REG TM HOECHST AG to 24 weeks. Dosage ranges in the tablet studies were 400 mg bid to tid and in the capsule studies, 200-400 mg tid. Hoechst-Roussel Pharmaceuticals Inc. Hoechst The table summarizes the incidence (in percent) of adverse reactions considered drug Somerville, New Jersey 08876 related, as well as the numbers of patients who received controlled-release Trental® The name and logo HOECHST are registered trademarks of Hoechst AG Help your patients take a step toward early detection and treatment of P.A.D Step Send away today or ask your Hoechst-Roussel Lively representative for your free supply of our patient Trental 400 mg education booklet, "Step Lively". Tablets (pentoxifylline) Name The only proven-effective agent for Address intermittent claudication, a symptom City State Zip of peripheral arterial disease Cut out and mail to: Step Lively, HOECHST-ROUSSEL PHARMACEUTICALS INC., P.O. Box 831, Andover, New Jersey 07821 Q73142-1088 The best advertising for CAPOTEN isn't found in ads. You'll find it in an extensive body of literature and in the personal experience of CAPOTEN prescribers. In hypertension* ® *CAPOTEN may be used as initial therapy in hypertension only for patients with normal renal function in whom the risk of neutropenia/agranulocytosis is relatively low (1 out of over 8,600 in clinical trials). Use special precautions in patients CAPOTEN (captopril tablets) BID with impaired renal function, collagen vascular disorders, or those exposed to other drugs known to affect the white blood cells or immune response. Evaluation of hypertensives should always include assessment of renal function. CAPOTEN may be dosed bid or tid. See brief summary of prescribing informa- tion on the adjacent page. Count on it. CAPOTEN* TABLETS Lithium-Increased serum lithium levels and symptoms of lithium toxicity have been reported in pa- Captopril Tablets tients receiving concomitant lithium and ACE inhibitor therapy. These drugs should be coadminis- INDICATIONS: Hypertension-CAPOTEN (captopril) is indicated for the treatment of hypertension. tered with caution and frequent monitoring of serum lithium levels is recommended. If a diuretic is Consideration should be given to the risk of neutropenia/agranulocytosis (see WARNINGS). CAPOTEN also used, it may increase the risk of lithium toxicity. is effective alone and in combination with other antihypertensive agents, especially thiazide-type diuretics. Drug/Laboratory Test Interaction: Captopril may cause a false-positive urine test for acetone. Heart Failure: CAPOTEN (captopril) is indicated in the treatment of congestive heart failure in pa- Carcinogenesis, Mutagenesis and Impairment of Fertility: Two-year studies with doses of 50 to tients who have not responded adequately to treatment with diuretics and digitalis. CAPOTEN should 1350 mg/kg/day in mice and rats failed to show any evidence of carcinogenic potential. Studies in generally be added to both of these agents except when digitalis use is poorly tolerated or other- rats have revealed no impairment of fertility. wise not feasible. Pregnancy: Category C: Embryocidal effects and craniofacial malformations were observed in rab- CONTRAINDICATIONS: CAPOTEN is contraindicated in patients who are hypersensitive to this prod- bits. Human Experience-There are no adequate and well-controlled studies of captopril in pregnant uct or any other angiotensin-converting enzyme inhibitor (e.g., a patient who has experienced an- women. Data are available that show captopril crosses the human placenta. Captopril should be used gioedema during therapy with any other ACE inhibitor. during pregnancy only if the potential benefit justifies the potential risk to the fetus. WARNINGS: Angioedema-Angioedema involving the extremities, face, lips, mucous membranes, Based on post-marketing experience with all ACE inhibitors, the following information has been col- tongue, glottis or larynx has been seen in patients treated with ACE inhibitors, including captopril. lected. Inadvertent exposure limited to the first trimester of pregnancy does not appear to affect fetal out- If angioedema involves the tongue, glottis or larynx, airway obstruction may occur and be fatal. come adversely. Fetal exposure during the second and third trimester of pregnancy has been associated Emergency therapy, including but not necessarily limited to, subcutaneous administration of a with fetal and neonatal morbidity and mortality. 1:1000 solution of epinephrine should be promptly instituted. When ACE inhibitors are used during the later stages of pregnancy, there have been reports of hypotension and decreased renal perfusion in the newborn. Oligohydramnios in the mother has also Neutropenia/Agranulocytosis-Neutropenia (<1000/mm³) with myeloid hypoplasia has resulted been reported. Infants exposed in utero to ACE inhibitors should be closely observed for hypoten- from use of captopril. About half of the neutropenic patients developed systemic or oral cavity in- sion, oliguria and hyperkalemia. If oliguria occurs, attention should be directed toward support of fections or other features of the syndrome of agranulocytosis. The risk of neutropenia is dependent blood pressure and renal perfusion with the administration of fluids and pressors as appropriate. on the clinical status of the patient: Problems associated with prematurity such as patent ductus arteriosus have occurred in associa- In clinical trials in patients with hypertension who have normal renal function (serum creatinine tion with maternal use of ACE inhibitors but it is not clear whether they are related to ACE inhibition, less than 1.6 mg/dL and no collagen vascular disease), neutropenia has been seen in one patient maternal hypertension or the underlying prematurity. out of over 8,600 exposed. In patients with some degree of renal failure (serum creatinine at least There is no experience with exchange transfusion, hemodialysis or peritoneal dialysis for remov- 1.6 mg/dL) but no collagen vascular disease, the risk in clinical trials was about 1 per 500. Doses ing captopril from the neonatal circulation. were relatively high in these patients, particularly in view of their diminished renal function. In pa- tients with collagen vascular diseases (e.g., systemic lupus erythematosus, scleroderma) and im- Nursing Mothers: Concentrations of captopril in human milk are approximately one percent of those paired renal function, neutropenia occurred in 3.7% of patients in clinical trials. While none of the in maternal blood. Because of the potential for serious adverse reactions in nursing infants from cap- over 750 patients in formal clinical trials of heart failure developed neutropenia, it has occurred topril, a decision should be made whether to discontinue nursing or to discontinue the drug, taking during the subsequent clinical experience. Of reported cases, about half had serum creatinine ≥ 1.6 into account the importance of CAPOTEN to the mother. (See PRECAUTIONS: Pediatric Use.) mg/dL and more than 75% received procainamide. In heart failure, it appears that the same risk Pediatric Use: Safety and effectiveness in children have not been established. There is limited ex- factors for neutropenia are present. perience reported in the literature with the use of captopril in the pediatric population; dosage, on Neutropenia has appeared usually within 3 months after starting therapy, associated with myeloid hy- a weight basis, was generally reported to be comparable to or less that that used in adults. poplasia and frequently accompanied by erythroid hypoplasia and decreased numbers of megakary- Infants, especially newborns, may be more susceptible to the adverse hemodynamic effects of ocytes (e.g., hypoplastic bone marrow and pancytopenia); anemia and thrombocytopenia were captopril. Excessive, prolonged and unpredictable decreases in blood pressure and associated com- sometimes seen. Neutrophils generally returned to normal in about 2 weeks after captopril was dis- plications, including oliguria and seizures, have been reported. continued, and serious infections were limited to clinically complex patients. About 13% of the cases CAPOTEN (captopril) should be used in children only if other measures for controlling blood of neutropenia have ended fatally, but almost all fatalities were in patients with serious illness, hav- pressure have not been effective. ing collagen vascular disease, renal failure, heart failure or immunosuppressant therapy, or a combi- ADVERSE REACTIONS: Reported incidences are based on clinical trials involving approximately nation of these complicating factors. Evaluation of the hypertensive or heart failure patient should 7000 patients. always include assessment of renal function. If captopril is used in patients with impaired renal Renal-About 1 of 100 patients developed proteinuria (see WARNINGS). Renal insufficiency, renal function, white blood cell and differential counts should be evaluated prior to starting treatment and failure, nephrotic syndrome, polyuria, oliguria, and urinary frequency in 1 to 2 of 1000 patients. at approximately 2-week intervals for about 3 months, then periodically. In patients with collagen vas- Hematologic-Neutropenia/agranulocytosis has occurred (see WARNINGS). Anemia, thrombocy- cular disease or who are exposed to other drugs known to affect the white cells or immune response, topenia, and pancytopenia have been reported. particularly when there is impaired renal function, captopril should be used only after an assessment Dermatologic-Rash, (usually maculopapular, rarely urticarial), often with pruritus, and sometimes of benefit and risk, and then with caution. All patients treated with captopril should be told to report with fever and eosinophilia, in about 4 to 7 of 100 patients (depending on renal status and dose), any signs of infection (e.g., sore throat, fever). If infection is suspected, perform white cell counts with- usually during the 1st 4 weeks of therapy. Pruritus, without rash, in about 2 of 100 patients. A re- out delay. Since discontinuation of captopril and other drugs has generally led to prompt return of versible associated pemphigoid-like lesion, and photosensitivity, have also been reported. Flushing the white count to normal, upon confirmation of neutropenia (neutrophil count <1000/mm³) withdraw or pallor in 2 to 5 of 1000 patients. captopril and closely follow the patient's course. Cardiovascular-Hypotension may occur; see WARNINGS and PRECAUTIONS [Drug Interactions] Proteinuria: Total urinary proteins >1 g per day were seen in about 0.7% of patients on captopril. for discussion of hypotension with captopril therapy. Tachycardia, chest pain, and palpitations each About 90% of affected patients had evidence of prior renal disease or received high doses (>150 in about 1 of 100 patients. Angina pectoris, myocardial infarction, Raynaud's syndrome, and con- mg/day), or both. The nephrotic syndrome occurred in about one-fifth of proteinuric patients. In most gestive heart failure each in 2 to 3 of 1000 patients. cases, proteinuria subsided or cleared within 6 months whether or not captopril was continued. The Dysgeusia-Approximately 2 to 4 (depending on renal status and dose) of 100 patients developed BUN and creatinine were seldom altered in proteinuric patients. Since most cases of proteinuria OC- a diminution or loss of taste perception; taste impairment is reversible and usually self-limited even curred by the 8th month of therapy with captopril, patients with prior renal disease or those receiving with continued drug use (2 to 3 months). captopril at doses 150 mg per day, should have urinary protein estimates (dip-stick on 1st morning Angioedema-Angioedema involving the extremities, face, lips, mucous membranes, tongue, glot- urine) before therapy, and periodically thereafter. tis or larynx has been reported in approximately one in 1000 patients. Angioedema involving the upper airways has caused fatal airway obstruction. (See WARNINGS.) Hypotension: Excessive hypotension was rarely seen in hypertensive patients but is a possible con- Cough-Cough has been reported in 0.5-2% of patients treated with captopril in clinical trials. sequence of captopril use in salt/volume depleted persons (such as those treated vigorously with The following have been reported in about 0.5 to 2 percent of patients but did not appear at in- diuretics), patients with heart failure or those patients undergoing renal dialysis. (See PRECAUTIONS [Drug Interactions].) In heart failure, where the blood pressure was either normal or low, transient creased frequency compared to placebo or other treatments used in controlled trials: gastric irrita- tion, abdominal pain, nausea, vomiting, diarrhea, anorexia, constipation, aphthous ulcers, peptic ulcer, decreases in mean blood pressure >20% were recorded in about half of the patients. This transient dizziness, headache, malaise, fatigue, insomnia, dry mouth, dyspnea, cough, alopecia, paresthesias. hypotension is more likely to occur after any of the first several doses and is usually well tolerated, although rarely it has been associated with arrhythmia or conduction defects. A starting dose of 6.25 Other clinical adverse effects reported since the drug was marketed are listed below by body sys- tem. In this setting, an incidence or causal relationship cannot be accurately determined. or 12.5 mg tid may minimize the hypotensive effect. Patients should be followed closely for the first 2 weeks of treatment and whenever the dose of captopril and/or diuretic is increased. General: Asthenia, gynecomastia. BECAUSE OF THE POTENTIAL FALL IN BLOOD PRESSURE IN THESE PATIENTS, THERAPY Cardiovascular: Cardiac arrest, cerebrovascular accident/insufficiency, rhythm disturbances, or- SHOULD BE STARTED UNDER VERY CLOSE MEDICAL SUPERVISION. thostatic hypotension, syncope. Dermatologic: Bullous pemphigus, erythema multiforme (including Stevens-Johnson syndrome), PRECAUTIONS: General: Impaired Renal Function-Hypertension-Some hypertensive patients with exfoliative dermatitis. renal disease, particularly those with severe renal artery stenosis, have developed increases in BUN Gastrointestinal: Pancreatitis, glossitis, dyspepsia. and serum creatinine. It may be necessary to reduce captopril dosage and/or discontinue diuretic. Hematologic: Anemia, including aplastic and hemolytic. For some of these patients, normalization of blood pressure and maintenance of adequate renal per- Hepatobiliary: Jaundice, hepatitis, including rare cases of necrosis, cholestasis. fusion may not be possible. Heart Failure-About 20% of patients develop stable elevations of BUN Metabolic: Symptomatic hyponatremia. and serum creatinine >20% above normal or baseline upon long-term treatment. Less than 5% of Musculoskeletal: Myalgia, myasthenia. patients, generally with severe preexisting renal disease, required discontinuation due to progres- Nervous/Psychiatric: Ataxia, confusion, depression, nervousness, somnolence. sively increasing creatinine. See DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS [Altered Laboratory Findings]. Hyperkalemia: Elevations in serum potassium have been observed in some Respiratory: Bronchospasm, eosinophilic pneumonitis, rhinitis. Special Senses: Blurred vision. patients treated with ACE inhibitors, including captopril. When treated with ACE inhibitors, patients at risk for the development of hyperkalemia include those with: renal insufficiency; diabetes melli- Urogenital: Impotence. tus; and those using concomitant potassium-sparing diuretics, potassium supplements or potassium- As with other ACE inhibitors, a syndrome has been reported which may include: fever, myalgia, containing salt substitutes; or other drugs associated with increases in serum potassium. (See arthralgia, interstitial nephritis, vasculitis, rash or other dermatologic manifestations, eosinophilia and PRECAUTIONS: Drug Interactions; ADVERSE REACTIONS: Altered Laboratory Findings.) Valvular an elevated ESR. Findings have usually resolved with discontinuation of treatment. Stenosis-A theoretical concern, for risk of decreased coronary perfusion, has been noted regarding Altered Laboratory Findings: Serum Electrolytes: Hyperkalemia: small increases in serum potas- vasodilator treatment in patients with aortic stenosis due to decreased afterload reduction. sium, especially in patients with renal impairment (see PRECAUTIONS). Surgery/Anesthesia-If hypotension occurs during surgery or anesthesia, and is considered due to Hyponatremia: particularly in patients receiving a low sodium diet or concomitant diuretics. the effects of captopril, it is correctable by volume expansion. BUN/Serum Creatinine: Transient elevations of BUN or serum creatinine especially in volume or Drug Interactions: Hypotension-Patients on Diuretic Therapy-Precipitous reduction of blood pressure salt depleted patients or those with renovascular hypertension may occur. Rapid reduction of long- may occasionally occur within the 1st hour after administration of the initial captopril dose in patients standing or markedly elevated blood pressure can result in decreases in the glomerular filtration rate on diuretics, especially those recently placed on diuretics, and those on severe dietary salt restriction and, in turn, lead to increases in BUN or serum creatinine. or dialysis. This possibility can be minimized by either discontinuing the diuretic or increasing the salt Hematologic: A positive ANA has been reported. intake about 1 week prior to initiation of captopril therapy or by initiating therapy with small doses (6.25 Liver Function Tests: Elevations of liver transaminases, alkaline phosphatase, and serum bilirubin or 12.5 mg). Alternatively, provide medical supervision for at least 1 hour after the initial dose. have occurred. Agents Having Vasodilator Activity-In heart failure patients, vasodilators should be administered with caution. OVERDOSAGE: Primary concern is correction of hypotension. Volume expansion with an I.V. infu- Agents Causing Renin Release-Captopril's effect will be augmented by antihypertensive agents sion of normal saline is the treatment of choice for restoration of blood pressure. Captopril may be that cause renin release. removed from the general circulation by hemodialysis. Agents Affecting Sympathetic Activity-The sympathetic nervous system may be especially impor- DOSAGE AND ADMINISTRATION: CAPOTEN (captopril) should be taken one hour before meals. tant in supporting blood pressure in patients receiving captopril alone or with diuretics. Beta-adren- In hypertension, CAPOTEN may be dosed bid or tid. Dosage must be individualized; see DOSAGE ergic blocking drugs add some further antihypertensive effect to captopril, but the overall response AND ADMINISTRATION section of package insert for detailed information regarding dosage in hy- is less than additive. Therefore, use agents affecting sympathetic activity (e.g., ganglionic blocking pertension and in heart failure. Because CAPOTEN (captopril) is excreted primarily by the kidneys, agents or adrenergic neuron blocking agents) with caution. dosage adjustments are recommended for patients with impaired renal function. Agents Increasing Serum Potassium-Give potassium-sparing diuretics or potassium supplements Consult package insert before prescribing CAPOTEN (captopril). only for documented hypokalemia, and then with caution, since they may lead to a significant in- crease of serum potassium. Use potassium-containing salt substitutes with caution. HOW SUPPLIED: Available in tablets of: 12.5 mg in bottles of 100 and 1000; 25 mg in bottles of Inhibitors of Endogenous Prostaglandin Synthesis-Indomethacin and other nonsteroidal anti- 100, 1000, and 5000; 50 mg in bottles of 100 and 1000; 100 mg in bottles of 100; and in UNIMATIC* inflammatory agents may reduce the antihypertensive effect of captopril, especially in low renin unit-dose packs of 100 tablets. hypertension. (J3-658U) III PRINCETON SQUIBB PHARMACEUTICAL PRODUCTS 1991 E.R. Squibb & Sons, Inc., Princeton, NJ 521-502 Issued: April 1991 2598 CONSIDER THESE NEW CLINICAL FINDINGS: Two Advil® tablets (ibuprofen 400 mg) were shown to be significantly more effective than two Tylenol® (600 mg) with Codeine (60 mg) No. 3 CIII tablets in two dental pain studies¹ MEAN PAIN RELIEF RATING OVER A SIX-HOUR PERIOD FOLLOWING PERIODONTAL SURGERY² 4 3.5 Ibuprofen 400 mg (n=50) 3 PAIN RELIEF SCORE O=no relief; 4=complete relief 2.5 2 Acetaminophen 600 mg/Codeine 60 mg (n=44) 1.5 1 Placebo (n=44) 0.5 0 0 1 2 3 4 5 6 TIME (Hours) Ibuprofen (400 mg) provided significantly better pain relief and pain reduction than acetaminophen (600 mg) with codeine (60 mg) following periodontal surgery (n = 138)² One Advil tablet (ibuprofen 200 mg) provides effective pain relief* Excellent safety profile Advil 1899 Advil 1955 OTC IBUPROFEN 200 MG TODAY should be your #1 choice for OTC analgesia References: 1. Cooper SA, Greene JJ, Schachtel BP, et al.: Ibuprofen 400 mg compared to acetaminophen 600 mg with codeine 60 mg. Clin Pharmacol Ther 45:176, 1989. 2. Schachtel BP, Fazio RC, Greene II: Ibuprofen 400 mg compared to acetaminophen 600 mg with codeine 60 mg for pain relief fol- lowing periodontal surgery. J Clin Pharmacol 30:846, 1990. Please advise patients to read and follow product labeling. Patients should not take this product if they have had a severe allergic reaction to aspirin. * Indicated for the temporary relief of minor aches and pains associated with the common cold, headache, toothache, muscular aches, backache, for the minor pain of arthritis, for the pain of menstrual cramps, and for the reduction of fever. Appearance of the brown ADVIL tablet and caplet is a trademark of Whitehall Laboratories, N.Y., N.Y. © 1990 WHITEHALL LABORATORIES A HEALTH CARE DIVISION OF AMERICAN HOME PRODUCTS CORPORATION Obituary Listing ARMSTRONG-RESSY Carlos T., 67; Hato Rey, DUGGAN, John Joseph, Jr, 66; St Louis, Mo; LESSE, Stanley, 68, M New York, NY; Jeffer- Puerto Rico; Meharry Medical College Louisiana State University School of Medi- son Medical College of Thomas Jefferson School of Medicine, 1946; certified by the cine in New Orleans, 1948; died November University, 1945; certified by the American American Board of Physical Medicine and 19, 1990. Board of Psychiatry and Neurology; died De- Rehabilitation; died April 2, 1990. cember 20, 1990. DUNN, John C., 77; Apopka, Fla; Georgetown BADGER, Demarious A. C., 80, M Albuquer- University School of Medicine, 1937; certi- LEWIS, Letteer G. H., 81, M Galva, Kan; Uni- que, NM; University of Michigan Medical fied by the American Board of Orthopaedic versity of Kansas Medical Center, School of School, 1934; died December 11, 1990. Surgery; died April 9, 1990. Medicine, 1937; died December 3, 1990. BATTALORA, George C., Sr, 90, M Pass Chris- FERNANDEZ, Serafin G., 85; Miami, Fla; Insti- LOOMIS, Leonard Joseph, 33; Oak Park, Ill; tian, Miss; Tulane University School of tuto Superior de Ciencias Médicas de La University of Rochester School of Medicine Medicine, 1920; certified by the American Habana, Havana, Cuba, 1928; died May 1, and Dentistry, 1985; died May 13, 1990. Board of Orthopaedic Surgery; died October 1990. 10, 1990. MICHAELSON, Ernest, 76, M Fort Lauderdale, FORSTER, Stuart William, 44; New York, NY; Fla; University of Maryland School of Medi- BERGER, Gustave K., 60, M Wilmington, Del; Albert Einstein College of Medicine of Yeshi- cine, 1938; died January 13, 1991. Faculteit der Geneeskunde, Katholieke Uni- va University, 1975; died January 11, 1991. versiteit Leuven, Belgium, 1957; died No- NISHIGAYA, Toru, 78, M Honolulu, Hawaii; vember 25, 1990. GALLAGER, Harry Stephen, 68, M Houston, Tulane University School of Medicine, 1938; Tex; Temple University School of Medicine, died November 2, 1990. BRINK, Donald M., 81; Hutchinson, Minn; The 1946; certified by the American Board of Pa- University of Minnesota Medical School, thology; died December 8, 1990. PRIMAKOFF, Harry William, 87, M Baltimore, 1937; died October 1, 1990. Md; George Washington University School HAMBRICK, Edward R., 72; San Francisco, of Medicine and Health Sciences, 1928; died BROCKBANK, Thomas William, 97, M Boca Ra- Calif; Meharry Medical College School of September 13, 1990. ton, Fla; Georgetown University School of Medicine, 1944; died October 7, 1990. Medicine, 1924; certified by the American RAVDIN, Emile M., 72, M Los Angeles, Calif; Board of Psychiatry and Neurology; died No- HELLER, Philip Henri, 71, M Hilton Head Is- Indiana University School of Medicine, vember 13, 1990. land, SC; Northwestern University Medical 1942; certified by the American Board of School, 1945; certified by the American Ophthalmology; died August 30, 1990. CAMPBELL, Lorne A., Jr, 79, M Clear Lake, Board of Family Practice; died January 10, Wis; The University of Minnesota Medical 1991. RICHARDSON, G. Robert, 49; Johns Island, School, 1939; died March 25, 1990. SC; Medical University of South Carolina HOLLAND, John J., 63, M Fort Myers, Fla; College of Medicine, 1967; certified by the CASSADAY, Charles Edgar, 77, M Mount Ver- Loyola University of Chicago Stritch School American Board of Pediatrics; died Novem- non, Ohio; University of Cincinnati College of Medicine, 1953; certified by the American ber 4, 1990. of Medicine, 1941; died November 13, 1990. Board of Ophthalmology; died December 16, 1990. RICHEY, Leo Delano, 78, M Elgin, Ill; Univer- COOKE, Everette Ellis, 71, M Oklahoma City, sity of Health Science, The Chicago Medical Okla; University of Oklahoma College of HOOTON, T. Campbell, 87, M San Mateo, Calif; School, 1942; died September 6, 1990. Medicine, 1943; certified by the American Columbia University College of Physicians Board of Surgery; died November 19, 1990. and Surgeons, 1932; died August 15, 1990. ROLLINS, Marvin, 67, M Chagrin Falls, Ohio; Case Western Reserve University School of CROSLEY, Willard Boaz, 79, M Glendale, Calif; ISAACSON, Stanford I., 74, M Pittsburgh, Pa; Medicine, 1952; certified by the American Case Western Reserve University School of University of Pittsburgh School of Medicine, Board of Radiology; died December 4, 1990. Medicine, 1940; certified by the American 1943; certified by the American Board of In- Board of Obstetrics and Gynecology; died ternal Medicine; died April 30, 1990. SANBORN, Neal Duane, 66, M Chula Vista, November 20, 1990. Calif; University of Colorado School of Medi- JONES, Francis A., Jr, 81, M St Joseph, Mich; cine, 1947; certified by the American Board DAVIES, Nicholas Edward, 65, M Atlanta, Ga; Yale University School of Medicine, 1935; of Preventive Medicine; died April 3, 1990. University of Virginia School of Medicine, certified by the American Board of Obstet- 1952; certified by the American Board of rics and Gynecology; died December 2, 1989. ST CLAIR, Robert Theron, 83, M Visalia, Calif; Internal Medicine; died April 5, 1991. The University of Minnesota Medical KARP, Howard N., 64; Santa Barbara, Calif; School, 1937; certified by the American Ohio State University College of Medicine, Board of Ophthalmology; died July 7, DE BONIS, Anthony M., 59; Wynantskill, NY; 1949; certified by the American Board of Psy- 1990. Facoltà di Medicina e Chirurgia, Università chiatry and Neurology; died August 11, 1990. di Bologna, Italy, 1960; certified by the THOMPSON, Douglas J., 68; Port Arthur, Tex; American Board of Internal Medicine; died KELLEY, Paul Robert John, 63; Skokie, Ill; University of Virginia School of Medicine, November 8, 1990. University of Illinois College of Medicine, 1949; died October 11, 1990. 1955; died November 3, 1990. DOLINSKY, Aaron, 64; White Plains, NY; VLASIS, George P., 71, M Oak Lawn, Ill; Uni- Medical College of Georgia School of Medi- KRESGE, Charles Leslie, 45; Middletown, versity of Illinois College of Medicine, 1943; cine, 1953; certified by the American Board Ohio; Indiana University School of Medi- certified by the American Board of Obstet- of Psychiatry and Neurology; died December cine, 1971; certified by the American Board rics and Gynecology; died January 5, 1991. 29, 1990. of Family Practice; died November 22, 1990. WHITTIER, John Rensselaer, 71; Orient, NY; M Indicates member of the American Medical LANDO, Leon, 80; Palos Heights, Ill; Univer- Columbia University College of Physicians Association. Obituary listing compiled by the Department of sity of Health Sciences, The Chicago Medical and Surgeons, 1943; certified by the Ameri- Physician Biographic Records. School, 1937; died May 29, 1990. can Board of Psychiatry and Neurology; died October 3, 1990. 2600 JAMA, May 15, 1991 265, No. 19 Obituary Listing OXIDATIVE DAMAGE INSIDE THE BODY IT'S CAUSED BY FREE RADICALS ROCHE Hoffmann-La Roche Copyright © 1990 by Hoffmann-La Roche Inc. All rights reserved. ® AT RISK: VITAL CELLULAR COMPONENTS SINGLET OXYGEN AND FREE This critical balance determines the extent of RADICALS CAN BE HAZARDOUS tissue damage. TO YOUR HEALTH They can injure cells and even kill them. They VITAMINS C, E AND BETA CAROTENE: can cause peroxidation of polyunsaturated DIETARY DEFENSES OF THE CELL fatty acids in cell membranes, enzyme inac- In the aqueous phase.. Vitamin C neutralizes tivation, and mutations by single-strand free radicals, the superoxide radical and sin- breaks in DNA. 1-3 glet oxygen. 12 GENERATED FROM INSIDE AND OUT In the lipid phase. Vitamin E is capable of breaking the self-propagating chain reaction These unstable, highly reactive molecules of lipid peroxidation thus preventing damage to (e.g., OH, ROO) are generated endogenously the plasma and organelle membranes.¹¹ as by-products of normal and pathologic meta- bolic processes and through exposure to Beta carotene, an extremely potent singlet ionizing radiation, sunlight, and certain oxygen quencher with unique antioxidant prop- drugs.⁴⁻⁷ They may also enter the body from erties, also offers protection in the lipid phase. exogenous sources such as air pollution and cigarette smoke. A POTENTIAL SAFEGUARD AGAINST CERTAIN DISEASES THE APPLE AND THE EYE While steps should be taken to ensure ade- Oxidative damage- visible as the browning of quate dietary sources of vitamins C, E and an apple - is also visible in the eye. Oxidants beta carotene, studies are under way to eval- have been found to damage the lens and ret- uate the efficacy of supplementing the diet ina. The immature retina is especially with these vitamins as a potential safeguard vulnerable to oxidants.⁷ against certain diseases. Free radicals have been implicated in the development of cataracts, as well as athero- sclerosis, cancer, emphysema, ischemia- References: 1. Southorn PA. Free radicals in medicine. I. Chemical nature and biologic reactions. Mayo Clin Proc. 1988;63:381-389. 2. Marx JL Oxy- reperfusion injury, Parkinson's disease, rheu- gen free radicals linked to many diseases. Science. 1987;235:529-531. matoid arthritis and in the aging process itself. 7-10 3. Borish ET, Prior WA. Cigarette smoking, free radicals, and free radicai DNA damage. In: Cross CE, moderator. Oxygen radicals and human disease. Ann Intern Med. 1987;107:526-545. 4. Harman D. Free radicals: aging and TISSUE DAMAGE disease. In: Cross CE, moderator. Oxygen radicals and human disease. Ann Intern Med. 1987; 107:526-545. 5. Lands WEM, Kulmacz RJ, Marshall PJ. HANGS IN THE BALANCE Lipid peroxide actions in the regulation of prostaglandin biosynthesis. In: Pryor WA, ed. Free Radicals in Biology. London: Academic Press, To minimize the toxicity of free radicals, the 1984;39-61. 6. Halliwell B. Oxygen radicals: A commonsense look at their cell utilizes a protective antioxidant system nature and medical importance. Med Bio. 1984;62:71-77.7. Cross CE. The spectrum of diseases. In: Cross CE, moderator. Oxygen radicals and human of enzymes (superoxide dismutase, catalase, disease. Ann Intern Med. 1987; 107:526-545. 8. McCord JM. Oxygen-derived peroxidases), scavengers of these radicals free radicals in postischemic tissue injury. N Engl J Med. 1985;312(3):159-163. 9. Pitarys CJ II, Forman MB. Free radicals in reperfusion injury and myocar- such as glutathione, and essential nutrients dial stunning. Cardio. 1989;6(3):112-125. 10. Blake DR et al. Hypoxic- reperfusion injury in the inflamed human joint. Lancet. 1989(Feb 11);289-293. (vitamins C, E and beta carotene). 11-13 11. Jenkinson SG. Oxygen toxicity. J Intensive Care Med. 1988;3:137-152. There is a critical balance between free 12. Bendich A et al. The antioxidant role of vitamin C. Adv in Free Radic Biol Med. 1986;2:419-444. 13. Burton GW, Ingold KU. Beta-carotene: an unusual radical generation and antioxidant defenses. type of lipid antioxidant. Science. 1984;224:569-573. ANTIOXIDANT PROTECTION VITAMIN C VITAMIN E BETA CAROTENE HHN 5444 2602 NORTHERN LIGHTS:PUBLIC HEALTH SERVICE STYLE Uptown or off the beaten path, one of our Salary and benefits that may surprise you exciting practice opportunities could be just The Public Health Service offers physicians a competitive your style. salary, paid malpractice coverage, a generous loan If you haven't looked at the U.S. Public Health Service repayment program, and a vacation package that gives lately, you'll be surprised at all that we have to offer. you time to experience life as well as medicine. Whether your rhythm is the fast pace of a large If you're a board-certified or fully residency- city the easy gait of a small town or the drum beat trained physician, we may have an opportunity that's of a Great Plains Indian Reservation-you can practice just your style. the hands-on medicine that you trained for - in a setting CALL TODAY: 1-800-221-9393 that's right for you. In Virginia: 1-703-734-6855 Our physicians practice medicine as it was meant to be, with interesting cases, a minimum of paperwork, and a chance to gain the satisfaction of giving care to those who need it most. With locations nationwide, your options include practicing in hospitals, community 1798 health centers, clinics, even small group practices. Advancing the Health of the Nation Important news for sufferers of as-sis-tant/-tent/(n): intestinal gas! 1) one who assists 2) one who gives supplementary A new double-acting anti-gas support or aid 3) a newsletter with authoritative coding tablet called Charcoal Plus is information from the American Medical Association now available to fight the pain, bloating and diarrhea caused by stomach or intesti- nal gas. Charcoal Plus is CPT Assistant, the AMA's new quarterly newsletter, brings you valuable, double-acting because it fights up-to-the-minute information on CPT coding and procedures. 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Kramer Laboratories 8778 S.W. 8th St. Assistant Miami, FL 33174 Please send FREE samples and literature Authoritative Coding Information from the American Medical Association on new CHARCOAL PLUS. Name pleased to introduce "CPT Assistant", the authoritative We newsletter are on coding from the AMA. Current Address Our premier issue contains articles As Procedural you know, Terminology the elaboration AMA maintains (CPT). of descriptors and The publishes AMA in is CPT. often Physicians' A called great individuals deal on for of inter- time are City/State/Zip on extremely pretations and realize that many these topics and up to date and Telephone important topics: is interested spent information researching in this information. on topics of Our concern goal to is to individuals provide who in use your CPT. For Immediate Action Call For the first time anywhere. timely We hope that the PT Assistant" will be a key resource 1-800-824-4894 an insight into the major efforts to ensure accurate coding, or 305/223-1287 changes in CPT for 1991: "Coding Commentary" What is HCPCS? Medicare Part B claims is system for submitting . Common Proce- 2604 CME Forum For The George information Washington on University WASHINGTON DC advertising SUMMER HEALTH POLICY INSTITUTE A Week-Long Intensive Course on your Developments in National Health Policy 1991 International Conference CME event, Featuring Key Washington Health Policymakers on Physician Health meeting or Leading Health Policy Analysts Nationally Prominent GWU Faculty conference, Topics Include: PHYSICIAN AND HOSPITAL PAYMENT June 6-8, 1991 please MEDICAL LIABILITY REFORM Toronto, Ontario, Canada HEALTH INSURANCE AND ACCESS TO CARE FEDERAL BUDGET PROCESS call. NATIONAL PRACTITIONER DATA BANK Sponsored by American Medical Association 312-464-2456 CME Credit Available Canadian Medical Association Federation of Medical Licensing June 24-28, 1991 Authorities of Canada For more information call or write: INTERNAL MEDICINE BOARD RE- Bradley Pine This year's conference, Caring for the VIEW, August 26-30, 1991, at Stanford Center For Health Policy Research Caregiver, will address a range of issues University School of Medicine. Regis- tration fee: $400-550. Contact: M. Am- 2136 Pennsylvania Ave., NW relative to physician health, including aging, lin, MSOB #X-365, Stanford Medical Washington, DC 20052 physical disabilities, psychiatric disorders, Center, Stanford, CA 94305; 415/723- Phone: (202) 676-5258 and substance abuse. Through the 5594. FAX: (202) 676-5261 presentation of scientific data and the provision of training workshops, this conference will offer an overview of the current status of the field as well as American College of Surgeons educational opportunities for the conference participants. 77th ANNUAL CLINICAL CONGRESS Please join the AMA, CMA, and October 20-25, 1991 Federation for this exciting and innovative conference, which: Chicago Gives participants an opportunity to hear of the latest developments in this important field Hundreds of scientific presentations-highlighting research in Provides opportunity to learn skills progress in all surgical specialties--and numerous panels on necessary for conducting research in socioeconomic issues in surgery will be featured during the 1991 Clinical Congress of the American College of Surgeons. various areas of physician health Examines the differing treatment Sessions will include: programs and their relative values Offers these important features- 20 postgraduate courses - State-of-the-art research More than 100 medical motion pictures presentations 100 hours of general and specialty sessions - Invited speakers More than 300 research-in-progress papers for the Surgical - Selected workshops Forum and papers sessions - Pre-conference institutes Hundreds of scientific and technical exhibits - Extensive networking The Chicago Hilton and Towers will serve as the headquarters hotel opportunities for the meeting: the scientific sessions will take place at McCormick Exhibits Place, the McCormick Center Hotel, and the Hilton. For more information regarding registration Plan now to attend the 77th Annual Clinical Congress. For more call toll-free 1-800-621-8335. For information on the meeting and a registration kit, contact Mr. Frank Arado, Dept. CME91, American College of Surgeons, 55 E. Erie event sponsorship, or invitation to exhibit call St., Chicago, IL 60611. Phone: 312/664-4050. Patrick W. McGuffin, PhD, at 1-312-464- 4064. JAMA, May 15, 1991 Vol 265, No. 19 CME Forum 2605 American Medical Television The Sunday morning head start to many of Monday morning's problem cases. 10 AM to NOON Sunday Medical Rounds A weekly half-hour of news and interviews on fast breaking medical issues. CME accredited. AMERICAN MEDICAL AMA VideoClinic TELEVISION A one hour program focusing on the latest develop- ments in medical science and technology and their MEMBERS MEDICAL ADDITIONAL relationship to patient care. CME accredited. Practical Medicine/ Each Sunday morning on Milestones in Medicine The Discovery Channel The first two Sundays of each month premieres a new half-hour program focusing on major new developments (10:00 am to Noon ET) in medicine. CME accredited. American Medical Television X Practical Medicine The last two Sundays of every month. The half-hour gathers some of the program focuses on socioeconomic issues such as world's most informed practice management, legal issues, professional- patient relations. CME accredited. physicians. Join them for these programs. American Medical Television only on The Discovery Channel (10:00 am to Noon ET) only through the American Medical Association only CME programming For more information call 1-800-933-4AMT. American Medical Television only on Discovery CHANNEL The AMA Hospital Medical Staff Section Seventeenth Assembly Meeting June 20 - 24, 1991 Chicago Marriott Hotel Chicago, Illinois Highlights of the Annual Meeting will include: an educational program on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Practice Parameters; presentation by the AMA-HMSS Governing Council of reports on medical staff issues including Evaluation of the Hospital Medical Director and Criteria for Evaluating the Performance of the Hospital Medical Director, PRO Required Education of Hospital Medical Staff and Patient Responsibility of On Call Physicians; an information exchange on PRO and Managed Care Review; AMA-HMSS Governing Council elections for the positions of Delegate, Alternate Delegate and one Member-At-Large. For Information Contact: Department of Hospital Medical Staff Services American Medical Association 515 North State Street Chicago, Illinois 60610 Phone (312) 464-4754 or 464-4761 AMERICAN MEDICAL ADDITIONAL HMSS 2608 JAMA, May 15, 1991 - Vol 265, No. 19 CME Forum Classified Advertising Allergy & Immunology ALLERGIST NEEDED BY BUSY MULTISPECIALTY GROUP. First year salary with incentive and corporate fringe benefits. Fine living environment in Midwestern community. Reply: Box 6250, c/o JAMA. M Blind Box Service Blind box numbers are available for all AMERICAN MEDICAL ASSIGNATION ads at an additional cost of $20 per Anesthesiology issue. READY FOR FREEDOM? IF YOU QUALIFY AS A CompHealth locum tenens physician, you can practice throughout the U.S. for as long or as briefly as you like...on Classified Display your own schedule. without politics and administrative en- tanglements. CompHealth, the nation's largest locum tenens Classified Advertising Index Advertising group, will provide you with a competitive income, housing, For information and rates on Classified transportation, licensure, and malpractice premiums. For immediate information, call 1-800-354-4050 toll-free. Display advertising, contact your JAMA Classification Page No. (800) FAST-GAS: THE NUMBER THAT THOUSANDS OF Classified Representative at hospitals and anesthesia professionals call for temporary Allergy & Immunology 2609 or permanent anesthesia services (physician and CRNA). (312)464-2490. Bay Area Anesthesia 800-327-8427. Anesthesiology 2609 Cardiology 2609 ANESTHESIOLOGIST (BC/BE) AND CRNA VACANCIES for progressive gen/med/surg teaching VA Medical Center Dermatology 2609 Continuing Medical Education located in beautiful NE Oklahoma. Physician to act as Director of Anesthesia Services. Two CRNAs on staff. All Emergency Medicine 2610 Call (312)464-2491 for information and types of general/vascular/non-cardiac and ENT/Urology/ Endocrinology 2610 rates on the "CME Forum." Orthopedics are done. Affiliated with Univ of OK Tulsa Medical College, providing training for all levels of surgical Family Practice 2610 residents. Salary/academic appointment dependent upon qualifications. Inquiries to Dr. Harris, Chief of Staff, VAMC Gastroenterology 2611 Medical Specialty Headings Muskogee, OK 74401/call 918-683-3261. EOE. Hematology/Oncology 2611 If the desired heading is not specified Internal Medicine 2611 when the ad is submitted, we will place it Nephrology 2612 Cardiology under the most appropriate Medical Obstetrics & Gynecology 2612 Specialty Heading. NONINVASIVE CARDIOLOGIST BC/BE: CENTRAL FLOR- Occupational Medicine 2613 ida, noninvasive, three physician group. Pleasant practice atmosphere, state-of-the-art-equipment, attractive compen- Ophthalmology 2613 sation with partnership. Contact Administrator 904-589- 0207. Otolaryngology 2613 Responding to JAMA Box Pathology 2613 Numbers BC/BE NONINVASIVE CARDIOLOGIST TO JOIN EXPAND- ing, well-established multi-specialty clinic in growing Eastern Pediatrics 2613 All replies must be in writing and must NC community of 50,000. New facilities adjacent to excellent 300-bed hospital with cardiac catheterization lab. Cardiac Pharmaceutical Medicine 2613 cite the box number in the ad. Example: surgery in community soon. Competitive salary with excel- Psychiatry 2613 Box XXXX, c/o JAMA, 515 North State lent benefits. Please call Dr. Dan Crocker at 919-443-9084 or send C.V. to Dr. Dan Crocker, 100 Nash Medical Arts Radiology 2614 Street, Chicago, IL 60610. JAMA is not Mall, Rocky Mount, NC 27804. Rheumatology 2614 permitted to divulge the identity of Surgical Specialties 2614 advertisers who wish their mail sent in CARDIOLOGISTS WANTED TEXAS: Enjoy a cardiology practice with liberal vacation and guaranteed private-practice Orthopedic Surgery 2615 care of the journal. Box replies are level compensation. Sterling Medical, the leading provider of Urology 2615 forwarded first class mail only. specialty medical services nationwide, is looking for permanent cardiologists for practice locations in Texas. Invasive and non- Multiple Specialties/ invasive positions available. As a Sterling Medical physician, Group Practice 2615 you will receive paid malpractice coverage, full holiday/vacation/ Send Orders, Materials and CME coverage and excellent guaranteed compensation. Call Graduate Training/ Richard Sheridan toll-free at 1-800-852-5678. Residencies Available 2617 Payment to: Locum Tenens Wanted 2619 JAMA Classified Advertising CARDIOLOGY: SEVEN PHYSICIAN CARDIOLOGY GROUP Chiefs/Department Heads/ 515 North State Street, 12th Floor offering immediate opportunity for non-invasive and/or in- Directors/Faculty 2623 Chicago, IL 60610 vasive (non-angioplasty) BC/BE Cardiologist(s). The oppor- tunity includes diagnostic catheterization, electrophysiolo- gical testing, and full non-invasive lab including nuclear Practices for Sale 2624 cardiology. First year salary negotiable with full partnership For Sale/For Rent/ Fax to: 312-464-2580 potential thereafter. Reply to: Abilene Cardiology Consult- ants, P.A., 598 Westwood, Suite 201, Abilene, Texas 79603. Real Estate 2624 915-673-7373. Phone: 312-464-2490 NONINVASIVE/INVASIVE CARDIOLOGIST SOUGHT FOR A busy, well established 3-person single specialty group. Purely consultative practice offers state-of-the-art equipment Classified Advertising Rates and a full spectrum of cardiology services. Incoming Cardi- ologist can perform any or all of the following: electrophys- iology, nuclear cardiology, TEE, ICU work, diagnostic cardiac 1991 Word Ad Rates cath, or pure clinical noninvasive Cardiology. The setting is Policy Regular 4.10 per word, per issue south of a Rochester, NY suburb, just 20 miles to the metropolitan area. For more information, send Curriculum Orders for classified advertising must be Bold 4.75 per word, per issue Vitae or call: Durham Medical Search, Inc., 6300 Transit Road, P.O. Box 478, Depew, NY 14043. 800-633-7724 submitted in writing. Although the The minimum charge is for 25 words. A National; 800-367-2356 NYS. American Medical Association believes word consists of one or more letters the classified advertisements in these Winter Haven, Florida: Non-invasive Car- surrounded by two spaces, as in the pages to be from reputable sources, the diologist to join 34-physician, multispecialty following examples: group. Community of 30,000 is located 20 Association does not investigate the minutes from Orlando. Take over $1.5 mil- offers made and assumes no liability San Francisco 2 words lion practice. Call/coverage provided. Op- concerning them. Acceptance of OB/GYN 1 word portunity is available immediately. Inter- advertising is restricted to employment May 9, 1991 3 words viewing expenses paid. Send CV or call and practice opportunities, medical 312-555-1212 1 word Greg Pilgrim, Jackson and Coker, Inc., 115 Perimeter Center Place, Suite 380 10711, equipment for sale and medical office G. H. Johnson, M.D. 4 words Atlanta, GA 30346, Tel. 1-800-544-1987. space available. The Association Closing Dates reserves the right to decline, withdraw or edit advertisements at its discretion. Issue Closing June 19 Every care is taken to avoid mistakes May 27 Dermatology June 26 June 3 but responsibility cannot be accepted by DERMATOLOGIST, BC/BE, WANTED TO JOIN PROGRES- the Association for clerical or printer's July 3 June 10 sive multispecialty group. Attractive salary with incentive- based bonus potential, early full shareholder status. Midwest errors. July 10 June 17 community offers quality lifestyle, proximity to major city, excellent schools. Reply: Box 6111, c/o JAMA. JAMA, May 15, 1991 265, No. 19 2609 DERMATOLOGIST SOUTH FLORIDA THREE-FOUR days/week. Excellent fee-for-service opportunity in Progressive, 106-bed healthcare facility seeking resort area of South Florida. Perfect for active Derma- for details. Call Richard Sheridan at 1-800-852-5678. Family BC/BE Family Practice physician. Take over solo tologist interested in more free time. Call immediately clinic practice with coverage from a large FP Practice Faculty group. Hospital is well-equipped and is affiliated with the Carilion Health System. Beautiful Emergency Medicine Southern Virginia community of 10,000 is located Natividad Medical Center, located near about one hour from Roanoke, Virginia, Winston- the beautiful Monterey Peninsula in Salem, North Carolina, and the Tri-Cities of Ten- Texas, Houston and Other Texas Areas: Med- California, is seeking a BC/BE Family nessee. Enjoy the beauty of the Blue Ridge Practitioner to fill a vacant faculty posi- Mountains, friendly people, good schools, beau- ical Networks allows you to choose the area to fit tiful homes, a growing economy, and an aggres- your lifestyle. We have opportunities at hospitals tion. NMC is a 211-bed, JCAHO accred- sive Chamber of Commerce dedicated to an ever- in pleasant rural and suburban settings or those ited teaching hospital (UCSF Family increasing quality lifestyle. Exceptional net in- located in the prestigious Texas Medical Center. Practice Residency Program) with full come guarantee including paid malpractice, and Director and staff positions are available with compensation packages ranging up to $250,000 ancillary services. interviewing and relocation expenses. Send CV or call Greg Poston, Jackson and Coker, Inc., 115 plus annually including paid $1M/$3M profes- Perimeter Center Place, Suite 380 10683, Atlanta, sional liability insurance. Send CV to Medical Responsibilities will include oversight GA 30346, Tel. 1-800-544-1987. Networks, Physician Resources Department, P.O. of the Family Practice Center, teaching Box 4448, Houston, Tx. 77210; or call 713/446- 9696 collect in Texas, 800/231-0223 outside of and directing patient care. Successful FAMILY HEALTH CARE PHYSICIANS-SAUDI ARABIA: RE- Texas. candidate will have clinical and/or source Sciences Arabia, Ltd., a U.S. managed firm, requires Family Health Care Physicians with E.R. experience for academic experience beyond resi- primary care/family clinics in Saudi Arabia. We offer an dency. Administrative experience is attractice, highly competitive compensation package includ- MAINE: ER DIRECTOR FOR BUSY, WELL-EQUIPPED, ing free housing, transportation, medical malpractice insur- 21,000 visits per year Emergency Medicine Department desirable. Excellent compensation ance, annual vacation, R&R leave, and liberal continuing in 94-bed, modern, acute care, community hospital. package with paid malpractice and education allowances. Current U.S. tax laws exempt the first Beautiful, four-season, lake and mountain region close $70,000 of foreign earned income from tax for qualifying to major ski area. Ninety minutes from Portland. Highly health and welfare benefits. Send C.V.'s individuals. Please send complete resume with copies of all rated schools in lovely, small town. Salary plus full to: pertinent licenses to Dept. 91-23: Holmes & Narver Ser- benefit package. Send C.V. to New England Health vices, Inc., 999 Town & Country Rd., Orange, CA 92668. Search, 63 Forest Avenue, Orono, Maine 04473. Call Stephanie Clymer Equal Opportunity Employer. 207-866-5680. Associate Personnel Analyst FAMILY PRACTICE BC/BE TO JOIN 60-MEMBER MULTI- specialty group in beautiful southern Wisconsin. Opportu- OHIO, NORTHEAST/CLEVELAND: EMERGENCY DEPART- Natividad Medical Center nities exist for urgent care without night call or hospitalization ment physicians needed for 20,000 to 40,000 patient volume and full practice with or without obstetrics. Excellent salary Emergency Departments in Greater Cleveland area. Phy- 1330 Natividad Road and benefits. Send C.V. to Dr. Stan Gruhn, Riverview Clinic, sician must be Board Certified in Emergency Medicine, 580 N. Washington St., Janesville, WI 53545. residency-trained in Emergency Medicine, or be Board- P.O. Box 81611 Prepared in Emergency Medicine. Salary and benefits NAPLES, FLORIDA: BC/BE FAMILY PHYSICIAN TO JOIN package worth $150K. Full partnership eligibility in two Salinas, CA 93912-1611 progressive family practice center. The most desirable family years. Interested individuals, please submit C.V. to: P.O. Box AA/EOE and recreational area in the U.S.A. Excellent salary/owner- 770551, Lakewood, OH 44107. ship option. Send C.V. Florida Family Care, William Leach, M.D., 1545 C.R. 951, Naples, Florida 33999. 813-455-4104. NATIVIDAD EMERGENCY ROOMS AROUND THE COUN- TRY NEED YOU. We need top-notch physicians MEDICAL Tampa, Florida - Family Practice - Opportunity for Family Physician to join FP, in partnership, to "hold the fort" in hospitals throughout the U.S. CENTER. in Plant City, Florida, a community of 25,000, for varying periods of time. We provide excellent earnings opportunities - and take care of travel, which is 20 minutes from Tampa. Hospital has housing, licensure, and malpractice premiums for 120 beds. Above average salary plus benefits you. You'll be relieved of time-consuming admin- and malpractice. Interviewing and relocation ex- istrative duties and enjoy your choice of schedule FAMILY PRACTICE EXCELLENT OPPORTUNITY FOR A penses paid. Send CV or call Greg Pilgrim, and work setting. Call CompHealth, the nation's BC/BQ Family Practitioner to join a ten-member well- established primary care group and assume large practice Jackson and Coker, Inc., 115 Perimeter Center largest locum tenens group, today at 1-800-328- of retiring physician. Competitive salary, paid malpractice, Place, Suite 380 10708, Atlanta, GA 30346, Tel. 3051 toll-free. growing patient population, excellent schools, university, 1-800-544-1987. and outdoor family activities in this scenic upstate New York community. Send C.V. to: D. Precopio, 33 Mitchell Avenue, Suite 204, Binghamton, NY 13903. 607-723-3346. RETIRING PHYSICIAN: GROWING SOUTHEASTERN COM- munity located in the foothills of Cumberland and Lookout Endocrinology DON'T ALLOW MALPRACTICE COSTS TO DISCOURAGE Mountain seeks General/Family Practitioner. Community you from practice! If you qualify as a CompHealth locum features sailing, water skiing, kayaking, golf, state parks and tenens, you can leave your malpractice worries behind. We'll its own snow ski resort. Many national softball tournaments ENDOCRINOLOGIST: MULTISPECIALTY INTERNAL MEDI- pay your malpractice premiums, licensure, housing and are hosted here annually. Local schools have received cine group in suburban Philadelphia with large office and transportation costs and provide you with an excellent national recognition for their advanced curriculum. Hospital hospital practice. Some internal medicine required. Reply income. You select practices, from Maine to Alaska, for as will provide turn-key practice set-up in fully equipped office Box 6790, c/o JAMA. long or as briefly as you like. a week, a month, a year or with no buy-in. Strong, stable economy and low unemploy- more. You'll also find yourself relieved of time-consuming ment. Financial package includes guaranteed six figure administrative duties. Call CompHealth, the nation's largest income, relocation and interviewing costs. For complete locum tenens group, today: 1-800-328-3051 toll-free. information, send your C.V. to Tom Hart, of Harris Kovacs STAFF POSITION IN Alderman, 4170 Ashford-Dunwoody Road, Suite 500, At- CLINICAL NUTRITION BC/BE FAMILY PRACTITIONER WANTED TO WORK AS A lanta, GA 30319, or call 800-347-7987, ext. #9-0095. private practitioner, yet be part of a primary care group in AT MAYO CLINIC/ Glendale, CA, 20 minutes North of downtown, L.A. Send SEEKING FULL-TIME OR PART-TIME FAMILY PRACTI- MAYO FOUNDATION C.V. to E. Kaufman, 1420 S. Central Ave., Glendale, CA tioner for busy practice in Northern Virginia, Alexandria 91204; 818-502-2371. area. Excellent opportunity. Candidates must be Certified DEPARTMENT OF MEDICINE or Eligible for certification by the American Board of Family DIVISION OF MEMPHIS, TN: SSG SEEKS FAMILY PRACTITIONERS FOR Practice. Please respond with C.V. to Box 6772, c/o JAMA. extremely busy practice. Competitive salary, benefits + ENDOCRINOLOGY & METABOLISM interviewing and relocation expenses. One-year to partner- FAMILY PRACTICE HAWAII: EXCELLENT OPPORTUNITY ship. Growing SE metropolitan area. Contact Jeff Hartline, & lifestyle. A multispecialty group, servicing West Kauai. Fulltime staff position in clinical nutrition with responsibil- 5000 Linbar Drive, Suite-240, Nashville, TN 37211. 800- Call or send C.V. to Business Manager, Garden Island 283-6611. Medical Group, P.O. Box 669, Waimea, HI 96796. Phone ities in Nutrition, Lipid and Diabetes Clinics and inpatient 808-338-1645. Nutrition Support Services. Position is in Division of FAMILY PRACTICE. ALASKA AREA NATIVE HEALTH SER- Endocrinology and Metabolism, a multidisciplinary group EXCELLENT GROUP OPPORTUNITY AVAILABLE FOR BC/ vice. Professionally rewarding, challenging, cross-cultural of 10 clinical nutritionists. Candidate must be certified in medicine. Medical school loan repayment to 25K/year plus BE Family Physicians in expanding, well-established, multi- Internal Medicine, certified or eligible for specialty board salary. Indian Health Service. Equal Opportunity Employer. specialty clinic. New facilities adjacent to excellent 300-bed 907-257-1457 collect. hospital in growing Eastern NC community of 50,000. certification in Endocrinology and Metabolism, and should Competitive salary with excellent benefits. Call Dr. Dan be certified or eligible for the American Board of Nutrition. FAMILY PRACTICE: LAKOTA, WINNEBAGO, CHIPPEWA, Crocker, 100 Nash Medical Arts Mall, Rocky Mount, NC Send letter and curriculum vitae to: P. J. Palumbo, M.D., Mandan, Arikara, Hidatsa, Omaha, Sac and Fox. The 27804. Director, Clinical Nutrition, Mayo Clinic, Rochester, MN Aberdeen Area Indian Health Service. Professionally re- FAMILY PRACTICE NORTHWEST TEXAS. $120,000.00 55905. Mayo Foundation is an affirmative action and warding, challenging, cross-cultural medicine. Medical guarantee. Free clinic space. Fully equipped and equal opportunity educator and employer. school loan repayment to 25K/yr plus salary. Equal Oppor- staffed 20-bed hospital. Community very supportive of tunity Employer. 605-226-7531 collect. medical personnel. Excellent schools and an ideal place to raise a family. Contact John B. Martin, Admin- istrator, Knox County Hospital, Box 608, Knox City, VIRGINIA: A unique FP opportunity to choose Texas 79529. 817-658-3535. After hours 915-773-5097. Family Practice the practice situation you desire. Solo or partner- ship opportunities available in the Norfolk/Virginia FAMILY PRACTITIONERS WANTED: NEVADA - THE ELKO REGIONAL MEDICAL CENTER Beach area. Location is on the Virginia coast and TEXAS and TENNESSEE seeks a Board Certified/Board Eligible Family Practitioner has a population of one million. Abundant shop- ping, entertainment, and beach activities. Net Sterling Medical, the nation's leading provider of general and specialty to join a multispecialty clinic. Fee for service with excellent medical services on a departmental basis, has several extremely collection ratio. Guaranteed salary for six months leading income guarantee. Interviewing and relocation attractive opportunities available for Family Practitioners (GMOs) at to full partnership. Comprehensive benefit package including expenses paid. Please send CV or call Doug Sterling Medical staffed hospitals in the South, West and Midwestern malpractice insurance. Elko is a thriving community sur- Henderson, Jackson and Coker, Inc., 115 Pe- states. As a Sterling Medical physician, you'll receive truly excellent rounded by mountains and wilderness areas. Recreation year round. Please send C.V. to Cherie Atwood, Administra- rimeter Center Place, Suite 380 10431, Atlanta, net compensation, vacation/holiday leave, limited or no on-call and GA 30346, Tel. 1-800-544-1987. full malpractice coverage. For information, call John Adams toll-free tor, Elko Reqional Medical Center, 762 14th Street, Elko, at 1-800-852-5678. Nevada 89801, 702-738-3111. 2610 JAMA, May 15, 1991 Vol 265, No. 19 VACANCY EXISTS FOR A BOARD CERTIFIED/BOARD ELI- KANSAS CITY gible Medical Oncologist or Board Certified/Board Eligible ASSISTANT/ASSOCIATE Hematologist/Medical Oncologist for our medical center. Family/General Practice physician to join two physi- This center is a 425-bed GM&S hospital (includes ICU/ PROFESSOR OF cians. 1 in 3 call/coverage. No Obstetrics. Salary plus RCU) with an 86-bed NHCU, 344-bed domiciliary, 4-bed dialysis unit, 60-bed psychiatry unit, and an expanding FAMILY MEDICINE bonus, malpractice insurance, and full benefits. Send ambulatory care (outpatient) section. Medical center is CV or call Neal Steinhoff, Jackson and Coker, Inc., located in a progressive community of 25,000 with southern Bartlesville Family Medicine Center, Department hospitality, excellent schools, recreation, community events, 115 Perimeter Center Place, Suite 380 10464, At- and suburban living and is located two and one-half hours of Family Practice, University of Oklahoma Col- lanta, GA 30346, Tel. 1-800-544-1987. from mountains and beaches. Special pay for geographic lege of Medicine Tulsa, is seeking faculty location available. English language proficiency is required members at the Assistant/Associate Professor for all direct patient care positions. This medical center is a level for a rejuvinated university-affiliated, FAMILY PRACTICE OR GP, OB OPTIONAL, MEDICAL AND smoke-free facility with desiginated smoking shelters. Con- community-based program associated with a 300 surgical group in northcentral Indiana. Urban area close to tact A.C. Pradhan, M.D., Chief, Medical Service, Carl Vinson big cities. Salary to $100,000 first year, malpractice and bed community hospital. This is a 1-2 program VA Medical Center, Dublin, GA 31021 at 912-272-1210, health insurance provided. Paid 2 weeks vacation after six with a total of 12 residents. Academic appoint- extension 289 or 307. Equal Opportunity Employer. months. Partnership after 2nd year. Incentive bonus in 2nd ment as Assistant/Associate Professor based year. Work 4 days a week. On call every 4th night and 4th on experience. weekend. Contact A. Das, M.D., 401 E. Reynolds Drive Kokomo, IN 46901; 317-453-0802. Candidates for this position must have an M.D. Internal Medicine degree from a recognized medical school and FLORIDA, VENICE, FULL OR PART-TIME POSITION FOR be Board Certified in Family Practice with private BC/BE Family Physician or Emergency Physician. Paid FLORIDA - TAMPA BAY AREA, CENTRAL AND COASTAL. malpractice and vacation. Florida license required. Salary practice experience. Administration and teaching Excellent opportunities for Internists. Complete confi- commensurate with experience. Resume to P.O. Box 537, experience desirable but not required. Must be Venice, FL 34284. dentiality. Contact Frank Lane, M.D., Medical Director, eligible for licensure in Oklahoma. Salary is based P.O. Box 272509, Tampa, FL 33688 or call 1-800-433- FAMILY PRACTICE: LA CLINICA DE LA RAZA, A NON- 6726. on experience with a full range of benefits. profit organization in the San Francisco Bay Area seeks PEORIA, IL: PROCTOR COMMUNITY HOSPITAL HAS This position is located in Northeastern physician to fill part-time vacancy (20 hrs/wk). Requirements practice opportunities for BC/BE Internists. Income guar- Oklahoma's "Green Country", 45 miles north of include current license to practice medicine in the State of antees and excellent benefits. Call or write: Timothy Walton, Tulsa. With a population of 35,000, Bartlesville California, BC/BE in Family Practice, current DEA registra- Director of Physician Resources, Proctor Professional Build- tion, plus 2 years working in a primary care clinic setting has multiple outdoor water recreational ac- ing, Suite #20, 5401 N. Knoxville, Peoria, IL 61614. 309- with emphasis in adolescent health care. Bilingual English/ tivities, excellent schools, a superb retirement 691-1043 or 1-800-332-3436, ext. 1043. Spanish or Cantonese preferred. Fee-for-service for all community and is the Corporate headquarters inpatient care. Malpractice insurance provided, excellent MEDICINE HOUSE PHYSICIANS NEEDED FOR NORTH- of Phillips Petroleum Company. fringe benefits. Send C.V. to: Patricia Royball, Personnel east Ohio suburban hospitals. $97-120K, paid malprac- Manager, La Clinica de la Raza, 1515 Fruitvale Ave., tice, never on call. Physician Staffing, Inc., 3628 Walnut Interested applicants please send resume and Oakland, CA 94601, or call: 415-534-0078, Ext. 230. Hills, Cleveland, Ohio 44122. 216-292-7445. questions to: T.L. Johannesen, M.D., 3500 S.E. Frank Phillips Blvd., Bartiesville, Oklahoma MAUI, HAWAII: FAMILY PHYSICIAN NEEDED FOR SMALL INTERNIST. COLMERY-O'NEIL VA MEDICAL CENTER IS clinic. Excellent opportunity for good income and free time actively recruiting for a Board Certified or Board Eligible 74006, or Jon Calvert, M.D., Ph.D., Chair, for golf, windsurfing, or sailing. Send C.V. to: John N. Withers, Internist with a subspecialty in hematology/oncology. This Department of Family Medicine, University M.D., Kihei Physicians, P.O. Box 1119, Kihei, Maui, Hawaii is a large medical center with an active residency program of Oklahoma College of Medicine Tulsa, 96753, or call 808-877-6655. and medical students. There is a complete CME program 2808 S. Sheridan Road, Tulsa, Oklahoma available and opportunity to take time off to attend medical 74129. meetings, seminars, etc. There are many fringe benefits in the Federal government which includes 30 days paid An Equal Opportunity Employer Gastroenterology vacation, 15 days sick leave, 10 federal holidays, low cost health and life insurance and retirement plan which includes JANE PHILLIPS tax-deferred options. Topeka is the capital city of Kansas BC/BE GASTROENTEROLOGIST WITH 3 YEARS TRAIN- and offers residents a quality environment. Interested can- EPISCOPAL MEMORIAL ing including hepatology for position in University academic didates should contact the Chief of Medical Service, (111) MEDICAL CENTER center. Primarily clinical responsibilities, experience in biliary Veterans Administration Medical Center, 2200 Gage, To- endoscopy diagnostic and therapeutic. Send C.V. to Univer- peka, Kansas 66622, or phone 913-272-3111, ext. 315. WHERE CARING MAKES THE DIFFERENCE sity of Miami School of Medicine, D-49, P.O. Box 016790, Equal Opportunity Employer. Miami, Florida 33101. EO/AA Employer. INTERNIST BC/BE TO JOIN MULTISPECIALTY GROUP GASTROENTEROLOGIST BC/BE FOR CHICAGO AND SUB- practice in Midwest. Subspecialty desirable but not neces- urban multi-hospital practice. Competitive salary and ben- sary. Excellent opportunity with competitive salary and fringe PHYSICIAN WANTED: FAMILY PRACTICE PHYSICIAN TO efits. Must be trained in all GI procedures. Send C.V. to Box benefits leading to early shareholder status. Fine living and join 17-physician, multi-specialty group with attached 40- 6579, c/o JAMA. work environment. Reply to Box 6107, c/o JAMA. bed hospital located in southern Idaho. Contact: Business MEMPHIS, TN: SSG SEEKS TWO INTERNISTS FOR EX- Administrator, Box 1233, Twin Falls, ID 83301. tremely busy practice. Competitive salary, benefits + inter- PRIMARY CARE PHYSICIAN WANTED FOR EXPANDING Hematology & Oncology viewing and relocation expenses. One year to partnership. Eastern Washington Clinic. Full and part-time positions Growing SE metropolitan area. Contact Jeff Hartline, 5000 available. Located in prime recreational area. Skiing, sailing, Linbar Drive, Suite 240, Nashville, TN 37211, 800-283- fishing, hunting all within short distance. Enjoy mild climate, MIDDLE TENNESSEE: EXCELLENT PRACTICE OPTION 6611. excellent schools and a major university branch campus in for BE/BC Hematologist/Oncologist in university community EAST TENNESSEE: BUSY INTERNIST SEEKS ASSOCIATE growing community of 100,000 plus. Challenging work in a of 75,000 Recently completed Cancer Center attached in community at the foot of the Smokies. Excellent financial superbly equipped clinic with state of the art lab, x-ray, laser to hospital needs Director for expanding program. Private package plus paid interviewing and relocation expenses. and endoscopy. Above average compensation and benefits practice package extremely competitive with reimbursed Convenient coverage situation. Beautiful area with all out- including malpractice, health insurance, and CME. Contact interviewing and relocation costs. Radiation Oncologist in door activities available plus one hour to Knoxville and Dr. Stephen L. Smith, 310 Torbett, Richland, WA 99352. place and ready for aggressive colleague. Historic commu- skiing. Contact Jeff Hartline, 5000 Linbar Drive, Suite 240, 509-545-8340 or Fax 509-545-1136. nity with proximity to Nashville. Contact Jeff Hartline, 5000 Nashville, TN 37211, 800-283-6611. Linbar Drive, Suite-240, Nashville, TN 37211, 800-283- SOUTHCENTRAL JCAHO MISSOURI HOSPITAL IN CON- 6611. GENERAL INTERNIST BC/BE TO JOIN 60-MEMBER MULTI- junction with metropolitan hospital located 90 miles away, specialty group in beautiful southern Wisconsin. Great has outstanding opportunity for BC/BE Family Practitioner. lifestyle and practice opportunity with or without night call Single specialty group offers excellent guarantee, retire- Oncologist Laurel, Mississippi - Join 4-phy- and hospitalization. Excellent salary and benefits leading to ment, profit sharing, disability & health insurance, 3 weeks sician group of 2 Internists, a Pulmonologist, and full partnership in one year. Send C.V. to Dr. Stan Gruhn, vacation, CME, ½ call and free housing. This progressive Riverview Clinic, 580 N. Washington St., Janesville, WI community has a junior college, airfield, excellent schools. a Gastroenterologist. 1 in 5 call/coverage. Search 53545. Mountains and lakes provide many outdoor activities. Bly/ Grove Associates, 1374 Clarkson/Clayton Center, Ballwin, sponsored by 275-bed hospital. Community of MACON, GA CHARTER NORTHSIDE HOSPITAL, A REL- Missouri 63011; 1-800-888-2266; fax 314-458-9168. 30,000 just 90 minutes from Gulf Coast and 60 atively new, fully equipped, 103-bed acute general hospital, has immediate private practice opportunities for BC/BE BE/BC FAMILY PRACTITIONER NEEDED FOR ASSOCIATE minutes from Jackson, Mississippi. Excellent fi- Internists or Family Practitioners in this beautiful city of position with partnership possibilities. Competitive salary nancial package. Paid interviewing and relocation 150,000. Abundant outdoor recreation, excellent public and with complete benefits. Located minutes from metro area in private schools, and cultural amenities combined with an North Carolina. For more information, send Curriculum Vitae expenses. Send CV or call Greg Pilgrim, Jackson outstanding practice offers an unsurpassed quality of life. or call: Durham Medical Search, Inc., 6300 Transit Road, and Coker, Inc., 115 Perimeter Center Place, Financial package includes income guarantee, relocation P.O. Box 478, Depew, NY 14043. 800-633-7724 National; assistance and more. For complete details, send your 800-367-2356 NYS. Suite 380 10705, Atlanta, GA 30346, Tel. 1-800- Curriculum Vitae to Administration, Charter Northside Hos- 544-1987. pital, P.O. Box 4627, Macon, GA 31210, or call 912-477- MIDWEST. EXCITING NEW FAMILY PRACTICE OPPORTU- 9520 today. nity located near large metropolitan area. Incoming physi- cians will have lucrative income guarantee, marketing assis- SENIOR HEMATOLOGIST. THE DIVISION OF HEMATOL- tance, cross-coverage and support of the community. ogy at Cook County Hospital is seeking a Board Certified GULF COAST Conveniently located in recreational area with close prox- Hematologist to head the Section of Inherited Hematologic imity to a large midwest city. Small town atmosphere permits Disorders. The divisional activities include general clinical Excellent four-physician Internal Medicine group community involvement, cultural actitivies and large AAA hematology, care for patients with hemoglobinopathies, in Mobile, Alabama seeks fifth IM to replace rated school system. Search conducted by: Physician hemophilia center, laboratory hematology, clinical research International, 4-J/FPW Vermont Street, Buffalo, NY 14213, and residency training in medicine as well as hematology. recently retired physician. Well-established pa- 1-800-622-4062. For further information contact: Ashok R. Patel, M.D., tient base, excellent reputation, and call rotation Chairman, Division of Hematology, Cook County Hospital, of 1 in 5. 250-bed community hospital has state- PENNSYLVANIA. EXCELLENT FAMILY PRACTICE OPPOR- 627 South Wood Street, Room 807, Chicago, Illinois 60612. of-the-art facilities. Mobile is a community of tunity to assume a busy existing practice or join an existing Phone: 312-633-7218. Equal Opportunity Employer. 250,000 which offers Gulf Coast living, nice hous- group, both with good coverage. They are conveniently ing, plenty of shopping, and good schools in an located within a one-half hour drive of a metropolitan area and major medical schools. This area has an excellent Opportunity for Oncologist in Valdosta, Georgia. Com- environment where outdoor activities are always economy and both opportunities are affiliated and supported munity of 50,000 is located on Florida/Georgia border. available. Excellent financial package with first- by a full service hospital. Search conducted by: Physician Solo opportunity with coverage. Join Radiation Thera- year salary of over $90,000 and productivity International, 4-J/FPP Vermont Street, Buffalo, NY 14213. pist in 12,000-square-foot cancer center at 288-bed thereafter. All benefits, including six-week vaca- 1-800-622-4062. hospital. Excellent financial package. Interviewing and tion, and paid interviewing and relocation ex- FAMILY PRACTICE, DEWITT, IOWA: (20 MILES NORTH OF relocation expenses paid. Send CV or call Greg Pilgrim, penses. Send CV or call Doug Henderson, Jack- Davenport, lowa). BC/BE F.P. needed to take over a practice Jackson and Coker, Inc., 115 Perimeter Center Place, son and Coker, Inc., 115 Perimeter Center Place, on June 1, 1992. Well established practice. Guaranteed Suite 380 10693, Atlanta, GA 30346, Tel. 1-800-544- Suite 380 10680, Atlanta, GA 30346, Tel. 1-800- salary. Jim Ragland, Administrator, DeWitt Community Hos- 1987. 544-1987. pital, 1118 11th Street, DeWitt, lowa 52742; 319-659-3241. JAMA, May 15, 1991 265, No. 19 2611 ORANGE PARK, FL (JACKSONVILLE SUBURB) - A OVER 400 PRACTICE OPPORTUNITIES group of four Internists wishes to replace a member who is leaving to devote more time to family. The group has been and continues to grow, therefore, the new member will be NATIONWIDE busy immediately. You can choose to share overhead and have your own practice or become a salaried member of the group. Excellent opportunity to take over an established practice as the retiring physician will turn all patients over to If you're thinking of relocating your practice, Jackson and Coker's network of seven the new Internist. For more information, send your C.V. to: regional offices can help you find the opportunity that fits your needs. Paul Coogan, Professional Relations, Humana, Inc., Dept. We receive information on new practice opportunities every day, and we're making good A-0515A, P.O. Box 1438, Louisville, KY 40201-1438. Or call toll-free 1-800-626-1590. news travel fast. Following is a sample of the outstanding Internal Medicine opportunities currently FULL-TIME INTERNIST FOR A COMMUNITY HEALTH CEN- available. ter in Hartford, Conn. Excellent benefits/relocation. Call Dr. Reddy 203-236-0857. NORTH DAKOTA: BC/BE General Internist to FLORIDA/GEORGIA: Board Certified/Board Eligible associate with long-standing, seven-physician Internist to join busy practice in South Georgia multispecialty group. Group serves population of community hospital. Proximity to both Florida Nephrology 40,000 located in upper Midwest. Community has coast lines and Tallahassee. CME/vacation, staff excellent public and private schools, as well as a support, excellent income guarantee, and four-year state university. Financial package NEPHROLOGIST UNIQUE OPPORTUNITY FOR BC/BE interviewing and relocation expenses provided. To includes first-year salary of $90,000 with incentive Nephrologist or B/C Internist with interest in critical care and inquire about site visit, send your CV or call BRAD nephrology to join an expanding group of Nephrologists and compensation and complete benefits. Send your CV PETERS. Internists in private practice in Marquette, Michigan. Mar- or call RON COATS. TEXAS: Internist to join progressive, 150-bed East quette General Hospital, the Regional Referral Center for Texas hospital. Be fifth IM on staff. Present staff the Upper Peninsula's 320,000 residents, operates an acute cannot keep up with patient demand and have and chronic Hemodialysis Department. A family practice MASSACHUSETTS: Join ground floor of new IM requested another IM. Share call equally. Hospital residency program and medical students from Michigan group being formed in the beautiful suburbs of State University's College of Human Medicine, offers teach- completely equipped with 8-bed centrally monitored Western Boston. Hospital has over 300 beds and ing opportunities. Financial incentives are available. Please ICU/CCU, MRI, and CT Scanner. Cath lab and affiliations with major teaching hospitals. Enjoy the send C.V. to Robert J. Raica, Marquette General Hospital, Radiation Therapy being developed. Quality lifestyle 420 West Magnetic Street, Marquette, MI 49855. excitement and challenge of a growing practice with is "second to none." Fine schools, including a four- an excellent case mix, the security of a strong year university, and many cultural and recreational THE DEPARTMENT OF INTERNAL MEDICINE IS SEEKING financial package, and the attractions of one of amenities simply enhance this tremendous an academic nephrologist, at the Assistant Professor level, America's most beautiful and cosmopolitan cities in with an interest in teaching, clinical nephrology and research opportunity. Exceptional financial package includes the hub of New England. Send your CV or call to join the Division of Nephrology and Hypertension at the guaranteed income to ensure financial success. University of South Florida College of Medicine. The can- DAVID CORNETT. Send your CV or call MARK HANNA. didate should be certified by the American Board of Internal Medicine and qualified or certified by the Subspecialty Board of Nephrology. Application recruiting deadline date is For complete details at no cost to you, June 20, 1991. Send Curriculum Vitae to: German Ramirez, M.D., Acting Director, Division of Nephrology and Hyperten- call: sion, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612- 4745. The University of South Florida is an Affirmative Action/Equal Opportunity Employer. 1-800-544-1987 EXT. 17 115 Perimeter Center Place Obstetrics & Gynecology JACKSON Suite 380 JFD1 OBSTETRICIAN-GYNECOLOGIST: THE PERMANENTE ANDCOKER Atlanta, GA 30346 Medical Group, Inc., of San Jose, California is looking for BC/BE physicians for immediate openings in the OB/GYN department. Positions available either at the main facility in San Jose, or at satellite medical offices in Gilroy. The young, dynamic department is still growing and currently has 17 physicians and two nurse practitioners. Our outstanding TEST THE WATERS. IF YOU ARE A PHYSICIAN OF EXCEL- INTERNIST, BOARD CERTIFIED/ELIGIBLE, FOR FULL- benefits package includes full coverage malpractice insur- lent caliber and don't want to settle into one practice until time faculty position/appointment with major Midwes- ance. San Jose and Gilroy share excellent access to Bay you've examined all your options, consider joining Comp- tern university affiliated 220-bed hospital educational Area cultural and recreational activities. Recent salary Health as a locum tenens physician. You'll have the chance program. Teaching and patient care responsibilities. advances allow extremely competitive compensation start- to practice from the Atlantic to the Pacific. You also set your ing with the first year of employment. For more information, Competitive salary with attractive fringe benefits. Call/ own schedule and the duration of your assignments. What's write Dennis Walter, M.D., Medical Director, Broadlawns please contact: Jerome L. Nehemiah, M.D., Chief, Depart- more, you'll earn an excellent income and we'll take care of ment of OB/GYN, The Permanente Medical Group, Inc., Medical Center, 18th & Hickman, Des Moines, lowa your malpractice premiums and major expenses. Immediate 260 International Circle, AD-JAMA, San Jose, CA 95119, 50314. Phone 515-282-2319. Equal Opportunity Em- or call collect 408-972-6180. EOE. openings available. Call now at 1-800-328-3061 toll-free. ployer. OB/GYN HOUSE PHYSICIANS NEEDED FOR NORTHEAST ATLANTA: BC/BE INTERNISTS TO JOIN MULTISPECIALTY BC/BE INTERNIST: NW PHILADELPHIA (ROXBOROUGH/ group. With/without specialty. Great on-call; only two nights Andorra) needed to join BC Internist. P.T., F.T. Affiliated with Ohio suburban hospitals. $100-150K, paid malpractice, a month. Half-day off each week. Immediate benefits. medical school hospital. Some teaching. Ideal situation for never on call. Physician Staffing, Inc., 3628 Walnut Hills, Cleveland, Ohio 44122. 216-292-7445. Guaranteed salary. Partnership in two years. Liberal vaca- person looking for entry into private practice. Call Ms. tion/CME time. Contact: B.J. Dawson, Southeastern Health Brennan at 215-521-5100. EOE/AAF. OBERLIN, OH MULTISPECIALTY GROUP SEEKS BC/BE Services, P.O. Box 724147, Atlanta, Georgia 30339. FRANKFORT, KENTUCKY: EXCEPTIONAL OPPORTUNITY Obstetrician/Gynecologist for growing patient load. North- INTERNIST WITH/WITHOUT SUBSPECIALTY, TO JOIN EX- for partnership with well-established, busy physician in office ern Ohio college town serving drawing area of 275,000. next to 190-bed hospital. Competitive salary, all insurances, Salary, liberal benefits first year with full shareholder status cellent and congenial group in Atlanta. BC/BE. Guaranteed benefits, and opportunity to practice broad spectrum of IM. available thereafter. Send your C.V. to Dr. VanDyke, 224 W. salary leads to partnership in two years. Box 6767, c/o Lorain, Oberlin, OH 44074. JAMA. Frankfort is the capital of Kentucky, ideally located between Louisville and Lexington. Send C.V. to Jamie Dooley, Quo- SEATTLE, WASHINGTON. OB/GYN FOR GROWING PA- DEPARTMENT OF VETERANS AFFAIRS. INTERNAL MED- rum Health Resources, 2515 Park Plaza, Nashville, TN icine: Immediate opening for BC/BE primary care internal 37203; or call 1-800-233-1470. tient load. Adjacent to community hospital with neonatal coverage. Seek individual with high moral and ethical medicine or family practice physician in VA Outpatient Clinic. No in-patient responsibility or after hours call schedule GENERAL INTERNIST: UNIQUE OPPORTUNITY IN GROW- character to join team of three physicians. Close to skiing, ing Orlando. Board Certified/Eligible. Good salary/benefits water and cultural events. Substantial benefit package with (8am-4:30pm). Competitive salary and fringe benefits in with early partnership. Florida Physician Placement Service: generous CME and vacation time. Send C.V. to: Brenda medium size midwestern city with many cultural opportu- nites. Write or call Dan Boatright, Clinic Director, 411 Dr. phone 407-876-0607: fax 407-876-3876. P.O. Box 16672, Weeda, South Seattle Women's Clinic, 16122 SW 8th, Suite Martin Luther King Jr. Drive, Peoria, IL 61605. 309-671- Orlando, Florida 32861. E-5, Seattle, WA 98166. 7359. NORTH CAROLINA COAST: SEEKING BC/BE GENERAL SEEKING BOARD CERTIFIED/BOARD ELIGIBLE OB/GYN Internist to join solo practitioner in small historic town by the to join an active 4-physician practice. Excellent opportunity. INTERNIST/FAMILY PRACTITIONER BC/BE CHILLICOTHE, water. Progressive, financially sound, JCAHO accredited Located in Northern Virginia suburbs of Washington, D.C. Ohio is a 45-minute drive South of Columbus, Ohio and possesses opportunities for cultural, recreational, and lei- hospital. Send C.V. or call: John Rider, Assistant Administra- Relocation assistance available. Please respond with C.V. sure activities. Excellent salary and federal benefits. Please tor, Chowan Hospital, P.O. Box 629, Edenton, NC 27932; to Box 6769, c/o JAMA. send inquiries and Curriculum Vitae to William Haskins, 919-482-6270 BC-E OB/GYN: CENTRAL FLORIDA. EXCELLENT FULL M.D., Acting Chief of Staff, VA Medical Center, 17273 State WANTED: GENERAL INTERNIST. IMMEDIATE OPENING time opportunity. Competitive salary. Position available in 8 Route 104, Chillicothe, OH 45601. 614-773-1141, ext. 7254. for BC/BE physician who enjoys busy hospital practice. person department. Liability coverage provided. Florida EOE. Salary and benefits are competitive. Responses to Box license required. Close to beaches, university center and RAPIDLY GROWING PRACTICE OF 9 INTERNISTS NEEDS 6787, c/o JAMA. Disney. For information call collect 813-534-3300 or write Personnel Director, Polk General Hospital, P.O. Box 816, several BC/BE Internists. Excellent benefits and guarantee INTERNAL MEDICINE: 3-PERSON INTERNAL MED GROUP Bartow, FL 33830. EOE. with partnership potential. Practice is associated with 405 seeking BC/BE associate to join well established practice in bed M/S facility in Mid-west community of 750,000 + Central Adirondack Region of NY State. Attractive compen- Growing economy, diverse cultural and recreational activi- sation package including guaranteed salary. Send C.V. to WISCONSIN ties. Superior educational systems. Bly/Grove Associates, 1374 Clarkson/Clayton Center, Ballwin, Missouri 63011; Adirondack Internal Medicine Group PC, RFD 410D, Sara- nac Lake, NY 12983. Third Board Certified/Board Eligible Obstetrician-Gy- 800-888-2266; FAX 314-458-9168. necologist to join financially strong, progressive, staff- CENTRAL NEW JERSEY, INTERNIST WITH OR WITHOUT INTERNAL MEDICINE: WISCONSIN-THE MANITOWIC subspecialty to share busy medical practice with one inter- model HMO. Community of 130,000 with a university Clinic seeks a BC/BE General Internist to join eight nist. Salary offered. Aesthetic high growth area. Close to located near Minneapolis-St. Paul. Excellent quality other Internists in a busy 19 physician multispecialty hospitals. Box 6789, c/o JAMA. lifestyle and outstanding recreational area. $145,000 group. Lovely community of 35,000 located mid-state salary, malpractice insurance, and full benefits. Send on the shore of Lake Michigan. Guaranteed first year MAUI, HAWAII: INTERNIST NEEDED FOR SMALL CLINIC. salary and excellent benefit package. Contact or send Excellent opportunity for good income and free time for golf, CV or call Neal Steinhoff, Jackson and Coker, Inc., C.V. to: James Robinson, Administrator, Manitowic windsurfing, or sailing. Send C.V. to: John N. Withers, M.D., 115 Perimeter Center Place, Suite 380 10467, At- Clinic, 601 Reed Avenue, Manitowic, WI 54221-1270. Kihei Physicians, P.O. Box 1119, Kihei, Maui, Hawaii 96753, lanta, GA 30346, Tel. 1-800-544-1987. Telephone 414-682-8841. or call 808-877-6655. 2612 JAMA, May 15, 1991 Vol 265, No. 19 OB/GYN NORTH CAROLINA: Located less than one hour from Raleigh-Durham area. Only Occupational Medicine an hour from North Carolina beaches. Hospital just completed new OB/GYN unit. Solo with A PRIVATE COMPANY PROVIDING HEALTH PROMOTION and Occupational Medicine Services is seeking to expand coverage. Your choice to set up your own practice it's Occupational Medicine Program and has a position VERELAN™ Verapamil HCI 240mg 120mg with a net guarantee from the hospital or become available for a BC/BE Occupational Medicine Physician or an employee of the hospital. All interviewing and an Internal Medicine Physician with appropriate experience. relocation expenses paid. Send CV or call Doug Unique opportunity and excellent potential for growth. PELLET-FILLED CAPSULES Please send C.V. to Steven M. Moffatt, M.D., 17 West Market Henderson, Jackson and Coker, Inc., 115 Perim- Street, Suite 1000, Indianapolis, IN 46204-2932. eter Center Place, Suite 380 10677, Atlanta, GA A CHANCE TO FOCUS ON WHAT'S IMPOR- 30346, Tel. 1-800-544-1987. TANT. If you're a physician who qualifies as a Ophthalmology CompHealth locum tenens physician, you can MAUI, HAWAII: OB/GYN PHYSICIAN NEEDED FOR SMALL leave onerous paperwork and overhead costs clinic. Excellent opportunity for good income and free time for golf, windsurfing, or sailing. Send C.V. to: John N. Withers, behind. With CompHealth you'll enjoy practice in ARE THERE PROFESSIONAL SETTINGS YOU'VE ALWAYS M.D., Kihei Physicians, P.O. Box 1119, Kihei, Maui, Hawaii wanted to sample? Consider joining CompHealth, the na- different locations throughout the U.S. for variable 96753, or call 808-877-6655. tion's largest locum tenens group. If you qualify, you can lengths of time. Earn an excellent income in a OB/GYN HAWAII: EXCELLENT OPPORTUNITY & LIFE- practice from Florida to Alaska for a week to several years variety of practice settings. CompHealth takes style. A multi-specialty group, servicing West Kauai. Call or or anything in between. it's your choice. You'll enjoy the care of all of the major expenses like malpractice send resume to Business Manager, Garden Island Medical experience of a lifetime. CompHealth provides competitive earnings and takes care of the malpractice premiums and premiums, housing, and transportation. You'll find Group, P.O. Box 669, Waimea, HI 96796. Phone 808-338- major expenses like housing and transportation. What's yourself free of administrative duties, with more 1645. more, you'll spend less time on paperwork and more time time to take care of the patients who need you. GYNECOLOGIST - INDIANAPOLIS, INDIANA TWO- on quality health care. Openings available now, call 1-800- Call today: 1-800-328-3073 toll-free. three days/week. Excellent fee-for-service opportunity 354-4050 toll-free. including surgical and non-surgical gynecological pro- cedures. No OB. High net compensation with overhead MIDDLE TENNESSEE: TWO PEDIATRICIANS NEEDED IM- and expenses paid. Call immediately for details. Call mediately for university community of 35,000 in Cumberland Richard Sheridan at 1-800-852-5678. Otolaryngology Mountains. 225-bed JCAHO approved hospital. Partnership, group, or solo options available. Abundant outdoor activities and one hour to metro area. Contact Jeff Hartline, 5000 OBSTETRICS / GYNECOLOGY - LAUREL, ASSOCIATE NEEDED. OPPORTUNITY IN NORTHEAST Linbar Drive, Suite 240, Nashville, TN 37211, 800-283- MISSISSIPPI: Join current Obstetrician in asso- Ohio for association in a practice of Otolaryngology, with an 6611. emphasis on head/neck reconstructive and plastic surgery. ciation. 1 in 2 call/coverage. Search sponsored Opportunity exists to take over the practice in 2-3 years. IMMEDIATE OPENING FOR A PEDIATRICIAN TO JOIN by 275-bed hospital. Community of 30,000 just The practice location is growing and offers a mix of urban another in private practice in Northwest Indiana. Send 90 minutes from Gulf Coast and 60 minutes from and rural lifestyles. Call: 216-296-4044. resume to P.O. Box 10575, Merrillville, IN 46411. Jackson, Mississippi. Excellent financial package. OTOLARYNGOLOGIST NEEDED - TENNESSEE: STERLING ARKANSAS: WELL ESTABLISHED PEDIATRIC GROUP Paid interviewing and relocation expenses. Send seeks 4th member in scenic community of 60,000. Located MEDICAL, the nation's leading provider of general and specialty CV or call Greg Pilgrim, Jackson and Coker, Inc., 40 miles south of Little Rock, AR. Affiliation with 400-bed medical services on a departmental basis, has an extremely regional medical center. Competitive financial package of- 115 Perimeter Center Place, Suite 380 10703, attractive opportunity available for an Otolaryngologist at a fered. Send C.V. to Andrew Johns, Physician Services of Atlanta, GA 30346, Tel. 1-800-544-1987. Sterling Medical staffed hospital in Tennessee. As a Sterling America, Suite 250, 2000 Warrington Way, Louisville, KY Medical physician, you'll receive high fee-for-service compen- 40222, or call 1-800-626-1857. FLORIDA SEVERAL OB/GYN PRACTICE OPPORTUNI- sation with generous hourly guarantee, limited or no on-call, MIDDLE TENNESSEE: PRESTIGIOUS SIX PERSON ties available. Communities in Panhandle, Central, East and vacation/holiday leave, and full malpractice coverage. For infor- group in university community of 35,000 seeks two addi- West Coast. Guarantees and full package of benefits. For mation, call Jon Adams at 1-800-852-5678. tional Pediatricians for busy practice. Competitive package more information, please call or send your C.V. to Dee Dee with paid interviewing and relocation expenses. Beautiful Ralston, HealthTrust, Inc., 4525 Harding Road, Nashville, hospital with over 1200 annual births. Historic community TN 37205, 1-800-825-3463. We are not an agency or HMO. with proximity to Nashville. Contact Jeff Hartline, 5000 Linbar Drive, Suite 240, Nashville, TN 37211, 800-283- OB/GYN: SOLO OPPORTUNITY, WITH COVERAGE, AVAIL- Pathology 6611. able in growing rural community in Georgia. Because of over 825 deliveries in the service area, the two OB/GYNs have a difficult time meeting the demand for both Obstetrics LSU SCHOOL OF MEDICINE, NEW ORLEANS, IS SEEKING LONG ISLAND, NEW YORK Pediatrician to join group and Gynecology. Central location near beaches, metropoli- AP/CP Board Certified Pathologist to practice in 200-bed tan areas and Georgia mountains. Licensed 150-bed full- LSU affiliated hospital in Baton Rouge, LA. Academic of four Board Certified physicians in Holbrook, New service facility. Hospital offers excellent incentive package. appointment at the Assistant Professor level. Some years York. Community of 60,000 is located one hour from Send C.V. to: Beverly Luke, Coffee Regional Hospital, P.O. of experience preferred but not mandatory. Salary competi- New York City. Group practices at SUNY-Stoneybrook. Box 1248, Douglas, GA 31533-1248; 1-800-873-7065. tive, depending on qualifications and experience. Send NORTH CAROLINA COAST: SEEKING BC/BE OB/GYN TO letters of application, Curriculum Vitae, and names of three Interviewing and relocation expenses paid. Send CV or references to Alfredo Suarez, M.D., Director of Clinical call Greg Pilgrim, Jackson and Coker, Inc., 115 join established 2-person practice in small, historic town by Laboratories, Earl K. Long Memorial Hospital, 5825 Airline the water. Progressive, financially sound, JCAHO accredited Perimeter Center Place, Suite 380 10696, Atlanta, GA hospital. Send C.V. or call: John Rider, Assistant Administra- Highway, Baton Rouge, LA 70805. LSUMC is an Equal tor, Chowan Hospital, P.O. Box 629, Edenton, NC 27932; Employment Opportunity/Affirmative Action Employer. 30346, Tel. 1-800-544-1987. 919-482-6270. FORENSIC PATHOLOGIST: FOR POSITION OF MEDICAL Examiner in Corpus Christi, Texas; send resume to: Nueces CALIFORNIA: SECOND BC/BE OB/GYN TO JOIN FINAN- County Medical Examiner's Office, 2435 Morgan, Corpus cially strong multispecialty group practice in Southern Cali- Christi, TX 78405. Pharmaceutical Medicine fornia, near downtown Los Angeles. Salary to $200K, malpractice and benefits. Send C.V. to Medical Director, ACMG, 2675 East Slauson Avenue, Huntington Park, CA NATION-WIDE PHARMACEUTICAL CLIENTS SEEK MDS 90255. Pediatrics for clinical research/professional services. Needed: IM Sub-specialties, Pharmacology, CNS, etc. Dr. Juliano, OB/GYN, NE - LIVE OUT WHAT OTHERS CAN ONLY BRJ Associates, 615 Sherwood Pkwy, Mountainside, dream of. Work only 4 days per week in an existing practice PEDIATRICIAN: MULTI-SPECIALTY CLINIC IN ELKO, NE- NJ 07092, 201-233-6000. with no overhead and no administrative headaches to worry about. Never pay malpractice again while you practice in a vada is looking for a BC/BE Pediatrician to join two other medium-sized hospital that just spent $8M on renovation. Pediatricians in a busy practice. All fee for service with good Can you see yourself in a Norman Rockwell setting, a land collection ratio. Guaranteed salary for six months leading of clean, crisp air and wholesome American values? The to full partnership. Comprehensive benefit package including Psychiatry hospital will pay all your expenses to come visit this malpractice insurance. Elko is a thriving community sur- Connecticut River community in the mountains of Vermont, rounded by mountains and wilderness. Recreation year round. Please send C.V. to Cherie Atwood, Administrator, MIDDLE TENNESSEE: EXCELLENT PRACTICE OPTION with buildings from the 1800's, cross-country skiing, and Elko Regional Medical Center, 762-14th Street, Elko, Ne- for BE/BC Psychiatrist in university community of 75,000 Dartmouth only 25 minutes away. Remember, I've been vada 89801. 702-738-3111. Dedicated in-patient unit with all support services. Private there and can verify all of the above. Please call me at 800- practice package extremely competitive with reimbursed 347-6987, ext. #0-0120 and I'll tell you all you want to know EAST COAST: GROUP/SOLO/PARTNERSHIP POSITIONS. interviewing and relocation costs. Local Psychiatrist anxious about the area; or send your C.V. to Joe Bishop, Harris Guaranteed incomes, shared call, etc. Contact Fox-Morris to provide coverage and possible association. Historic Kovacs Alderman, 4170 Ashford Dunwoody Road, Suite Assoc., 47 Perimeter Center East, Suite 540, Atlanta, GA community with proximity to Nashville. Contact Jeff Hartline, 500, Atlanta, GA 30319. 30346 or 800-899-0933. 5000 Linbar Drive, Suite 240, Nashville, TN 37211, 800- 283-6611. CLINICAL DIRECTOR IMMEDIATE OPENING FOR A Research works. Board Certified Psychiatrist to restructure health care team. Two additional openings for Board Qualified Psychiatrists, with private practice potential and a university teaching appointment if desired, in the stable, progressive community of Hastings, NE. Generous retirement and health benefits, CME/professional expenses, competitive salary and hous- ing are all part of the package. To learn more about this outstanding professional opportunity, contact Nancy Stal- lings, CompHealth, 4021 South 700 East, Salt Lake City, UT 84107, 1-800-328-3035. CENTRAL CALIFORNIA. INTERDISCIPLINARIAN MENTAL health group seeks child Psychiatrist to join group. Premier Psychiatric group offers lucrative guaranteed first year salary, extraordinary benefits package, and shareholder opportunity. Excellent inpatient facility. Bedroom community American Heart for Bay area conveniently near Sierra Mountains, Lake Tahoe and Monterrey. One of the fastest growing cities in Association California offers a growing economy, cultural activities and an affordable real estate market. Search conducted by: Physician International, 4-J/PY Vermont Street, Buffalo, NY 14213. 1-800-622-4062. JAMA, May 15, 1991 265, No. 19 2613 RADIOLOGISTS WANTED: CHIEF EL PASO, TEXAS; WASHINGTON, D.C. BC/BE NEUROSURGEON- Enjoy a radiology practice with limited on-call, liberal leave time PSYCHIATRIST and guaranteed private-practice level compensation. Sterling needed to join an existing solo neurosurgery practitioner on the staff Medical, the leading provider of specialty medical services of a progressive, 462-bed hospital in Gastonia, North Carolina, a nationwide, is looking for permanent radiologists for practice growing community of 50,000 situated 17 miles west of Charlotte locations in the West, and Eastern Seaboard. As a Sterling This need has arisen due to the continuing growth in demand for Natividad Medical Center, Medical physician, you will be guaranteed paid malpractice, full holiday/vacation/CME coverage and very good compensation. neurological care in the community. This effort is fully supported by located on the beautiful Call Steve Bernard toll-free at 1-800-852-5678. our medical staff. As a result, you can expect a high level of professional cooperation. Our incumbent Neurosurgeon is pre- Monterey Peninsula in pared to offer the necessary financial incentives to ensure a IMMEDIATE OPENING BOARD CERTIFIED RADIOLOGIST. successful start-up and will pay interviewing and relocation ex- California, is seeking a Imaging fellowship, angiography and general radiology. Attractive salary/benefits; partnership. South Suburban Chi- penses. Chief Psychiatrist. NMC is cago, 220-bed hospital. John M. Nayden, M.D., 708-799- Please respond with CV to: Box 6734, c/o JAMA 8000, ext. 3276. a 211-bed, JCAHO accred- VETERANS AFFAIRS MEDICAL CENTER, SAGINAW, MICH- ited teaching hospital Rheumatology igan, needs BC or BE Surgeon with or without subspecialty. Call Joyce Shappes, Personnel Service, 517-793-2340, (UCSF Family Practice extension 3076. An Equal Opportunity Employer. RHEUMATOLOGIST BISMARK, NORTH DAKOTA. AS- Residency Program) with sociate/partner needed for group practice. Send C.V. to Box BC/BE VASCULAR SURGEON TO JOIN ESTABLISHED 6761, c/o JAMA: surgical group practice. Office provides a full-time RVT in full ancillary services. the vascular lab. Eastern PA location. Will introduce. Send RHEUMATOLOGIST TO JOIN ESTABLISHED GROUP IN C.V. to Box 6782, c/o JAMA. Bismark, North Dakota which provides services to 300,000 Contracted position with area residents. Send C.V. to: Box 6785, c/o JAMA. ROCKY MOUNTAINS excellent compensation SOUTHERN COLORADO package and paid mal- Surgical Specialties GENERAL SURGERY practice. Send V.'s to: SURGICAL HOUSE PHYSICIANS NEEDED FOR NORTH- Colorful Colorado, mountains, lakes, for- east Ohio suburban hospitals. $95-104K, paid malprac- Stephanie Clymer tice, never on call. Physician Staffing, Inc., 3628 Walnut ests, full time ANS and RAD. Tremendous Hills, Cleveland, Ohio 44122. 216-292-7445. Associate Personnel Analyst need, excellent income guarantee and po- VASCULAR SURGEON: FELLOWSHIP TRAINED, WANTED Natividad Medical Center tential. For more information on this oppor- to join solo practitioner in the Finger Lakes region of Upstate 1330 Natividad Road New York. Great opportunity, competitive salary and early tunity call Gerry Weipert or Roger Hamilton partnership. Reply immediately. Box 6709, c/o JAMA. P.O. Box 81611 at (800) 876-0500 or (214) 444-2200 or Salinas, CA 93912-1611 send your CV to Merritt, Hawkins & Asso- General Surgery opportunity in Princeton, Kentucky. AA/EOE One hour from Nashville, Tennessee, Evansville, Indi- ciates, 222 W. Las Colinas Blvd., Suite ana, and Paducah, Kentucky. Community of 10,000 is 1920, Irving, TX 75039. Please reference NATIVIDAD looking for solo General Surgeon with coverage. Lo- 808. cated on Kentucky Lake and Lake Barkley. 50-bed M hospital recently completed $2 million renovation add- MEDICAL ing three OR suites. Excellent income guarantee. SURGEON: FIVE SURGEONS WITH A WELL ESTABLISHED Interviewing and relocation expenses paid. Send CV or group practice in beautiful Central Pennsylvania are seeking CENTER. call Greg Pilgrim, Jackson and Coker, Inc., 115 a sixth general, oncologic, or colorectal surgeon. Excellent Perimeter Center Place, Suite 380 10691, Atlanta, GA starting salary, early partnership, and plenty of vacation time 30346, Tel. 1-800-544-1987. available. Excellent medical community with all medical/ surgical subspecialties available. Please send C.V. to Tim- othy J. Pagana, M.D., FACS, 699 Rural Avenue, Williams- CHIEF, DIVISION OF PERIPHERAL VASCULAR SURGERY: port, PA 17701. The Department of Surgery, Medical College of Ohio is MIDDLE TENNESSEE GENERAL SURGERY. CLINIC Radiology seeking a Board Certified or Board Eligible Surgeon to lead its Division of Peripheral Vascular Surgery. Responsibilities located on beautiful Center Hill Lake is looking to add an will include patient care, research and education of under- additional physician. Practice will be fully managed. For RADIOLOGIST NUCLEAR/GENERAL - NEEDED FOR graduate and graduate students. Curriculum Vitae and more information contact: Dee Dee Ralston, 1-800-825- South Jersey hospital practice. BC or in process. $175- bibliography should be submitted to Neil R. Thomford, M.D., 3463, HealthTrust, Inc., 4525 Harding Road, Nashville, TN. $200K + base salary plus excellent benefit package. Also Chairman, Department of Surgery, P.O. Box 10008, Toledo, We are not an agency or HMO. need qualified locum tenens for immediate coverage. Send OH 43699-0008. The Medical College of Ohio is an Equal C.V. in confidence to Box 6732, c/o JAMA. Opportunity Employer. BC/BE General Surgeon with thoracic and/or WHY DID YOU GO INTO RADIOLOGY IN THE FIRST DIRECTOR, CARDIAC TRANSPLANT PROGRAM: THE DE- vascular interests to join well-established four- place? Have you had enough politics, paperwork and partment of Surgery, Medical College of Ohio is seeking a pressure? If you'd like more time to focus on quality health Board Certified or Board Eligible Cardiothoracic Surgeon to person practice. City of 50,000 has well-rounded care, consider practicing with CompHealth, the nation's direct established heart transplant program. Curriculum medical community and is the home of Cornell largest locum tenens group. If you qualify, you'll determine Vitae and bibliography should be submitted to Neil R. University. Outstanding cultural, scenic and rec- the setting: From Maine to Hawaii - and the duration - Thomford, M.D., Chairman, Department of Surgery, P.O. reational resources. Send CV to: Surgical Asso- from a week to a year or more. We relieve you of the time- Box 10008, Toledo, OH 43699-0008. The Medical College consuming administrative duties, provide a competitive of Ohio is an Equal Opportunity Employer. ciates of Ithaca, P.C., 1301 Trumansburg Rd., income, and take care of housing, transportation, licensure Ithaca, NY 14850. and malpractice premiums. Call now: 1-800-328-3084 toll- free. PARTNERSHIP General Surgeon to join successful Vascular Surgeon in scenic Tennessee city of 30,000. TRANSPLANT SURGEON BC/BE TO JOIN AN EXPAND- WEST TENNESSEE: FIVE PERSON GROUP SEEKS SIXTH Some vascular experience required. 80% of practice ing Midwest transplant program based at a University person for busy practice. All modalities in state-of-the-art will be GS cases. Fabulous office adjacent to modern affiliated tertiary referral center. Renal and extra-renal trans- facilities. Excellent salary and benefits + interviewing and relocation expenses. National School of Excellence. Low 275-bed hospital. Unsurpassed, quality lifestyle with plant background necessary including short and long term unemployment. Proximity to Memphis. Contact Jeff Hartline, quick access to Nashville. Send CV or call Ken immunosuppressive management. Pancreas transplant ex- perience desirable. Excellent lifestyle, competitive salary 5000 Linbar Drive, Suite-240, Nashville, TN 37211, 800- Cunningham, Jackson and Coker, Inc., 115 Perimeter and benefits. Resident and student teaching and clinical 283-6611. Center Place, Suite 380 10686, Atlanta, GA 30346, research opportunities. Please send Curriculum Vitae to: MIDDLE TENNESSEE: BUSY THREE PERSON GROUP Tel. 1-800-544-1987. Marcia Cordell, Vice President, Physician Recruiting, Re- search Health Services System, 2316 E. Meyer Blvd., looking for fourth Radiologist. All modalities. Excellent first Kansas City, MO 64132. year package plus early partnership. Reimbursed interview- BC/BE GENERAL SURGEON WITH VASCULAR FELLOW- ing and relocation expenses. Bustling community near ship to join busy NYC practice. Excellent salary and benefits BUSY GENERAL SURGEON IN CONNECTICUT SEEKING Nashville with excellent schools and housing. Contact Jeff with potential for partnership. Send C.V. and references to BC/BE General Surgeon for immediate opening as associ- Hartline, 5000 Linbar Drive, Suite 240, Nashville, TN 37211, P.O. Box 58, Purchase, NY 10577. ate. Office adjacent to 300-bed teaching hospital, 2 hours 800-283-6611. from Boston and New York. Excellent salary and benefits. WANTED: SURGICAL SPECIALTIES. IMMEDIATE OPPOR- RADIOLOGIST INTERVENTIONAL NEEDED FOR Send C.V. to Dr. A. Sarma, 40 Hart Street, New Britain, tunity for BC/BE General Surgeon with interest in vascular Connecticut 06052. 203-225-9431. South Jersey hospital practice. BC or in process. $175- surgery for family oriented group practice. Located near $200K + base salary plus excellent benefit package. Also Chicago, IL. We have an attractive practice with three BC need qualified locum tenens for immediate coverage. Send General Surgeons and four BC Family Practitioners. Excel- C.V. in confidence to Box 6758, c/o JAMA. MISSISSIPPI - Associate with established sur- lent compensation and benefit package with potential for SCHOOLCRAFT MEMORIAL HOSPITAL IN MICHIGAN'S partnership. Submit C.V. to: Family Medical Group, 330 geon or go solo and share call coverage. Sunbelt beautiful Upper Peninsula seeks a person with strong Madison, Joliet, IL 60435, Attn: J. Walsh. city of 11,000 has 102-bed hospital with recent training and or experience in all areas except MRI. Should BE/BC PHYSICIAN TO JOIN WELL-ESTABLISHED GEN- $10 million expansion. State-of-the-art facility is be Board Certified and demonstrate skills in diagnosis, eral E.N.T. group (2 person). Partnership after first year. No utilized by a staff of six OBG's, 4 FP's, 3 IM's and floura, U.S., mammography and CT. The radiology depart- buy-in required. Houston area. Send C.V. to Box 6554, c/o ment at Schoolcraft Memorial Hospital was recently reno- JAMA. 3 PD's, and a Radiologist certified for VS support. vated and has a new x-ray machine and mammographic Enjoy a huge practice and a quality lifestyle with unit, gamma camera and services of a mobile CT scanner. THORACIC-CARDIOVASCULAR SURGERY: BC/BE THO- the full support of the medical staff and adminis- Please direct your C.V. and all correspondence to: David B. racic Surgeon. New grads are welcome. Pennsylvania Jahn, Administrator, Schoolcraft Memorial Hospital, 500 license required. Competitive salary and benefits. Send tration. Outstanding income guarantee. Send CV Main St., Manistique, MI 49854. Call collect: 906-341-2163. C.V. to Box 6776, c/o JAMA. or call Ken Cunningham, Jackson and Coker, Inc., IMMEDIATE POSITION AVAILABLE FOR A RADIOLOGIST WANTED: GENERAL SURGEON (BC/BE) TO JOIN BUSY 115 Perimeter Center Place, Suite 380 10688, in a free-standing outpatient MRI/CT imaging center in General Surgeon in Finger Lakes region of upstate New Atlanta, GA 30346, Tel. 1-800-544-1987. Central New Jersey. Send C.V. to Box 6788, c/o JAMA. York. Send C.V. to Box 6779, c/o JAMA. 2614 JAMA, May 15, 265, No. 19 Orthopedic Surgery NATION WIDE Excellent opportunities available Solo, group or hospital based Interested in a Orthopedic Surgeon to join two-physician practice in ALL SPECIALTIES Mobile, Alabama. Busy General ORS group in com- send CV: munity of 250,000 on the Gulf Coast. Practice has a better practice good reputation, hospital's support, and excellent MARVEL MEDICAL RECRUITERS facilities. Easy access to several pleasant beaches, nice 3690 Orange Place #260 cultural amenities, and good restaurants make ths a III Beachwoòd, OH 44122 opportunity? better-than-average coastal community. Competitive 800-338-1257 216-292-2855 financial package with all benefits includes interviewing A simple phone call will put you in and relocation expenses. Send CV or call Doug Hen- PHYSICIANS: ALL SPECIALTIES. RECRUITING FOR CLIN- touch with the widest range of derson, Jackson and Coker, Inc., 115 Perimeter Center ics & hospitals throughout Midwest. Send C.V. to Physician Placement, 310 E. Water St., Medina, ND 58467. 701-486- Place, Suite 380 10682, Atlanta, GA 30346, Tel. 1- 3222. opportunities in any specialty. 800-544-1987. POSITION AVAILABLE: BC/BE INTERNIST OR FAMILY All opportunities have been Practice with established multi-specialty group. Excellent benefit package including insurance and guarantee. If thoroughly researched and we can ORTHOPEDIC SURGEON: PROGRESSIVE, 150-BED RE- interested, send C.V. to: Leroy W. Kitch, Administrator, gional hospital located in growing area of south Georgia has Skinner Clinic, 124 Dallas St., San Antonio, Texas 78205. provide you with information on: great need for Orthopedic Surgeon. The hospital performed over 2800 surgeries and over 18,000 ER visits during 1990. Service Area Homes Orthopedic cases were referred out-of-town. The 28-physi- PRIVATE PRACTICE OPPORTUNITIES cian medical staff will welcome you, and the hospital will Facilities In all specialties, TX & Sunbelt states Geography assist you in establishing your practice. Build this fine practice while enjoying a quality lifestyle in the South. Send Call 1-800-284-4560/Houston 785-3722 Income Recreation C.V. or call: Beverly Luke, Coffee Regional Hospital, P.O. Box 1248, Douglas, GA 31533-1248; 1-800-873-7065. Or send CV to: Reuben Lifestyle Schools 11140 Westheimer Bronstein NE (ORS) - NO BUY-IN, TAKE OVER EXISTING PRACTICE Suite #144 We have 12 years of experience at 181 bed, state-of-the-art facility that offers 24-hour M.D. anesthesia, full-time radiology, fixed CT and mobile MRI. Houston, TX 77042 & Associates making relocations easy and suc- Very competitive net income guarantee, along with ½ call coverage. The community is surrounded by 3 snow skiing PENNSYLVANIA, CENTRAL: STABLE EMERGENCY PHY- cessful for physicians. That's why resorts and located within 30 minutes of all the amenities if sician group seeking BC/BP physician in primary care the metropolitan city. You will find yourself with plenty of free specialty for full time opportunity beginning June 1, 1991. we're the largest physician search time because of the rotating call to play golf or enjoy boating Double coverage. Competitive salary. Excellent benefits. firm in the nation. For information on one of the area's many lakes. Remember, the community Send C.V. to Dr. Robin Wilkening, Chief, Department of will pay all your overhead and moving expenses. I've been Emergency Medicine, Lewistown Hospital, Lewistown, PA to this community and met the covering doctors; believe 17044 or call 717-242-7179. on current opportunities, call: me, there is a strong need. Please call me at 800-347-6987, ext. #1-051, or send your C.V. to Joe Bishop, Harris Kovacs TEXAS DEPARTMENT OF CORRECTIONS - SEEKING 1-800-544-1987 EXT. 16 Alderman, 4170 Ashford Dunwoody Road, Suite 500, At- full-time Physicians ($63,470 to $84,180) and Psychiatrists lanta, GA 30319. ($81,900 to $129,300) in Correctional Health Care Facilities. Must be Texas licensed, Board Eligible. Excellent benefits. Inquiries to: TDC, PO Box 99, Personnel Annex, Huntsville, JACKSON Griffin, Georgia - Join four-physician group TX 77342. 409-294-2755. ANDCOKER based in Atlanta. Practice in satellite office located 115 Perimeter Center Place, BEST NATIONWIDE OPPORTUNITIES Suite 380 JDI 40 miles south of Atlanta in Griffin. Population of Atlanta, Georgia 30346 30,000. 160-bed hospital. Excellent salary. Inter- In All Specialties viewing and relocation expenses paid. Send CV Permanent Placement and Locum Tenens If Your Serious About Your Future, WE NEED YOUR C.V. or call Greg Pilgrim, Jackson and Coker, Inc., 115 CONSOLIDATED PHYSICIAN RELOCATION SERVICES Perimeter Center Place, Suite 380 10700, Atlanta, One San Jose Place, #17 GA 30346, Tel. 1-800-544-1987. NASHVILLE Jacksonville, FL. 32257 1-800-733-7999 HEALTHCARE GROUP "WE LISTEN TO YOUR NEEDS" The Nashville HealthCare Group Urology TEXAS: FULL-SERVICE HOSPITAL ONE HOUR NORTH OF has excellent immediate and future Dallas has immediate need for Family Practitioners/Inter- nists/Orthopod. Excellent 1st year package, 3 beautiful opportunities for BC/BE Family Phy- office buildings available now. Reply: Northeast Medical UROLOGIST NEEDED - GEORGIA, TEXAS: STERLING sicians, Internists, and Pediatricians, Center, 903-583-8585, (ex.314), P.O. Drawer C, Bonham, MEDICAL, the nation's leading provider of specialty Texas 75418. with a newly formed primary care prac- medical services on a departmental basis, has positions SPINAL CORD INJURY VACANCY EXISTS FOR STAFF tice affiliated with one of the nation's immediately available in Urology for practice locations Physician BE/BC in Physiatry, Internal Medicine or Family largest health plans. The Nashville in Georgia and Texas. Truly excellent net compensation Practice in this active GM&S Medical Center affiliated with with paid malpractice, and vacation/CME/holiday leave. the Medical College of Georgia. Spinal Cord Injury Service HealthCare Group offers a practice consists of a 60-bed acute Rehabilitation Care and Treat- For immediate information, call Richard Blatt, toll-free setting which is conducive to the de- ment Unit. Augusta enjoys a moderate climate, reasonable at 1-800-852-5678. cost of living, numerous recreational facilities and institutions velopment of individual talents and of higher learning. Augusta is known as the Garden City of style in a pre-paid environment. the South and home of the Masters golf tournament. An Equal Opportunity Employer. Interested applicants send Curriculum Vitae to Dr. Vidya C. Sridharan, Chief, Spinal The Nashville HealthCare Group BC/BE Urologist Cord Injury Service, VA Medical Center, Augusta, GA 30910 provides a guaranteed salary and a or call 404-823-2216 comprehensive benefits package needed to join the staff of a 10-man multi-specialty PRIMARY CARE PHYSICIAN NEEDED FOR GROUP WITH which includes health, dental, life, and group located 40 miles from Birmingham, Ala- three other physicians. Competitive salary with full range of benefits included. Located in North Carolina 15 minutes short and long-term disability and mal- bama. Our practice offers the advantages of built-in from suburban area and classified as State and Federal practice insurances, licensing fees, referrals and an income distribution plan that does loan repayment area. For more information, send Curriculum not penalize high-volume producers. We are pre- Vitae to: Durham Medical Search, Inc., 6300 Transit Road, and bonus program. Physicians will be P.O. Box 478, Depew, NY 14043. 800-633-7724 National; pared to offer the necessary financial incentives to eligible for ownership in the practice. 800-367-2356 NYS. ensure a successful start-up and will pay interview- ing and relocation expenses. TO The Nashville Metropolitan Area of- fers a strong economy, four seasons, Respond with CV to: box 6783 c/o JAMA $2,500 exceptional educational institutions, diverse cultural activities and many SIGN ON BONUS avenues for professional and personal growth. Multiple Specialties/ Southeastern openings - All specialties Im- Group Practice mediate needs for GP/FP, OB/GYN, Occupa- Please forward curriculum vitae and tional Medicine, Anesthesiology, Internal Med- letter of interest to: icine, Orthopedic, Pathologist and Radiologist. OCCUPATIONAL/FAMILY PRACTICE MEDICINE. THE West Coast's leading outpatient medical provider has op- MEDICAL D. Mark Mahler, M.D., portunities for Primary Care Physicians to join an expanding The Nashville HealthCare Group 150 person medical group. Full/part-time openings in the ECRUITERS San Francisco Bay Area and throughout California and 227 French Landing Drive Seattle-Tacoma, Washington. Attractive package includes TLANTA Inc. Suite 300 excellent base salary plus incentive program, malpractice insurance, comprehensive benefits, 401(k) plan, vacation/ Nashville, TN 37228 sick/holiday/CME. Contact Marilyn Burke, ReadiCare/ Suite 170, 1800 Water Place, Atlanta, GA 30339 CHEC, 446 Oakmead Parkway, Sunnyvale, California 1 800 523-1351 or call 1-800-626-7131. 94086. 408-737-8531. JAMA, May 15, 1991- Vol 265, No. 19 2615 CAREER PRACTICE OPPORTUNITIES We know one thing very well ! Our national network of clients define exactly what their needs are. Are you that thoroughly prepared? Your C.V. does not define what you want. Confidential discussion with our professional consultants concerning specific opportunities will bring about that definition. Our goal is to connect you and your family with positions that foster long term commitments. We are dedicated to finding the right match between your career objectives, personal goals, and the criteria of our clients. We care. Our success can not be separated from your success. If you are seeking a career opportunity you should know one thing very well -- Cejka & Company. START THE PROCESS Mail CV to: Fax in CV to: 314-726-0026 Cejka & Company Or call: Karen Williams 222 S. Central 800-365-2237 Corporate Offices, Suite 400 St. Louis, MO 63105 Humana has the right locations. HOW TO FIND INTERNAL MEDICINE ORTHOPEDIC SURGERY OBSTETRICS/GYNECOLOGY Group, associate and solo opportunities are DR. RIGHT? available in a variety of settings. Here are a few INFECTIOUS DISEASE/ to pick from: INTERNAL MEDICINE Alabama Louisiana Cardiologist Family Physician FAMILY PRACTICE FP/IM OB/GYN INVASIVE CARDIOLOGY OB/GYN Orthopedic Surgeon Orthopedic Surgeon Kansas City, MO NON-INVASIVE Otolaryngologist The AMA Physicians Family Physician TM CARDIOLOGY Phoenix, AZ OB/GYN Career Resource is Family Physician Orthopedic Surgeon PHYSICIANS a multidimensional RHEUMATOLOGY OB/GYN Natchez, MS CAREER Orthopedic Surgeon OB/GYN recruiting service that The Humana-Michael Reese HMO, a large RESOURCE well-established HMO serving its members in Denver, co Oncologist offers access to physi- Internist 21 Health Centers throughout the Chicago Chattanooga, TN Neurologist cians registered with Physicians Place- Orthopedic Surgeon Metro area, is seeking additional Board Central Florida Perinatologist ment Service, listings in one of the Certified/Eligible physicians in the above Cardiologist Beaumont, TX country's most respected placement specialties. OB/GYN Anesth (OB) Orthopedic Surgeon Family Physician journals, and advertising as a place- Physicians with the Humana-Michael Reese Jacksonville, FL HMO enjoy a full practice with modern Orthopedic Surgeon ment resource. GYN (no OB) facilities and equipment as well as College Station, TX Internist Neonatologist We help you recruit the right doctor opportunities for teaching. South Florida Rheumatologist for your practice opening. A highly-competitive salary and excellent OB/GYN Dallas, TX benefits complement a rewarding practice Pediatrician Cardiologist (INV) For more information, call or write: and lifestyle. Dodge City, KS Diabetologist Neurologist San Antonio, TX Physicians Career Resource Interested applicants should address Orthopedic Surgeon Family Physician inquiries to: Pediatrician American Medical Association Internist Alfred Kendrick, M.D. Louisville, KY OB/GYN P.O. Box 10012 M Medical Affairs FP/IM Layton, UT OB/GYN Chicago, IL 60610 HUMANA-MICHAEL REESE HMO Internist Radiologist OB/GYN (800) 955-3565 2545 King Drive, Chicago 60616 Call TOLL-FREE 1-800-626-1590, or send your MEDICAL or call (312) 808-4551 curriculum vitae to: Manager, Professional Rela- tions, Humana Inc., Dept. A-0515, P.O. Box 1438, Humana-Michael Reese HMO Louisville, KY 40201-1438. an equal opportunity employer m/f/h Humana 2616 JAMA, May 15, 1991 Vol 265, No. 19 OPPORTUNITIES NATIONWIDE PHYSICIANS: ALL SPECIALTIES All fees assumed by our client companies. Submit curriculum vitae or call toll-free. Thousands CLINICAL SEARCH ASSOCIATES The Clinical Pavilion, Scott Plaza Two Philadelphia, PA 19113 800-872-8626/215-521-5103 OfDoctors A division of PMGPC EOE/M/F BUSY ORTHOPEDIC OUTPATIENT OFFICE IS LOOKING for physician with primary care background and maybe with some orthopedic experience in Florida. Phone 813-933- 6666. Get Away PRIVATE PRACTICE OPPORTUNITIES IN MINNESOTA: Dermatology, Emergency Medicine, Geriatrics, Family Prac- tice, Internal Medicine, Ophthalmology, Pediatrics. Contact: Jerry Hess or Bill Tendle, LifeSpan, 800 East 28th Street, With It. Minneapolis, MN 55407. 800-248-4921. Kron pioneered locum tenens so you could take UNIQUE FREE SERVICE your practice, and your life, where you want TO PHYSICIANS them to go. You work as much as you want, when you want. While we guarantee your income. Pay Register now with the nation's best resource for physicians seeking new opportunities. Distributed to over 7,000 your expenses. And provide the best malpractice hospitals, clinics, group practices, HMO's, etc. throughout the country. Completely confidential. Send CV and/or insurance around. It's a total package. And letter outlining training, experience, interests, and geo- it's only available from Kron. Call Kron at graphical area. 1-800-MEDICAL. NATIONAL PHYSICIANS REGISTER, DEPT J 295 Cambridge St., Suite 422 Boston, Mass 02114 (800) 342-1007 KRON COUNTY HEALTH OFFICER/ADMINISTRATOR: LARAMIE Is Locum Tenens County, Cheyenne, WY needs qualified health officer/ad- ministrator; clean, healthy, family-type environment, low crime rate, good schools, excellent outdoor recreational Practice Made Perfect. opportunities; good balance between clinical and adminis- trative responsibilities; public health and administration background preferred; doctor of medicine degree, Wyoming licensed. Laramie County Personnel, 1915 Pioneer, Chey- enne, WY 82001. 307-638-4355. ORGAN TRANSPLANT FELLOWSHIP: ORGAN TRANS- plant Fellowship available July 1, 1991 at Boston University IMPORTANT OPPORTUNITIES FOR OVER 5000 Medical Center, Boston. Two year training program approved by the American Society of Transplant Surgeons. Starting PRACTICES NATIONWIDE salary is $37,000 and completion of residency training in DERMATOLOGIST OBSTETRICS-GYNECOLOGY general surgery is required. Please send C.V. to Transplant FAMILY PRACTICE PULMONOLOGIST 1-800-284-3322 Service, University Hospital, 88 E. Newton St., D-511, GASTROENTEROLOGIST UROLOGIST Boston, MA 02118 or call 617-638-8430. GENERAL/THORACIC SURGEON PRACTICE OPPORTUNITIES, INC. PGY-1 OPENING IN FAMILY MEDICINE AVAILABLE FOR P.O. BOX 110379 NASH, TN 37222-0379 July, 1991. New state-of-the-art Family Health center. 504- BE/BC for expanding 36 physician multispecialty group. bed community hospital. Program affilitaed with Mercer Dynamic area hub city of 30,000 ranked 7th in Midwest in University School of Medicine. Good pay, full medical desirability/quality of life. Referral area 250,000 including COLLEGE HEALTH PHYSICIAN: MODERN, DAY-TIME ONLY, benefits, affordable living in beautiful, historical Macon, six important satellites. Superb secondary level hospital outpatient clinic. Beautiful campus, East Texas recreational Georgia. Contact: Dr. Robert L. Buckley, 3780 Eisenhower advantages. Equidistant from Minneapolis and Des Moines area. 10.5-month position, no call or hospital duties. Re- Parkway, Macon, Georgia 31206. on I-35. Secure future with guaranteed salary, incentive quires primary-care experience, Texas license. Two open- FELLOWSHIP IN PAIN MANAGEMENT. MULTIDISCIPLI- income, outstanding benefits. Information WATS 1-800- ings available: April 1991; September 1, 1991. Contact Dr. nary Pain Service at Massachusetts General Hospital seeks Ray Johnson, P.O. Box 13058, SFA Station, Nacogdoches, 798-4321, or write to Recruitment Coordinator, Park Clinic, fellows who desire intensive clinical experience in the care Texas 75962, 409-568-4008. EO/AAE. 890 N. Eisenhower Ave., Mason City, Iowa 50401. of an extraordinarily diverse group of patients with acute or chronic pain. This one-year fellowship meets the require- Graduate Training/ ments for subspecialty certification in pain management recently approved by the Accreditation Council for Graduate DENVER, COLORADO - COLORADO'S LARGEST MULTI- Residencies Available Medical, and the guidelines for pain fellowship training specialty group practice HMO is seeking BC/BE Physicians established by the International Association for the Study in the following specialties: Anesthesiology, Emergentology, MANAGEMENT TRAINING FOR PHYSICIANS - THE UNC of Pain. Comprehensive approach includes in-patient and Internal Medicine, Neonatology, Orthopedics, Otolaryngol- KRON Scholars Program is America's model management outpatient consultations on patients with chronic pain, dia- ogist, Physiatry, and Psychiatry. For additional information, training program for current and future physician executives. gnositc and therapeutic nerve blocks, and acute pain please contact: V.A. LaFleur, M.D., Associate Medical Direc- It consists of five intense, in-residence management training consultation and treatment. Faculty are qualified in Anesthe- tor, Colorado Permanente Medical Group, P.C., 10350 East sessions taught by the highly acclaimed faculty of the siology, Neurology, Internal Medicine. Close collaborative Dakota Avenue, Denver, CO 80231. 303-344-7294. EOE. Business School at the University of North Carolina, Chapel relationships with MGH/Harvard colleagues in Surgery, Hill. Optional clinical field placements provide convenient Oncology, Psychiatry, Orthopedic Surgery, Neurosurgery, SOUTHERN CALIFORNIA: PRESTIGIOUS PHYSICIAN-RUN funding to offset tuition, and diversified experience in differ- Pediatrics and Rehabilitation. Busy and expanding program. multispecialty group practice seeking BC/BE physicians in ent medical organizations. Apply with C.V. to: UNC KRON Salary commensurate with qualifications. Contact: Dr. Daniel Internal Medicine, Internal Medicine/Infectious Disease, Scholars, 725 Airport Road, 3rd Floor, Chapel Hill, NC B. Carr, Harvard University Department of Anesthesia at the Family Practice, Orthopedic Surgery, Urgent Care, Pediatric 27514 or call: 1-800-633-4225, Dept. of Academic Affairs. Massachusetts General Hospital, Boston, MA 02114. Neurology, Cardiology, or Infectious Disease. Individuals for HEMATOLOGY FELLOWSHIP: FIRST YEAR POSITION consideration must be hard working, team players, and PGY-II POSITION IN INTERNAL MEDICINE BEGINNING available July 1992. A 500-bed teaching hospital in NYC enjoy California sunshine. Competitive salary with partner- July 1, 1991 at West Suburban Hospital Medical Center. A (Manhattan). Excellent program. Oncology Fellowship: First ship possible in 18 months. Located in one of the nations fully accredited, catagorical, university-affiliated, community year position available July 1992. A 500-bed teaching most rapidly growing areas, surrounded by excellent hospital based program. Contact Malcolm A. Deam, M.D., hospital in NYC (Manhattan). Excellent program. Contact: schools, cultural and recreational facilities. Send C.V. to Program Director, West Suburban Hospital Medical Center, Dr. Ariel Distenfeld, Cabrini Medical Center, 227 East 19th Director of Physician Recruitment, Riverside Medical Clinic, Oak Park, Illinois 60302. 708-383-6200, extension 6908. Street, New York, NY 10022. 212-995-6629. 3660 Arlington Avenue, Riverside, CA 92506. NEED HELP IN PASSING BOARDS? TRY GUIDE TO SUC- PLASTIC SURGERY FELLOWSHIP BEGINNING JULY 1991 cess in FLEX-SPEX-NMB-FMGEMS, 2nd Edition. $12.00. for one year. Emphasis on spinal cord injury, reconstruction, Overseas Publishing, P.O. Box 25577, Seattle, WA 98125. dorothea bowlby associates hand surgery and microsurgery. Send C.V.: Dr. Salzberg, Burn Unit-WCMC, Valhalla, NY 10595. Medical Bureau COMBINED INTERNAL MEDICINE/PEDIATRIC GRAD P.O. Box 347, Winnetka, Illinois 60093 year 1: Unexpected opening in fully approved 4-year PGY = POSITION IN FAMILY PRACTICE. ESTABLISHED, Telephone: Area Code (312) 263-5293 program. Contact St. John Hospital and Medical Center, University of Illinois affiliated, community based program in Opportunities are available for Physicians in all Specialties Department of Health Education, 22101 Moross Road, metropolitan area of 350,000. No competing residencies. 8- and General Practice; Associates, Solo & Group Practice; Detroit, Michigan 48236. 313-343-3875. 8-8 program in a 489 bed hospital. Salary $26,500 plus Medical Education. Medical Directors. Clinical Investigation liberal benefits and paid work opportuntiies. Excellent resi- or Occupational Medicine. Please write for our analysis form. PGY-2 FAMILY PRACTICE. UNEXPECTED OPENING JULY dent and faculty group. Longitudinal behavioral science Dorothea Bowlby, Director 1, 1991. Send C.V.: Keith Ellis, M.D., Memorial Medical emphasis. Contact Fred Z. White, M.D., Program Director, established in 1957 Center, Inc., Department of Family Practice, P.O. Box 23089, Methodist Medical Center, 120 NE Glen Oak, Peoria, IL Savannah, GA 31403-3089. 61603. 309-672-5743. JAMA, May 15, 1991 Vol 265, No. 19 2617 HMSS Assembly Information Exchange Thursday, June 20, 1991 7:00 p.m. - 8:30 p.m. PRO and Managed Care Review: Combating the Hassle Factor A distinguished panel to include Alice G. Gosfield, JD, Alice G. Gosfield and Associates, Philadelphia; T. Reginald Harris, MD, AMA Council on Medical Service; and Bob Becker, MD, American Medical Care Review Association, Washington, DC., will be available to provide the most recent activities and advancements made in dealing with the hassle factor of interaction with regulatory systems and managed care companies. Following the presentations, a 45-minute question-and-answer period will permit medical staff participants to offer questions regarding their day-to-day interactions with medical review organizations, and ideas for combating the hassle factor. Assembly Education Program Friday, June 21, 1991 2:30 p.m.-5:30 p.m. Part 1: Update on JCAHO: The AMA Perspective AMA JCAHO Board of Commissioners will bring HMSS Representatives up to date on their interactions and initiatives with the JCAHO, undertaken in the interest of medical staffs. Part 2: Practice Parameters: Policy, Applications and Issues American Medical Association's extensive activities in the practice parameters arena will be addressed, as well as current applications and advancements in the development of practice parameters. A question-and-answer session will be provided after each panel discussion. For Information Contact: Department of Hospital Medical Staff Services American Medical Association 515 North State Street Chicago, Illinois 60610 Phone (312) 464-4754 or 464-4761 AMERICAN MEDICAL HMSS 2618 JAMA, May 15, 1991 - Vol 265, No. 19 FELLOWSHIP POSITIONS AVAILABLE BEGINNING JULY 91 at the Washington Hospital Center in transplant Surgery for graduates of general Surgery or Urology training programs. Send C.V.s to or call: Dr. Jimmy Light, Director, Transplan- tation Services, Washington Hospital Center, 110 Irving Street, NW Washington, DC 20010. 202-877-6059 or 1- 800-252-2442. Physician Locum Tenens Wanted CHALLENGING LOCUM TENENS POSITIONS AVAILABLE now. Work at your convenience, full or part-time. Com- Executives petitive compensation. No hassles, politics or paper- work. Paid malpractice insurance, housing and trans- portation. Put an experienced leader to work for you! Contact: Locum Medical Group, 30100 Chagrin Blvd., Cleveland, Ohio 44124, 1-800-752-5515. Can't Manage IPR MEDICAL, INC. Placement and Recruitment Without It. Permanent and Locum Tenens Placement for Physicians Our UNC Kron Scholars Program provides We work Nationwide and specialize in valuable training and certification for managing YOU medical services. You'll receive in-depth executive 7207 W. Greenfield Ave. Milwaukee, WI 53214 education from the prestigious business school 1-800-966-3627 1-414-257-3959 FAX 1-414-257-3691 at UNC-Chapel Hill. Optional field placements enhance your experience and pay your tuition. Call our Department of Academic Affairs at 1-800-MEDICAL. For: Professional, Personalized, Successful Locum Tenens and Permanent Positions Contact: KRON PHYSICIAN PLACEMENT SPECIALISTS Jerry Ortiz, President P.O. Box 791 Is Locum Tenens Brookfield, WI 53008-0791 1-800-776-7212 Practice Made Perfect. 414-784-9524 When you decide to IT'S EVERYTHING YOU expand your horizons LOVE ABOUT MEDICINE AND LESS It's staying involved in medicine without practicing full-time, running a business, or managing a staff. It's treating patients. Working where your skills are really needed and appreciated. Teaching contact Locum Tenens, Inc. and learning from respected colleagues. Seeing Excellent practice locations the country. Earning a good income. nationwide. Assignments from two weeks to one year. Paid travel, It's locum tenens practice with CompHealth, malpractice, lodging and trans- the nation's locum portation, competitive salaries, tenens leader. licensure, and an experienced staff Because sometimes, CompHealth to coordinate your activities. less is more. THE PHYSICIAN GROUP LOCUM 1-800-453-3030 TENENS. INC. Salt Lake City Atlanta Grand Rapids, Mich. A Division of Jackson and Coker 1-800-272-2707 ext.62 for Ask The Career 115 Perimeter Center Place / Suite 380-JDLT1 / Atlanta, GA 30346 JAMA, May 15, 1991 Vol 265, No. 19 2619 Screening.Maimmography Women with No Symptoms Age: 35-39 Baseline 40-49 Every 1-2 years 50 & up Every year What will you tell her about screening mammography? Many of your patients will hear about screening your regular breast examinations and their monthly mammography through a program launched by the self examinations, offers the best chance of early American Cancer Society and the American College detection of breast cancer, a disease which will strike of Radiology, and they may come to you with one woman in 10. questions. What will you tell them? If you have questions about breast cancer We hope you'll encourage them to have a detection for asymptomatic women, please contact screening mammogram, because that, along with us. AMERICAN Professional Education Dept. CANCER National Headquarters acr American 1891 Preston White Drive 90 Park Avenue College of Reston, Virginia 22091 SOCIETY New York, New York 10016 Radiology (703) 648-8900 or your local society 2620 JAMA, May 15, 1991 - Vol 265, No. 19 VISTA Careers STAFFING SOLUTIONS Have Been Freedom Flexibility Responsibility Changed By It. Kron is the perfect way to change your practice or transform your career. Because your Kron experience allows you to define new goals. Explore new possibilities. Develop new pursuits. And discover what you want out of life. Think you're ready for a change? VISTA Call Kron at 1-800-MEDICAL. A Locum Tenens Group For information call: KRON 1-800-366-1884 Is Locum Tenens VISTA Staffing Solutions 675 East 2100 South, Suite 390 Practice Made Perfect. Salt Lake City, Utah 84106 LOCUM INSULIN IS NOT A TENENS CAREER CURE FOR DIABETES. FLEXIBILITY FOR TODAY'S TM PHYSICIAN ITJUST KEEPS PHYSICIANS CAREER The broad career plans RESOURCE of many physicians demand flexibility. They want time PEOPLE ALIVE UNTIL away from their practices for contin- uing education or personal pursuits. And to maintain the integrity of their WE FIND ONE. practices, they recruit short-term replacements. The AMA's Locum Tenens Service is the ideal resource for physicians interested in assign- ments of less than a year. For registration information contact: Locum Tenens Service Physicians Career Resource American Medical Association P.O. Box 10012 M Chicago, IL 60610 (800) 955-3565 AMERICAN MEDICAL Support the Research of the American Diabetes American Diabetes Association Association 2621 Resident Physicians: Plan to participate in the AMA-RPS Annual Assembly Meeting June 21-22, 1991 Chicago, IL Residents from across the country will be addressing vital issues and concerns such as resident work hours and supervision, student loan deferment, and maternity leave at the meeting. A highlight of the meeting is an educational program on resident physician and medical student abuse. This timely program will give special attention to the incidence and types of abuse, ways of managing and controlling abuse, and recourse for the abused. The Resident Physicians Section of the American Medical Association, nearly 40,000 members strong, is a vital component of organized medicine, and represents the needs and concerns of all resident physicians. To be part of the AMA-RPS is to be part of the most active and influential organization of residents in the country. For further information about the meeting or joining the AMA-RPS, contact the AMA Department of Resident Physician Services; 312/464-4751 AMA RPS 2622 JAMA, May 15, 1991 - Vol 265, No. 19 Chiefs/Department Heads/ PROGRAM DIRECTOR Directors/Faculty THE MEDICAL CENTER OF DELAWARE, AN 1100-BED, FAMILY PRACTICE Director tertiary care major teaching affiliate of Thomas Jefferson University, seeks a full-time Chairman of the Department of Bartlesville Family Medicine Center, Department Obstetrics-Gynecology. Over 6500 deliveries and 34,000 of Family Practice, University of Oklahoma Col- operations are done annually. There is an approved, suc- cessful OB-GYN residency program and an active research lege of Medicine Tulsa, Oklahoma and Jane program. Candidates should have recognized clinical skills, Phillips Episcopal-Memorial Medical Center are Spine Center proven administrative ability and experience in managing jointly seeking a Program Director for a re- The Cleveland Clinic Foundation is seek- OB-GYN residency and research programs. The successful juvinated university-affiliated community-based candidate will have a senior academic appointment at program associated with a 300 bed community ing a Medical Director for its multidiscipli- Jefferson Medical College of the Thomas Jefferson Univer- hospital. It is a 1-2 program with a total of 12 nary Spine Center. The Center serves as sity in Philadelphia, Pennsylvania. Please send Curriculum Vitae and three references to George Hilty, M.D., Chairman, residents. Academic appointment as Assis- the primary access point for patients with Search Committee, Medical Center of Delaware, c/o Patti tant/Associate Professor based on experience. spinal disorders and has its own dedicated Falkowski, CMSC, P.O. Box 1668, Wilmington, DE 19899. The Medical Center of Delaware is an Affirmative Action/ Candidates for this position must have an M.D. space with exam rooms, psychiatric con- Equal Opportunity Employer. degree from a recognized medical school and sultation, staff and ancillary offices. It has MEDICAL DIRECTOR/SOUTHERN FLORIDA: LIBERTY be Board Certified in Family Practice. Two years Healthcare Corporation, a physician-owned medical man- of practice and two years of administrative its own dedicated physical therapy staff agement group, seeks a BE/BC physician for the position teaching experience is required. Must be eligi- and is immediately contiguous to the Pain of Medical Director for a modern, long term care facility in ble for licensure in Oklahoma. Salary is based Management and Physical Therapy areas. sunny, warm Southern Florida. Position offers a highly on experience with a full range of benefits. competitive salary, paid malpractice insurance, nine weeks All involved services are fully integrated. paid time off, and relocation assistance. Candidate with This position is located in Northeastern The Spine Center is an autonomous busi- medical administrative management background, please Oklahoma's "Green Country", 45 miles north contact Dr. Herbert T. Caskey, M.D., Liberty Healthcare, 399 ness unit with its own table of organiza- of Tulsa. With a population of 35,000, Bartlesville Market St., Ste. 400, Phila., PA 19106. You may fax your has multiple outdoor water recreational ac- tion, capital and operational budget. C.V. to 215-592-4652 for an immediate response. EOE. tivities, excellent schools, a superb retirement INSTRUCTOR/NEONATOLOGIST DEPARTMENT OF PEDI- community and is the Corporate headquarters Candidates should have specialist training atrics at Mount Sinai Hospital Medical Center seeks appli- of Phillips Petroleum Company. and/or experiences in the spinal disorders cants to engage in teaching and medical research. Require- ments include M.D., Pediatric Residency, Neonatal-perinatal Interested applicants please send resume and as well as an interest in teaching and re- Fellowship, and skills/experience conducting basic research in the development of the kidney. Additional interest in questions to: T.L. Johannesen, M.D., 3500 search. Income and academic rank are de- clinical research is encouraged. Academic appointment is S.E. Frank Phillips Blvd., Bartlesville, pendent upon qualifications and experi- with the UHS/Chicago Medical School and is commensurate Oklahoma 74006, or Jon Calvert, M.D., ences. Send your CV to Jane Sheahan- with qualifications. Applicants must possess a State of Ph.D., Chair, Department of Family Illinois Medical License or be immediately eligible thereof. Medicine, University of Oklahoma College McMahon, The Cleveland Clinic Send Curriculum Vitae and 3 letters of recommendation to: of Medicine Tulsa, 2808 S. Sheridan Foundation, H-18, 9500 Euclid Ave- Howard B. Levy, M.D., Chairman, Department of Pediatrics, Mount Sinai Hospital Medical Center, 15th Street at Califor- Road, Tulsa, Oklahoma 74129. nue, Cleveland, Ohio 44195. nia Avenue, Chicago, Illinois 60608. Mount Sinai Hospital An Equal Opportunity Employer Medical Center is an Affirmative Action/Equal Employment Opportunity Employer. JANE PHILLIPS THE CLEVELAND CLINIC CHAIRMAN, DEPARTMENT OF ANESTHESIOLOGY. SEEK- FOUNDATION ing Board Certified Anesthesiologist to provide independent contract services in a non-teaching community hospital MEDICAL CENTER which does not have obstetrics or heart surgery services. WHERE CARING MAKES THE DIFFERENCE An Foual Opportunity mployer Contractor would also serve as Chairman of the Medical Smoke-Free Environment Staff Department of Anesthesiology. Located in the Virginia suburbs of Washington, D.C. Relocation assistance avail- able. Please respond with C.V. to Box 6771, c/o JAMA. UNIVERSITY OF FLORIDA: DEPARTMENT OF COMMU- nity Health and Family Medicine seeking full-time, tenure THE UNIVERSITY OF MICHIGAN MEDICAL SCHOOL, DE- track Assistant or Associate Professor for teaching, patient partment of Radiology, has on occasion open faculty posi- care, medical directorship of nursing home, and related tions within the Department and its affiliated hospitals. scholarly activities in Family Practice Residency Program Physicians filling these positions will take part in the program There's only and undergraduate program. Must have M.D., interest in of patient care, teaching, and research in the Department of geriatrics and BC/FP. Application receipt closing date is Radiology. They will supervise the activities of House June 14, 1991. Send C.V. and three recommendation letters Officers and aid in the teaching of House Officers and to: Ken Grauer, M.D., University of Florida College of medical students. Qualified applicants must be American one way to Medicine, 625 S.W. 4th Avenue, Gainesville, Florida 32601. Board of Radiology-Certified or Board-Eligible. Previous Equal Employment Opportunity/Affirmative Action Em- training or work experience in an academic institution as come out ahead ployer. well as demonstration of previous academic research and teaching experience are desirable. Academic rank will VICE PRESIDENT MEDICAL AFFAIRS: EXCELLENT OP- depend on qualifications and experience. Interested appli- portunity for a physician to assume responsibility for a cants should contact: William Martel, M.D., Chairman, senior medical/administrative position in the newly created of the pack. Department of Radiology, The University of Michigan Med- position of Vice President Medical Affairs. Individual will act ical School, Ann Arbor, MI 48109-0030. A Nondiscriminatory, as a full time liaison to assure both medical staff input and Affirmative Action Employer. participation in hospital administrative affairs. Our modern and expanding hospital is located in beautiful, central New CARDIOLOGISTS: ACADEMIC CARDIOLOGISTS: CLINICAL Jersey on the Bay of the Atlantic Ocean. The hospital is noninvasive cardiologists (BC/BE), preferably with expertise near beaches and marinas and just 45 minutes drive to New in echocardiography and/or nuclear cardiology needed for York City. We offer a competitive salary and a modern full full-time tenure track or non-tenure track positions at Assis- range flexible benefits program. Experience in medical tant or Associate Professor level. Position involves clinical administrative management is preferred. Interested physi- duties and teaching reponsibilities, with opportunity for cians should submit Curriculum Vitae and salary require- clincial research in active, fast-paced setting with growing ments to: Mr. Stephen Kay, Executive Vice President, section. Superb clinical material and experienced senior Bayshore Community Hospital, Bayshore Community faculty make this an excellent choice for academically- Health Services, Inc., 727 No. Beers Street, Holmdel, NJ oriented individuals. Reply with C.V. and letter stating 07733. E.O.E. QU personal and career goals to: Charles M. Gross, M.D., PRINCIPAL OFFICER, AMERICAN RED CROSS. THE AP- Associate Professor of Medicine and Interim Chief of Car- palachian Regional Blood Services program in Roa- diology, Medical College of Georgia, Augusta, GA 30912- noke, Virginia is looking for a dynamic, medical exec- 3105. EOE/AAP. utive to manage a medium-sized blood operation, ASSOCIATE DEAN FOR ACADEMIC AFFAIRS/DIRECTOR extensively regulated by federal and state agencies, offering a full range of services. This is a part-time or of Medical Education. Applications are invited for a newly full-time position reporting to the Senior Vice Presi- created position of Associate Dean for Academic Affairs of dent, Biomedical Services (Washington, D.C.) and is a the School of Medicine and Director of Medical Education member of the national Blood Services Executive staff. at the Medical Center of Central Georgia, the school's Requirements include: *M.D. (hematology, pathology) principal teaching hospital. Responsibilities include medical with a minimum of 7 years progressively responsible student education, graduate medical education, continuing experience in blood or a related field. Licensure to medical education, library and learning resources. An M.D. practice medicine in Virginia required. *Business man- is required. Experiences with small group, problem-based agement skills preferred. Board certification in blood learning and medical education programs in a community banking desirable. Roanoke, Virginia offers an excel- hospital are desirable. Women and minorities are encour- lent environment for families, and an opportunity to get aged to apply. C.V's should be sent to: W. Douglas Skelton, away from the hustle and bustle of a metropolitan area. M.D., Provost for Medical Affairs and Dean; Mercer Univer- Salary is negotiable. An excellent opportunity for ad- sity School of Medicine, 1550 College Street, Macon, vancement within the American Red Cross system. Georgia 31207. Deadline for receipt of applications is June Minorities are strongly encouraged to apply. EOE, M/F/ 1, 1991. Starting date is July 1, 1991. Mercer University is H/V. Send Curriculum Vitae to: The American Red Cross, an Affirmative Action, Equal Opportunity Employer. Attn: William J. Branscom, Chairman, Principal Officer FACULTY POSITION AVAILABLE AS RESEARCH ASSIS- Search Committee, 352 Church Avenue, SW, Roanoke, American Heart VA 24016. tant Professor of Surgery. Candidates must have Ph.D. in physics or biophysics, with expertise in nonlinear dynamical ACADEMIC FACULTY POSITIONS AT THE ASSISTANT/ analysis and its applications to cardiovascular physiology. Association Associate Professor level for the following: Glaucoma Spe- Working familiarity with computer hardware, computer lan- cialist, Resident Director. Both require BE/BC and New York guage programming and interfacing with physiolocal trans- WE'RE FIGHTING FOR license; glaucoma requires fellowship training. Teaching, ducers required. Send Curriculum Vitae, bibliography and research, patient care. The State University of New York at three recommendation letters to Box 6791, c/o JAMA. The YOUR LIFE Buffalo is an AA/EEO Employer. Send C.V. to Ophthalmology University of Pennsylvania is an Equal Opportunity/Affir- Department, ECMC, 462 Grider Street, Buffalo, NY 14221. mative Action Employer. JAMA, May 15, 1991 Vol 265, No. 19 2623 Practices For Sale Index to advertisers FAMILY PRACTICE. WELL ESTABLISHED, NEAR ST. LOUIS in Illinois, fully equipped office. 1137 Birchgate, St. Louis, MO 63135. 314-521-7933. FLORIDA GENERAL OPHTHALMOLOGY PRACTICE. Turn-key operation. Seller wishes to retire after 20 years eye surgery/medicine in Northeast Florida oceanside com- Astra Pharmaceuticals Merck Sharp & Dohme munity. Reply to Box 6760, c/o JAMA. Metoprolol 2438-2439 Pepcid 2476, 2476A-B* Vasotec 2592A-B* BUYING OR SELLING A PRACTICE? Boehringer Mannheim Corp. LET JACKSON AND COKER SHOW YOU HOW! CONTACT - BETTE CLOUD Corporate 2457 Miles, Inc. 1-800-544-1987 Tracer II 2477 Cipro 2520C-D Practice Sales and Transition Consulting Services, Practice Appraisal Services, Practice Listing Service Bristol Myers/Squibb Pharmaceuticals National Dairy Board 115 Perimeter Center Place Suite 380 JPB1, Atlanta, GA 30346 Capoten 2443-2444, 2597-2598 Corporate 2485 Corgard 2452A-D*, 2600A-B* PACIFIC NORTHWEST, PORTLAND OREGON AREA. Corporate 2462-2463 National Livestock & Meat Board Large family practice, some lab facilities and X-Ray plus Corporate 2582-2583 computerized bookkeeping. Well-established practice 20 minutes from downtown Portland, in suburban community Burroughs Wellcome Company of approximately 30,000 located on Lake Oswego. Nine Lanoxin 2584A-B* Ortho Pharmaceutical Corp./McNeil hospitals within radius of 7 to 25 miles. Practice set-up to operate 4 days per week with extra half-day on alternate Zovirax 2579-2580 Pharmaceutical weekends. Could expand if you so desire. 1½ hours driving Floxin time from picturesque Oregon coast or Cascade mountains 2444A-J* which offer year-round skiing. Physician retiring. Flexible Center Laboratories terms. For further information call 503-636-4535. Epipen Auto-Injector 2475 Roche Laboratories, Div. of FAMILY PRACTICE, CALIFORNIA, MONTEREY BAY AREA. Ideal coastal climate. Gross 210K. Established 13 years, Hoffmann-LaRoche, Inc. fully equipped, small lab, beautiful new building. Price $55K, Ciba Pharmaceuticals Accutane 2486-2489 terms. Call 408-722-9629. Transderm-Scop 2455-2456 Medical Director's Page 2568 SO. CALIFORNIA FAMILY PRACTICE NEAR LONG BEACH, CA. High income area. Gross $360,000 + /year. X-Ray lab, Medical Education 2478-2479 treadmill, much equipment. $200,000. 213-809-1200. Cigna Healthplan Valium Cover 2, 2437 SOLO ALLERGY PRACTICE IN OKLAHOMA CITY FOR Recruitment 2450 Vitamins 2601-2602 sale by retiring Allergist. Established clinic, well staffed, in ideal medical location, with excellent growth potential. 100% financing available. Send responses to Box 6781, c/o JAMA. Eastman Kodak Clinical products Roerig, Div. of Pfizer, Inc. DERMATOLOGY PRACTICE AVAIABLE: FALL 1991. EXCEL- 2440 Cardura 2460A-F lent income opportunity in expanding area of Middle Ten- nessee. Great fishing and hunting; close to metropolitan Forest Pharmaceuticals Diflucan 2468A-D areas. Reply to Box 6784, c/o JAMA. Aerobid 2470-2472 Sinequan 2449-2450 BEAUTIFUL OLYMPIA, WASHINGTON. ASSUME ESTAB- lished solo practice of retiring family physician. Richard Grant, MD, 1407 College St., SE, Olympia, WA 98503. Glaxo Incorporated Schering Laboratories LUCRATIVE INTERNAL MEDICINE PRACTICE FOR SALE Zantac 2576A-H* Gyne-Lotrimin 2586-2587 in historic coastal town, southern Delaware. Office adjacent to modern 130-bed hospital. Excellent growth potential. Good schools and recreational activities in surrounding Herbert Laboratories G.D. Searle Company area. Reply Internal Medicine, 400 Savannah Road, Lewes, Elimite 2522-2524 Calan-SR Delaware 19958. 302-645-6910 evenings. 2465-2468 OFFICE OB/GYNECOLOGY AND PRIMARY CARE PRAC- Cytotec 2484E-F* tice for sale. Must go. Ideally located in Downers Grove with Hoechst-Roussel Pharmaceuticals access to 3 community hospitals. Fully equipped office. Altace 2577-2578 Stuart Pharmaceuticals Price $42,000. Call 1-708-852-2204. Trental 2594-2596 Zestril 2568A-D*, 2569 For Sale/For Rent/Real Estate ICI Pharma, Division of Syntex Laboratories, Inc. ICI Americas, Inc. Anaprox 2570-2572 SAN JOSE, CALIFORNIA. MEDICAL 1707 S.F. BUILDING Tenormin for sale. Campus environment. Agent 408-867-2582. 2520A-B* U.S. Air Force Janssen Pharmaceuticals Recruitment 2593 Hismanal JAMA Journal Club 2446-2448 U.S. Navy Required readings from the Knoll Pharmaceuticals Recruitment 2521 May 15, 1991, issue Isoptin 2476C-D 1. Health Insurance Values and Imple- U.S. Public Health Service mentation in the Netherlands and the Kramer Laboratories Recruitment 2603 Federal Republic of Germany, p 2496. Charcoal Plus 2604 2. Health Access America-Strength- University of California at Los Angeles ening the US Health Care System, Lederle Laboratories Recruitment p 2503. 2450 3. Universal Health Insurance Suprax 2575 Through Incentives Reform, p 2532. Upjohn Company Marion Merrell Dow, Inc. Xanax Cover 3, Cover 4 Additional recommended readings Carafate 2452E-F 1. Magistrelli P, et al. Surgical treat- Cardizem 2484A-D*, 2608A-B* Whitehall Laboratories ment of hydatid disease of the liver: a Advil 2599 20-year experience. Arch Surg. McNeil Laboratories 1991;126:518-523. Lactaid 2585 Wyeth-Ayerst Laboratories 2. Frangieh GT, et al. Prospective cor- Tylenol 2473 Orudis 2490 neal topographic analysis in surgery for postkeratoplasty astigmatism. Arch Ophthalmol. 1991;109:506-510. 3. Hinman AR. What will it take to fully protect all American children with vac- *Demographic/Geographic Insert cines? AJDC. 1991;145:559-562. While every precaution is taken to ensure accuracy, we cannot guarantee against the possibility of an occasional change or omission in the preparation of this index. 2624 JAMA, May 15, 1991-Vol 265, No. 19 XANAX® Tablets Central nervous system: Drowsiness, light-headedness, depression, headache, (alprazolam, @ Upjohn) confusion, insomnia, nervousness, syncope, dizziness, akathisia, and tiredness/ INDICATIONS AND USAGE sleepiness. Impaired coordination, irritability, memory impairment, cognitive disorder, Generalized anxiety disorder, short-term relief of the symptoms of anxiety, and dysarthria, anxiety, abnormal involuntary movement, changed libido, muscular anxiety associated with depression. Anxiety or tension associated with the stress twitching, weakness, muscle-tone disorders, agitation, disinhibition, paresthesia, of everyday life usually does not require an anxiolytic. talkativeness, vasomotor disturbances, derealization, dream abnormalities, fear, Panic disorder, with or without agoraphobia. feeling warm. Effectiveness has been established for up to 4 months for anxiety disorder and Gastrointestinal: Dry mouth, constipation, diarrhea, nausea/vomiting, increased 4 to 10 weeks for panic disorder; but panic disorder has been treated open label salivation, decreased salivation, and abdominal distress. for up to 8 months with no apparent loss of benefit. The usefulness should be Cardiorespiratory: Tachycardia/palpitations, hypotension, nasal congestion, reassessed periodically. chest pain, hyperventilation, upper respiratory infection. Other: Blurred vision, rigidity and tremor, tinnitus, muscular stiffness and cramps, CONTRAINDICATIONS sweating, skin disorders, rash, change in appetite, micturition difficulties, menstrual Sensitivity to XANAX or other benzodiazepines and in acute narrow-angle glaucoma. disorders, sexual dysfunction, edema, incontinence, infection, dermatitis/allergy, WARNINGS weight gain, and weight loss. Dependence and withdrawal reactions, including seizures Withdrawal seizures with rapid decrease or abrupt discontinuation. (See Physical dependence to XANAX can produce certain adverse clinical events, WARNINGS.) some life-threatening. These include a spectrum of withdrawal symptoms-the most To discontinue treatment, dosage must be reduced slowly by no more than 0.5 important is seizure. Even after relatively short-term use at 0.75 to 4 mg per day, mg every 3 days. there is some risk of dependence; but the risk and severity seem to be greater in The following adverse events have been reported with benzodiazepines: dystonia, patients treated with doses above 4 mg/day for more than 8 to 12 weeks. concentration difficulties, anorexia, slurred speech, jaundice, pruritus, diplopia. Treatment of panic disorder: Dose and risks of XANAX Untreated panic disorder has been associated with depressive disorders and Panic-disorder patients often need doses greater than 4 mg/day, hence the risk of suicide. When treating panic patients, the same caution must be used as in treating dependence may be greater than in patients treated for less severe anxiety. Based patients with depression or suicidal ideation. on studies involving 641 patients, the most frequent symptoms seen during dis- Paradoxical reactions such as stimulation, agitation, rage, increased muscle continuation were: spasticity, sleep disturbances, and hallucinations may occur. Should these occur, Neurologic: Insomnia, light-headedness, abnormal involuntary movement, head- discontinue the drug. ache, muscular twitching, impaired coordination, muscle-tone disorders, weakness. During prolonged treatment, periodic blood counts, urinalysis, and blood Psychiatric: Anxiety, fatigue and tiredness, irritability, cognitive disorder, memory chemistry analysis are advisable. Minor EEG changes, of unknown significance, impairment, depression, confusional state. have been observed. Gastrointestinal: Nausea/vomiting, diarrhea, decreased salivation. Liver enzyme elevations, gynecomastia, and galactorrhea have been reported, Other systems: Weight loss, decreased appetite, sweating, tachycardia, blurred but no causal relationship was established. vision. It has not yet been determined if these symptoms are clearly related to dose DRUG ABUSE AND DEPENDENCE and duration of therapy. In two controlled trials of the discontinuation of XANAX Physical and psychologic dependence: Withdrawal symptoms like those noted lasting 6 to 8 weeks, 71% to 93% of patients treated with XANAX compared with 89% with sedative/hypnotics and alcohol have been seen after discontinuance of benzo- to 96% of placebo patients tapered completely off medication. The ability of patients diazepines. Symptoms can range from mild dysphoria and insomnia to a major to completely discontinue after long-term therapy has not been reliably determined. syndrome including abdominal and muscle cramps, vomiting, sweating, tremors, Seizures were reported in 8 of 1,980 patients who took more than 4 mg XANAX and convulsions. The distinction between withdrawal symptoms and recurrence of daily for over 3 months, generally during abrupt dose reduction. There have been illness is difficult. Withdrawal typically includes new symptoms, occurs toward the occasional reports of seizures during gradual taper; the risk seems to be greatest end of taper or shortly after discontinuation, and decreases with time. Recurrent 24 to 72 hours after discontinuation. panic disorder recurs early or late, with persistent symptoms similar to the initial Status epilepticus and its treatment: Discontinuation of XANAX has been asso- presentation. When necessary XANAX should be restarted in adequate dosage. ciated with seizures. In most cases a single seizure was reported; however, multiple Withdrawal symptoms, including seizures, may occur after brief therapy with doses seizures and status epilepticus have been reported. Treatment is the same as that of 0.75 to 4 mg/day, but severity and incidence are apparently increased after doses for status of any cause. above 4 mg/day, after rapid decrease of dosage or abrupt discontinuation. Dosage Interdose symptoms: Early morning anxiety and emergence of anxiety symptoms should be gradually tapered under close supervision, especially in patients with a between doses have been reported in panic patients taking XANAX. It can usually history of seizures or epilepsy. be managed with more frequent administration of the same total daily dose or by Psychologic dependence is a risk with all benzodiazepines, increasing at higher increasing total dosage. doses, with long-term use, and in patients with a history of alcohol or drug abuse. Risks of dose reduction: Withdrawal reactions may occur with dosage reduction Addiction-prone patients should be closely supervised when receiving XANAX for any reason; dosage should be reduced gradually. (See DOSAGE AND and repeat prescriptions limited. ADMINISTRATION.) Controlled Substance Class: XANAX is a controlled substance and has been XANAX is not of value in treating psychosis and should not be used in lieu of assigned to schedule IV. appropriate treatment. Patients receiving XANAX should be cautioned about hazardous occupations or activities requiring full alertness and also about simul- OVERDOSAGE taneous ingestion of alcohol or other CNS depressants. Manifestations include somnolence, confusion, impaired coordination, diminished Benzodiazepines can cause fetal harm in pregnant women, hence women who reflexes, and coma. Death has been reported with overdosage of benzodiazepines may become pregnant should be warned. Avoid during the first trimester. (See by themselves or in combination with overdosage of alcohol. DRUG ABUSE AND DEPENDENCE and DOSAGE AND ADMINISTRATION.) DOSAGE AND ADMINISTRATION PRECAUTIONS Dosage should be individualized, using the lowest effective dose. The need for General: If XANAX is combined with other psychotropics or anticonvulsants, treatment should be reassessed frequently. consider drug potentiation. (See DRUG INTERACTIONS.) Use the usual precautions Anxiety: The usual starting dose is .25 to 0.5 mg t.i.d. Maximum daily dose is 4 mg. in patients with impaired renal, hepatic, or pulmonary function and regarding pre- Patients who are elderly or debilitated, or have advanced liver disease, may be es- scription size in depressed and suicidal patients. Use the smallest effective dose pecially sensitive to benzodiazepines, and the starting dose is 0.25 mg b.i.d. or t.i.d. to avoid ataxia or oversedation, which may be a particular problem in elderly or Reduce dosage gradually, by no more than 0.5 mg every 3 days, or more slowly. debilitated patients. Alprazolam plasma half-life may be prolonged in obese patients Panic disorder: Many patients required more than 4 mg daily. Mean dosage in or those with alcoholic liver disease. There have been rare reports of death in studies was 5 to 6 mg/day, with a maximum of 10 mg/day. Treatment may be initiated patients with severe pulmonary disease shortly after the start of therapy with XANAX. with 0.5 mg t.i.d. Depending on the response, dose may be increased every 3 or 4 Episodes of mania and hypomania have been reported in depressed patients. days by up to 1 mg daily. After extended freedom from attacks, dosage should be Alprazolam is weakly uricosuric. carefully tapered by, at most, 0.5 mg every 3 days. Some patients may be resistant Information for patients: For all users of XANAX. Alert patients about: to all discontinuation regimens. (1) consumption of alcohol and drugs, (2) not taking any benzodiazepine during HOW SUPPLIED pregnancy or while nursing, (3) operating machinery or driving, (4) not increasing XANAX Tablets are available in 0.25-mg, 0.5-mg, 1-mg, and 2-mg strengths. the dose due to risk of dependence, (5) not stopping the drug abruptly. Additional advice for panic patients: Use of more than 4 mg per day of XANAX for long periods of time may cause CAUTION: FEDERAL LAW PROHIBITS DISPENSING WITHOUT PRESCRIPTION. severe emotional and physical dependence in some patients, and these patients may find it difficult to stop treatment. In two studies lasting 6 to 8 weeks, 7% to 29% of patients treated with XANAX did not completely taper off therapy. The ability of patients to completely discontinue therapy has not been determined. Also, extended use of high doses appears to increase the incidence and severity of withdrawal reactions when XANAX is discontinued. These are generally minor, but seizure, which can be life-threatening, can occur, especially if dose is reduced too rapidly or stopped abruptly. Laboratory tests: Not ordinarily required in otherwise healthy patients. Drug interactions: Additive CNS depressant effects with other psychotropics, anticonvulsants, antihistamines, ethanol, and other CNS depressants. Plasma levels of imipramine and desipramine are increased. Pharmacokinetic interactions with other drugs have been reported. Cimetidine and oral contraceptives can delay clearance of benzodiazepines. Drug/laboratory test interactions: No con- sistent pattern. Carcinogenesis, mutagenesis, impairment of fertility: No carcinogenic potential or impairment of fertility in rats. Pregnancy: See WARN- INGS. Nonteratogenic effects: The child born of a mother on benzodiazepines may be at some risk for withdrawal symptoms, neonatal flaccidity, and respiratory problems. Labor and delivery: No established use. Nursing mothers: Benzodiaz- epines are excreted in human milk. Women on XANAX should not nurse. Pediatric use: Safety and effectiveness in children below the age of 18 have not been established. ADVERSE REACTIONS Side effects are generally observed at the beginning of therapy and usually dis- appear with continued medication. In the usual patient, the most frequent side Upjohn THE UPJOHN COMPANY effects are likely to be an extension of the pharmacologic activity of XANAX, eg, Kalamazoo, Michigan 49001, USA B-9-S drowsiness or light-headedness. USJ-4071.00 Printed in USA January 1991 For anxiety with associated depressive symptoms Хапах alprazolam (V Upjohn THE UPJOHN COMPANY Kalamazoo. Michigan 49001. USA Please see adjacent page for brief summary of prescribing information. © 1991 The Upjohn Company Caring for the Uninsured and Underinsured A Compendium From the Specialty Journals of the American Medical Association AMERICAN JOURNAL OF DISEASES OF CHILDREN ARCHIVES OF DERMATOLOGY ARCHIVES OF GENERAL PSYCHIATRY ARCHIVES OF INTERNAL MEDICINE ARCHIVES OF NEUROLOGY ARCHIVES OF OPHTHALMOLOGY ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY ARCHIVES OF PATHOLOGY & LABORATORY MEDICINE ARCHIVES OF SURGERY American Medical Association Physicians dedicated to the health of America AMERICAN MEDICAL American Medical Association Trustees Lonnie R. Bristow, MD*; Rufus K. Broadaway, MD; Mary Ann Contogiannis, MD (Resident); Nancy W. Dickey, MD; Palma E. Formica, MD; William E. Jacott, MD; Audrey J. Ludwig (Student); Robert E. McAfee, MD* (Vice-Chairman); Joseph T. Painter, MD* (Chairman); Thomas R. Reardon, MD; Raymond Scalettar, MD*; Jerald R. Schenken, MD* (Secretary); P. John Seward, MD; Frank B. Walker, MD *Executive Committee Officers President, C. John Tupper, MD* President-Elect, John J. Ring, MD* Immediate Past President, Alan R. Nelson, MD Secretary-Treasurer, Jerald R. Schenken, MD* Speaker, House of Delegates, John L. Clowe, MD Vice-Speaker, House of Delegates, Daniel H. Johnson, Jr, MD Executive Staff Executive Vice President, James S. Todd, MD Deputy Executive Vice President, Kenneth E. Monroe Senior Vice President, Larry E. Joyce Vice President, Publishing, Robert L. Kennett Editor-in-Chief, Scientific Publications, George D. Lundberg, MD Vice President, Special Projects, Steven V. Seekins, MPA Director, Publication Production and Printing Division, Nawin Gupta, PhD Publication Staff Managing Editor and Director, AMA Specialty Journals, Michael D. Springer Production Manager, Marlene M. Hinsch Electronic Manager, Mary C. Steermann Electronic Coordinator, Mary Ellen Johnston Production Coordinator, Diane Darnell Production Associate, Melinda Arcabos Senior Electronic Layout Artist and Cover Design, Juliana K. Mills Electronic Production Operators, Brenda Chandler and Debra Lucas Proofreaders, Jennifer Reiling and Teresa Omiotek Copyright © 1991 by the American Medical Association All rights reserved ISBN: 0-89970-417-4 Articles appearing in this issue compendium have appeared previously in the May 1991 issues of the following publications by the American Medical Association: American Journal of Diseases of Children Archives of Dermatology Archives of General Psychiatry Archives of Internal Medicine Archives of Neurology Archives of Ophthalmology Archives of Otolaryngology-Head & Neck Surgery Archives of Pathology & Laboratory Medicine Archives of Surgery Comments or Inquiries to: Vice President for Special Projects American Medical Association 515 North State Street Chicago, Illinois 60610 ii PREFACE Caring for the Uninsured and Underinsured This volume, when taken with the May 15, 1991 edition of The Journal of the American Medical Association, forms the most definitive collection available to date of work on reform of the American health care system. We are proud the American Medical Association has expended the time, people, and financial resources to make this work available to everyone interested in this effort. Certainly, as principal authors of the AMA proposal in the JAMA issue mentioned above, we believe the AMA's Health Access America pro- posal merits the serious consideration of the nation. But, more impor- tantly, we believe the country needs to be committed to the serious process of dialogue and debate that will bring us to the system reform most believe must take place. The time for change is now and together these two volumes point to both the current conflicts and emerging consensus. JAMES S. TODD, MD Executive Vice-President American Medical Association STEVEN V. SEEKINS, MPA Vice-President, Special Projects American Medical Association iii FOREWORD Caring for the Uninsured and Underinsured A Compendium From the Specialty Journals of the American Medical Association A basic measure of the magnitude of any problem is the voices are represented in this single volume so as to give number of persons affected by it. By that criterion, the a comprehensive view of the issues, from many and varied challenge facing the health care system of the United perspectives: national, state, and county; urban and rural; States is substantial. More than 40 million Americans are office-based practice and academic research; national spe- not part of our health care system at all, or are not provided cialty societies and individuals; government agencies and for adequately. Identifying this fundamental, critical need private institutions and foundations; elderly patients and and placing it at the top of our national agenda is a start, neonates; men, women, and children; from the widest- and has been a priority of the American Medical Associ- sweeping national proposals to the smallest 'points of ation and other concerned parties. The next step is to seek light.' a workable solution, and for that the primary agenda must A compelling cross-section of medicine is represented be a frank, urgent, and wide-ranging debate of ideas and in this volume as well: surgical care; mental health; neu- approaches. The time for that debate is now. rologic disorders; pediatric care; eye care; AIDS; diseases In May 1991 the ten journals of the American Medical of the head and neck; cardiology; rheumatology; immu- Association- weekly JAMA and the nine monthly spe- nology; infectious diseases; and trauma care, to name only cialty journals listed on the following page-all are ded- a few. icated to a common theme: caring for the American un- We are grateful to the superb editors of our family of insured and underinsured. This collaborative effort has journals who devoted their time, energy, and pages to this been a year in the making. It is unlikely that any other effort, and to all the authors whose perspectives are pub- publisher or organization could have undertaken a project lished in the journals and collected here, as well as to those of this scope, since it relies so heavily on the cooperation many others who submitted proposals and papers that and collegiality of 10 separate journals and 10 individual could not be included because of lack of space. The prob- editors sharing a unanimity of focus and purpose, as well lem may not be resolved quickly, so we will continue to as many authors from multiple fields interested in this publish new ideas and solutions as they are developed. problem. Logistically it was a challenge as well, involving We hope that the May 1991 issues of the AMA journals and the acceptance and processing of 50 articles from the spe- this volume will provide a starting point for a fresh na- cialty journals (plus 16 of 82 submitted for JAMA), the re- tional dialogue and serve as a source of reference material view of many more, a common embargo date and coor- for the future on what may be the most fundamental health dinated media planning, and production and distribution issue of our time: access to care for all Americans. of the journals to an aggregate worldwide audience of more than 1 million recipients. MICHAEL D. SPRINGER This compendium is the fruit of that labor. Taken with Managing Editor and Director the May 15, 1991 dedicated theme issue of The Journal of Office of Specialty Journals the American Medical Association, it provides a snapshot of GEORGE D. LUNDBERG, MD where we are (and how far we have to go) in addressing Editor-in-Chief the question of the uninsured and underinsured. Many Scientific Publications V Specialty Journal Editors Kenneth A. Arndt, MD Archives of Dermatology Beth Israel Hospital 330 Brookline Ave, LY 127-1 Boston, MA 02215 Byron J. Bailey, MD Archives of Otolaryngology-Head & Neck Surgery Substation 1, PO Box 103 Galveston, TX 77550 James E. Dalen, MD Archives of Internal Medicine 2601 N Campbell Ave, Suite 202 Tucson, AZ 85719 Daniel X. Freedman, MD Archives of General Psychiatry UCLA Neuropsychiatric Institute 760 Westwood Plaza Los Angeles, CA 90024 Vincent A. Fulginiti, MD American Journal of Diseases of Children Dean's Office, Room 1529 Tulane University, School of Medicine 1430 Tulane Ave New Orleans, LA 70112 Morton F. Goldberg, MD Archives of Ophthalmology The Wilmer Institute The Johns Hopkins Hospital 600 N Wolfe St Baltimore, MD 21205 Robert J. Joynt, MD, PhD Archives of Neurology 601 Elmwood Ave Rochester, NY 14642 William W. McLendon, MD Archives of Pathology & Laboratory Medicine University of North Carolina School of Medicine Department of Pathology CB#7525 Chapel Hill, NC 27599-7525 Claude H. Organ, Jr, MD Archives of Surgery University of California-Davis, East Bay 1411 E 31st St Oakland, CA 94602 vii Caring for the Uninsured and Underinsured A Compendium From the Specialty Journals of the American Medical Association Far From the Ideal: The Plight of Poor Children in the United States 1 Vincent A. Fulginiti, MD Youth Alienation as an Emerging Pediatric Health Care Issue 3 James A. Farrow, MD The Growing Neglect of American Children 5 Harold M. Maurer, MD Redoing the Health Care Quilt: Patches or Whole Cloth 6 William W. Cleveland, MD The Challenge of Care for the Poor Child 12 Steve Kohl, MD Poverty and the Health of American Children: Implications forAcademic Pediatrics 14 Richard B. Johnston, Jr, MD Serving the Underserved 17 Carol D. Berkowitz, MD Improving Health Care Provision to Neonates in the United States 19 Mildred T. Stahlman, MD Child Abuse and Neglect: Critical First Steps in Response to a National Emergency: The Report of the US Advisory Board on Child Abuse and Neglect 22 Richard D. Krugman, MD A Survey of the Health of Homeless Children in Philadelphia Shelters 25 Ruth M. Parker, MD; Leslie A. Rescorla, PhD; Jonathan A. Finkelstein, MD; Nathaniel Barnes, MD; John H. Holmes, MS; Paul D. Stolley, MD, MPH ix Children in and of the Streets: Health, Social Policy, and the Homeless Young 32 James D. Wright, PhD Children's Services in an Era of Budget Deficits 36 Barbara B. Blum, Susan Blank What Will It Take to Fully Protect All American Children With Vaccines? 40 Alan R. Hinman, MD, MPH The Challenge of Caring for Indigent Children With Rheumatologic Diseases 45 Michael L. Miller, MD, Patience H. White, MD Poverty and Cardiac Disease in Children 50 Hugh D. Allen, MD; Kathryn A. Taubert, PhD; Richard J. Deckelbaum, MD; David Driscoll, MD; Ann Dunnigan, MD; Samuel S. Gidding, MD; Paul Herndon, MD; Rae-Ellen W. Kavey, MD; Charles Mullins, MD; A. Rebecca Snider, MD; William B. Strong, MD; Reginald Washington, MD Pediatric Acquired Immunodeficiency Syndrome, Poverty, 54 and National Priorities Margaret C. Heagarty, MD Pediatric Human Immunodeficiency Virus Infection and 56 the Acquired Immunodeficiency Syndrome: A Health Care Crisis of Children and Families Russell B. Van Dyke, MD New Initiatives in Adolescent Health Promotion 60 Arthur B. Elster, MD Care of the Poor and Underserved in America: Older Adolescents: A Group at Special Risk 62 Robert J. Haggerty, MD A Regional Pediatric Approach to the Epidemic of Social Ills Within Our Cities 65 Waldo E. Nelson, MD The Caring Program for Children: The Michigan Experience 67 Marianne Udow, MHSA; Vernon K. Smith, PhD; Margaret H. Mason, MHSA Health Care for Pregnant Women and Young Children 69 Richard E. Behrman, MD, Carol S. Larson, JD Improving Health Care for Underserved Infants, Children, and Adolescents: The Robert Wood Johnson Foundation's Experience 72 Michael P. Beachler X The Challenge of Care for the Poor and Underserved in the United States : An American College of Obstetricians and Gynecologists Perspective on Access to Care for Underserved Women 76 Ezra C. Davidson, Jr, MD; Charles E. Gibbs, MD; Janet Chapin, MPH The American Academy of Pediatrics Response to 80 the Growing Health Needs of Children James E. Strain, MD Socioeconomic Status and Visual Impairment Among Urban Americans 84 James M. Tielsch, PhD; Alfred Sommer, MD; Joanne Katz, MS; Harry Quigley, MD; Sandi Ezrine, MS; and the Baltimore Eye Survey Research Group SightFirst: Lions Conquering Blindness 89 Julie Foreman, MS Indigent Patient Care-Then and Now 90 Loring W. Pratt, MD Indigent Care-Now 92 Neil O. Ward, MD Who Ought to Get Decent Health Care? 94 Ronald A. Carson, PhD The Canadian Health Care System 96 Patrick J. Doyle, MD Access to Trauma Care 97 Dale H. Rice, MD Preserving Access With Dignity for the Elderly: Tulsa's VIP Program 99 John G. Campbell, MD, Rollie E. Rhodes, Jr, MD Access to Care-The Problem for the Uninsured and Underinsured: The View From Washington 101 Jerome C. Goldstein, MD Access to Health Care in the United States 104 Byron J. Bailey, MD Caring for the Underserved: Health Insurance Coverage Is Not Enough 107 Matthew Menken, MD xi Access to Health Care: One Neurologist's Perspective 111 Michael P. Earnest, MD Access to Neurological Care for Minorities 116 Edgar J. Kenton, MD Freeze the Ocean 120 Robert J. Joynt, MD, PhD Poverty and Psychiatric Status: Longitudinal Evidence From the New Haven Epidemiologic Catchment Area Study 121 Martha Livingston Bruce, PhD, MPH; David T. Takeuchi, PhD; Philip J. Leaf, PhD Mental Health Needs of the Uninsured 127 Grayson Norquist, MD, MSPH, Kenneth Wells, MD, MPH The Dilemma of the Uninsured and Underinsured 132 Marvin Young, MD The Underinsured and the Uninsured 134 Maria D. Allo, MD Surgical Care for the Uninsured and Underinsured 135 Claude H. Organ, Jr, MD Caring for the Uninsured: The Oregon Experience 137 Richard Allen, MD Prioritization of Health Care Services: A Progress Report by the Oregon Health Services Commission 140 Harvey D. Klevit, MD; Alan C. Bates, DO; Tina Castanares, MD; E. Paul Kirk, MB; Paige R. Sipes-Metzler, DPA; Richard Wopat, MD Overcoming the Prejudice Against Establishing 146 a National Health Care System Richard J. Botelho, MD Universal Access to Health Care: A Comprehensive Tax-Based Approach 154 Jack A. Meyer, PhD; Sharon Silow-Carroll, MSW, MBA; Carl J. Sardegna, MBA Insuring the Uninsured Is Not Enough 160 James E. Dalen, MD, Jose Santiago, MD On the Care of the Poor and the Uninsured 163 Boris M. Astrachan, MD, Donald J. Scherl, MD xii Far From the Ideal The Plight of Poor Children in the United States Vincent A. Fulginiti, MD T he child on the cover of this month's issue of AJDC was most of this population, preventive services are nonex- visualized as an ideal by an unknown painter in co- istent or inaccessible because of poverty, lack of knowl- lonial times. The child is beautiful, well nourished, placid, edge, or failure of insurance programs to cover preventive and obviously well cared for. This is the ideal that many services. The legacy of this neglect will be felt for many think of when asked to picture our aspirations for our chil- generations to come if we do not take urgent and emphatic dren. Unfortunately, in the United States today, we fall far action. We will have a host of unhealthy adults and lose short of providing that ideal for millions of infants, chil- significant numbers of otherwise contributing members of dren, adolescents, and young adults. This issue of AJDC society. We also will lose the diversity of ethnicity that is is devoted to exploring the dimensions of and reasons for desirable in our leadership ranks in all areas of society. the problems as well as offering potential corrective ac- 2. The reasons for the lack of medical care are legion; tions that might be applied to the plight of our unders-- the most often cited in the reports in this issue are financial. erved or unserved youth. We embarked on this issue as Our national economic plight, with high national debt, part of the family of American Medical Association jour- diversion of funds from social programs to other areas of nals' efforts to highlight what has become a national dis- the budget, redistribution of federal support to states and grace: 47 000 000 or more individuals are neglected at a cities (which cannot supply the redistributed services be- time when many in the United States enjoy the highest cause of their own economic difficulties), and now, the level of health in the history of humanity. We hope that added potential cost of the conflict in the Persian Gulf area, our readers will learn of this awful circumstance and, to has resulted in inadequate resources for health-related the extent possible, take action locally, regionally, and na- programs. Non-health care social programs suffer from tionally to effect some of our authors' remedial sugges- the same maldistribution of resources. As a result, poverty tions. increases, homelessness skyrockets, and the causes of ill We embarked on the development of this issue by in- health multiply. viting commentaries from individual leaders in pediatrics, Apart from financial considerations, which are a major from spokespersons for our professional societies, and part of the problem, societal issues combine to deny ad- from directors of our major foundations and organizations equate health care. For reasons that are unclear, children that offer support and funding for programs that benefit lack a voice in the halls of power, especially compared with children. We may not have invited all who could partic- other segments of our population, such as the elderly. So- ipate to do so, and some of those invited did not respond. ciety voices the bland sentiment that children are our However, a cross section of individuals did respond and "most valuable resource" but does not protest when we covered all of the issues one might think of when con- do not ensure that this most valuable resource has an op- sidering the extent of the problems. We thank those who portunity for a healthy life. In recent years, the American did so and offer our readers their comments. Academy of Pediatrics has become a voice heard in Con- We also received unsolicited manuscripts whose themes gress and in other settings as an advocate for children and were consistent with the major intent of this issue of the their needs. However, this is a relatively recent phenom- journal. We have included those that seemed pertinent in enon and has not yet reached the magnitude of advocacy our "Pediatric Forum" and "Original Article" departments. for the elderly. Strain's contribution¹ in this issue outlines They form a unified whole with the solicited articles. the approach taken by the academy to influence adequate To highlight some of the generic issues common to health planning for our youth. many of the thematic articles in this issue, I offer the fol- Children whose parents have habits that result in con- lowing observations: genital drug addiction and/or congenital infection with hu- 1. The dimension of the problem is enormous. More man immunodeficiency or hepatitis viruses receive a leg- than 37 million children live in poverty, an additional 10 acy over which they have no control. They are innocent million have no health insurance, and an unknown num- victims of society's inability or lack of commitment to deal ber have inadequate health care. Many of these children with these problems of their parents. Several contributors receive no care at all or only urgent care, in fragmented to this issue focus on the resulting ill health attendant on fashion, often for late-stage or even end-stage disease. For such neglect. Accepted for publication February 1, 1991. Another contributing factor is what I term the disease of From the Dean's Office, Tulane University School of Medicine, the month mentality prevalent in allocating money to health New Orleans, La. programs. Many governmental and private programs are Reprinted from AJDC (1991;145:489-490). funded to satisfy the demands of potent advocacy groups 2 Caring for the Uninsured and Underinsured for specific diseases. In other instances, a powerful indi- considerable funding and a change in our national pri- vidual, sometimes for personal reasons, supports a spe- orities. However, most readers reach the overwhelming cific disease program. Added to this set of factors is ad- conclusion that we need a fundamental change in our na- vocacy by specific professional societies, each with its own tional commitment. We need to behave as if children are agenda. Although this kind of advocacy, and subsequent really our most valuable resource and our future. There- funding, results in good care for some segments of the fore, mothers must be afforded healthy pregnancies so population, such specialized program development often newborns will be healthy and born at term, and children substitutes for a more coherent, more widely applicable must be freed from preventable childhood diseases. They medical or preventive care program that could offer must enjoy normal growth and development and receive greater benefit for a larger proportion of our population. an effective education, which should include knowledge Cleveland² elaborates on this theme in his discussion of and skills needed to understand health and to effect be- the "patchwork" vs "quilt" approach to health care. havioral changes that lead to prevention and avoidance of Society also has neglected our adolescents, whose rising disease. Parents and children must also learn how to gain pregnancy rate results in increased prematurity, inade- early and effective access to the health care system. quate parenting, and reinforcement of poverty, ill health, Rather than be discouraged by the scope of the problem, and dangerous life-styles. A number of our authors have we suggest that readers use the data and recommenda- highlighted this critical area. tions in this issue to take action in individual practices, Members of society "bill and coo" over the infant born professional societies, medical schools, residency pro- to parents in good financial condition, but ignore the mi- grams, and communities to become advocates for change nority infant in the intensive care unit who struggles first at all levels of government. We need to take such actions to exist and then to remain functionally intact. Members now, not later. We can solve these problems with a unified of society bemoan our high neonatal and infant mortality will, but it will take a society that is willing to move itself rates compared with other developed societies but do little from complacency to a new position of concern and action. to advocate for the resources that are needed to prevent We at AJDC believe we have taken a first step by presenting prematurity and manage conditions leading to excessive the articles in this issue; each of you can now take the morbidity and mortality. Commentators in this issue high- necessary steps in the immediate future. light the toll resulting from such inattention to this critical period in life. References 3. Potential corrective actions are outlined for each of 1. Strain JE. The American Academy of Pediatrics response to the areas covered by the articles in this issue. Some are the growing health needs of children. AJDC. 1991;145:536-539. relatively simple to accomplish, requiring some rededi- 2. Cleveland WW. Redoing the health care quilt: patches or cation of effort but little extra funding. Others will require whole cloth? AJDC. 1991;145:499-504. Youth Alienation as an Emerging Pediatric Health Care Issue James A. Farrow, MD M any young people have withdrawn or are separated are unemployable; thus, they are unlikely to become pro- from the values of their society or family. These are ductive citizens. our alienated youth. The number of adolescents without The number of alienated youth in America is large. By a defined role in modern society is growing.¹ The inability conservative estimates, more than 1 million youth run of children to find a meaningful and productive place in away from home each year.6 Nationwide, more than 25% American society both contributes to and stems from the of all high school students drop out. More than ½ million "new morbidities of youth," including early sexual activ- adolescents are incarcerated in secure facilities each year.⁸ ity, drug abuse, school failure, family violence, and the Estimates of the number of homeless teenagers on the like. A dearth of descriptive information exists on this street are rough at best. It is impossible to obtain accurate growing population of alienated adolescents, which in- data for these large groups, in part because they do not cludes runaways, teenaged prostitutes, street youth, congregate and many return home and to the streets in an school dropouts, and delinquents, to name but a few.2 unpredictable fashion. At a very young age these adoles- The problem of alienation during adolescence, which be- cents begin having difficulties fitting in, and the likelihood gan to be of major sociological concern in the 1960s, today is high that as young adults they will have even more dif- constitutes an emergent area of study for health care pro- ficulty becoming independent, productive members of so- fessionals. ciety. These young people, because of forced or adopted de- Alienated youth are frequently outside the health care structive life-styles, are exposed more than most youth to system and tend to remain there unless efforts are made both physical and emotional illness and to the untoward to identify them and develop health services that are ac- consequences of early sexual activity, such as pregnancy ceptable to them. The adoption of destructive life-styles by and exposure to sexually transmitted diseases, including many of these youth contributes heavily to physical and acquired immunodeficiency syndrome.³ For example, psychological morbidity and to an alarmingly high mor- more than half of all homeless adolescent girls become tality rate. Because health care is one of the more accept- pregnant while on the streets.⁴ Likewise, those who live able areas of interaction with these adolescents, some in inner cities and come from the underclass often migrate members of the health care community have been remark- to environments where violence and bodily injury occur ably creative in their outreach and development of health frequently and gang affiliation becomes inevitable. Op- services. A few model adolescent and young adult "street portunities therefore to reclaim these "wayward" youth clinics" offer free, comprehensive health care services to become more difficult if the pattern of alienation is not this population. Those clinics that are affiliated with med- recognized early. ical schools and specifically adolescent medicine provide While the largest group of alienated young people are many opportunities for pediatricians in training or in prac- of ethnic minority backgrounds, generally from the lower tice to be involved. socioeconomic strata, their values and attitudes often re- Even when the pediatrician is not involved in the regular main similar to those of their families and culture.⁵ Equally care of homeless and alienated adolescents, motivated cli- alarming is the increasing number of alienated youth who nicians are aware of specialized resources in the commu- come from middle-class America: runaways, street youth, nity for this group. These resources include shelter ser- punk rockers, delinquents, and school dropouts. Many of vices, free or easy-access adolescent clinics, counseling or these youth are in conflict with their families and middle- support groups for gay and lesbian youth, adolescent class institutions because of a rejection of parental values chemical dependency treatment programs, and alterna- or an attraction to subcultures that are perceived as more tive schools. However, few cities have successfully devel- akin to themselves and supportive than their families, oped comprehensive service programs and many of these schools, or everyday peers. Few of these young people are components of care may not be available, or homeless and running away from unfortunate or abusive home lives. Yet "emancipated" minors may not be eligible. Job training pro- another group, the so-called throwaway kids, are asked grams for runaways, juveniles involved in prostitution, and by their families to leave at a young age. Many of these older street youth are becoming more prevalent in cities, but young people are depressed, have limited educations, and often cannot meet the great demand for services.⁹ Perhaps even more important is the pediatrician's ad- Accepted for publication January 31, 1991. From the Division of Adolescent Medicine, University of Wash- vocacy role in promoting healthier outcomes before the ington, Seattle. alienation process progresses in adolescence. Pediatri- Reprinted from AJDC (1991;145:491-492). cians frequently see children who are beginning to have 4 Caring for the Uninsured and Underinsured problems associated with alienation. Alienation is often meet the needs of alienated youth. They can volunteer to preceded by childhood emotional trauma and ongoing serve on agency boards, committees, and groups to pro- stress. Repeated stress-related illness, school absences, vide the expertise and understanding of a physician who new behaviors stemming from depression, irritability, or is familiar with these youth and their health issues. The anxiety may ultimately escalate into a situation during health perspective is important. We are at great risk of early adolescence that makes reconciliation between chil- losing through apathy, illness, injury, and death many dren and parents more difficult. children who have a great deal more potential for pro- The pediatrician should take every opportunity during ductive adult lives than we often recognize. the earlier years to explore family relationship concerns and problem behaviors with children and parents. For References older children and younger adolescents, the general psy- 1. Nightingale EO, Wolverton L. Adolescent Rolelessness in chosocial history should be discussed with the young per- Modern Society. New York, NY: Carnegie Corporation of New son in a confidential setting. The degree to which the York; 1988. young person has begun to separate himself or herself 2. Resnick MD, Hibbard R. Chronic physical and social condi- from activities normal for his or her age should be as- tions of youth. Presented at the National Invitational Conference sessed. Family relationships, leisure activities, the pa- on Health Futures of Adolescents; April 2-5, 1986; Daytona Beach, tient's association with a deviant peer group, school at- Fla. tendance and performance, alcohol and drug experience, 3. Kusserow RP. HIV Infection Among Street Youth. Wash- ington, DC: Office of Inspector General; 1990. US Department sexual behaviors and concerns about sexual identity, and of Health and Human Services publication OEI-01-90-00500. symptoms of depression and withdrawal are important 4. Deisher RW, Farrow JA, Hope K, Litchfield C. The pregnant areas to explore. Alienated youth have usually encoun- adolescent prostitute. AJDC. 1989; 143:1162-1165. tered problems in most of these areas. 5. Deisher RW, Farrow JA. Recognizing and dealing with alien- Early intervention and referral, orchestrated by a caring ated youth in clinical practice. Pediatr Ann. 1986; 15:759-763. pediatrician who recognizes the early signs of alienation, 6. National Network of Runaway and Youth Services. AIDS who has developed empathy for the experience of these Education: Programs for Out-of-School Youth Slowly Evolving. young people and their families, and who knows com- Washington, DC: US General Accounting Office; May 1990. munity resources can be of great help in averting future HRD-90-111. adoption of destructive behaviors and life-styles. 7. Commission on Work, Family and Citizenship. The For- While physicians as individual practitioners have a re- gotten Half: Pathways to Success for America's Youth and Young Families. New York, NY: William T. Grant Foundation; 1988. sponsibility for providing anticipatory guidance to fami- 8. Stone D. Juvenile crime rate: myth vs reality. Youth Law lies and caring for these youth in clinical settings, a great News. 1982;2:1-2. deal more regional and national attention should be given 9. Deisher RW. Our alienated youth. Presented at the Na- to this large portion of American youth. Physicians can tional Invitational Conference on Health Futures of Adoles- take an active role in developing community resources to cents; April 2-5, 1986; Daytona Beach, Fla. The Growing Neglect of American Children Harold M. Maurer, MD A merica is not doing enough to meet the health care illness, promote health, and save lives. We must provide needs of poor children. Unless we face up to this access to health and social services for all pregnant women growing neglect, our nation's future is in doubt. Although and children through the provision of universal health in- we frequently hear that "children are our greatest national surance. The plan proposed by the American Academy of resource," we see little evidence to indicate that our policy Pediatrics meets this objective, and this plan or an equivalent makers believe it or are willing to act to prevent the terrible one should be enacted into law. In addition, we must pro- waste in human resources as a result of poverty. The vide a "medical home" for every pregnant woman and child money spent on health care for the elderly in America is so that primary health and continuity of care can be provided 15 times that spent on health care for children. Although to promote health. Widening medical coverage alone to children represent 50% of the Medicaid population, they cover more pregnant women may not be the answer. receive less than 20% of the money spent for health ser- Women must be able to enroll before they become pregnant, vices.¹ Furthermore, Medicaid reimbursement for health or else they may become pregnant months before they sign services for children is so low that few physicians in private up. The application process also needs to be accelerated and practice can afford to see Medicaid patients. health care should be provided during the processing of the The facts regarding impoverished children are stagger- application. We should support all programs, agencies, pol- ing. They are cause for concern regarding the values and icies, and strategies that guarantee the full spectrum of health priorities of our nation. The data speak for themselves. care services for these underserved. 1. Thirty-seven million American children live in pov- Expanding access to health care will also affect health erty, 9 to 12 million have no health insurance, and millions manpower needs. More primary care physicians will be of others have less than adequate health insurance.² Chil- required to care for the population of pregnant women and dren are the poorest group in society. children who are currently underserved, or whose needs 2. One in four to six pregnant women lacks health in- are not being met. Resident physician education should surance for maternity care, and one in four does not re- include a curriculum segment that deals with the specific ceive prenatal care during the first trimester.² health care needs of the poor.4 Moreover, incentives such 3. The infant mortality rate is higher in America than as loan forgiveness should be created to attract residents in some third-world countries. In 1989, there were 9.7 to pursue careers in serving the poor. deaths per 1000 live births; it was twice that for blacks.³ During the next century, we can expect considerable 4. Nearly 5000 low-birth-weight babies are born every change in the demographics of our nation. The current week in America. 1 Low birth weight, which, in many in- migration of people throughout the world is greater than stances, is preventable through improved prenatal care for ever before. The distinction between minority and major- the mother, places these babies at high risk for serious ity groups will fade. In the next century minority groups illness and handicapping conditions.¹ will become the majority of the population in the United 5. Each year, as many as 1 million teenagers become States. It is essential that we recognize this changing en- pregnant, and 18% of newborn infants in some city hos- vironment and begin to provide access to health care for pitals are victims of transplacental exposure to alcohol, poor women who do not receive prenatal care and for poor crack, and other hard drugs (The New York Times Magazine. children in our society. We must ensure that every child September 9, 1990:41). has the opportunity to grow up healthy, gain an educa- 6. One third of poor children are not immunized by the tion, and become economically productive. second year of life against measles, mumps, and rubella.² The following are the members of the Executive Committee of the Ten percent of children younger than 4 years have not seen Association of Medical School Pediatric Department Chairmen Inc: a physician in a year.2 Poor children tend to be taken epi- Robert P. Kelch, MD, president; Ralph Feigin, MD, president-elect; sodically to costly city or county hospital emergency depart- Michael A. Simmons, MD, secretary-treasurer; George W. Brumley, ments for care, often late in the course of an illness. Because MD; Robert A. Hoekelman, MD; Harold M. Maurer, MD; Donald N. poor children lack a "medical home," they often do not re- Mederis, Jr, MD; Alfred E. Michael, MD; Carol F. Phillips, MD; Irving Schulman, MD; James A. Stockman III, MD. ceive continuing care, anticipatory guidance, or counseling, References which could eliminate preventable health problems. 1. Myth vs Reality Fact Sheet. Washington DC: American Acad- America must come to grips with these devastating but emy of Pediatrics Department of Government Liaison; 1990. correctable problems. We have the knowledge to prevent 2. A Promise to Keep: A Conference on Cross-National Com- parisons of Child Health. Sponsored by the American Academy Accepted for publication January 22, 1991. of Pediatrics. March 17-19, 1990. From the Association of Medical School Pediatric Department 3. Saving infants lives. Faulkner & Gray's Medicine and Chairmen Inc, Salt Lake City, Utah, and the Department of Pedi- Health. 1990;44:36. atrics, Children's Medical Center, Medical College of Virginia, Vir- 4. Educating Pediatric Residents to Provide Health Care to Un- ginia Commonwealth University, Richmond. derserved Children. McLean, Va: Ambulatory Pediatric Asso- Reprinted from AJDC (1991; 145:540-541). ciation; 1990. Redoing the Health Care Quilt Patches or Whole Cloth? William W. Cleveland, MD T he current health care system of the United States, like charges is a familiar problem. For the patient, dealing with a quilt that is tattered and full of holes, badly needs these groups is perhaps even more difficult. The bureau- attention. The question is whether we should repair it with cracy of health care appears to be in a state of chronic and patches or replace it with a new quilt of whole cloth. That self-sustained hyperplasia. the system needs fixing is evident; the deficiencies have An Inadequate Medicaid Program. - This system is fed- been described by abundant commentaries. The major de- erally mandated but managed through varying policies by ficiencies include those cited below. the states. These variances include the standards for in- The Uninsured. - An estimated 37 million people in the clusion in the program, the scope of benefits provided, the United States do not have health insurance. Of these, amount of public funds allocated, and rates of provider about 12 million are children; another major segment com- reimbursement. Financial criteria for eligibility vary prises pregnant women. These numbers are estimated to widely, but in most states a significant portion of the in- have increased approximately 30% in the last decade. This digent population of children and pregnant women is not reflects lack of employee coverage, particularly in small covered. For persons eligible, the mechanisms for regis- businesses, and a high rate of job turnover. It also reflects tration are often cumbersome and patients with limited an inadequate Medicaid program that varies by state but social resources may not be able to gain access to the sys- that generally leaves a significant fraction of indigent fam- tem. A further deficiency is that payment to providers may ilies uncovered. The problem of uninsured children has be so low as to offer no incentive to render services. In been extensively reviewed by Oberg.¹ some states, payments for preventive care, including well- Expanding Health Care Costs and an Apparent Lack of child visits, are so low that they do not cover physicians' Efficiency. If infant mortality rate is an acceptable in- overhead, much less reimburse them for professional ser- dicator of maternal and child health, the comparison of vices. rates in the United States with those of other nations rel- A Troubled Health Insurance Industry than ative to expenditure provides a discouraging picture in- 1500 health plans in this country compete for coverage in deed (Fig 1).2 Our per capita medical expenditure is the an entrepreneurial system. Each maintains its separate ad- highest in the world, but we rank 21st in infant mortality ministration; each has its own policies as to eligibility and rates. When infant mortality rates are compared in terms coverage and each is a for-profit operation. Providers must of percentage of gross national product spent on health deal with a variety of provisions and regulations that sig- care, the result is the same (Fig 2). One factor to be con- nificantly contribute to costs of delivering care. Insurance sidered is whether the US government is spending its companies also must spend large amounts of money on money in the right places. For example, if infant mortality administrative costs-approximately 12% of premiums. rates among developed nations are compared with the Lack of Emphasis on Prevention. The insurance in- percentage of health care dollars spent for public health, dustry does not embrace preventive medicine as its goal. our position is reversed-the United States spends the Pediatricians in Florida were able to promote legislation lowest percentage for public health and is still 21st in mor- mandating well-child care provision by insurers; this was tality rate (Fig 3). accomplished with great travail and with much resistance A Burdensome Bureaucracy. Costs of administering by the industry. As previously noted, an inordinately low US health care programs are staggering. Of the approx- percentage of our health care funds goes to public health imately 11.5% of the gross national product expended, an agencies. Medicaid struggles to provide treatment of ill- estimated 2.6% funds the bureaucracy. For the physician, ness with incomplete success, and little is left for preven- penetrating the administrative barriers of either govern- tive care. mental agencies or insurance companies to render service Litigious Factors Expanding Costs.-Physicians who practice in areas where malpractice suits flourish and at- Accepted for publication January 11, 1991. torneys become rich cannot help but be influenced by this From the Department of Pediatrics, School of Medicine, Univer- threat in making clinical decisions. The remote chance that sity of Miami (Fla). a child not growing well has a hypothalmic lesion not clin- Reprinted from AJDC (1991;45:499-504). ically evident provokes the performance of magnetic res- Redoing Health Care 7 2200 12 United States United States 2000 11 1800 10 1600 9 Sweden 1400 8 Dollars Sweden 1200 Percentage 7 Japan 1000 6 Japan 800 5 600 4 400 3 2 200 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Infant Mortality Rate, No. Per 1000 Live Births Infant Mortality Rate, No. Per 1000 Live Births Fig Per capita health expenditures and infant mortality rates in Fig 2. Infant mortality rates and public health expenditures as per- 1987. centages of all health expenditures in 1987. onance imaging, which currently costs $1200. (Why this 100 procedure should cost $1200 or growth hormone should Sweden cost $50/mg is also of interest, but that is the subject of 80 another essay.) And so it goes-the expansion of these Japan ultraconservative decisions contributes to health care costs, to say nothing of its contribution to the costs of mal- 60 practice insurance. The many holes in the ragged quilt are evident. All agree that repairs are urgently needed. The Percentage question remains as to the best approach. Many alterna- 40 United States tives have been proposed-patches and new quilts of whole cloth. 20 THE PATCHES Various proposals have been made at several levels to 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 patch the holes. The essential features of some of these are summarized below. The review is intended to be illus- Infant Mortality Rate, No. Per 1000 Live Births trative but not all-inclusive. Fig Infant mortality rates and health expenditures as percentages Medicaid Expansion and Reform.- This is a part of sev- of gross national product in 1987. eral proposals listed below, but has been specifically ad- dressed by the Health Policy Agenda for the American 6. Medicaid expansion should include policies and in- People. 3,4 Eight major reforms were recommended by the centives to encourage broader health care provider par- Ad Hoc Committee on Medicaid and are as follows: ticipation. 1. The Medicaid program should be governed by na- 7. A greater burden of the fiscal impact of eligibility ex- tional standards and goals. pansion should be borne by the federal government, and 2. The categorical link of Medicaid eligibility to public the federal formula governing reimbursement to states cash assistance (welfare) programs should be broken; in- should be revised to correct for tax-burden inequities. come eligibility for the program should be set at no less 8. Long-term care services should be continued under than the federal poverty level. Medicaid or through a structurally improved program. 3. All states should be mandated to adopt a Medically Basic Health For All Americans Act.-Proposed by Needy program with "spend down" eligibility provisions. Kennedy5 in 1987, the act recommends major expansion Asset testing should be an acceptable eligibility require- of employer coverage for health care and mandates a min- ment only through the Medically Needy provisions. imum level of health benefits to be provided, including "Medically needy" persons are those whose incomes ex- hospital and physician care, preventive testing, prenatal ceed the Medicaid eligibility level but who have been im- testing, and well-baby care. poverished by catastrophic medical bills. Universal Maternal And Child Health Program.-Pro- 4. A standard benefit package should be provided by posed by Oberg,¹ this would ensure universal and equi- each state and federally mandated. It should include phy- table access to health services by pregnant women and sician services, inpatient and outpatient hospital services, children independent of age, income, family composition, laboratory and roentgenogram services, prescription or employment. Coverage would be provided for preven- drugs, institutional care for the elderly and the physically tive as well as acute and catastrophic services. or mentally disabled, dental services, early and periodic Recommendations of the Pepper Commission.- The health screenings, diagnostic and treatment services, fam- commission's recommendations6? include insurance re- ily planning services, home health and personal care ser- forms by which income-based cost sharing of premiums vices, and other medically necessary professional services. by employers and a public plan guaranteeing health care 5. Medicaid expansion should include measures to pro- coverage for all workers would be implemented. Ulti- mote cost-effective provision of services. mately, this plan would provide coverage for all children. 8 Caring for the Uninsured and Underinsured Insurance reforms would include coverage of primary and tizing medical services on the basis of cost and benefit to preventive care, elimination of exclusions because of pre- the overall public. A list of such priorities has been gen- existing conditions, and elimination of coinsurance pay- erated. Different priorities have been established for dif- ments by consumers for prenatal and well-child care. The ferent age groups. High priorities are given to family plan- commission also recommended Medicaid reforms (includ- ning, prenatal care (including nutritional care), childhood ing physician reimbursement for obstetric and pediatric immunizations, labor and delivery services, and the treat- care), ultimate replacement of Medicaid with a new federal ment of acute illness. Low-priority items include infertility program expanding access and payment according to services, plastic surgery, routine dental care for adults, Medicare rules, a quality assurance strategy that would and most transplantations. These priorities are established include reform of the medical malpractice system, and cost by a Health Services Commission consisting of five phy- containment measures. sicians, a public health nurse, a social worker, and four American Academy of Pediatrics National Child consumers. The basic principle is expansion of numbers Health Policy. - This policy⁸ includes health care coverage served by restriction of services provided. Thus far it pro- for all children and adolescents through age 21 years and poses rationing services only to those served by Medicaid. mandates employer-based coverage or coverage by pri- Rationing Medical Progress. - Callahan¹⁴ describes his vate insurance companies contracted by the state. The pol- proposal as follows: "In any case, we must be prepared to icy also calls for state health care funding (including fund- ration medical progress and in particular to forego poten- ing of Medicaid expenditures), state and federal insurance tially beneficial advances in the application and develop- premiums, an employer payroll tax for those employers ment of new techniques. I am not proposing a diminution who choose not to cover pregnant women and children, of efforts to extend our store of theoretical biologic and and methods of ensuring adequate provider reimburse- medical knowledge. A strong commitment to basic bio- ment. medical research remains an attractive and desirable goal. HR 4280 Health Insurance for Children and Mothers That commitment is not incompatible, however, with sev- Act of 1990. - This act9 requires health insurance for preg- eral insistent requirements: (1) that clinical applications be nant women and children, mandates comprehensive ben- subjected to stringent technological assessments before efits, calls for elimination of financial barriers to health care dissemination; (2) that the social and economic standards (development of a one-tier health care system), recom- for the assessment be biased toward restrictiveness mends that Medicaid dollars be refocused in a more ef- ('straight is the gate and narrow the way' might be a per- ficient and effective program, emphasizes preventive ser- tinent maxim here); and (3) that it is understood and ac- vices (including immunizations, and prenatal and well- cepted that some, perhaps many, beneficial applications child care), and directs that payroll tax be increased to will have to be passed over on grounds of cost and other, match current Medicare tax paid by employer and em- more pressing social priorities." ployees. Rationing Health Care According to Age. -Levensky15 A Consumer Choice Health Plan for Universal Health summarized these proposals as follows: "Why is it accept- Insurance. - The proposal¹⁰ states that "To remedy the able to propose limits on health care for the elderly, in deprivation, we propose that everyone not covered by contrast to the obvious unacceptibility of such a proposal Medicare, Medicaid, or some other public program be en- applied to other groups and classes of citizens? A number abled to buy affordable coverage, either through their em- of philosophers and medical ethicists, prominent among them Callahan, Daniels, and Veatch, have published care- ployers or through a 'public sponsor. To attack the excess, fully formulated arguments favoring the use of age as a we propose a strategy of managed competition in which criterion for rationing health care. Although the details of collective agents, called sponsors, such as the Health Care their various arguments differ, the essential philosophical Financing Administration and large employers, contract underpinnings are quite similar. They argue that limits on with competing health plans and manage a process of in- health care for the elderly are justifiable because each cit- formed cost-conscious consumer choice that requires pro- izen, throughout a lifetime, would benefit if funds now viders who deliver high-quality care economically." used to extend life at its end were redirected to earlier State Programs. - These programs include Massachu- stages of life. They envision the national health care bud- setts legislation designed "to make health security avail- get equitably distributed among all citizens. Each person able to all citizens of the Commonwealth and to improve would be entitled to a fair share of national health care hospital financing." This legislation would create a De- expenditures as a personal lifetime 'health care budget.' " partment of Medical Security that contracts with health plans to make coverage available to small businesses and THE QUILTS unsponsored individuals. It proposes a tax on all employ- The Canadian Health Care System ers of five or more workers. 11 The New York State De- Much discussion of adopting a variant of the Canadian partment of Health has developed a program called Uni- system has been heard. 16 In Canada, one national health versal New York Health Care, or UNY-CARE. 12 It would program is administered by the provinces, and universal retain existing payers, including employer-based insur- coverage for all citizens is provided regardless of age, ance coverage, but would combine them in a one-payer health status, or financial means. framework. This one payer would be the only resource for All medical costs, with no copayments or deductibles most services and would negotiate reimbursement rates, and including costs of long-term stays in health care fa- hopefully to exercise some cost controls. cilities, are covered. Services include care by physicians. in Rationing Health Services. Oregon legislation pro- offices, in hospitals, and at home. Also covered are di- poses altering Medicaid coverage to provide services agnosis and treatment of illness and injury (including and based on a "net benefit" concept. 13 This involves priori- drugs prenatal and postnatal obstetrical care); laboratory, Redoing Health Care 9 radiologic, and other ancillary services; radiotherapy; and proved with some restrictions. home dialysis. Most of the provinces also provide land and Benefits. - The plan provides very broad coverage, in- air ambulance services. Private or semiprivate hospital ac- cluding physicians' and other professional medical ser- commodations are not covered by the plan but may be vices, inpatient and outpatient hospital care, diagnostic financed through commercial insurers with premiums and screening tests, prenatal and well-baby care, mental paid by employers. (These plans may not, however, offer health services, long-term care, and hospice services. Pre- benefits provided by the provincial plans.) ventive services would include basic immunizations, pre- Payments to providers include fee-for-service reim- natal and postnatal care, well-child care (including peri- bursement of physicians according to a schedule negoti- odic physical examinations and hearing and vision ated between organized medicine and provincial govern- screening until age 23 years), Papanicolaou smears, and ment. Some provinces have capitation systems. Patients mammographic examinations. This legislation also pro- can choose any physician. Extra billing by physicians is poses extensive programs for long-term and geriatric care barred. Hospitals are paid an annual global sum for pro- and authorization for support of research of acquired im- vision of services, which is similarly negotiated. In Can- munodeficiency syndrome, hypertension, sickle cell ane- ada, centralized government controls are exercised over mia, infant mortality, and breast cancer. major forms of technology and capital spending, with an effort to regionalize highly technologic services. The sys- Mediplan tem is financed by payment of premiums by employers This proposal mandates a broad health care program¹⁸ and individuals. Funding is also provided by the provin- by which all US residents would be enrolled and issued cial and federal governments through general revenues. a Mediplan card entitling them to care. Subsequently, res- Participants older than age 65 years pay no premiums; idents would be enrolled at birth. Children, pregnant individuals or families lacking resources to pay also are not women, and low-income groups particularly are identified charged. to receive services. Benefits would include those provided Comprehensive Health Care for currently by Medicare and special preventive health ser- All Americans Act (the Claude Pepper Comprehensive vices for women and children (including well-child care Health Care Act) and pregnancy-related services). Providers would be paid This comprehensive plan includes many features of the according to a resource-based relative value scale. Phy- Canadian system. 17 Its principal elements are as follows: sicians would be required to accept a Mediplan rate and Eligibility. All residents of the United States who are charge no additional fees. Mediplan includes a global ob- citizens, nationals, or lawful resident aliens may enroll. stetrical fee and a bonus for prenatal care. Children, preg- The enrollee may choose among qualified health plans as nant women, and low-income groups would be exempt approved by the state of residency. from the $500 annual deductible. Financing of Mediplan Administration. The act would establish a National would be generated from income tax, employer contribu- Comprehensive Health Care (CHC) Board to which each tions, and income-related employer premiums. Deduct- state would submit a plan for its CHC program. To be ibles, copayments, and co-insurance would be limited to approved, the state plan must provide for (among other $2500 per year. things): adequate financing, freedom of choice among qualified health plans by enrollees, effective cost contain- A National Health Program for the United States: ment measures, adequate administration (including es- A Physician's Proposal tablishment of a public advisory boards), responsive qual- Himmelstein et al¹⁹ and Woolhandler and Himmel- ity control mechanisms, and organization of a state stein,² along with the Writing Committee of the Working commission to reduce excess hospital beds. The National Group on Program Design representing Physicians for a CHC Board would establish a commission to provide ad- National Health Program, describe a comprehensive vice regarding technology development and effectiveness health plan by which everyone would be covered by one and to recommend such technologies for inclusion as cov- public plan and all alternative insurance coverage, copay- ered health services. Each state CHC program would ap- ments, and deductibles would be eliminated. All medical prove qualified health plans for inclusion based on defined services, including those to treat acute problems and prob- criteria. The number might be limited, except for health lems requiring long-term and rehabilitative care, would be maintenance organizations. covered. Prevention and public health programs would be Financing. - The federal CHC program would make a covered, as would dental services and occupational ther- per capita contribution to each state annually according to apy. A lump-sum budget would be negotiated annually defined criteria for support of the state plan. The state with hospitals for patient services. Improvements, expan- CHC program would generate funds from general reve- sion, and major capital services would be funded by in- nues, earmarked taxes, sales taxes, employer and em- dependent appropriations. Three options would be avail- ployee health insurance premiums, and cost sharing. Ser- able: fee-for-service, salaried positions in institutions vices for low-income groups, pregnant women, and well- receiving global budgets, and per capita payments to child care might be exempt from premiums or cost sharing. group practices or health maintenance organizations. Fee Reimbursement. The CHC program would include schedules would be negotiated by a medical organization, payment of institutions according to a biennial budget and extra billing would be limited to uncovered services plan and to physicians according to payment schedules such as cosmetic surgery. All funding sources currently negotiated with medical organizations and based on a na- used would continue during a transitional period (includ- tional relative value scale. Alternate methods such as cap- ing insurance premiums, Medicaid, Medicare, and em- itation, annual salary, and hourly payments might be ap- ployer contributions), but all would flow through a single 10 Caring for the Uninsured and Underinsured payer, the national health plan. Private health insurance practice and by controlling capital expenditures by insti- would be phased out over 3 years, and general tax rev- tutions. The chances of implementing any of these pro- enues would be developed based on income or some other posals seem slim.²⁴ progressive tax. If we are to consider a new quilt, how should it be sewn? The Canadian system has been much discussed²⁵⁻²⁸ and COMMENT Most would agree that our health care system needs has many advantages: universal coverage under one plan; urgent attention. There are obviously many options. The coverage of all reasonable benefits; one system of man- continuing flow of thoughtful commentaries on the prob- agement that simplifies procedures for patients, physi- lem in our medical journals21-34 reflects the intense interest cians, and hospitals; free choice of physicians; emphasis of health care professionals. Various polls have demon- on the role of the primary care practitioner; regulated ap- strated that Americans favor a major overhaul of the health plication of new technology that encourages regionaliza- care system, but their dissatisfaction has apparently not tion; controlled capital expenditures; fee-for-service phy- reached a level sufficient to bring pressure on politicians, sician reimbursement; and controlled hospital costs which is ultimately needed if change is to occur. In con- through development of an annual, realistically- trast, powerful elements in the health care industry exert negotiated budget. Studies comparing the Canadian and major influence in determining changes or lack thereof. As American health care systems27,28 have emphasized re- Levey and Hill21 put it: "The voices now raised to support duced administrative costs in Canada, costs that contrib- national health care will not produce universal health in- ute to premiums for patients and to overhead for physi- Americans lack a necessary level of cians in the United States. The cost of health care in the surance soon discontent with our health care system, agreement on a United States is approximately 11% of the gross national widely endorsed program of universal health insurance, product, while in Canada it is approximately 8%, despite and the political stamina to drive legislation through Con- the latter's broader coverage. The difference has been at- gress." However, perhaps enlightened leadership in the tributed largely to our higher administrative costs, higher medical community can stimulate the necessary action in payments to physicians, and hospital costs. Concerns both lay and professional circles. Relman, 22 in a valuable about the Canadian system include its larger role of gov- discussion of the subject, reviews the options and con- ernment and the potential of increased regulation, yet cludes: "In my view, nothing short of a comprehensive there is apparently more regulation of clinical practice in plan which includes improved technology assessments this country than in Canada. Evans et al²⁸ point out that and malpractice reform as well as other reforms of medical "In the United States corporate competitors or employers practice is likely to achieve the goals of universal access, may turn out to be more ruthless than public regulators." cost containment and preservation of quality that every- Another concern, not so regularly expressed, is the impact one seems to want Now is the time for our profession on physician's incomes. A comparison of fee costs in 198527 to make common cause with government and with the revealed the following ratios for some services. major private payers in seeking solutions to a pressing social problem that is not going to solve itself." Fee Ratio, If political and other realities limit us to patches, even Service United States to Canada if in the process of shopping for a new quilt, then we Surgery 3.21:1 should get on with it. The most practical of these is mod- Anesthesiology 3.73:1 ification of the Medicaid program: extended coverage for indigent children and pregnant women; increased bene- Radiology 3.50:1 fits provided, with emphasis on preventive care; and pay- Office visit 1.56:1 ments to providers that are adequate to attract their ser- Hospital visit 4.77:1 vices. These changes can be relatively simply made by federal and state governments. This is an urgently needed A comparison of net physician incomes (US physicians first step that can be taken while plans for broader cov- vs Canadian physicians) produced a ratio of 1.35:1, and, erage are being developed. Medicaid expansion in one or according to one report, after adjustment for costs of re- another form is part of several broader recommendations, sources (including liability insurance) the ratio became including the legislation proposed by Stark,⁸ the American 1.30:1. 16 In 1984, the mean net income of physicians (before Academy of Pediatrics,⁹ and, at least temporarily, the Pep- taxes) in Ontario was $160 000 per year for specialists and per Commission. 5,6 If we pursue patchwork remedies, approximately $112 for general practitioners. Another these broader proposals should be evaluated as to overall report²⁷ lists net income for office-based physicians in Can- benefit and political reality. ada in 1985 as 607, compared with $112 109 in the A modification of the Medicaid patch proposed by the United States. Interestingly, this report states that pay- state of Oregon would ration services based on net benefit. ments to physicians (before income taxes) represent 52% (This is in contrast to our present system of rationing care of the gross income in the United States and 66% in Can- by limiting populations served.) This proposal has gen- ada. erated much and varied reaction. 13,23,24 Variations on this The United States needs a health care system that will idea causing even more violent reactions have included provide access to coverage by all citizens. It must provide Callahan's proposal¹⁴ to ration new technology and a services of broad scope and high quality, and it must do scheme to ration services based on age, restricting access so with emphasis on measures for cost containment and to some benefits by the elderly. The Canadian system con- preventive health. The evidence seems compelling that trols provision of some services by having the health plan this can be done only by the institution of a new system. approve implementation of new technology in clinical As Iglehart25 puts it, "Muddling through, as we are now Redoing Health Care 11 doing, is not a prescription for the ages, nor is it a policy 14. Callahan D. Rationing medical progress: the way to af- that allows the United States to stand tall." Of the options, fordable health care. N Engl J Med. 1990;322:1810-1813. a variant of the Canadian system appears most attractive. 15. Levensky NG. Age as a criterion for rationing health care. The program described by Himmelstein et al¹⁹,²⁰ embraces N Engl J Med. 1990;322:1813-1815. many of the desirable features and would be a new, first- 16. Iglehart JK. Canada's health care system. N Engl J Med. class quilt, but quilts imply bedfellows, and it is desirable, 1986;315:202-208, 778-784, 1623-1628. almost essential, that bedfellows be compatible. There are 17. The Comprehensive Health Care for All Americans Act of a number of large fellows in the bed, including the health 1990. HR 4253. insurance industry, hospitals, employers, government, 18. Mediplan Act of 1990. HR 5300. politicians, and the public. The chances of compatibility 19. Himmelstein DU, Woolhandler S, The Writing Commit- under a new quilt seem remote, particularly when some tee of the Working Group on Program Design. A national health bedfellows may get kicked out of bed. Nevertheless, it is program for the United States: a physician's proposal. N Engl imperative that we keep trying and that the medical pro- J Med. 1989;320:102-108. fession lead the efforts to ultimately find a new quilt rather 20. Woolhandler S, Himmelstein DU. A national health pro- gram: northern light at the end of the tunnel. JAMA. than to continue patching the old one. 1989;262:2136-2137. References 21. Levey S, Hill J. National health insurance: the triumph of 1. Oberg CN. Medically uninsured children in the United equivocation. N Engl J Med. 1989;321:1750-1753. States: a challenge to public policy. Pediatrics. 1990;85:824-832. 22. Relman AS. Universal health insurance: its time has 2. Wegman ME. Annual summary of vital statistics. Pediatrics. come. N Engl J Med. 1989;320:117-118. 1989;84:943-956. 3. Boyle JD. Health policy agenda for the American people. 23. Russell LB. Some of the tough decisions required by a JAMA. 1987;257:1199-1210. national health plan. Science. 1989;246:892-896. 4. Tallon JR. A health policy agenda proposal for including the 24. Relman AS. The trouble with rationing. N Engl J Med. poor. JAMA. 1989;261:1044. 1990;323:911-913. 5. Basic Health for All Americans Act of 1987. S768. 25. Iglehart JK. The United States looks at Canadian Health 6. Rockefeller JD. Access to Health Care and Long Term Care Care. N Engl J Med. 1989;321:1767-1772. for all Americans: Preliminary Recommendations to the 101st 26. Linton AL. The Canadian health care system: a Canadian Congress by the Pepper Commission. March 2, 1990. physician's perspective. N Engl J Med. 1990;322:197-199. 7. Rockefeller JD. The Pepper Commission report on com- 27. Fuchs VR, Hahn JS. How does Canada do it?: a compar- prehensive health care. N Engl J Med. 1990;323:1005-1007. ison of expenditures for physician's services in the United States 8. Health Insurance for Children and Mothers Act of 1990. HR and Canada. N Engl J Med. 1990;323:884-890. 4280. 28. Evans RG, Lomas J, Rarer ML, et al. Controlling health 9. Harvey B. Toward a national child health policy. JAMA. expenditures: the Canadian reality. N Engl Med. 1989;320:571- 1990;264:252-253. 577. 10. Enthoven A, Kronick R. A consumer-choice health plan 29. Ginzberg E. Health care reform: why so slow? N Engl J for the 1990s: universal health insurance IHA system designed Med. 1990;322:1464-1465. to promote quality and economy. N Engl J Med. 1989;320:29-37, 94-101. 30. Schorr AL. Job turnover: a problem with employer-based 11. Sager A, Hiam P, Socolar D. Promise and Performance: health care. N Engl / Med. 1990;323:543-545. First Monitoring Report on 'An Act to Make Health Security Avail- 31. Shortell SM, McNerney WJ. Criteria and guidelines for able to All Citizens of the Commonwealth and to Improve Hos- reforming the health care system. N Engl J Med. 1990;322:463- pital Financing. 'Boston, Mass: Boston University School of Pub- 466. lic Health; 1989. 32. Kinzer DM. Universal entitlement to health care: can we 12. Beauchamp DE, Rouse RL. Universal New York health get there from here? N Engl J Med. 1990;322:467-470. care: a single payer strategy linking cost control and universal 33. Relman AS. Reforming the health care system. N Engl J access. N Engl J Med. 1990;323:640-644. Med. 1990;323:991-992. 13. Relman AS. Is rationing inevitable? N Engl J Med. 34. Newachek PW. Improving access to health care for chil- 1990;322:1809-1810. dren, youth and pregnant women. Pediatrics. 1990;86:626-635. The Challenge of Care for the Poor Child The Research Agenda Steve Kohl, MD T he Society for Pediatric Research is a diverse group of to the increased incidence of meningitis in poor children scientists bonded by the common interest in research are being elucidated. 1,2 dealing with problems of children. Many of the society's The definition of the basic immune response on the mo- members have very strong feelings regarding the social lecular level, with particular attention given to possible and political problems of health care for the poor and, in immune defects in special population groups to the eti- particular, health care for poor children. Nevertheless, it ologic pathogens,³ have spurred rational development of is not in the usual scope of our organization to comment vaccines (as we are now seeing with conjugate polysac- as a group on these problems or even to claim particular charide vaccines). These are active areas of research bear- expertise in this area. Indeed, other segments of the pe- ing directly on this particular problem of health care for diatric community have been asked to address these is- poor children. Finally, it is critical that research be con- sues, and their efforts can be found in this issue. ducted into systems of health care provision on a societal As a research-oriented organization, the Society for level that will facilitate reliable access for the poor child to Pediatric Research can make cogent comments and sug- the fruits of the health care system, in this case vaccine gestions concerning the role of investigation in this prob- provision. lem area. In this regard, one must view research in its This type of investigation is not as "sexy" as dissection broadest sense; that is, research on the molecular level at of molecular mechanisms, but in the broad sense is every one end to research on the societal level at the other end. bit as valid a research question. In this area, as in all other There is a clear and pressing role for research methods in areas, the research must be scientifically rigorous and cre- identifying the problems facing the poor and in arriving ative, with a mechanistic, not purely descriptive, ap- at rational solutions to them on all levels. proach. Without such research, society would deprive the To enumerate many of the health problems particularly most financially and health-deficient members of our pop- facing poor children in this country would surely be re- ulation of the benefits of the more basic research advances. dundant. I will outline only a few that are of markedly have used the specific example of H influenzae meningitis, increased incidence in poor children, take a deadly toll, but equally cogent and perhaps more dramatic cases can and are obviously amenable to investigation. These in- be made for any of the problems outlined above. While clude prematurity, perinatal infections (including ac- some are less basic (eg, the behavioral problems) than oth- quired immunodeficiency syndrome), substance abuse ef- ers (eg, acquired immunodeficiency syndrome and infec- fect on the fetus and infant, infectious diseases of early tious diseases), in all there is a complex and as yet poorly childhood (notably gastrointestinal and respiratory infec- understood blend of basic biologic and sociopolitical is- tions, meningitis, and measles), child abuse, trauma, sues. homicide and suicide, teenage pregnancy, and school Identification of the problems is the first step in finding failure. The impact of these maladies converts potentially possible solutions. To arrive at accurate solutions requires valuable and productive members of society into long- research. Again, this must include research in the broadest term financial liabilities as well as poignant catastrophes. sense, from the molecular to the societal arena. One prom- Each of these problems can be, and indeed must be, ising new approach is the recently established Child attacked from the research level to find a cogent solution. Health Research Centers program within the National In- As an infectious disease expert, I think it is reasonable to stitute for Child Health and Human Development. Seven use Haemophilus influenzae meningitis as an example. This centers were established in 1990 with the expectation of is the most common type of bacterial meningitis in the creating "centers of excellence" in a specific subject area, young child, resulting in considerable sequelae. The in- with considerable flexibility provided to promote the de- cidence of this illness is markedly increased in the poor velopment of new pediatric investigators. Unfortunately, child. 1,2 The particular epidemiology of various organisms with the exception of this new initiative, research in gen- and host interactions can be discerned to determine the eral, and research into child health issues in particular, reasons for the increased incidence. The relationships of remains among the lower priorities in this country. With family crowding, day-care center care, and breast-feeding the current financial situation, there has been a progres- sive decline in newly funded research grants and a re- Accepted for publication November 30, 1990. duction in funding to established grants. The percentage From the Division of Pediatric Infectious Diseases, University of of funded NIH grants has dropped from 62% in 1974 to California, San Francisco, and San Francisco General Hospital. an estimated 22% to 24% in 1990.4-⁷ I would like to offer Reprinted from AJDC (1991;145:542-543). a list of possible solutions to these problems: Poor Child 13 1. A basic shift in national priorities to acknowledge lutions to the problems of child health involve the tradi- that the main threat to our security comes from profound tional research methods focused on a broad plane. Once internal societal problems, not external military chal- a reliable database is established and interventional tech- lenges. niques are validated, the solutions themselves can be in- 2. A fundamental restructuring of budgetary goals to stituted. Some believe that a conflict exists between re- acknowledge the change in national priorities; health care search and health care for the poor, since each requires research would be placed closer to the top of the list along scarce resources. It is my contention that this nation is with other social and domestic programs. wealthy enough to fund both adequately once we reorder 3. Acknowledgment that problems of the poor child our priorities. Indeed, it will be the poor, so dispropor- and child health in particular, if not addressed, will lead tionately burdened by ill health, who will benefit the most to crippling problems in society as the demand for pro- from the fruits of all research advances. ductive and increasingly skilled workers accelerates. The theme of the 1991 Society for Pediatric Research's 4. With this acknowledgment, increased funding of all Presidential State of the Art Symposium (occurring at our areas of child health problems becomes vital. annual meeting in May in New Orleans, La) is entitled 5. Recognition that funding of scientifically rigorous, "The Medical-Social Crisis in Child Health." The main ar- creative, and mechanistic research into broad societal eas discussed will include an overview of the vulnerable problems is as valid as research into molecular mecha- child, pediatric acquired immunodeficiency syndrome, nisms. substance abuse, and health care access for children. Thus, 6. Similarly, increased awareness in the pediatric aca- the research societies are acknowledging and beginning to demic world, including our medical school departments come to grips with these issues. It will be up to the nation and research organizations, of the breadth of research, to further use the tools of pediatric research to aid in the with rewards for the societal-oriented researcher being solution of these problems. similar to those for the molecular scientist. 7. Creation of a cadre of pediatric scientists rigorously I would like to thank the following people for their reviews and trained in the social sciences (eg, sociology, economics, helpful comments: Larry J. Shapiro, MD, president-elect of the So- and epidemiology) to enable them to contribute to the so- ciety for Pediatric Research, Department of Pediatrics, UCLA School of Medicine, Los Angeles, Calif; Thomas N. Hansen, MD, secretary- lution of the broad arena of medicosocial problems of the treasurer of the Society for Pediatric Research, Baylor College of Med- poor child through research. icine, Houston, Tex; Moses Grossman, MD, University of California 8. A rational, long-term plan for stable national funding Medical School and San Francisco General Hospital; Richard E. Behr- mechanisms to maintain the fragile research infrastruc- man, MD, Stanford (Calif) University and the Center for the Future ture, to provide a level of confidence in the research com- of Children, David and Lucille Packard Foundation, Los Altos, Calif; munity, and to ensure a continuity of research and training and Myron Genel, MD, Yale University, New Haven, Conn, chair- man of the Public Policy Council. of entry-level researchers. 9. Increased funding for the Child Health Research References Centers to allow the opening of more than the initial seven 1. Cochi SL, Fleming DW, Hightower AW, et al. Primary in- funded centers. vasive Haemophilus influenzae type b disease: a population- based assessment of risk factors. J Pediatr. 1986;108:887-896. 10. Broadening the scope of Child Health Research 2. Wilfert CM. Epidemiology of Haemophilus influenzae type Centers to include training and research on every level into b infection. Pediatrics. 1990;85:631-635. the problems that affect children, and enhanced coordi- 3. Granoff DM, Sheetz K, Pandey JP, et al. Host and bacterial nation of molecular and societal research efforts. factors associated with Haemophilus influenzae type b disease 11. Enhanced cooperation among the public sectors of in Minnesota children vaccinated with type b polysaccharide funding and the private sectors, including foundations vaccine. J Infect Dis. 1989;159:908-916. and industry, regarding child health problems. 4. Cassman M. Issues behind the drop in the NIH award rate. The problems we face in child health care, and child ASM News. 1990;56:465-469. health care of the poor in particular, are immense. Nev- 5. Institute of Medicine. 1990 Funding Health Sciences Re- ertheless, they are every bit as amenable to solution as search: A Strategy to Restore Balance. Washington, DC: Na- tional Academy of Sciences; 1990. those involving Middle East oil or the savings and loan 6. Kennedy DE. The rising cost of NIH-funded biomedical re- institutions. Indeed, health care problems will erode this search? Acad Med. 1990;65:63-73. nation's security as surely as will the more publicized na- 7. Kelley DM. NIH Funding for biomedical research, 1990: tional and international problems. The most efficient so- perceptions and reality. Endocrinology. 1990;126:2233-2236. Poverty and the Health of American Children Implications for Academic Pediatrics Richard B. Johnston, Jr, MD T he headline of a recent editorial in the Philadelphia In- Nevertheless, the validity of the challenge remains, and quirer posed a loaded question: "How is it that we it is hard to escape the conclusion that we have a respon- have such great hospitals-and such poor public health?" sibility in academic pediatrics to respond somehow to (August 22, 1989:14-A). these issues as they relate to children. Those children who The reference point was Philadelphia in which "high- have reduced access to preventive medical care suffer the tech progress and abysmal public health performance most illness. Poor children have significantly higher rates coexist too comfortably." Instead of just "cranking out of a variety of health-related problems, from infant mor- specialists," the editorial said, "academic medicine ought tality and traumatic death to prematurity (and conse- to be taking stock of its broader mission preventing sick- quently its related disabilities), failure to thrive, iron de- ness, making care more easily available and figuring ways ficiency anemia, lead poisoning, perforated appendix, to improve the state of public health." The present focus sick days out of school, and hearing loss.¹ The physical, of medical schools has led to sophisticated methods of intellectual, and emotional sequelae of these largely treatment but preventable conditions can only decrease the chances has left too much undone, too many unserved, in a nation with that these children will work their way out of poverty as the resources and imagination to make life healthier, even for the adults. poorest, most vulnerable of its people. On matters of public If academic pediatrics has a responsibility to respond to health, academic medicine has been embarrassingly slow to show this tragic situation, what should we do? What about staff- leadership. Doctors have won heroic fights to save babies. ing clinics in underserved areas? Editors of the American But when it has come to shaping strategies to save generations, Medical Association and the American Bar Association their record is skimpier. Medicine has been reactive, repairing the damage after it has been done. journals have advocated giving 1 week per year for pro bono service, reminding us of an historic element of pro- The editorial was indeed provocative. The responses fessionalism that may have faded in recent years. Cer- from the academic medicine and public health commu- tainly, this sort of service can make a major difference in nities correctly emphasized the unfair implication that the lives of the children actually treated, and it can be re- medical schools and their hospitals can be blamed for the warding for the physician. However, to suggest that ac- serious health issues that affect the city. Little was said, ademic personnel should necessarily contribute even however, in response to the editorial's basic question: more free medical care, with even further dilution of their What are medical school people doing to correct these academic efforts, seems, in the long run, unwise. Aca- health problems that affect so many humans so pro- demic departments have special opportunities and faculty foundly? The fact that the editorial's fundamental ques- with special expertise. These offer the potential to go be- tion also should have been addressed to our political lead- yond the immediate problems toward more fundamental ers at a local and national level is frustrating. That so many solutions with more lasting benefits. of the city's (and the country's) people do not receive even Education is obviously the special province of the ac- basic medical care cannot reasonably be blamed on aca- ademic institution, but what should we teach? The prob- demic medical centers. In fact, these centers bear much of lems are overwhelming, and we have little to offer in the the burden of this society's failure in public health, be- way of solutions; perhaps this is what our students and cause they spend a great deal of largely nonreimbursed residents should learn first. It is a widely held tenet of time, emotion, and expertise dealing with its conse- education that the student learns better when knowledge quences. This underreimbursed effort, as important as it is gained by his or her own initiative and best of all when may be, makes it harder for academic medicine to accom- he or she is truly involved. Involvement in this case ne- plish its special mission of education and research. cessitates exposure to the societal failures that are related so closely to the poor health of many Americans. This Accepted for publication January 22, 1991. means that students and residents must leave the medical From the Department of Pediatrics, University of Pennsylvania school and hospital and go out into the community where School of Medicine and The Children's Hospital of Philadelphia. they can see first-hand the consequences of weak edu- Reprinted from AJDC (1991;145:507-509). cation systems, insufficient job training, inadequate low- Health of American Children 15 income housing, the high costs of medical care, and the there has been too little research conducted regarding pos- downward, grinding spiral of poverty. Endorsement and sible solutions to the health problems of the poor in Amer- collaboration of community leaders are prerequisites. The ica, and an estimated one fifth of our nation's children fall format might be health promotion and provision of med- into that socioeconomic class.⁴ The critical peer-review ical care (with faculty) at housing projects, schools, shel- system that controls expenditure of public research funds ters, and clinics within an underserved community, but should endorse with enthusiasm good scientific investi- these activities should be part of an educational program gation into health promotion and disease prevention. with defined educational goals. What questions could be more substantial in pediatrics For example, with guidance from pediatric faculty, res- than those related to the reduction of problems such as idents and medical students in Philadelphia have taught adolescent pregnancy, premature delivery, adolescent health care in inner-city biology classes, conducted per- suicide, and accidental deaths? inatal clinics in housing projects, made home visits to ad- Research is needed regarding methods to provide care olescent mothers, and assumed responsibility for pediatric to poor children in our cities and remote rural areas. How care in shelters for homeless or battered women. Partic- can we be more accessible to these children? How can we ipating residents carry a beeper that allows them to offer finance systems to provide this care? How can we reduce 24-hour coverage. Teams comprising a resident and one medical expenditures in other areas and release funds to or two medical or nursing students make shelter calls meet the need for basic care for poor children? How can weekly and conduct health fairs at 4- to 6-week intervals we maintain a medical record that will be easily accessible to immunize, screen for disease, and educate mothers. to any pediatrician? What have the students and residents learned from Research into outcomes is needed. Which programs these experiences? Most respond first that they have work, and which programs are worth the money and ef- gained a "gut feeling" for the broad needs of the mothers fort? For example, can improved education and counsel- and children. The complexity of poverty and the plight of ing reduce prematurity? The fundamental question is real people elicit frustration, anger, and sadness. A second whether preventive medicine is cost-effective. Common lesson has been that health is not a survival issue for poor sense and a quick review of hospital costs suggest that it people. When food, clothes, and shelter cannot be as- is, and experience with programs for prenatal care, im- sured, baby shots or even treatment for infection or ane- munizations, and supplemental food for women, infants, mia become minor concerns; poor compliance is under- and children (WIC program) support this view. 5,6 How- stood differently. Third, these residents and students ever, the content of medical school and residency curricula have learned the serious handicap imposed by the lack of and the behavior of organized medicine, hospitals, gov- a record system to track children who have no consistent ernment agencies, and insurance companies reflect little source of care, no consistent financial aid, and sometimes support for such a concept. In their defense, too little sci- no consistent parent or caregiver. Three additional lessons entifically based research has been done in this area to have probably been the most important: (1) Most residents prove that the principle of cost-effective prevention is report a new recognition of their own limitations in ad- broadly applicable. dressing the enormity of the need. (2) Most residents Consider, for example, extracorporeal membrane oxy- clearly realize that throwing even larger numbers of med- genation (ECMO) and the problem of nonreimbursed ical personnel at this problem in efforts like theirs will not costs for long-term care in nurseries. It is hard to believe make it go away. (3) Finally, often to their surprise, the that ECMO, employed to save selected neonates, is more residents identify a clear need for research-research on cost-effective (much less more humane) than adding fundamental causes, on what really works, and even on equivalent nursing and support personnel to try to pre- whether their own efforts have made a lasting impact. vent unwanted adolescent pregnancy, to help carry preg- Projects like these, established for the purpose of service nancies to term, or to make routine home nurse visits after and education, may be very important to many individual delivery, which is the standard of care in Britain. Yet more children, but they do not represent a solution to the fun- and more hospitals are establishing ECMO programs but damental problems; however, they can function as an im- not programs to prevent prematurity in the communities portant means toward that end. Projects like these could they serve. Research is needed. serve to recruit the next generation of researchers, teach- Research such as that which might compare cost- ers, and policymakers, better prepared as a group than effectiveness and outcomes of ECMO and preventive care their predecessors to formulate meaningful and answer- is extremely difficult to conduct, however. Few academic able research questions, to emphasize the importance of pediatricians have yet had sufficient knowledge, funding, disease prevention, and to create public health policies or whatever it takes to try. Although foundations have that will work. At the very least, participants will be un- provided some financial support for such research, too likely to underestimate the magnitude of the problem, and little public money has been available for this purpose some will become informed and intelligent advocates for compared with the human need, the critical importance change. of healthy children to the country's future, and the rea- How can academic pediatrics work most effectively to sonable possibility that research might lead to a reduction achieve fundamental, broad-based solutions? A major in health care costs. The Medical Treatment Effectiveness part of the answer must lie with research, obviously an Program, established in 1989 under the Agency for Health essential function of the academic medical center. Basic Care Policy and Research, US Public Health Service, may biomedical research has made tremendous contributions begin to correct this serious deficiency. This program sup- to public health and also, incidentally, to reduced expen- ports research into fundamental issues of health services, ditures for the treatment of many diseases.³ However, such as which treatments actually work best and which are 16 Caring for the Uninsured and Underinsured cost-effective. (Inquiries may be addressed to the Agency participate? Not all of them, as the poor are not our only for Health Care Policy and Research, 18-12 Parklawn Bldg, responsibility, but more is needed than we have offered Rockville, MD 20857.) so far, especially with regard to research. No group un- Although experimental proof of cost-effectiveness and derstands the needs of children better or cares more clinical efficacy is necessary to effect fundamental, broad- deeply than do pediatricians. The longer we wait for oth- based change, provision of the data will not guarantee ers to solve the problem, the longer the preventable suf- implementation. Federal and state governments have only fering will continue, the greater the number of children recently appropriated enough money to support approx- who will sustain permanent injury, and the more pro- imately 60% of those eligible for the women, infants, and found will be the losses to their future and to ours. Ac- children (WIC) supplemental food program, fewer than ademic pediatrics has a responsibility to use its special tal- one sixth of those eligible for Head Start, and about half ents to address these problems. Those faculty who accept those who need remedial education, and these programs the challenge deserve our highest respect and support. have been proved to be effective.⁷ Expenditures for de- I thank Donald Schwartz, MD, Kenneth R. Ginsburg, MD, Robert fense, in the meantime, have far exceeded those for all E. Merrill, MD, and Waldo E. Nelson, MD, for inspiration and guid- children's programs combined. Not many pediatricians, ance and Charles L. Johnston and Margi Ide for critical review. either academic or practicing, have had the fortitude to References take on the shameful, short-sighted governmental policies 1. Wise PH, Meyers A. Poverty and child health. Pediatr Clin that ignore the critical needs of so many of our children. North Am. 1988;35:1169-1186. Fortunately, a few have done so, and our professional or- 2. Lundberg GD, Bodine L. Fifty hours for the poor. JAMA. 1989;262:3045. ganizations have begun to guide us toward more effective 3. Schroeder SA, Zones JS, Showstack JA. Academic medi- participation in the area of public policy. Pediatricians are cine as a public trust. JAMA. 1989;262:803-812. uniquely and eminently qualified to participate effectively 4. Bane MJ, Ellwood DT. One fifth of the nation's children: by testifying or writing about and by lobbying for legis- why are they poor? Science. 1989;245:1047-1053. lation related to children.⁸ Considering the critical impor- 5. Dutton DB. Social class, health, and illness. In: Aiken LH, tance of directing public support toward children, serious Mechanic D, eds. Applications of Social Science to Clinical Med- efforts to accomplish this should be recognized as legit- icine and Health Policy. New Brunswick, NJ: Rutgers University imate academic endeavor, worthy of endorsement by the Press; 1986:31-62. departmental and medical school promotions committees. 6. Committee to Study the Prevention of Low Birthweight, The devastating effect of poverty on the health of so Division of Health Promotion and Disease Prevention, Institute many American children has created opportunities that of Medicine. Preventing Low Birthweight: Summary. Washing- ton, DC: National Academy Press; 1985. are as intellectually demanding, emotionally fulfilling, 7. Children 1990: A Report Card, Briefing Book, and Action and immediately important as any available in academic Primer. Washington, DC: Children's Defense Fund; 1990:11-12. pediatrics. The laboratory becomes the community of 8. Berger LR. The pediatrician's role in child advocacy. Adv which the medical school is a part. Which faculty should Pediatr. 1982;29:273-291. Serving the Underserved Impact on Resident Education Carol D. Berkowitz, MD N umerous obstacles stand in the way of universal ac- problems of the underserved and educates individuals cess to health care. 1,2 Some of these barriers are po- about diseases unique to or at higher incidence among litical, and influencing them is more problematic, slow, certain populations. An example of this would be recog- and subject to the climate of the time. Other aspects may nizing and being prepared to treat conditions such as tu- be addressed by increasing the pool of physicians aware berculosis, child abuse and neglect, and dental caries of and involved in the issues of serving the underserved. among migrant farm workers and their children.⁵ The Ambulatory Pediatric Association (APA), under the A third clinical issue involves the teaching of the in- leadership of Paul McCarthy, MD, began addressing the is- terpersonal aspects of care, focusing on psychosocial is- sue of serving the underserved in March 1990. A conference, sues and interviewing skills. The means to teach these to cosponsored by the APA and the Bureau of Maternal and house officers have been eloquently addressed by Julia Child Health, was convened. Participants in the conference Hamilton, MSW, CISW, a social worker from Yale-New included nurses, social workers, and physicians, many of Haven (Conn) Medical Center.⁶ Ms Hamilton teaches whom were chief residents in their respective training pro- about the "five C" model of intervention. These five stages grams. These individuals were representative of different include caring, confrontation, creativity, culture, and clo- regions in our nation and cared for different populations sure. The stages are consecutive and developmental, and within these regions. Participants were asked to address one require mastery of one before proceeding to the next. They aspect of the impact of underserved children on resident ed- are practical and readily learned by house officers. Caring ucation. The proceedings of this conference have been pub- means demonstrating to the patient (by touching or lished and distributed.⁴ The reasons for this focus on edu- through statements) that one cares. Confrontation in- cation were multiple. It is readily apparent that the volves open discussions with patients about their goals underserved represent a diverse group, including a large and expectations from the health care system. Creativity portion of financially disadvantaged and/or geographically includes role modeling or reframing things for patients isolated children (rural and migrant workers). Care of these and their parents. Culture means being sensitive not just children, particularly the economically restricted, often falls to ethnic differences, but to the culture of poverty. Last, into the bailiwick of pediatricians in training. By properly closure means letting go, and allowing the family to solve preparing these (and all) residents, not only may health care its problems on its own. The goal of Ms Hamilton's five be improved for the children, but commitment and advocacy C model is to nurture the unnurtured. Intimately inte- by the house staff may be encouraged. How will this be grated in the clinical issues is teaching the house staff to achieved? The purpose of this article is to outline the means identify strengths in families and children and to utilize to accomplish this end. these strengths while providing health care. These fam- The APA took on as a project the development of a stra- ilies can often benefit from a family systems approach.⁷ tegic plan regarding residency education. This plan has In addition to teaching the resident about clinical issues, both short- and long-term objectives. The major short- the curriculum must also include community or environ- term objective is the development of a core curriculum of mental issues. First, one must address ecology, the relation- fundamental knowledge, of necessary skills, and of ship of the child to his or her environment, family, and the unique techniques for resident education. Methods for social systems that regulate his or her life. One must be curriculum implementation will also be defined. knowledgeable about public laws, such as 94-142, that affect The first curriculum category concerns what can broadly the care of children. Likewise, the physician must know be referred to as clinical issues. First, the house officer about available categorical programs, such as the Special needs to be able to identify the underserved individual and Supplemental Food Program for Women, Infants, and Chil- recognize the numerous barriers (ie, financial, govern- dren; Aid to Families With Dependent Children; and Med- mental, geographic, institutional, or personal) to health icaid, and help patients achieve access to these programs.⁸ care. The second clinical issue addresses the specific health The issues of advocacy, ethics, and the legislative process Accepted for publication November 19, 1990. should be addressed in a formal way. Didactic sessions, as From the Ambulatory Pediatric Association, McLean, Va, and the well as opportunities to become involved in organizations Department of Pediatrics, UCLA School of Medicine. geared to muster change, should be offered. Reprinted from AJDC (1991;145:544-545). The house officer needs to be taught about the orga- 18 Caring for the Uninsured and Underinsured nization of health care systems. Included in this is formal tion on caring for the underserved should be a priority in all instruction on practice management.⁹ Residents should be federally funded primary care programs. Primary-care fellow- given career counseling. The realities of reimbursement ships with a focus on the underserved should be developed. should be taught. Residents should be encouraged (in- Likewise, financial issues related to the underserved spired) to assume some responsibility for the health care of should be addressed. Physicians need to be encouraged to individuals whose major barrier is a financial one. Instruc- join organizations that actively lobby for universal access to tion about health care access and barriers, both financial and health care regardless of financial status. Physicians, indi- otherwise, should be given. vidually and as members of organizations, should then be How many training programs already address these is- encouraged to support agencies (eg, the Health Resources sues, and what methods are available to teaching house and Services Administration and the Bureau of Maternal and staff about serving the underserved? The APA is devel- Child Health) that focus on the underserved and support oping a questionnaire to assess the extent of such pro- health policies that provide full funding or primary-care ser- grams. It is hoped that programs with an established cur- vices and a full spectrum of care for the underserved. Loan riculum will make their curriculum available to others. forgiveness for those pursuing careers in serving the under- There are key methods in teaching residents to care for the served should be encouraged. underserved. First, institutions may develop rosters of fac- The APA as an organization is firmly committed to the ulty mentors, individuals who are knowledgeable about the issue of serving the underserved. To date, the organization issues of the underserved, who care for the underserved, has held a conference exploring this issue and the impact that and who are role models for young physicians. Such faculty underserved children have on residency education. The members are often the ones who are overworked and over- APA has chosen to focus on teaching house staff about un- utilized. They often do not have time to do what they do, derserved children as one approach to combating the prob- much less take on additional tasks as mentors. However, lem. It is both hoped and anticipated that better training of academic acknowledgment for their contribution would val- house officers will result in a pool of physicians who are not idate the importance of their role. Didactic lectures are an- only more knowledgeable about health care issues of the other forum in which to teach about serving the under- underserved, but also more willing to care for such children, served. These may be included in continuing care and serve as advocates and forces for change. conferences. The continuing care clinic, for many house of- References ficers, is an excellent setting in which to recognize psycho- 1. Hubbell A, Waitzkin H, Mishra SI, Dombrink 1. Evaluating social and medical concerns of underserved children. 10 The health care needs of the poor: a community-oriented approach. five C model of intervention could be incorporated in this Am J Med. 1989;87:127-131. 2. Schmidt DD. The challenge of caring for the underserved. setting.⁶ Block rotations could be developed, particularly in Fam Med. 1989;21:257-260. specific underserved communities. Institutions could de- 3. Lurie N, Yergan J. Teaching residents to care for vulnerable velop "exchange" programs to allow for greater exposure of populations in the outpatient setting. J Gen Intern Med. house staff to different underserved populations. Examples 1989;5(suppl):526. of such block rotations would include the homeless, migrant 4. Educating Pediatric Residents to Provide Health Care to Un- children, inner-city health care, etc. Built these rotations, derserved Children. McLean, Va: Ambulatory Pediatric Asso- or as a separate part of the training experience, would be ciation; 1990. structured extramural experiences such as home visits, or 5. Markello J. Children of migrant farm workers living in rural visits to the welfare office. Such experiences are meant to poverty. In: Educating Pediatric Residents to Provide Health help the house officer understand and empathize with the Care to Underserved Children. Alexandria, Va: Ambulatory Pe- diatric Association; 1990:63-69. day-to-day struggle many of the underserved face. 6. Hamilton J. The process of helping residents learn how to The educational experience of working on a multidis- nurture the unnurtured. In: Educating Pediatric Residents to ciplinary team cannot be overstated. The purpose of such Provide Health Care to Underserved Children. Alexandria, Va: exposure is to increase the skills of the house officer Ambulatory Pediatric Association; 1990:11-15. through contact with individuals with greater expertise in 7. Allmond BW Jr, Buckman W, Gofman HF. The Family Is the areas such as interviewing. 11 The use of timely feedback Patient: An Approach to Behavioral Pediatrics for the Clinician. using tools such as videotaping is also important to the St Louis, Mo: CV Mosby Co; 1979. teaching of communication skills.¹² 8. Modena W. Serving the underserved: public policy issues. The appropriate timing of this instruction is also im- In: Educating Pediatric Residents to Provide Health Care to Un- derserved Children. Alexandria, Va: Ambulatory Pediatric Asso- portant. It is critical to use the orientation process to teach ciation; 1990:29-34. the house staff about the demographics of the people for 9. Berkelhamer JE. The organization of practice for underserved whom they are caring. Likewise, a separate house staff children: implications for resident education. In: Educating Pe- retreat, away from the hectic hospital setting, is to be en- diatric Residents to Provide Health Care to Underserved Children. couraged as a means to reinspire house staff and focus on Alexandria, Va: Ambulatory Pediatric Association; 1990:29-34. these issues. The idealism of the medical student is lost (or 10. Hodge RH. The method for assuring continuity of care in put on the back burner) after graduation by the new de- residency training experience. J Med Educ. 1977;52:739-744. mands and responsibilities of being a house officer.¹³ 11. Berkowitz C. Comprehensive pediatric management of fail- In addition to working toward developing a curriculum, ure to thrive: an interdisciplinary approach. In: Drotar D, ed. New Directions in Failure to Thrive. New York, NY: Plenum Press; 1985. organizations such as the APA should work to affect public 12. Menahem S. Interviewing and examination skills in pe- policy to encourage resident education in the area of un- diatric medicine: videotape analysis of student and consultant derserved children. For example, state and federal programs performance. J R Soc Med. 1987;80:138-142. that would fund initiatives in resident education regarding 13. Thomas CB. What becomes of medical students: the dark the underserved should be encouraged. Inclusion of instruc- side. Johns Hopkins Med J. 1976;139:185-195. Improving Health Care Provision to Neonates in the United States Mildred T. Stahlman, MD A ny discussion concerning the possible approaches to- and, to some extent, affordable if we set our priorities ward improving health care provision to neonates straight. Preventive measures have long-term benefits, naturally encompasses the improvement of health care with no exciting publicity or dramatic breakthroughs, but, provision to their mothers, both before and after delivery. in the long run, they save more lives and prove to be more In a larger sense, it encompasses solving the deficiencies cost effective than crisis medicine. They require, in a coun- in health care provision to the entire population, as babies try such as ours with such a wide diversity of health care and their mothers are only two of the overlapping circles provisions and patient acceptance, a hard sell from kin- in this large Venn diagram. dergarten onward. It is too late to try to change health Thirty-seven million Americans are without health in- patterns in high school, and well nigh impossible in adults surance, and therefore frequently without access to nec- with their fixed life-styles. This is especially true in the essary care. Simultaneously, we devote a larger portion of medically underserved since they are trapped in an en- our gross domestic product to health care than any other vironment in which changes in life-style to improve health industrialized country, yet we rank 15th in male life ex- may be totally unrealistic. pectancy, seventh in female life expectancy, and 19th in Easily learning new ideas is one of the characteristics of infant mortality. There is a national realization, by poli- the very young, and the focus on good health patterns ticians and the public alike, that health care costs are not must begin then. Successful approaches elsewhere have only excessively high, but that health care resources are been to assign each child to the equivalent of a public unwisely and inequitably distributed.¹ health nurse, who then knows each child's health prob- A change in perception of the problem is necessary be- lems sequentially and sees to it that parents take advan- fore a solution can be found. We must learn that health, tage of available facilities. both mental and physical, is a by-product of a national This begins with immunizations and well child care, not standard of living, which includes adequate housing and with the first major illness. Public television programs are nutrition, a meaningful job with reasonable pay scale, a used to promote preventive medicine, often called "social good (we hope excellent) public educational system, and medicine," as the society takes responsibility for its or- a national economy that does not fluctuate extremely with ganization and cost. If preventive medicine is begun early changes in political leadership. Second, we must admit in life, a generation of essentially healthy young adults can that despite our high national expenditure on health care, grow up and, with good health care availability and ac- we are unwilling to pay, as a national priority, for equal cessibility ingrained in them, pregnant women can care for access and basic care for all, including those who cannot themselves and their fetuses from conception onward. pay. This will not be an easy concept to sell, either to the Con- In days of increasingly restricted federal and state bud- gress or to neonatal intensive care unit (NICU) physicians, gets and skyrocketing medical costs, the inevitable ques- but in the long run it will be seen as a necessity. tions arise about the direction we should choose (assum- If we are to change health care provision to mothers and ing we still have a choice): should we limit our babies, we must first change their lives. We must educate expenditures for tertiary care medicine and opt for better- them to consider health as a goal rather than to expect supported preventive medicine for the majority of pa- society to provide crisis care that might have been avoided. tients, or should we continue to support, without regard One of our major problems is the many medical and social to the cost-benefit ratio, each new and exciting techno- consequences of teenage pregnancy. Unless we can re- logical advance, which may be lifesaving for the few who verse this social trend, high-risk pregnancies and very ex- need it but extremely costly for the patient, third-party pensive, very-low-birth-weight infants will continue to carriers, and society in general? Nobody wants to make consume an inordinate amount of our dwindling health these hard choices, but clearly the time is rapidly coming care dollars. when someone must. If the medical profession does not How do we decrease the incidence of teenage pregnan- choose to participate in this debate, health care planners cies? First, we must admit the truth about the sexual mores and politicians will dictate their decisions to us. of the young. Ever since the introduction of the birth con- I propose that both approaches are desirable, necessary, trol pill in the early 1960s and the sexual revolution that followed, sexual activity, much of it casual, has been in- Accepted for publication November 12, 1990. creasing among our teenage population. Unfortunately, From the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn. we have failed to encourage the use of responsible and Reprinted from AJDC (1991;145:510-512). effective contraception, and unwanted and high-risk preg- 20 Caring for the Uninsured and Underinsured nancies and infants have been the consequences of this tional evidence, that there is a level of maturation nec- failure. essary for successful extrauterine life, even when all cur- Another social result has been the 1½ million abortions rent technologies are available. Perhaps now is the time performed each year in this country. Until parents, for consensus on withholding extraordinary means of life schools, churches, and society in general become realistic support to the extremely immature but live-born fetus. about their children's sexual mores and either educate The development of regional high-risk perinatal and them to different social mores or provide them with the neonatal care networks during the 1970s was one of the knowledge and means to prevent unwanted pregnancy, most important concepts leading to improved health care abortions, high-risk pregnancies, and low-birth-weight provision to newborns and mothers. It was medically infants will continue to be the result. This lack of respon- sound and fiscally responsible, as it served to provide the sibility on the part of parents, schools, communities, pol- most highly skilled individuals with the most sophisti- iticians, and teenagers themselves presents appalling con- cated (and expensive) technology for high-risk patient sequences to those whose responsibility it is to provide care. Most regional centers have had an important edu- medical and social care for the tragic outcomes of these cational component, serving to raise the regional hospi- failures. We cannot change social mores overnight, but we tals' level of expertise to be commensurate with their fa- must begin by telling it like it is. The specter of acquired cilities and personnel. This system has proved to be cost immunodeficiency syndrome has begun to have an impact effective and has been associated with a dramatic lowering on so-called safe sex, but it is ironic that a social good-the of perinatal mortality and morbidity, the byproduct of prevention of teenage pregnancy-may be a consequence which has been the survival of infants with lower and of fear of an international plague! lower birth weights. One of the most pressing current ethical questions in A new move, called deregionalization by some, has de- NICUs is that of resuscitating infants of borderline via- veloped in recent years, brought about by an overabun- bility. Some would even put it in financial terms. It is an dant number of trainees flocking into an exciting new field, excellent example of expending a large amount of health the realization by hospital administrators that newborn care resources on a small number of infants who can ques- intensive care can be profitable for the hospital, and the tionably benefit from them. Should we continue to resus- willingness of third-party payers to pay both hospitals and citate infants born before 25 weeks' gestation and/or physicians for high-risk care. Private hospitals have cho- whose birth weight is below 500 g? There are those who sen to leave the network and rely on their own facilities would put the question at even more mature limits. In and personnel for this highly visible service. The conse- contrast to this are some societies in which health care is quence, in many instances, is the skimming off of paying a priority and prenatal care is provided to all pregnant and insured patients, leaving the regional center, usually women early in gestation; in these countries (eg, Sweden), a university teaching hospital, to care for the uninsured, ultrasonography is routinely performed by 16 weeks' ges- the poor, and the highest-risk and most costly patients, tation and correct dating of almost all pregnancies can be socially and medically. No reversal of this trend is fore- done. seeable, and I believe that catastrophic health insurance In this country, especially among teenagers, the med- and some method of limiting the enormous profits from ically underserved, and the poor, accurate estimation of high technology and high-risk care will be the ultimate gestational age is often impossible. Likewise, intrauterine solution. estimates of birth weight are very likely to be overesti- When I worked briefly as a cardiologist, I said that I was mates. We then are faced with the terrible decision in the interested in cardiac success, not cardiac failure. We must delivery room in cases of fetuses of borderline weight. be more interested in successful pregnancy outcome than These infants are almost always in need of some sort of pregnancy failure. Our NICUs are filled with these failures resuscitation, and delay in doing so may affect outcome and we tend to focus on them as the exciting problems. adversely in very important ways. The decision is fre- However, this excitement generates new ideas and new quently the responsibility of a young house officer serving approaches to patient care, and neonatal/perinatal 're- time in a neonatal intensive care unit who may not be pre- search has been responsible during the last 30 years for the pared by experience or ethical considerations to make such dramatic changes in survival of the high-risk and very- important decisions. low-birth-weight newborn. We should not abandon new- One of our best perinatal centers has taken the position born intensive care, but should try to limit our use of tech- of using constant positive airway pressure (CPAP) and nology in place of careful clinical medicine. oxygen in the delivery room if needed, and delaying as- Above all, NICUs should be the breeding grounds for sisted ventilation in most cases of borderline viability until bright young investigators who will make the break- the infant can be carefully assessed with regard to maturity throughs and solve the clinical problems, with basic re- and chances of survivability. If the decision is made to search followed by carefully designed clinical trials. An continue the most intensive care, nothing reasonable is interesting suggestion has been made that in times of se- withheld until the infant is clearly unsalvageable. If, how- vere fiscal restraints, such as now, a fixed percentage of ever, the infant is judged too immature to survive after the entitlement programs should be set aside for research, weighing and careful examination, including functional much as industry sets aside a fixed percentage of costs for estimates of maturation, no additional intensive care pro- research and development (R. B. Cotton, MD, oral com- cedures are carried out. This is a hard line to draw, but munication, October 1990). Without continuous research, some guidelines need to be agreed on since the need to and without a continuous cadre of bright young investi- discontinue intensive care, once begun, can be a difficult gators entering neonatology, we will find ourselves frozen dilemma to face. We know, based on anatomic and func- in time with no innovations in patient care in the near Health Care to Neonates 21 future. The by-product of exciting new ideas makes much rely on their own skills rather than those of others or on of the pain, frustration, and cost of intensive care worth- machines and tests. The downside, of course, would be while. the enormous inequity of accessibility to needed expertise I am not a medical economist. I was not educated to be and technology in-complicated cases that are unreimburs- one, and the idea of matching the quality of patient care able. with dollars is abhorrent to me. However, it does not take This two-tiered system is not the answer to the lack of a financial genius to see the enormous profits that the prac- universal health care insurance, and catastrophic health tice of medicine, the hospitalization of the sick, and the insurance is an imperative. Nowhere is this more apparent provision of technology and medication can provide to than in newborn intensive care. A realistic reassessment their respective areas of the health care provision system. of physicians' fees and hospital reimbursement coupled It has been said that this is the "me" generation, and many with the need to accept patients on the basis of medical physicians have joined those who rank patients' interests need might even start a trend toward lower charges! below those of first, themselves, the care providers; sec- Some corporate participants in the health care provision ond, the hospital or academic institution; and finally, third system, such as for-profit hospitals, pharmaceutical parties (ie, insurance companies, the government, and houses, and high-technology equipment manufacturers, employers). This attitude is unfortunately becoming in- and a small percentage of physicians have always been creasingly prevalent in maternal and newborn high-risk considered to be motivated, at least in part, by greed. Until care. recently, these were considered the few bad apples in the Third-party reimbursement engendered by procedures barrel to be identified and avoided. However, the public's and action rather than by thoughtful and responsible in- perception has shifted and polls now show that physicians action has become the norm. The insistence on shorter are no longer esteemed above other members of society. hours for medical personnel, less personal responsibility, Many physicians are considered to not care about their and more consultations, as well as the reliance on tech- patients' welfare, and medical negligence is the common nology, the pressures of hospital administrators to fill beds complaint leading to malpractice litigation. with paying patients, and the enormous markup on phar- Communication has broken down between physician maceutical and disposable products, all contribute to enor- and patient, and we have lost our youthful idealism. We, mous patient charges, to less personal satisfaction on the part of care providers, and to more malpractice suits stem- as physicians, are seen as part of the problem of mal- ming from failures in communication. The result is now distribution of adequate health care, rather than as part of the real threat of rationing high-risk (high-cost) care and its solution. Darwin taught us that we must change or our the development of a two-tiered system of health care pro- species would disappear. Before it is too late, physician, vision. heal thyself. One tier would provide basic, less costly care for the poor and uninsured, and a second tier would provide spe- References cialized, more costly care, including all the new techno- 1. Priester R. Overview on Distributing Limited Health Care Resources. Biomedical Ethics Reading Packet No. 5. Minneap- logical advances, for the insured and those who can pay. olis, Minn: Center for Biomedical Ethics, University of Minne- The use of technology has been shown to be directly re- sota Health Center; December 1988:1-13. lated to reimbursement for its use.² The only redeeming 2. Evans RW. Health care technology and the inevitability of feature of such a two-tiered system besides the expense resource allocation and rationing decisions, part 1. JAMA. might be the reemergence of physicians in the first tier who 1983;249:2047-2053. Child Abuse and Neglect: Critical First Steps in Response to a National Emergency The Report of the US Advisory Board on Child Abuse and Neglect Richard D. Krugman, MD I n June 1990, the US Advisory Board on Child Abuse and problem in our society and take personal responsibility to Neglect presented its first report to the Secretary of the join with others to resolve this emergency. Department of Health and Human Services and Congress. The board had studied the status of the child protection PROVIDING LEADERSHIP system (broadly defined as the system, not just the child The president (recommendation 4), the governors of the protective services (CPS) agencies involved in the mul- several states (recommendation 5), the county executives, tidisciplinary recognition, intervention, treatment, and and mayors (recommendation 6) are called on to become prevention of child abuse and neglect). The board was visible and effective leaders within their jurisdiction in re- established under provisions of public law 100-294, and newed child protection efforts. Legislative bodies at all lev- the 1988 Amendments to the Child Abuse Prevention and els are urged to support these efforts by providing funding Treatment Act. The mission of the board is to evaluate the for the initiatives developed. The rebuilding of our family- nation's efforts to accomplish the purposes of the Act and support infrastructure is as important as our willingness to make recommendations on ways in which those efforts to rebuild our banking system (recommendation 7). Sci- can be improved. entific societies and professional organizations are urged The board concluded that child abuse and neglect in the to respond to the emergency by making the issue a pri- United States now represents a national emergency. This ority, stimulating research, and providing guidance to conclusion is based on three findings: (1) each year, hun- their members (recommendation 8). dreds of thousands of children are being starved and aban- COORDINATING EFFORTS doned, burned and severely beaten, raped and sod- omized, berated and belittled; (2) the system created by The secretary is called on to work with the governors of the nation to respond to child abuse and neglect is failing; the states to eliminate barriers that stand in the way of and (3) the United States spends billions of dollars on pro- providing coordinated community services related to the grams that deal with the results of the nation's failure to protection of children (recommendation 9), to work with prevent and treat child abuse and neglect. the director of the Office of National Drug Control Policy in the White House to assure coordination of efforts to The board believes that the extent of the emergency is so compelling that it dictates an immediate response and control substance abuse and child abuse (recommendation has recommended 31 critical first steps that will provide 10), and to coordinate with the attorney general to address a framework for a decade of review and reconstruction of the issue of fatal child abuse and neglect (recommendation policies and programs that have exacerbated the emer- 11). gency. These 31 critical first steps, if implemented, will GENERATING KNOWLEDGE only control the emergency. Once it is brought under con- This area has four recommendations shaped by the trol, the board believes that the nation should commit itself board's conviction that good policy begins with good facts. to: achieving an equally important goal: the replacement The secretary is asked to establish a federal data collection of the existing child protection system with a new, na- system that reflects not only social service dimensions' of tional, child-centered, neighborhood-based, child protec- the problem, but the public health, mental health, and tion strategy. The Board's 31 recommendations (num- legal/judicial dimensions as well (recommendation 12). bered in parentheses below) are organized into the The secretary is also asked to launch major coordinated following eight areas. initiatives to promote the systematic conduct of research RECOGNIZING THE NATIONAL EMERGENCY related to abuse and neglect (recommendation 13), to co- Each citizen (recommendation 1), each elected official ordinate knowledge about what does and does not work (recommendation 2), and each legislative body (recom- in the child protection system (recommendation 14), and mendation 3) is called on to recognize the extent of the to increase the number and professional qualifications of researchers in child abuse and neglect (recommendation Accepted for publication January 23, 1991. 15). From the Department of Pediatrics University of Colorado School of Medicine, Denver, and the C. Henry Kempe National Center for DIFFUSING KNOWLEDGE the Prevention of Child Abuse and Neglect, Denver. The secretary is asked to ensure that practitioners, policy Reprinted from AJDC (1991;145:513-515). makers, and the general public have ready and continuous Child Abuse and Neglect 23 access to information through the establishment of a per- strategy for the protection of children. The board proposes manent governmental unit (recommendation 16). The that Congress direct an appropriate research agency to de- board also asks journalists, broadcast executives, publish- termine the cost of developing and implementing a com- ers, as well as individual media outlets to join in a cam- prehensive national program for the prevention and treat- paign to promote public understanding of the emergency ment of child abuse and neglect, as well as the projected and the most effective ways of addressing it (recommen- cost of not developing and implementing such a program dation 17). (recommendation 30). Finally, the secretary, in concert INCREASING HUMAN RESOURCES with the National Governors Association, the US Confer- These six recommendations are shaped by the board's ence of Mayors, and the National Association of Counties, conviction that the status, qualifications, training, work- is asked to develop a model planning process aimed at load, and representiveness of public agency CPS workers generating plans for the coordinated comprehensive are intrinsic to the crisis in the child protection system. The community-based prevention, identification, and treat- secretary is asked to establish the position of public agency ment of abuse and neglect with steps taken to ensure that "CPS caseworker" as a professional specialty (recommen- the model process is implemented throughout the nation dation 18), establish minimum educational requirements (recommendation 31). for the position of a public agency CPS worker (recom- In presenting these recommendations to the nation, the mendation 19), and ensure that all public agency CPS board has attempted to provide direction, vision, and lead- workers receive adequate preservice and in-service edu- ership and expects that its recommendations will serve as cation and training (recommendation 20). The board pro- the impetus for much needed action to address the na- poses that the secretary and Congress, with their coun- tional emergency. What does this mean for pediatricians, terparts at state and county levels, establish acceptable and why should we care? caseload standards for these workers (recommendation Throughout the United States, many pediatricians are 21). State and local social service officials are asked to faced with a major dilemma; they are knowledgeable launch an aggressive campaign for recruitment of CPS about statutes that require them to report all cases of sus- workers representative of the racial, ethnic, and cultural pected abuse and neglect and yet, in many communities, composition of the caseload population (recommendation they observe that their reports are received but inade- 22). The secretary is also asked to ensure a steady increase quately acted on. The child protection system in the in the total number of the nation's professionals in med- United States is fragmented, under-funded, overworked, icine, social work, law, law enforcement, mental health, episodic, and unable to generate any information that and education who possess the necessary competence and would let us know that children are, in fact, being pro- skill to participate effectively in the protection of children tected. Some physicians have deliberately followed a pat- (recommendation 23). tern of civil disobedience and do not report child abuse PROVIDING AND IMPROVING because of their belief that above all they should "do no PROGRAMS harm." In my view, such an approach leaves physicians, The secretary is asked to ensure that more resources are and more importantly children, at serious risk. The answer allocated to establishing voluntary and nonpunitive access is not to capitulate and abandon a child protection system to help. It should become as easy for a person to pick up that is in crisis. As the US Advisory Board suggests, it may the telephone and receive help before abusing a child as be necessary to replace our existing system with one that it is now for a neighbor to report that person after the fact works, but our efforts need to be focused on rebuilding the (recommendation 24). The secretary and governors are supportive infrastructure for families that has been lost in asked to ensure that efforts to prevent the maltreatment this country (ie, the prevention and treatment arms of the of children are substantially increased. At a minimum, this system) without abandoning our recognition and inves- should involve significant expansion of the availability of tigation arm. All over the United States, CPS agencies are home visitation and follow-up services for all families of refusing to open more and more cases so that they will newborns (recommendation 25). Congress and state and have fewer and fewer with which to deal. local legislatures are asked to ensure that resources de- In Colorado, a bill is currently pending in the legislature voted to prevention and to treatment do not come at the that would raise the requirements necessary to "prove" a expense of each other (recommendation 26). Private sector case of abuse from "credible evidence" to "the prepon- organizations are encouraged to increase significantly the derance of the evidence." The bill will also remove the involvement of their local affiliates and outlet members or requirement that home visits be done on all reports, and employees and child protection efforts (recommendation finally will put in statute that CPS agencies need no longer 27). Congress, the attorney-general, and chief justices are be involved when children are abused outside the family. asked to ensure that all state and local courts resolve cases This is already happening in practice, but if it becomes the promptly and fairly (recommendation 28). The Secretary norm nationally to reset in statute those things that we are of Education and his counterparts at the state and local doing instead of those things that we should be doing, it level are asked to launch a major initiative to establish and is clear that we will continue to erode our ability to protect strengthen the role of every public and private school in children. Such statutes are the single best milestones of the the prevention, identification, and treatment of abuse and decline of a society's moral values. neglect (recommendation 29). If children are to be protected and death rates are to PLANNING FOR THE FUTURE decline, we must do more about prevention. Throughout The final two recommendations are shaped by the the country, efforts are being made to develop "family board's intention to design and propose a new national preservation programs." These programs, described over 24 Caring for the Uninsured and Underinsured 20 years ago by Kempe and colleagues¹ have been redis- work in both the clinical and research areas of abuse and covered. They provide intensive 4- to 8-week treatment to neglect. We need to take responsibility for prevention. The families to help them out of crises, and have the advantage work by Gray et al,2 Olds et al,³ Helfer,⁴ and others has of leaving children in the home. They are clearly cost ef- shown that we have the technology to be able to prevent fective in that they reduce the need for foster care, but an the physical abuse of children. Not implementing what we 8-week fix for after-the-fact abuse is treatment, not pre- know is tantamount to the withholding of poliovirus vac- vention, and may be insufficient for long-term success. cine from children when an epidemic is poised to strike. It is time for pediatricians in this country to recognize Pediatricians, through their contact with families, can that our long experiment in making the departments of make a difference. They can develop home visitation sys- social services in the country responsible for the protection tems out of their offices, multispecialty groups, or hos- of children has failed. It is not their fault. Beset by budget pitals that will provide support to new families in their cuts, caught in a web of legal expectations that they could community. Ultimately, if we make it as easy for a family not possibly fulfill, public child welfare agencies, public to pick up the telephone and get help before they abuse their health nursing, and mental health agencies simply cannot child as it is now for their neighbors to report them after do what they should be doing. These three critical com- the abuse has occurred, we will have taken a major step ponents of the supportive infrastructure that used to care in preventing the abuse and neglect of our children. The for families have literally disappeared. The role of child Advisory Board's recommendations make it clear that this welfare is now primarily income maintenance and inves- is no easy task. A future report will outline a new, coor- tigation of abuse reports. Public health nursing is now pri- marily fee for service home health care nursing. The men- dinated, comprehensive, child-centered neighborhood- tal. health system is completely clogged with the long- based child protection system. Pediatricians need to be term, deinstitutionalized, severely mentally ill. It is no part of that system so that we can avoid spending millions longer possible in this country for a family who needs help of dollars on the technology that allows babies born at 28 before they abuse their child to get that help by calling any weeks' gestation to leave the hospital only to go home to of these three agencies. Further, the approach of these an environment in which they are violently shaken or agencies is episodic: none has continuity of care as a prin- killed within weeks or months of their discharge, or stand ciple. It is increasingly difficult in our competitive, prepaid by helplessly while millions more go to build prisons that health care environment to provide the continuity of care will house the abused children of the 1970s and 1980s who that these families desperately need, but it is my view that are the failures of our present child protection system. only the health system has the opportunity to save chil- dren from the failures of our child protection system. There are several recommendations within the Advisory References Board Report that would form the basis of what pedia- 1. Kempe CH, Helfer RE, eds. Helping the Battered Child and tricians can do. We need to recognize that this is an emer- His Family. Philadelphia, Pa: JB Lippincott; 1972. gency! We can provide leadership through our profes- 2. Gray JD, Cutler CA, Dean JG, Kempe CH. Prediction and sional societies to ensure that the problems of abuse and prevention of child abuse and neglect. / Soc Issues. 1984;35:127. 3. Olds D, Chamberlin R, Henderson C. The prevention of neglect will be dealt with as a priority during the coming child abuse and neglect: a randomized trial of nurse home vis- decade (not the priority, but one of the priorities that we itation. Pediatrics. 1986;78:65. must pay attention to during this decade). We desperately 4. Helfer RE. A review of the literature on the prevention of need more physicians and child health professionals to child abuse and neglect. Child Abuse Negl. 1982;251:6 A Survey of the Health of Homeless Children in Philadelphia Shelters Ruth M. Parker, MD; Leslie A. Rescorla, PhD; Jonathan A. Finkelstein, MD; Nathaniel Barnes, MD; John H. Holmes, MS; Paul D. Stolley, MD, MPH We conducted a random-sample survey of homeless chil- 5 years who attended a primary care clinic in New York, dren and their mothers residing in Philadelphia (Pa) shelters. NY. Higher rates of hospitalization, higher serum lead lev- One hundred forty-six families were included in the final els, delayed immunization, and increased reports of child sample, resulting in an 80% response rate. The aims of the abuse were found compared with a population of children survey were to characterize the child's current and past of the same age and socioeconomic status who lived at health status, to determine access to and use of medical ser- home but attended the same clinic. vices, and to determine the serum erythrocyte protoporphy- A 1986 probability sample of homeless families in King rin levels and tuberculin skin test status of the children. In County, Washington, described 82 families with 158 chil- addition, psychological tests were administered to both dren younger than age 17 years. Thirteen percent of these child and parent to assess developmental level and psycho- parents reported their children's health as "fair" or "poor." logical problems. Finally, detailed questions were asked con- Compared with the general US population, this sample of cerning the reasons for the homeless condition. The impor- homeless persons had a higher rate of emergency depart- tant reasons for homelessness cited in the survey included ment use, and a higher proportion had no health insur- physical abuse, substance abuse, disagreements with land- ance (35% vs 12.5% for the general US population). The lords, and poor living conditions. The children's health prob- population studied was 27% white, 44% black, 8% His- lems included a high incidence of reported accidents and panic, 6% native American, and 15% mixed. Approxi- injuries, burns, and lead toxicity; the parents suffered from mately one third of the children were obese, scoring above depression, physical abuse, and substance abuse. School- the 95th percentile in weight for height measurements.³ aged children tended to have low scores on tests of expres- Comparing 98 children younger than age 12 years re- sive vocabulary and word decoding, and preschoolers siding in New York City welfare hotels with 253 domiciled seemed to be below age expectations in receptive vocab- poor children, Acker et al4 found an increased rate of iron ulary and visual motor skills. The findings of this study sug- deficiency among the homeless children. gest that homeless children tend to score poorly on devel- The Health Care for the Homeless Project5 listed the most opmental and psychological tests and tend to sustain serious common reasons homeless children were brought by their burns and accidents. Policy implications of the survey in- parents to see health care workers: respiratory infection, clude suggestions for health screening, rehabilitation, and minor skin problems, ear problems, gastrointestinal com- education. plaints, trauma, eye problems, and lice infestations. PHILADELPHIA SHELTER SYSTEM FOR S everal studies have described the health problems of HOMELESS FAMILIES homeless persons. The health of homeless families Estimates of the composition of the homeless popula- and their children is less well defined, but a few studies tion in Philadelphia were derived from a project directed examining the health status of homeless children are avail- by the Philadelphia Health Management Corporation, and able. Bassuck et al¹ studied 80 families and their 151 chil- the 1985 estimates portray a total homeless population in dren living in 14 Massachusetts shelters in 1985 and re- Philadelphia of 10000 to 13 000 people.⁶ At the time of the ported that about half of the children had developmental study, an estimated 2500 to 5000 homeless children lived lags as assessed by the Denver Developmental Screening Test. in Philadelphia, a majority of whom were thought to be They also reported a high frequency of learning disabil- younger than age 5 years. ities, depression, and anxiety. Alperstein et al² reviewed The city shelter network included the one city-owned clinic records of 256 homeless children younger than age facility and 22 other privately owned shelters under con- tract with the city. On presentation to the city authorities, Accepted for publication January 30, 1991. From the Department of Medicine, Emory University School of an appropriate space was usually located and the family Medicine, Atlanta, Ga (Dr Parker); the Department of Human De- was placed within a few hours; however, if an appropriate velopment, Bryn Mawr (Pa) College (Dr Rescorla); the Department unit could not be found, the family was housed in a large of Pediatrics, Children's Hospital, Boston, Mass (Dr Finkelstein); gymnasiumlike room at the city-owned facility, which ac- the Department of Urology, Duke University Medical Center, commodated as many as 75 families. Durham, NC (Dr Barnes); and the Clinical Epidemiology Unit, Sec- tion of General Internal Medicine, Department of Medicine, Uni- All of the 22 shelter buildings in our sample were struc- versity of Pennsylvania School of Medicine, Philadelphia (Mr tures converted from former uses, ie, a car dealership, a Holmes and Dr Stolley). retirement home, an orphanage, a funeral home, and a Reprinted from AJDC (1991;145:520-526). school. The capacity of the shelters and the actual living 26 Caring for the Uninsured and Underinsured SUBJECTS AND METHODS Sampling Frame Defining the Population and the Sampling Method 454 Families With 1131 Children After receiving permission from the Philadelphia gov- ernment to conduct the study, we obtained information 40% Random Sample Drawn regarding the number, type, and location of all shelters with which the city contracts. We excluded homeless fam- 183 Families With 183 Children ilies residing at noncontracting shelters since there was no available list of all such facilities and they housed only a small proportion of the city's homeless families. We con- 12 "No Shows" Eight Refusals tacted each of the 21 privately owned shelters and the one city-owned facility to request their participation in our Three Nonparticipants 12 Not Located due to Acute study and to ascértain their current occupancy. Two shel- Medical Problems One Transferred ters, each housing about 20 families, refused to participate; seven shelters had only one to eight families present and were excluded from our sampling frame due to their small Final Sample size. Because homeless families were randomly assigned 145 Adults An 80% to shelters regardless of shelter size, the exclusion of these Response nonparticipating shelters was unlikely to have biased our 146 Children Rate sample. The remaining 13 shelters agreed to participate. We conducted on-site visits to interview shelter directors Diagrammatic representation of sample and final response rate. and conduct the survey. Our research team spent prearranged days at each shel- arrangements for families varied greatly, with from one to ter conducting the survey. Each shelter maintained a ros- six families housed in one room. Few cribs were available ter of resident families. Using a table of random numbers, and only one shelter had an isolation room for persons with communicable diseases. All of the shelters housed we selected from 28% to 49% of the families present at each single women with dependent children, and four of the shelter for study. The family was contacted at least twice shelters also housed single women without children. One to set up an appointment. Next, we randomly selected one shelter housed a large proportion of troubled girls placed child, aged 12 years or younger, from each family and in- there for supervision and guardianship. vited this child to participate in the study. There were 454 Most shelters referred their clients to local neighbor- families, with 1131 children, in the 13 shelters during our hood clinics or hospitals for medical assistance. One shel- census. One hundred eighty-three families, with one ran- ter had a nurse and an infirmary, and another shelter em- domly selected child per family, were selected for study. ployed the services of a visiting nurse practitioner One hundred forty-six families enrolled in the study. organization. All shelters had paid staff, including night- There were 37 nonrespondents, including eight who re- time staff. Three privately owned shelters were managed fused to participate, 12 who did not show up for inter- by formerly homeless women who resided there. views, 12 who could not be located to request participation AIMS AND OBJECTIVES on at least two attempts, three who could not participate When we planned our study in September 1987, there due to acute medical problems (ie, premature labor for one was little published information concerning the health sta- woman and bleeding during pregnancy for two women), one who was transferred to another shelter before her tus of homeless families, and much of what was available had not been obtained using random sampling methods. scheduled appointment, and one who was inebriated on We therefore designed a survey of homeless families re- the two occasions we arranged for the interview. The siding in shelters in Philadelphia to obtain descriptive in- mother's responses in this latter case were not included formation that would be helpful in health planning and in in our analysis, but those of her child were included. identifying specific problems and unmet health needs. In The study included information on 145 families and 146 surveying randomly selected homeless families in Phila- children (Figure). Psychometric data were requested only delphia shelters to describe their health status and other for the 98 children aged 2 years and older. Following com- characteristics, we targeted seven main areas: (1) the pletion of this study of homeless children, we were able child's health, including general health perceptions, med- to collect psychometric data on a small sample of inner- ical history, and recent illnesses; (2) access to health ser- city-domiciled children in Philadelphia. These compara- vices for children; (3) social, economic, and demographic tive data are reported elsewhere.⁷ features of the family, such as family structure, income, Parents signed informed consent forms, and an oral in- work history, and school performance; (4) parental health terview was conducted lasting 45 minutes. The survey history, which focused on drug and alcohol use, chronic questionnaire targeted four main areas: (1) demographic illnesses, and childbearing history; (5) visual screening of and socioeconomic characteristics, including family struc- the children; (6) laboratory investigation of the children ture, a calendar of homelessness (a chronological list of all using a tine test for tuberculosis and determination of places the family resided in the previous 5 years), and use erythrocyte protoporphyrin (EP) levels; and (7) develop- of social services; (2) access to medical care; (3) the child's mental and psychological screening of the children using health history, including perceptions of general health, tests appropriate to their ages. By obtaining such infor- functional status, chronic medical conditions, hospitaliza- mation we hoped to better understand how resources can tions, immunization status, and school performance; and be best allocated to the homeless population. (4) parental health history, including chronic and recent Homeless Children 27 Table Highest Level of Education Achieved by Table 2. Parity of Homeless Mothers (N = 145) Homeless Mothers = 145) No. of No. (%) No. (%) Children of Mothers Cumulative % Education Level of Mothers 1 22 (15) 15 <12 years of school 72 (50) 2 35 (24) 39 <12 years and vocational school 2 (1) 3 44 (30) 69 High school equivalence degree 5 (3) 4 20 (14) 83 High school graduate 38 (26) 5 9 (6) 89 High School graduate and vocational school 18 (12) 6 8 (6) 95 Some college 10 (7) 7 2 (1) 96 College graduate 0 8 3 (2) 98 9 2 (1) 99 acute illnesses, history of smoking, and alcohol and drug use. Adult subjects completed the Peabody Picture Vocab- Table 3. Maternal Age at Delivery of First Child = 145) ulary Test-Revised (PPVT-R), Beck Depression Inventory Maternal No. (%) (BDI), and an age-appropriate Achenbach Child Behavior Age, y of Mothers Cumulative % Checklist (CBCL). Simultaneously, the children com- 13 1 (1) 1 pleted a battery of age-appropriate psychological and de- 14 6 (4) 5 velopmental tests, listed and described below. 15 13 (9) 14 Tests Administered 16 21 (14) 28 17 20 (14) 42 Wechsler Intelligence Scale for Children-Revised 18 25 (17) 59 (WISC-R) Vocabulary. - The best predictor of WISC-RIQ, 19 14 (10) 69 this subtest involves asking the child to give definitions for a list of vocabulary words. The test was given to children 20 14 (10) 79 aged 6 to 12 years to measure verbal ability. ≥21 31 (21) 100 WISC-R Block Design.-The child assembles geomet- ric blocks to duplicate a model under a time limit. Block Design is the subtest correlating most highly with WISC-R Table 4. Incidence of Illness Among Homeless Performance Scale IQ, and was given to children aged 6 Children During Previous 4 Weeks (N=145) to 12 years. No. (%) Wide Range Achievement Test-Revised (WRAT-R) Type of Illness of Children Reading.-On this subtest, the children aged 6 to 12 years Gastrointestinal 54 (37) were asked to read a list of words. Children who could not read were asked to match and identify letters of the alphabet. Cough with fever 35 (24) House-Tree-Person (HTP). - The child is asked to draw Ear infection 29 (20) a picture of a house, a tree, and a person and then to an- Conjunctivitis 25 (17) swer a few questions about each drawing. The drawing of Other 2 (1) a person was scored by certified school psychologists us- ing the Goodenough-Harris developmental system. Stanford-Binet Intelligence Scale: Fourth Edition (IV) line, cross, and circle). Vocabulary. This subtest assesses a child's ability to la- CBCL.-Mothers of all the children completed the bel pictures and give word definitions for common words. CBCL. This involved reading a list of 118 behavioral symp- The vocabulary subtest is the best predictor of overall toms and indicating for each one whether it was "untrue," Stanford-Binet IV Test Composite Score (IQ) and was "somewhat true," or "very true" of her child. The scores given to children aged 2 to 5 years. for "Total Problems," "Externalizing," and "Internalizing" PPVT-R.-This test was given to children aged 3 to 5 were calculated for each child. years to assess their receptive vocabulary by asking them BDI. questionnaire for adults (mothers in this to point to one of four pictures on a page that depicts the study) was administered that measures the presence and stimulus word. degree of "depression" or depressive affect. Beery Visual-Motor Integration (VMI) The Beery Three Wishes.-Each child was asked to tell three VMI Test involves copying a series of simple geometric things he or she would wish for if wishes could come true. forms (eg, line, circle, and cross) and was given to children Children older than age 6 years had their vision aged 3 to 5 years. screened using the Richmond Kindergarten Test Chart. Yale Cubes. Children aged 2 to 5 years were asked to Parents gave separate informed consent for laboratory copy a series of cube formations (ie, tower, bridge, house, testing of their children. These tests included a tine test and steps). This task was drawn from the Gesell Preschool placed on the right forearm by a standard procedure (read Screening Test and the Yale Developmental Schedules. by an interviewer 48 to 72 hours later) and a determination Yale Two-year-old children were asked to of the EP level from a finger stick sample of blood to assess copy a set of geometric forms (ie, vertical line, horizontal lead exposure. The EP level was determined by the City 28 Caring for the Uninsured and Underinsured Table .-Incidence of Major Accidents, Injuries, Table 6. Reasons for the Hospitalization of or Medical Conditions Over the Lifetime Homeless Children in the Previous Year = 145) of Homeless Children = 145) Reason for No. (%) No. (%) Hospitalization of Children Hospitalized Condition of Children Injury 12 (8) Burn with scar formation 20 (14) Other illness 12 (8) Lead poisoning 16 (11) Asthma 7 (5) Poison/pill ingestion 10 (7) Dehydration 6 (4) Fracture 9 (6) Seizure disorder 4 (3) Unconsciousness 9 (6) Respiratory infection 3 (2) Seizure 6 (4) Other infection 3 (2) of Philadelphia Health Department Laboratory. Values greater than 0.62 µmol/L were considered abnormal, and Table 7.- Chronic Illnesses of Homeless Mothers a follow-up determination of serum levels was requested. Requiring Regular Medical Care (N=145) Parents were notified of abnormal EP levels and instructed No. (%) on the proper follow-up procedures. Illness of Mothers RESULTS Hypertension 13 (9) Population Studied Renal disease 6 (4) Adults. One hundred forty-five adults completed our Cardiovascular disorder 5 (3) interview and examination. One hundred thirty-one sub- Diabetes mellitus 4 (3) jects (90%) were black, 11 (8%) were white, and three (2%) Cancer 3 (2) were white or Hispanic. Fifteen percent stated that they were currently married and 46% were "never married"; Physical disability 6 (4) the remainder said they were divorced or separated. Half Other 23 (16) of these 145 adult respondents had not completed high school; 10 (7%) of the participants in the study stated that Table 8.- Drug Use Reported by Homeless they had completed at least 1 year of college (Table 1). Mothers in the Previous Year (N=145) Concerning parity, 44 (30%) of the 145 respondents re- ported that they had three or more living children, and two No. (%) individuals (1%) reported that they had nine children (Ta- Type of Drug of Mothers ble 2). Eighty six (59%) of the respondents had delivered Marijuana 61 (42) their first child by age 18 years (Table 3). One-hundred Cocaine ("crack") 32 (22) forty (97%) of the 145 mothers stated that they were not Amphetamines 4 (3) working; only five (3%) were currently engaged in some Polychlorinated biphenyl 4 (3) part-time work. None 44 (30) Although the mean length of stay in the current shelter was 12.7 weeks, the range was wide (<1 week to 82 weeks), and the mean length of homelessness was 19.3 good"; 29 (20%), "good"; 19 (13%), "fair"; and only three weeks. Families had resided in a mean of 3.2 places (range, (2%) thought that their child's health was "poor." This fa- one to 20 places) in the previous 12 months, and in the vorable assessment of their children's health was restated previous 5 years had moved a mean of 4.7 times (range, when the parents were asked to compare the health of their one to 22 times). In the previous year, 14 (10%) owned their child with that of other children; very few stated that their own homes, 112 (77%) rented their own apartments, 72 child's health was worse than that of most other children. (50%) lived with their mothers, 78 (54%) "doubled up" or Furthermore, only nine (6%) of 145 parents said that their shared housing, and 10 (7%) lived on the streets, in aban- child had a condition that interfered with usual activities. doned buildings, or in cars. (This total is greater than 100% When mothers were asked about recent health problems because more than one living arrangement was possible their child had encountered in the previous 4 weeks, gas- during the year.) troenteritis, otitis, cough, and conjunctivitis were the con- When asked about their primary reason for homeless- ness, 36 (25%) cited poor living conditions at a previous ditions most frequently mentioned (Table 4). Twenty-nine residence; 33 (23%) were evicted; 29 (20%) had disagree- (20%) of the 145 respondents for these questions reported ments with their landlord, other tenants, or family mem- that their child had been seen in an emergency department bers; 15 (10%) attributed their homelessness to a lack of during the past year as a result of an injury or fall, and nine money or loss of a job; 10 (7%) had experienced a disaster (6%) of these children had sustained a fracture; nine children (eg, fire or flood); seven (5%) cited abuse, and four (3%) (6%) were reported "knocked unconscious" because of cited divorce or separaton. trauma during the previous year. Twenty (14%) of the 145 children had received burns during the previous year severe Findings Concerning General Health and enough to have scarred; 10 children (7%) had swallowed a Use of Services poison or medicine and required emergency treatment (Ta- When queried about their child's health, 55 (38%) of the ble 5). respondents believed it was "excellent"; 39 (27%), "very Seventeen of the children (12%) had been hospitalized Homeless Children 29 Table 9. Descriptive Statistics for Psychometric Measures Mean (SD) School-Aged Preschool Toddlers Age (6-12 y) (aged 3-5 y) (aged 2 y) Mothers Measure* Range, y Domain Normative (n=43) (n=40) (n=15) (n=145) WISC-R Vocabulary 6-12 Verbal ability 10 (3) 6.67 (2.92) WISC-R Block 6-12 Nonverbal 10 (3) 7.72 (3.33) Design problem solving WRAT-R Reading 6-12 Reading, decoding 100 (15) 80.88 (20.81) Draw-A-Person 3-12 Visual-motor skill 100 (15) 85.50 (16.22) 79.96 (13.12) Binet IV 2-5 Verbal ability 50 (8) 41.44 (4.25) 45.27 (2.97) Vocabulary PPVT-R 3-5, Receptive 100 (15) 67.84 (13.89) 71.99 (14.48) Mothers vocabulary Beery VMI 3-5 Visual-motor 100+ 82.46 (9.06) skill Yale Cubes 2-5 Nonverbal 100+ 85.41 (21.43) 87.13 (11.72) problem solving Yale Drawings 2 Visual motor skill 100+ 88.67 (32.28) CBCL 2-12 Emotional problems 50 (10) 57.02 (9.11) 59.05 (11.61) 47.00 (6.98) Internalizing CBCL 2-12 Behavior problems 50 (10) 57.68 (11.49) 55.05 (9.56) 45.13 (7.90) Externalizing CBCL Total 2-12 Overall problems 50 (10) 57.92 (10.42) 59.87 (11.08) 44.73 (8.06) Problems Beck Depression Mothers Depression 13.26 (10.28) Inventory *WISC-R indicates Wechsler Intelligence Scale for Children-Revised; WRAT-R, Wide Range Achievement Test-Revised; PPVT-R, Peabody Picture Vocabulary Test-Revised; Beery VMI, Beery Visual-Motor Integration; and CBCL, Child Behavior Checklist. +Quotients produced by dividing mental age by chronological age. during the previous year; the major reasons for hospitaliza- clotting or insufficient quantity. Nine (12%) of the remain- tion included injury, seizures, dehydration, asthma, and ing 76 samples had abnormal values (>35 µg/dL). other respiratory infections (Table 6). Visual acuity of children older than age 6 years was The mothers of the homeless children were asked about checked using the Richmond Kindergarten Test Chart. Ten the antenatal care they received when pregnant with the (26%) of the 39 children tested failed to identify pictures at child in question: only four (4%) of the 104 mothers who a distance of 600 cm with visual acuity better than 20/40. answered this question reported receiving no care at all, and most of the other respondents reported first receiving care Health of Parents during their first trimester. Fourteen (13%) said that their The reported health status of the mothers is summarized care began during the fifth month of pregnancy or later. in Table 7. Seventeen (12%) of the 138 respondents stated By and large, parents seemed to have found some sort that they were pregnant at the time of the interview. of medical care for themselves and their child; however, Ninety-nine (68%) of 145 mothers rated their own health 23 (19%) of 124 respondents could not identify a place to as "good" or better, but specific health problems were which they could go for care. Fifty-five (44%) used the cited by many women. Six (4%) of 145 respondents re- hospital emergency department or clinics for care, 53 ported physical disabilities that interfered with their daily (43%) went to a community clinic, 12 (10%) went to a pri- activities, and 13 (9%) reported that they had hyperten- vate physician's office, and only four (3%) visited a health sion. Twenty-one respondents (14%) reported having maintenance organization. been hospitalized in the previous year for a reason other Dental care was harder to evaluate since many of the than childbirth. While most respondents felt their health children were aged 3 years or younger, an age group that was "adequate," a significant number had conditions that usually does not receive regular dental care. required short- or long-term medical care, and this may have contributed to their difficulties in finding employ- Findings of Physical and Laboratory Examinations ment, housing, and child care. Tine tests to screen for tuberculosis were placed on 92 The incidence of emotional difficulties severe enough to children. Interviewers read the results between 48 and 72 cause the mother to consult a psychiatrist, counselor, or hours later and found six positive findings (7%) from 0 to therapist in the preceding 6 months was 14% (20 respon- 5 mm, one positive finding (1%) from 6 to 10 mm, and 69 dents), and seven mothers (5%) reported having been hos- negative findings (75%). We were unable to locate 16 chil- pitalized at some time in their lives specifically for mental dren (17%) for the test reading. Finger-stick blood samples illness. for EP determination by extraction were obtained from 96 The prevalence of reported alcohol use was surprisingly children, but 20 samples were not processed because of low, with 102 (70%) of the 145 women stating that they 30 Caring for the Uninsured and Underinsured consumed less than one alcoholic drink per day, and only children performed even more poorly in the PPVT-R, the four (3%) stating that their alcohol use had contributed, test of receptive vocabulary; their mean score of 67.8 was even slightly, to their present circumstances. Seventeen more than two SDs below the mean for the general pop- (12%) reported that alcohol use by others in their house- ulation. This was comparable with the performance of hold was "a big part" or "the main cause" of their present their mothers, who obtained a mean PPVT-R score of 72.0, problems. Thirteen women (9%) reported that their own indicating extremely poor receptive vocabulary skills. drug use was "a big part" or "the main cause" of their The 40 preschool children scored below age level on the present problems; 26 (18%) reported that drug use by oth- Yale Cubes, with a mean score of 85.6. These preschool ers had created a significant problem for them. Table 8 children obtained a mean score of 82.5 on the VMI, in- shows the number of respondents who used specific drugs dicating below-average performance on design copying. during the previous year. Visual motor immaturity was also shown on the DAP test, Finally, thirty-one women (21%) reported having been in which the mean score (based on the Goodenough- battered or physically abused in the preceding 12 months, Harris norms) was 79.7; however, only 26 (65%) of 40 of while only four (3%) reported that their children had been the 3- to 5-year-olds were able to draw anything even physically abused in the preceding year. "scorable" on the DAP. The estimates of the incidence and prevalence of these health and substance use problems may be falsely low be- Psychometric Data on 2-Year-Old Children cause of underreporting. It is possible, for instance, that Few 2-year-olds were tested; their mean score on the Binet the clients perceived that admitting to some of these prob- IV Vocabulary was 45.3, which is within one SD of the pop- lems might cause them to be forced out of the shelter, ulation mean. These 2-year-olds performed somewhat be- despite our guarantees of confidentiality. low age level on the Yale Cubes, with a mean score of 87.1. These women appeared to have the range of health Their visual-motor skills were examined with the Yale draw- problems found in the general population of women in ings. Based on a ratio score using developmental age, these this age group. However, the number who became preg- children scored slightly below average for their ages (88.7). nant as teenagers, who had been recently battered, and Behavioral-Emotional Adjustment of who cited drugs as a major cause of their difficulties was All Age Groups impressive, although we have no control group with The mother of each child aged 2 years and older com- which to compare the data. pleted the CBCL. Research has demonstrated that differ- Psychometric Data on School-Aged Children ences by social and economic group are minimal on this Descriptive statistics for the psychometric data for the measure.⁹ Maternal reports on the CBCL for school-aged and preschool children yielded mean scores close to the 6- to 12-year-old children appear in Table 9. These 43 chil- dren scored significantly below average in WISC-R Vo- population mean; CBCL scores for the 2-year-olds were cabulary and Block Design tests. However, these scores slightly below the mean (Table 9). Four (9%) of the 43 older were within the range of scores obtained by black children children had scores above 70, or in the "clinical range," while seven children had scores between 65 and 70 for whose parents are in the lowest occupational category of the WISC-R standardization sample.⁸ "Total Problems." Eight (20%) of 40 preschoolers had "To- The mean score for this group of children aged 6 to 12 tal Problems" scores in the "clinical range." No 2-year-olds years on the Goodenough-Harris scoring of Draw-A- were reported to score in the "clinical range" for "Total Person (DAP) was 85.5, indicating performance about one Problems," "Internalizing," or "Externalizing." On aver- age, they did not show more emotional or behavioral SD below average. Only 28% of the children scored in the symptoms than 2-year-olds in the CBCL standardization average range or higher on the human figure drawing. sample.¹⁰ The mean score on the reading subtest of the WRAT-R for these 43 children was 80.9, or more than one SD below These 145 homeless mothers reported substantial de- the mean for the standardization sample. Only one third pression, according to the Beck Depression Inventory. 11 of the children were reading at age level. This is consistent Although 69 (48%) scored in the normal range, 38 (26%) with the fact that only 25 (63%) of 40 children were in the scored in the mild-to-moderate range, and 38 (26%) scored correct grade for their age. However, it is somewhat in- in the moderate-to-severe range of depression. consistent with the mothers' reports that 19 (48%) of 40 Clinical Measures: Three Wishes and children had "good" or "excellent" performance in school, HTP Drawings 11 (28%) had "average performance," and only 10 (25%) The school-aged children showed a strong tendency to performed "below average" or were not attending school. wish for major changes in their life situation, indicating an School information was not obtained for three of the 43 intense awareness of their plight as homeless poor people. school-aged children. Thirteen (48%) of the 27 older boys and eight (50%) of the Absence from school was a major problem for these 16 older girls made at least one wish to be out of the shelter homeless children: 12 (30%) of 40 had missed 10 or more or to have a new house. Fourteen (33%) of the 43 older boys days of school in the past 2 months and another eight (20%) and girls wished for money. Four (25%) of the 16 older girls had missed between 5 and 9 days. wished for the family to be together and healthy, and 10 (37%) of the 27 boys wished for a car. In contrast, only 11 Psychometric Data on Preschool Children (28%) of the 40 younger children wished for these major Table 9 presents the scores on the Binet IV Vocabulary life-style changes affecting the family. Rather, preschool- subtest, which measures expressive vocabulary perfor- ers showed a strong tendency to wish for more immediate mance. These 40 homeless preschool children scored personal pleasures: 11 (85%) of the 13 younger boys and about 1 SD below the mean for the general population. The 12 (44%) of the 27 younger girls wished for toys. Only Homeless Children 31 younger children used their wishes for miscellaneous or ing abused by husbands or male companions. In addition minor objects. Thirty one percent of older girls (five girls) to self-reported emotional difficulties requiring recent hos- and younger boys (four boys) wished for fulfillment of pitalization, many mothers reported significant chronic "dreams," such as to be a princess, to be a flower, to visit medical problems. Disney World, to be a "man," or to "do anything I want." The children had poor school attendance records and The older children's drawings of houses were remark- scored poorly on intelligence tests and receptive vocab- able as expressions of their wish for a comfortable and ulary tests, as well as having impaired ability to perform well-appointed home. Embellishments such as curtains, visual-motor skills. The older children expressed yearn- flower pots, "welcome" signs, and decorative details were ings for a stable family structure, a desire to leave the shel- common. The children's comments explicitly and poi- ter, and hope to have a home. gnantly expressed their unhappiness at being homeless The problems of the homeless are protean and complex, and their desire for an inviting house in which to live. just as the causes are multifactorial. The shelter system, created to supply emergency and temporary housing, is COMMENT often the residence for homeless persons for prolonged This 1988 survey of homeless families residing in Phil- periods. The health of the resident mothers was charac- adelphia shelters revealed some results that were expected terized by depression and multiparity as well as the pres- and some that were surprising. Unlike many previous ence of serious psychiatric and medical illnesses for some. studies of this population, selection of participants was The resident children tended to suffer serious injuries, random and should therefore be representative of Phil- such as burns, and many may have had anemia and/or adelphia's homeless population at that time. Because this high blood lead levels. The children scored poorly on de- was a field study, the conditions of data collection were velopmental and psychological tests. suboptimal. There was often no appropriate area to in- Some of the problems of homeless persons living in shel- terview parents or test children. Technical problems (20 of ters that need to be addressed include lead toxicity, ane- 96 blood specimens clotted before reaching the laboratory) mia, and accidents of children, as well as substance abuse and probable underreporting, especially on issues of drug and physical abuse of mothers. The psychological and de- use and physical abuse, may have hampered data inter- velopmental needs of homeless children may require spe- pretation. A comprehensive assessment of causes and cial programs if these deficits are to be overcome. consequences of homelessness would require compara- tive sampling, which was beyond the scope of this project. This work was supported by a grant from the University of Penn- Thus, our analysis was limited to descriptive statistics. sylvania Research Foundation, the United Way, the Manealoff Foun- dation, and the Robert Wood Johnson Clinical Scholars Program. The homeless parents interviewed most commonly Drs Barnes and Finkelstein were Charles A. Dana Foundation cited poor living conditions, eviction, or disagreement Scholars at the time of this study, and Dr Parker was a Robert Wood with a landlord as their primary reasons for homelessness. Johnson Clinical Scholar at the University of Pennsylvania School of Thirty-nine (27%) described illegal drug use by themselves Medicine, Philadelphia. or other household members as a major contributor to their current problems. Our overall impression was that References the majority of these families lived in marginal situations 1. Bassuck EL, Rubin L, Lauriat AS. Characteristics of shel- (ie, doubled up, overcrowded, and/or unsafe), until some tered homeless families. Am / Public Health. 1986;76:1097-1101. recent event (ie, argument, abuse, drug problem, preg- 2. Alperstein G, Rappaport C, Flanigan JM. Health problems nancy, or birth of a baby) forced them to leave. Many fam- of homeless children in New York City. Am J Public Health. 1988;78:1232-1233. ilies described "choosing" to enter the shelter system as 3. Miller DS, Lin E. Children in sheltered homeless families: a better alternative than their current housing arrange- reported health status and use of health services. Pediatrics. ments. 1988;81:668-673. The children's reported health problems were those 4. Acker PJ, Fierman AH, Dreyer BP. An assessment of pa- most prevalent at this socioeconomic level. Injuries and rameters of health care and nutrition in homeless children. accidents were commonly reported, as were communica- AJDC. 1987;141:388. ble diseases, such as gastroenteritis and upper respiratory 5. Wright JD, Weber E. Homelessness and Health. Washing- infections. Nine (12%) of 76 children had abnormally ton, DC: McGraw Hill International Book Co; 1987:112. high free EP levels. We do not know what proportion of 6. Homelessness in Philadelphia: People, Needs, Services. these results represents lead intoxication or anemia from Philadelphia, Pa: Philadelphia Health Management Corpora- tion; 1985. iron deficiency or other causes. However, parents re- 7. Rescorla L, Parker R, Stolley PD. Ability, achievement and ported that 16 (11%) of 145 children had been diagnosed adjustment in homeless children. Am J Orthopsychiatry. In as having lead poisoning in the previous year. press. Despite the health problems described by parents, most 8. Kaufman AS, Doppelt JE. Analysis of WISC-R standardiza- believed that their children were in good or excellent tion data in terms of the stratification variables. Child Dev. health. Although most families could identify a source of 1976;47:165-171. care, almost half named a hospital emergency department 9. Achenbach TM, Edelbrock CS. Behavioral problems and or clinic rather than local health centers or individual prac- competencies reported by parents of normal and disturbed chil- titioners. dren aged four through sixteen. Monogr Soc Res Child Dev. 1981;46. The homeless mothers had a high degree of parity and, 10. Achenbach T, Edelbrock CS, Howell C. Empirically-based on average, had delivered their first children while teen- assessment of the behavioral/emotional problems of 2-3-year- agers. Their level of schooling was low and they per- old children. J Abnorm Child Psychol. 1987;15:629-650. formed poorly on a test of receptive vocabulary. They 11. Beck AT. Depression: Causes and Treatment. Philadel- tended to suffer from depression, and many reported be- phia, Pa: University of Pennsylvania Press; 1987. Children in and of the Streets Health, Social Policy, and the Homeless Young James D. Wright, PhD T he nature of homelessness in the United States was parent. But homelessness is a mean existence in which transformed dramatically in the 1980s. Once domi- tenderness, love, and care are often in short supply. Fur- nated by older, largely white, broken-down, alcohol- ther compounding the difficulties are an often inadequate abusive men, today's homeless population contains a siz- diet, uncertain sleeping location, limited facilities for daily able fraction of women and children. 1,2 Indeed, women, hygiene, exposure to the elements and to the social en- children, and youth now comprise perhaps three eighths vironment of the streets, extended periods on one's feet, of the total. 3 What are the effects of homelessness on the an absence of support networks to draw on in times of health and well-being of children? How do these effects illness, extreme poverty, and on through a long list. 4-8 compare with those of simply being poor? What are the Among homeless children and youth in particular, there likely long-term consequences of these effects on the abil- are additional complications. The shelters for women and ity of homeless children to mature normally and to achieve children may well present optimal conditions for trans- productive, independent adult lives? Scholars have been mitting the infectious and communicable diseases of child- researching these and a range of related questions for the hood.9 A second problem is that immunization protocols past 10 years, and the results are not encouraging. are frequently found to be incomplete or nonexistent¹⁰; a That homelessness and extreme destitution exist at all third is the possibility of widespread physical and sexual in a society so affluent as ours is shocking. That increasing abuse. Among homeless teens already out on their own, numbers of the homeless are women, children, and rates of pregnancy, sexually transmitted diseases, and al- youth-groups that society has traditionally obliged itself cohol and drug abuse and the associated health problems to protect-further offends one's sensibilities. It is easy are all inordinately high. 11,12 enough (too easy, perhaps) to be indifferent to the plight Many of the health and nutritional problems of home- of Skid Row drunks, but indifference to the circumstances less children and youth stem from the extreme poverty of of homeless women and their children requires an un- their parents. (The notion that most, many, or even a siz- mistakable coldness of heart. able number of the homeless are "homeless by choice" has There are many good reasons for the pediatric commu- been thoroughly discredited by the research of the past nity to be concerned about the health status of homeless decade. ¹³) The evident role of poverty in creating home- children and youth. Poor physical health and especially lessness also implies that the recent increases in the num- chronic physical illness contribute to the cycle of poverty, bers of homeless women (and therefore homeless chil- whereby sick, homeless children of today become the un- dren) are a consequence of the so-called feminization of employable, destitute, and homeless adults of tomorrow. poverty about which much has recently been written. 14-16 Recurring health problems of even minimal severity dis- In 1984, approximately two thirds of the nation's poor rupt school attendance and interfere with studying and adults were women¹⁴; this proportion is increasing. As a homework activities. Chronically poor health or physical consequence, the poverty rate among American children disabilities will interfere with, if not preclude, normal la- is about twice that of adults. Four of 10 poor people in the bor force participation and, with it, the ability to lead an United States today are children.¹⁷ independent adult existence. Thus, poor health is one Poverty is a well-known "risk factor" for poor health mechanism by which homelessness reproduces itself in among children and certainly contributes to the poor subsequent generations. health of homeless children. Poverty is strongly correlated Every aspect of a homeless existence compromises with infant mortality in every study that has inquired into physical health to some degree or at least complicates the the matter, and is also associated with a range of mor- provision of adequate health services; this is true of both bidities as well. Homeless children, being poor, must suf- children and adults. Life without shelter corrodes physical fer the health consequences of their poverty as well as well-being in 1000 different ways, most of them too ob- those resulting from their unsettled living conditions. vious to belabor here. Much that ails children requires little Although the effects of poverty on infant mortality are more than a day or two at home in bed-but what if you well documented, no study has yet examined the rate of have neither home nor bed? Nothing is quite so thera- infant mortality among the homeless poor. Among home- peutic to an ailing child as the tender, loving care of a less adults, mortality is exceptionally high⁸,¹⁸; indeed, the Accepted for publication December 5, 1990. average age at death for various samples of the homeless From the Department of Sociology, Tulane University, New Or- is reported to be in the range of 50 to 55 years. It is, there- leans, La. fore, a safe bet that homeless infants also die prematurely Reprinted from AJDC (1991;145:516-519). at a rate substantially higher than average, although, as Street Children 33 indicated, this point has yet to be researched. Mental health problems of homeless children have been One mechanism that links poverty to poor health is in- studied in depth by Bassuk et al²¹ and Bassuk and Rubin. 22 adequate nutrition-a problem for poor children in gen- Depression, developmental delays of varying severity, eral and the homeless poor in particular. Specific studies anxiety, and learning difficulties are reported to be dis- of dietary intake or nutritional deficiency disorders among tressingly common. Psychiatric morbidity is also wide- homeless persons, whether child or adult, are relatively spread among homeless adults. 23,24 rare. Winick19 has noted that the menu used by the city of The general configuration of illness among homeless New York in its shelters for homeless persons supplies at children is similar to that of children in general. That is to least one third of the daily requirements for all known say, the health problems faced by homeless children are nutrients, and is to that extent "sufficient." These diets, not exotic or unusual; they are, rather, the same health however, are typically high in cholesterol, fat, sugar, salt, problems that all children face. In all studies, by far the and starch, so while they may well offer adequate caloric most common disorders observed among homeless chil- intake, they are far short of optimal. As for the nutrition dren are minor upper respiratory infections, followed by of those homeless who do not avail themselves of shelters minor skin ailments, ear disorders (mostly otitis media), and soup kitchens and who eat mainly what they can scav- then gastrointestinal problems, trauma, eye disorders, enge from street sources, nothing further need be said. and lice infestations. In most cases, differences in the rates A few studies have inquired into the prevalence of nu- of disorder between homeless boys and girls are reported tritional deficiency disorders among homeless children; as to be minor. would be expected, the rates are high. I¹¹ reported that Differences between homeless children and children in 2.2% of homeless children who received care during the general, in contrast, are often large and in some cases dra- first year of the National Health Care for the Homeless matically large. Although the general pattern of illness program were diagnosed as anemic; this is twice the rate among homeless children is not atypical of children's ill- for "normal" children seen in ambulatory pediatric clinics nesses in general, the comparative rates of occurrence are nationwide. 20 An additional 1.6% of the homeless children often inordinately elevated. had nutritional deficiency disorders other than anemia Children, clearly, are not immune to the deleterious ef- (most of them vitamin deficiency disorders); among chil- fects of homelessness on physical health. That many of dren in general, such deficiencies are practically nonex- these children are over age 5 years and therefore required istent (Wright, 11 Table 1). About 2% of the homeless chil- to attend school, where their illnesses can then circulate dren studied by Miller and Lin20 were diagnosed as having to other children, is an additional point of concern. "growth problems," possibly secondary to dietary insuf- It is important to stress here that the best available stud- ficiencies, similar to the results reported by Alperstein et ies of the effects of poverty on child health report relatively al.¹⁰ slight differences in the prevalence of most disorders be- General morbidity among homeless children appears to tween poor and nonpoor children, whether chronic or be much more widespread than among children in general acute. 25,26 The larger differences are found in the ensuing or among poor children in particular. Miller and Lin20 stud- consequences of disease. Differentials on the order of those ied 158 homeless children in Seattle, Wash, and reported reported in the studies of homelessness and child health that "although the majority of the children were consid- are not to be found anywhere in the published literature ered to be in good or excellent health, the proportion on poverty and child health. The evidently disproportion- whose health was described as 'fair' or 'poor' was four ate rate of illness observed among homeless children, in times higher than in the general US pediatric short, is not just a consequence of their impoverished cir- population. "20(pp671-672) This study also found a high prev- cumstances. Homelessness is an independent and quite alence of abnormal anthropometry and immunization de- consequential risk factor in its own right. lays within this population. Homeless children appear to The life chances of homeless children are obviously not overutilize emergency department services, underutilize bright to begin with. They are saddled first with the bur- preventive health services, and have far fewer dental visits dens of poverty and then with the unique burdens of not than the general pediatric population. Similar results for having a safe, stable place to live. The effects of home- homeless children in Boston have been reported by Bassuk lessness on school performance and intellectual develop- et al,21 and for homeless children in New York by Alp- ment are now well-known,22 as are the effects on various erstein et al. 10 physical disorders, both acute and chronic. Among the Ill compared the health problems of homeless children many good reasons to "do something" about homeless- seen in the National Health Care for the Homeless pro- ness is that homelessness makes people ill. gram with those of children included in the National Am- These days, the people being made ill by homelessness bulatory Medical Care Survey. Nearly all disorders are are increasingly children and youth, who comprise a tenth more common among the homeless group. About 7% of or more of the total homeless population. To be a poor the homeless children were found to have scabies and lice child is one thing, but to be poor and homeless is a thing infestations, for example, compared with 0.2% of the Na- apart. It is hard to imagine a social environment less con- tional Ambulatory Medical Care Survey children; upper ducive to health or normal maturation and development. respiratory infections were about twice as common, skin Pediatricians at the New York City Children's Health disorders four times as common, poor dentition 10 times Project have identified what they call the "homeless child as common, etc. Homeless children were also more likely syndrome," which comprises "poverty related health than normal children to suffer from chronic physical dis- problems, immunization delays, untreated or under- orders. Similar patterns were observed among homeless treated acute and chronic illnesses, unrecognized disor- teenagers as well. 12 ders, school, behavioral, and psychological problems, 34 Caring for the Uninsured and Underinsured child abuse and neglect. "27 It is not true that all homeless sands of children around the nation are being destroyed children exhibit all aspects of this syndrome. However, by forces over which they have no control. The Children's most homeless children do exhibit one or more of these Defense Fund estimates that "more children die each year problems and disorders; at the very least, they are more from poverty-related causes than traffic fatalities and sui- commonly observed among homeless children than cides combined," and while this is probably an exagger- among children in general or even those at the poverty ation, it is nonetheless an exaggeration that makes a point. level. It is useful, if troubling, to ask, What does the very ex- Knowing how and to what extent homelessness affects istence of homeless children say about us as a nation? the health of children does not in itself tell us what needs What image does this present to the world? to be done. Most of what has been done to date is along In February 1987, I appeared at hearings before the the lines of amelioration. There is an evident need to con- House Select Committee on Children, Youth, and Families tinue such programs: aggressive screening of homeless to testify to the effects of homelessness on the physical children for health disorders and proper treatment and health of children. Among the several witnesses present health care once problems have been identified. But here, at the hearings was a lovely 12-year-old Hispanic girl living as in many other areas of public health, the only long-term with her mother and three siblings at one of the large wel- solutions are to be found in prevention. We will avoid the fare hotels in midtown Manhattan. In the course of her negative consequences of homelessness on the health of testimony, this young woman remarked, "If I could have children only when we find a way to prevent children from anything that I could want, I wish that we could have our being homeless in the first place. own apartment in a nice clean building and a place that Sad to say, this obvious truth is much easier to state than I could go outside to play in that is safe. I want that most to act on. Homelessness is a complex problem rooted in of all for me and my family." A clean place to live and a recent trends in the political economy of the nation. 13 A safe place to play do not seem like too much to ask. These rising poverty rate coupled with a serious and ongoing are not the rapacious demands of some welfare- decline in available low-income housing has served to dependent drug addict, but the plaintive wishes of a price an increasingly large segment of the urban poverty young child to have those things that normal children population out of the private housing market. 28 Inflation have. As the hearings closed, the thought occurred to me, has reduced the purchasing power of Aid to Families with What kind of world is this, where such simple things can Dependent Children and other welfare programs to the only be a dream to some children? As a kind and generous point where the welfare-dependent can no longer main- nation, are we truly prepared to let this continue? tain stable residences with their monthly payments.² In This report has been adapted from a previously published study the absence of other sources of support, mothers with chil- by Dr Wright.31 dren dependent on Aid to Families with Dependent Chil- dren find themselves virtually consigned to homelessness References in all but the most generous states, unless they are also 1. Lam J. Homeless Women in America: Their Social and among those fortunate enough to receive a federal Section Health Characteristics. Amherst, Mass: University of Massachu- Eight housing voucher. setts; 1987. Thesis. An aggressive, broad-scale federal assault on homeless- 2. Rossi PH. Without Shelter: Homelessness in the 1990s. ness in all its various manifestations would easily add sev- New York, NY: Priority Press; 1989. eral tens of billions of dollars to the annual federal expen- 3. Wright JD. The worthy and unworthy homeless. Society. diture on housing, health, and human services. 29 No one 1988;25:64-69. who has followed the Washington, DC, scene closely for 4. Brickner PW, Scharer LK, Conanan B, Elvy A, Savarese M, the past few years would consider this the least bit likely eds. Health Care of Homeless People. New York, NY: Springer- Verlag NY Inc; 1985. anytime in the coming decade. The prospects for 5. Brickner PW, Scharer LK, Conanan BA, Savarese M, Scan- community-based local programs are scarcely brighter, lan BC, eds. Under the Safety Net: The Health and Social Welfare since most of the cities and states face budget problems of the Homeless in the United States. New York, NY: WW every bit as serious as the federal problem. That would Norton; 1990. seem to leave the private sector as the most promising 6. Institute of Medicine. Homelessness, Health and Human source for new programs, but the limit may well have been Needs. Washington, DC: National Academy Press; 1988. reached here as well. In fact, approximately three quarters 7. Wright JD, Brickner PW. The health status of the homeless: of the total national expenditure for assistance to the diverse people, diverse problems, diverse needs. Presented at the annual meeting of the American Public Health Association; homeless already comes from the private sector, princi- November 15, 1985; Washington, DC. pally the churches, and one is entitled to wonder just how 8. Wright JD, Weber E. Homelessness and Health. New York, much wattage can be cranked from the "thousand points NY: McGraw-Hill International Book Co; 1987. of light." Thus, for the foreseeable future, we will have to 9. Gross TP, Rosenberg ML. Shelters for battered women and content ourselves with programs of amelioration such as their children: an under-recognized source of communicable those embodied in the Stewart B. McKinney Homeless As- disease transmission. Am J Public Health. 1987;77:1198-1201. sistance Act, knowing full well that such measures do not 10. Alperstein G, Rappaport C, Flanigan J. Health problems and cannot provide any final solutions to this problem. of homeless children in New York City. Am J Public Health. 1988;78:1232-1233. The large number of children now being seen on the 11. Wright JD. Homelessness is not healthy for children and streets and in the shelters and other facilities providing other living things. Child and Youth Services. 1990;14:65-88. services to homeless people means that the homelessness 12. Yates G, MacKenzie R, Pennbridge J, Cohen E. A risk pro- of the 21st century is already being created today. As this file comparison of runaway and non-runaway youth. Am Public is being written, the lives and futures of many tens of thou- Health. 1988;78:820-821. Street Children 35 13. Wright JD. Address Unknown: Homelessness in Contem- homeless families. Am / Public Health. 1986;76:1097-1101. porary America. Hawthorne, NY: Aldine de Gruyter; 1989. 22. Bassuk E, Rubin L. Homeless children: a neglected pop- 14. Sidel R. Women and Children Last: The Plight of Poor ulation. Am / Orthopsychiatry. 1987;57:279-286. Women in Affluent America. New York, NY: Viking Penguin; 23. Bassuk E. The homeless problem. Sci Am. 1984;251:40-45. 1986. 24. Wright JD. The mentally ill homeless: what is myth and 15. Ehrenreich B, Piven F. The feminization of poverty. Dis- what is fact? Soc Problems. 1988;35:182-191. sent. 1984;31:162-170. 25. Egbuono L, Starfield B. Child health and social status. Pe- 16. Duncan G. Years of Poverty, Years of Plenty. Ann Arbor, diatrics. 1982;69:550-557. Mich: Institute for Social Research Press; 1984. 26. Newacheck P, Starfield B. Morbidity and use of ambu- 17. US Department of Commerce. Money Income and Pov- latory care services among poor and nonpoor children. Am J erty Status in the United States. Washington, DC: Bureau of the Public Health. 1988;78:927-933. Census, Current Population Reports; 1987. Consumer Income 27. Today's Child. 1988. 'The homeless child syndrome.' To- Series P-60, Number 161. day's Child. 1988;2:4. 18. Alstrom CH, Lindelius R, Salum I. Mortality among home- 28. Rubin B, Wright JD, Devine JA. Unhousing the urban less men. Br J Addict. 1975;70:245-252. poor: the Reagan legacy. / Sociol Soc Welfare. In press. 19. Winick M. Nutritional and vitamin deficiency states. In: 29. Wright JD. Science, passion and polemics. Society. Brickner PW, Scharer LK, Conanan BA, Savarese M, Scanlan BC, 1989;26:21-23. eds. Health Care of Homeless People. New York, NY: Springer- 30. Oberg C. Pediatrics and poverty. Pediatrics. 1987;79:567- Verlag NY Inc; 1985;8:103-108. 568. 20. Miller D, Lin E. Children in sheltered homeless families: 31. Wright JD. Poverty, homelessness, health, nutrition, and reported health status and use of health services. Pediatrics. children. In: Kryder-Coe I, Salamon L, Molnar I, eds. Homeless 1988;81:668-673. Children and Youth: A New American Dilemma. New Brun- 21. Bassuk E, Rubin L, Lauriat A. Characteristics of sheltered swick, NJ: Trans-action Books; 1990. Children's Services in an Era of Budget Deficits Barbara B. Blum, Susan Blank - t is virtually impossible to address the issue of how to However, efforts to make poor children more visible to improve the care of the nation's poor children without the public at large will be of little consequence unless un- confronting the question of the resources society is willing derlying questions about resources can be answered. to spend on those children. As a first step in examining Growing state and federal budget deficits confront chil- that question, I suggest we visualize an increasingly com- dren's advocates with a seemingly open-and-shut objec- mon sight in contemporary hospitals: a premature, low- tion to greater investments in services. Children do have birth-weight infant, born with medical complications and unmet needs, concede the budget cutters, but there is sim- hooked up to a life-support system. The baby's mother is ply no more money. Government, they contend, is in penniless; the hospital, or, in other words, society at large much the same position as a poor family that needs every will spend thousands of dollars to give the infant all the penny to make it through the week. When short-term bud- medical assistance he or she needs to breathe and eat and gets are tight, long-term prevention gets defined as a lux- develop. ury. What the scenario tells us is that in this instance, society For the family, pinched resources manifest themselves has concluded that almost no amount of money is too as hesitating to take a child to the doctor until an illness much to spend to save the life of a child. The statement grows sufficiently serious to require treatment in the emer- is a powerful one. Granted, the work of the neonatal care gency department. For society, budget constraints mean unit reflects society's stake in preserving any human life, spending more on shelters and welfare hotels after people but it is fair to say that commitment assumes a special force become homeless than on raising the public assistance al- and urgency when its subject is a young life. The resources lowance, or they mean providing expensive neonatal care we devote to premature infants born into poverty suggest to some women because prenatal care is not universally that we honor the potential to develop and grow in any available. Just as the family scrapes enough together to child, however frail or disadvantaged. buy a used car, but has nothing left for its upkeep, so so- But that commitment to children has its limits. If we ciety funds the popular Head Start program but dissipates pursued it to its logical conclusion, we would not live in its gains by failing to provide the high-quality education a society that cares for the baby until he or she can leave that would reinforce the enriched early childhood expe- the neonatal unit and then allows the infant to go home rience. Scarce resources must be reserved for averting or to an apartment infested with rats. When the infant alleviating crises; prevention and long-term maintenance reaches school age, we could not be satisfied to let the child are worthy but unattainable luxuries. These principles, ar- begin an education in a badly overcrowded and dilapi- gue supporters of fiscal austerity, are as true for govern- dated building where it takes years to fix a leaky roof. We ment as they are for families. would also not be able to live with the fact that the emer- However persuasive, the analogy is flawed. A wealthy gency department will be that child's only source of health society with its government in budget straits is not the care. same as a family in budget straits. The government simply Clearly, almost no one actively endorses such a level of has more choices. To pay for better services to meet chil- risk to children's health and development, yet childhood dren's basic needs, this wealthy nation can raise taxes. deprivation persists and worsens. One reason is the iso- Used for better prenatal care or drug treatment for preg- lation of poor children. Despite growing attention to child- nant addicts or decent housing allowances, the resources hood poverty in the United States, many low-income chil- would be money well spent. dren live in neighborhoods separated from a mainstream At this juncture, however, another set of objections to society that reads about them in newspapers but does not investing in services must be confronted. There are two personally witness their plight. meanings to the phrase "money well spent," and we have Another reason for the neglect of children is the racism thus far focused only on the first, the sense that resources and classism that pervade a supposedly egalitarian soci- will be used for worthwhile ends. When the services are ety. Racism and classism make it easier to ignore children better health care, housing, and early childhood educa- in poor neighborhoods; indeed, racism and classism may tion, their value is easy to defend. It is the second meaning even make it more attractive to care for babies in the highly of "money well spent," the concept of money used efficiently, technological professionalized neonatal environment that raises more difficult questions. than in the communities to which they return. The source of the difficulty is that as currently struc- tured, our human services system does waste resources. To a degree, the problem is the one already discussed: the Accepted for publication November 30, 1990. From the Foundation for Child Development, New York, NY. overemphasis on costly crisis intervention at the expense Reprinted from AJDC (1991;145:575-578). of prevention. However, the crisis mode is not the only Children's Services 37 source of inefficiency. Another is the lack of accountability precious resources in duplicative intake processes and re- for public funds spent on human services. The problem porting requirements and in the time and energy spent is familiar. A program is launched, funds are allocated, piecing together funds from different sources to support and, once established, the program continues to receive single programs. support year after year. The principal measure of the pro- How should the system function? There are a variety of gram's performance is whether it follows certain proce- ways to conceptualize what reform would look like. Many dures. Too little effort is made to find out whether the of us who are familiar with social services in New York City program is making a difference for children and families. like to point to an exemplary program, the Center for Fam- As the public sees it, tax dollars disappear into a void. ily Life in the low-income community of Sunset Park, In fact, considerable progress has been made on this Brooklyn, to illustrate what could be done. The center, front, and to a certain extent public perceptions have not which is supported by a mixture of private and public caught up with what has been accomplished. We must funding sources, is open to any family in the neighbor- recognize that this country is the beneficiary of more than hood with children. Through the center, families have ac- a decade of large-scale experimental research efforts that cess to a rich array of services, including a therapeutic have used controlled studies to measure the effects of var- nursery program, job search assistance, parenting edu- ious programs. Even when it is impossible to conduct so- cation, and many others. phisticated treatment/control group studies, as is the case Regardless of the reason why someone first walks with most programs, officials recognize more and more through the center's door, staff members are always alert the value of regularly examining indicators on families at to other kinds of help that that person and his or her family risk. In the absence of controlled studies, it is of course may need. While a child may enroll in the center's after- impossible to know precisely how much change can be school program, the mother may later avail herself of its attributed to particular interventions and how much to counseling services, turn to its employment program for external factors. Nevertheless, as new programs are tried, help in finding a job, and, as she comes to feel at home, indicators do offer practitioners, policymakers, and the bring her whole family to its community dinners. The cen- public a general sense of whether initiatives are moving ter client, say its staff, is typically not an individual, but in the right direction. the entire family. Every effort is made to avoid artificial One of the many examples of this new interest in pro- distinctions between, for example, "child welfare fami- gram accountability comes from the Council of Governors' lies," "substance abusing families," and "families receiv- Policy Advisors (formerly the Council of State Policy and ing public assistance." Instead, the criterion for service is, Planning Agencies), an affiliate of the National Governors' What help does the family need to function well? Association, which, in the summer of 1990, completed Around the country are hundreds of local programs that what it calls a Policy Academy on children and families at share the center's vision of holistic services. They operate risk. The academies are intensive technical assistance con- with many different funding sources, from many different ferences for teams of top state officials who meet to de- bases, serving many kinds of families and communities. velop a plan for solving complex policy problems. The However, the efforts of these innovative community- teams taking part in the recent academy series on children based programs are overshadowed by the large public bu- and families devoted a great deal of time to the issue of reaucracies that poor families must typically turn to for how to gauge the success of the plans they developed by assistance. The question is, can these bureaucracies pos- examining changes in specific indicators, such as rates of sibly be reconfigured so that the maze becomes a neigh- low-birth-weight infants or of teen pregnancy. We need borhood center? The center would be friendly and con- to infuse much more of the planning associated with hu- venient, its mode of operation would be to keep a limited man services with this approach, which moves beyond number of staff members closely and continuously in- mechanistic, procedural measures of how a program func- volved with one family, and, finally, it would give the tions to a more probing assessment of whether it seems family easy access to many different kinds of key services, to be effecting change. such as income and housing assistance, preventive health Another, still more fundamental source of inefficiency care and child welfare programs, employment and train- in the way money is spent to help families is the very struc- ing initiatives, and drug treatment programs. ture of the country's health and human services systems. In New York City, where children's advocates have re- These systems are both overly centralized and frag- peatedly called for integration and decentralization of mented. Multiple agencies with multiple funding streams publicly funded services for poor families, there is now are charged with specialized responsibilities for serving some ground for optimism. A project called Agenda for the same families. These families are neither equipped nor Children Tomorrow (ACT), which was privately initiated inclined to sort through their life problems and fit them but is now supported in part by the mayor's office, is be- into boxes constructed by government. Consequently, ginning to map service needs and usage patterns in 10 of they often do not know which agency they should ap- the city's poorest neighborhoods. The mapping is the first proach for help. When they do locate the right system, step in a plan to build a neighborhood-based service sys- they often discover that services are offered only at central, tem in these districts and eventually throughout the city. inconvenient locations. It will take time, patience, skill, political commitment, Families pay a high price in frustration and discourage- and a generous portion of good luck to create coordinated ment when they try to negotiate the service maze. Society community services in New York City. However, those pays a high price when the maze keeps multiproblem fam- of us who have been involved with ACT are gratified ilies from getting access to the help they need, thereby that at last a systematic effort to realize the vision is under allowing their problems to worsen. Government wastes way. 38 Caring for the Uninsured and Underinsured Local reform efforts like ACT, however, cannot proceed active in encouraging states to undertake demonstrations. in a vacuum. Initiatives to reconfigure services at the com- Also, rather than confining itself to demonstrations, the munity level are much more likely to succeed if they enjoy task force could also simplify the waiver process when a supportive policy environment at the state and national states wish to apply for experiments that involve admin- levels. Unfortunately, the federal environment often chills istrative, nonresearch activities. In addition, the rule now and constricts, rather than nurtures, state and local ex- followed by the task force that waivers will be approved perimentation. As with almost all generalizations, this one only for demonstrations that are revenue neutral should demands qualifications. First, most federal officials want be modified. Because this stipulation ignores the start-up to foster flexibility. However, legislative and institutional costs associated with almost all demonstration programs, practices frequently obstruct that good impulse. Second, some developments of the 1980s, including, for example, it places unnecessary restraints on experimentation. the use of block grants or the new latitude given to states Expanding the functions of the task force is one possible to create their own welfare-to-work programs, did favor route that the federal government could take to make it service coordination. Too often, however, the freedom easier for states to innovate; there are clearly many others given to states and localities by the federal government that would likewise offer states greater flexibility in the use was undercut by funding cuts and freezes. More impor- of funds, leaving them in a stronger position to support tantly, despite block grants and special programs that en- locally based, coordinated services. courage coordination, state and local officials are still met States, however, do not inherit all their problems in at every turn with federal policies that encourage them to this area; some are indigenous. Like the federal govern- think categorically rather than holistically. We need to look ment, states have legislative committees that carve the no further than the Congressional committee structure for needs of high-risk families into pieces that are difficult to an example of this problem. fit together. Similarly, states have their own centralized Congressional staffers, when approached with ideas for bureaucracies that take too many decisions out of the new federal initiatives that crosscut conventional program hands of communities. areas, typically acknowledge that the House and Senate There are, however, signs of change. In many ways, committee structures are hurdles that must be sur- states are now exploring possibilities for restructuring. For mounted if more integrated programs are to be autho- example, the American Public Welfare Association has rized. Because Congress should serve as an aid, not an formed a commission of top state welfare and child welfare obstacle, to decategorization, careful thought is needed officials to recommend reforms in the child welfare sys- about how to rationalize the way the committees do busi- tem, and that group strongly supports the creation of a ness. more integrated service system for children and families. At best, however, improvements will be very gradual. Efforts to build integrated family services are already un- Thus, we must also consider if there are ways to give states der way in Iowa and in states taking part in a special child more immediate relief from the constraints of federal pol- welfare initiative sponsored by the Annie E. Casey Foun- icies. One answer may be to modify the assumptions that dation. underlie decisions about whether to grant states waivers In addition to the federal and state policy environments, for federal regulations on programs for children and fam- ilies to presume that states should be permitted flexibil- a third sector of our society, the professional community, ity in following the rules established for categorical fund- must change if more efficient and helpful local service sys- ing unless there is good evidence to the contrary. tems are to be developed. The challenge to professionals has two dimensions, each reflecting one of the two struc- A starting point for this more short-term reform might be to look into the work of a panel that until recently was tural problems in contemporary health and human ser- known as the Low Income Opportunity Control Board. vices systems discussed earlier: their fragmentation and overcentralization. Established in 1987 under the White House Office of Policy Development, the panel has been renamed the Economic First, to heal the system's fragmentation, the psychol- Empowerment Task Force and will operate under the di- ogist, child welfare worker, nurse, and many other pro- rection of Housing Secretary Jack Kemp. The task force is fessionals must be willing to move outside the confines of an unusual federal entity in that it brings together assistant their own disciplines. The social worker cannot become a secretaries from the wide range of departments that over- public health specialist, but perhaps he or she can become see social welfare programs. Its mission is to examine ideas more attuned to the way the public health specialist views for state-sponsored demonstrations-programs estab- families and their needs. The employment specialist need lished for the purposes of evaluation-and a key element not be a child welfare worker, but perhaps he or she of that work is to review state requests for waivers to con- should become more conversant in the language that child duct them. With representatives from all the agencies from welfare workers speak. which a state would be likely to need waivers, the board Second, to decentralize systems and make them more offers a shortcut to states that would otherwise need to accessible to clients, professionals must be willing to hand apply to multiple agencies to launch a complex demon- some of the control they now exercise over to local leaders stration. and, ultimately, to families. Families must have a choice The board's new name and leadership suggest there is in the way services are designed, provided, and priori- probably federal interest in broadening its authority to tized. If they say they prefer family day care to center- take advantage of its unusually wide-ranging represen- based programs, if they believe the neighborhood needs tation. There are several good possibilities for such an ex- drug treatment more than recreational services, and if pansion. Perhaps the task force could become more pro- they conclude that a single mothers' group established for Children's Services 39 parenting education purposes should focus less on child- likely to be a necessary but insufficient step to bring about rearing and more on how to find a job, then professionals the full measure of systemic change that should occur. should listen. Services can be integrated, but if they are of poor quality In fact, many professionals are beginning to collaborate or if there are simply not enough of them, little has been across disciplines and shape programs in response to what gained. families themselves say they need. In some cases, these On the other hand, the potential benefits of coordina- professionals have the wholehearted backing of their agencies, but, overall, more top-down institutional sup- tion are undervalued if there is an assumption that the way port is needed for this kind of innovation. in which services are provided has little or nothing to do In addition, workers must be trained to function in a with their substance. In fact, the kind of reconfiguration more multidisciplinary system. On-the-job innovation is discussed here could improve the quality and possibly heartening, but many of the fresh approaches now being even the quantity of family interventions. Convenient, ac- taken by health and human service professionals ought to cessible services provided by workers who think about the become the standard practice taught to students before needs of the entire family constellation would axiomati- they begin their careers. Equally important is orienting cally be better services. As to the question of supply, if current workers to the challenges and demands of coor- integration reforms created systems that made more sense dinated and locally based service provision. to workers and families than do current arrangements, the Because there is a tendency to oversell every solution to improved morale could, in turn, help to convince the pub- poverty problems in this country, we should be well aware lic to invest the dollars needed to create a decent supply that, however desirable, a more coordinated and decen- of services for children at risk. tralized service system is no panacea. First, while coor- Perhaps it is idealistic to expect that the country can dination should save precious resources, it will also re- create a new and vital service system during the next 10 quire new investments in the short run. Changing service to 20 years, but there are times when idealism is the only systems requires planning, training, and consulting, and appropriate response to reality. In 1991, when large num- none of these activities is without its price tag. bers of children are vulnerable to poverty, homelessness, Second, and even more critical, is the fact that clustering ill health, and developmental disabilities, it is time, if not services and even clustering them in neighborhoods is past time, for bold and creative systemic change. What Will It Take to Fully Protect All American Children With Vaccines? Alan R. Hinman, MD, MPH Although 95% of children have had a full course of vac- Committee)² are that the Red Book Committee recommends cines by the time they enter school, immunization levels two immunization visits during the second year of life (at 15 among poor inner-city preschoolers may be substantially months for measles, mumps, and rubella [MMR] and Hae- lower. Among the factors responsible for the disparity are mophilus b conjugate vaccines and at 18 months for diph- the lack of a uniform data system to identify children who theria and tetanus toxoids and pertussis vaccine [DTP] and need vaccine; missed opportunities to offer immunizations; oral polio vaccine [OPV]) and also recommends that the sec- overinterpretation of contraindications; and administrative ond dose of MMR vaccine be given at approximately 12 years barriers to immunization. Remedies lie in a multifaceted ap- of age, rather than at 5 to 6 years of age, along with DTP and proach: a tracking system that will prompt a reminder and OPV. Thus, a child being immunized according to the Red then sound an alarm when an immunization is overdue; Book schedule would have six immunization visits before means of informing parents, probably best accomplished by school entry (and a seventh later). an outreach worker of the same racial or ethnic background Half of US children receive are immunized by private phy- as the parent; removal of administrative barriers and in- sicians (commonly pediatricians) as part of overall well-child creased access to services; incentives, either positive or neg- preventive care. Their parents either pay for this service or ative, to raise the priority of immunizations; and more ed- have it paid for by third-party reimbursement mechanisms. ucation for health care providers to ensure that they The current private-sector price for the vaccines each child understand contraindications and do not miss opportunities should receive totals $198.55; with an estimated cost per phy- to offer vaccines. Other possibilities are "express lane" ser- sician visit of $15, the total for full immunization would be vices to immunize all children who come to a health care $303.55, following the Red Book schedule. provider and the delivery of immunizations in child care The other half of US children receive immunizations in settings and in programs such as Women, Infants, and Chil- the public-sector, often as a specific, categorical service dren, and Aid to Families With Dependent Children. independent of other preventive care services. Their par- ents do not pay for the vaccine received (which at current public sector prices totals $92.53) but may pay a small fee R ecent newspaper and journal articles headline the con- for administration. These children are likely to be mem- tinuing occurrence of measles outbreaks in this bers of racial or ethnic minorities and to be socioeconom- country and report that a high proportion of young chil- ically disadvantaged. dren are unvaccinated. At the same time, the Centers for Since passage of the Vaccination Assistance Act of 1962, Disease Control, Atlanta, Ga, describes immunization lev- a federal grant program, administered by the Centers for els in school-age children as being at an all-time high, with Disease Control, has provided financial and technical as- more than 95% of students having records documenting sistance to supplement state and local health department receipt of a full course of vaccines. In this article, I will efforts to provide the public sector immunizations. Grant assert that both of these seemingly contradictory state- funds typically provide half of the public-sector vaccines ments are true, attempt to describe some of the factors (approximately one quarter of the national total). The level responsible for the present situation, and consider pos- of funding for this program has increased dramatically in sible remedies. the past 14 years (Figure), from a low of $5 million in fiscal BACKGROUND year 1976 to the fiscal year 1991 appropriation of $185 mil- Current recommendations call for a child to receive eight lion. The striking increases are largely a reflection of the different vaccines or toxoids (many in combination form and dramatic increases in vaccine prices and the introduction all requiring more than one dose) in a total of five visits for of new vaccines. As shown by the nonvaccine grant dollars immunization between birth and school entry. The basic im- in the Figure, funding for program operations (surveil- munization schedule of the US Public Health Service's Im- lance of disease and adverse events, coordination, assess- munization Practices Advisory Committee is summarized in ment of immunization coverage, evaluation, education, Table 1.¹ Two discrepancies between this committee's rec- etc) has not increased significantly. Grant funds have not ommendations and those of the American Academy of Pe- paid for actual administration of vaccine; this typically diatrics Committee on Infectious Diseases (the "Red Book" comes from local or state health department funds, al- though some funds from the Federal Prevention Services Accepted for publication December 27, 1990. Block Grant, Maternal and Child Health Block Grant, or From the Center for Prevention Services, Centers for Disease Medicaid may also be used. Control, Atlanta, Ga. Because of the existence and enforcement of laws re- Reprinted from AJDC (1991;145:559-562). Vaccination 41 Table 1. - Routine Immunization Schedule* Table 2.-Immunization Levels Vaccines United States, 1989-1990 School Year Age, mo 2 DTP, OPV, HbCV Weighted Average, % 4 DTP, OPV, HbCV Head Day Vaccine Start Care K-1 K-12 6 DTP, HbCV MMR, HbCV, DTP, OPV DTP 97 95 98 98 15 Polio 97 95 98 98 School entry (4-6 y) DTP, OPV, MMR Measles 95 95 97 98 *Based on recommendations of the immunization Practices Rubella 94 95 97 98 Advisory Committee. DTP indicates diphtheria and tetanus toxoids Mumps 97 95 98 98 and pertussis vaccine; OPV, oral polio vaccine; HbCV, Haemo- philus b conjugate vaccine (the dose at 6 months of age may not be *Provisional. K-1 and K-12 indicate kindergarten through first required, depending on which vaccine is used); and MMR, and 12th grades; DTP, diphtheria and tetanus toxoids and pertus- sis vaccine. measles, mumps, and rubella vaccine. quiring immunization before school entry in all 50 states, there is a mechanism for ascertaining with confidence the 200 200 immunization levels of 5- to 6-year-old children. For the 1989-1990 school year, more than 97% of such children had 160 160 documentary evidence of having received a full course each of DTP, MMR, and OPV (Table with little variation from Head Start and other licensed day-care centers, Dollars (Millions) 120 120 around the country. Levels nearly as high are reported 80 80 where the school immunization requirements also apply. By contrast, there is no single nationwide mechanism for monitoring immunization levels in infants and young chil- 40 40 dren and no mechanism for requiring immunizations. In the past, the US Immunization Survey carried out by the 0 0 Bureau of the Census³ was used, but it was discontinued 1963 1965 1967 1969 1971 1975 1977 1979 1981 1983 1985 1987 1989 1991 in 1985 because of concerns about accuracy and budgetary Year restrictions. It is estimated that, nationwide, 70% to 80% of children have received a full series of individual im- Immunization grant dollars, 1963 to 1991, including supplemental munizations by the time of their second birthday (a con- funding in 1970, 1974, 1977, 1979, and 1982; grant dollars at current value (solid line), grant dollars adjusted at the 1964 purchasing power venient measuring point), although the proportion who base (broken line with circles), and nonvaccine grant dollars ad- have received the full course of all immunizations is doubt- justed to the 1963 purchasing power base (broken line). less lower. However, there is marked variation around the country. In particular, immunization levels among poor cess in assuring immunization in school-age children and inner-city children may be substantially lower. A survey the unacceptable levels seen in inner-city (and in some in early 1990 of kindergarten and first-grade public school nonurban area) preschoolers demonstrates two important students in eight inner-city areas (Boston, Mass; Bronx, facts. First, the high immunization levels in schoolchildren NY; Cleveland, Ohio; Houston, Tex; Jersey City, NJ; Phoe- indicate that parents want to have (or at least do not mind nix, Ariz; Pittsburgh, Pa; and Seattle, Wash) revealed that, having) their children immunized. Immunization ranks although more than 95% had received measles vaccine by with motherhood and apple pie as a value for most Amer- the time of school entry, only 51% to 81% (depending on icans. Aggressive enforcement of the school immuniza- the city) had received the vaccine before their second birth- tion requirements, which began in the late 1970s, did not day (median, 68%).4 Some had been vaccinated only meet widespread opposition. Indeed, in Los Angeles, Ca- shortly before entering school to comply with school im- lif, and New York, NY, to cite two examples, although munization requirements and thus had been at risk of dis- thousands of children were denied entry to school (or were ease for several years. sent home) because of a lack of evidence of immunization, Those who are not immunized on time are likely to be most returned to school within 1 or 2 days, either having members of racial and ethnic minorities and to be socio- found their immunization records or having been immu- economically disadvantaged. A recent investigation in nized. Chicago, III, demonstrated that only 50% of the students Second, the private and public "system" to deliver im- enrolled in predominantly black and Hispanic schools had munizations in the United States has the capacity to serve been immunized against measles by their second birth- all children (because it ultimately does so) and that the day, compared with 80% of students in predominantly costs of immunization in either the private or the public white schools.⁵ In predominantly black or Hispanic sector do not pose insurmountable barriers (again, be- schools 25% to 30% of the students had been vaccinated cause almost every child ultimately is immunized). This shortly before school entry, presumably to meet school is not to say that the costs of immunization are unimpor- entry criteria. An inverse correlation was noted between tant; any parent would find the $59.01 (private sector) vac- immunization coverage by the age of 2 years and the in- cine cost of the 15- to 18-month immunization with DTP, cidence of measles in preschoolers. OPV, MMR, and Haemophilus b conjugate vaccine daunt- The striking disparity between the extraordinary suc- ing. In fact, postponing this expenditure may contribute 42 Caring for the Uninsured and Underinsured to the delayed receipt of vaccines. However, in the final noted earlier, immunization levels in these settings are gen- analysis, some way is found to meet these costs. erally high. However, more than two thirds of these children FACTORS RESPONSIBLE (and more than 85% of those younger than 2 years) are being Given a willing populace and a system capable of meet- cared for in another setting, such as a home. Bringing these ing the need, why is it that we are in such trouble? Here children to immunization clinics (or bringing immunization the analysis gets softer with difficulty in documentation services to them) may be difficult. and in assigning weights. At least three factors seem to be Barriers to Immunization involved. Barriers may be as seemingly trivial as the requirement Inattention by the Provider in some health department clinics that immunizations be This is a problem both in the private and the public sec- given only by appointment rather than on a walk-in basis, tors. Even though all births are registered with vital sta- or they may be more apparent, such as limited clinic hours, tistics authorities and more than 98% of children in this no evening or weekend clinics, or insufficient staff. A re- country are born in hospitals, no uniform data system cent survey of state health department immunization keeps track of all children and identifies those in need of projects revealed that 50% had such barriers.⁸ a dose of vaccine at a particular time. Individual physician It is important that parents understand all of the benefits offices may have reminder systems, but surveys of private and risks of immunizations, and considerable effort (and physician records have demonstrated that 10% to 30% (or legislation) has gone into trying to ensure this.9 However, more) of their patients are not up-to-date for immuniza- the "Vaccine Information Pamphlets" that are being de- tions. In the public sector, some health departments have veloped and are required for use with all vaccines may them- automated systems that track individual children, identify selves pose a barrier. Despite considerable work, they are those in need of immunizations, and may even generate written at an eighth-grade reading comprehension level and mailed reminders. A few may employ outreach workers average 2000 words each. Given that many adults read fewer who go into the community and talk with parents about than 100 words per minute and that there will be three forms the need for immunization. In the majority of both private to be read at the 15-month visit (DTP, polio, and MMR), it and public providers, however, it seems that no compre- seems likely that the process itself might be a disincentive hensive system exists to identify and notify individuals to parents, not to mention creating an office traffic problem who need immunization or to assess overall immunization and tying up office staff, whose time may not be adequately levels in their client populations. Thus, appropriate im- reimbursed by third-party payers. munization may depend on a highly motivated parent or Another potential barrier is less obvious and also results a provider who views immunization as a priority. from good intentions: the desire to provide comprehen- Another problem arises when the provider does not re- sive care. This may be manifested by a requirement that view immunization status and offer needed immuniza- a child have a complete well-child appraisal before receiv- tions when a child is seen for whatever reason. Each con- ing vaccines. Because many health care providers (par- tact with the health care system should include review of ticularly in the public sector) are overextended, children immunization status and provision of needed immuniza- must wait weeks to months for these appraisals. Mean- tions. Other factors include excessive interpretation of while, they remain susceptible to vaccine-preventable dis- contraindications to vaccination and failure to administer eases (and, in fact, may be exposed to such diseases when all indicated vaccines at a single visit. A recent review of they visit the health care provider). This recalls Voltaire's records at a public health department child health clinic maxim that "the best is the enemy of the good."¹⁰ in L'os Angeles revealed that only two thirds of the children Financial barriers may also exist. More than 15% of pre- received MMR vaccine on their first visit after becoming schoolers are covered neither by health insurance nor eligible (K. M. Farizo, MD, P. A. Stehr-Green, DrPH, L. Medicaid and almost 10% have no regular source of care. 11 E. Markowitz, MD, and P. A. Patriarca, MD, unpublished If free public services are not readily available, these chil- data, August 1988). None of the "missed opportunities" dren may lose out. In addition, reimbursement mecha- arose from a valid reason for withholding the vaccine. nisms may cover acute curative care but not preventive services such as immunizations; only 45% of employment- Competing Priorities based conventional health insurance plans covered basic Simply put, modern parents have many things on their childhood immunizations in a recent survey.¹² minds. Many children are being raised by single parents who have jobs that do not pay well and that do not provide many POSSIBLE REMEDIES benefits. In addition, other children in the home may have The easiest recommendation is to say, "Put more re- other problems. Thus, priorities may focus on more imme- sources into immunization programs." Although I agree diate needs, such as food, shelter, clothing, or acute medical that more resources will be required, it seems clear that care. "Nonurgent" issues, such as immunization of a well money alone is not the answer. child, simply do not reach the threshold for action. Some have proposed that the government should pro- Another indication that immunization may not achieve vide all recommended childhood vaccines as an entitle- high priority comes from a consideration of where (and with ment for all children. 13 As a lifelong advocate of immu- whom) children are during the day. Sixty percent of children nization, I find it difficult to argue that this would be younger than 5 years are in a child-care setting (including inappropriate. However, further reflection suggests that 50% of those younger than 2 years, who are most in need this would not solve the problem. The government (fed- of immunization).⁷ Of these, 31% are in a group-care setting eral, state, or local) provides vaccines for socioeconomi- (eg, nursery, preschool, or day-care center) where state im- cally disadvantaged children. Consequently, additional munization requirements may ensure immunization. As government expenditures for vaccines would essentially Vaccination 43 subsidize vaccination for the middle class and well-to-do, need to be increased, in terms of their overall capacity, who seem to be getting immunized on schedule. Never- their location, and the times at which they are offered. This theless, arguments have been made that free services strengthening of the public health "infrastructure" has should be provided for all, not just for the poor, so as not historically been primarily a local and state activity, with to establish a "two-tier" or "second-class" category of care federal involvement playing a minor role. A recent Insti- for the disadvantaged. Another reason, given increasing tute of Medicine study has described the public health sys- vaccine costs and the increasing number of vaccines, tem in this country as being "in disarray," not just in terms would be to prevent diversion of private-sector patients to of immunizations but with regard to the entire public the public sector (where vaccines are free), thus prevent- health mandate. A societal commitment is necessary to ing further fragmentation of care. In any event, continued ensure that the public sector is capable of providing government support for all recommended vaccines for so- needed services, and this will require increased public- cioeconomically disadvantaged children is essential. sector resources from all levels. More likely remedies flow from the factors mentioned More education is needed for health care providers to in the preceding section. First, information systems must ensure that they realize the importance of immunizations, be developed and put into practice to (1) track the immu- understand true and false contraindications, and elimi- nization status of each child, (2) prompt a reminder of nate missed opportunities for immunizations. Profes- needed immunizations coming up, and (3) sound an alarm sional societies can play a leading role in this aspect. when a child is overdue. Possibly even more important, It is not at all clear how we can reconcile the need to such information systems would allow health care pro- ensure informed participation with the fact of extensive, viders to assess how well they are doing in protecting their and often conflicting, information about the benefits and clientele. The suboptimal immunization levels found on risks of particular vaccines. It is clear, however, that the record reviews are usually a surprise to the provider and days have gone of the "MDeity" deciding unilaterally what commonly result in remedial action. is best for the patient. Second, effective means must be developed to get the Reducing the barriers relating to the desire for compre- word to the child's parents. In many areas, mail or tele- hensive care may be difficult but should not be impossible. phone may suffice, but in many poorer areas, parents may Even while scheduling children for future comprehensive be marginally literate, distrust official mail, or have no tele- evaluations, it should be possible to establish "express lane" immunization services to immunize all children who phone. Direct contact by an outreach worker seems most likely to be successful in these circumstances, particularly come to a health care provider. Leadership from profes- if the outreach worker is of the same racial or ethnic back- sional societies will be essential to bring about this change ground as the parent. However, additional resources in orientation. Immunizations should also be brought to children in child-care settings and in programs such as the would be required to fund such labor-intensive activities. Third, some mechanism must be found to raise the pri- Women, Infants, and Children program and Aid to Families With Dependent Children. Given the overburdened facili- ority of immunization. Mechanisms that come to mind are ties of the Women, Infants, and Children program and Aid incentives, either positive or negative. A positive incentive to Families with Dependent Children, the provision of im- might include payment (either monetary or in kind) to the munization on site will require increased resources. parent when the child is immunized. A negative incentive might be the threat of denial of services or support if the COMMENT child is not immunized. A large proportion of the children Although we have much to be proud of in the way we are most likely to be behind schedule are enrolled in some type protecting our children with immunizations, significant of public-assistance program. In four large, inner-city problems remain. No single "magic bullet" is apparent that measles outbreaks recently investigated, it was found would remove all the problems. A multifaceted approach is that, of the nonimmunized children with measles who needed to reduce the problems already identified, and re- were old enough to have been vaccinated, as many as 86% search is needed to define the factors involved in immuni- were enrolled in the Aid to Families With Dependent Chil- zation and nonimmunization and to develop more effective dren program and up to 61% were enrolled in the Special interventions. Immunizations are among the most precious Supplemental Food Program for Women, Infants, and health gifts we can give our children; we must find the ways Children. 14 Perhaps it would be possible to require age- to ensure full and equitable distribution of these gifts. appropriate immunization as a condition for continued References participation (not initial enrollment) in these programs. 1. Centers for Disease Control. General recommendations on Although there is justifiable concern that this might result immunization. MMWR. 1989;38:205-214, 219-227. in needy children being denied services, it seems likely 2. American Academy of Pediatrics, Committee on Infectious that the experience encountered when first enforcing Diseases. Measles. Pediatrics. 1989;84:1110-1113. school immunization requirements would be repeated, 3. Orenstein WA, Bernier RH. Surveillance. Pediatr Clin and no, or only temporary, withdrawal of benefits would North Am. 1990;37:709-734. occur. Additionally, such a process would also ensure that 4. Centers for Disease Control. Measles vaccination levels children were gotten into the health care system where among preschool-aged children in 8 selected cities, United they could receive other important services. States. MMWR. 1991;40:36-39. Increased efforts to promote or "market" immunizations 5. Centers for Disease Control. Update: measles outbreak- Chicago, 1989. MMWR. 1990:39:317-319, 325-326. are needed to raise the priority of immunizations. 6. Ector WL. Immunization levels of children in private prac- Efforts to reduce barriers are also needed. Administra- tice. In: Proceedings of the 15th Immunization Conference of tive procedures must be reviewed to ensure that they do the Centers for Disease Control; March 10-13, 1980; Denver, not impede immunization. In addition, clinic services Colo; pp 70-72. 44 Caring for the Uninsured and Underinsured 7. Dawson DA, Cain VS. Child care arrangements: health of our 11. Bloom B. Health insurance and medical care: health of our nation's children, United States, 1988. Advance data No. 187. nation's children, United States, 1988. Advance data No. 188. Hyattsville, Md; National Center for Health Statistics; 1990. 1990; Hyattsville, Md: National Center for Health Statistics; 1990. 8. Orenstein WA, Atkinson W, Mason D, Bernier RH. Barriers 12. Health Insurance Association of America Survey 1989. Wash- to vaccination of preschool children. / Health Care Poor Un- ington, DC: Health Insurance Association of America; 1989. derserved. 1990;1:315-329. 13. American Academy of Pediatrics. Cross-national compar- 9. Bruce R. Status and use of vaccine information pamphlets. isons of child health. Pediatrics. In press. In: Proceedings of the 24th National Immunization Conference 14. Hutchins SS. Access of preschool-aged children to health of the Centers for Disease Control; May 21-25, 1990; Orlando, care services and federal assistance programs. In: Proceedings Fla; pp 99-100. of the 24th National Immunization Conference of the Centers 10. Arouet FM (Voltaire). Dictionnaire Philosophique. 1764. for Disease Control; May 21-25, 1990; Orlando, Fla; pp 87-92. The Challenge of Caring for Indigent Children With Rheumatologic Diseases Michael L. Miller, MD, Patience H. White, MD Poverty and lack of insurance prevent complete access to insured. For the uninsured, the Medicaid program has yet tertiary care for many children with rheumatologic diseases. to live up to its promise. Although it increased access to Long-term solutions to provide community based support ambulatory services for children of lower socioeconomic for local teams and other services are needed. Physicians status, Medicaid has covered less than half of children need to work with colleagues in health care systems and from low-income groups during the past decade.² This government to make the health care system fully available may explain why indigent children with health problems to all families. Medical schools can act as catalysts in helping do not visit physicians as often as those from higher so- government agencies redefine policies to support outreach cioeconomic groups. 3,4 Because their parents cannot af- and other health care programs for the indigent. Govern- ford it, many indigent children with chronic diseases do mental agencies must collaborate with insurance companies not receive continuing primary care. Thus, impoverished to change policies so as to cover all aspects of service, in- children with arthritis often cannot get longitudinal mon- cluding those provided by arthritis health professionals. itoring of their illness. The result can be delayed diagnosis With coordinated effort, the goal of adequate services to and later referral to pediatric rheumatology centers, which indigent children with rheumatologic and other chronic ill- can affect prognosis. nesses can become reality. Even when Medicaid or insurance companies cover rheumatologic illnesses, many children cannot get the co- P overty amplifies problems that rheumatologic dis- ordinated services they need for optimal care. Federal and eases impose on children and their families. Provid- state governmental agencies do not pay for all the nec- ing adequate care becomes a challenge for society no less essary care. Those indigent families with some form of than for physicians and other health care professionals. health insurance are usually underinsured because their For the many indigent children with these diseases who employers offer benefits programs that do not provide full do not receive continuing primary care, access to pediatric coverage. As health care costs increase, coverage becomes rheumatology centers becomes difficult. Those who do get even more restricted. Reimbursement for physical and oc- to pediatric rheumatology centers often have difficulty in cupational therapy, nutritional counseling, and orthotic getting prescribed services, such as physical therapy. As devices is either insufficient or, in some cases, nonexist- a result, potentially reversible problems, such as joint con- ent. Families with marginal incomes often cannot afford tractures, may last well into adulthood; persisting disabil- to pay for uncovered services.⁵ ity can interfere with the ability to work. This articie will Decreased access to care for indigent children with chronic examine problems with access to and delivery of care for rheumatologic diseases causes serious consequences. Fam- impoverished children with rheumatologic diseases. We ilies experience fragmentation of services: they may need to will suggest some approaches health care professionals choose between paying for primary preventative care locally can take in dealing with these problems. or for transportation to and care at tertiary care centers. De- creased services can lead to uncorrected disability that wors- PROBLEMS IN ACCESSING CARE ens over time. Community-based services could provide Poverty and lack of insurance prevent access to tertiary some of these services if they were more complete. Respite care for many children with rheumatologic and muscu- programs offering parents help with affected children and loskeletal diseases. Among youths aged 19 to 24 years, their siblings are only partially funded. these illnesses account for more than half of chronic dis- Impoverished children with arthritis face additional abilities in this country; 20% of affected children are un- problems when they enter the adult world. Young adults may lose funding for medical care because of age limits set by state agencies. Those on the lower end of the socio- Accepted for publication December 27, 1990. From the Department of Pediatrics, University of Texas Health economic scale tend to have lower educational achieve- Science Center, San Antonio (Dr Miller); and the Department of ments. In adults with rheumatoid arthritis, low educa- Pediatrics, Children's National Medical Center, George Washing- tional levels correlate with worse prognosis⁶; the resulting ton University, Washington, DC (Dr White). disabilities make getting work more difficult. Available Reprinted from AJDC (1991;45:554-558). jobs often do not offer adequate health insurance, perpet- 46 Caring for the Uninsured and Underinsured uating the cycle of decreased access to health care. Thus, ilies in a variety of ways, such as helping them get emer- indigent young adults who are poorly educated may have gency funds to purchase food or obtain, complete, and the most severe disease and the last access to health care. follow up on application forms for state and federal aid. Since parents of children with chronic illnesses are more SERVICES THAT ARE NEEDED likely to divorce, social workers provide counseling for FOR OPTIMAL CARE families in distress. Social workers identify and arrange For children who regularly visit pediatric rheumatology intervention for children at risk for medical or physical neglect. These important services are seldom reimbursed. centers, prognosis depends on the nature of their illness Yet social workers obtain clinical revenues from state and and the availability of medical services. The three most federal sources for medical care that would otherwise be common rheumatologic illnesses of childhood are juvenile unavailable. rheumatoid arthritis (JRA), systemic lupus erythemato- sus, and dermatomyositis.⁷ Juvenile rheumatoid arthritis Many children with JRA and other rheumatologic ill- is not rare; in the United States, it is estimated to affect nesses need to improve their independence by increasing more than 10 children per 100 000.⁸ Juvenile rheumatoid joint mobility and muscle strength, obtaining adaptive arthritis is classified into systemic, pauciarticular, and aids for daily living, and learning coping skills to minimize polyarticular types, based on clinical presentation, includ- pain. Physical therapists can help by recommending ex- ing number of joints affected, and course. Patients with ercise programs for home and school. When joint flexion JRA need close monitoring of their anti-inflammatory contractures develop in patients with JRA, occupational medications. They also need close follow-up by ophthal- therapists can make some of the necessary splints. They mologists, physical and occupational therapists, and other also work with patients to improve activities of daily liv- health care professionals. Lupus, an autoimmune disease ing. Occupational therapists work with school personnel of unknown etiology, can present at any age, but most to adjust schedules, giving appropriate periods for rest or pediatric cases occur in adolescent girls. Services needed for walking between classes. They monitor other changes depend on complications, which include chronic renal dis- in the school environment that will improve the student's ability to function. ease, pleuritis, pericarditis, and arthritis. Patients with systemic lupus erythematosus often re- Some patients with JRA have growth abnormalities,9.11 quire chemotherapeutic agents, necessitating regular hos- become anorectic, 12 or are at risk for becoming malnour- pitalization and outpatient follow-up. Dermatomyositis, ished. 13 These problems are exacerbated by the difficulty an inflammatory disease of skin and muscle, requires in- many poor families have in affording sufficient food to tensive physical therapy and anti-inflammatory or immu- feed their children. 14,15 Dieticians on pediatric rheumatol- nosuppressive medication. Most pediatric rheumatologic ogy teams document food intake and identify for the social patients survive into adulthood. Because their illnesses worker which families need aid for nutritional supple- often remain active, they need complex transition ser- ments. They counsel families on how to prepare a bal- anced diet on a limited income. vices. These include identifying primary care physicians familiar with their type of illness, training in job readiness Career maturity is often delayed in adolescents with skills, and sex counseling (as many are at risk for teenage rheumatologic diseases, compared with their nondisabled pregnancy). peers. It is most severe in those teenagers whose disease No matter what their socioeconomic status, children onset was in early adolescence. 16 In most of the United with rheumatologic illnesses and their families need help States, current services are inadequate to handle this group of chronically ill and disabled adolescents. For ex- in using disparate resources scattered throughout the ample, a recent Harris poll found that between 50% and community. This is often best done in a planning process called "case management" by pediatric rheumatology 75% of young adults with disabilities are jobless; 67% of teams. The coordinating team often includes parent rep- those who were unemployed wanted to work. 17 However, resentatives, physicians, nurses, social workers, and the Federal Vocational Rehabilitation System only pro- physical and occupational therapists. Team members also vides services to young adults over 18 years old in many use their individual skills to provide coordinated care in states. Earlier delivery of vocational programs might help a single setting. For instance, children and their families children with rheumatologic diseases make a better tran- need to comprehend clearly the nature of their illness. sition from school to work. The widespread absence of this Nurses help families to understand further the informa- type of program typifies some of the problems that exist in delivering services. tion communicated by other health care professionals. Families can then select from the many materials (includ- PROBLEMS IN DELIVERING SERVICES ing videotapes, pamphlets, and coloring books) now avail- Delivering services to indigent children with rheuma- able on JRA and other rheumatologic diseases. Nurses are tologic diseases is difficult. Parents may be unable to take often the first to help families decide whether a visit to the children for physical or occupational therapy if they lack primary physician or subspecialist is needed. In this sense, funds for transportation. Delays in insurance reimburse- pediatric rheumatology nurses perform triage as impor- ment sometimes prevent families ineligible for assistance tant as that provided in emergency departments for pa- from buying medications. Inadequate funding for services tients with acute problems. makes it difficult for some medical centers to recruit and Indigent families need help in using resources effec- keep arthritis health care professionals. tively. They often do not know where to find local com- School districts in poverty-stricken areas do not always munity services; they may not understand the bureau- provide special education services mandated by the fed- cratic processes required to maintain eligibility for aid. eral Public Law No. 94-142 (Education for All Handi- Social workers on pediatric rheumatology teams help fam- capped Act, 20 USC, §1401 (1). (15)) for children with Indigent Children 47 "other health impairments," including JRA. 18 Low bud- diseases will only receive services for which society is will- gets may prevent administrators from providing school ing to pay. Enhancing those existing services that are sub- facilities that have adequate access for the physically hand- optimal will require advocacy. Therefore, parents must icapped. To be able to sit in the classroom and write their form new coalitions with health care professionals, com- assignments, some students with severe arthritis need munity agencies, and foundations in being strong advo- range of motion and stretching exercises in school. How- cates for government-supported services for all indigent ever, many poor school districts cannot offer competitive children with chronic illnesses. salaries or fees to recruit physical therapists, even when The American Juvenile Arthritis Organization (AJAO), state funds are available for therapy sessions. Children part of the Arthritis Foundation, provides parents a forum with arthritis in these districts may suffer increasing pain, for advocacy, education, and support. Both parents and weakness, or joint contractures. As a result, they miss professionals belong to and help operate AJAO. A quar- more days of school; when in school, they have difficulty terly newsletter provides information on care and research in concentrating. 19,20 of JRA and related illnesses. Local chapters conduct camps In many states throughout the country, agencies that and other activities. An excellent compendium of infor- administer the Chronically Ill and Disabled Children's Ser- mation about JRA is available through the Arthritis Foun- vices programs encounter fiscal constraints in caring for dation. 21 indigent children. To meet budgets passed by cost- conscious state legislatures, these agencies sometimes The Arthritis Foundation is interested in new ways in must set limits on reimbursement that interfere with care which parents can get better care for their children with for chronic illness. Limits to the number of hospital days rheumatologic diseases. For instance, the AJAO will be reimbursable for rehabilitation deny some impoverished starting a new program to involve parents in regionaliza- children with severe arthritis and dermatomyositis the in- tion of services. Regionalization is described by Perrin and tensive inpatient physical and occupational therapy Ireys⁵ as the establishment of regionwide standards of re- ferral, evaluation, and care of children with chronic ill- needed for optimal recovery. Agencies in some states must also restrict the coverable diagnoses or complications to nesses. The authors discuss the utility of a database that meet budgets; for instance, only musculoskeletal compli- identifies medical and nonmedical resources, and they cations of systemic lupus erythematosus may be covered. recommend a plan for regional care that includes referral States do not always cover costs for necessary services pro- mechanisms and community education. vided by team members. Social work services, for exam- To establish its program fostering regionalization, the ple, are rarely covered. Nutritional counseling for poor Arthritis Foundation collaborated with Daniel Lovell, MD, children may not be available in states that do not offer MPH, University of Cincinnati, Ohio, in obtaining federal reimbursement. Another example of limited service for support from the Maternal and Child Health Bureau of the children with arthritis concerns splinting, often necessary US Department of Health and Human Services. The Ar- to restore function to contracted joints. When budget cri- thritis Foundation is establishing the National Resource ses affect state medical programs, state agencies are forced Center for Childhood Rheumatic Diseases (NRCCRD). to delay reimbursements to vendors, who in turn may not The NRCCRD will train parents to participate in support honor orthotic prescriptions. Ironically, the result may be groups, become advocates for improved services, and give a nonbiologic seasonal variation in the duration of joint feedback concerning programs to health care profession- contractures, in which increases occur at the end of the als. Local Arthritis Foundation chapters will train parent- state's fiscal year. professional teams, which will in turn train parents in pe- State funding problems have also affected some out- diatric rheumatology centers. Indigent families can receive reach programs, in which pediatric rheumatologists visit training directly from these teams. The NRCCRD may outlying areas. They work with locally based health care serve as a model for involving indigent parents of children teams, which may also care for children with other chronic with many other chronic illnesses in the regionalization of illnesses. The federal or private grants that start these pro- health care delivery. grams are usually temporary; when support ends, local Community organizations need to petition state legis- funding may not always be sufficient to maintain all the latures and the federal government to fund services at ad- local team members. Long-term solutions to provide equate levels for children with rheumatologic and other community-based support for local teams and other ser- chronic diseases. Many organizations are currently advo- vices are needed. cating improvements in health care coverage for children with chronic illnesses, including rheumatic disease. The POSSIBLE APPROACHES American Academy of Pediatrics (AAP) has proposed a Physicians and other health care professionals have comprehensive health insurance plan. 22 The AAP is also been making progress on the problems described above. collaborating with the Maternal and Child Health Bureau Much work remains to be done by people at all levels of in developing strategies for improving community-based the health care system. Parents, community organiza- access to care. tions, primary care physicians, pediatric rheumatologists Health services research has documented the need for and their teams, and medical schools all have their role to services; communities can help investigators get funding play. With coordinated effort, the goal of adequate ser- for further research through fund-raising and legislative vices to indigent children with rheumatologic and other advocacy. Some local health departments have been suc- chronic illnesses can become reality. cessful in convincing public health degree candidates to Parents are their children's best advocates when they conduct research on delivery of health care as part of their understand some fundamental issues about health care. training. Local organizations can also learn more about Specifically, impoverished children with rheumatologic these issues and meet some service needs by offering to 48 Caring for the Uninsured and Underinsured place volunteers in outreach clinics for children with rheu- other health care programs for the indigent. For example, matologic and other chronic illnesses. the University of Texas, San Antonio, has begun a pro- Pediatricians and other primary care physicians provide gram for working with state health agencies in delivering critical help for indigent children with chronic rheuma- care to the poor of all ages in the Rio Grande Valley. In this tologic illnesses by following up these children along with program, called the University of Texas System Valley/ subspecialty health care teams. In clinics serving indigent Border Health Services Task Force, university health care areas, primary care physicians are the first to identify prob- professionals and administrators meet with local and state lems worsened by poverty. Close communication be- counterparts in designing delivery systems that conserve tween primary care physicians and pediatric rheumatol- fiscal and professional resources. The collaboration be- ogy teams allows the teams to identify which children tween university, state government, and local health de- need help with noncompliance and school problems. Pri- partments is critical in linking primary and specialty health mary care physicians also work closely with pediatric care in south Texas. rheumatology teams in coordinating provision of local ser- Children's hospitals can establish programs for adoles- vices for families, thus helping to reduce fragmentation. cents with chronic illnesses that help them prepare for If primary care physicians and other health care pro- employment. At the Children's National Medical Center fessionals need more information about pediatric rheu- in Washington, DC, the Adolescent Employment Readi- matologic illnesses, information is available through local ness Center offers career and academic counseling to in- continuing medical education and AAP education pro- dividual teenagers. A newsletter informs adolescents and grams. The Arthritis Foundation and the American Col- their families about career awareness and other work- lege of Rheumatology also provide educational materials. shops. The center also holds seminars for schools, com- In addition, programs are available where health care pro- munity groups, and employers. fessionals can rotate through pediatric rheumatology ser- Economic conditions in the immediate future may re- vices. Informed health care professionals can work more quire a decrease in budgets for the care of children with closely with community groups, local schools, and sub- rheumatologic diseases. The approaches mentioned will specialty health care teams. Using limited resources, they be feasible only if financial planning is at the core of plan- can make the best choices possible in upgrading local ning coordinated programs. For instance, some children's health care delivery. hospitals cannot afford dedicated pediatric rheumatology Members of pediatric rheumatology teams help provide teams. They may be able to establish teams caring for chil- comprehensive service to indigent children with rheuma- dren with related problems, such as musculoskeletal tologic illnesses, as mentioned above. In the future, the teams for children with rheumatologic and orthopedic increased use of questionnaires will help pediatric rheu- problems. Health care teams can use computer programs matology team members evaluate and monitor the to produce more efficient schedules by tracking time re- progress of children with JRA and related diseases. A quired to deliver services. Administrators may be able to school questionnaire assesses the physical problems con- help teams set up fiscal models. Such models could de- fronting children in school and suggests solutions to these termine the most cost-effective use of community re- problems. 18 The Family Environment Scale measures the sources by families as well as by the teams. ability of families to cope with emotional issues. 23 Myones Eliminating rheumatologic diseases through cures gen- et al²⁴ have used it to study families of patients with JRA. erated by basic research is the ultimate solution to prob- Dieticians use 24-hour recall questionnaires and diet di- lems worsened by poverty. Research establishing a vac- aries. Monitoring the functional disability caused by JRA cine resulted in eliminating polio as a major health problem. Similarly, etiologies and better treatment will can help pediatric rheumatology teams identify patients in need of rapid services. Lovell et al²⁵ recently developed probably be determined by studies of transgenic mice. and validated a pediatric version of the Health Assessment However, the best therapy is only as good as the ability Questionnaire used in adults with arthritis. Indigent chil- to make it uniformly available. Governmental agencies must collaborate with insurance companies to change pol- dren will benefit greatly; the Lovell et al instrument can icies so as to cover all aspects of service, including those monitor the ability of intervention to improve function in provided by arthritis health care professionals. Physicians situations where many complex underlying factors may need to work with colleagues in health care systems, gov- contribute to impairment. ernment, and the Arthritis Foundation to make the health Outreach programs are an important indicator of how care system fully available to all families. Educating the carefully different professionals must work together. As public about chronic illnesses in childhood will be nec- mentioned, government or foundation sources of initial essary to reach this goal. Only then will children with funds will not always provide continuing support. The rheumatic diseases, irrespective of their socioeconomic survival of outreach programs therefore requires that local status, get the primary and coordinated subspecialty care medical and nonmedical organizations arrange for con- they deserve. tinuing financial support through foundations, fund- raising, and advocacy through state legislatures. During We greatly appreciate comments on the manuscript provided by the planning stages for new outreach programs, local or- John A. Mangos, MD, and Victor German, MD, PhD. ganizations, state agencies, and medical schools need to References discuss how they can best make the transition from tem- 1. McManus MA, Newacheck PW, Greaney AM. Young adults with special health care needs: prevalence, severity, and porary to permanent sources of funding without inter- access to health services. Pediatrics. 1990;86:674-682. rupting services. 2. Newacheck PW, Halfon N. Access to ambulatory care ser- Medical schools can act as catalysts in helping govern- vices for economically disadvantaged children. Pediatrics. ment agencies redefine policies to support outreach and 1986;78:813-819. Indigent Children 49 3. Kleinman JC, Gold M, Makuc D. Use of ambulatory medical 16. White PH, Gussak D, Hixson D. Career maturity of ad- care by the poor: another look at equity. Med Care. olescents with juvenile rheumatoid arthritis (JRA) compared to 1981;19:1011-1029. other chronically ill adolescents. Arthritis Rheum. 1989;32S:29. 4. Newacheck PW, Starfield B. Morbidity and use of ambu- 17. Rosch D, Phelps A. Secondary special education and tran- latory care services among poor and nonpoor children. Am J sition from school to work: a national priority. Except Child. Public Health. 1988;78:927-933. 1987;53:487-491. 5. Perrin JM, Ireys HT. The organization of services for chron- 18. Spencer CH, Zanga J, Passo M, Walker D. The child with ically ill children and their families. Pediatr Clin North Am. arthritis in the school setting. Pediatr Clin North Am. 1986; 1984;31:235-257. 33:1251-1264. 6. Callahan LF, Pincus T. Formal education level as a signif- 19. Stoff E, Bacon MC, White PH. The effects of fatigue, dis- icant marker of clinical status in rheumatoid arthritis. Arthritis tractibility, and absenteeism on school achievement in children Rheum. 1988;31:1346-1357. with rheumatologic diseases. Arthritis Care Res. 1989;2:49-53. 7. Cassidy JT, ed. Textbook of Pediatric Rheumatology. New York, NY: John Wiley & Sons Inc; 1982. 20. Lovell D, Arthreya B, Emery H, et al. School attendance 8. Towner SR, Michet CJ Jr, O'Fallon WM, Nelson AM. The patterns, special services, and special needs in pediatric pa- epidemiology of juvenile arthritis in Rochester, Minnesota. Ar- tients with rheumatoid diseases: results of a multicenter study. thritis Rheum. 1983;26:1208-1213. Arthritis Care Res. In press. 9. Lovell DJ, White PH. Growth and nutrition in juvenile rheu- 21. Kovalesky A, Boutaugh M, Erlandson D, et al. Juvenile matoid arthritis. In: Woo P, ed. Pediatric Rheumatology Update. Rheumatoid Arthritis: A Health Professional's Guide to Teaching New York, NY: Oxford University Press Inc; 1990:47-56. Children and Patients. Atlanta, Ga: Arthritis Foundation; 1987. 10. White PH. Growth abnormalities in children with juvenile 22. Harvey B.A proposal to provide health insurance to all chil- arthritis. Clin Orthop. 1990;259:46-50. dren and all pregnant women. N Engl J Med. 1990;323:1216-1220. 11. Bacon MC, White PH, Raiten DJ, et al. Nutritional status 23. Moos RH, Moos BS. Family Environment Scale Manual. and growth in juvenile rheumatoid arthritis. Semin Arthritis Palo Alto, Calif: Consulting Psychologists Press; 1981. Rheum. 1990;20:97-106. 24. Myones BL, Williams GF, Billings A, Miller III JJ. Social 12. Miller ML, Chacko JA, Young EA. Dietary deficiencies in environment in families of children with juvenile arthritis. Ar- children with juvenile rheumatoid arthritis. Arthritis Care Res. thritis Care Res. 1988;1:17-22. 1989;2:22-24. 25. Lovell DJ, Howe S, Shear E, et al. Development of a dis- 13. Henderson CJ, Lovell DJ. Assessment of protein-energy ability measurement tool for juvenile rheumatoid arthritis: the malnutrition in children and adolescents with juvenile rheuma- Juvenile Arthritis Functional Assessment Scale. Arthritis Rheum. toid arthritis. Arthritis Care Res. 1989;2:108-113. 1989;32:1390-1395. 14. Karp RJ. Undernutrition and the cycle of poverty. Pediatr 26. Fries JF, Spitz P, Kraines RG, Holman HR. Measurement Ann. 1990;19:268-271, 274-275. of patient outcome in arthritis. Arthritis Rheum. 1980;23:137- 15. Karp RJ. The social context of malnutrition in childhood. 145. Bull N Y Acad Med. 1989;65:1026-1031. Poverty and Cardiac Disease in Children Hugh D. Allen, MD; Kathryn A. Taubert, PhD; Richard J. Deckelbaum, MD; David Driscoll, MD; Ann Dunnigan, MD; Samuel S. Gidding, MD; Paul Herndon, MD; Rae-Ellen W. Kavey, MD; Charles Mullins, MD; A. Rebecca Snider, MD; William B. Strong, MD; Reginald Washington, MD A lmost 80 million children live in the United States. At dren require access to the pediatric cardiac health care sys- least eight of every 1000 infants born each year have tem. congenital heart defects.¹ When mortality and spontane- UNIQUENESS OF THE ous defect improvement are factored into live birth data, POVERTY POPULATION Roberts and Cretin² estimated that by 1995 there will be 300 000 children under the age of 21 years with congenital Pregnant women who live in poverty have less prenatal heart disease; 38% will have had one or more surgical pro- care than affluent patients. This creates a problem for cer- cedures. Other children will develop acquired heart dis- tain fetal conditions that must be detected in enough time ease, such as cardiomyopathies, rheumatic fever, acquired to institute treatment that will allow fetal salvage. For ex- immunodeficiency syndrome with its myocarditis, Ka- ample, fetal echocardiography permits the diagnosis of wasaki disease, and arrhythmias. The projected incidence supraventricular tachycardia in hydropic fetuses. These estimate for supraventricular tachycardia alone is between can be successfully treated by administration of antiar- one and four per 1000.³ Familial hypercholesterolemia will rhythmic drugs to the mother. Otherwise the fetus could die. Detection and careful control of the diabetic mother affect the future of an unknown but probably large number of children. Therefore, at least one-half million children in results in less frequent occurrence of diabetic cardiomy- the United States have some form of cardiac problem. opathy in the newborn. Maternal drug abuse and acquired One quarter to one third4,5 of the more than 4 million immunodeficiency syndrome are both associated with poverty and with newborn cardiac disorders. 8-10 infants born each year⁶ are born into poverty. Therefore, The poor have greater exposure to certain environmental approximately 150 000 to 200 000 children have the prob- lems of both being poor and having heart disease. Con- risk factors, such as lead, solvents, traffic and factory emis- sidering the birth rate and incidence of heart disease, 8000 sions, and pesticides. 11,12 They can be exposed to these at- to 10 000 infants with heart problems will be added to this mospheric teratogens both at home and in the workplace. population each year. The impact of illegal immigrants on The poor have a higher illiteracy rate, often have large the overall population figure is unknown. Additionally, families, and often experience difficulty accessing (or pay- the assignment of the term poverty for a family of four at ing for) transportation to cardiac care for their children. $12 675 is probably unrealistic; according to the National This is especially the situation for the rural poor. The qual- ity of the system accessed can be variable. All these factors Center for Health Statistics, many families will still live in poverty even at a breakpoint of $20 000.7 Some families contribute to fewer postnatal visits where early detection with incomes greater than $20 000 live in a notch group of cardiovascular disorders can make a significant differ- between poverty and affordability. These groups will fur- ence in the survival rate of children who have potentially treatable lesions that are lethal if not detected and treated. ther inflate the numbers of poor children with heart prob- lems. Subsequent problems of infants and older children with Nearly every child who has been diagnosed as having heart disease include availability of and receiving immu- a heart problem will require some follow-up care. In the nizations, proper nutrition, and ability to comply with on- Baltimore-Washington Infant Study, for example, among going treatment plans, including filling prescriptions. If the child with a significant cardiac defect becomes infected all patients with heart disease diagnosed during the 1st year of life, more than 80% required ongoing pediatric car- with, for example, pertussis, that superimposed disease diology visits. Furthermore, about 50% required invasive could prove fatal in the already compromised patient. diagnostic procedures and approximately 40% needed car- Children with cyanotic heart disease, those with conges- diac surgery (C. Ferencz, MD, MPH, Principal Investiga- tive heart failure, and those being prepared for operation or who have had an operation require proper nutrition to tor, Baltimore-Washington Infant Study, unpublished data, 1981-1987). Regardless of ability to pay, affected chil- maintain growth and to keep up with increased energy intake demands imposed by their condition. The child may receive an initial prescription provided by a cardi- ologist; however, access to a pharmacy or ability to afford Accepted for publication November 19, 1990. the sometimes very expensive drugs necessary to control From the Committee on Congenital Cardiac Defects, the Com- mittee on Atherosclerosis and Hypertension in Childhood, and the the child's condition may prevent the parent from pro- Committee on Rheumatic Fever, Endocarditis, and Kawasaki Dis- viding that medication on an ongoing basis. Compliance ease of the Council on Cardiovascular Disease in the Young of the with administration of the medication is sometimes com- American Heart Association, Dallas, Tex. promised by problems as simple as the parent's inability Reprinted from AJDC (1991;145:550-553). to read and understand the directions printed on the label. Poverty and Cardiac Disease in Children 51 Older children in the poverty level have more risk fac- have formed the majority of the poverty population (the tors for cardiovascular disease as adults than do the af- so-called new poor) and also represent the segment with fluent. These include at least hypertension, smoking, and the least insurance coverage. 23,25 Over 4 million children diet. With their known increased exposure to drug abuse, uninsured and living in poverty are not eligible for Med- they have a greater risk of endocarditis, of acquired im- icaid. 26 The popular press has also recently discussed this munodeficiency syndrome with its myocarditis, and of problem. Time magazine reported that between 1978 and their own offspring having congenital heart disease, such 1987, spending on programs for the elderly rose 52% while as that encountered with exposure to cocaine and alcohol. spending on children dropped 4% (October 8, 1990:41-48). Rheumatic fever has always been primarily considered a It is apparent, therefore, that children have much less vo- disease of the poor, and studies from the 1970s and 1980s cal representation and impact at the voting booth. continue to show this pattern. 13-15 Recent data show that Children of the homeless, the migrant worker, and the rheumatic fever attacks are still being reported in all areas illegal immigrant may have greater problems than those of the country. 16 Other published focal experiences have who have permanent shelter. These include less coverage shown that numbers of cases of acute rheumatic fever are because of their transience, variations in state Medicaid increasing at least in these areas, which may or may not coverage, language difficulties, problems understanding portend a national phenomenon. 17-21 Compliance with on- the application process, and fear of discovery of their im- going prophylactic measures for prevention of secondary migrant status.⁴ attacks of rheumatic fever is compromised by poverty, ac- cess to medication, and understanding of the disease pro- cess. UTILIZATION OF THE SYSTEM Some pediatric cardiology systems are not user friendly COVERAGE PATTERNS and can be confusing and intimidating, especially for poor Crippled Children's Services or Medicaid coverage is patients. Difficulties can include transportation to the fa- available to many poor children with heart disease. For cility, parking or finding the right bus line, finding some- those who can afford it, insurance is available but may not one to stay with the other children at home, and coping be granted to those with preexisting conditions. With ris- with an inpatient environment where the child's illness ing costs of health insurance, insurance may not be af- already imposes confusion and anxiety. Many of these fordable to those just above the poverty level no matter parents cannot afford food or housing for themselves dur- whether the condition is covered or not. Certain groups ing their child's inpatient stay. Furthermore, they may have unique problems. These include the young adult have no resources for the care of the children who remain over 21 years of age who previously had Crippled Chil- at home. dren's Services coverage but no longer qualifies because Outpatient costs may be affordable for such situations of age. Another is the young adult who leaves college as a physician visit but not for expensive testing, such as and/or reaches the age of 23 years and is no longer eligible Doppler echocardiography or magnetic resonance imag- for parental private health insurance coverage. If these pa- ing. All of these factors tend to discourage the parents from tients are faced with the need for a major intervention, keeping return appointments, refilling prescriptions, or such as cardiac surgery, their lack of coverage, no matter dealing with their child's ongoing cardiac health care what profession they have entered, may move them into needs. poverty. This group was much smaller in the past because There are up to 3 million homeless people in the United many of these children did not survive into adulthood. States. Depending on the geographic location, one third However, surgical and medical advances have improved to three quarters are children. 27,28 Characteristics of this the survival and quality of life for these young adult cardiac population include less use of the health care system, as patients, and many more will enter adulthood during the eating is a higher priority; episodic usage of acute facilities next decades. when problems arise; and less follow-up care because of A notch group of those parents who do not qualify for their mobility and difficulty in accessing a consistent sys- public assistance yet cannot afford private insurance can tem. Similarly, children of migrant workers, whether hav- be similarly devastated by an expensive interventional ing immigrated illegally or not, do not have access to on- procedure that is considered necessary for treating their going health care. Such parents do not always have a clear child's cardiac condition. This sometimes presents the di- understanding of their child's cardiac condition, do not lemma of either entering poverty or not treating the heart remember the name of their last provider, and move from problem. community to community without carrying adequate doc- Only 53% of the children below the poverty line are cov- umentation of their child's condition. This, in addition to ered by Medicaid for reasons of either not qualifying, not lack of continuity of care in one location, complicates the applying, or not understanding the application. 22 Most situation for their child with a cardiac condition. Addi- states limit children's Medicaid eligibility level, some to a tionally, cultural differences, language difficulty, and fear level as low as 14% of the poverty line. 23 Particularly af- of being detected as an illegal immigrant often delay or fecting the cardiac patient is that several states limit the inhibit proper cardiac health care to this group. Certain number of hospital days covered and/or the number of hospitals, because of economic pressures, deny admission physician visits allowed.²⁴ or care to these children unless an absolute and dire emer- Since the introduction of the "War on Poverty" 25 years gency is detected. They then force early discharge after the ago and the birth of Medicare/Medicaid, a dramatic but not child's condition has been stabilized, but not necessarily yet adequate reduction in the percentage of the elderly when maximum benefit has been achieved. classified as "poor" (28.5% in 1966 to 12.4% in 1986) has Guidelines and handout materials are often written for been achieved. 23 During the same time span, children those who have attained a fairly high educational level. For 52 Caring for the Uninsured and Underinsured example, nutritional advice is sometimes aimed at the af- The number of pediatric cardiologists in the United fluent but does not take into account foodstuffs available States is limited. To provide the time for provision of equal to the poor, who must be careful of every dollar spent at and adequate care, more must be trained, and that training the supermarket. must be supported. Present resources should be used Atherosclerotic risk factor prevention is likewise di- more discriminantly. For example, pediatric specialists rected toward the affluent. Such physical activities as (pediatricians) should be able to examine patients with swimming or tennis almost categorically exclude the poor, chest pain and innocent murmurs and provide follow-up who do not have access to such sports facilities. Tobacco for patients with less significant cardiac problems, such as advertising is characteristically directed at the poor. Risk small ventricular septal defects, mild pulmonary stenosis, factor education and implementation may be available and the like. This can be accomplished by their gaining only through the schools, but many inner-city or rural greater confidence through continuing education and ex- schools cannot afford to provide nutritional programs, hy- perience. The medicolegal climate that currently drives pe- pertension screening, or physical education programs diatric specialists to refer and not to manage such condi- aimed toward improved fitness. tions must be modified so that fear of inappropriate RESPONSE OF THE litigation is not a factor behind these actions. Likewise, PRESENT SYSTEM patient attitudes must be modified to accept the pediatric Pediatric cardiologists currently respond to these prob- specialist as a consultant and provider for such cases. An- lems by availability, especially for emergencies on a cillary health personnel should be used to greater advan- 24-hour basis, writing off bills, and providing free care tage for patient education, handling minor problems, writ- both in outpatient clinics and as inpatient teaching attend- ing to schools and insurance companies, and handling ing physicians. Some offer flexible office hours and sched- other paperwork that absorbs much of the pediatric car- uling to meet the time constraints of working families. diologist's time. Many provide free or less expensive care at outlying clinics All pediatric cardiac care providers should be sensitive throughout their state, which are usually sponsored by to the problems of the poor. Their practices should be near Crippled Children's Services or the Bureau of Maternal mass transportation. They should track their patients' and Child Health. These take the physician to the patient follow-up appointments and treatments to assure com- and often offer care that would otherwise be unavailable. pliance. This may be accomplished through development Many pediatric cardiologists also provide education and of computer databases that are simple enough to be used exert political influence directly or through such organi- even by those of us who are not "computer literate." zations as the American Heart Association, American Printed materials and patient teaching materials should be Academy of Pediatrics, and the American College of Car- written to the reading level and in the language under- diology. For example, the American Heart Association stood by the patient's parent. When programs are devel- Schoolsite Program has presented heart health education oped that include general population strategies, such as to more than 7 million US schoolchildren. hypertension education and treatment, those materials Most pediatric cardiology programs directly include so- and programs must be critiqued by the group for whom cial workers and nurse clinicians as members of the cardiac their use is intended, and those critiques must receive an health care team. A few programs have access to patient acceptable response before implementation. ombudsmen and translators. Many hospitals allow room- Preventive programs should be coordinated through the ing in and recognize and help with the other individual school system. After-school care could be provided by par- needs of parents. ents and siblings from the same population, offering em- Certain private and charitable organizations offer sup- ployment opportunities to them that would otherwise not port for these patients. Some of these include the Variety be available. Physical activity programs should include all Club, Ronald McDonald housing programs, Children's children without creating embarrassment for any child, Heart Fund, Make-A-Wish Foundation, and the business- even the clumsiest. Exercise should be viewed as fun, and man's Wings of Hope program, which uses unoccupied lifelong sport activities should be taught instead of sports corporate jet seats to allow transportation between the in which only a few will achieve success. Not every child child's home and a cardiac center. will ultimately be a professional athlete. Cafeteria meal CONCLUSIONS AND RECOMMENDATIONS planning should address heart-healthy eating habits, and FOR THE FUTURE poor children should eat two meals per day at the school Physicians who provide prenatal, perinatal, and pedi- site. Cities should provide funding for health clinics based atric cardiac care must increase collaborative efforts that at the school. With these school health clinics, health pro- will lend insight into identification and care of the at-risk motion, not just disease diagnosis, should be emphasized. poverty mother at a level equivalent to that offered the Children should receive anti-smoking education that is affluent. Ways must be found to identify and treat the proved to be effective, and tobacco usage advertising di- at-risk pregnant woman. Strategies should be directed to- rected toward children and the disadvantaged should be ward adequate nutrition, maternal diabetes detection and outlawed. Other community resources, such as churches treatment, substance abuse prevention (including smok- and community centers, should be included in develop- ing), the effects of maternal age, and the influence of mul- ment of cardiovascular and other health strategies that will tiple pregnancies. Similarly, research support and activ- help the poor. ities should evaluate reasons for inadequate follow-up of There must be universal access of adequate care to the poor children who have cardiac disease. This could in- child with cardiac disease no matter what the socioeco- clude evaluation of problems with transportation, system nomic status. Medicaid and Crippled Children's Services access, finances, and disease understanding. eligibility and coverage must be improved. Care of those Poverty and Cardiac Disease in Children 53 over age 21 years who had heart problems as children must cular malformations (CVM). Teratology. 1990;41:545. receive continued funding similar to that provided to pa- 12. Ferencz C, Neill CA, Brenner JI, Perry LW, Martin GR. tients with cystic fibrosis or hemophilia. Private insurance Ventricular septal defect in infants: an eight-year population- carriers may wish to consider strategies to cover this based study. Am J Cardiol. 1990;66:524. group, which might include making a general insurance 13. Griffiths SP, Gersony WM. Acute rheumatic fever in New pool available to all with cardiac disease. If no private so- York City (1969 to 1988): a comparative study of two decades. lution to the problem is forthcoming, a national health J Pediatr. 1990;116:882-887. insurance alternative may be the only answer. 14. Land MA, Bisno AL. Acute rheumatic fever: a vanishing disease in suburbia. JAMA. 1983;249:895-898. These children do not have a voice in politics. The effects 15. Bisno AL, Ferguson GW, Shultz JM. Epidemiology of acute of that lack are apparent as their general support has de- rheumatic fever in Miami, Florida, USA, 1984-1988. XI Lancefield clined despite increases in other segments of the popu- Symposium on Streptococci and Streptoccal Diseases; Septem- lation. These children must be treated fairly, and it is up ber 10-14, 1990; Siena, Italy. Abstract L37. to us as their providers to be an effective political voice that 16. Taubert KA, Rowley AH, Shulman ST. A U.S. nationwide will be heard on their behalf. hospital survey of Kawasaki disease (KD) and acute rheumatic References fever (ARF), 1984-1987. Interscience Conference on Antimicro- 1. Clark EB, Takao A. Overview: a focus for research in car- bial Agents and Chemotherapy; September 17-20, 1990; Hous- diovascular development. In: Clark EB, Takao A, eds. Devel- ton, Tex. Abstract 827. opment Cardiology: Morphogenesis and Function. Mount 17. Veasy LG, Wiedmeier SE, Orsmond GS, et al. Resurgence Kisco, NY: Futura Publishing Co Inc; 1990:3. of acute rheumatic fever in the intermountain area of the United 2. Roberts NK, Cretin S. The changing face of congenital heart States. N Engl J Med. 1986;316:421-427. disease: a method for predicting the influence of cardiac sur- 18. Congeni B, Rizzo C, Congeni J, Sreenivasan VV. Outbreak gery upon the prevalence and spectrum of congenital heart dis- of acute rheumatic fever in northeast Ohio. J Pediatr. ease. Med Care. 1980;18:930-939. 1987;111:176-179. 3. Ludomirsky A, Garson A Jr. Supraventricular tachycardia. 19. Wald ER, Dashefsky B, Feidt C, Chiponis D, Byers C. Acute In: Garson Jr, Bricker JT, McNamara DG, eds. The Science and rheumatic fever in western Pennsylvania and the tristate area. Practice of Pediatric Cardiology. Philadelphia, Pa: Lea & Febiger; Pediatrics. 1987;80:371-374. 1990:1809. 20. Hosier DM, Craenen JM, Teske DW, Wheller JJ. Resur- 4. Children's Defense Fund. Testimony of the Children's De- gence of acute rheumatic fever. AJDC. 1987;141:730-733. fense Fund Before the House Energy and Commerce Committee 21. Westlake RM, Graham TP, Edwards KM. An outbreak of Subcommittee on Health and the Environment; September 10, acute rheumatic fever in Tennessee. Pediatr Infect Dis J. 1990; Washington, DC. 1990;9:97-100. 5. Sealing PA. Profile of Child Health in the United States. 22. Newacheck PW. Improving access to health care for chil- Alexandria, Va: National Association of Children's Hospitals dren, youth, and pregnant women. Pediatrics. 1990;86:626-635. and Related Institutions; 1989. 6. National Center for Health Statistics. Monthly Vital Statis- 23. Steinhardt BJ, DeCuypere M. Assuring Children's Access tics Report. Washington, DC: US Dept of Health and Human to Health Care: Fixing the Medicaid Safety Net. Alexandria, Va: Services; 1990;39(6):1. National Association of Children's Hospitals and Related Insti- 7. Ries P. Americans assess their health: United States, 1987. tutions; 1989. Vital Health Stat 10. 1990; No.174:10. 24. Medicaid Source Book: Background Data and Analysis. 8. Johnson SF, McCarter RJ, Ferencz C. Changes in alcohol, Washington, DC: Congressional Research Service; November cigarette, and recreational drug use during pregnancy: impli- 1988. cations for intervention. Am J Epidemiol. 1987;126:695-702. 25. Oberg CN. Medically uninsured children in the United 9. Curran JW, Jaffe HW, Hardy AM, Morgan WM, Selik RM, States: a challenge to public policy. Pediatrics. 1990;85:824-833. Dondero TJ. Epidemiology of HIV infection and AIDS in the 26. Waxman HA. Kids and Medicaid: progress but continuing United States. Science. 1988;239:610-616. problems. Am / Public Health. 1989;79:1217-1218. 10. Little BB, Snell LM, Klein VR, Gilstrap LC III. Cocaine 27. Hu DJ, Covell RM, Morgan J, Arcia J. Health care needs abuse during pregnancy: maternal and fetal implications. Ob- for the children of the recently homeless. J Community Health. stet Gynecol. 1989;73:157-160. 1989;14:1-8. 11. Correa A, Loffredo C, Ferencz C, Wilson PD. Lead and 28. Committee on Community Health Services. Health needs solvent exposure during pregnancy: possible risk of cardiovas- of homeless children. Pediatrics. 1988;82:938-940. Pediatric Acquired Immunodeficiency Syndrome, Poverty, and National Priorities Margaret C. Heagarty, MD H uman immunodeficiency virus (HIV) infection or ac- which these children are particularly prone. Second, re- quired immunodeficiency syndrome (AIDS), as search and development of scientific antiviral therapy for found in children, represents a microcosm of the problems children, which, at times, has seemed too slow and too and failures of this nation's health care system for the poor. little, has finally become available in most areas in which significant numbers of children with the disease are found. EPIDEMIOLOGY While much more research is required before we fully un- When Oleske et al 1 and Rubenstein et al² first described derstand AIDS and therefore its medical treatment, by the disease in children, it was not evident that AIDS was now, some 10 years into the AIDS epidemic, the prognosis tolbecome a disease found predominantly in poor children for children with AIDS has improved. Nevertheless, these of.minority status. But in the years since those first reports children and their families face a complicated, chronic dis- appeared, epidemiologic studies have demonstrated that ease with a very guarded prognosis. AIDS in children is largely acquired through perinatal transmission from HIV-infected mothers who are or have MEDICAL CARE SYSTEM been involved in intravenous drug use or who have had intercourse with someone involved in the drug culture. Because these children and their families are poor, they About 15% of children with AIDS are hemophiliacs or must also face a system that at times seems designed to others who were infected by contaminated blood products impede rather than facilitate the provision of medical care. before the advent of the national universal HIV blood During the past 40 or more years, local and federal gov- screening program. Presumably, the number of ernments have developed a series of social and financial transfusion-related cases will decrease with time. supports for the poor. However, the statutory and reg- To date, children with AIDS have been found in most ulatory requirements of these programs are so complex, urban areas of the country, but the disease continues to dysfunctional, fragmented, and disorganized that profes- cluster in three distinct geographic areas: low-income ar- sionals providing care for these families often spend as eas of New York City, Northern New Jersey, and Miami, much or more time dealing with a variety of local, state, Fla. Those who live in these disadvantaged communities and federal governmental bureaucracies as they do pro- are of either African American or Hispanic origin; 53.4% viding direct medical care or social support. In our zeal to of children with AIDS are from New York, New Jersey, or make absolutely certain that no rascals or scoundrels get something to which we judge they are not entitled, we Florida, and 77.5% are of either Hispanic or African Amer- have constructed paper edifices and barriers that no one ican ethnicity.³ Since many are children of intravenous drug-using parents, some of whom have AIDS them- could easily master. We wonder why the most socially selves, they and their parents live on the fringes of their disorganized and disadvantaged members of our commu- disadvantaged communities, often isolated from their nities have trouble "getting on Medicaid" or registering for this or that social program. Indeed, we sometimes blame larger families or from other social supports that might be them, call them unmotivated, noncompliant, or worse. more easily mobilized for other, more advantaged groups with such a serious, lethal disease. In short, most children Since I have an acute anxiety attack when facing a Bureau of Motor Vehicles for a driver's license, I suspect that I, and with AIDS and their families come largely from the most socially disorganized, economically deprived segments of probably most of us, would decompensate entirely if we had AIDS and had to try to qualify for Medicaid or Social our society. Security benefits. PROGNOSIS Finally, more than half the cases of AIDS reported to the Centers for Disease Control, Atlanta, Ga, have come from During the recent past, the prognosis for children with AIDS has improved for two reasons. First, pediatricians only 15 cities in this nation. Because our major urban dis- in areas in which the disease is prevalent have become advantaged communities contain large numbers of intra- venous drug users and because HIV is transmitted via the more experienced in its early diagnosis and in the use of vigorous antibiotic therapy for bacterial infections to shared needles of intravenous drug users, the prevalence of HIV infection in these communities is very high. This increased prevalence of the infection has led to rapid Accepted for publication January 3, 1991. From the Department of Pediatrics, Harlem Hospital Center, and spread, not only among the intravenous drug-using pop- the College of Physicians and Surgeons of Columbia University, ulation, but also by heterosexual contact among adults New York, NY. who do not use drugs. It is not uncommon to make the Reprinted from AJDC (1991;145:527-528). diagnosis of AIDS in a child of a woman who is not a drug Pediatric AIDS 55 user and who is completely unaware that she has acquired obsession with budget deficits, the needs of constituencies the HIV infection from an infected sexual partner. with political power, and foreign policy issues, the care Because AIDS in children is a disease of the urban poor, and welfare of the nation's children do not seem to have the public general hospitals in our major cities provide a high priority in the national agenda. While our political much, if not most, of their medical care. In the best of rhetoric may deny such an assertion, actions speak louder times, these city or county hospitals are underfinanced, than words. The reality is that we are unwilling to provide embattled medical care institutions of last resort. Histor- ically, they have survived in a financial hand-to-mouth the resources necessary to provide medical care to children existence, relying on funds from local governments to sub- with AIDS, to provide medical care to all poor children, sidize the cost of care for the medically indigent. Unfor- or even to provide them with adequate housing or edu- tunately, these same cities are also besieged by the current cation. drug epidemic so that these institutions must deal not only To solve the problems of children with AIDS and indeed with the increased burden of AIDS, but also with the mor- of all poor children, we must develop a simple method of bidity and mortality associated with crack/cocaine. financing medical care for the poor. For large numbers of While their public health institutions are struggling to families and children to have no access to medical care cope with these serious problems, these municipalities, because of a lack of financial resources is simply unac- particularly those in the Northeast, also face serious eco- ceptable. Over the years, any number of proposals to re- nomic problems. Despite the increased needs associated move the financial barriers to health care have been de- with AIDS and the drug epidemic in these cities, medical bated. A detailed analysis of these proposals is beyond the and social care systems for the poor must cope with fixed scope of this essay, but one thing is clear: any remedy to or declining resources. This serious lack of resources im- this problem must have much simpler administrative pro- perils the care not only for children with AIDS, but for all cedures than does our current highly bureaucratic Med- who must rely on these systems for medical care. icaid system. While money is a necessity, it is not sufficient EFFECT ON THE FAMILY for the humane care of these children and their families Any serious, chronic disease obviously affects the func- who represent some of the most socially isolated and be- tion of the entire family, including adults and siblings, as reft of our society. We must develop social support, hous- well as the ill child. But AIDS is even more catastrophic ing, and respite systems that afford them the compassion for families. Because most children have been infected by and care that any of us would need in the face of such a their mothers during pregnancy, the family must deal not devastating illness. only with the disease in the child, but also in the mother A nation that neglects its children places itself in greater and often in the father. While the problems of children danger than any foreign power could possibly muster. The with AIDS have been widely publicized in the lay press, the fact that virtually all their mothers are infected and thus clich'e is true: children are the future of the country. If we at risk for developing the disease has not been equally do not begin to attend to the needs of children with AIDS, appreciated. However, estimates from the New York City indeed all children in poverty, the final judgment of his- Department of Health suggest that in that city alone, some tory will surely be very harsh indeed. 40 000 children may be orphaned by AIDS during the next decade (Pauline Thomas, MD, director of AIDS and HIV Surveillance, oral communication, September 1990). Fi- References nally, despite considerable efforts at public and profes- 1. Oleske J, Minnefor A, Cooper R Jr, et al. Immunodefi- sional education, the fear of AIDS with the resulting dis- ciency syndrome in children. JAMA. 1983;249:2345-2349. crimination makes the care and support of these 2. Rubenstein A, Sicklick M, Gupta A, et al. Acquired immu- unfortunate children and their families even more prob- nodeficiency with reversed T4/T8 ratios in infants born to pro- lematic. miscuous and drug addicted mothers. JAMA. 1983;249:2350- 2356. A CALL TO ACTION 3. Centers for Disease Control. HIVIAIDS Surveillance Re- The story of AIDS in children mirrors our lack of concern port. Atlanta, Ga: Centers for Disease Control; September for the poor children of this nation. In our current national 1990:1-18. Pediatric Human Immunodeficiency Virus Infection and the Acquired Immunodeficiency Syndrome A Health Care Crisis of Children and Families Russell B. Van Dyke, MD The number of children infected with the human immu- proximately 3000 pediatric AIDS cases in the United nodeficiency virus (HIV) is rapidly increasing. Most infected States. Most cases of AIDS in children result from the ver- children acquire their infection by vertical transmission tical transmission of human immunodeficiency virus from an infected mother, and this increase in the number of (HIV) from an infected mother to her child, and the rising infected children reflects a similar increase in the number number of pediatric AIDS cases reflects a parallel rise in of infected women. Many features of HIV infection in chil- the number of HIV-infected women. Between 20% and dren differ from those in adults, and it is important for the 40% of infants born to an HIV-infected mother become physician to be familiar with the varied presentations of pe- infected themselves. 1-3 Factors that influence the transmis- diatric HIV infection. Transmission of HIV during adoles- sion rate are not clearly defined, but maternal antibodies cence, by sexual contact and illicit drug use, is also a growing directed against specific portions of HIV surface glycopro- problem, accounting for most cases of acquired immuno- teins appear to be an important factor in protecting the deficiency syndrome (AIDS) seen in young adults in their infant from infection. 4-6 20's. The HIV-infected child represents only one member of The proportion of AIDS cases in the United States that afamily affected by the HIV virus; frequently, multiple other occur in women has been rising steadily since the onset members of the family are infected as well. These families of the epidemic and currently stands at 11% of all reported are predominantly underpriviledged, coming from inner city cases. Between 1988 and 1989, the number of cases in minority populations with limited access to medical care and women increased by 29%, while the number in men rose social service support. Pediatric AIDS is a preventable dis- by only 18%.7 Approximately one half of women with ease, by the prevention of HIV infection in women. In short AIDS acquired their infection through parenteral drug term, it is likely that education will have the greatest impact use, while one third acquired their infection through het- on altering the course of the AIDS epidemic. Most infected erosexual transmission. Most HIV-infected women are of children are cared for in a limited number of public inner childbearing age. The proportion of AIDS cases in the city hospitals, and the ability of these hospitals to continue United States due to heterosexual transmission increased to provide adequate care will be threatened by the rising from 0.9% in 1983 to 6% in 1990, with this rise expected number of cases. A multidisciplinary approach to providing to continue. This emphasizes that HIV is fundamentally care for these children and their families is essential, with a sexually transmitted disease, spread by both heterosex- ual and homosexual contact. Heterosexual transmission is the primary care physician coordinating this effort. Rapid advances in the treatment of HIV and its associated oppor- the principal route of transmission of HIV in many de- veloping countries and is playing an increasingly impor- tunistic diseases raise difficult questions concerning the ac- tant role in the United States. cess of women, including pregnant women, and children to Although many of the clinical features of HIV infection clinical trials of investigational agents. The commitment of are similar in adults and children, some are unique to chil- individual health care workers and an increased level of fi- dren.⁸ The typical clinical presentation of pediatric AIDS nancial support will be necessary to provide the care that includes growth failure, developmental delay, hep- these children and their families require and deserve. atosplenomegaly, diffuse lymphadenopathy, recurrent bacterial infections, and chronic Candida infections. How- the syndrome (AIDS) was ever, in many children the infection presents in an atypical in the United States in 1981 as a dis- fashion, manifesting isolated features of the disease, such ease occurring in homosexual men. However, as the ep- as thrombocytopenia, pneumonia, parotitis, diarrhea, re- idemic evolved, the disease appeared in other groups, in- current infections, failure to thrive, or loss of developmen- cluding hemophiliacs, intravenous drug users, women, tal milestones. Involvement of the central nervous system and children. Currently, children less than 13 years of age is a particularly important problem in children with HIV comprise 1.8% of all cases of AIDS in the United States; infection. Since children have not yet reached physical and by the end of 1991, it is estimated that there will be ap- developmental maturity, early features of HIV infection include poor growth and loss of mental and motor mile- Accepted for publication January 28, 1991. stones. The immunologic immaturity and naïveté of chil- From the Section of Pediatric Infectious Diseases, Department of dren makes them prone to recurrent infections with com- Pediatrics, Tulane University School of Medicine, New Orleans, La. mon bacterial pathogens. Reprinted from AJDC (1991;145:529-532). Infection with HIV must now be considered when a Pediatric HIV and AIDS 57 broad range of common and uncommon clinical syn- provides this care, resulting in a large number of hospi- dromes are seen in children. Testing for HIV should be talized "boarder babies" in regions with a large number of performed as part of the diagnostic evaluation of these pediatric AIDS cases. At Harlem Hospital (New York, children, whether or not risk factors for HIV infection are NY), more than 20% of hospitalizations of children with present. Consequently, the clinician must understand the AIDS resulted from social problems rather than medical difficulties in establishing HIV infection in children, par- needs. The mean length of stay for these boarder babies ticularly in those less than 15 months of age, in whom was 339 days, as opposed to 89 days for children cared for maternal antibody can result in a falsely positive HIV an- at home. 14 The cost of this care is great; in that report from tibody test.⁹ The results of HIV testing must be kept con- 1988, the authors estimated the mean lifetime hospital cost fidential. I believe that parents should be informed when- for a child with AIDS to be greater than $90000. The in- ever HIV testing is performed on their child, but informed creased use of outpatient services and foster care substan- consent is usually not required unless mandated locally. tially reduces unnecessary hospitalizations among these Concerns about confidentiality should not prevent a child children. 15 from being examined for HIV infection when appropriate. Pediatric AIDS has its greatest impact on those minority Infection with HIV in the adolescent is a problem that groups that have the poorest access to medical care and deserves special attention. Currently, only 3.8% of AIDS are least likely to benefit from advances being made in the cases in the United States occur in individuals between 13 prevention and treatment of this disease. Indeed, more and 19 years of age. However, the proportion of cases in than any other disease, pediatric AIDS highlights the de- this age group due to heterosexual transmission has in- ficiencies in the health care system that exists in the United creased substantially in recent years and currently stands States today. Our efforts at delivering health care to these at 23% for male patients and 44% for female patients. 10 disadvantaged children have not been completely success- Females currently make up 20% of adolescents with AIDS, ful. For example, less than two thirds of nonwhite children in contrast to only 9% of adults with AIDS, further point- in the United States are up to date in their immunizations ing out that heterosexual transmission plays a major role at 2 years of age. 16 It can only be hoped that we will be more in the spread of HIV during adolescence. successful at delivering preventive and therapeutic care to Furthermore, these figures underestimate the impor- HIV-infected children. tance of HIV transmission during adolescence. Currently, The rising number of children with AIDS will impact all 20% of all cases of AIDS occur in young adults between areas of health care and rapidly overwhelm those areas 20 and 29 years of age. Since the median incubation period where cases are concentrated. Infection with HIV is cur- of AIDS in adults is between 8 and 10 years, the majority rently the ninth leading cause of death among children of individuals who develop AIDS in their 20's acquired aged 1 to 4 years in the United States. By the end of 1991, their HIV infection during adolescence. The growing it is anticipated that children with AIDS will occupy 10% problem of HIV transmission during adolescence requires of all pediatric hospital beds in the United States. 17 Most a response directed toward prevention of infection. This of these children will not have private health insurance, is particularly important in light of the increasing propor- and their medical care will be funded by such public tion of adolescents who are sexually active. At the present sources as the Medicaid program. Of the children in our time in the United States, 32% of 16-year-old girls and 70% pediatric HIV clinic, approximately 90% qualify for Med- icaid through the Aid to Families With Dependent Chil- of 18-year-old women engage in premarital sexual activ- dren program. An additional 5% qualify through partic- ity. 11 There are several reasons why adolescents are at in- ipation in the Supplemental Security Income program, creased risk of HIV infection: they have a greater risk of which is available only to those children who carry an other sexually transmitted diseases than older persons, AIDS diagnosis. The remaining 5% of children have other they are less likely to use barrier methods of contraception, sources of insurance or do not qualify for Medicaid. Un- and they frequently have multiple sexual partners. 12 How- fortunately, each state administers its own Medicaid pro- ever, adolescents are receptive to being taught about gram, and states have differing eligibility criteria and ben- AIDS; Steiner et al¹³ demonstrated an excellent level of efits. In many states, the level of reimbursement is too low knowledge about this disease among a group of adoles- to meet adequately the needs of the child. In addition, cents in Wisconsin. One hopes that these young adults home nursing care, ambulatory care, foster care, hospice will apply this knowledge to their own behavior. care, and social service support may not be available or Pediatric AIDS is not only a disease of the child; it is a have limited benefits in some states. Finally, many health disease of the whole family unit. Eighty percent of children care providers do not accept Medicaid patients, further with AIDS, and nearly all seropositive infants, have a limiting access of these children to medical care. mother who is HIV infected. Frequently, the mother's sex- The impact of pediatric AIDS on the practice of pedi- ual partner is infected, and other children in the family atrics and the training of young pediatricians needs to be may be infected as well. A disproportionate number of addressed. All pediatric subspecialists will need to de- children with AIDS belong to minority groups; 53% are velop expertise in the problems of HIV-infected children. black and 23% Hispanic. Most cases occur in inner-city However, in most instances, the pediatrician or family populations, which suffer from poverty, racism, illicit practitioner will provide primary care for these children. drug use, inadequate housing, poor access to medical care, In the ideal situation, the primary care physician will work and a nonintact family unit. As the HIV infection with a team of specialists, including pediatric subspecial- progresses in the child's parents, they are unable to care ists, nurses, social workers, nutritionists, and develop- adequately for themselves and their child, and it falls on mentalists. The assessment and treatment of HIV-infected the extended family or the community to provide this care. children must become part of the curriculum of all pedi- These children are very difficult to place in foster care and atric and family practice training programs. Itis hoped that hospice care. Not surprisingly, then, the hospital often the increasing number of HIV-infected children will not be 58 Caring for the Uninsured and Underinsured seen as a deterrent to those entering the field of pediatrics, fected, and why only one of three infants born to an in- but rather as a challenge to those committed to the health fected mother becomes infected. The AIDS Clinical Trials of children and their families. Group is initiating a study to determine whether the ad- A major concern raised by those caring for HIV-infected ministration of zidovudine during the second and third children has been a delay in access to new forms of treat- trimesters of pregnancy, and continued in the infant for ment. Children have traditionally been excluded from 6 weeks after delivery, will interrupt perinatal transmis- clinical trials involving new medications until efficacy has sion. Other strategies for the prevention of perinatal trans- been demonstrated in adults. The intent of this is to protect mission being considered include passive and active im- the child from possible adverse effects of a new medication munization of the woman before delivery and the until efficacy is established and the profile of adverse re- prevention of infection in the child after delivery by the actions is known. Unfortunately, it also delays the initi- administration of such agents as recombinant CD4, which ation of clinical trials in children and ultimately the avail- blocks infection from being established. We clearly need ability of effective new forms of therapy. For instance, to learn much more about the mechanism and immunol- zidovudine was not available to children until clinical trials ogy of perinatal HIV infection. in adults were completed. The AIDS Clinical Trials Group, Because of the complex medical and social needs of HIV- a collaborative group of AIDS researchers funded by the infected children and their families, a multidisciplinary National Institutes of Health, has an active group of pe- team approach to providing care is necessary. In our Pe- diatric investigators responsible for designing and con- diatric HIV Clinic at Charity Hospital of New Orleans (La), ducting clinical trials in HIV-infected children. This group has been very vocal in this concern, and children and primary ongoing care is provided by general pediatricians with an interest in HIV disease, supported by pediatric women are currently benefiting from early involvement in the evaluation of promising new agents. subspecialists in infectious diseases, hematology, neurol- ogy, and other subspecialties. Adolescents infected with A question that arises in designing treatment protocols for children is whether results obtained in adult trials HIV are cared for by an adolescent medicine physician in should be applied to children. An example is the recent the pediatrics clinic. We are currently developing a com- bined mother-child clinic to allow HIV-infected mothers demonstration that the early administration of corticos- and their infants to be seen at the same clinic visit. This teroids increases survival in adults with Pneumocystis car- takes advantage of our observation that HIV-infected inii pneumonia. 18 There is reason to suspect that pediatric P carinii pneumonia may respond differently than adult women are much more compliant with their child's care disease, because it represents primary infection rather than with their own care. A case manager/social worker than reactivation disease. The pediatric members of the is assigned to each family to assist with financial arrange- AIDS Clinical Trials Group are currently considering ments, transportation to and from the clinic, home health whether a similar trial should be conducted in children. care, and referrals to other health care agencies. Finally, What should the response of the medical community be a pediatric therapist and clinical psychologist assist in neu- to the growing problem of HIV-infected children? In the rodevelopmental evaluations and provide physical ther- short term, the most successful response to the AIDS ep- apy. idemic will be in the area of prevention. Pediatric AIDS is This multidisciplinary approach to providing care is ex- a preventable disease-by the prevention of HIV infection pensive and requires the commitment of a large group of in women of childbearing age. To protect themselves, all health care professionals. Funds must be made available young adults must understand, before they become sex- to support these programs, and personnel must be trained ually active, that HIV is a sexually transmitted disease. to provide the care. Developed countries, such as the They need access to counseling about HIV and other sex- United States, have the resources to deliver this care; it ually transmitted diseases, and they need to know how to remains to be seen whether we have the wisdom to insist protect themselves from infection, including the use of that it be done. condoms. In addition, they need to understand the risk of parenteral drug use. Information about HIV transmis- sion and AIDS must be taught to all children while they References are in middle or junior high school. Finally, women need 1. The European Collaborative Study. Mother-to-child trans- greater access to HIV testing so that pregnancy prevention mission of HIV infection. Lancet. 1988;2:1039-1043. and termination can be considered by those who are in- 2. Blanche S, Rouzioux C, Moscato MG, et al. A prospective fected. Guidelines for HIV testing of pregnant women study of infants born to women seropositive for human immu- have been published.¹⁷ nodeficiency virus type 1. N Engl / Med. 1989;320:1643-1648. 3. Willoughby A, Mendez H, Goedert J, et al. Natural history The development of new forms of treatment for HIV and of infants born to HIV-positive women. Program and abstract the opportunistic diseases associated with AIDS must be of the Fifth International Conference on AIDS; June 4-9, 1989; of the highest priority. It is gratifying that the AIDS Clinical Montreal, Quebec. Abstract MBO 2. Trials Group has recently identified pediatrics as a major 4. Davish Y, Calvelli TA, Wood DG, et al. Vertical transmission area of emphasis, and funds have been made available for of human immunodeficiency virus is correlated with the ab- additional sites to conduct pediatric studies. Both clinical sence of high-affinity/avidity maternal antibodies to the gp120 research and basic research in the field of AIDS deserve principal neutralizing domain. Proc Natl Acad Sci U S A. additional support. 1990;87:3445-3449. 5. Rossi P, Moschese V, Broliden PA, et al. Presence of ma- It is currently unknown whether HIV infection can be prevented in the child born to an infected mother. We are ternal antibodies to human immunodeficiency virus 1 envelope glycoprotein gp120 epitopes correlates with the uninfected sta- hindered by a lack of understanding of two key points: tus of children born to seropositive mothers. Proc Natl Acad Sci when during gestation and delivery the child becomes in- US A. 1989;86:8055-8058. Pediatric HIV and AIDS 59 6. Goedert JJ, Mendez H, Drummond JE, et al. Mother-to- 13. Steiner JD, Sorokin G, Schiedermayer DL, Van Susteren infant transmission of human immunodeficiency virus type 1: TJ. Are adolescents getting smarter about acquired immuno- association with prematurity or low anti-gp 120. Lancet. deficiency syndrome? AJDC. 1990;144:302-306. 1989;2:1351-1355. 14. Hegarty JD, Abrams EJ, Hutchinson VE, et al. The medical 7. Centers for Disease Control. AIDS in women-United care costs of human immunodeficiency virus-infected children States. MMWR. 1990;39:845-846. in Harlem. JAMA. 1988;260:1901-1905. 8. Falloon J, Eddy J, Wiener L, Pizzo PA. Human immuno- 15. Kemper K, Forsyth B. Medically unnecessary hospital use deficiency virus infection in children. J Pediatr. 1989;114:1-30. in children seropositive for human immunodeficiency virus. 9. Husson RN, Comeau AN, Hoff R. Diagnosis of human im- JAMA. 1988;260:1906-1909. munodeficiency virus infection in infants and children. Pedi- 16. Centers for Disease Control. U.S. Immunization Survey. atrics. 1990;86:1-10. 10. Centers for Disease Control. HIVIAIDS Surveillance Re- Atlanta, Ga: Centers for Disease Control; 1986. port 11. Atlanta, Ga: Centers for Disease Control; November 17. Working Group on HIV Testing of Pregnant Women and 1990:1-18. Newborns. HIV infection, pregnant women, and newborns: a 11. Centers for Disease Control. Premarital sexual experi- policy proposal for information and testing. JAMA.1990;264: ence among adolescent women-United States 1970-1988. 2416-2420. MMWR. 1991;39:929-932. 18. Bozzette SA, Stattler FR, Chiu J, et al. A controlled trial of 12. Cates W Jr. The epidemiology and control of sexually early adjunctive treatment with corticosteroids for Pneumocys- transmitted diseases in adolescents. Adolesc Med. 1990;1:409- tis carinii pneumonia in the acquired immunodeficiency syn- 427. drome. N Engl J Med. 1990;323:1451-1457. New Initiatives in Adolescent Health Promotion Arthur B. Elster, MD H ealth issues facing adolescents have changed dramat- The Guide to Clinical Preventive Services, the final report ically over the last several decades. Twenty years of the US Preventive Services Task Force,³ describes 169 ago, adolescent morbidity and mortality were associated clinical screening, counseling, and immunization prac- predominantly with natural causes. Adolescents today, tices recommended for treatment or therapy of 60 target however, are endangered predominantly by their own be- conditions. The procedures are grouped by patient age, haviors. Drinking, tobacco and drug use, pregnancy, sex- including preadolescents (aged 8 to 12 years), young ad- ually transmitted diseases, and injuries take a major toll olescents (aged 13 to 17 years), and older adolescents (aged on youth and place them at risk of developing disease as 18 to 24 years). Only those conditions for which effective adults. Because these health risks do not lend themselves preventive intervention procedures exist or that cause a to traditional models of medical intervention, greater em- high "burden of suffering" were addressed in the report. phasis is needed on prevention as a way to improve the Most of the conditions relating to adolescents qualified for health and well-being of adolescents. inclusion in the latter category. The process of identifying and implementing a broad For at least four reasons, these two documents are im- prevention strategy has gained momentum with the re- portant to those who work to improve the health of ad- cent release of two documents by the US Public Health olescents. First, they direct the debate on improving ad- Service (PHS):- Healthy People 2000: The National Health olescent health to developing and implementing more Promotion and Disease Prevention Objectives² and the Guide effective preventive strategies. Most adolescent preven- to Clinical Preventive Services. Unfortunately, pediatricians tive interventions now are provided by schools, churches, and other health care professionals treating adolescents youth organizations, or media campaigns. Not only do the have been relatively quiet in the national dialogue stim- PHS documents promote these methods of intervention, ulated by these documents. Because the information con- but they also renew interest in how physicians and other tained in these two reports can, however, affect the pro- health care providers can provide effective preventive ser- vision of health care to adolescents, they are worth vices in the office. Second, these documents present a reviewing. framework for actions that can be taken by both the private Healthy People 2000 was developed to focus a na- and public health sectors. They provide impetus for the tional strategy for significantly improving the health of the development of new strategies for physicians and health Nation over the coming decade. The initiative promotes professionals who work in both traditional (eg, hospitals three broad health goals: "(1) increase the span of healthy and private, community, and public health clinics) and life for Americans; (2) reduce health disparities among nontraditional (eg, school clinics, correctional institutions, Americans; and (3) achieve access to preventive services and drop-in centers) settings. Third, Healthy People 2000 for all Americans." To meet these goals, the PHS defined provides a structure for focusing human and financial re- 22 areas for special emphasis. Eight relate to health pro- sources. States, communities, and health organizations motion topics (eg, physical activity and fitness, mental can use it to determine health priorities for their popu- health, and mental disorders), five involve health protec- lations. With clearly defined objectives, organizations and tion topics (eg, unintentional injuries and oral health), health care professionals can better coordinate their ef- eight involve preventive services for targeted issues (eg, forts, producing a more efficient and comprehensive pre- sexually transmitted disease and maternal and child ventive health strategy. As called for in the recent report health), and one relates to surveillance and data systems. from the National Commission on the Role of the School Except for surveillance and data systems, each area in- and the Community in Promoting Adolescent Health,⁴ cludes health status, risk reduction, and service and pro- better access to appropriate, comprehensive, coordinated, tection objectives. Of the almost 300 national health ob- and confidential health services is necessary to solve the jectives in the document, 45 target adolescents directly, complex array of adolescent health problems. Providing and approximately 51 affect adolescents as part of the such services will require cooperation and focused efforts broader population. An introductory section of the doc- from all segments of the health care community. Fourth, ument delineates the predominant health problems ex- the PHS documents set goals that provide opportunities perienced by various age groups (including adolescents) that allow for research on the effectiveness of various pre- and by special populations, such as people with low in- vention strategies. As preventive interventions are devel- come, minorities, and the disabled. oped and implemented, a rigorous agenda for evaluation Accepted for publication January 11, 1991. of research must be followed to determine how best to use From the Department of Adolescent Health, American Medical scarce health care funds. Association, Chicago, III. Neither the national health objectives nor the Guide to Reprinted from AJDC (1991;145:495-496). Clinical Preventive Services has received universal Adolescent Health 61 approval. The public health care community is concerned Various organizations have been funded by the PHS to that the national health objectives # have no imple- promote the national health objectives as they relate to mentation plan, they overemphasize individual respon- special populations or settings, such as Hispanics, blacks, sibility, and they abrogate governmental responsibility."5 schools, and hospitals. As part of these efforts, the Amer- Critics also state that preventive health goals cannot be ican Medical Association received funds to be used in the achieved without additional federal funding and that the dissemination of information related to adolescents. For multifunded nature of the US health care system precludes information on this initiative for adolescents, write effective implementation.6 The professional pediatric to the Department of Adolescent Health, AMA, 515 N community has criticized the Guide because it recom- State St, Chicago, IL 60610. For general information, write mends a specified frequency of preventive health visits for to the Office of Disease Prevention and Health Promotion, adults while leaving the frequency of such visits by ad- Department of Health and Human Services, Washington, olescents and children to the discretion of the provider.⁷ DC 20201. Other concerns are that the recommendations do not in- clude all pediatric preventive health practices and that References they tend to overemphasize change in existing behavior 1. Gans JE, Blyth DA, Elster AB, Gaveras LL. America's Ado- rather than focusing on anticipatory guidance as a way to lescents: How Healthy Are They? Chicago, III: American Medical prevent the onset of health-compromising behavior. In Association; 1990. general, the Guide fails to recognize many of the risks that 2. Healthy People 2000: National Health Promotion and Dis- endanger adolescents specifically and the opportunity for ease Prevention Objectives. Washington, DC: Department of Health and Human Services; 1990. US Public Health Service promoting healthy behaviors during this developmental publication 017-001-00474-0. period. Although the Guide clearly "shortchanges" chil- 3. US Preventive Services Task Force. Guide to Clinical Pre- dren and youth, it and Healthy People 2000 together provide ventive Services. Baltimore, Md: Williams & Wilkins; 1989. health professionals, administrators, and the federal gov- 4. National Commission on the Role of the School and the ernment a structure on which to build sound preventive Community in Promoting Adolescent Health. Code Blue: Unit- health strategies for adolescents. ing for Healthier Youth. Chicago, III: American Medical Asso- It is important that advocates of adolescent health work ciation; 1990. to ensure that the interests of adolescents are well rep- 5. Nation's Health: Year 2000 Objectives Are Important, But resented as the nation begins to implement broad inter- Imperfect Guide. Washington, DC: American Public Health As- sociation; 1990. vention strategies for preventive health. Because adoles- 6. Media Information Alert. Washington, DC: Advocacy In- cents and children are not empowered politically, stitute; November 14, 1990. adolescent health concerns easily may be overshadowed 7. AAP News: From the President. Elk Grove Village, III: Amer- by concerns of other populations. ican Academy of Pediatrics; February 1990. Care of the Poor and Underserved in America Older Adolescents: A Group at Special Risk Robert J. Haggerty, MD J eff, a 19-year-old who dropped out of school after tenth skill jobs rather than manual jobs, has led to a sharp in- grade, has lived "emancipated" for the past 3 years on crease in a new poor and underserved group. his own in New York, and survived for a time as a male prostitute. At a community health center he was recently CONSEQUENCES OF A POOR JOB MARKET discovered to have AIDS. When his disease progressed far We usually do not think of the health and related prob- enough to require hospitalization, it was found that he was lems that result from poor jobs, but they are many. Be- ineligible for Medicaid without a prior assessment of cause unemployed men, or even those with full-time but whether his parents' health insurance covered him. But he dead-end jobs at minimum wage, cannot support families, did not want his parents to know that he had AIDS. While young women are quite understandably reluctant to this may be seen as a problem with Jeff's pride, the fact marry them. Yet given current sexual practices, they have that there is not presumptive eligibility for Medicaid, as their children. Unwed teen pregnancy can be a conse- there is for pregnancy, is a failure of our health system. quence of poor jobs. High school graduates earn more This catch-22 situation is extreme, to be sure, but Jeff is one than non-high school graduates, and are more likely to be example of a group of poor and underserved children of- married (Fig 3). Lack of coverage by health insurance is a ten forgotten by pediatricians and, indeed, by society: major problem for this age group, especially for those with young people roughly 16 to 24 years of age who drop out low-paying and part-time jobs that traditionally offer little of high school or do not go on to any further education. employee health insurance. However, these young peo- The William T. Grant Commission on "Youth and Amer- ple, when employed, earn slightly above the Medicaid el- ica's Future"¹ labeled this group "the forgotten half." igibility level. They are in limbo regarding health insur- There are many other groups of children who are poor and ance. One major finding of several research groups is the underserved in America. Other authors in this issue ad- large number of fully employed young men who earn too dress these. Older adolescents and youth are often for- little to support a family, have no health insurance, and gotten by pediatricians and society. have a high risk of health problems. Why are the forgotten half a problem today? In past While this presents a bleak picture, we should not blame decades, the majority of young people did not graduate the victim. A particularly revealing finding of the W. T. from high school, and certainly not from college. Why are Grant Foundation's Commission is that the vast majority they now part of the growing population of poor and un- of youth are trying to get jobs, trying to "make it" (82% derserved young people? Because the world, especially of the 20- to 24-year-olds are in the work force). It is not the United States, has changed. The job opportunities for that we have a generation of lazy workers. Young people today's young workers who begin their careers with only today seem little different from those of the past. Inter- a high school diploma or less are far more constrained than views with hundreds of inner-city and rural young people they were 15 or 20 years ago. Jobs in manufacturing that in the forgotten half study demonstrate that they have the offer pay sufficient to raise a family are far less available same aspirations and willingness to work as those who go for this group than they were 20 years ago. Unemploy- on to college, but our current economy has far fewer places ment for this age and educational group is high, irrespec- for such youth, and the health consequences are great. tive of race, but especially for black and other minority Certainly not all cases of substance abuse, teen preg- youth. And even those with jobs have had a steep decline nancy, sexually transmitted diseases, acquired immuno- in income. The mean earnings of young male workers deficiency syndrome, and low-birth-weight babies come (from 20 to 24 years of age) dropped from $12 166 in 1973 from this group, but for a variety of reasons the risk of all to $9027 in 1984 (and the figures are probably even lower of these problems is greater among the forgotten half. In today). For those young men who are trying to head a addition, these problems often cluster together in the same family, the decline in earnings is striking (Fig 1, Table 1). individuals, thus geometrically compounding the prob- If the family is headed by a woman or belongs to a minority lem. The medical system has greater difficulty dealing group (or both), the decline in income is even greater. Be- with these problems in people from this group, since they tween 1967 and 1986 the poverty rate among young fam- have so many associated social problems. ilies has doubled (Fig 2, Table 2). WHY SHOULD PEDIATRICIANS The changing economy, which calls for workers in high- BE CONCERNED? Accepted for publication November 19, 1990. Young people 16 to 24 years of age have not traditionally From the William T. Grant Foundation, New York, NY. been the responsibility of pediatricians. Why should we Reprinted from AJDC (1991:145:569-571). now focus on this group? I believe that pediatricians Older Adolescents 63 32000 30000 All Families Table 2. - Primary Families With Income Below the 28000 Poverty Line, by Age of Family Head, 1967-1986 (in Percentages)* 26000 Income, 1985 Dollars 24000 Head Age of 22000 25-29 Years Old Family Head, y All 20000 Year Families <30 <25 18000 1967 11.4 12.1 15.3 16000 Head 20-24 Years Old 1971 10.0 NA 14000 18.0 12000 1973 8.8 12.3 15.8 1979 9.1 14.5 19.1 1967 1973 1979 1985 1986 1982 12.2 20.6 26.1 Fig Incomes in 1985 dollars of all families and those families with 1985 11.4 21.8 30.2 heads aged between 20 and 24 years and between 25 and 29 years 1986 10.9 21.6 32.6 for the period 1967 to 1986. *NA indicates not available. Table Trends in Real Median Incomes of Families, 80 1967-1986, by Age of Family Head (in 1985 Dollars) 70 Age of 60 Family Head, y All Year Families 25-29 1973 29 175 27 551 20 821 Married and Living With Spouse, 50 High School Graduates 20-24 40 1967 25 560 25 132 19 654 30 20 High School Dropouts 1979 29 028 26 676 20 025 10 1985 27 735 24 000 16 000 0 1986 28 898 24 400 15 107 1250 3750 6250 8750 11250 13750 16250 18750 21250 237505000+ % change 1986 Earnings, Dollars 1967-1973 +14.1 +9.6 +5.9 Fig 3. Proportion of 20- to 24-year-old men who were married and 1973-1986 -1.0 -11.4 -27.4 living with their spouses by 1986 annual earnings and by educational subgroup (March 1987). 35 Among all young people, health coverage is poor, but 30 blacks, Hispanics, and other minorities are even less likely Growth of Poverty to have health insurance than other American youth. In 25 1984, 21.4% of 16- to 24-year-olds nationwide (7.4 million % Below Poverty Line young people) had no health insurance, compared with 20 13.3% of all the civilian population. Second, the diseases young people have are similar to 15 those of younger children rather than being the degen- erative diseases of older people that constitute such a large 10 part of internal medical practice. Pediatricians are likely to be very competent in dealing with these health problems. 5 Third, no other medical specialty really specializes in all of the many interrelated problems of this age group, such 0 1967 1971 1973 1979 1982 1985 1986 as substance abuse, sexually transmitted diseases, infec- Fig 2. - Growth of poverty in all families (open bars) and families with tions, and closely related social problems. True, these heads aged less than 30 years (shaded bars) and less than 25 years problems require skills in social pediatrics, but many pe- (solid bars) for the years 1967, 1971, 1973, 1979, 1982, 1985, and 1986. diatricians are well versed in these skills. Pediatricians NA indicates not available. have generally been more involved in social action than should become more involved at least with the health care many medical specialists. of this group, and if they do, they will of necessity become Fourth, the field of chronic illness in this age group, involved as advocates for change in the socioeconomic and while small, is especially pertinent for pediatricians. Many educational aspects of these young people's lives. Without children with chronic childhood illnesses, such as asthma, such involvement, medical care by itself will be of only cystic fibrosis, hemophilia, and rheumatoid arthritis, now moderate benefit. live into their twenties. If they have been under pediatric First, few other medical specialties are dealing with this care earlier, it makes little sense to transfer their care to age group, in part because of their lack of health insurance. another specialty when they are 16 or 18 or 20 years old, 64 Caring for the Uninsured and Underinsured since their medical care is very similar to what it was when they will turn to activities, legal or illegal, that yield some they were 10 years old. income. Many of the successful "volunteer" corps pro- Finally, we now recognize that considerable develop- grams provide incentives for further education by provid- ment, especially psychological, is still going on while ing an amount (usually around $5000) for each year com- young people are in their early twenties. Few young peo- pleted toward further education. Many high school ple take on permanently the major tasks of adult- systems are now requiring a certain amount of community hood family, permanent career, and citizen participa- service as a requirement for graduation. Such service uti- tion in their early twenties. Most, especially middle-class lizes the idealism of the young, brings them in contact with children, try out a number of possibilities in their twenties adults, and gives them a true sense of value to society. One before settling in. One of the problems of disadvantaged group in New York City provided an opportunity for youth is the difficulty they have in getting second and third young people to read to elderly people in nursing homes. chances. Since understanding development is one of the Teachers have noticed that these young people, who could pediatrician's main skills, it makes sense for us to add to not sit still in school, became very patient and invested in our knowledge and skill to provide health care for a group their relationships with the old people. This also gave the of young people undergoing rapid social and emotional young people a real sense of accomplishment. Every com- development in their late teens and early twenties. munity can organize some youth activities such as these. WHAT CAN PEDIATRICIANS DO FOR THIS GROUP OF POOR AND UNDERSERVED CHILDREN? COMMENT At first glance, one can legitimately question whether Young people in late adolescence and young adulthood, pediatricians can do much for the forgotten half, since so roughly 16 to 24 years of age, are a neglected group of many of their problems lie in the changed economic children in our society. They are neglected by schools, sphere. It is true that without change in job opportunities health services, and employers. If they have not graduated other services are going to be less than adequate. Pedi- from high school or do not go on to higher education, their atricians need to advocate promising programs in the job future today in America is limited. They are the forgotten area, such as better vocational education programs, ap- half. While most are energetic and ambitious, without ad- prenticeship (school-job linkage) programs, educational equate jobs to support a family, they are at increased risk reform that produces schools that encourage an individ- of becoming single parents, engaging in substance abuse, ual's strengths and foster success, and enhanced job train- contracting diseases, and exhibiting problem behaviors. ing partnership programs. Most of these require national Even those who go on to higher education often go initiatives and policy changes, and we can at best be sup- through a period of testing alternatives in intimate social portive. relations, jobs, and citizen roles. There are a number of initiatives at the local level that A number of solutions are possible for the problems of pediatricians can take to meet the needs of this group of this age group, but they require attention to programs that poor and underserved youth. Closest to home would be combine education reform, job opportunities, integrated to foster comprehensive service programs. Most such comprehensive services, meaningful community roles, youth need a combination of social services, remedial ed- and contact with adults. Pediatricians have an important ucation, and rehabilitation, together with medical care. role as part of the team caring for youth, but they must also Sometimes this can be organized in a group practice set- be willing to work with other disciplines in comprehensive ting. More often the pediatrician will have to go where the programs and as advocates for this age group. young people are the school, workplace, church, or com- We may not be able to solve Jeff's problem by ourselves, munity service center. The need for age-appropriate com- but with more of the comprehensive community ap- prehensive services rather than any one of these services proaches I have outlined, we should be able to prevent in isolation is very great. We can work toward that goal many young people from reaching his state. Prevention in every community. has always been the pediatrician's main job. Now it re- Strengthening of families is another very important quires social change as well as immunizations. task. We often think that this age group is totally eman- Some will ask, How can we convince the public of the cipated, but most still maintain contact with their parents; need? People accuse me of being a congenital optimist, but indeed, many remain in the parental home. Many of the I see more opportunity now than in the past 10 years. Busi- young people interviewed by the W. T. Grant Foundation nesses are concerned that there will not be enough skilled Commission expressed the wish to have more contact with workers in the future. Schools are being reformed. Links parents and adults. Parent education programs, enhance- between school and work are being developed. The task ment of parent participation in schools, involvement of will not be easy, but pediatricians must add their prestige parents in health programs, mentoring programs for to these efforts, and join the growing chorus of those who youth, and efforts by parents, teachers, and employers to are coming together in coalitions to make the lives of the plan reasonable part-time work schedules can be done at forgotten half more healthy and effective. In so doing, they a local level. Communities must tap the youthful energy will improve the competitiveness of America in the future. and idealism of youth. Many youths volunteer their time Reference to rebuild communities. Such volunteer programs have 1. The William T. Grant Foundation Commission on Work, d'emonstrated useful ways to capture this energy of young Family and Citizenship. The Forgotten Half: Pathways to Success people. For the poor, however, all of this activity cannot for America's Youth and Young Families. Washington, DC: The be voluntary. Such young people must be paid, or else William T. Grant Foundation; 1988. A Regional Pediatric Approach to the Epidemic of Social Ills Within Our Cities Waldo E. Nelson, MD 'T was midsummer 1990, I received a letter from Vince nurse practitioners, and through their respective counter- Fulginiti: parts in the community and tertiary hospitals.¹ In May 1991, each of the AMA family of journals will devote The regional medical unit will contain a number of all or most of their issues to articles that report individual and neighborhood hospitals (secondary), and at least one ter- professional societies' ideas and suggestions for improving tiary (usually associated with a medical school) hospital. health care to the poor and underserved in this country. AJDC In most large metropolitan areas there are usually two or will focus on infants, children, adolescents, and young adults more medical schools. Each hospital will naturally have its who are not receiving it [health care] currently, or who are poorly own coterie of practicing physicians who preferentially re- served by our present system. This would be an excellent fer their patients who need specialized care. Hospitals that opportunity for you to [record] your concept of the academic have attained particular competence in a certain highly health center/community relationships [for the health care specialized clinical field should expect preferential refer- of] the underserved and unserved rals to them from the primary physician whose principal Vince (my one-time student, now colleague, and from affiliation is with another tertiary hospital and even from the beginning, my teacher) is correct in his implication that the clinical staffs of other academic hospitals. If such an an overriding concern of mine is that the state of our na- objective policy were adhered to, it would represent a ma- tional health care is not nearly as good as it could be. The jor step toward high-quality care in that regional medical most serious deficits are evident in the health care avail- unit. able for the poor and are, to a great extent, concentrated For such a utopia to come into existence, not only good- in our large metropolitan areas. The issue at hand for the will but free and open communication among the phy- medical community appears to be not only the search for sicians within that region will be required. Furthermore, ways to improve the quality of health care, but also for an it will necessitate elimination of competitive advertising by adequate distribution of it and the means to pay for it. This hospitals, health maintenance organizations, and individ- is not a new concept. My own recognition of these inad- ual physicians. To be sure, such activity is not only con- equacies goes back to the mid 1920s. doned by the federal government, it is even encouraged, No attempt will be made here to review the many as- and so far as I am aware, it is not objected to by AMA- pects of this multifaceted subject. Rather, I venture to sug- related societies. It can only be destructive in some of its gest an initiative for medical care of the underprivileged current forms. Information about services available in the that may have some potential to be effective now, and even various hospitals, health maintenance organizations, and to provide some serendipitous dividends for the future. other medical service units is essential for the primary phy- am convinced that more is likely to be gained at the local sician and for the lay public, but inflammatory advertising level within an area or region that functions as a natural that is unjustly self-serving should be abolished. medical service unit rather than by a limited national pro- What I speak for is simply a realistic bonding between gram. In recent years there have been several national pro- practicing physicians and those in academia in accepting grams designed to provide care for the socioeconomically responsibility for the quality of medical care within and deprived, especially within the inner cities. At best they "beyond their office walls," ie, within their respective re- were of limited value and were relatively expensive. gion. I tend to designate those physicians who are pri- The medical unit in this concept is a regional area with marily in private practice as "The Town" and those who complete primary, secondary, and tertiary medical ser- are solely or mainly in academic activities as "The Gown." vices for its inhabitants. In general, they are not demar- It is the close integration of these physicians within a given cated by state or other political boundaries, but have been region that is so essential in determining the ways and determined by growth and developmental factors within means to meet the medical needs of the underserved. and around urban centers and extend into the surround- Those of us in the medical field should sense our per- ing rural areas. Primary services are those available sonal responsibility not only for the quality of medical care through physicians in private practice, in particular, pe- in our respective roles, but also for the quality of health diatricians, internists, family practitioners, and pediatric care within our community. 1 For example, activities cen- tered more or less in the Philadelphia Pediatric Society, Accepted for publication December 27, 1990. concerning the epidemic proportions of socioeconomic From the Department of Pediatrics, Temple University School of health problems among children and youth in our area, Medicine at St Christopher's Hospital for Children, Philadelphia, Pa. led to the formation of a task force under the leadership Reprinted from AJDC (1991;145:505-506). of William N. Mebane, MD, Director of the Family Practice 66 Caring for the Uninsured and Underinsured Residency Program at the Chestnut Hill (Pa) Hospital. It committed to the search for excellence in the provision of was thought that this group could bring together those in health care is simply that in each successive period, the the Gown sector (medical school hospitals) who were cur- medical care for each person, in health and in disease, will rently involved in pediatric activities in public schools and come to approximate the potentials of the moment; that in shelters for the homeless with members of the Town such high-quality health care will be available to all those sector who might be interested in sharing in this work. who want and can profit from it; that the lay person will Both resident physicians and medical students are becom- recognize that he or she must come to appreciate "good ing involved in these activities. care" and be responsible for cooperating with it and for Recently, the Philadelphia Pediatric Society circulated a maintaining a healthy pattern of living; and that the legal questionnaire among its membership to identify addi- profession will share in attempts to develop a truly ob- tional Town and Gown physicians who might be inter- jective and ethical climate in the region. ested in joining in this work. To date, there have been Within our own time, what can be done by the medical some 120 favorable replies. It will be of considerable in- profession and, especially, by the pediatric segment of it, terest to see what eventually evolves from these activities. to develop a workable plan to meet the above-mentioned One of the recent encouraging outcomes has been the goals? "spontaneous creation" by the resident physicians from 1. Town and Gown will join together in determination one of the hospitals of a volunteer group of their own to to see "that their (invisible) walls shall come tumbling provide medical services at an evening clinic in one of the down," a true bonding.² Their constant priority will be to shelters, an activity that does not interfere with their hos- assume joint responsibility for the general health of the pital program. I visited an evening clinic recently. It was community in conjunction with their public health depart- a busy sight that included mothers, some fathers, infants ments, including those of the school systems. and children, doctors, a nurse, and two social workers. It 2. Town will have access to and make use of Gown's was truly a rewarding experience. Had one not known, personnel and facilities, when indicated, in the treatment one would not have surmised the variety of medical prob- of their acutely ill patients as well as in the study and treat- lems that were represented. ment of chronically ill ones, often on a continuing basis. A necessary step will be the funding of this local effort. 3. Gown will tap the Town segment for bolstering its At the moment it is expected that the salaried members of teaching programs in inpatient and outpatient divisions. the pediatric departments will continue receiving their Some of our best teachers are among the Town personnel current support, and it is hoped that, at least for the fore- and some of our best clinicians among the Gown segment.¹ seeable future, the private physicians from the Town will 4. Town and Gown will participate in efforts to devise "gain most," if they serve on a volunteer basis. In days a health insurance program available to all citizens, and past, when the Town was so essential in sharing in the everyone, including professionals and laity, will cooperate clinical teaching load of pediatric departments, most of in efforts to make its operation fiscally sound. them served without pay. To this day, I have not found Important as the medical aspects are, the social, edu- more loyal members of the two departments I was priv- cational, and economic deficits present as great or greater ileged to serve in my active days than those whose par- challenges in planning a total community program. These ticipation was on a volunteer basis. However, there will deficits are manifested by the lack of personal motivation be a need for additional money. More can be expected from among school-age children, the number of school drop- a number of sources-local governments, foundations, outs, the failure to take advantage of work opportunities, corporations, labor unions, and private individuals. teenage pregnancies, and other deviations that often re- Separate from our considerations in support of a re- sult in anger against society, not only leading to lives of gional approach to the solution of community health prob- crime but to loss of potentially productive careers. lems is the necessity to devise a new national health in- The issue at hand is patently a moral one that will not surance program that will include all persons on as nearly go away except by appropriate mass determination and an equitable basis as possible. The time is past when we action. It is my contention that the desired goal of giving should expect anything less. It is estimated that 30 to 40 each child the opportunities that could lead to readiness million of our children who are mainly in the lowest so- for responsible adulthood is most likely to be attained by cioeconomic grouping are either uninsured or underin- local efforts within multiple communities. sured. To include them in a revised program will likely Those of us in the health field constitute one channel of necessitate reduction in the payments to some of those in support. Within the confines of our communities, we can, the older age group. There will be opposition, and the in conjunction with other disciplines, the family, educa- lobby for this group is not impotent. I am in this age group, tion, business, law and, not the least, the church, find and I am comfortable in saying that there are a number of ways to reactivate the spirit and determination to make us who could do with less in "third party payments" for this country truly a land of equality in freedom and in care in our terminal years even if it is not the most pleasant opportunity for the child to find a fulfilling role in society. of possibilities. The uninsured children must also be References served. They have years of growth and development and of contribution to mankind ahead of them. 1. Nelson WE. Regionalization of pediatric activities: a chal- lenge for Town and Gown. 30th Anniversary, The Ambulatory A national commission made up of competent, objec- Pediatric Association - Its History and The Collection of the tive, and socially minded citizens should be formulated to George Armstrong Lectureships (1960-1990). develop such a program, and soon! 2. Nelson WE. And the walls come tumbling down: a tribute So, my concept of a common goal for those who are to Lee Forrest Hill. J Pediatr. 1976;89:1-2. The Caring Program for Children The Michigan Experience Marianne Udow, MHSA; Vernon K. Smith, PhD; Margaret H. Mason, MHSA Public-private partnerships may offer the best opportu- families cannot afford private insurance, as a private effort nity in the near-term for addressing the problem of the un- the programs have had relatively modest impacts on the insured. In Michigan, a broad spectrum of groups has studied problem of uninsured children. In Michigan, the Depart- the issue of the uninsured and, despite the diversity of the ment of Social Services (DSS) and Blue Cross and Blue groups, arrived at a consensus that providing coverage to Shield of Michigan (BCBSM) have worked together to ex- uninsured children is an urgent priority. The Caring Program pand the CPC into a public-private partnership plan. This for Children, a private program initiated by Blue Cross of effort will be a laboratory to test the effectiveness of com- Western Pennsylvania to provide primary and preventive bining federal, state, and private funding to offer health health care coverage to children in low-income, uninsured benefits through a private delivery and administrative families, gained support from the Michigan legislature and mechanism. advocacy and provider groups as a means to address the problem. Blue Cross Blue Shield of Michigan and the Mich- BACKGROUND igan Department of Social Services joined to expand the Car- Across the United States over the last half decade, key ing Program for Children from a private program to a public- state and local policymakers have become involved in ef- private venture funded by federal and state funds and private forts to identify the number of uninsured Americans and donations that has the potential to provide coverage to more to devise local strategies to address the problem. Some than 12000 children. The Michigan experience may be in- states have initiated programs ranging from universal ac- structive to other states attempting to devise immediate local cess models and mandated employer-based health cov- solutions to the problem of the uninsured. erage to initiatives that target specific population groups. There is no "silver bullet" approach toward which pol- H ealth care financing and delivery mechanisms used in icymakers automatically migrate as each state grapples other industrialized nations have been suggested by with the need to strike a balance between cost and cov- many as models for reform of the American health care erage. Common to all the states' efforts, however, is that system. Given the pluralistic nature of American politics, diverse groups and coalitions have developed consensus however, it is unlikely that approaches used by other on the urgency of the local situation and that the solutions countries can be successfully duplicated in this country. reflect the unique circumstances and conditions each lo- At least in the near term, reforms that build on the current cality. The recent Michigan experience illustrates how co- system rather than necessitating radical restructuring of alitions can develop to create a policy environment con- existing mechanisms are most likely to garner sufficient ducive to implementation of programs that address health support to be implemented. We describe one approach to care for the uninsured. building on the current financing and delivery mecha- In the middle to late 1980s, the increasing priority given nisms to address issues of access to care. Implications for to health care of the uninsured in Michigan was reflected broader applicability are also considered. in the creation of task forces, commissions, and work The Caring Program for Children (CPC) is a well- groups by provider, advocate, and health policy organi- established private program offering health benefits to un- zations. In Michigan, this included The Greater Detroit insured children who meet eligibility criteria. The program Area Health Council, the Michigan Hospital Association, was initiated by Blue Cross of Western Pennsylvania and the Michigan State Medical Society, the Michigan Protec- implemented in 11 additional Blue Cross and Blue Shield tion and Advocacy Service, and the Michigan League for plans throughout the country. While the programs have Human Services. Remarkably, given the diversity of the provided health benefit coverage to some children who are groups examining the issue, a sense of urgency about the not eligible for other private or public programs and whose creation of programs to provide health care for children Accepted for publication February 5, 1991. was common among all groups. The findings that one From Blue Cross and Blue Shield of Michigan, Detroit (Mss Udow third, or about 300 000, of the uninsured in Michigan are and Mason) and the Michigan Department of Social Services, Lan- children-most of them in families of the "working sing (Dr Smith). poor" and that uninsured children in need of medical Reprinted from AJDC (1991;145:579-580). care do face severe obstacles to obtaining care, generated 68 Caring for the Uninsured and Underinsured consensus that any strategy should include as its first pri- given to children of employed former welfare recipients. ority a focus on children. All who studied this issue con- All eligible children in a family are required to enroll si- cluded that neither private nor public approaches alone multaneously to provide a mixed risk pool of sick and well will solve this problem, but that a combination of public children. Enrollees are recertified annually. and private approaches will be necessary. Benefits For example, based on the findings of the Governor's Benefits under the CPC are aimed at providing the basic Task Force on Access to Health Care, a broadly represen- preventive and primary health care coverage children tative, 40-member body, "Healthy Start" was proposed as need to avoid chronic illness and permanent disability. an expansion of Medicaid to provide health care coverage Because children are hospitalized less often than adults, to children up to age 18 years in families with incomes of and to provide coverage for as many children as possible, up to 200% of the federal poverty level. At the same time, inpatient care is not covered under the program. Benefits BCBSM announced plans to implement the CPC, to be of CPC include preventive care (including well-child care financed by private donations. The DSS and BCBSM began and immunizations), office visits to physicians, outpatient discussing ways to work together to ensure that the pro- and office diagnostic and therapeutic laboratory and ra- grams would be complementary. diology services, outpatient and office surgery and anes- Meanwhile, two legislative committees were examining thesia, outpatient and office accident medical emergency the issue of the uninsured. The House Republican Task care, outpatient substance abuse services, and prescrip- Force on Affordable Health Care for the Uninsured in- tion drugs. These are covered in full, with no deductibles cluded in its final report,¹ issued in July 1990, eight rec- or copayments. ommendations largely focused on making health insur- Provider Arrangements ance more affordable to small-business owners. Notably, All BCBSM participating physicians and BCBSM Par- the primary recommendation was that legislation should ticipating Provider Organization pharmacies are eligible be enacted to allow BCBSM to implement the CPC. The for reimbursement through the CPC. A number of pedi- House Democratic Commission on Families identified atricians, family practitioners, and other providers are par- health care as one of the key issues affecting the strength ticipating with BCBSM especially for the CPC. of families and urged in its September 1990 report² that Funding priority be given to the adoption of statutory changes nec- The CPC is supported by private funds raised by BCBSM essary to implement the CPC. and state funds, which are matched by a special grant from Owing to other budget priorities, Healthy Start was not the federal government. Private contributions to the pro- enacted by the 1990 state legislature. The DSS and BCBSM gram are tax deductible. then joined forces and secured a 3-year, $6.6 million IMPLICATIONS matching grant from the Health Care Financing Admin- While the Michigan CPC is only a relatively small step istration to supplement private and state funds for the toward providing health benefit coverage to the unin- CPC. Underlying the grant proposal was the premise that sured, it can have profound lessons for a more compre- through public-private partnerships programs such as the hensive solution. First, the program is easily duplicated in CPC are greatly enhanced-use of public funds allows the other states. Second, existing structures necessary to im- Michigan CPC to provide coverage to more children and plement the program are for the most part already in place broaden benefit coverage, while use of private sector de- so that implementation can occur relatively quickly. Fi- livery mechanisms offers access to more providers. The nally, the program builds widespread coalition support. federal grant allowed the CPC to expand coverage to in- Indeed, the strength of this effort has been the broad base clude prescription drugs, and the program has the po- of interest from providers and consumers of health care tential to provide coverage to more than 12 000 children. as well as from private health benefit carriers, financiers, PROGRAM DESIGN regulators, and legislators. The depth of this support, in- The CPC is designed to provide the highest priority ser- cluding the willingness to commit to this effort on a long- vices to the population group with the greatest need for term basis, will be key to the general applicability of this health care services. kind of an approach. Administrative Structure In the long term, more radical restructuring of our mech- Blue Cross and Blue Shield of Michigan provides free anisms to finance health care may be necessary to ensure administrative services, and the DSS administers the access to health care for all. It does not appear, however, funds and assists with outreach and coordination with that this country is yet ready for such a major change in government programs. To ensure broad community in- health policy. In that context, much can be learned from volvement in the program, an advisory committee com- the several efforts under way across the country that use posed of 30 representatives from business, labor, religious public-private partnerships to deliver health care services organizations, the health care providers, parents, and to segments of the uninsured populations. Programs that state government provides fund-raising, outreach sup- can be implemented now and that maximize funding and port, and general oversight of the CPC. administrative capabilities from all sources, such as the Michigan CPC, are likely to have much more immediate Target Population The CPC provides primary health care coverage to chil- impacts on delivering needed care to the uninsured. References dren aged 18 years and younger whose household in- 1. House Republican Policy Committee. Recommendations comes are at or below 185% of the federal poverty level and of the House Republican Task Force on Affordable Health Care who are not eligible for Medicaid or other sponsored for the Uninsured. July 1990. health coverage. Under the terms of the Health Care Fi- 2. The House Majority Commission on Families. Interim Re- nancing Administration grant, priority for coverage is port. September 1989. Health Care for Pregnant Women and Young Children Richard E. Behrman, MD, Carol S. Larson, JD I nadequacy of family resources to purchase health care most vulnerable population totals about 26 million indi- is the major reason poor, near-poor, and underserved viduals, consisting of approximately 22 million children children and youth do not obtain needed preventive, aged 5 years or younger and 4 million pregnant women. acute, and chronic health care services.¹ Other factors also An estimated 23% of this population are below the poverty can significantly limit access to health service, such as dis- line⁴ and particularly likely to fall into a health care gap, tance to facilities, availability of health providers, barriers ie, are likely not to receive important health and related in the organization and function of the health care system, services between conception and delivery (eg, prenatal and the attitudes and behaviors of patients. 2,3 However, care and treatment of substance abuse) and between birth inadequacy of resources to purchase medical care is the and entering public programs (eg, Head Start, child care, central problem. The child population whose families are or school, which can provide such services as immuni- unable to afford medical insurance coverage now includes zation and screening for disabilities). 5,6 27 to 28 million infants, children, and youth who are un- The families of children without disabilities or illness can insured, partially insured, or enrolled in Medicaid. The often bridge any gaps financially to see that their children number of pregnant women who cannot afford care must receive the care they need. Many families cannot afford the also be considered when addressing the health care needs health services their children require, however, and are of children. Twenty-seven percent of women between ineligible for Medicaid and other programs.³ Indeed, ages 20 and 24 years are without private health insurance, given the widely varying eligibility standards of Medicaid as are 22% of teenage girls and women between ages 15 among the states, whether poor children are covered has and 19 years.³ more to do with where they live than what they need. Even It is time for this country to meet the health care needs families with children covered either by Medicaid or pri- of its pregnant women and children. A strengthened part- vate insurance can experience tragic gaps in health care. nership between the private and public sectors can meet Both public and private benefit packages are limited in these needs through a uniform, comprehensive, and fed- coverage, and an increasing number of barriers make it erally initiated plan. As the debate proceeds over major more difficult to maintain coverage and obtain access to restructuring of the health care system, comparatively mi- services. nor changes to the current system can be made today to Myriad proposals have emerged in recent years to re- care for our youngest and most vulnerable population. form the health system for people of all ages. Some build These changes could apply immediately to pregnant on the current structure; others urge a complete overhaul. women and all young children or could be phased in by They use, in different combinations, diverse strategies birth cohorts. In the long run, the costs of providing this such as a single-payer system, managed care, and health care will be low compared with the health and social employer-mandated coverage. costs that follow in adulthood from lack of health care dur- The debate over health care provision in this country is ing early childhood. not likely to be resolved quickly. Indeed, a new health care system may most likely evolve from lessons learned from BACKGROUND relatively incremental change. If so, that change should The opportunity for many of our nation's children to start with pregnant women and young children. As the fulfill their potentials as productive citizens is being se- recent congressional expansions of Medicaid attest, there verely compromised even before they reach school age. A is consensus that the health needs of this population child's capacity to thrive in later years is limited by health should receive high priority. and developmental problems ignored in early life during The American Academy of Pediatrics (AAP) has pro- the especially critical period from conception through age posed a plan that would build on the current system to 5 years. This is also the period of life for which the evidence better meet the health care needs of pregnant women and of the beneficial effects of appropriate health and devel- children.⁷ The following proposal contains many of the opmental interventions is strongest. At any time, this components of that plan and a few additional provisions: to allow a phase-in that targets young children first, to establish health providers in underserved areas, to estab- Accepted for publication November 19, 1990. lish a national insurance commission, to create a pub- From the Center for the Future of Children, the David and Lucile lic/private council for citizen participation in the monitor- Packard Foundation, Los Altos, California. ing of health care provision, and to provide ongoing Reprinted from AJDC (1991;145:572-574) outcome measures of effectiveness. 70 Caring for the Uninsured and Underinsured PROPOSAL 5. Reimbursements to providers would be based on di- We propose a targeted national health care program that agnosis related groups and a professional relative value could be phased in incrementally over 6 years by enrolling system schedule developed for this population. all pregnant women and newborns each year by birth co- 6. A Federal Child Health Insurance Commission would horts. In addition to requiring lower initial outlays, this be created to establish standards and the basic benefit approach would also provide an opportunity to imple- package, to coordinate states and their insurance commis- ment a new public/private health insurance partnership sions, and to oversee the insurance broker function and program without significantly disrupting the existing negotiation and payment of premiums. State agencies complex of health care providers, payers, and employers. would be identified as the agents for disbursement of pub- Furthermore, the program could be implemented on a lic funds. controlled, small scale that would make it possible to trou- 7. A Council for Children's Health and Related Social bleshoot unforeseen problems during the phase-in. This Services would be established with broad representation approach also takes a first step in addressing the larger from private and public sectors, including appropriate health insurance problem in this country without incur- professionals. This council would be a national umbrella ring the enormous financial obligation inherent in the organization to advise and monitor the health delivery sys- more global solutions that have been proposed. tem. The council would have state and local units, creating The major points in this proposal are as follows: a federation of local volunteer and public agencies 1. All pregnant women and young children would be throughout the country to assist in monitoring and co- ordinating outreach and volunteer efforts in health care. covered by private health insurance (indemnity or man- The national council would be responsible for making aged care) purchased through either public or private recommendations about the basic benefit package to the funds and consisting of a basic benefit package (including federal and state insurance commissions and for moni- preventive health and screening programs, ambulatory toring the implementation of these recommendations. Its and hospital care, and related social services). The health recommendations would also inform the premium nego- benefit package would be developed with reference to the tiations. AAP benefit list and current provisions of the Medicaid The national council, in cooperation with the Depart- and Early Periodic Screening, Diagnosis, and Treatment ment of Health and Human Services and state depart- program.⁷ ments of health and education, would also annually re- 2. All private health insurance policies and contracts view and report on the status of this insured population would be required to include this benefit package, and a based on available selected health outcome measures, special payroll tax would be levied on employers who did such as the proportion of women receiving late or no pre- not offer insurance. For children whose parents cannot natal care, infant mortality, immunization rates, hospital afford a policy and do not receive coverage from an em- use by children, and primary school absenteeism and per- ployer, coverage would be purchased and premiums paid formance. 8,9 This would be an important element in eval- through a combination of income-graduated, family pay- uating effectiveness of the services provided under this ments; public funds financed by the payroll tax on em- program and in making recommendations for change in ployers and employees; and allocations from federal and benefits, payments, or other services. state budgets. Payments from the latter sources might be The state and local affiliates of the council would assist indexed to the proportion of children under age 6 years in oversight and coordination of services, community in- in the state. Premiums for insurance purchased by the novation, and problem solving. "Lead organizations" public fund would be negotiated with consideration of the would be selected at the state and local levels from among cost of purchasing the health benefits in the marketplace the private and public organizations concerned with child and of variations in health care costs. health and welfare. These lead organizations would be responsible for working with families, providers, and var- 3. Many of the health and related services that would ious local voluntary and public agencies to ensure that be required under this proposed children's health plan are each pregnant woman and young child obtains needed currently provided for some children through a variety of high-quality services. These groups would also regularly federal and state programs, and these program funds report to the council on provider and insurance carrier would be transferred and consolidated to fund this plan. performance. These reports would be incorporated into This would likely include transfers from federal programs the council's recommendations to the insurance commis- such as Medicaid; Title V of the Social Security Act; the sion. Supplemental Food Program for Women, Infants, and Children; and immunization grants. 4. The existing provider health provision systems would COSTS AND ADMINISTRATION be used. The Public Health Service would be expanded The AAP estimates that its plan to insure pregnant and authorized to provide care in areas where numbers of women and children aged 18 years and younger would health professionals are inadequate. This public program increase the $98.8 billion currently spent on this popula- would include a voluntary program by private physicians, tion annually to $111.4 billion.⁷ This more modest plan perhaps with subsidized professional insurance coverage focusing on the youngest children would cost significantly less. Because of its incremental approach and the relatively or other provisions to attract these health providers. Re- small population covered, it would facilitate the field- cruitment of young physicians to the Public Health Service testing of the new administrative structures and the might also be facilitated by an educational loan forgiveness private-public partnership in program implementation. program in exchange for service. Thus, unanticipated problems could be better dealt with Health Care 71 than might otherwise be possible. It would cause minimal problem by focusing on pregnant women and young chil- disruption in the insurance industry and various provider dren, those whose health needs are not only great, but also systems. will have consequences for the well-being of this country for decades to come. CONCLUSION Initiating change in the current system would be less References costly than maintaining the status quo. Failing to provide 1. Oberg CN. Medically uninsured children in the United preventive health and early treatment services results in States: a challenge to public policy. Pediatrics. 1990;85:824-833. larger direct and indirect costs to society than providing 2. Children's Defense Fund. The Health of America's Chil- services early in life. In addition, the costs of such a pro- dren: Maternal and Child Health Data Book. Washington, DC: gram are probably lower than one might assume because Children's Defense Fund; 1989. most members of this population are healthy. The costs 3. Erdman K, Wolfe SM. Poor Health Care for Poor Americans: of providing health services for all children and pregnant A Ranking of State Medicaid Programs. Washington, DC: Public Citizen Health Research Group; 1988. women account for a relatively small portion of total na- 4. National Center for Children in Poverty. Five Million Chil- tional health care expenditures. dren: A Statistical Profile of Our Poorest Young Citizens. New To address the health needs of this overlooked group in York, NY: Columbia University; 1990. a cost-efficient way, we need to elicit significant efforts 5. National Commission on Children. Reference Book. from local private and public sectors and from the federal Washington, DC: National Commission on Children; 1989. government. All share in the potential benefits when these 6. Wise PH, Meyers A. Poverty and child health. Pediatr Clin children succeed in becoming productive citizens. North Am. 1988;35:1169-1186. Failure to address the health needs of today's children 7. Harvey B. A proposal to provide health insurance to all is having insidious consequences for our society, causing children and all pregnant women. N Engl J Med. 1990;323:1216- 1220. uncertainty and suffering for our families and compromis- 8. US Office of Technology Assessment. Healthy Children: ing our future productivity and competitiveness. 6,9 Our Investing in the Future. Washington, DC: US Government Print- future will be mortgaged to a much greater extent by this ing Office; 1988. negligence than by failure to reduce the federal budget 9. US Public Health Service. Healthy People 2000. Washing- deficit. The proposed program would start to address this ton, DC: US Dept of Health and Human Services; 1990. Improving Health Care for Underserved Infants, Children, and Adolescents The Robert Wood Johnson Foundation's Experience Michael P. Beachler improving the health care of this nation's infants, chil- programs was increasing, but by the early 1980s, an era dren, and adolescents has been a priority of The Robert of fiscal retrenchment, it was no longer realistic. Wood Johnson Foundation since its inception as a national In the late 1970s, the number of children without health philanthropy in 1972. The foundation has awarded grants insurance was increasing, yet in the early 1980s public fi- totaling almost $243 million, approximately 22% of the nancing for child health services was cut back. From 1977 foundation's overall grant-making to date, to programs to 1985, the proportion of children younger than age 18 whose aim is to improve the health of infants, children, years without public or private health insurance increased and adolescents. from 17.6% to 23.4% 1,2 Today, more than one third of the The foundation has used three major strategies in its child uninsured are children. health efforts: service demonstrations to develop and test Economic changes have had a major influence on the new models of care, research to improve the knowledge base decrease in private insurance coverage for children. For and assess the efficacy of its service demonstrations, and some, parents' manufacturing jobs, and accompanying training to better prepare health care providers to address health insurance, have been lost, to be replaced with common child health problems. Given the foundation's mis- service-sector jobs less likely to provide health insurance sion to improve the health care system, and particularly its benefits. The growth of single-parent households and a long-standing interest in improving access to care, more than reduction in the share of group health premiums paid by two thirds of its child health funding has supported service employers have also contributed to the decrease in private projects targeting underserved children. coverage.³ Regarding public insurance, changes in Med- The foundation's primary objective in its early years (1972 icaid eligibility requirements reduced the proportion of to 1980) was to increase access to personal health services. low-income Americans covered from 63% in 1975 to 46% In light of the nation's high infant mortality rate, which ac- in 1983.4 From 1978 to 1984, Medicaid expenditures (mea- counted for 70% of all deaths among children under age 15 sured in constant dollars) declined 13%, and federal fund- years, many of the foundation's early child health efforts ing for three important sources of primary health care for emphasized improving access to perinatal care. poor women and children-maternal and child health ser- In the early 1980s, the foundation announced a broader vices, community health centers, and health centers for agenda, one that went beyond improving access to include migrants-declined 32%. support of programs to help people maintain or regain During this period, a shift in responsibility for child health maximum attainable function and to make health care ar- policy from the federal to the state level occurred under the rangements more effective and affordable. Reagan administration's "New Federalism" policy. States The development of its most recent child health efforts now had primary administrative responsibility for several has been influenced by major changes in the organization key child health programs, such as the Maternal and Child and financing of child health services and by the changing Health; Prevention; and Alcohol, Drug Abuse, and Mental nature of child health problems. Health block grant programs. Accompanying federal fund- ing cuts pressured state governments to increase their sup- A CHANGING HEALTH CARE port of these services. Federal Medicaid policy also started ENVIRONMENT FOR CHILDREN to allow states greater flexibility concerning the range of child With the foundation's earliest child health efforts, it was health services they could cover and greater discretion as to presumed that once a program was successfully imple- who was eligible for services. In the last 5 years, Congress mented the health system would have sufficient resources passed legislation allowing states to increase covered ser- to sustain it beyond the grant period and to replicate it vices and to provide Medicaid coverage to mothers and chil- more broadly. This expectation may have been appropri- dren without having to increase welfare payments. ate in the 1970s when federal financing for child health While these policy changes unfolded, the changing health problems of America's children presented signif- Accepted for publication December 21, 1990. icant new challenges. The premature infant of the early From The Robert Wood Johnson Foundation, Princeton, NJ. 1970s may have required admission to a state-of-the-art The views expressed in this article are those of the author, and no official endorsement by The Robert Wood Johnson Foundation neonatal intensive care unit; by contrast, today's cocaine- is intended or should be inferred. addicted premature infant-in addition to neonatal inten Reprinted from AJDC (1991;145:565-568). sive care-may require detoxification, foster care, and Improving Health Care 73 many other health and social services involving many into their permanent systems of care. In contrast to the two agencies, institutions, and funding sources. The mother earlier programs, in which the grantees were academic also requires drug treatment and help coping with an at- medical centers, the grantees in the Healthy Futures pro- risk newborn. In a child health system that is fragmented gram are the state health departments in five southern and funded through a bewildering array of separate cat- states and Puerto Rico. (Another six sites are funded egorical programs at the federal, state, and local levels, through the federal government's Healthy Generations ensuring that a child with multiple health problems ob- Program, which resembles and has worked closely with tains needed services becomes extremely difficult. the Healthy Futures program.) This $7.2-million program These changes in public policy, children's needs, and emphasizes promotion of regionalized systems and pre- what are considered health-related problems have re- natal care outreach, improved coordination between the sulted in a broader focus for the foundation's programs in state's maternal and child health and Medicaid agencies, this area, which now concentrate on helping the child better financing for the state's perinatal care service sys- health system be more responsive to children's health tem, and increased cooperation between public officials needs. and private providers. SELECTED CHILD HEALTH EFFORTS The grantees in this program have made considerable This evolution in the foundation's programs can be il- progress during the first 2 years of foundation support. For lustrated through brief descriptions of several of its major example, several states have actively promoted the adop- maternal and infant care programs. The first major ini- tion of uniform prenatal risk assessment tools and have tiative in this area was the Perinatal Program, an eight-site improved financing (eg, expanded Medicaid eligibility, re- demonstration program, implemented between 1975 and imbursement, and perinatal service coverage). 1980, designed to demonstrate the feasibility of region- Another example of a program developed with this alized perinatal services and to measure their impact on broader focus is the Mental Health Services Program for infant mortality and morbidity. Through this program, Youth (1989 to 1994). Here, too, the grantees are state major medical centers worked with community hospitals agencies. In this eight-site, $20.4-million program, the to establish common perinatal risk assessment systems, foundation seeks to demonstrate that through a collabo- maternal and neonatal transport systems, consultation rative effort between states and local communities, ser- and outreach education programs, and management in- vices for children and youth with serious mental illnesses formation systems to track care. An independent evalu- can be organized and delivered far more effectively. Men- ation of the program found that neonatal mortality rates tal health, child welfare, juvenile justice, and special ed- declined by an average of 20% at the eight sites. At the ucation agencies at the community and state levels are same time, there was no increase in the number or pro- responsible for improving the financing and coordination portion of infants with serious physical or developmental handicaps at age 1 year.6 The concept of regionalizing per- of services. They also are charged with developing a con- inatal care has taken hold strongly in most parts of the tinuum of mental health and supportive services to main- country, yet, key elements of this system-common tain seriously mentally ill children in the most appropriate records, training, and outreach-are not widely adopted. settings. During the 1-year development phase of the pro- In fact, even former grantees have had difficulty sustain- gram, each of the sites made statewide financing changes ing these components of a regional system.⁷ that will increase the availability of home-and community- The Rural Infant Care Program (1980 to 1985) extended based services. this regionalized approach to isolated rural areas that had The importance of multiple agencies and community extremely high infant mortality rates. This effort supple- leaders in making the child health system more responsive mented the federal government's Improved Perinatal Out- is also illustrated by the School-Based Adolescent Health comes and Improved Child Health programs. The Rural Care Program (1987 to 1993). This 18-site, $14.5 million Infant Care Program mobilized 10 medical schools to pro- program is a collaborative effort involving schools, health vide technical support to providers in outlying commu- care providers (such as hospitals or community health cen- nities. It also included aggressive efforts by nurses and lay ters), and the community (through a formal community outreach workers to encourage high-risk mothers to ob- advisory committee). The program provides start-up sup- tain prenatal care early in their pregnancies. The evalu- port for school-based health centers that offer a compre- ators of the program found significantly greater reductions hensive range of services in public secondary schools. The in infant mortality in most of the program sites compared partnership between the schools and the community with other rural counties in their states without this pro- health providers has helped the sites secure third-party gram. They also found that a significantly larger propor- reimbursement of clinical services. In the 1989 to 1990 tion of low-birth-weight deliveries in the area served were taking place in medical centers.⁸ Almost all of the sites school year, reports Julia Lear, PhD, program codirector, more than 15 200 students received health services in the have maintained some identifiable elements of the pro- gram, although the project's interventions have not been 23 schools involved, and more than 58 000 patient visits widely implemented in other sites in these states. were made (oral communication, November 1990). By the mid-1980s, the foundation's focus had shifted. The foundation's most recent multi-site child health ef- The intent of Healthy Futures: A Program to Improve Ma- fort is a 3-year pilot test of the feasibility of restructuring ternal and Infant Care in the South (1988 to 1992) is not publicly funded health services for children with a special to demonstrate the effectiveness of new models of care, emphasis on how these services are financed and deliv- but to encourage states and communities to incorporate ered. It is intended to help communities simplify the com- what has already been learned from past demonstrations plex web of categorical programs that fund services for 74 Caring for the Uninsured and Underinsured children with many health needs and to make these ser- response, the foundation designed the Infant Health and vices more accessible. The hoped-for result is a system Development Program (1983 to 1990), the largest random- more responsive to the needs of the individual child. ized clinical trial of intensive early childhood interventions for low-birth-weight infants. The study principally was SINGLE-SITE PROJECTS underwritten by the foundation with additional support In addition to these demonstration programs, the foun- from the federal government, The Pew Charitable Trusts, dation also supports many single-site projects funded in and Stanford (Calif) University's Center for the Study of response to unsolicited proposals. Some of these projects Families, Children, and Youth. Eight cities were involved also are aimed at improving children's health by making in the program: Boston, Mass; Dallas, Tex; Little Rock, the health and social service systems more responsive. Ark; Miami, Fla; New Haven, Conn; New York, NY; Phil- Harlem Hospital, New York, NY, for example, has de- adelphia, Pa; and Seattle, Wash. The 985 children in the veloped an injury prevention program (1988 to 1992) that study sample were randomly assigned to one of two mobilizes coalitions of parents and community leaders to groups: children in the intervention group received home work with representatives from the city departments of visits and were enrolled in special child development cen- education, parks and recreation, and transportation. Dur- ters, with support groups for parents; children in the in- ing the last 2 years, substantial improvements have been tervention and follow-up groups received high-quality pe- made in the maintenance and supervision of equipment diatric follow-up care. The study found that children in the at 28 playgrounds, and a recent hospital survey indicates intervention group had significantly higher mean IQ that window-guard use in apartments has increased from scores and fewer maternally reported behavior problems 50% to 80% during the last few years. The hospital's child- than children in the control group. The study also pro- hood injury-related admissions declined by 14% from vided conclusive evidence that high-quality group day 1988 to 1989-the first recorded reduction since 1975. Dur- care can be both safe and beneficial to low-birth-weight ing the next 2 years, the injury prevention program will infants, despite their increased vulnerability to illness and continue to expand the playground and window safety their special developmental needs.9 projects and will develop programs targeted at adoles- Another foundation-supported child health research ef- cents. fort (1979 to 1983), conducted by the University of Roch- In another urban project targeting underserved chil- ester (NY) School of Medicine, assessed the effectiveness dren, Montefiore Medical Center, New York, NY, has de- of a nurse home-visitor program for pregnant women and veloped a lead poisoning prevention and treatment pro- their infants in rural Chemung County, New York. Ad- gram (1988 to 1992) in The Bronx that combines new ditional support for this project came from the W.T. Grant services and creative financing and involves city and state and Ford Foundations and the federal government. The social service, health, and housing agencies. The project study found that children whose families received home includes community-based mobile screening and a full visits tended to have better language and fine motor skills, range of treatment. Two new services-outpatient che- less use of emergency room and hospital services, and lation and transitional housing-will complement Mon- lower rates of child abuse than did children in families that tefiore's existing inpatient chelation, nutritional counsel- did not receive these services. Home-visited mothers had ing, and after-care services. The project has already fewer additional pregnancies and therapeutic abortions, secured financing for some transitional housing from city were more likely to return to work, and used fewer welfare and state housing agencies and will work with housing services. 10 The positive findings of this randomized con- and Medicaid agencies to increase this capacity and secure trolled trial have led to a second study (1988 to 1994) to test permanent financing for the mobile screening and out- whether the model could be replicated in an urban setting patient chelation services. (Memphis, Tenn), again supported by multiple funding In a rural project (1988 to 1990) funded by The Robert agencies, including The Robert Wood Johnson Founda- Wood Johnson Foundation, the Freedom from Hunger tion, the federal government, The Pew Charitable Trusts, Foundation is working with the Mississippi Cooperative the Carnegie Corporation of New York, and the W. T. Extension Service and the state health department to re- Grant Foundation. duce nutrition-related health problems among children in the Mississippi Delta. The project is designed to integrate CONTINUATION AND REPLICATION the nutrition education efforts of the Extension Service- The foundation faces a continuing challenge in helping administered Expanded Food and Nutrition Service Pro- grantees identify sources of ongoing support for program gram and the state-administered Supplemental Food Pro- services following grant expiration. Identifying such fund- gram for Women, Infants, and Children (WIC). Program ing sources also has significant implications for whether coordinators are training Cooperative Extension Service foundation-supported programs can be replicated more staff in six counties and revising policies and procedures broadly. to facilitate better coordination of the two agencies' efforts. To help grantees address these issues, the foundation encourages the early involvement of potential long-term CHILD HEALTH RESEARCH EFFORTS funders, sometimes through the use of declining-balance The Robert Wood Johnson Foundation's child health budgeting (by which foundation funds decrease over demonstration programs have raised many important re- time) and matching funds requirements. In addition, sev- search questions. For example, the success of the regional eral of the foundation's recent child health programs, such Perinatal Program in improving the survival of low-birth- as the Mental Health Services for Youth Program and the weight infants raised the critical question of what, if any- Child Health Initiative, are specifically designed to en- thing, can be done to improve long-term health and de- courage agencies to redeploy existing funds to maximize velopmental outcomes of low-birth-weight infants. In their impact. Improving Health Care 75 Clearly, meeting the needs of underserved children and ington, DC: US House of Representatives Select Committee on youth will remain a major and important challenge for Children, Youth and Families; July 1, 1987. families, the health care system, and this country. Factors 4. Blendon R, Aiken L, Freeman H, Kirkman-Liff B, Murphy such as poverty, homelessness, and family dysfunction T. Uncompensated care by public hospitals or public insurance make it difficult to address adequately the health care for the poor: does it make a difference? N Engl J Med. needs of children with complex problems, such as ac- 1986;314:1160-1163. quired immunodeficiency syndrome, substance abuse, 5. Healthy Children: Investing in the Future. Washington, and mental illnesses. For the foreseeable future, multiple DC: Office of Technology Assessment; 1988:5-6. organizations and constituencies, from both the health 6. McCormick MC, Shapiro S, and Starfield BH. The region- alization of perinatal services: summary of the evaluation of a and other child-serving sectors, must be engaged in efforts national demonstration program. JAMA. 1985;253:799-804. to develop a comprehensive response to children's needs. 7. The Robert Wood Johnson Foundation Special Report: The I would like to acknowledge the thoughtful contributions of my Perinatal Program: What Has Been Learned? Princeton, NJ: The colleagues, Ruby P. Hearn, PhD, Paul Jellinek, PhD, Richard Rey- Robert Wood Johnson Foundation; 1985:8. nolds, MD, and Steven Schroeder, MD. 8. The Robert Wood Johnson Foundation Special Report: The References Rural Infant Care Program. Princeton, NJ: The Robert Wood 1. 1977 National Health Care Expenditures Survey. Washing- Johnson Foundation; 1986:6. ton, DC: US Dept of Health and Human Services; 1980:6. Pub- 9. Gross R, Spiker D, Contstantine NA, et al. Enhancing the lication (PHS) 85-3377. outcomes of low-birth-weight, premature infants: a multisite 2. 1987 National Medical Expenditures Survey. Washington, randomized trial. JAMA. 1990;263:3035-3042. DC: US Dept of Health and Human Services; 1990:6. Publication 10. Olds DL, Henderson CR Jr, Tutelbaum R, Chamberlin R. (PHS) 90-3469. Improving the delivery of prenatal care and outcomes of preg- 3. Chollet D. The Changing Pattern of Health Insurance Cov- nancy: a randomized trial of nurse home visitation. Pediatrics. erage Among Non-Elderly Families [oral presentation]. Wash- 1986;86:16-28. The Challenge of Care for the Poor and Underserved in the United States An American College of Obstetricians and Gynecologists Perspective on Access to Care for Underserved Women Ezra C. Davidson, Jr, MD; Charles E. Gibbs, MD; Janet Chapin, MPH Access to pregnancy-related care for women and their ance to cover maternity care, and 15% of the 3.7 million infants and to reproductive health services for adolescents births in that year were to women with no health insurance are significant concerns to the American College of Obste- coverage.⁵ tricians and Gynecologists (ACOG). Adolescent and young One measure of access is entry into prenatal care. In adult women are among those most likely to be uninsured 1988, for the nation as a whole, 24% of the women who and lack access to health care services. Adolescent preg- gave birth did not receive prenatal care in the first trimester nancy, low-birth weight, and infant mortality remain major of pregnancy, and 6% received little or no care at all before national burdens. The ACOG has taken the position that delivery. For black women, the situation was worse; 40% quality health care should be accessible to all women. The did not receive care in the first trimester, and 11% received ACOG recommendations regarding health services for ad- little or no care during pregnancy.¹ olescents and the ACOG Committee on Health Care for Un- Access to prenatal care is a major factor associated with derserved Women's statement of principles regarding uni- low birth weight and infant mortality.6 The personal and versal access for pregnancy-related care, which includes the public costs of the stubbornly high percentage of low- basic scope of benefits, the characteristics of the providers, birth-weight infants remain a national burden. The Office and the organization of services are described. of Technology Assessment has estimated that a single low- birth-weight infant incurs between $12 000 to $40 000 in short-term hospital costs. Handicapping conditions occur I n 1988, more than 794 women did not receive pre- in approximately 5% to 16% of the low-birth-weight in- natal care in the first trimester of pregnancy.¹ Every fants treated in today's neonatal intensive care units.⁷ year, more than 10% of all 15- to 19-year-old women be- Long-term domiciliary and education costs for these dis- come pregnant.² Access to care for underserved wome- abled children are estimated at $6000 to $37 000 per year. n-in particular, pregnancy-related care for women and In addition, adolescents and young adults are among their infants and reproductive health services for adoles- the groups more likely to be uninsured for health care ser- cents-is a significant concern to the American College of vices. As of 1984, about one in every seven adolescents, Obstetricians and Gynecologists (ACOG). More than 30 approximately 4.5 million adolescents aged 10 to 18 years, reports and policy recommendations have been published had no health insurance coverage. Black adolescents were in the past 5 years alone on the subjects of infant mortality 63% more likely than white adolescents to be uninsured. and access to pregnancy-related services.³ Reports on ad- Hispanic adolescents were nearly three times as likely as olescent pregnancy have multiplied, reflecting the con- non-Hispanic whites to be uninsured. Adolescents living cerns about pregnancies in this age group. Although some in families earning less than the federal poverty standard responses to the recommendations have been forthcom- were three times more likely than their nonpoor coun- ing at the state and federal levels, much more is needed terparts to be uninsured.9 before we will see significant improvements in health sta- More than 6 million young adults, 26% of those 19 to tus. The time for study is past. Although we always need 24 years old, were uninsured in 1984. Hispanic, black, current data, it is time now to move forward to implement poor and near poor, unemployed, and high school drop- many of these recommendations. outs were among those young adults most likely to be without insurance. Three fourths of white young adults THE PROBLEMS 19 to 24 years of age had private insurance compared with Lack of health insurance decreases the likelihood that a only half of blacks of the same age. More than 40% of His- woman will receive appropriate health care.⁴ In 1985, of panics had no insurance, twice the rate of non-Hispanic the women of reproductive age, 26% did not have insur- whites.⁹ One of the most troubling issues in adolescent health care is adolescent pregnancy. More than 1 million adolescents become pregnant every year in the United Accepted for publication January 24, 1991. From the American College of Obstetricians and Gynecologists, States.² The birth rate for teens aged 15 to 17 years rose Washington, DC. in 1988 for the first time in a decade, to 33.8 births per 1000 Reprinted from AJDC (1991;145:546-549). women aged 15 to 17 years.¹ Compared with the rate in Care for Underserved Women 77 other developed countries, the pregnancy rate among The issue of confidentiality has been identified by both American teenagers is among the highest in the world. It providers and young people as having a significant impact is twice the rate in England, Wales, and Canada, three on access to health care. This is particularly true for times that in Sweden, and more than six times the rate in reproductive health services. Health professionals have an the Netherlands.² ethical obligation to provide the best possible care and counseling in response to the needs of their adolescent ACOG RECOMMENDATIONS patients. This obligation includes reasonable efforts to Since 1971, ACOG has taken the position that quality encourage the adolescent to involve her or his parents in health care should be accessible to all women. 10 This po- health care decisions. The support of parents can, in many sition was reaffirmed in a policy statement adopted in July instances, increase the potential for resolving the adoles- 1988. 11 Since 1985, through its Committee on Health Care cent's problems on a continuing basis. The restrictive laws for Underserved Women, ACOG has addressed various and regulations affecting confidentiality found in many components of the problems related to access to care. The jurisdictions are often impediments to care and need to be ACOG also has a long-standing interest in the develop- revised as a matter of public policy. The ACOG, in ment of adequate, comprehensive, and high-quality collaboration with the American Academy of Family Phy- health services for adolescents, with special reference to sicians, the American Academy of Pediatrics, NAA- reproductive health services. Since 1964, ACOG has or- COG-the Organization of Obstetric, Gynecologic ganized initiatives in the area of adolescent health. Over and Neonatal Nurses, and the National Medical Associ- the years, more than 10 policy statements, as well as nu- ation, has developed a policy statement on confidentiality, merous other reports and committee statements regarding since such assurances are essential to serve adolescents adolescent health, have been issued. In 1985, ACOG be- effectively. This policy statement sets forth the obligation gan a public education program that broke network tele- of the providers of adolescent health care to protect vision barriers that prevented the provision of good, re- confidentiality, as well as suggesting methods for clari- liable information on unintended pregnancy to the fying the relationship to the adolescent and her or his American public. parents.¹⁴ SERVICES FOR ADOLESCENTS IMPROVING ACCESS TO The ACOG holds the position that health services for PREGNANCY-RELATED CARE adolescents must be broad in scope and must be provided FOR UNDERSERVED WOMEN in the context of adequate education, social services, and Although access to all health services is important for family support. Health education that includes education women of all ages, among the most critical needs is access regarding sexuality and reproduction, beginning early in to pregnancy-related care. The ACOG Committee on a child's life, is a cornerstone of effective reproductive Health Care for Underserved Women has developed a health services. statement of principles regarding universal access for Moreover, contraception and family planning services pregnancy-related care and the necessary characteristics must be available and accessible for all women, regardless of any legislation or plan that would provide such care. of age, whose sexual behavior exposes them to the risk of The ACOG is aware of the importance of controlling unintended pregnancy. Contraceptive services should be costs, and this statement of principles regarding universal offered, whenever possible, in a general health care setting access should not be seen as a call for unrestrained spend- that includes counseling regarding psychosocial consid- ing. To the contrary, the college believes that comprehen- erations and sexually transmitted diseases. Much more sive pregnancy-related care, appropriate to the various outreach and publicity should be undertaken to inform needs of each patient, is worth the initial costs and will sexually active adolescents about the importance and contribute importantly to cost containment. For example, safety of contraceptive use, as well as to assist them in a good system of care will facilitate rapid and accurate eval- locating and accessing services. The ACOG has called for uation of the effectiveness and the role of new technol- responsible advertising of prescription and over-the- ogies and therefore is likely to prevent unnecessary, ex- counter contraceptives and has indicated that it would be pensive services. Administering authorities and financing willing to work with publishers and broadcasters to make plans for universal access need to be specified, but these sure the advertising claims were accurate and scientifically issues are beyond the scope of the current development verifiable.¹² of the ACOG statement of principles. The ACOG endorses the programs, including those lo- cated in schools, that provide reproductive health services Universal Access in areas where such services are not available and where Access to the full range of pregnancy-related services such services have the support and input of parents and (see the list below) should be provided for all women and communities. These programs appear to be most effective infants who live in the United States. It is important to note when they are offered within a system of comprehensive that these principles do not call for all women and infants health care services. One aim of such programs should be to be covered under a single program, but there must be to encourage sexually responsible behavior that is both certain characteristics common to all coverage. Minimum nondestructive and nonexploitive. The ACOG also sup- benefits for all coverage and the eligibility requirements for ports the recommendations of the National Academy of any publicly funded and operated program should be es- Science's report Risking the Future: Adolescent Sexuality, tablished across the nation. Care must be organized and Pregnancy and Childbearing, including the need to maintain delivered in a manner appropriate for, and acceptable to, the availability of adoption and abortion as needed options the pregnant woman and her family. Current public and for adolescents.¹³ private resources should be used whenever possible. Any 78 Caring for the Uninsured and Underinsured publicly funded and operated health services must be kept tween the primary and referral levels of care, and between entirely separate, administratively and financially, from the various disciplines involved in care, should be clearly public assistance/welfare programs. defined in contractual documents between providers. Such agreements tend to clarify both responsibility and Scope of Services in Maternal authority and also describe the extent to which any pro- and Infant Care vider should commit resources. These contracts should The ACOG Committee on Health Care for Underserved contain cancellation clauses and should be renegotiated at Women has established the following list of basic elements regular intervals. of care to which it is particularly important to ensure ac- cessibility. Pregnancy-related care must be understood as Organization of Services broad in scope and variable in intensity and complexity. Maternal and infant health services may be delivered by To the degree that an element is needed but missing or both private and publicly funded and operated services. inadequate, the care is deficient. Additional emphasis There are, however, certain characteristics that are impor- should be placed on prevention and early intervention in tant for all components. The focus of care should be health- all services, and all services should be coordinated and outcome oriented. However, outreach (recruitment) for linked. both patients and providers should be supported finan- Planning pregnancy, and the prevention of those preg- cially, and undergraduate, graduate, and continuing ed- nancies that are unplanned, is an important strategy to ucation should be supported to provide an ongoing supply improve maternal and infant health. All women in the of qualified providers. Additionally, research designed to United States should have access to family planning and improve patient care should be identified and a suitable contraceptive services. environment for investigation encouraged. Additionally, ACOG actively supports individual The organization and methods used to deliver services choice in regard to abortion as a necessary and safe option should be efficient and cost-effective and responsive to for all women. This position is based on the belief that patient needs. Both the management and clinical compo- decisions concerning abortion are so bound in ethical, nents of the programs should be evaluated by means of moral, and religious complexities, as well as other per- outcome and process objectives, and these evaluation re- sonal considerations, that they are best left to a woman in sults should be used in decision making. All types of qual- consultation with her physician. The ACOG believes that ified health care professionals and other providers should continued availability of safe, legal abortion services is es- be used, and incentives must be available to encourage the sential to maternal health. provision of services in geographic areas that are difficult A prepregnancy-related health examination is impor- to serve. tant to identify behavioral and medical factors that require Certain administrative characteristics are important for modification before pregnancy to improve outcome, such any private or public organization or agency that pays for as control of diabetes or smoking cessation, and should be health services. There must be a simple, responsive, and available to all women. This evaluation is not meant to prompt paper and reimbursement flow for patients and include infertility services. Additionally, early pregnancy providers. Easy access to decision makers and clerical- diagnosis facilitates appropriate and timely prenatal care level workers is essential for both patients and providers. and should be available. Furthermore, reliable, sufficient, and consistent funding Prenatal, pregnancy-related services should be based on mechanisms must be present. risk assessment with an appropriate response and include Additional characteristics apply specifically to those that care for new or preexisting conditions that affect the preg- are publicly funded and operated. The administrating nancy, fetal evaluation, health and childbirth education, agency should have a simple table of organization with nutritional support and counseling, substance abuse clear lines of responsibility. Clinical expertise should be counseling and treatment, and linkage of prenatal care and present within the senior management, with assurance of delivery. both professional and consumer input at the governance Labor and delivery should be provided in an optimal, level. Where or when it is necessary to restrict the breadth risk-appropriate environment, as should neonatal care ap- or depth of the services to be supported or provided, the propriate to the needs of the infant. Postpartum evaluation selection of the services included or excluded should be and services, including family planning and postpartum determined by a group including both health care pro- sterilization, and infant follow-up for at least 1 year should fessionals and lay persons. The particulars of reimburse- be provided after delivery. Social services support as ment, quality assurance, and utilization review should be needed should be provided throughout the pregnancy specified through a negotiated contract between the pro- and follow-up period. vider and the administrating authority. Health services should be completely separate from welfare services, in Provider Characteristics attitude and approach. Providers of pregnancy-related services include health care professionals and such institutions as laboratories, CONCLUSION: FUTURE ACTIONS hospitals, health departments, and community and mi- The ACOG will continue its organizational focus on grant health centers. All providers should be licensed or these issues through two permanently established com- certified when license is not required in their jurisdiction mittees of its executive board. In 1990, a specific goal of and subject to a quality review process involving peer re- advocacy for access to prenatal care for all women was view. There must be a sufficient number of providers, and articulated by the ACOG. A significant portion of ACOG's they must be of the appropriate disciplines required to government relations activity focuses on improving access render all of the necessary services. The relationships be- to quality health care. The college believes that this nation Care for Underserved Women 79 has a moral obligation to ensure health care for women and mary of all ACOG policies regarding adolescent health are available children at the most vulnerable time in their lives. Fur- from the Resource Center of the American College of Obstetricians thermore, providing effective maternal and infant care is and Gynecologists, 409 12th St SW, Washington, DC 20024-2188. cost-effective for our society as a whole. Public education must continue to focus on the conse- References quences that will result if we fail to improve the system 1. National Center for Health Statistics. Advance report of of health care for pregnant women and infants in this final natality statistics, 1988. Monthly Vital Stat Rep. 1990;39(4; country. The ACOG intends to educate its fellows about suppl) 1-48. how to improve systems of health care and access to care 2. Henshaw SK, Kenney AH, Somberg D, Van Vort J. Teenage and to solicit their involvement, in conjunction with gov- Pregnancy in the United States: The Scope of the Problem and ernment and other policy makers, in actively working to- State Responses. New York, NY: Alan Guttmacher Institute; 1989. ward these solutions. 3. Healthy mothers, healthy babies: recent policy recom- Perhaps one of our most important activities is the re- mendations. In: Supplement to a Compendium of Program cently established National Fetal and Infant Mortality Re- Ideas for Serving Low Income Women. Washington, DC: US view Program. With grant support from the Maternal and Dept of Health and Human Services, Public Health Service, Child Health Bureau, we have brought together many or- Health Resources and Services Administration, Maternal and ganizations to provide guidance and assistance to com- Child Health Bureau; January 1990:1-4. munities to identify the specific causes of fetal and infant 4. Medicaid Recipients and Uninsured Women Obtain Insuf- mortality in their areas and to develop solutions targeted ficient Care. Washington, DC: United States General Account- to those specific problems. ing Office; September 1987. Several other aspects of this nation's health care delivery 5. Blessed Events and the Bottom Line: Financing Maternity system must be repaired if access to care for the poor and Care in the United States. New York, NY: Alan Guttmacher In- the uninsured is to be guaranteed. stitute; 1987. The problems regarding professional liability must be 6. Brown S, ed. Preventing Low Birthweight. Washington, DC: National Academy Press; 1985. ameliorated by ensuring care for affected infants and sup- 7. Neonatal Intensive Care for Low Birthweight Infants: Costs port for their families. To promote self-discipline in the and Effectiveness, Health Technology Case Study 38. Washing- profession, there must be protection for those who par- ton, DC: Congress of the United States, Office of Technology ticipate in peer review and sanctioning activities. Assessment; December 1987. In addition, difficulties surrounding referrals, transfers 8. Healthy Children: Investing in the Future. Washington, of high-risk patients, and the provision of consultation DC: Congress of the United States, Office of Technology As- must be resolved in ways that both protect patients and sessment; February 1988. OTA-H-345. allow physicians to provide appropriate levels of care for 9. Newacheck PW, McManus MA, Brindis C. Financing higher-risk patients. Furthermore, reimbursement and health care for adolescents: problems, prospects, and propos- compensation for nurses, technical workers, and hospitals als. / Adolesc Health Care. 1990;11:398-403. must be enhanced. 10. American College of Obstetricians and Gynecologists. It is clear that public hospitals and health departments, National health care for women. Obstet Gynecol. 1972;39:603- 608. which constitute only a portion of the current system, can 11. Access to Women's Health Care: ACOG Policy Statement. no longer be expected to bear the major burden of pro- Washington, DC: American College of Obstetricians and Gy- viding care for the poor and uninsured without a greatly necologists; 1988. increased level of support. 12. Contraceptive Advertising: ACOG Policy Statement. It is naive to assume that one organization or group of Washington, DC: American College of Obstetricians and Gy- organizations alone, such as organized medicine, no mat- necologists; 1987. ter how well intentioned, can solve the problems of access 13. Hayes C, ed. Risking the Future: Adolescent Sexuality, to care. What is needed in this country, as in other coun- Pregnancy and Childbearing. Washington, DC: National Acad- tries, is leadership and the social will to make sure that emy Press; 1987. universal access to care becomes a reality. 14. Confidentiality in Adolescent Health Care: ACOG Policy Statement. Washington, DC: American College of Obstetri- A history of ACOG activities in adolescent health care and a sum- cians and Gynecologists; 1988. The American Academy of Pediatrics Response to the Growing Health Needs of Children James E. Strain, MD At its planning meeting in May 1988, the executive More than one in five children in this nation live in pov- board of the American Academy of Pediatrics (AAP) erty.3 About half of the poor children are receiving Med- established the promotion of access to child health care as icaid benefits.⁴ Although 52% of those eligible for Med- its top priority. Later in the year, the following resolution icaid are children, less than 20% of Medicaid dollars are was passed at the chapter president's forum: "That the spent for their care.⁴ Thus, in both the private and public Academy develop and support legislation to assure a sectors, there are significant gaps in the health insurance health program that guarantees all children and pregnant coverage for children. women access to a comprehensive (basic) package of Uninsured children utilize physician services less often health care benefits that treats all children and pregnant than do insured children, particularly preventive health women equally, and that the Academy work with legis- services.⁶ Delays in treatment often add to the cost of care lators to draft a model program that, to the extent prac- and reduce the likelihood of a successful outcome. ticable, maintains parental control of health care decisions, To meet the needs of all children, including the unin- preserves the physician's primary obligation to his or her sured, underinsured, and uninsurable, the AAP has de- patient, and effectively utilizes private insurers." veloped a proposal that guarantees financial access to care In October 1988, the executive board approved a uni- for all children through age 21 years and all pregnant versal access-to-care proposal consisting of three compo- women. This plan is designed to be the least disruptive of nents: (1) the introduction of federal legislation that guar- the present health care system. It is a one-tiered system antees financial access to medical care for all children and in which children insured in the private and public sectors pregnant women; (2) the establishment of community- have equal benefits. These benefits include preventive based health projects that meet the special needs of chil- health services, the treatment of acute and chronic ill- dren at the local level; and (3) the introduction of a public nesses, and the management of disabling conditions that relations program that increases public awareness of the require care coordination. Standards of care will be set at importance of child health issues. The three components the federal level, but administration of the program will of the AAP access initiative are described in this article. be left to the states. The cost of the program will be borne by the public and private sectors, and families that can FEDERAL LEGISLATION afford to pay will share in the costs. There will be a fair In 1987, approximately 10 million children aged 0 and equitable payment for services rendered and a sim- through 21 years were without health insurance for the plified billing system. entire year. Another 10 million were uninsured for part of the year. 1 Employers faced with escalating insurance costs THE AAP PLAN Benefits are increasing employees' share of premium costs for de- pendents, thereby discouraging dependent coverage.² In Benefits include preventive health care, primary med- addition, plans that do cover dependents often fail to meet ical care, and extended care requiring coordination of ser- the health needs of children. Most child health services are vices. provided in an ambulatory setting and are often not cov- 1. Preventive health care includes the following: (a), of- ered by health insurance. Traditional insurance has been fice visits, immunizations, and laboratory services as rec- designed to cover hospital care. While this type of cov- ommended by the AAP in its periodicity schedule; (b) ma- erage is important for the occasional child with a cata- ternity services; (c) family planning services; (d) care of the strophic or long-term illness, the vast majority of children newborn, including physician attendance at high-risk de- will have no need for this service. liveries; (e) child abuse and neglect assessment; and (f) Some children are classified as uninsurable because of preventive dental care. Because of the importance of pre- a preexisting condition. Children with congenital defects, ventive health care, there will be no copayments or de- chronic diseases, or other disabling conditions are often ductibles for anyone receiving these services. excluded from coverage, particularly when a parent 2. Primary medical care includes the following: (a) hos- changes jobs. Insurance companies are reluctant to accept pital care; (b) physician services for acute and chronic con- children who may require more than the usual amount of ditions; (c) laboratory and other diagnostic services; (d) care. acute dental care; (e) medical and surgical supplies; (f) cor- rective eyeglasses and lenses; (g) hearing aids; (h) medical Accepted for publication January 3, 1991. equipment; and (i) prescription drugs, including nutri- From the American Academy of Pediatrics, Elk Grove Village, III. tional supplements. For families below 133% of the pov- Reprinted from AJDC (1991;145:536-539). erty level, no coinsurance or deductibles will be required Health Needs of Children 81 for these services. For those above 200% of the poverty Administration level, there will be a $200 annual deductible per family and The federal government will mandate a benefit package. a 20% copayment. A sliding scale will be used for families The Secretary of the US Department of Health and Human between 133% and 200% of the poverty level. Services will have the authority to establish boundaries 3. Extended medical care requiring care coordination within which the states must function. includes the following: (a) care coordination for chroni- The actual administration of the program will be at the cally ill and other "at risk" children; (b) orthodontia; state level. States will establish policies that control mar- (c) treatment of developmental and learning disabilities; keting of insurance and will develop and maintain the sys- (d) substance abuse services; (e) speech therapy; (f) occu- tem. They will monitor the health status of children and pational therapy; (g) physical therapy; (h) hospice care; (i) pregnant women and will collect data on unmet needs. respite care; (j) recuperative stays in long-term care facil- They will be responsible for regulating fiscal intermedi- ities; and (k) nutritional assessment and counseling. For aries and for developing performance standards for in- those above 200% of the poverty level, there will be a max- surers. imum coinsurance of 30% for these services. No copay- COMMENT ments or deductibles will be required of families with in- comes below 133% of poverty. A sliding scale will be used The AAP plan replaces the children's and pregnant wom- for families between 133% and 200% of poverty. There will en's portions of Medicaid. Medicaid has perpetuated a two- be an out-of-pocket cap of 10% of family income or $1000 tiered system of care in which eligibility, benefits, and re- per year for an individual and $3000 per family, whichever imbursement limited by lack of funds, vary from state to state. Physician participation in Medicaid has declined in re- is less, for all services provided under the plan. To the extent possible, insurance mechanisms will be cent years.6 Billing procedures have become burdensome. used to fund benefits included in the AAP proposal. How- The plan proposed by the AAP provides a uniform pack- ever, direct state or federal funding will be required for age of benefits for all children and pregnant women. It is some services. Services for children with special health an insurance-based program with private insurers bidding care needs and primary care services where none are lo- for contracts in the public and private sectors. It provides cally available are among those that may need direct fund- for cost sharing of premiums, copayments, and deduct- ing. The state Title V maternal and child health agencies ibles based on the ability to pay. It underwrites the cost of care for the poor. will continue to play an important role in monitoring care The AAP's proposal will increase the total cost of health and providing services not covered by insurance. services for children and pregnant women from the 1990 level of $98.8 billion to $111.4 billion, an increase of ap- Financing proximately $12 billion. Compared with the total cost of Funding for this plan will come from private and public medical care in the United States, which was $650 billion sources. In the private sector, employers will be required in 1990,7 the added cost of providing health care for all to provide the mandated benefit package for children and children and pregnant women is relatively low. pregnant women or pay a 3.17% employee payroll tax The AAP intends to introduce legislation in the 1991 based on 1990 calculations. The shared cost of dependent session of Congress that incorporates the principles enun- coverage cannot be a greater percentage of the total pre- ciated in the plan. Because of the widespread dissatisfac- mium than the shared cost of the employee coverage and tion with the current methods of financing health care, it cannot exceed 25% of the total premium. is likely that many new health care financing proposals In the public sector, a fund will be established at the state will be considered by the 102nd Congress. The AAP plan level to purchase insurance for families not covered by is the only one that specifically addresses the care of chil- employer insurance. It will have several income streams. dren and pregnant women. The AAP supports guaran- The tax imposed on employers who elect not to provide teed financial access to care for all United States citizens, coverage for dependents of their employees or whose ben- but we believe that if an incremental approach is neces- efit package fails to meet mandated benefit standards will sary, the first step should be coverage for children and be one source of funding. Federal and state Medicaid pregnant women. The value of preventive care and early funds currently being used to provide medical services for intervention for children and pregnant women, the rel- children and pregnant women will be another source. Fi- atively low cost, and the large number of women and chil- nally, premiums paid by families not covered by employer dren living in poverty are strong arguments for making insurance will be added to the fund. If the family income children and pregnant women our top priority. is above 200% of the poverty level, an annual premium of Community-Based Programs $458 will be paid per family. No premium payments will While providing health insurance for all children and be required for those families below 133% of the poverty pregnant women is an important first step in guaranteeing level, and a sliding scale will be used to determine the access to medical care, it is clearly not the total solution to premium costs for families falling between 133% and 200% the mounting health problems of the young. Poverty and of the poverty level. its social consequences account for much of the morbidity Multiple private insurers will bid on the state contracts in our nation's children. Until mothers and children live just as they do in the private sector. The benefit package in a safe environment and have sufficient food and ade- must be the same for employer insurance and for the state- quate housing, the availability of medical care will have administered fund. In the required package, insurers will limited impact on the health of our children. be allowed some flexibility in the scope and duration of These societal problems are beyond the scope of activity benefits and in the amount of cost sharing, provided the of the AAP; however, we should be able to address many plan is actuarially equivalent. nonfinancial barriers to health care. For example, there are 82 Caring for the Uninsured and Underinsured inadequate numbers of health professionals to deliver care children, and a program for the care of handicapped chil- in some parts of the country, particularly in rural and dren in rural America. inner-city areas. Transportation to and from the sources Healthy Children has demonstrated that a broad base of care can be difficult when medical care is not readily of community leadership is needed to successfully intro- accessible. The process of enrollment in the Medicaid pro- duce a health care program at the community level. Public gram is often difficult and demeaning. Many of the Med- health officials, school administrators, political leaders, icaid registration requirements appear to be designed to nurses, child advocates, church leaders, and pediatricians keep children out of the program rather than bring them all bring special skills and experience to the programs. All in. can play a significant role in meeting the needs of children In addition, cultural differences sometimes make it dif- in their communities. ficult for families to use traditional health care services. During the past 2 years, as a result of funding from the They often feel ill-at-ease in physicians' offices or in emer- Robert Wood Johnson Foundation, the Healthy Children gency centers. Reliance on folklore medicine is common concepts have been incorporated into an AAP program to among some ethnic groups. assist local communities in their planning efforts. The pro- The AAP believes that many of these problems can be gram does not make grants, but provides technical assis- solved at the local level. Communities understand the tance and advice under the direction of Dr Porter. Forty health needs of their children and, given the necessary thousand pediatricians have learned about the program resources, are able to develop programs that meet those through direct mailings from the AAP. Using the existing needs. network of state AAP chapters, pediatricians with a special To assist communities in this effort, the AAP initiated interest in community-based activities have been identi- fied and have agreed to serve as state facilitators. two community-based programs. The first, "The Healthy In August 1990, these facilitators met in Chicago, III, to Tomorrows Partnership For Children," is a program discuss their programs and share information. This very funded by the federal Maternal and Child Health Bureau successful conference laid the groundwork for future de- and jointly administered with the AAP. The program is velopment of community-based programs throughout the designed to fund community-based projects in areas country. In addition, lessons learned from these programs where access to care is limited and child health needs are can contribute to a better understanding of child health not being met. A funded program receives $50 000 each needs and to the establishment of an effective national year for 5 years provided that annual matching funds of child health policy. $100 are obtained from local sources. An additional requirement is the participation of the local pediatric com- Public Awareness Program munity and the state Maternal and Child Health Agency. The third component of the AAP access initiative is the In 1989, 113 grant applications were submitted. Ten public awareness program. The public must become con- were selected by a panel of experts appointed by the AAP vinced of the importance of child health to the future of and Maternal and Child Health Bureau. Among the the nation. We must assume responsibility for the health projects selected were the Family Care Center Health of all of our children-rich and poor, black and white, dis- Project in Lexington, Ky; the Healthy Start Children's abled and healthy. This will require a commitment on the Clinic in Fort Collins, Colo; the Parent-Pediatric Partner- part of the public and, ultimately, state and federal leg- ship in Honolulu, Hawaii; and Project Caring in Pitts- islators to put children's issues first. The AAP expects to burgh, Pa. Site visits were carried out by members of the accomplish this with the public awareness program. AAP Project Advisory Committee and each of the 10 pro- Health professionals have an important role to play in grams has been approved for continued funding for a sec- keeping children healthy and in treating their illnesses. ond year. However, other factors are equally important. A polluted The program was continued in 1990 with the selection environment can have serious health consequences. Lead of 10 additional projects, all created to meet the special and toxic chemicals can have damaging effects on chil- needs of children in local communities. These include the dren. 8,9 Certain activities related to life-styles, such as sub- Jackson County Prenatal Clinic in Jackson, Mich; the First stance abuse and risk-taking behaviors, have an imme- Steps Primary Program in Baton Rouge, La; and the Rural diate impact on health. Inappropriate diets, sedentary behavior, and tobacco use can also have long-term con- Partnership For Children in Omaha, Neb. sequences. The second AAP community-based effort is the Healthy There is a definite relation between health and educa- Children program, originally conceived and directed by tion. An unhealthy child will not do well in school. In 1988, Philip Porter, MD, and funded by the Robert Wood there were 4 children and young adults aged 14 to Johnson Foundation. Dr Porter has had great success dur- 24 years who did not attend school regularly and/or had ing the past 20 years in helping communities recognize not completed 12th grade or received a general equiva- their child health needs and sharing with them the ex- lency degree. 10 Many children who do graduate are func- periences of other communities. He has accomplished this tionally illiterate. These are alarming statistics in a nation by providing consultants from other successful programs that is being forced to compete in the world market. Chil- and advising on new and innovative ways to secure local dren's health and education go hand in hand and must be funding. Among the programs developed with the assis- our nation's highest priorities. tance of Dr Porter are a school-based primary care pro- These messages will be taken to the public with the as- gram, a program for social enrichment and primary care sistance of a national public relations firm. Marketing a of preschool children, a pregnancy prevention program, product is difficult and expensive. Marketing an idea is a comprehensive primary care program for mothers and even more challenging. The AAP intends to seek industry Health Needs of Children 83 support for programs that highlight solutions to the prob- References lems of children. We believe industry is interested, not 1. Short P. Estimates of the Uninsured Population, Calendar only from a humanistic point of view, but also out of con- Year 1987. Rockville, Md: US Public Health Service; 1990. US cern for the health and education of our nation's future Dept of Health and Human Services publication (PHS) 90-3469. work force. Contributions from foundations and individ- 2. Congressional Research Service. Health Insurance and the uals will also be solicited to support the public awareness Uninsured: Background Data and Analysis. Washington, DC: program. US Government Printing Office; 1988. The AAP also recognizes that there are other groups 3. Plotnick RD. Directions for reducing child poverty. Social with an interest in promoting child health. We intend to Work. 1989;34:523-530. work with these organizations to enhance their activities 4. Office of Maternal and Child Health. Child Health USA and to broaden their scope of influence. 1989. Washington, DC: US Government Printing Office; 1989. The specific objectives of the public awareness program 5. Rosenbach ML. The impact of Medicaid on physician use by low-income children. Am J Public Health. 1989;79:1220-1226. are (1) to convince business leaders, legislators, and the 6. Bloom B. Health Insurance and Medical Care: Health of public at large of the importance of child health and the Our Nation's Children, United States, 1988. Hyattsville, Md: Na- long-term benefits of improving the health of our nation's tional Center for Health Statistics; 1990. children, and (2) to generate public support for improving 7. Yudkowsky BK, Cartland JDC, Flint S. Pediatrician partic- access to care for children and pregnant women by de- ipation in Medicaid 1978-1989. Pediatrics. 1990;85:567-577. fining the barriers to care and the means of overcoming 8. American Academy of Pediatrics, Committee on Environ- those barriers. mental Hazards and Committee on Accident and Poison Pre- The AAP is under no illusion that changing public opin- vention. Childhood lead poisoning. Pediatrics. 1989;83:799- ion or creating a ground swell of public support for chil- 800. dren's health issues will be easily accomplished, but over 9. American Academy of Pediatrics, Committee on Environ- a period of time, we believe an informed and aroused pub- mental Hazards. Pesticide residue in the diet of children. AAP lic will demand that children's issues be given a higher News. 1989;5:10. priority on the legislative agenda. 10. Statistical Abstract of the United States. The National Data The AAP invites the support and participation of all pe- Book. 110th ed. US Department of Commerce, Bureau of the diatric organizations and other child advocates in these Census; 1990. important child health initiatives. : : Socioeconomic Status and Visual Impairment Among Urban Americans James M. Tielsch, PhD; Alfred Sommer, MD; Joanne Katz, MS; Harry Quigley, MD; Sandi Ezrine, MS; and the Baltimore Eye Survey Research Group The Baltimore Eye Survey is a population-based study of pairment by age, race, and sex. Herein, we focus on ocular disorders conducted in East Baltimore, Md, designed socioeconomic risk factors and their influence on the to determine the prevalence and severity of vision loss and definitions of groups at high risk of developing vision loss. ocular disease and their relationships to socioeconomic and PATIENTS AND METHODS other risk factors. This survey comprised 5300 subjects The Baltimore Eye Survey examined ocular disorders (2911 whites and 2389 blacks). Visual impairment was as- among subjects aged 40 years or older conducted in the sociated with age, race, general health status, educational neighborhoods of East Baltimore, Md. Detailed methods of level, income, and employment status. An identified asso- this study, a summary of which is contained here, have been ciation of race with blindness and visual impairment was published elsewhere.⁵ reduced, but not eliminated, after adjustment for these so- A stratified cluster sampling technique with probability cioeconomic factors, indicating that socioeconomic status of selection proportionate to cluster size was used to select itself is an important determinant of visual impairment. 16 cluster areas in the eastern and southeastern Health Planning Districts of Baltimore City with the goal being to obtain samples of roughly equal numbers of blacks and A number of population-based surveys on visual im- whites. This sampling strategy began by stratifying census pairment have been conducted over the last 20 years tracts into three categories based on the racial distribution in the United States, 1-4 most of which have originated from of the population as reported in the 1980 census and in- extensive, multipurpose health interview or examination cluded black, white, and mixed-race strata. Black and surveys; blindness registration systems; and in-depth sur- white tracts were defined when greater than 75% of per- veys of specific populations. In general, these studies have sons aged 40 years or older were of either race. Each census reported prevalence rates of blindness and/or visual im- tract was divided into clusters of approximately 600 per- pairment stratified by selected demographic and sociode- sons aged 40 years or older. Within each stratum, census mographic variables. 1-4 Little work has been done, how- tracts were ordered geographically from east to west to ever, to sort out the independent associations of these avoid clustering of the sample close to one source of med- variables with reduced vision. Such analyses are impor- ical care. A systematic sample of census tracts was drawn tant for obtaining leads for future etiologic research and from these ordered lists based on the proportion of total to provide parameters that can be used to target subgroups clusters in each race-specific stratum. Within each selected of the population for special intervention programs. In ad- census tract, a cluster was selected at random. All subjects dition, much of the work done in this area has relied on aged 40 years or older who resided in these cluster areas self-reported measures of vision loss based on question- were recruited for participation through personal field vis- naire responses. While these measures focus on impair- its. Within each cluster, an initial household screening for ments of functional importance to patients, they also suf- eligible subjects was conducted at 99.2% of the 7754 res- fer from a lack of standardization among subjects. idential dwelling units. A total of 7194 eligible subjects was The Baltimore Eye Survey is a population-based prev- identified. An enrollment interview was then conducted alence and risk factor survey of ocular disorders designed with 6892 (95.8%) of the eligible subjects. This short in- to fill many of the gaps in our current understanding of terview included questions on demographic factors, use the prevalence and severity of vision loss. Detailed infor- of general health and eye care services, and history of glau- mation was collected for a variety of demographic and so- coma. cial variables so that high-risk groups could be described Subjects who completed the enrollment interview and and the independent association of such factors with vi- who were medically capable of completing an ophthal- sion loss could be measured. A previously published ar- mologic screening examination were recruited for such an ticle⁵ described the prevalence of blindness and visual im- examination at screening centers established in their neighborhoods. The screening examination consisted of Accepted for publication February 15, 1991. measuring height, weight, blood pressure, pulse, refrac- From the Dana Center for Preventive Ophthalmology, Wilmer Eye tion, visual acuity, and visual fields; applanation tonom- Institute, and the School of Hygiene and Public Health, The Johns Hopkins University (Drs Tielsch, Sommer, and Quigley and Ms etry, and stereo fundus photography; and detailed per- Katz), and Survey Research Associates, Inc (Ms Ezrine), Baltimore, sonal interviews about ophthalmic medical histories and Md. prescription drug, tobacco, and alcohol use. Visual acuity Reprinted from Archives of Ophthalmology (1991;109:637-641). was measured at 4 m using the charts described by Ferris Socioeconomic Status 85 et al⁶ and Ferris and Sperduto⁷ and a specially constructed, backlit box. Visual acuity was measured separately for Table .-Prevalence of Blindness and Visual Impairment each eye and defined as the lowest line on the chart for by Educational Level Adjusted for Age and Race* which the majority of letters were read correctly. Visual Visual Impairment, Blindness, No. of Years No. (Adjusted No. (Adjusted acuity was measured with the refractive correction worn of Education Rate, %) Rate, %) by the subject in place to the screening center and again 0-6 (n = 1017) 75 (5.09) 28 (1.80) with the full refractive correction as determined by the 7-11 (n = 2750) screening examination. If still less than 20/20, visual acuity 58 (2.35) 24 (1.01) was measured using a pinhole. Best corrected visual acuity 12 (n = 1070) 16 (2.86) 8 (1.22) was defined as the best of all visual acuity measurements >12 (n=400) 3 (1.94) 1 (0.64) in the better eye. Screening results were obtained for 5341 P (79.2%) of the 6746 subjects who qualified for examination. F testt .0003 .20 Subjects who met any of the referral criteria, including Student's t test# .0002 .03 elevated intraocular pressure, best corrected visual acuity ß⁶ .003 .001 of worse than 20/30 in either eye, visual field loss, abnor- *Information on educational level was unavailable from 63 mal optic disc findings, or a history of glaucoma under- subjects. went a definitive ophthalmologic examination at the tFor educational level as a categorical variable. Wilmer Eye Institute, Baltimore, Md, with subspecialty #Test of the continuous regression coefficient. referral if necessary. Blindness and visual impairment Regression coefficient for years of education as a continuous were defined using the traditional cutoff points used in the variable. United States: visual acuity of 20/200 or worse for blind- ness and visual acuity between 20/40 and 20/200 for visual Level of education as measured by the number of years impairment. of schooling completed was inversely associated with the Socioeconomic variables available for analysis were col- prevalence of blindness and visual impairment (Table 1). lected during the enrollment interview and included age, Educational level was significantly associated with visual race, sex, marital status, educational level, general health impairment and showed a roughly linear decrease in prev- status, employment status, and frequency of visits to phy- alence with increasing numbers of years of education (Ta- sicians and eye-care specialists. Additional data, including ble 1). A similar association was observed regarding the household income and the proportion of households be- prevalence of blindness, but this was not significant at the low poverty level, were available at the census tract level 5% level because of the small numbers of blind subjects. from the 1980 census. The prevalence of blindness and Using years of education as a continuous variable yielded visual impairment by age, race, and sex have been pre- essentially the same patterns (Table 1). viously reported.⁵ This article focuses on associations of Employment status was strongly associated with both the remaining socioeconomic variables with blindness and blindness and visual impairment (Table 2). Most of this visual impairment. effect, however, was due to those subjects who were clas- Adjustment for age (and sometimes race) was per- sified as disabled. Disabled persons had between two and formed using linear regression techniques. Age was in- cluded in the regression as a second-order polynomial and 10 times higher adjusted prevalences than those in the race as a dichotomous variable. Other variables such as other employment categories. Employed, retired, unem- educational level, employment status, general and relative ployed subjects, and housewives had similar prevalences health status, and use of health care services were cate- of blindness. Retired subjects had significantly lower prev- gorized into the groups shown in the tables. Gender was alences of visual impairment than employed subjects, un- not associated with the prevalence of blindness or visual employed subjects, and housewives. Disabled subjects impairment⁵ and, therefore, was not taken into account in had significantly higher prevalences of visual impairment the adjustment. than subjects in any of these groups. Despite this strong Regression analyses of visual impairment (visual acuity association, 12.4% or fewer disabled subjects had visual between 20/40 and 20/200) excluded the blind. Additional acuities of worse than 20/40, indicating that vision loss was analyses included all those with best-corrected visual acu- a relatively minor determinant in classifying this group as ities of worse than 20/40. disabled for employment purposes. F tests were based on the test for conditional error, in Data on household income were not collected because which a full model was fit to the data, then a second model of concerns about the potential impact of these sensitive fit to the data that excluded all categories of a particular questions on response rates to the examination compo- variable.⁸ Results do not account for the cluster sampling nent of the study. To examine the association of vision loss strategy because there was no indication that blindness or and income, we calculated the age-adjusted rates of low visual impairment clustered after controlling for age and vision (worse than 20/40) for each of the 16 sample clusters race. and compared those adjusted rates with the median household income and proportion of the population be- RESULTS low the poverty level for the census tracts of the clusters A total of 5341 subjects underwent the ophthalmologic as reported by the 1980 census.⁹ The age-adjusted rates screening examination (2913 whites, 2395 blacks, and 33 were plotted against median household income and pro- subjects of other races). The "other race" group was ex- portion of households below poverty level; the results are cluded owing to the smallness of the sample, and visual shown in Figs 1 and 2. Both analyses showed strong cor- acuity information regarding eight subjects was unavail- relations between the prevalence of low vision and these able, leaving 5300 subjects available for analysis. two measures of household income. The regression model 86 Caring for the Uninsured and Underinsured 8 Table -Prevalence of Blindness and Visual Impairment by Employment Status Adjusted for Age and Race* 7 Visual Impairment, Blindness, No. (Adjusted No. (Adjusted 6 Employment Status Rate, %) Rate, %) Employed = 1714) 7 (3.07) 4 (0.96) Homemaker = 1057) 38 (2.68) 7 (0.43) Retired = 1569) 59 (0.84) 25 (0.88) Disabled (n=653) 49 (8.11) 28 (4.31) Age-Adjusted Rate, % 5 4 3 Unemployed = 302) 4 (3.65) 0 (0.49) Pt <.0001 2 <.0001 *Data on employment status were unavailable from five 1 subjects. tFor employment status as a categorical variable. 0 estimated that for every additional $1000 of median in- 2000 4500 7000 9500 12000 14500 come, the prevalence of vision worse than 20/40 declined Median Household Income, Dollars by 0.32% (P<.005), and for every 10% rise in the propor- Fig Scattergram and least-squares regression line of age-adjusted tion of families below poverty level, the prevalence of low prevalence of low vision (worse than 20/40) and median household vision rose 0.44% (P<.03). income of 16 sample areas in East Baltimore, Md. Subjects who reported poor general health or poor health relative to others their age had significantly higher 8 rates of blindness and visual impairment than those who reported better health (Table 3). This strong association 7 was confined to the extremes of the distributions of health status. Those who reported excellent, good, or fair general 6 health and those whose health status was better than or similar to others their age had similar rates of blindness and visual impairment. Age-Adjusted Rate, % 5 4 There was little association of blindness and visual im- pairment with use of health care services (Table 4). The 3 prevalence of blindness and visual impairment was higher among those who had been to a physician or received eye 2 care in the 12 months before the survey began than among those who had received such services between 1 and 5 1 years prior to the survey. Among those who last received 0 such services more than 5 years prior to the survey, the 0 10 20 30 40 50 60 prevalence of blindness and visual impairment was even 70 80 higher than that of the most recent users of health care Households Below Poverty Level, % services. Neither of these differences in measures of health -Scattergram and least-squares regression line of age-adjusted service use reached statistical significance (Table 4). prevalence of low vision (worse than 20/40) and the proportion of To evaluate the independent association of these socio- households below poverty level of 16 sample areas in East Baltimore, Md. demographic variables with blindness and visual impair- ment, a regression model was constructed that included age, age squared, race, educational level (6 years or less reported in Table 4, with those reporting poor general vs more than 6 years), employment status, and general health having higher rates of visual impairment. health status (excellent to fair vs poor). Relative health Interestingly, this analysis showed a substantial reduc- status was not included because it essentially duplicated tion in the association of race and the prevalence of blind- the information in the general health status variable, and ness and visual impairment after adjusting for the other use of health care services was not included because there sociodemographic variables. Adjusting only for age pro- was no evidence that it was associated with blindness and duced prevalence ratios (blacks to whites) of 1.79 for visual visual impairment after adjustment for age and race. The impairment and 2.30 for blindness, both of which were results are presented in Table 5 and show no major significantly different from 1.0 at the 1% level.⁵ After ad- changes in the patterns of associations from those de- justing for the other variables in this report, the prevalence scribed in the previous tables. Education remained sig- ratios (blacks to whites) decreased to 1.22 and 1.42 for vi- nificantly associated with visual impairment. The pattern sual impairment and blindness, respectively, indicating of employment status as shown in the tables was also sim- significant confounding of the association of poor vision ilar, with disabled subjects having a significantly higher and race using these other sociodemographic factors. prevalence of blindness and visual impairment than sub- jects in other employment categories for both definitions COMMENT of poor vision. Retired subjects also had significantly lower The association of visual impairment with lower socio- rates of visual impairment than did all other groups. Gen- economic status was not a surprise and has been noted in eral health status showed little change from the patterns other studies. The National Health Interview Survey Socioeconomic Status 87 Table 3.-Prevalence of Blindness and Visual Table .-Adjusted Prevalence Rates of Blindness Impairment by Health Status Adjusted for and Visual Impairment* Age and Race* Visual Visual Impairment, Blindness, Impairment, Blindness, No. (Adjusted No. (Adjusted Adjusted Adjusted Rate, %) Rate, %) Variable Rate, % (P) Rate, % (P) General health status Race Excellent (n=707) 12 (2.42) 4 (0.82) White 2.65 1.03 (.20) (.16) Good (n=2325) 40 (1.92) 21 (0.98) Black 3.25 1.46 Fair (n=1618) 45 (2.67) 20 (1.18) Educational level, y Poor (n=640) 59 (8.50) 19 (2.54) 0-6 4.45 1.55 (0.002) (.31) Pt <.0001 .01 >6 2.56 1.14 Health status relative to Employment status + others of the same age Employed 3.36 0.99 Better (n=2047) 53 (2.25) 21 (0.90) Homemaker 2.83 (.44) 0.52 (.29) Same (n=2336) 46 (2.34) 24 (1.15) Retired 0.97 (.001) 0.87 (.80) Worse (n=638) 47 (7.36) 16 (2.41) Disabled 6.40 (.0003) 4.14 (<.0001) Pt <.0001 .009 Unemployed 3.45 (.93) 0.49 (.45) *Data on general health status were unavailable from 10 sub- General health status jects, and data on relative health status were available from 279 subjects. Excellent to fair 2.37 1.19 (<.0001) (.61) +By an F test of health status as a categorical variable. Poor 7.05 1.44 *All prevalence rates were adjusted for age, race, educational level, employment status, and general health status. P values are Table 4. -Prevalence of Blindness and by t tests of linear regression coefficients in comparison with the Visual Impairment by Use of indicated reference category. Health Care Services Adjusted for Age and Race* tP values are comparisons with the employed. Visual Impairment, Blindness, No. (Adjusted No. (Adjusted impaired and nonimpaired workers can approach 50%.10 Rate, %) Rate, %) Our data also confirm an association between visual im- Time since last visit to a physician, y pairment and employment status, especially among the disabled. Again, the direction of any causal inference re- <1 (n=4323) 136 (3.00) 57 (1.26) garding the association between employment status and 1-2 (n=464) 11 (3.59) 3 (0.94) visual impairment is difficult. This is also true of general 3-5 (n=283) 2 (1.40) 1 (0.56) health status because poor vision is likely to influence a >5 (n=219) 6 (3.50) 3 (1.68) person's self-reported level of well-being. While the causal Pt .33 .62 implications are unclear, subjects with poor health and the Time since last visit for eye care, y disabled are more frequent users of medical care services. <1 (n=2537) 77 (2.83) 38 (1.18) Such care settings, therefore, may offer an opportunity to identify patients with ocular disorders that lead to visual 1-2 (n=1477) 39 (3.12) 10 (0.75) impairment so that necessary ophthalmologic care of their 3-5 (n=714) 21 (2.73) 4 (0.28) treatable conditions is obtained. >5 (n=548) 18 (3.48) 10 (1.51) We were surprised by the lack of association between Pt .81 .11 use of general health care or eye care services and blind- *Data on visits to physicians were unavailable from 11 subjects, ness or visual impairment. Given that as much as 40% of and data on medical visits for eye care were unavailable from all bilateral blindness in this study was potentially curable 24 subjects with appropriate surgical intervention (data not shown), +By an F test of health care use as a categorical variable. it would be reasonable to expect that use of such services would be lower among blind and visually impaired sub- showed strong associations between self-reported inabil- jects than among nonimpaired subjects. This incongruity ity to read a newspaper and both educational level of the may be due to the lack of adequate detail in our questions head of household and family income.⁴ The National regarding use of health care services. More specific ques- Health and Nutrition Examination Survey also showed an tions addressing adequate use given a person's risk status inverse association of visual acuity with educational level. may have been more sensitive to such differences. Barriers Our data corroborate these reports even after adjusting for to care other than physical access (eg, extent and quality other potentially confounding variables such as age and of care) may have played a role in preventing patients with race. This association, however, is unlikely to be unidi- treatable diseases from being informed about their con- rectional. While it is likely that persons with lower eco- ditions or from taking advantage of appropriate services. nomic status in the United States may be more likely to In a previous report, race was also strongly associated suffer from poor vision for many reasons, it is also likely with low vision. Blacks had an age-adjusted twofold ex- that visual impairment lowers earning potential because cess prevalence relative to whites.⁵ On adjustment for of both unemployment and underemployment of visually other socioeconomic variables such as educational level, impaired workers. Such earnings gaps between visually employment status, and general health status, the relative 88 Caring for the Uninsured and Underinsured prevalence dropped to between 1.2 and 1.5. This suggests Model Reporting Area, 1969-1970. Washington, DC: Public that blacks may not be inherently at higher risk of visual Health Service; 1973. Office of Biometry and Epidemiology, Na- impairment than whites, but that a constellation of other tional Eye Institute, US Dept of Health, Education, and Welfare factors associated with visual loss are, in an American ur- publication (NIH) 73-427. ban population, also associated with race. This lack of pre- 3. Leibowitz HM, Krueger DE, Maunder LR, et al. The disposition to high rates of blindess and visual impairment Framingham Eye Study monograph. Surv Ophthalmol. was expected given the diversity of pathogenic mecha- 1980;24(suppl):335-610. nisms that can lead to blindness or visual impairment. The 4. Kirchner C, Peterson R. The latest data on visual disability from NCHS. / Vis Impair Blind. 1979;73:151-153. lack of a causal link between race and visual loss does not, 5. Tielsch JM, Sommer A, Witt K, Katz J, Royall RM, Baltimore however, limit the importance of race as an indicator of Eye Survey Research Group. Blindness and visual impairment high-risk populations in urban America that need addi- in an American urban population: the Baltimore Eye Survey. tional resources directed to blindness prevention. Arch Ophthalmol. 1990; 108:286-290. This work was supported by grants EY-03605, EY-05091, and RR- 6. Ferris FL, Kassoff A, Bresnick GH, Bailey I. New visual acuity 04060 from the National Institutes of Health, Bethesda, Md. charts for clinical research. Am J Ophthalmol. 1982;94:91-96. The Baltimore Eye Survey Research Group is composed of the fol- 7. Ferris FL, Sperduto RD. Standardized illumination for vi- lowing individuals: Alfred Sommer, MD, MHSc, Principal Investi- sual acuity testing in clinical research. Am J Ophthalmol. gator; James M. Tielsch, PhD, Project Director; Harry Quigley, MD; 1982;94:97-98. John Gottsch, MD; Richard Royall, PhD; Joanne Katz, MS; Kathe 8. Draper N, Smith H. Applied Regression Analysis. 2nd ed. Witt, COMT; Kuldev Singh, MD; and Jonathan Javitt, MD, from The New York, NY: John Wiley & Sons Inc; 1981. Johns Hopkins University; and Sandi Ezrine, MS, from Survey Re- 9. Bureau of the Census, US Dept of Commerce. 1980 Census search Associates, Inc. of Population and Housing, Census Tract, Baltimore, Md, Stan- References dard Metropolitan Statistical Area, PHC80-2-82. Washington, 1. Roberts J, Lundford J. National Center for Health Statistics: DC: US Government Printing Office; 1983. monocular visual acuity of persons 4-74 years, United States, 10. Kirchner C, Peterson R. Worktime, occupational status, 1971-1972. Vital and Health Statistics. Washington, DC: Public and annual earnings: an assessment of underemployment. In: Health Service; 1977. US Dept of Health, Education, and Welfare Kirchner C, ed. Data on Blindness and Visual Impairment in the publication (HRA) 77-1646; series 11, no. 201. U.S. 2nd ed. New York, NY: American Foundation for the Blind; 2. Kahn HA, Moorhead HB. Statistics on Blindness in the 1988. SightFirst: Lions Conquering Blindness Julie Foreman, MS Oak Brook, Ill. - The Lions Clubs International have The blindness prevention strategies adopted by the launched their attack on preventable and reversible blind- Lions for their SightFirst project are: ness with SightFirst, one of the most comprehensive and To develop and/or strengthen the primary care infra- far-reaching blindness prevention programs ever under- structure. SightFirst projects will build eye care hospitals, taken by a volunteer service organization. establish rural clinics, and provide mobile eye care units There are 40 million blind people in the world today, and to serve remote communities. it is estimated that, in 25 years, that number will double. To develop manpower and managerial skills. SightFirst Eighty percent of this current blindness could have been projects will provide fully trained ophthalmologists, eye care prevented or can be cured. The Lions Clubs International auxiliaries, and surgical assistants as well as provide basic have accepted the challenge of bringing blindness under eye care training to community health care workers. control on a global scale. To promote community mobilization. The key to The Lions Clubs International has been associated with blindness prevention is public education and awareness fighting blindness since 1925, when Helen Keller called on of the threat of blinding diseases, such as glaucoma and the Lions to become "Knights of the Blind." Since that time diabetic retinopathy. All SightFirst projects will promote they have saved the sight of millions. Now, going a step the importance of regular eye examinations and preven- further, the Lions have designed a program to dramati- tive eye care practices. cally reduce the incidence and prevalence of preventable To further operations research. SightFirst projects and curable blindness. will compile vital information that will enable future pro- SightFirst seeks to remedy blindness by providing qual- grams to determine the effectiveness of different blindness ity eye care delivery systems to millions who suffer blind- prevention models. ness needlessly. The targeted causes of preventable and The anticipated cost of the program is $100 million and curable blindess are cataract, glaucoma, diabetic retinop- is to be funded primarily through the Lions Clubs Inter- athy, onchocerciasis, trachoma, and xerophthalmia. The national Foundation. Additional funds are being provided projects will focus on developing health care infrastruc- by corporations and foundations in many areas of the tures and eye care delivery systems in countries where world. SightFirst grants will be awarded to Lions Clubs blindness is endemic. Ninety percent of those persons los- organized on a national level to fund projects that address ing sight live in developing countries. Therefore, the first the specific eye care needs of that region. The program is eight projects are planned for Latin America. to be implemented over a 6-year period. The SightFirst projects will be conducted on national or The idea for SightFirst came about in 1988, when the district levels within countries under the guidance of a Long Range Planning Committee of Lions Clubs Interna- technical adviser. The technical advisers will be ophthal- tional began to explore how the organization could make mologists employed by the Lions Clubs International to the greatest impact in humanitarian service. The commit- help local Lions determine the causes and prevalence of tee selected reducing blindness on a greater level as the blindness in their region. The advisers will assist in de- goal. In March 1989, Lions Clubs International began to signing a SightFirst project and ensure that the project establish a global blindness prevention effort. The first coincides with the national blindness prevention program eight projects are now in the planning stages. of that country, as well as following the SightFirst guide- Along with the immediate benefits of the projects, Sight- lines. The advisers will also see that the projects employ First will provide long-term benefits for the fight against appropriate technology, do not duplicate existing efforts blindness, such as reducing the millions of people who to prevent and cure blindness, and are able to continue have curable forms of blindness, providing a major boost operating beyond the life of Lions' direct involvement. to the worldwide effort to ultimately eradicate preventable blindness, further developing the health care infrastruc- ture of many developing nations, and providing a model Ms Foreman is the Associate Editor of the AMA specialty journals. for a more effective private/public partnership in deliv- Reprinted from Archives of Ophthalmology (1991;109:624). ering health care. Indigent Patient Care-Then and Now Loring W. Pratt, MD C are of the indigent patient was the physician's respon- financial status, except as it affected his ability to cooperate sibility and privilege in the 1940s, as it had been for with the prescribed care. Physicians were completely an eternity before. Every physician recognized his respon- oblivious to the possibility of remuneration from this sibility to provide this care and donated one half day or group of patients. one whole day a week to the care of these patients. The In the outside world of medical practice, where training care that the patients received was generally excellent and, programs were not extant, the indigent patient usually in some instances, better than that provided for the paying was treated in clinics, held at regular intervals, or by the patient. Often an effort was made to contain the expense physician in his office at no charge. The indigent status of of the patient with medium income so that he did not re- the patient was often identified by a social worker or friend ceive the generous laboratory testing and diagnostic without the benefit of a means test; and the patient was workup, which was freely accorded to both the indigent treated well, kindly, and efficiently by the physician who and the wealthy. The patient's contribution was to provide considered the care of the indigent patient to be a normal an opportunity for medical students and residents to learn part of his medical practice and that it was both his ob- the rudiments of medicine and patient care from their ill- ligation and privilege to care for those less fortunate. nesses. In 1965, Medicaid was passed as an afterthought to In cities, there were large hospital clinics, for the pur- Medicare, and thus the government, in its wisdom de- pose of caring for indigents, staffed by the same physicians creed that no patient shall be thought of as indigent. This who cared for the general hospital population. Often these was considered to be demeaning to the patient and, there- were identified as "resident clinics," and the resident staff of the hospital managed the patients under the watchful fore, all patients would thereafter be handled as paying patients thereby maintaining their self-esteem. This eye of the "visiting staff." These patients were the so- change in practice has now been in operation for a number called teaching patients and, thus, they received the very of years and in 1991 we are able to see how this program best of everything available for care. The visiting staff phy- has worked for patients in general. It is of interest to note sician's privilege to admit patients to the hospital was de- that even today the only individuals with a constitutional pendent on his performance and regular attendance at right to medical care are prisoners. clinics to which he was assigned. In those days, there were two schools of thought in pa- In large cities, resident clinics are still held and patients tient management as far as laboratory testing was con- are seen in the same fashion as in yesteryear under the cerned. The most popular school was to obtain results supervision of visiting or full-time staff. The government from all of the possibly useful tests. These tests were done pays for their care through Medicare or Medicaid pro- grams; but the allowed fee often does not cover the real in' a logical fashion, over the course of a few days, new tests being ordered in a logical progression on the basis of the cost of the patient's care. Many physicians in these areas results of testing already done. The physician who ordered will not care for Medicaid or Medicare patients in their a large battery of tests on admission and had all the data offices but refer them to the clinics where such patients are to sort from was decried as a "shotgun" physician. The cared for. In many areas, the truly indigent patient finds second school applied Occam's Razor and ordered only it difficult, and sometimes impossible, to obtain care be- those tests deemed necessary to make the diagnosis. In cause of the complex requirements of governmental bu- teaching institutions, and in dealing with indigent pa- reaucracy and the inadequacy of the allowed fee. Older tients, this was not considered to be a desirable practice. persons now pay more for their care, in addition to the The young physicians were encouraged to take the same Medicare allowance, than they previously paid for their total care. sort of thoughtful approach that they would want for themselves and to request all desirable tests, without re- In rural areas, where patients have no clinic to go to, gard to the expense of the procedures. They were to be there are now physicians who do not "accept" Medicaid overwhelmed by the evidence leading to a particular di- and other indigent patients for care. In the 1940s, they agnosis. In the course of their training, they took the cares would have lost their hospital admitting privileges had and problems of their patients to heart and worked dil- they practiced in this fashion. They say that they cannot afford to take care of these people because the allowed fee igently to see that they provided top quality care for the for care is below the cost of operating their office. patient, and remained unconcerned about the patient's Another facet of today's problem is the cost imposed by Accepted for publication February 26, 1991. third party payers. Under the diagnosis related group pro- Dr Pratt is in private practice in Fairfield, Me. gram, fixed fees for different types of care are allowed. by Reprinted from Archives of Otolaryngology-Head & Neck Sur- the government. It is often the case that the fee allowed gery (1991;117:484-485). is inadequate and the amount of time allowed for hospi- Indigent Patient Care-Then and Now 91 talization is likewise inadequate. When a hospital finds able only if it is to be paid for and delivered by a physician that a particular type of illness costs them more than they who is often discontent with the monetary allowance, has receive from their third party payer, they proscribe the made a major inroad on the care of the indigent, and has treatment of such patients within their hospital and insist in the same fashion weakened the physician-patient bond. that they be referred to a more sophisticated hospital for This change has resulted from payment plans that have care. This sort of patient "dumping" has occurred in both been forced on the physician by governmental and other rural and metropolitan areas, and it is practiced subtly to- third party agencies. It is likely that this erosion of trust day by some physicians within their own practice spheres. has been a contributing factor in the increasing litigious Change in the physician's attitude from considering it nature of the population at large. Perhaps the time has a responsibility and a privilege to care for the indigent come to turn the clock back! patient to the present state where such care is readily avail- Indigent Care-Now Neil O. Ward, MD D r Pratt has shared with us indigent care experiences profits to a few entrepreneurs and little medical service to from the past; but it is the description of a foreign citizen subscribers. land to which we "cannot go home again." The Flinn Foundation is a philanthropic organization Today we have a larger population of older patients, established in Phoenix, Ariz, with a stated purpose of ob- improved but expensive technology, substance abuse, ac- taining information that will help guide those working to quired immunodeficiency syndrome, aggressive business improve the health care system. In 1989, the Flinn Foun- practices, liability concerns, and governmental regulation dation commissioned a major survey of Arizona health by beyond the dreams of even the most imaginative bureau- Louis Harris & Associates Inc, New York, NY. Research crats of yesteryear. The Health and Human Services Sec- specialists from the School of Health Administration and retary, Louis Sullivan, pointed out that health outlays by Policy at Arizona State University, Tempe, provided as- all public and private sources have been rising faster than sistance.¹ general inflation for years (Washington Post. November The progress report on AHCCCS revealed that 53% of 1990). The resulting high cost of health care has created adults currently and formerly enrolled in AHCCCS expe- unprecedented pressures on the methods of delivery. rienced easier access to their AHCCCS provider compared Much has been written about the needs of our medically with their previous provider. One might have expected an indigent patients, and locally some recommended rem- even higher percentage of easier access given the plan de- edies have been put to the test. Arizona is the only state sign of "farming out" health care from overcrowded in the Union that does not have a Medicaid program based county clinics to local physicians' offices. on fee-for-service indemnification. In 1982, the Arizona Only 46% of currently and formerly enrolled adult pa- Legislature opted for a capitated, prepaid plan, called the tients assessed their care as "better" under AHCCCS, al- Arizona Health Care Cost Containment System (AHC- though 58% were "completely satisfied." Patient satisfac- CCS). The AHCCCS contracts with competitively man- tion is an important component of imperfectly defined aged care plans; these plans then contract with physicians "quality care." and hospitals. Potential patients must meet income qual- The AHCCCS (and military) patients had the highest ifications, enroll in one of the plans, and visit a contracted utilization of Arizona emergency departments and the sec- provider to receive services. ond highest rate of hospitalization (after Medicare) when It may be enlightening to share with you almost a decade compared with all other insureds and noninsureds. High of experience in this unique system designed specifically utilization and higher costs should be anticipated in the to provide health care for the "poorest of the poor" and sickest segment of society. to pay for indigent health care services in Arizona. An Patient outcomes are of greater significance to the clin- insurance scheme designed for the medically indigent ical otolaryngologist concerned with quality of care issues. population has inborn weaknesses. If the best insurance Information is available from the Flinn Foundation report: plans spread the risk over the greatest number of citizens, The Health of Arizona's School Children.² When compared AHCCCS does not qualify as a "best" plan; for it spreads with other insurances and uninsureds, AHCCCS children risk over one of the sickest segments of society with a small have the highest incidence of ear infections detected by but significant number of citizens characterized as "non- school nurse examinations of 1419 kindergarten and 1258 compliant." fifth-grade students. Attracted by the opportunity to serve and by the "up- The long-term effects of hearing loss associated with un- front payment of premiums," a number of organizations treated otitis media are well documented in our English- contracted to become AHCCCS providers. Initial financial language literature. These effects are not limited to indi- incentives to discourage "gatekeepers" referrals to spe- vidual disability but include societal losses related to cialists have been replaced by preauthorizations and com- behavioral problems, educational deficits, and economic mittee reviews. Prepaid capitation for care arguably mo- drains. Analysis by an otolaryngologist of over 20000 tivates a few physicians to offer less time and care to school nurse visits over a 2-year period shows that AH- patients who represent a fixed monthly payment. There CCCS children appear to have a higher incidence of upper is no legislative cure for greed. Arizona is still in court respiratory infections but, more importantly, are the least attempting to retrieve prepayments that resulted in large likely to be receiving medication dispensed by the school nurse! Are the incentives in the AHCCCS program working to Accepted for publication February 5, 1991. withhold treatment? Is it too difficult to get to an AHCCCS Dr Ward is in private practice in Phoenix, Ariz. Reprinted from Archives of Otolaryngology-Head & Neck Sur- provider? Are AHCCCS providers unaware of the value gery (1991;117:486-487). of treating ear problems associated with upper respiratory Indigent Care-Now 93 Measles 60 55.8 All Children 9 50 Private Insurance 8 44.0 AHCCCS Uninsured 9 lowa Test of Basic Skills Scores 41.4 15 40 30 20 DPT All Children 2 10 Private Insurance 2 AHCCCS 5 0 No Group Group Visits Average Average Uninsured 4 4.8 Visits 19.4 Visits School Nurse Visits Per Year Fig Poor performance correlates with frequent nurse visits.² Polio Well-meaning and altruistic social engineers who are All Children 5 designing the utopia in which we will live and work to- morrow need all the help they can get! We are faced with Private Insurance 5 a complex problem that will not be solved by importing AHCCCS 9 simple solutions like another country's health system. To expect a new system or financing mechanism to solve our Uninsured 6 health care needs is to ignore recent and profound changes 0 2 4 6 8 10 12 14 16 18 in personal behavior, family structure, economic priori- ties, and technological choices. In our many-faceted so- Percentage Without ciety, there is an interface on which each of us should re- Routine Immunization flect. Some of us can provide "free" care to the needy; all Fig Percentage of Arizona school children without routine im- munization, by insurance status. AHCCCS indicates Arizona Health of us can teach good health habits and the importance of Care Cost Containment System; DPT, diphtheria, pertussis, and tet- compliance with proven medical regimens; we can work anus. to reduce the expense of professional liability; we can de- fine appropriate and cost-effective treatment; we can iden- infections? Are parents willing to hurdle the hassle of AH tify and retrain (if not restrain) profiteers in our profession; CCCS enrollment but indifferent to, or ignorant of, the and we can participate in coalitions to develop policy rec- needs of their children? Figure 1 suggests parental indif- ommendations.³ ference to, or irresponsibility for, obtaining available rou- The brilliance of America is in the opportunity to act on tine immunizations for AHCCCS children. ideas and to accommodate diversity. The solution to our A striking correlation between poor health (as measured problem is not here yet, but it is evolving. Your partici- by the number of visits to the school nurse) and scholastic pation in the process is vital for the future. When nothing performance is demonstrated in Fig 2. The more fre- is certain, anything is possible. quently a child visits the school nurse, the poorer the per- References formance on standardized tests. It has been documented 1. Health Care in Arizona: A Profile. Phoenix, Ariz: The Flinn Foundation; 1989. that citizens are more likely to be unhealthy-and without 2. Surveys by Louis Harris & Associates and UCLA School of health insurance-if they have not attained a high school Medicine. The Health of Arizona's School Children. Phoenix, education. 1 Where do we break the cycle of poor health Ariz: The Flinn Foundation; 1986 and 1987. leading to inadequate education leading to low incomes 3. Politser P. America's uninsured: some proposed solu- leading to no health insurance leading to poor health? tions. Am Coll Surg Bull. 1990;75:11-18. Who Ought to Get Decent Health Care? Ronald A. Carson, PhD O ught belongs to the vocabulary of ethics. It specifies ambulatory settings. Cost-shifting has also been curtailed responsible action. To say that one ought to do with the result that Americans who have no health in- something implies that one is duty bound to do it. It is not surance cannot get into the system and those who are in- optional but obligatory. Failure to do what one ought to adequately insured cannot get the care they need. The do is an abrogation of responsibility. number of those citizens has grown by half since the 1970s This being so, the answer to the question that titles this to 37 million, 12 million of whom are children. essay seems obvious. Surely everyone has decent health Over the past decade, with the emergence of for-profit care coming, but who is "everyone"? Everyone who wants enterprises and the centralizing of health care organiza- it, whether or not they need it? Everyone who needs it, tions to provide comprehensive services, commercial val- irrespective of their ability to pay for it? And what con- ues have come into competition with the value of service stitutes decent health care? Preventive care, catastrophic that has traditionally been the hallmark of medical care. care, long-term care? The ethical question as to who ought In the process, whether as consequence or corollary, the to get decent health care is a complicated one. profession's charitable impulses have become noticeably A system of health care provision is made up of several less robust. Many individual physicians continue to pro- crucial features, notably quality, cost, and access. In keep- vide a share of care where it is needed, irrespective of how ing with the theme of this issue of the ARCHIVES, this essay it is to be paid for, but as public financing programs are focuses on the element of access to health care services. squeezed and insurance companies strip down health Who has access to which services, and in what measure? plans for clients who represent bad risks to business, phy- Who gets left out, and why? sicians become more concerned about inadequate levels of Public attitudes toward the American health care system reimbursement and mounting paperwork. Such concerns are changing dramatically. Americans who have ready ac- are legitimate, but they pale in significance when com- cess to health care are increasingly critical of the US health pared with the needs of sick people for adequate medical system. A recent opinion survey reports that "A striking care. Legitimate or not, when such concerns become com- 89% of Americans see the US health care system as re- plaints, ordinary people begin to question the profession's quiring fundamental change in its direction and structure. commitment to care. If the profession is perceived to be Only 10% see their health care arrangements as working equivocating on that fundamental commitment, the trust reasonably well.' Such studies do not take into account that sustains the healing relationship is likely to erode. the views of those whose access to the system is limited What can be done to improve access to decent health or altogether barred by their inability to pay for health care care for those who need it? Under the nation's Medicaid services. It is safe to surmise that these disenfranchised program, the federal government pays 40% to 60% of med- citizens too would support changes in the mechanisms of ical expenses and the states pay the rest. This program access that would make needed services available to them covers about 26 million people, less than half of those who and their families. need its services, a disproportionate number of whom re- The uninsured have long been among us, but their in- side in states with weak tax bases and high concentrations ability to get needed care caused concern among physi- of poor people. Young poor people and old poor people cians and legislators alike. Throughout the 1970s, approx- unwittingly compete for funds. Only one in every three imately 25 million people lacked health insurance and, poor women of childbearing age is covered by Medicaid. therefore, had diminished access to services.² But many Seventy percent of Medicaid's eligible population consists of these people were cared for by physicians who carried of low-income families with children, and yet only 25% of on a venerable tradition of professional charity and by hos- the Medicaid budget is expended to assist them. Almost pitals that shifted the costs of uncompensated care to in- half of Medicaid expenditures are devoted to long-term sured patients. In the 1980s, these two responses began care, primarily for the elderly because no other program to change. Prospective payment systems and managed finances long-term care.⁵ care plans were introduced with such mechanisms as A 1986 survey found that 15 million Americans encoun- preadmission certification, utilization review, and capita- tered barriers to health care for financial reasons. Eight tion arrangements. Consequently, the rapid rise in hos- million people with chronic or serious illness put off seek- pital costs has been considerably slowed, notably by mov- ing care when it was needed, and one million people were ing many inpatient diagnostic and surgical procedures to denied care because they could not pay for it.⁶ Physicians Accepted for publication March 11, 1991. cannot solve this aspect of the access problem alone, but From the University of Texas Medical Branch, Galveston. taking care of patients insured by Medicaid and accepting Reprinted from Archives of Otolaryngology-Head & Neck Sur- Medicaid reimbursement as payment in full would di- gery (1991;117:496-497). rectly and immediately improve access for the needy. Who Ought to Get Decent Health Care? 95 Two recent studies show that a patient's ability to pay judgment that is the very métier of physicians. 10 If, in- also makes a difference in that person's treatment after stead, the answer is: Relative to dollar costs, then a policy admission to a hospital. Uninsured patients tend to enter determination is required. Experienced physicians have the hospital sicker than insured patients, but they receive valuable first-hand knowledge of the benefits and burdens fewer diagnostic tests and are released sooner than in- of the techniques and treatments at their disposal. Such sured patients. They are also far less likely to undergo knowledge can influence policy discussions regarding the high-cost procedures. One study found that hip replace- justifiable limits of treatment recommendations for which ments were 45% less likely and coronary bypass surgery the expected human benefits are small relative to dollar 29% less likely to be done on uninsured patients.⁷ In an- costs. 11 But it is important that clinical judgment and social other study, researchers found that privately insured pa- judgment be sharply distinguished, especially when they tients were 80% more likely to receive angiography and are rendered by one and the same person. Otherwise, in- 28% more likely to undergo angioplasty than their unin- dividual patient care is likely to be corrupted by social ne- sured compatriots.⁸ Clearly, financial considerations have cessity. intruded on the doctor-patient relationship and are com- The hue and cry about setting limits to services and con- promising the value of fairness. taining costs has obscured the question Americans wor- Despite the fact that Medicare and Medicaid pay for one ried about until the early 1980s: How can we ensure every third of the nation's hospital expenditures, there are sig- citizen access to a limited but fair system of health care nificant gaps and costly exceptions in coverage. An in- provision adequate to his or her need? If we can set our creasing proportion of the cost of health care for people compass on this fixed point of social conscience, we will over 65 years old is paid out-of-pocket.9 Consequently, be able to steer a straighter course. The sailing may not be elderly people who cannot afford private insurance to sup- smooth, but the winds of profit and loss will no longer plement Medicare and are not poor enough to be eligible buffet us. Instead, they will follow in the wake of care. for Medicaid put off going to the doctor until they are too sick not to. Although the policy of fixed advance payments References to hospitals is based on diagnosis-related costs, the policy 1. Blendon RJ. The public's view of the future of health care. JAMA. 1988;259:3587-3593. has caused an increase in expense to nursing homes, 2. Congressional Budget Office. Profile of Health Care Cov- home-health agencies, and families caring for frail elderly erage: The Haves and Have-Nots: Background Paper. Washing- members at home. Physicians can help here too, by mak- ton, DC: US Congressional Budget Office; March 1979. ing house calls as occasions warrant and by charging pa- 3. 25% of all office based physicians accept no Medicaid pa- tients on an equitable sliding scale according to their ability tients: Medicaid mill: fact or fiction. Health Care Financ Rev. to pay. 1980;2:37-49. Nearly a third of the annual Medicare budget is spent 4. Blendon RJ. What should be done about the uninsured in the final year of patients' lives, much of it in intensive poor? JAMA. 1988;260:3176-3177. last-ditch efforts to resist death a little longer. We des- 5. Mechanic D. Challenges in long-term care policy. Health Aff (Millwood). 1987;6:22-33. perately need policies regarding what "rescue treatments" 6. Access to Health Care in the United States: Results of a 1986 it is reasonable to offer very sick people. It goes without Survey. Princeton, NJ: Robert Wood Johnson Foundation; No- saying that these vulnerable people should have the best vember 1987. Report 2. of care. Open to question is what that care should consist 7. Hadley J, Steinberg EP, Feder J. Comparison of uninsured of, in particular, how much death-defying care is medi- and privately insured hospital patients. JAMA. 1991;265:374-379. cally reasonable and humanly desirable. 8. Wenneker MB, Weissman JS, Epstein AM. The association To offer patients useless treatment is bad medicine. of payer with utilization of cardiac procedures in Massachusetts. With more and more treatment modalities available, the JAMA. 1990;264:1255-1260. following question arises: Are physicians obligated to offer 9. Health Care Financing Administration. Annu Rep. 1987. marginally beneficial treatments? This prompts an addi- 10. Bone RC, Rackow EC, Weg JC, et al. Ethical and moral guidelines for the initiation, continuation, and withdrawal of tional question: Marginally beneficial relative to what? If intensive care. Chest. 1990;97:949-958. the answer is: Relative to the human cost likely to be borne 11. Roper WL, Winkenwerder W, Hachbarth GM, et al. Ef- by the patient, we are dealing with a question of clinical fectiveness in health care. N Engl J Med. 1988;319:1197-1202. The Canadian Health Care System Patrick J. Doyle, MD I S Canada's the best health care system in the world? The budget, it is necessary to limit access to the facilities. This majority of Canadians believe that it is. The system was is done by refusing to increase the funding for hospitals, designed to provide equal access to medical and hospital diagnostic facilities, and physicians. services for all Canadians and to ensure that no one was Each hospital is provided with a global budget. It is the financially ruined by illness. The plan may have fulfilled this responsibility of the hospital to decide which services it role as nearly as it is possible to do so, butitis far from perfect. can provide while living within its budget. A global budget I have practiced in Canada prior to and since the in- is also provided for medical services. Physicians bill on a troduction of Medicare, and I also have practiced in the fee-for-service basis, but it is the responsibility of the med- United States. Many of the problems one faces as a prac- ical association to set a fee schedule that will keep total cost ticing otolaryngologist-head and neck surgeon are similar, within the budget. Each specialty must negotiate with the particularly as the administrative bureaucracy in the medical association to set the schedule. Extra billing, be- United States catches, and in some ways, passes their Ca- yond the schedule of fees, is illegal. nadian counterpart. Since access is limited, who suffers? In my opinion, the There is no difference between the quality of facilities middle-income group suffer. and medical expertise available in Canada and the United Equal access is the number one argument in favor of States. Medical and paramedical personnel have identical Medicare. Theoretically, we have provided equal access in training, ability, and dedication. Hospitals and diagnostic Canada, but in fact, we have not. facilities are "state of the art" in both countries. Only the very naive can believe that a politician, a phy- There is another common denominator between health sician, or a person with physician and hospital adminis- care in Canada and the United States. Neither country can tration friends must line up for care. Patients with such afford to provide the ultimate in health care to all of their influence are able to move to the front of the line for office citizens by means of a universal health care system. visits, hospital beds, surgery, or diagnostic procedures. Is there a way to provide equal access to all members of This does not differ from the pre-Medicare era, but what society? Is there any way to do this and provide the highest is different is that these privileged people do not pay an quality care in all instances? In my opinion, the answer to additional fee for the red carpet service. The rest of the both of these questions is no. Health care is expensive. The population, the average-wage earner, the poor, and the budget for medical care for three million people in the elderly are treated equally. They do all the waiting. The Province of British Columbia is over five billion dollars. Canadian Medicare plan is a good arrangement for the This money is derived from a combination of monthly privileged and the poor. The privileged obtain care at min- premiums and taxation. Unfortunately, there is a signif- imal cost; the poor obtain care otherwise not available. It icant shortfall in the money required to provide quick and is less satisfactory for the average-wage earner who pays easy access to all services. Universal health care results in handsomely for his care and a large portion of the care overutilization. Both the public and the medical profession provided to the other groups. are responsible for this, and it is particularly noticeable in Universal health care in Canada is here to stay. It is nei- the use of special diagnostic procedures such as computed ther all good nor all bad. Some changes would result in tomographic scanning and magnetic resonance imaging. immediate improvement at reduced cost. Individuals This overutilization places a strain on the system and re- above a certain income should be required to provide their sults in serious delays for urgent diagnostic procedures. own private insurance. The argument that this would cre- Patients, particularly those with medical problems, are ate a two-tiered system is not valid since one group already kept in the hospital longer than necessary. Since the pa- receives red carpet treatment. The small percentage of tients have no responsibility for the cost of hospital ser- physicians and patients guilty of over-utilization creates vices, they do not object to the longer stay. This places a a major problem that is correctable. More effort must be premium on hospital beds for acute illness and inpatient put into preventive medicine because a successful preven- surgery. Operating room time is restricted because of high tive medicine program is the only way to keep the costs costs. Long waiting lists for elective surgery are the rule of acute and chronic care within reasonable bounds. rather than the exception. When universal Medicare was brought in, the politicians The budget simply cannot handle an unlimited number told us that "everyone deserves the best possible care." Now or unlimited quality of patient care. To stay within the that they have found that is impossible, they say, "everyone deserves average care." Average care is not good enough. Accepted for publication March 17, 1991. From St Paul's Hospital, University of British Columbia Medical Excellent care for all is possible if the tax dollars are spent Center, Vancouver. wisely to provide care for those who cannot afford to provide Reprinted from Archives of Otolaryngology-Head & Neck Sur- their own and if the health of the nation is improved through gery (1991;117:495). a comprehensive program of preventive medicine. Access to Trauma Care The Los Angeles County Trauma System: A Case History Dale H. Rice, MD T rauma is the leading cause of death among people aged between $15 000 and $34 400. All 96 hospitals in Los An- between 1 and 38 years, and it is the third leading geles County, with basic emergency service and a phy- cause of death in people of all ages. Over 150 000 deaths sician on duty 24 hours per day, were approached regard- and 350 000 permanent disablements occur each year in ing interest in opening a trauma center. The Department the United States as a result of accidents, suicides, and of Health Services required hospitals interested in estab- homicides. In 1982 alone, trauma is estimated to have cost lishing trauma centers to meet criteria for being classified the United States over 60 billion dollars, with one third as a level one, level two, or rural trauma facility. Initial attributed to treatment costs and the remaining to lost hospital response was positive. Between December 1983 earnings. Since trauma primarily affects younger people and July 1986, 23 hospitals opened trauma centers with in the earlier stages of their productive work years, it exacts County designations of level one, level two, or rural. a higher cost in terms of lost years of potential than that Trauma centers in Los Angeles County were designated of cardiovascular disease and cancer combined. In Cali- as level one, level two, or rural, according to trauma cri- fornia, two thirds of all trauma patients are involved in teria for designation established by the County Board of "blunt" trauma, usually from highway-related traffic ac- Supervisors. In addition to exceeding the requirements of cidents. The remaining third are involved in penetrating emergency department care, all County designated trauma. The trauma milieu is defined by the American trauma centers require both a general surgeon and an an- College of Surgeons as "a life threatening injury or series esthesiologist to be in-house, and immediately available, of injuries that requires immediate surgical intervention if 24 hours per day. Further, trauma centers must have the the patient is to survive." The County of Los Angeles De- following services: clinical laboratory, surgical service, ba- partment of Health Services has offered the following def- sic emergency service, intensive care unit, pediatric care; inition of the trauma patient: "critical trauma patients in- and the following capabilities: acute hemodialysis, acute clude, but are not limited to, those with major blood loss, spinal cord injury management, and programs for quality and/or shock, severe cardiac or respiratory distress, blunt assurance. or penetrating wounds to the trunk, head, neck or spine The County Board of Supervisors had a clear vision and requiring prompt surgical intervention." direction for County-wide trauma care when it originally In previous times, the concept of trauma care had long formulated the County trauma system. There was a broad been associated with war. During the Napoleonic Wars, consensus to support the trauma system at both County the French Army, recognizing the importance of reducing and State levels, and private hospitals eagerly participated the time between injury and surgical treatment, devel- in the system because they had financial and other incen- oped the flying ambulance. The high survival rate from tives. The original vision for the trauma system received operative amputations was considered a major break- wide support as a program not requiring heavy govern- through for that period. The US Army's Military Air Ser- mental funding, as it was originally felt that trauma centers vice Hospital units are similar examples of military trauma would break even or make money through two mecha- care facilities. Improvements in US military and field hos- nisms. The first was to balance the catchment areas so that pitals and blood transfusion systems resulted in soldier a significant percentage of patients would be expected to mortality rates declining from 4.5% of live arrivals in be covered by third party payers. The second was to cost World War II, to under 2% in the Vietnam War. shift between those covered by third party payers and THE CONCEPT those not covered. Two unanticipated factors unraveled In 1983, the Los Angeles County (California) Depart- this plan. The first was the development of the 20-minute ment of Health Services began implementing the current transport rule (see below) that prevented the design of trauma care system, which was approved by the County balanced catchment areas. The second was diagnosis re- Board of Supervisors. Participating hospitals would agree lated groups that effectively prohibited cost shifting. to participate in the trauma care system, including paying THE BEGINNING an annual fee of $15 000. The annual fee has since varied The original Los Angeles County trauma care network Accepted for publication February 26, 1991. was based on the "golden hour" concept, in which de- From the University of Southern California School of Medicine, finitive surgical services could be provided to a trauma Los Angeles. patient within the critical first 60 minutes after injury. Reprinted from Archives of Otolaryngology-Head & Neck Sur- Trauma center locations were selected strategically to min- gery (1991;117:493-494). imize paramedic ambulance transit time from most areas 98 Caring for the Uninsured and Underinsured of the County to nearby trauma centers. In Los Angeles, covered under MediCal (California's Medicaid program) the majority of paramedic ambulance services are pro- and $4230 among those classified as cash patients. Seven vided by fire departments. The fire departments initially of the nine hospitals that subsequently withdrew from the were reluctant to have paramedic personnel and equipment County trauma system cited economic reasons for their venture out of their primary areas of service for extended withdrawal. Economic considerations include cost of staff- periods. A concern existed that they would not then be avail- ing, inadequate MediCal reimbursement, and the inability able to respond to the next emergency call. Thus, a com- of some patients to pay for medical service. The year 1987 promise was reached, whereby paramedics could venture was the one of greatest attrition, with five of the hospitals from their stations to the extent that nearby trauma victims withdrawing in that year alone. The first hospital to drop could be transported to a trauma center within 20 minutes. out, located in a particularly urban area, anticipated the This became a basis for establishing the trauma care network. next year's losses to be in excess of five million dollars. In addition to paramedics and ground transportation, airam- Another large hospital withdrew after 3 years of partici- bulance helicopters were available. However, because of the pation when it realized that 45% of its patients were in- difficulty of landing near busy roadways, and developed res- digent and the hospital was losing about two million dol- idential areas, most air ambulance helicopters were used for lars per year. Another hospital cited 55% as nonpaying, interhospital transport of patients rather than for initial de- with a similar annual two million dollar loss. livery of trauma patients to available trauma centers. For With the withdrawal of these hospitals, a significant por- most urban areas of Los Angeles County, automobile am- tion of people in Los Angeles were not within the des- bulance transport was both quicker and more cost effective ignated 20-minute distance to a trauma center. This in- than air ambulance helicopters. The current cost for air am- cluded portions of West County, the Eastern San Gabriel bulance helicopter services is approximately $2000 per trip. Valley, communities in the vicinity of Los Angeles Inter- At its height, the system had 23 trauma centers: 10 Level national Airport, and East San Fernando Valley. In ad- One, nine Level Two, and four Rural. Three of the 10 Level dition, access from the Antelope Valley, mountainous ar- One centers were County Hospital facilities, and they saw eas, and Catalina Island to a designated trauma hospital the largest number of patients by far. The County emergency is dependent on the availability of helicopter transport. It medical services system responded to approximately is estimated that 2.5 million of the 10 million residents are 420 000 calls in 1986. Of that number, 11 456 were identified no longer within 20 minutes of a trauma center. Another as trauma victims and were transported to trauma centers. problem is that as the number of trauma patients grows, The number of trauma patients grew steadily, and, in 1988, the number of nonpaying patients increases and is concen- over 14000 trauma patients were treated. trated in a smaller number of centers. In 1988, approxi- mately 14 000 trauma patients were seen in the 16 remain- SUBSEQUENT EVENTS ing trauma centers. That is a 22% increase in the number When the trauma care network was originally proposed, of patients over 3 years, with a 40% decrease in the number hospital boards of private hospitals enthusiastically em- of centers. braced the concept of trauma care. Trauma centers were CONCLUSION viewed not only as a potentially significant revenue gen- While many small steps might be taken to improve the erator, but also as a powerful marketing tool to attract a existing system, the main continuing problem is that of wider patient market. Other perceived benefits to a private funding. Additional State and County funding will be nec- hospital for having a trauma center included the following: essary to maintain and sustain an adequate trauma sys- (1) offering trauma care saves lives, an important element tem. Some obvious revenue sources present themselves. of the hospital's overall mission or purpose; (2) it generates Since the majority of trauma cases are automobile related, good will in the community; (3) the center could be used vehicle taxes, gasoline taxes, or automobile insurance re- as a loss leader marketing tool with the anticipation that covery offer additional revenue. Other more general rem- the value of overall benefits might exceed actual trauma edies might be taken, such as sales taxes, taxes on beer and care costs; (4) the existence of a trauma center could make wine, universal mandated health insurance, or creation of a hospital more attractive to those concerned about emer- a special assessment for the sole purpose of emergency gencies; (5) hospitals could gain the reputation of provid- medical services enhancement. Some additional funding ing full service care; and (6) teaching hospitals could attract has recently become available from Tobacco Tax Initiative, better house officers for training. which will be distributed to the remaining hospitals in this Some of these assumptions were erroneous. Data pro- system. It is hoped that additional funding will be pro- vided by the Hospital Council of Southern California in- vided in the near future so that trauma patients in Los dicate that among 12 private hospitals surveyed, the av- Angeles County will have rapid access to the emergency erage loss per trauma patient was $11 514 for those trauma care, which they need. Preserving Access With Dignity for the Elderly Tulsa's VIP Program John G. Campbell, MD, Rollie E. Rhodes, Jr, MD T here is an escalating trend toward federal- and state- teria for eligibility. This same group of volunteers was legislated Medicare mandatory assignment. Al- trained to interview and to identify those people who met ready, six states have mandatory assignment regulations the established criteria. All administrative costs were and similar laws are pending in 12 to 15 more states. In borne by the Tulsa County Medical Society. Most of the Oklahoma, although only 36% of the medical doctors are work was donated by the senior volunteers. There was no participating physicians, we voluntarily accepted assign- fee for enrolling. ment of benefits on 70% of Part B Medicare claims in 1990. Eligibility for the VIP program depends on a person Believing that voluntary agreements are preferable to gov- meeting one of three criteria: (1) social security is the only ernmental edicts, the Very Important Person (VIP) pro- source of income; (2) certified to receive medical care under gram was established in 1986 by the Tulsa (Okla) County Medicaid (Title XIX); and (3) total annual income (includ- Medical Society. It has since been adopted by the Okla- ing spouse and dependent children) is less than $2000 homa State Medical Association and received official rec- above the current poverty index. Currently, the Federal ognition from the American Medical Association (Chi- Poverty Index Guidelines are $6280 for a single person and cago, III). $8420 for a couple. When used properly, the VIP program enables physi- One of the key ingredients is that the program certifies cians to accurately identify individuals who need special the beneficiary outside the physician's office and the cer- consideration in obtaining their medical care because of tification is done by peers. Thereafter, when a VIP card is limited resources. In other words, it serves to differentiate presented, Medicare assignment is accepted automatically those financially needy Medicare patients from those who without the patient's having to ask for special consider- are as able as the remainder of the Medicare population ation or discuss limited resources. This preserves the dig- to pay for their health care. This program is unique in that nity of the patient and allows the physician to feel that this it is voluntary on the part of both the Medicare enrollee patient has been identified as low-income elderly and and the physician. It was designed as a local program to qualifies as such. Underscoring the uniqueness of this VIP help low-income elderly people, while preserving their program is that it is voluntary by both the Medicare en- dignity. rollee and the physician. At the time the VIP program was started, there was a Enrollment is completed by filling out and signing a perception that physicians were a major cause of the rising form provided by the Tulsa County Medical Society of- cost of health care. The legislative response was to intro- fices. This form can be received by simply calling the Tulsa duce a program of participating assignment, which was a County Medical Society administrative offices. The en- step toward mandatory assignment and nationalized rollee checks which criterion makes him/her eligible, signs health regulation. Our response to these events was the it, and returns it to the Tulsa County Medical Society of- development of the voluntary income program. In Okla- fices. The enrollee then receives a VIP card (Fig 1), which homa, this effort was led by one of us (R.E.R.) during his looks a lot like his/her Medicare card. Physicians enroll by presidency of the Tulsa County Medical Society. calling the Tulsa County Medical Society and stating a de- In May 1985, the Tulsa County Medical Society Board sire to participate in the VIP program. Physicians may dis- of Directors, acting in concert with several authorized play a small sign in their offices to indicate VIP program groups who work with senior citizens, developed a pro- participation (Fig 2). gram to assure the availability of medical care for recipients Currently, 25% of Oklahoma physicians in over 60% of of the Medicare Health Plan who have limited incomes and our 77 counties are VIP participants. Patients needing spe- for whom the progressively increasing costs of health care cial consideration can identify and reach participating had become a formidable burden. Eligibility requirements physicians without undue hardship. In Tulsa County, and forced means testing were concerns addressed by this where this program originated, 40% of the eligible recip- coalition. Its members judged that information needed re- ients have been certified. No figures are available for the garding income and medical need would have to be pro- entire state. The American Medical Association's House vided on a voluntary basis. Consequently, volunteers of Delegates recognized the Oklahoma State Medical As- from senior citizens' organizations helped define the cri- sociation's resolution regarding the VIP program in June Accepted for publication February 5, 1991. 1988. In the American Medical Association's publication, The authors are in private practice in Tulsa, Okla. Medical Society Programs for Voluntary Acceptance of Medicare Reprinted from Archives of Otolaryngology-Head & Neck Sur- Assignment, November 1988, physicians are encouraged gery (1991; 117:488-489). 100 Caring for the Uninsured and Underinsured PARTICIPATING certification THIS CERTIFIES THAT PHYSICIAN IS ELIGIBLE THE VIP TULSA COUNTY MEDICAL SOCIETY VII. PROGRAM EXP. CERTIFIER program Fig Card to identify Very Important Person patient. "to respond to the economic hardship of their Medicare patients" by considering "the financial aspects of the pa- tient on a case-by-case basis," or "to create voluntary pro- TULSA COUNTY grams such as those described in this document." Features of importance in Oklahoma's program include MEDICAL SOCIETY the following. 1. The VIP-type program counters current and pending legislative efforts to enforce mandatory assignment on all physicians. It is hoped that this evidence of physicians Fig 2.-Sign to identify office of Very Important Person physician. volunteering to help identify and to treat those truly re- quiring special consideration will suggest that govern- mental demands may not be the only, nor the best, way to correct the problem. assignment. However, unless there is greater participa- 2. Truly deserving patients are accurately identified. tion by both physicians and potential enrollees nation- 3. Patients establish eligibility outside the physician's wide, as recommended by the American Medical Asso- office with the inclusion of volunteer senior citizens' ciation, this goal will not be accomplished. The VIP groups. program will only be successful with strong leadership at 4. Patient dignity is preserved during the encounter local, state, and national levels. Local and state organi- with the physician and his/her staff. zations will need to market the attributes of this program 5. Patients feel comfortable that the extent of the care in concert with the individual physician. It is important they are offered is not limited by their financial means. that local volunteer senior groups be involved in the de- 6. Office staffs save valuable time by recognizing these velopment of the program from the beginning. Greater patients in advance. participation will occur as misunderstandings and appre- 7. The uniqueness of this program is that it is voluntary hensions dissipate through increased communication and by both the Medicare enrollees and the physicians. education of both senior citizens and physician groups. The VIP program is designed to obviate the need for Physicians need to recognize the potential this approach laws requiring that physicians accept mandatory Medicare has to avert mandatory assignment legislation. Access to Care-The Problem for the Uninsured and Underinsured The View From Washington Jerome C. Goldstein, MD T he fact that some 30% of the US population is unin- sician shall not be subject to penalty, but the on-call phy- sured or underinsured underscores the urgency to sician, who failed to appear, is. address the growing problem of many Americans lacking A physician who knowingly violates the statute may be access to health care. The past year has seen some 15 dif- subject to financial penalties up to $50 000 for each vio- ferent proposed plans in Congress to deal with the un- lation and be barred from Medicare and Medicaid for up insured, plus the Pepper Commission recommendations. to 5 years. The problem of access to health care involves issues of cost, To a large measure, in the absence of Federal initiatives, quality of care, and the hassle factor of burdensome ad- "it has fallen to the states in the face of severe budget prob- ministrative paperwork. lems of their own challenge" (from Medicine and Health Per- The problem is being addressed both at the Federal and spective. November 26, 1990). But the working poor are state levels. The only federal regulation that I am aware seriously disadvantaged as states tighten their eligibility of that directly concerns access is the "antidumping" reg- requirements for Medicaid. These folks are too rich for ulation passed in 1986. This action was designed to pro- Medicaid and too poor to afford private insurance, so they hibit hospitals from refusing treatment to indigent pa- have nothing. In general, it can be said that less than half tients with medical emergencies, including women in of those below the Federal poverty level qualify for Med- labor. Changes effective July 1, 1990, tightened require- icaid benefits. And, because Medicaid payments for ser- ments and stiffened penalties. The amended regulation vices are substantially discounted, the payments slow, requirements basically state that if a Medicare- and the paperwork burdensome, the Medicaid patient's participating hospital has an emergency room, it must pro- choices of providers are often limited. "For these and other vide an appropriate medical screening examination to any reasons, the Medicaid program as presently constituted individual (whether or not eligible for Medicare) who re- does not offer a viable mechanism for addressing the prob- quests an examination or treatment. If it is determined that lem of access for the uninsured."1 there is an "emergency medical condition," the hospital What is happening at the state level? Hawaii's approach must either provide services necessary to stabilize the pa- is the broadest. Our 50th state has mandated employer tient or transfer the patient to another medical facility, in coverage since 1974 under its Pre-paid Health Care Act. accordance with very specific requirements. "Emergency In 1989, Hawaii created the State Health Insurance Plan medical condition" is clearly defined in the regulation. It to allow families with income as high as 300% of the state is specifically stated that "a hospital may not delay the poverty line to sign up with participating health insurance required medical screening examination. or further plans. The Inter-Governmental Health Policy Project2 re- medical examination and treatment in order to inquire ports that 6000 residents and 900 providers have boarded about the individual's method of payment or insurance State Health Insurance Plan and Employee Retirement In- status." Financial penalties and disqualification from the come Security Act of 1974. Challenge may arise. Employee Medicare program may be imposed on a hospital that vi- Retirement Income Security Act exempts self-insured olates this statute. companies from state regulation. It took Hawaii 6 years to The law also states that if a physician determines that get an Employee Retirement Income Security Act exemp- the individual requires the service of a physician listed by tion when sued by an oil firm in 1976. With about 95% of the hospital on its list of on-call physicians and notifies the the population currently having some type of health in- on-call physician, and the on-call physician refuses or fails surance, Hawaii is believed to have the fewest number of to appear within a reasonable period of time, and the at- uninsured residents. This is basically a mandated tending physician orders the transfer of the individual be- employer-subsidized health insurance for most employ- cause the physician determines that without the service of ees working at least 20 hours a week. the on-call physician, the benefits of a transfer outweigh In 1988, Massachusetts became the second state to ap- the risks of transfer. In this situation the transferring phy- prove a universal insurance plan-the Health Security Act- which remains in legislative limbo. This law would Accepted for publication March 14, 1991. require most Bay State employers to insure full-time work- From the American Academy of Otolaryngology-Head and Neck ers, with a $1680 annual per worker tax on employers who Surgery, Alexandria, Va. Reprinted from Archives of Ototlaryngology-Head & Neck Sur- do not insure. A change of governors in that state has gery (1991;117:490-492). delayed implementation. The Health Security Act was de- 102 Caring for the Uninsured and Underinsured signed to provide coverage for uninsured workers as well mitting recommendations by the spring of 1991: the Pep- as unemployed individuals, disabled adults and children, per Commission, the Steelman Commission (the quadren- and college students who lack health insurance. Several nial Social Security Advisory Council, headed by Deborah portions of that 1988 legislation have been implemented. Steelman), and an internal Health and Human Services The "common health" portion of Massachusetts' universal Task Force, headed by Under-Secretary Constance health care law began operation July 1, 1988. Medicaid Horner. The Health and Human Services Secretary Louis benefits are extended to residents who leave the welfare Sullivan, MD, was directed in President Bush's 1990 State program to return to work. People with preexisting med- of the Union Address to review the various reports for the ical conditions are also able to enroll, and thus far some Administration. In addition, numerous members of Con- 18 000 people are covered under the Common Health Pro- gress have introduced bills aimed at providing health care gram. All full-time college students in Massachusetts are for uninsured people. The most notable ones are Senator required to document their coverage or purchase such cov- Kennedy and Representative Waxman (S.768 and 1845) erage through their schools at an average yearly cost of and Representative Stark (HR4965). about $270. As a result, the number of uninsured college In addition to these efforts at the Federal level, the pri- students in this state has been reduced by approximately vate sector has a number of proposals to increase access 50 000. Pilot programs are under study involving Health to care for medically indigent individuals. Enthoven and Maintenance Organizations and one insurance company. Kronick³ proposed universal coverage through the use of January 1, 1990, the state began requiring employers with various public and private "sponsors" who would func- six or more employees to begin an annual $16.80 fee for tion as brokers purchasing group coverage from compet- each of their employees. It is intriguing that this is the same ing plans. Physicians for a National Health Program has number as the required tax mentioned before, but with the proposed a plan similar to the Canadian health care system decimal point in a different place. This fee was intended under which Medicare, Medicaid, and all private insur- to help low-income workers who are on unemployment ances would be eliminated, and all Americans would be compensation to purchase health insurance. However, covered by a public plan funded by the federal govern- the immediate future of this entire program appears to be ment, but administered at the state and local levels. The quite shaky as more and more employers seem to be voting Coalition for Health Care Reform (50 business and pro- with their feet and moving vans. fessional organizations, including the American Associ- Oregon has taken perhaps the most radical tack with still ation of Retired Persons and the American College of Phy- another type of comprehensive health care plan. Facing sicians) plans to develop a new public-private partnership 388 000 uninsured (17.1% of its population), the state and a systematic reform plan, which will move current wants to rank some 1600 medical procedures used mainly public policy debate forward by presenting new cost con- by women and children under Medicaid, cutting off cov- trol elements, a financing plan, and administrative sim- erage for some underutilized or unrewarding services ac- plification among other suggestions (press release, March cording to a formula intended to reflect both the cost ben- 14, 1990). The Coalition expects to publish its proposal efit values and per unit cost of each procedure. In order sometime in 1991. to proceed with this "rationing" plan, Oregon must get a From all of this some good must come. The seriousness Medicaid rules' waiver from Health Care Financing Ad- of our present situation is highlighted in the second report ministration or Congress, which, as yet, is still forthcom- of the Council on Graduate Medical Education, which re- ing. ports the alarming news that the hospital total margins Washington State with its 800 000 residents is moving have decreased for all hospitals and, as a result, that bond toward universal access. The Health Care Access Act of ratings for these hospitals tend to be downgraded. The 1987 mandates an insurance-risk pool to cover the med- major teaching hospitals have the lowest total margins in ically uninsurable. The Washington Basic Health Plan the industry despite the fact that they have relatively high gives residents under 65 years of age a choice of prepaid, prospective payment system operating margins. This is capitated, or managed care plans. To keep costs low, IHPP due in large part to the amount of uncompensated care that says that enrollment was limited to 30 000 in 1990 through they deliver. All other things being equal, as the teaching 1992; 13 500 have signed up, and the state hopes to hit hospital prospective payment system operating margins 25 000 by mid-1991. As IHPP notes, the number of un- continue to decline, their total margins will continue to insured is slightly higher now than 3 years ago when the deteriorate, resulting in a threat to the size and quality of process began. Washington's Governor Booth Gardner their graduate medical education programs and the ability (Democrat) is heading a national governors' association of these institutions to provide care to the poor. One rec- task force on the topic. ommendation that the Council on Graduate Medical Ed- California will probably be the scene of the next big fight ucation makes is that payment from all payers to teaching over universal coverage. Assembly Speaker Willie Brown hospitals should be sufficient to enable them to deliver (Democrat) pushed through an employer mandate bill in quality patient care and to offer exemplary teaching pro- 1989 that Governor Deukmejian vetoed. Brown will try grams to students and residents. Congress must consider again in 1991 with the hope that Governor Wilson will be the impact of its decisions on the total margins of all hos- less inclined to veto it. As a senator, Wilson tended to back pitals generally and of teaching hospitals specifically. This public-private partnerships on health care issues (from will be particularly important as policies concerning the Medicine and Health Perspective. November 26, 1990). issue of care for the uninsured and underinsured are for- What does the future hold? You can surely believe that mulated. Congress must urgently address the issue of un- health insurance reforms will be implemented during the compensated and undercompensated care that teaching 1990s. Three separate commissions have or will be sub- hospitals provide. Access to Care 103 What does the American Academy of Otolaryngol- physicians continue to provide health care services at re- ogy-Head and Neck Surgery recommend for the imme- duced rates or without charge to those who cannot afford diate future? We support the four principles of the Phy- health care cost. This is perhaps not as well recognized by sician Organizations for Access to Health Care, a coalition the public as it should be. of 21 medical societies to which the Academy belongs (and is a member of the Steering Committee). These are (1) References employer-provided health insurance with appropriate cost-sharing by the employees with tax relief to reduce the 1. American Academy of Family Physicians Board report. financial burden on small businesses; (2) expanded and AAFP Physicians Statement on Access to Health Care for Un- improved Medicaid with minimum eligibility and benefit insured. Board report K. August 1989. levels and incentives to enhance provider participation; (3) 2. Inter-Governmental Health Policy Project Report. The subsidized programs with cost sharing on a sliding scale States and the Uninsured: Slowly but Surely Filling the Gaps. premium basis for those not eligible for employer-based Washington, DC: Inter-Governmental Health Policy Project; 1990. insurance and who have incomes in excess of the en- 3. Enthoven A, Kronick R. A consumer-choice health plan for hanced Medicaid eligibility level; and (4) health insurance the 1990s: universal health insurance in a system designed to programs, public or private, providing access to basic promote quality and economy. N Engl J Med. 1989;320:29-37, physical and mental health benefits. In the meantime, 94-101. Access to Health Care in the United States Byron J. Bailey, MD J ust in case you arrived recently on this planet from an- in many regions, eg, the Texas Medical Association, Aus- other spot in the universe or have just awakened from tin, established a Task Force on Indigent Health Care in a 20-year coma, let me inform you that the current status May of 1988.¹ This group is providing leadership in the of the health care system in this country is being debated improvement of access to current programs and in initi- hotly. The basic issues being scrutinized are access, qual- ating new programs to serve the indigent. It has also in- ity, and cost. These three issues are tightly interwoven, creased physician participation in the provision of health and to a degree they are inseparable, but access issues have care to the poor and to Medicaid patients and has raised moved to the top of the list in contemporary proposals that the public's recognition of the dedication of many phy- are likely to shape our health care system during the 1990s. sicians in serving this group. More than three million Tex- This month, the ARCHIVES focuses attention on the gen- ans (about 20% of the total population) lack health insur- eral theme of access to health care for the uninsured and ance, and close to four million Texans are underinsured underinsured in this country. Who are these 33 million and cannot pay the difference between what they are Americans who lack adequate access to the high-quality, billed and what the insurance company pays (because of technologically advanced medicine that is practiced in the the strict income and resource-eligibility criteria). United States? The state auditor has reported that $4.9 billion was spent They comprise: in 1988 to provide health care for the medically indigent 24 million working Americans and their families, in Texas, but this was woefully inadequate to meet the 3 million "uninsurable" persons, some of whom are em- need. During that same year, $1.3 billion uncompensated ployed, and care was provided by hospitals in Texas, and many times 6 million indigent Americans whose income is below that amount was provided by physicians through their poverty level, but who lack coverage by the Medicaid offices. Texas physicians currently serve almost two mil- system (which provides assistance to only about 40% of lion patients per year without any compensation. our poor). In spite of these impressive efforts, we are failing to meet It is readily apparent that this is not a new problem. the health needs of our citizens. The economic and social Historically, this country has been generous in caring for consequences of relying on the current system of publicly the needs of the poor and underprivileged. Individuals, financed care in our state are quite clear: churches, foundations, and governmental entities at all Texas has the highest rate of teenage pregnancies in the levels have a tradition of philanthropic coalitions that have United States, built hospitals and created programs designed to meet the 25% of pregnant women in Texas receive no prenatal needs of those who are less fortunate in our society. care, For example, 100 years ago John Sealy, a wealthy res- Over 40% of children younger than 4 years of age have ident of Galveston, Tex, bequeathed $50 000 to establish not received immunization. a hospital that should "treat the poor and when the time comes, In many regions of the country, this is a problem that the hospital will be given to the University of Texas" to serve is concentrated in densely populated urban areas, but in its newly chartered medical school. Over the past century, Texas we see that rural patients are much more likely to the John Sealy Hospital evolved into a complex of health live in poverty and to have limited access to health care care facilities that provided $142 000 in uncompen- facilities. The need for expansion of current efforts, im- sated health care to the citizens of Texas last year. With pressive as they are, is evident. Changes are inevitable. seven hospitals, 1100 beds, and over 250 000 outpatient So, what will drive these changes? Why is it necessary visits per year, those of us at our medical center, University to formulate a new approach to such an old problem? I of Texas Medical Branch at Galveston, address indigent believe that most of the changes will revolve around key care problems in Texas, but because they are enormous, areas that have become buzzwords for challenges and we only make a modest dent in them. Across the land, we changes, such as: find that cities, counties, and states are pushing an ex- Expectations (anything can be cured, a single standard of panding load up an ever-steeper slope, and into increas- excellence for all should be established), ingly rarified air. The enterprise is definitely "in trouble." Attitudes (patients, physicians, employers, and insur- State medical societies have taken this matter to heart ers), Politics (government at all levels), Accepted for publication March 26, 1991. Costs (corporate and governmental deficits), From the Department of Otolaryngology, University of Texas Perceptions (uncaring nurses and physicians), Medical Branch, Galveston. Litigation (if things do not turn out well, it must be some- Reprinted from Archives of Otolaryngology-Head & Neck Sur- gery (1991;117:481-483). one's fault), Access to Health Care in the United States 105 Medicine as a commodity, arena. I have sensed a major shift, especially during the Medicine as a right, past 5 years. Medicine as a lever (to get something else, eg, elected The emphasis in approaching issues of patient access to office). has been directed toward finding fair, pragmatic solutions Did the changes grow out of the Great Depression and to complex dilemmas. Further emphasis is placed on the Franklin Roosevelt's New Deal? How much change re- strengths of medicine in the United States, which continues sulted from the social upheaval of World War II and the to be the major research-and-development fountain for postwar 1950s? Some medical historians cite the enact- scientific advancement. We have a system that is the envy ment of Medicare legislation as the turning point; if that of the world, but it is now a system under challenge and observation is valid, we must realize that legislation af- a system under society's microscope. fecting access to health care has great potential for chang- You must become familiar with the structural components ing the system fundamentally. of this premiere health care system-beyond access, quality, At the moment, the conventional wisdom is that the and cost we need to maintain the patients' freedom to select access problem is a national issue that can be addressed how health care will be provided to each individual and how effectively only by national legislative programs. While the the system's vitality can be maintained. media have given some attention to state and local initi- The AMA has taken the lead in proposing a compre- atives to manage scarce resources (translate that to ration- hensive and specific program to meet these challenges. ing health care, as in Oregon), the focus has clearly been There are 16 proposals within the "Health Access Amer- on the federal government as the center of the debate. ica" initiative of the AMA. They are sufficiently important For instance, two national bodies are at work analyzing to warrant your careful study of each proposal individu- access issues. The Advisory Council on Social Security, ally, but they are listed below in the briefest of terms to Washington, DC, will propose a plan to assure access to provide some general awareness of where organized med- health care in the private sector as well as in the public icine is heading. The proposal is a blueprint for extending programs it supervises. The Pepper Commission of the US access, controlling inappropriate health care cost in- Congress will recommend solutions for problems of access creases, and sustaining the Medicare program to assure to long-term care and health services for uninsured Amer- proper health care for all. It is summarized as follows: icans. At the same time, insurance companies and large 1. Effect major Medicaid reform to provide uniform ad- corporations are lobbying vigorously in Washington, DC, equate benefits to all persons below the poverty level. for just the right kind of universal health insurance pro- 2. Require employer provision of health insurance for gram (the kind that has federal financial support). all full-time employees and their families, creating tax in- No one has all of the answers to these challenging ques- centives and state risk pools to enable new and small busi- tions, but it is time to debate them and to seek fair, work- nesses to afford such coverage. able, affordable solutions. This month we highlight the 3. Create risk pools in all states to make coverage avail- issue of access to health care by needy Americans. We have able for the medically uninsurable and others for whom invited the following several experienced and involved cli- individual health insurance policies are too expensive and nicians and an ethicist to address some of the key areas group coverage is unavailable. of interest: 4. Enact Medicare reform to avoid future bankruptcy of Indigent Care Then-Loring Pratt, MD, Fairfield, Me, the program by creating an actuarially sound, prefunded Indigent Care Now-Neil Ward, MD, Phoenix, Ariz program to assure the aging population of continued ac- Preserving Access With Dignity for the Elderly-John cess to quality health care. The program would include Campbell, MD, and Rollie Rhodes, MD, Tulsa, Okla, catastrophic benefits and be funded through individual The View From Washington, DC-Jerry Goldstein, MD, and employer tax contributions during working years. No Alexandria, Va, program tax will be placed on senior citizens. Access to Trauma Care-Dale Rice, MD, Los Angeles, 5. Expand long-term care financing through expansion Calif, of private sector coverage encouraged by tax incentives, The Canadian Health Care System-Patrick Doyle, MD, with protection for personal assets, and Medicaid cover- Vancouver, British Columbia age for those below the poverty level. Who Ought to Get Good Health Care-Ronald A. Car- 6. Enact professional liability reform essential to reduc- son, PhD, Galveston, Tex. ing inordinate costs attributable to liability insurance and In future issues of the ARCHIVES, we hope to explore other defensive medicine, thus reducing health care costs. aspects of our health care system. We also welcome your 7. Develop professional practice parameters under the comments and opinions. Our pages are here waiting to be direction of physician organizations to help assure that filled with words and ideas that will ultimately improve only appropriate, high-quality medical services are pro- the quality of health care in the United States and abroad. vided, lowering costs and maintaining quality of care. Your ideas are welcome and your participation is encour- 8. Alter the tax treatment of employee health care ben- aged. efits to reward people for making economical health care Few physicians have a comprehensive understanding of insurance choices. the time, effort, and expense that has been devoted by the 9. Develop proposals that encourage cost-conscious de- American Medical Association (AMA) staff and member- cisions by patients. ship to these challenges. The AMA has been labeled as 10. Seek innovation in insurance underwriting, includ- reactionary and overly protective of physicians' interests ing new approaches to creating larger, rather than smaller, in prior engagements within the political/socioeconomic risk-spreading groups and reinsurance. 106 Caring for the Uninsured and Underinsured 11. Urge expanded federal support for medical educa- delivery and diminish the excessive and complicated pa- tion, research, and the National Institutes of Health, Be- perwork faced by patients and physicians alike. thesda, Md, to continue progress toward medical break- 16. Encourage physicians to practice in accordance with throughs that historically have resulted in many life- the highest ethical standards and to provide voluntary care saving and cost-effective discoveries. for persons who are without insurance and who cannot 12. Encourage health promotion by both physicians and afford health services. patients to promote healthier life-styles and disease pre- vention. Strengthening the US health care system through the 13. Amend the Employee Retirement Income Security elements contained in this proposal will present an enor- Act (ERISA) or the federal tax code so that the same stan- mous challenge to all concerned. There will be no easy dards and requirements apply to self-insured (ERISA) solutions to these problems. Each one of us will either be plans as to state-regulated health insurance policies, pro- a part of the problem or a part of the solution. We urge viding fair competition. you to read the following essays and to involve yourself 14. Repeal or override state-mandated benefit laws to in the area most important to you. help reduce the cost of health insurance, while assuring Reference through legislation that adequate benefits are provided in 1. Jones DB. Physicians caring for Texans: no matter what. all insurance, including self-insurance programs. Texas Med. 1990;86:34. 15. See reductions in administrative costs of health care Caring for the Underserved Health Insurance Coverage Is Not Enough Matthew Menken, MD T he President's Commission for the Study of Ethical greatly exceeds the number of uninsured and underin- Problems in Medicine and Biomedical and Behavioral sured. For example, many health indicators demonstrate Research stated in 1983 that "Society has a moral obligation a disparity among people of different racial and ethnic to ensure that everyone has access to adequate care with- groups that cannot be ascribed entirely to cost. In 1987, the out being subjected to excessive burdens.' By this mea- age-adjusted death rate for stroke among the black pop- sure, the health system of the United States is failing, since ulation was nearly twice that of white people, while the millions of citizens are unable to obtain necessary care each infant mortality rate for black infants (17.9 per 1000 live year. This is a paradox, given the large annual medical care births) was more than twice the rate for white infants (8.6 expenditures in the United States. In 1991, such expen- per 1000 live births). About 79% of white mothers began ditures will exceed $600 billion, or 11.5% of the gross na- prenatal care in the first trimester, compared with 61% of tional product, an average of $2500 per capita. Compar- black and American Indian mothers.⁵ ative health care figures reveal that the United States Such data suggest that, although cost is an important spends per capita 38% more money than Canada, 88% barrier to health care for many Americans, other access more than West Germany, and 124% more than Japan. barriers may be paramount for some people. For example, Moreover, expenditures in the United States are rising rap- geographic barriers are important for many rural families. idly. Between 1980 and 1987, health expenditures in the In 1985, there were 53 physicians per 100 000 people in US United States increased from $248 billion to $500 billion, counties whose total population was less than 10 000, an increase of 102% during this brief period.² compared with a national average of 165 physicians per I suggest that the proportion of the gross national product 100 000 people. Geographic and language barriers, and now spent on health care in the United States is probably the "culture of poverty," are also important problems in more than sufficient to provide comprehensive care for all access in blighted urban areas where the mortality rate for people, including the provision of effective and high-quality adult black men exceeds that of some developing coun- medical care for those people presently underserved.³ No tries. Between 1963 and 1980, office-based physicians in other country has such readily available technology, an such urban areas declined 45%. 6 With the exception of equivalent density of well-trained physicians in 24 special- some adult and pediatric training programs in hospitals ties, or the institutional resources needed for first-rate med- that emphasize culturally appropriate care, there is a con- ical care. American biomedical and health services research sensus that inner-city hospital-based care is often more is generally acknowledged to be a bigger and better enter- impersonal and less culturally sensitive than office-based prise than anywhere else. A major deficiency is the system's care, especially when such care is provided by minority failure to provide care for approximately 37 million people, physicians.⁷ or 15% of the population, who are unable to afford private Furthermore, medical care is only one factor in the de- insurance and are also ineligible for publicly funded pro- termination of health status, which also depends on many grams.⁴ Contrary to popular belief, nearly three fourths of other sociocultural parameters. Sanitation, the quality of these uninsured citizens are working Americans and their the food supply, the level of education in the community, families, and more than two thirds are white. Only 40% of among other factors, influence personal health status. If all of our citizens below the poverty level (including many medical care were the only determinant of health, and cost children) are insured through Medicaid, a program osten- the only access barrier, then one would anticipate that a sibly designed for the poor. Given this disturbing evidence, cost-free health care system, as under the National Health it is not surprising that public opinion polls find many US Service in the United Kingdom, would demonstrate health citizens dissatisfied with their health care system. There is status equality for all population groups. Many studies in little doubt that health care access and cost are the major the United Kingdom conducted over two decades have issues of concern for most of these Americans. demonstrated a robust negative association between social BARRIERS TO ACCESS class (often called socioeconomic status in the United Since cost is only one of the barriers to access for high- States) and all-cause mortality.⁸ The lower the social class, quality care, the total number of underserved people the greater the mortality. This remarkably consistent find- ing occurs at all levels of society, and it is not limited only Accepted for publication January 16, 1991. to those people who are overtly poor and deprived. For From the Robert Wood Johnson Medical School, University of example, individuals in upper managerial roles and their Medicine and Dentistry of New Jersey, New Brunswick. families have a lower rate of all-cause mortality than do Reprinted from Archives of Neurology (1991;48:472-475). those in middle-management roles and their families. The 108 Caring for the Uninsured and Underinsured same negative correlation has been observed for many in the basic Medicare part B monthly premium. Although medical and neurological disorders such as coronary ar- mandated benefits under this law were quite generous, tery disease, stroke, and many forms of cancer.⁹ the constituency of the American Association of Retired Such data suggest that solving the problem of caring for Persons opposed this measure vigorously. Fearing polit- the "uninsured and underinsured," although certainly of ical fallout, Congress hurriedly repealed the law alto- great importance, is not coextensive with the larger and gether, leaving those senior citizens without supplemen- more difficult task of caring for the underserved, as might tary private insurance more vulnerable than ever to be implied by the rubric of this theme issue of the increasing medical bills. 12 ARCHIVES under which this article is subsumed. The con- The many proposals for improving insurance coverage ventional wisdom notwithstanding, individual physi- reflect a consensus that something needs to be done, but cians and the American Medical Association should make a controversy about what to do. 13,14 A proposal by Phy- it clear to policymakers that insurance reform and financial sicians for a National Health Program calls for a national measures alone, now as in the past, will likely fail to solve health insurance program modeled on the system in Can- the twin societal goals of caring for the underserved and ada, with a single public insurance payor for all health further improving care quality. In 1929, when national care, and a predetermined annual cap on payment to hos- expenditures of $3.6 billion, or $30 per capita, were already pitals. 15 Another proposal, the Consumer Choice Health a source of great public concern, the prestigious Commit- Plan, would convert all insurance plans to prepaid cov- tee on the Costs of Medical Care discovered "much waste" erage, and would require employers to purchase insur- in such features of the health system as payments for in- ance for employees' health care from competing managed effective medications, uncoordinated private practices, care plans. 16 The National Leadership Commission on and inefficiently used hospitals. This Committee Health Care proposal would provide health care for the called for changes in the organization and patterns of de- uninsured through a state-based program funded by gov- livery of medical care as the appropriate way to control ernment, employers, and beneficiaries (on the basis of in- costs, in view of the widespread lack of needed med- come), and would include an expanded technology as- ical care "10 sessment and outcome evaluation effort. 17 The American It remains unchanged after more than half a century that Medical Association has presented a 16-point proposal, many factors that contribute to differences in health status Health Access America, that includes reform of Medicaid, as a reflection of the social stratification of society and the Medicare, and professional liability, also requires em- material aspects of living, such as housing, education lev- ployer provision of health insurance, and would create els, and working conditions, are not readily influenced by state-run risk pools for the uninsured. 18 medical interventions, however accessible. The same pub- lic resistance to provide necessary resources for neuro- CARING FOR THE UNDERSERVED science research and the medically underserved applies H. L. Mencken is reputed to have said that for every also in the case of the nutritionally underserved, the hous- complex human problem there is a solution that is simple, ing underserved, and the educationally underserved. elegant, and wrong. What is generically problematic with There are an estimated 2 million homeless people in the many proposals for health system reform is a viewpoint United States, and 20 million illiterate adults. For these sharply focused on health insurance and cost. This focus people, a more humanitarian system of financing medical on selected aspects or abstractions of an actual situation care would obviously be beneficial, but much more needs or problem, while ignoring other factors of relevance, is to be done. Clearly, the mitigation of poverty (especially an example of a common source of logical error in many child poverty), homelessness, and social deprivation can scientific fields, which has been called the Fallacy of Mis- contribute greatly to improved national health indicators placed Concreteness. 19 I would suggest that the American and the relief of human suffering. Given the focus of na- Medical Association's framework for change is exceptional tional attention on the cost of care, it should be under- and noteworthy, in part because it lends itself more readily scored repeatedly that caring for the underserved and car- than most other proposals to such structural and proce- ing for the uninsured and underinsured are qualitatively dural changes in the delivery of medical services as may different conceptualizations for public policy. be needed to provide better care for the underserved. Car- ing for the uninsured and underinsured is an important CARING FOR THE UNINSURED AND first step, but equity and social justice in health care also UNDERINSURED require caring for all of the underserved. As an additional Given the multifaceted and labyrinthine problems of the step toward resolution of this problem, I would propose underserved, it is not surprising that proposals to mitigate the following measures as ones that merit thoughtful and the lack of health insurance abound, whereas the broader open-minded discussion. care crisis among the underserved has received much less First, efforts to improve the scientific underpinning of attention. 11 It seems likely that even these more limited medical care must be expanded, as a logical step toward proposals will face rough sailing in the political arena. On prevention of disorders that rely for treatment on expen- July 1, 1988, President- Reagan signed the Medicare Cat- sive "halfway" interventions. For example, it has been es- astrophic Coverage Act of 1988, the largest expansion of timated that mortality from metastatic female breast can- federal involvement in health care since 1965, when the cer can be reduced 30% by regular breast examination and Social Security Amendments of 1965 (Medicare and Med- mammography performed at recommended intervals. 20 icaid) were first implemented. Unlike prior policy that paid Moreover, about 30% of total Medicare hospital expen- for coverage out of general tax revenues, the 1988 law re- ditures are on behalf of patients in the last year of life, quired that the wealthier beneficiaries pay an income tax mostly the last 6 months, many of whom suffer from surcharge, and that all beneficiaries pay an additional $4 Alzheimer's disease and other dementias. Given the large Far From the Ideal 109 cost of services for patients with dementia, and a prev- school. Each medical school might set its own arbitrary alence of Alzheimer's disease of nearly half of all people threshold level of academic grades and examination scores older than 85 years of age (the most rapidly growing seg- that all candidates must surpass, but once that is done, ment of the US population), it is astonishing that research grades and scores no longer matter in the selection process funding for this disorder amounts to only 0.15% of the for those individuals who exceed the cutoff level. 31 Finally, costs of care. 21,22 is there any doubt that the framework for physician pay- Although Health Access America, the AMA's health care ment and professional liability needs to be modified so that proposal, correctly calls for the expansion of biomedical doctors can care for the underserved without great risk to research, a broader paradigm of research is necessary to their personal and family's financial security? provide comprehensive care for the underserved. As I Third, medical schools need to develop appropriate have suggested previously, amplification of the investi- community-oriented learning experiences for all medical gative effort should logically include much more research students. In terms of faculty prestige and status, students in the social and behavioral sciences relevant to human learn that the "ins" are in (hospital based), and the "outs" health and disease,² as well as an expanded health ser- are out (ambulatorium). Some schools have experimented vices research agenda to foster intersectoral cooperation with educational programs in health maintenance orga- with workers in such fields as nutrition, education, and nizations, community health centers, and other facilities. housing. 24 Such health services research activity in the re- It is also a question of decentralizing a health system that cent past has included an expanded effort to measure the preferentially directs resources to surgical and procedural appropriateness and effectiveness of medical care, an ex- interventions carried out in hospitals, leaving community- amination of health system administrative costs and the based and preventive services seriously underfunded. effects of reimbursement reform, as well as "the technol- Given the widespread dissatisfaction of many people with ogy of patient experience" (outcomes research), as in the the health system, and the declining number of applicants recent initiatives of the American College of Physicians to American medical schools, health science centers need and the Public Health Service's Agency for Health Care to identify the task of medicine, in its broadest sense, for Policy and Research. 25-27 all students and residents, as well as the role of the doctor Second, the absolute number and relative proportion of in an industrialized society. We seem to have forgotten primary care physicians must be expanded. The President that scientific expertise and technical competence are not of the Association of American Medical Colleges has noted the foundations of patient satisfaction in many situations. that our academic medical centers will lose vital na- When learning is exclusively carried out in teaching hos- tional and public support if they do not respond to soci- pitals, students sometimes get the erroneous impression ety's desire for more primary care physicians." Of all that caring is what is left for doctors to do when curative medicine has failed. physicians in the United Kingdom, Canada, and the United States, 70%, 50%, and 30%, respectively, are gen- In terms of caring for the underserved, learning expe- eralists. In my view, solving the crisis in primary care is riences in the community will heighten student and res- an essential component of any solution to the problem of ident awareness of local priority health problems based on caring for the underserved in the United States. Put an- sound epidemiological principles, as in the educational other way, most of the care requirements of the under- model developed by an international task force commis- served fall within the domain of primary care medicine. sioned by the Network of Community-Oriented Educa- tional Institutions for Health Sciences. Such "real life" Hence, providing adequate insurance for all people cannot be expected to correct the mismatch between actual health experiences, in which students live and learn in selected needs and the specialty distribution of physicians. This community settings, are likely to foster the linkage be- keystone issue is one that often goes unnoticed or unsup- tween knowledge and skills, on the one hand, and the ported by many neurologists and other specialists. It is a concept of social responsibility, on the other, so that all question of our orientation and commitment to provide students understand why the social role of every doctor, high-quality medical care for individual patients, without regardless of the field of specialization, must extend be- a concomitant awareness of those people who are not re- yond the care of individual patients. ceiving care, as well as the differential burden of illness in CONCLUSIONS the entire population to be served. This is an example of In May 1977, the Thirtieth World Health Assembly re- what has been called the Inverse Care Law, which holds that solved that "the main social target of governments and the market forces cause medical care to vary inversely with the World Health Organization in the coming decades should need for it in the population to be served.²⁹ be the attainment by all citizens of the world by the year What is needed to address this issue, first of all, is a 2000 of a level of health that will permit them to lead a major initiative to recruit minority health professionals socially and economically productive life."3 To achieve and strengthen minority medical institutions. Among this goal in the United States, expanding insurance cov- 15 433 senior medical students in 1989 through 1990, only erage for the uninsured and underinsured is an important 826, or 5.3%, were black. (As of September 1, 1989, there step. However, the many barriers to care other than cost, were only 29 black neurology residents on duty, including and the limited role of medical care as a determinant of the one child-neurology resident.) Moreover, special mea- overall health status of the population, call for a more com- sures are needed to recruit talented students from rural prehensive framework for reform that views health care and other underserved areas, since these individuals are for all of the underserved in its social context. more likely to establish primary care practices were they I suggest that the proposal of the American Medical As- are most needed. Perhaps it is time to reform the criteria sociation, Health Access America, might be modified and by which candidates are selected for enrollment in medical enlarged to address these concerns. The expansion of the 110 Caring for the Uninsured and Underinsured biomedical research agenda should be matched by a much namic jigsaw puzzle. Arch Intern Med. 1990;150:256-258. larger research effort in the social and behavioral sciences 13. Kinzer DM. Universal entitlement to health care: can we relevant to human health and disease, as well as the health get there from here? N Engl J Med. 1990;322:467-470. services research agenda. The mismatch between the spe- 14. Rockefeller JD. The Pepper Commission report on com- cialty distribution of physicians and the health needs of the prehensive health care. N Engl / Med. 1990;323:1005-1007. entire population to be served calls for an increase in the 15. Himmelstein DU, Woolhandler S. A national health pro- number and proportion of primary care physicians, and gram for the United States. N Engl / Med. 1989;320:102-108. the recruitment of a larger number of minority medical 16. Enthoven A, Kronick R. A consumer-choice health plan for the 1990s. N Engl J Med. 1989;320:94-101. students. Finally, all medical students should have active 17. Relman AS. The National Leadership Commission's health learning experiences in a community-oriented framework care plan. N Engl J Med. 1989;320:314-315. of service provision to ensure that future generations of 18. American Medical Association. Health Access America. physicians understand the role of medical care for pop- Chicago, III: American Medical Association; February 1990. ulation groups as well as individual patients. Together, 19. Whitehead AN. Science and the Modern World. New such changes signify the addition of relevance to the equa- York, NY: Macmillan Publishing Co Inc; 1962:75. tion of access, cost, and quality in caring for the under- 20. Amler RW, Dull HB. Closing the Gap: The Burden of Un- served. necessary Illness. New York, NY: Oxford University Press Inc; 1987. References 1. President's Commission for the Study of Ethical Problems 21. Moss M, Alpert M. Alzheimer' disease and other dement- in Medical and Biomedical and Behavioral Research. Report: ing disorders. In: Alpert M, Moss M, eds. Geriatric Neuropsy- The Ethical Implications of Differences in the Availability of chology. New York, NY: Guilford Press; 1988:145-178. Health Services. Washington, DC; March 1983;1:22. 22. Weiler PG. The public health impact of Alzheimer's dis- 2. Politser P, Cunico E. Socio-Economic Factbook for Surgery ease. Am J Public Health. 1987;77:1157-1158. 1989. Chicago, III: American College of Surgeons; 1989. 23. Menken M. The changing paradigm of neurologic prac- 3. Wennberg JE. Outcomes research, cost containment, and tice and care: implications for the undergraduate curriculum. the fear of health care rationing. N Engl / Med. 1990;323:1202- Arch Neurol. 1990;47:334-336. 1204. 24. Schaefer M. Home and health: on solid foundations? 4. Braveman P, Oliva G, Miller MG, Schaaf VM, Reiter R. World Health Forum. 1990;11:38-45. Women without health insurance: links between access, pov- 25. Ellwood PM. Outcomes management: technology of pa- erty, ethnicity, and health. West J Med. 1988;149:708-711. tient experience. N Engl / Med. 1988;318:1549-1556. Shattuck 5. National Center for Health Statistics. Health, United States, lecture. 1989. Hyattsville, Md: Public Health Service; 1990. 26. Ginsburg JA, Prout DM. Access to health care. Ann Intern 6. Kindig DA, Movassaghi H, Dunham NC, Zwick DI, Taylor Med. 1990;112:641-661. CM. Trends in physician availability in 10 urban areas from 1963 27. Clinton JJ. From the Agency for Health Care Policy and to 1980. Inquiry. 1987;24:136-146. Research. JAMA. 1990;263:2158. 7. Gessert C, Blossom J, Sommers PS, Canfield MD, Jones C. 28. Petersdorf RG. Medical education. JAMA. 1990;263:2652- Family physicians for underserved areas: the role of residency 2654. training. West J Med. 1989;150:226-230. 29. Hart JT. The inverse care law. Lancet. 1971;1:405-412. 8. Morris JN. Inequalities in health: ten years and little further 30. DeFriese GH, Ricketts TC. Primary health care in rural ar- on. Lancet. 1990;336:491-493. eas: an agenda for research. Health Serv Res. 1989;23:931-973. 9. Bunker JP, Gomby DS, Kehrer BH. Pathways to Health: The 31. Antonovsky A. Medical student selection at the Ben- Role of Social Factors. Menlo Park, Calif: The Henry J. Kaiser Gurion University of the Negev. Isr J Med Sci. 1987;23:969-975. Family Foundation; 1989. 32. Neufeld VR, Bearpark S. Winterton C. Optimal outcomes 10. Falk IS, Rorem CR, Ring MD. The Costs of Medical Care. of clinical education. In: Gastel B, Rogers DE. Clinical Education Chicago, III: The University of Chicago Press; 1933;592-593. and the Doctor of Tomorrow. New York, NY: New York Acad- 11. Education of Physicians to Improve Access to Care for the emy of Medicine; 1989:11-23. Underserved. Hyattsville, Md: Health Resources and Services 33. World Health Organization Regional Office for Europe. Administration, US Dept of Health and Human Services; 1990. Targets for Health for All. Geneva, Switzerland: World Health 12. Ahluwalia JS. Health care in the United States: our dy- Organization; 1985. Access to Health Care One Neurologist's Perspective Michael P. Earnest, MD Millions of residents of the United States have difficulty still fed by gastrostomy. He remained in the rehabilitation unit. He was obtaining health care. Barriers impeding access to care in- not expected to return to work and so had applied for welfare assistance clude poverty, physical unavailability of health care ser- and Medicaid. The rehabilitation staff expected he would have to stay at vices, absence of health insurance, and physicians unwilling least several weeks in a nursing home. He hoped eventually to resume to care for uninsured patients. Many patients do not suc- independent living and to be able to swallow food again. cessfully use health services because of educational, cul- tural, and language barriers. A major access barrier is lack M any residents of the United States have difficulty ob- of health insurance. Over 30 million people in the United taining needed health care (Table 1). 1,2 Growing States have none, the so-called medically indigent. Among concern about barriers between patients and health care them are over 3 million people with neurologic disorders. has prompted numerous governmental and medical re- They have additional barriers to overcome because often ports on inadequate access to health care, the effect of this they cannot work, cannot drive, have difficulty using public on health status, and possible solutions to the problem. 3-6 transportation, and have major cognitive and communica- FACTORS AFFECTING ACCESS tion impairments. Medical and governmental bodies are de- TO HEALTH CARE bating solutions to the health care access crisis. Physicians An individual's access to health care depends on several should actively participate in this national debate. Neurol- interrelated factors that fall into the following four prin- ogists should address the special needs of patients with neu- cipal categories: financial, health care system, personal/ rological disorders. cultural, and social system. 7,8 The financial determinants of access to care are health insurance (eg, private or A 52-year-old laborer had a long history of poorly controlled hyper- employer-based insurance or Medicare/Medicaid cover- tension. A stroke at age 40 years caused a mild left hemiparesis, but he age) and personal cash reserves to pay the expected bills, was able to continue working part-time and he was fully independent medication prescriptions, and related costs, including in his daily living. He had no health insurance and no savings. He had transportation. Access to the health care system is deter- last seen a physician at a public clinic but admitted he had not taken the antihypertensive medications that had been prescribed. He admitted to mined by the physical availability of a physician, clinic, or prior heavy alcohol use but denied any alcohol use since the stroke. hospital⁶ and the capacity or willingness of those providers Three days before his admission on December 5, 1990, while at home, to see the patient. Personal and cultural determinants of he had sudden vertigo, nausea, and vomiting and then fell. He could not access are the characteristics of the patient that enable suc- recall subsequent events but was found 48 hours later still on the floor, cessful acquisition of health care services. Education, abil- conscious but confused and unable to get up because of a severe left hemi- ity to speak and read English, attitude toward health and paresis. He was taken by ambulance to a private hospital, where he was health care, and cognitive ability are all important. Social treated in the emergency department. A computed tomographic scan system access to Medicaid or other public assistance pro- showed an old right-sided cerebral infarct. Twelve hours later, he was grams for health care depend on availability of state and transferred to Denver (Colo) General Hospital and was admitted. The patient stated he was transferred because "I didn't have any money." federal programs and accessible entry systems, including local offices. During this hospitalization, he was in the intensive care unit 18 days for management of severe hypertension, aspiration pneumonia, respi- A sick person can obtain health care services if there is ratory failure, recurrent chest pain, and thrombophlebitis. He had a gas- a physician's office or other health facility available, the trostomy because of dysphagia and aspiration. After 30 days, he was patient has sufficient insurance or cash, is motivated to transferred to the rehabilitation unit. The total bill for the 30 days was seek care, and can communicate with the provider about $61 185. the illness. However, multiple barriers prevent many US Five weeks later his left arm remained totally paralyzed. He could take citizens from receiving needed care. Poverty, lack of health a few steps using a walker and a leg brace and with assistance. He was insurance, absence of physicians and clinics in rural and Accepted for publication March 11, 1991. inner-city areas, low level of education, inability to speak From the Chairman of the Task Force on Access to Health Care or read English, and intimidating health system and social of the American Academy of Neurology, Minneapolis, Minn, and services bureaucracies all create barriers between many the Departments of Neurology, Denver (Colo) General Hospital and people and health care. 1,7-10 University of Colorado School of Medicine, Denver. The opinions expressed in this article are those of the author People with neurological disorders may have even more alone. They do not necessarily reflect the opinions, nor are they difficulty obtaining health care than do others. The au- policy, of the American Academy of Neurology, its Executive Board, thor's clinical experience in an urban municipal hospital or the Task Force on Access to Health Care. indicates that patients with dementia, stroke, Parkinson's Reprinted from Archives of Neurology (1991;48:476-479). disease, multiple sclerosis, and epilepsy have special 112 Caring for the Uninsured and Underinsured Table 1. - Percentage of 10 130 Respondents Reporting Difficulty Obtaining Health Care* Black, 17.0% Type of Difficulty % (22% of All Blacks) Hispanic, 16.1% (31.5% of All Hispanics) People with chronic or serious illness who had no physician visit in prior 12 months 18.5 Needed care but had difficulty obtaining it 16.1 Pregnant women without care in first trimester 15.8 Others, 5.3% Economic barriers to receiving health services 7.8 Tried to get care but could not, for financial reasons 0.4 White, 61.6% *Adapted from Robert Wood Johnson Foundation Special (12.4% of All Whites) Report.¹ problems obtaining health care. Those diseases often cause loss of jobs, inability to obtain health insurance, Uninsured US Population by race (from King³). problems driving a car or using public transportation, and impaired mental and communication ability, all of which NEUROLOGIC DISORDERS AMONG interfere with obtaining health care. Public assistance pro- THE MEDICALLY INDIGENT grams, such as Medicaid, offer only partial relief of the The prevalence and incidence of neurologic disorders financial problems, but the other problems remain formi- among the medically indigent have not been studied. dable. Kurtzke¹⁶ estimated that neurologic disorders affect about 9.5% of the entire US population, ie, a point prevalence THE NATIONAL PROBLEM rate of 9500 per 100 Extrapolating that figure to the 34 OF MEDICAL INDIGENCY million medically indigent, 3.2 million people have neu- Because the United States has no universal health in- rologic disorders. Using his estimates for prevalence of surance system, individuals here must pay for medical specific disorders, 272 000 people have cerebrovascular care through personal health insurance or with out-of- disease or transient ischemic attacks, 221 000 have epi- pocket cash. Absence of health insurance is a major barrier lepsy, 100 000 have lumbosacral herniated disk, 85000 to obtaining health care in our nation. 1,3,6,9,11 More than 30 have cerebral palsy, 85 000 have dementia, and 68 000 have million people under the age of 65 years have no health Parkinson's disease. Using Kurtzke's annual incidence fig- care insurance. 3,11 Estimates of this "medically indigent" ure, 850 000 medically indigent people develop a neuro- population are as high as 37 million, about 15% of the US logic disorder within a given year. 16 Many of those patients population.³ This group has substantially increased dur- need both acute and continuing neurological care.¹⁷ ing the last two decades. 1,3,11 Over half of these people are An additional large but unquantified number of cases of employed or are dependents of full-time employees; many the acquired immunodeficiency syndrome (AIDS) exist others are the poor who are not eligible for Medicaid. 3,11 among the medically indigent, and the prevalence of cases About 62% are non-Hispanic whites, 17% are black, and is still increasing. Employed people with AIDS eventually 16% Hispanic (Figure). 3,12 Ten million of the medically in- lose their jobs and then their health insurance, becoming digent are under the age of 19 years.³ medically indigent. Neurologic complications occur in Why do so many people have no health insurance? Fed- over half of the people with AIDS,¹ 18 so neurologic con- eral and state health insurance systems cover many seg- sultations, computed tomographic and magnetic reso- ments of the population. Medicare covers those over 65 nance scans of the brain, and other neurologic tests often years old and some chronically disabled people. Medicaid are needed. covers many impoverished pregnant women, mothers with dependent children, and most impoverished chron- NONFINANCIAL BARRIERS ically disabled adults. However, state-funded Medicaid TO HEALTH CARE programs do not cover many people below the poverty Regardless of employment and insurance status, many level. 3,5 Also, many young people just entering the work patients in rural areas and in large inner-city poverty tracts force have no insurance for themselves or for their fam- have no access to care because physicians, clinics, and hos- ilies.³ Because of high premium costs, many employers, pitals are not located there. Those patients must travel especially small and service-industry companies, offer no longer distances and incur higher costs in transportation health insurance benefits. 3,11 Self-employed workers can and time to seek medical care. The physical and cognitive purchase insurance, but many cannot afford the high disabilities associated with neurologic diseases create even price. All of these gaps in health insurance coverage com- more problems traveling to distant clinics. The poor face bine to create the huge medically indigent population. other important access barriers. 7-10 Limited education, es- A consensus is growing among political and medical pecially about health, leads to delay in seeking acute care, leaders that the absence of health insurance prevents peo- inattention to preventive services (eg, detection and treat- ple from receiving needed health care. 1,3,6,13 Long-term ef- ment of hypertension to prevent stroke), and noncompli- fects of reduced access probably are higher morbidity and ance with medical instructions and medication usage. mortality for uninsured people. 14,15 The excess morbidity Language barriers interfere with access for Spanish- and mortality increase unemployment and increase ex- speaking, Asian, and other non-English-speaking pa- penditures of public funds for the health-impaired pop- tients. Cultural values that deny illness or values that em- ulation. 13 Widespread lack of health insurance is a major phasize traditional healing methods may interfere with economic issue, not just one of social justice. proper use of available medical care. The high prevalence Health Access 113 Table 2. - Features Common to Many Proposals tinuing major services has begun (eg, pediatrics and men- for Providing Health Insurance to All US Citizens tal health). These steps are intended to increase revenues and decrease expenses, but they all create further barriers Expanded Medicaid to include the poor currently not to access. covered Mandate that employers provide health insurance to all PROPOSALS TO SOLVE THE NATIONAL employees HEALTH CARE CRISIS Establish state insurance "pools" to cover those Numerous reports and plans have been published by "uninsurable" because of severe medical conditions governmental commissions, private study groups, and Develop insurance to pay for catastrophic illness and medical associations proposing steps to resolve the health long-term care care access crisis. 3-6,13,25-27 Several features are common to many proposals (Table 2). First, they propose that the of alcohol and other substance abuse and of severe mental Medicaid program should be expanded to cover all people illness in inner-city poor populations compounds the ed- below the federal poverty level who currently are unin- ucational and cultural factors. 19 sured. The uninsured poor with incomes above the pov- Even middle-class, educated, insured patients are facing erty level could enroll in Medicaid by paying a graduated more barriers to neurologic care. Managed-care systems, premium based on income. Second, the working unin- trying to limit utilization and hold down costs, discourage sured would be covered by employer-sponsored health primary care physicians from referring patients to special- insurance. Small business employers would be given tax ists (eg, neurologists) and from ordering expensive tests, incentives, thus reducing their cost for providing insur- including computed tomographic and magnetic reso- ance. Third, state-sponsored insurance pools would cover nance scans. Hospital admissions are being limited by the "uninsurable" population, people with chronic costly utilization-review plans and lengths of hospital stay con- diseases who cannot obtain insurance and who also are trolled by diagnosis related group reimbursement. How not eligible for Medicaid. Finally, long-term care and cat- much these mechanisms deny access to needed health ser- astrophic illness coverage would be provided. vices is unclear. Nonetheless, even though the purpose Other proposals advocate a federal government-spon- may be laudable, they are barriers between patients and sored national health insurance plan, possibly based on health care services, including neurological services. the Canadian health insurance system. 28 Several states, among them Massachusetts, Hawaii, and New York, have WHO TREATS THE ACCESS-POOR established statewide universal health insurance plans. PATIENTS? Some proposals advocate community action and more do- Most patients with limited access to medical care are nated charity care by hospitals and physicians. 30,31 treated in public clinics and hospitals and in urban teach- In spite of the numerous commissions, studies, and pro- ing hospitals, both public and private. The "general hos- posals, major obstacles to any national solution exist. The pital" and its clinics have long been the "safety net" for first is the extraordinarily rapid growth in costs of health meeting health needs of the urban Medicaid and unin- care and the corresponding growth of health care insur- sured population. 6,20 However, these facilities are under ance premiums. Expenditures for health care in the United extreme financial and political pressure. 21,22 Emergency States grew from $75 billion in 1980 to nearly $500 billion departments, clinics, and wards are strained to the point in 1987 (Am Med News. Jan 12, 1990:25-26). 32 Health care that an acceptable quality of care often is compromised.6 expenses escalated from 7.4% of the gross national prod- Reduced reimbursements from Medicaid, increasing uct in 1970 to 11% in 1988. Any solution to the health in- numbers of uninsured patients, the epidemics of AIDS, surance crisis must include provisions to pay for imple- drug abuse, and violence in the inner cities, and increased menting the plan and must include steps to restrict the hospital operating costs have driven many public and pri- rapid growth in health care costs. Illustrating the costs in- vate teaching hospitals deeply into debt. 21,22 Some have volved, expansion of the federal Medicaid program to even closed. 21,23 Those that remain open are short-staffed cover the currently uninsured poor would cost between and overcrowded. $9 and $35 billion, the exact amount depending on the Physicians in their private offices and hospitals have tra- services covered and the population included. ditionally cared for many Medicaid and medically indigent Efforts to curb costs include "rationing" or "prioritizing" patients. However, inadequate Medicaid and other gov- care by setting limited benefit packages, 13 requiring pa- ernmental reimbursement, rising overhead costs, fear of tient copayment, imposing managed care plans in which malpractice liability and decreased ability to shift costs primary care providers act as "gatekeepers" between pa- from the "no-pay" to the "full-pay" patients have forced tients and high-cost care, and second opinions for high- private physicians and hospitals to reduce charity care. cost procedures. Unfortunately, these cost-cutting mea- Now, they give emergency care and then arrange further sures are also barriers between a patient and health treatment at a public agency, 21,24 the practice commonly services. termed "dumping." The problem of cost also leads to contradictory public With the private sector giving less charity care and the opinions about health care. Polls indicate that we want public sector unable to keep up with the increasing de- everyone, even the poor, to have access to health care (Am mand, indigent patients suffer even more. In the author's Med News. July 27, 1990:6). 34,35 We also want access to the hospital and clinics, waiting times for visits have in- latest, most expensive tests and treatments. Yet we do not creased, heavy patient copayments have been instituted want increased taxes or cuts in nonhealth programs to pay (eg, $250 for elective surgery), clinic hours have been re- health care costs for the medically indigent (Am Med News. duced, and, now, discussion of reducing or even discon- July 27, 1990:6). 34,35 114 Caring for the Uninsured and Underinsured Even if a comprehensive nationwide health insurance higher morbidity and mortality in the medically indigent plan were enacted, other access barriers would remain. population. Exploding costs and widespread opposition Limited access would persist because of inequitable dis- to spending more on health care both preclude "quick-fix" tribution of health providers and because of the educa- solutions to the problem. Many different proposals have tional, cultural, and social factors. been made, and state legislatures and Congress are de- bating the issues. WHAT CAN PHYSICIANS DO? Under any future national health plan, physicians will Individual physicians cannot solve the health care ac- provide the health care. We should take an active part in cess problems for over 30 million uninsured or for the com- the national debate on access to that care. Neurologists parably large Medicaid population. However, a physician should speak out for the needs of patients with neurologic can treat an individual person who needs care. Physicians disorders, including the special needs of those among the in private practice, especially specialists (eg, neurologists) medically indigent. who may only need to perform a diagnostic consultation and then see the patient again a few times, can help by My thanks to L.P. Rowland, MD, New York, and J. A. Cohen, MD, accepting uninsured and Medicaid patients. The editor of Denver, Colo, for helpful comments and to Denise Lovato for pre- the Journal of the American Medical Association encouraged paring the manuscript. such professional commitment. Physicians who work in References municipal hospitals, public clinics, and teaching hospitals 1. Robert Wood Johnson Foundation Special Report. Access can help by continuing to provide as much high-quality, to Health Care in the United States: Results of a 1986 Survey. readily accessible care as is possible. Private and public Princeton, NJ: Robert Wood Johnson Foundation; 1987. physicians alike can urge administrators and boards of 2. Aday LA, Fleming GV, Andersen R. Access to Medical Care in the US: Who Has It, Who Doesn't. Chicago, III: Pluribus Press; their hospitals and clinics to remain fully available and 1984. responsive to the needs of patients who come for care. At 3. King M. Medical Indigency and Uncompensated Health the same time, all physicians can limit health care costs for Care Costs. Denver, Colo: National Conference of State Leg- individual patients, and collectively for all of society, by islatures; 1989. charging reasonable fees, ordering tests prudently, and 4. American Academy of Pediatrics. AAP Special Report: Bar- managing cases in a cost-effective fashion. riers to Care: Why Millions of Children Live in the Shadows, At the community level, physicians and medical soci- Unable to Receive Appropriate Health Care. Elk Grove Village, eties can donate services to public clinics and hospitals. III: American Academy of Pediatrics; 1989. They can establish voluntary free clinics to give care to 5. American Medical Association. Health Policy Agenda for the American People: The Final Report of the Ad Hoc Committee people with no other resources. They can work with com- on Medicaid. Chicago, III: American Medical Association; 1989. munity groups concerned about the problems of medical 6. Nutter DO. Medical indigency and the public health care indigency, long-term care, cost of health care, and related crisis: the need for a definitive solution. N Engl / Med. issues. 31 Neurologists can advocate, with special author- 1987;316:1155-1158. ity, provision of services for people with chronic neuro- 7. American Academy of Pediatrics. Solutions: An Overview logic impairments, especially those in the medically in- of the Academy's Three-Part Access to Care Campaign. Elk Grove digent population. Village, III: American Academy of Pediatrics; 1990. On the state and national levels, organized physician 8. Bunker JP, Gomby DS, Kelvier BH, eds. Pathways to Health: associations can educate legislatures and governmental The Role of Social Factors. Menlo Park, Calif: The Henry J. Kaiser Family Foundation; 1989. agencies about the health needs of the indigent and rec- 9. Davis K, Rowland D. Uninsured and underserved: ineq- ommend programs to improve access to health care. Spe- uities in health care in the United States. Milbank Q. cialty societies, including neurologic societies, can de- 1983;61:149-176. velop plans focused on the needs of their specific patients. 10. Dutton DB. Social class, health, and illness. In: Aiken LH, They can publicize those programs through the press and Mechanic D, eds. Applications of Social Science to Clinical Med- their own publications. The American Medical Associa- icine and Health Policy. New Brunswick, NJ: Rutgers University; tion, American Society of Internal Medicine, American 1986:31-62. Academy of Pediatrics, and American College of Physi- 11. Wilensky GR. Filling the gaps in health insurance: impact cians, among others, have developed specific propos- on competition. Health Aff. Summer 1988:133-149. 4,5,7,26,36,37 The American Academy of Neurology has 12. Trevino FM, Moyer ME, Valdez B, Stroup-Benham CA. Health insurance coverage and utilization of health services by created a Task Force on Access to Health Care to study Mexican Americans, mainland Puerto Ricans, and Cuban Amer- access and economic issues for patients with neurologic icans. JAMA. 1991;265:233-237. disorders. 38 Professional associations can also speak out 13. Kitzhaber J. Uncompensated care: the threat and the on behalf of adequate funding for the health care agencies challenge. West J Med. 1988;148:711-716. that provide care to the indigent and Medicaid popula- 14. Braverman P, Oliva G, Miller MG, Reiter R, Egerter S. Ad- tions. verse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982 to 1986. N Engl J Med. COMMENT 1989;321:508-513. Access to health care has become more difficult for tens 15. Hadley J, Steinberg EP, Feder J. Comparison of uninsured of millions of people in the United States, many of whom and privately insured hospital patients: condition on admission, cannot obtain needed health care. More than 3 million resource use, and outcome. JAMA. 1991;265:374-379. 16. Kurtzke JF. The current neurologic burden of illness and among that population have neurologic disorders. The injury in the United States. Neurology. 1982;32:1207-1214. long-term consequences of inadequate access to care can- 17. Kurtzke, JF, Bennett DR, Berg BO, Beringer GB, Goldstein not be predicted, but clinical common sense and available M, Yates TS Jr. On national needs for neurologists. Neurology. research studies indicate that the consequences will be 1986;36:383-388. Health Access 115 18. Leehey M, Gilden D. Neurologic disorders associated tee. A national health program for the United States: a physi- with the HIV and HTLV-I viruses. Cur Neurol. 1990; 10:1-63. cians' proposal. N Engl / Med. 1989;320:120-128. 19. Shern D, Dilts SL. The concentration of severely disturbed 29. Beauchamp DE, Rouse RL. Universal New York health CMI in a core urban population. Admin Mental Health. care: a single-payer strategy linking cost control and universal 1987;15:18-28. access. N Engl J Med. 1990;323:640-644. 20. Gage LS, Andrulis DP. Our nation's great public hospitals. 30. Lundberg GD, Bodine L. Fifty hours for the poor. JAMA. JAMA. 1987;257:1942-1943. 1989;262:3045. 21. Friedman E. Problems plaguing public hospitals: unin- 31. Mayster V, Waitzkin H, Hubbel A, Rucker L. Local advo- sured patient transfers, tight funds, mismanagement and mis- cacy for the medically indigent: strategies and accomplish- perception. JAMA. 1987;257:1850-1857. ments in one county. JAMA. 1990;263:262-268. 22. Friedman E. Public hospitals often face unmet capital 32. Levit KR, Freeland MS. National medical care spending. needs, underfunding, and uncompensated patient-care costs. Health Aff. Winter 1988:124-136. JAMA. 1987;257:1698-1701. 33. Thorpe KE, Siegel JE, Dailey T. Including the poor: the 23. Bindman AB, Keane D, Lurie N. A public hospital closes: fiscal impacts of Medicaid expansion. JAMA. 1989:261:1003- impact on patients' access to care and health status. JAMA. 1007. 1990;264:2899-2904. 34. Blendon RJ. The public's view of the future of health care. 24. Ansell DA, Schiff RL. Patient dumping: status, implica- JAMA. 1988;259:3587-3593. tions, and policy recommendations. JAMA. 1987;257:1500-1501. 35. Gabel J, Cohen H, Fink S. Americans' views on health 25. A Call for Action: Final Report. Washington, DC: The Pep- care: foolish inconsistencies? Health Aff. Spring 1989:103-118. per Commission, US Bipartisan Commission on Comprehen- 36. American Society of Internal Medicine. Ending Separate sive Health Care; 1990. and Unequal Health Care. Washington, DC: American Society 26. The Health Care Crisis: A Report to the American People. of Internal Medicine; 1990. Washington, DC: Senate Committee on Labor and Human Re- 37. Ginsburg JA, Prout DM. Access to health care: position sources; 1990. paper of the American College of Physicians. Ann Intern Med. 27. American Medical Association. Health Access America: 1990;112:641-661. The AMA Proposal to Improve Access to Affordable, Quality 38. Earnest MP. Access to health care in the United States: Health Care. Chicago, III. American Medical Association; 1990. barriers for neurologic patients, challenges for neurologic phy- 28. Himmelstein DU, Woolhandler S, the Writing Commit- sicians. Neurology. 1990;40:1815-1819. Access to Neurological Care for Minorities Edgar J. Kenton, MD Minority groups comprise a major segment of the esti- onance imaging of the brain for fear of brain injury. Others mated more than 34 million Americans without insurance fail to initiate or maintain medication due to cost. coverage and also the underinsured. Neurologic disease and The incidence of stroke has declined 60% over the past neurologic complications of the major causes of morbidity three decades, yet such cannot be stated at a similar rate and mortality affect minorities protracted by limited access in minorities.⁸ There has been little impact on mortality to health care. Hypertension, a major cause of stroke in the during the initial 3 days following stroke onset and only black population, is just one example of the impact of ac- a slight improvement in the 30-day mortality rate. Studies cessibility to intervention in central nervous system disease. have been reported by the National Cancer Institute, the Health statistics note the persisting gap between minority National Minority Health Association Inc, the National groups and the nation's norms for life expectancy. Aging Medical Association, and the Urban League, citing the re- America and particularly black elderly women, combined lation of limited access for health care among with the lagging infant mortality among minority groups, minorities. 10-13 Hypertension, heart disease, and athero- demonstrate limited access issues beyond economics, re- sclerosis are the major factors influencing stroke and are flecting inner city mores, cultural barriers, and communi- clearly related to access issues. Illustrating the gravity of cation delay limiting contact with the practicing neurologist. the current situation, Charles Francis, MD, Director of Awareness of such access limitations to neurological care for Medicine, Harlem Hospital, New York, NY, reported on minorities demands the attention of the practicing neurol- the crises of compliance with antihypertensive medication ogist and the neurological societies. in the inner city¹⁴ and indicated that hypertension control rates among Harlem patients have fallen from more than M any reports in recent medical and lay literature cite 80% to only 50% over the past several years. increasingly limited access to our health care system Statistics, however, suggest neurologic complications of by minority populations. The American College of Phy- the leading mortality causes affecting minorities may, in- sicians, the nation's largest medical specialty society, pub- deed, be remedial as attempts are being made by many lished a position paper in 1990 calling for a nationwide medical organizations to improve access to health care. program to improve access to health care for all Ameri- The National Center for Health Statistics revealed the av- cans.¹ They cited the growing number of Americans with- erage life expectancy in 1988 that for blacks was 69.2 years out access to health care. It is well documented that access and for whites, 75.6 years. 15 From 1984 through 1988, the to health care is dependent on one's socioeconomic level gap between life expectancies for whites and blacks in- and also that minorities comprise the majority of the lower creased from 5.6 years to 6.4 years. However, the year 1989 socioeconomic scale. 2-4 It follows that limited access to showed a distinct improvement in life expectancy for the health care affects many minority groups seeking care. Mi- population as a whole over 1988 and in blacks' life expect- norities comprise a large component of the estimated 34 ancy, despite a 32% increase in deaths from human im- to 37 million Americans under age 65 who have no health munodeficiency virus infection and an increase in homi- care insurance.⁵ Furthermore, life expectancy among cides in the United States. Death rates for cerebrovascular many minority groups has declined in recent years. Mor- diseases, heart disease, and atherosclerosis were less in tality rates among the poor and disadvantaged are higher 1989 than in 1988; heart disease, stroke, and cancer all for most causes of death as are prevalence rates of major showed a decline in mortality compared with those in the disabilities including heart disease, cancer, and stroke. 6,7 previous year. Statistics suggest neurologic complications Practicing neurologists can attest that complications of of such major mortality and morbidity issues, contributors heart disease, cancer, and stroke damage the central ner- to significant components of the nation's health care costs, vous system. Early intervention can prevent or reduce the demand our attention in removing existing barriers of ac- severity of those disorders; limited access to medical at- cess to neurological care for minorities. tention probably accentuates severity. To disadvantaged While the uninsured and the underinsured face socio- minorities, neurologic symptoms and signs as well as the economic barriers inhibiting access to neurological care, discipline itself are enigmas. They may refuse a lumbar there are other minority-based issues that restrict access. puncture for fear of paralysis or fear of spreading the mal- As discussed by the several articles in the recent JAMA ady, or equate multiple sclerosis with muscular dystrophy issue on Hispanic health in the United States, there is high or defer a computed tomographic scan or magnetic res- minority density in the inner cities where few private doc- : Accepted for publication March 11, 1991. tors and clinics are available and primary health care is From the Division of Neurology, Lankenau Hospital, Philadelphia, provided by overcrowded emergency rooms and public Pa. clinics. 16 Those initial lines of medical defense usually do Reprinted from Archives of Neurology (1991;48:480-483). not address the many subtleties of neurologic diagnoses, Care for Minorities 117 nor do they provide continuity of care often required in with hypertension probably are more susceptible than are neurologic management, for example, continuing treat- hypertensive whites to the neurologic complications of the ment of epilepsy. Generations of minorities distrust such disease. Yet, according to the JAMA articles, whites and facilities, often remembering the bad experiences of their blacks respond similarly to antihypertensive therapy, ancestors; and tradition dies hard. achieving control at about the same numbers. Yet, mi- In addition, many minority senior citizens supported by nority populations do not receive antihypertensive ther- Medicare and adequate supplementary insurance could apy to the same degree as the white population because afford a private doctor. But often they are admitted from of access-limiting costs of drugs, continuity of care, early emergency rooms to the teaching services as unassigned intervention, and education of drug effects. The implica- patients to be followed thereafter by residents in the out- tions of such limited access to antihypertensive regimens patient clinics and not as private patients. Thus, they have can be seen in such reports by Francis¹⁴ and others²⁷⁻³⁰ re- limited access to more experienced physicians, are ex- vealing deteriorated health care for minorities and con- posed to the resident rotation system, and are relegated tributing to end-stage disease. to a system usually established for the underinsured. Also, Other studies have shown that the delay from onset of how many minority patients have the resources required symptoms for stroke to arrival at the hospital³¹ was mark- to secure disability benefits for chronic neurologic impair- edly prolonged for minorities compared with predomi- ment from a complex, uncaring, and bureaucratic social nantly white populations. 13 The same is true for the latency services system? They often need legal assistance. Many period from arrival at the hospital to neurologic consul- minority stroke patients with diagnosis related group-lim- tation for minorities, if such consultation is obtained at all. ited hospital stay would rather return to the supportive The "graying" of America is one of the most significant familiarity of the home and family, but cannot because of demographic barriers to neurologic care access. Current working spouses or children. Indeed, many minority in- national population projections indicate that the number dividuals with primary neurologic illness such as transient in all age categories of 60 years will be considerably larger ischemic attacks, "mini strokes," multiple sclerosis, dis- at the end of this century and will continue to grow for the abling peripheral neuropathies, and spondylitic spastic first three decades of the 21st century. The black elderly paraparesis never see a neurologist, preferring the con- are the most economically disadvantaged of any of the tinuity of the family physician over the impersonal public minority groups. The black elderly are more likely to be clinic or hospital. sick and disabled with higher rates of hypertension, cere- To limit access discussions to economic issues and in- brovascular disease, cardiogenic stroke, spondylitic para- surance coverage, therefore, avoids historically inculcated paresis, peripheral polyneuropathy, and dementia. Eld- and culturally ingrained ingredients that impair utilization erly black women are revealed by studies to be the most of neurologic services. Minorities, regardless of econom- apt to be living alone, relying on increasingly shrinking ics, because of their limited contact with physicians of their access to and availability of our nation's home health care own background and because of the low rate of preventive providers. 32 physical examinations, such as recommended by the US Recognizing these factors of minority-based health care Preventive Services Task Force, continue to lag behind the that contribute to neurologic complications, what is the nation's norms in access to all health care, including neu- role of the neurologist in easing access to neurological rologic care. 17 To the extent that acculturation succeeds care? Minorities experience complex health disadvantages through education, job opportunities, social and commu- related to poverty, disinformation, and racial bias, limiting nity action programs, and physician participation will ac- access to quality health care. However, neurologists first cess to health care proceed. and foremost must be aware of these issues. If we wish The Medicare/Medicaid programs, created in the mid- to implement the plan proposed by the National Advisory 1960s, produced significant improvement in the health Neurological Disorders and Stroke Council of the National status of minorities. However, those same populations Institute of Neurologic Diseases and Stroke for the "de- continue to lag behind the white population not only in cade of the brain," the issues of access to health care be- infant mortality but also in life expectancy of its senior come fundamental for enabling such efforts. 33 Louis Sul- citizens affected by stroke, Parkinson's disease, and de- livan, MD, Secretary of Health and Human Services, mentia. 18,19 JAMA, in its issue focusing on minority health, stated that what we do now in areas of prevention will pay highlighted a 1986 survey on the utilization of health ser- off well into the 21st century and that our health, its main- vices. That survey demonstrated significant lack of access tenance, and prevention of disease have become a high to health care among black compared with white Amer- priority in the black community.34 icans experienced at all socioeconomic levels. Also, blacks Matthew Menken, in his editorial in the November issue compared with whites were less likely to be satisfied with of the ARCHIVES, concerning the practice of neurology, com- the quality of physician care and hospital care, and they mented that "As an educational tool the anecdotal method were more likely to believe length of stay too short. 20-22 assumes that the practicing physician who is roughly right Hypertension, a leading cause of stroke in minorities, is preferable to one who is precisely wrong. "35 The wealth seriously impacts on neurologic care. Numerous of anecdotal experience of practicing neurologists in both studies²³⁻²⁵ reveal that approximately 28% of adult blacks the public and private sectors who deal with minority suffer from hypertension compared with about 17% of health care indicates that access to neurological care is an adult whites and that blacks develop hypertension at a important health care issue. Minority patients with stroke, younger age than do whites. Advanced hypertension is epilepsy, cerebral palsy, dementia, developmental dis- five times more common in blacks. Stroke mortality in ability, head trauma, and neurological complications of blacks is 65% higher than that in whites. Black persons acquired immunodeficiency syndrome need neurological 118 Caring for the Uninsured and Underinsured consultations and may need computed tomographic scans demographics of the population into the 1990s and the 21st or magnetic resonance imaging and then continuing, long- century requires neuro-epidemiologic studies of our shift- term management. The personal experience of the author ing black, Hispanic, Asian-American, and Native Amer- and other neurologists³⁶ indicates that minorities have dif- ican populations. One can extrapolate from the Kurtzke⁴¹ ficulty obtaining neurologic care. Precise data on the ex- data on the neurologic burden of illness and injury in the tent of the problem for neurological patients are not avail- United States an estimate of individuals with neurologic able. However, the national problem for minority patients disorders among the approximated millions of uninsured overall is well documented and the problem demands cor- and underinsured Americans. 36 However, the paucity of rective action. Our specialty organizations must mobilize minority risk factor data for stroke can be seen in the oth- the support and the participation of neurologists in prac- erwise comprehensive special report of the World Health tice to address the chief complaints of the minority com- Organization task force on stroke and other cerebrovas- munity in their quest for access, ie, how to obtain quality cular disorders published in 1989.4 Two studies sup- neurologic care. The symptoms and signs of access malady ported by the National Institute of Neurologic Diseases must be addressed, ie, problems that minority groups and Stroke are presently addressing the disparity of stroke have communicating with providers of neurologic care, incidence and mortality between black and white Amer- plus limited education especially about health, impeding icans. 43 Studies such as these at Columbia University and disease detection and prevention, and culturally based the University of Maryland are examples of the need to lack of motivation to seek help. Many community re- pursue minority neurologic demographics. A poster pre- sources should be utilized to help solve the problem in- sentation on race and incidence of hemorrhagic stroke pre- cluding minority churches, social organizations, and po- sented at the stroke meetings in San Francisco is encour- litical groups. Practicing neurologists and our specialty aging in this regard.⁴⁴ societies can develop studies such as conducted by the Finally, the behavior of many office-based neurologists Robert Wood Johnson Foundation⁵ and the Massachusetts toward Medicaid patients, Medicare assignment, and the Institute of Technology, Cambridge, Mass, and can stim- many mettlesome problems associated with caring for ulate activities by private foundations in their commu- such patients need to be addressed. Bureaucratic enforced nity. 38,39 The American Academy of Neurology has estab- payment fees and burdensome accompanying paperwork lished a task force on access to neurologic care. 35 We, as are relegating such patients to second-class or lower strata neurologists, must heed the call of the minority commu- in access to high-level health care. The ever-increasing nity and provide the availability of neurologic care. overhead of the neurologist in office practice limits the Blacks constitute 12% of the population, 4% of doctors entrance of such patients into such quality care assumed under age 40, and only 2.5% of neurology residents in the by the private-pay patients. Indeed, such rationing of 1980s. 40 What can and should the neurologic societies do about such disturbing numbers? Programs should be de- health care inherent in any second-party- and third- party-subsidized delivery system since its inception, is veloped in coordination with the task force on access to now deeply embedded in various proposals to curtail ris- neurological care, educating its members in such issues. Programs can be provided addressing neurological prob- ing health care costs further challenging the economics lems of minorities for presentation to the minority com- and ethics of the office- and hospital-based neurologist. munities in detection and early intervention strategies. Hence, the neurologist must join the minority community High school student programs in minority communities and its leaders in providing incentives to ease such pa- dealing with neurological issues can be highly effective in tients in the quality delivery of health care. If various tax recruiting medical school applicants. Neurological societ- and business incentives, long established for businesses ies can also encourage minority medical student appli- and corporations, can be directed toward such access bar- cants for currently available student training grants in neu- riers created by Medicaid and Medicare assignments, the rological research. What can individual neurologists do in neurologist will be aided in behavior modification toward addition to becoming more aware of this enormously com- such patients. The skills of the neurologists can be bartered plex issue? In addition to participation in such proposed for items of need to exercise such skills just as small busi- programs and encouraging such by the various neurolog- nesses are taking such an approach in such recessionary ical societies, the neurologist must pursue legislation at the times. The time has come for the community and the federal, state, and local levels addressing these issues. health care provider to establish innovative financing They must educate their colleagues, students, residents, strategies to maintain its citizens at the first-class attitudes and patients in limiting unessential studies and hospital- of both the provider and the recipient. izations, becoming allies of third-party payers. They must As Secretary Louis Sullivan, MD, indicated in his key- establish and participate in medical ethics committees for note address to a satellite meeting of the 1991 International hospital staffs, guiding the appropriate health care and Conference on Stroke, the costs of stroke is a $25 billion peer review of death and dying for the terminally neu- health problem and stroke is a discriminating disease dis- rologic patient. proportionately affecting women and blacks. Secretary As neurologists we must study the demographics for Sullivan highlighted access to medical care, contingent on minority neurology in the United States. Such demo- personal responsibility for disease prevention, contain- graphics have yet to be established. While various studies ment of health care costs, a public health system for the of specific neurologic disorders accumulated in the liter- poor, a reexamination of the private insurance system, and ature might note the incidence and prevalence of a par- providing outcome studies of effectiveness of treatment ticular disease in a minority group, usually stated as non- strategies. 45 In all such areas, the neurologist and neuro- white, few indicate specific minority ratios. The changing logical societies need participate. Care for Minorities 119 References cerebrovascular disease: a review. Stroke. 1986;17:648-655. 1. American College of Physicians Position Paper. Access to 24. Berkson DM, Brown MC, Stanton H. Changing trends in health care. Ann Intern Med. 1990;112:641-661. hypertension detection and control: the Chicago experience. 2. Kleinman JC, Gold M, Makuc D. Use of ambulatory medical Am / Public Health. 1980;70:389-393. care by the poor: another look at equity. Med Care. 25. 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Guide to Clinical Pre- Washington, DC: Dept of Health and Human Services; 1990. ventive Services. Baltimore, Md: Williams & Wilkins; 1989. 41. Kurtzke JF. The current neurologic burden of illness and 18. Health of America's Children. Washington, DC: Chil- injury in the United States. Neurology. 1982;32:1207-1214. dren's Defense Fund; 1989. 42. World Health Organization. Report of the WHO Task 19. Edelman, M. Black children in America. In: The State of Force on Stroke and Other Cerebral Vascular Disorders: Black America. Washington, DC: Urban League; 1989:63-76. Stroke-1989. Geneva, Switzerland: World Health Organiza- 20. Blendon RJ, Aiken LH, Freeman HE, Corey CR. Access to tion; 1989. medical care for black and white Americans: a matter of con- 43. Stroke 1990 Research Program NINDS. Bethesda, Md: tinuing concern. JAMA. 1989;261:278-281. Dept of Health and Human Services 1990. 21. Freeman HE, Blendon RJ, Aiken LH, et al. Americans re- 44. Broderick JP, Brott TG, Miller R, Huster G. Race and in- port their access to care. Health Aff (Millwood). 1987;6:6-18. cidence of hemorrhagic stroke. Stroke. 1991;22:126. Abstract. 22. Report of the Secretary's Task Force on Black and Minority 45. Sullivan L. Socio-economic impact and racial consider- Health. Bethesda, Md: Dept of Health and Human Services, ations. Presented at the Satellite Meeting of the Sixteenth In- August 1985. ternational Conference on Stroke; February 21, 1991; San Fran- 23. Caplan LR, Gorelick PB, Hier DB. Race, sex, and occlusive cisco, Calif. Freeze the Ocean Robert J. Joynt, MD, PhD T he Journal of the American Medical Association and its fam- tent are parts of the complaint. The transplantability of the ily of specialty journals are addressing the issue of system is also questioned, often along culture lines. A Ca- access to medical care. Matthew Menken presents a nadian health official pointed out that Americans were thoughtful look at this problem in a special article in this paranoid about their government in that they did not trust issue.¹ One of the major priorities in most industrialized it; on the other hand, the Canadians are schizophrenic in nations is the provision of universal access to high-quality that they had a greater trust in government but felt the medical care at low cost. There have been varying degrees government went about it all wrong. However, there are of success and many failures, and an ideal program has many excellent features of their system such as global bud- not been found. Certainly, the system in the United States geting of hospitals and greater control of placement of ex- has failed as there are millions of citizens who are under- pensive technology. insured or poorly insured. Basic desiderata just mentioned The British National Health System, again with univer- fall apart when other elements are deemed important, as sal access, has a fundamental difference from the Cana- instant and convenient access to care, free choice, unra- dian system. The National Health System became both tioned care, finest technology, and adequate reimburse- payer and provider by nationalizing the hospitals and em- ment for the providers (hospitals, physicians, nurses). ploying the physicians. The system has evolved and has There is then a trade-off, and, unfortunately in this coun- been modified since its inception in 1948. During the try, it is universal access. Also, as Menken points out, the Thatcher years it came under increasing scrutiny, and in care even when available may not serve the patient's 1989 a government White Paper recommended major re- needs. forms.6 Many of the proposed reforms had the govern- The medical care in the United States when at its best ment lessening its control over hospitals and practitioners. is likely unparalleled anywhere in the world. Certainly, it What will evolve from this is yet to be seen, but major is the most expensive by far. But consistently, in surveys concerns about restriction in services have already arisen. done in industrialized countries of the world, we are the No system seems to have the perfect solution as Men- least satisfied with our health care system.2 The dissatis- ken, quoting Mencken, suggests in his special article.¹ It faction does not arise from the quality of care but from the is likely that we all know what is needed and desirable. fear that we may not have the insurance or sufficient in- We can land a man on the moon and put a bomb down surance when it is required. A fear that is not shared with a chimney from 10 000 feet, but these projects pale when citizens of other countries surveyed. we deal with the multifarious and diverse elements of the The Canadian system of health care has the highest sat- health care system. We are in the situation of the admiral isfaction rating by its own citizens. It is also the system who was asked what to do about the U-boat threat. He most admired by United States citizens. Even in Britain, replied immediately, "Freeze the ocean. Those on the top which has the lowest cost per capita for health care, the can't go down. and those on the bottom can't come up." satisfaction rate is higher than in this country. When asked how this would be accomplished, he replied, At this time when we are critically evaluating our own "I just set the policy, you work out the details." It is the system with the possibility of more government involve- details that will be difficult. ment, both the Canadian and British systems are showing References major stresses. The Canadian government through the 1. Menken M. Caring for the underserved: health insurance provinces is the single payer. The Canadian system saves coverage is not enough. Arch Neurol. 1991;48:472-473. a significant portion on administrative costs and global 2. Blendon RJ, Leitman R, Morrison I, Donelan K. Satisfaction hospital budgeting.³ Payment to individual physicians is with health systems in ten nations. Health Affairs. Summer less, but disparity in income is not great as overheads due 1990;185-192. tobilling costs and malpractice insurance are considerably 3. Evans RG, Lomas 1, Barer ML, Labelle RJ, et al. Controlling less.⁴ Our idyllic view of the health system north of the health expenditures: the Canadian reality. N Engl J Med. border is now being questioned as more and more stresses 1989;9:571-577. appear in the Canadian system.⁵ Long waits for services, 4. Fuchs VR, Hahn JS. How does Canada do it? A comparison inconvenient services, inadequate access to technology, of expenditures for physicians' services in the United States and Canada. N Engl J Med. 1990;323:884-890. lack of innovative delivery systems, and provider discon- 5. Iglehart JK. Canada's health care system faces its problems. Accepted for publication January 30, 1991. N Engl J Med. 1990;322:562-568. From the University of Rochester (NY) School of Medicine and 6. Lister J. Reform of the British National Health Services. Dentistry. From White Paper to Bill in Parliament. N Engl J Med. Reprinted from Archives of Neurology (1991;48:471). 1990;322:410-412. Poverty and Psychiatric Status Longitudinal Evidence From the New Haven Epidemiologic Catchment Area Study Martha Livingston Bruce, PhD, MPH; David T. Takeuchi, PhD; Philip J. Leaf, PhD We assessed the effect of poverty on psychiatric status Only recently have researchers been able to specify the using two waves of New Haven (Conn) Epidemiologic Catch- cross-sectional relationships between socioeconomic sta- ment Area data. Poverty was defined using federal poverty tus and specific psychiatric disorders.⁶ In the past, guidelines; psychiatric status was assessed by the Diagnostic community-based studies generally measured symptoms Interview Schedule (DIS). When examining the course of within the domain of a specific psychiatric disorder (in healthy respondents at the first interview, respondents in particular, depression¹⁴), aggregated measures of any psy- poverty had a twofold-increased risk (controlling for demo- chopathologic conditions, or assessed the more general graphic factors) for an episode of at least one DIS/DSM-III state of psychological distress or discomfort. 15 Consider- Axis I psychiatric disorder. Rates of most specific psychiatric able variation exists in the epidemiologic variables and disorders were comparably higher for respondents meeting clinical manifestations of the different psychiatric disor- poverty criteria compared with those not in poverty, al- ders defined by DSM-III, 16 suggesting that the relationship though these differences were not always statistically sig- between poverty and any single measure should not be nificant. The effects of poverty did not differ by sex, age, generalized across a range of psychiatric disorders. More- race, or history of psychiatric episodes. over, because the prevalences of the specific disorders vary widely and there is a great deal of comorbidity among P overty, a persistent problem in the United States, is disorders, findings based on aggregate measures may well associated with a range of economic and social prob- be weighted by the effects of the more prevalent disorders. lems. 1,2 A well-documented correlate is the greater prev- This study differs from other research on socioeconomic alence of mental health problems among lower socioeco- status and mental health by using federal guidelines to nomic groups. 3-11 Despite the large number of classify individuals as poor. Use of federally defined investigators and the consistency of their overall findings, guidelines of poverty gives us the opportunity to examine questions remain about the nature of this association: the effects of socioeconomic status on mental health (1) To what extent does poverty increase the risk of psy- among a group already categorized as poor by government chiatric episodes in healthy people? (2) How do the effects officials and already eligible for specific health and social of poverty compare across a variety of psychiatric diag- service entitlement programs. noses? This study addresses these questions using lon- gitudinal data from the New Haven (Conn) Epidemiologic SUBJECTS AND METHODS Catchment Area (ECA) project to examine the risk of new Data (first or recurring) episodes of psychiatric disorders, as as- Data for these analyses were collected as part of the first sessed by the Diagnostic Interview Schedule (DIS), 12,13 in two waves of the New Haven ECA program. The ECA groups defined by poverty status according to federal pov- program is a collaborative multiwave study of the prev- erty guidelines. alence and incidence of major psychiatric disorders and Most prior studies of the relationships between socio- the use of health and mental health services across five US economic status and psychiatric disorders have employed sites. 17 These analyses are confined to the New Haven data cross-sectional data and are inappropriate for estimating to take advantage of information on household compo- the magnitude of poverty's effects on the onset or recur- sition unavailable at the other sites and to emphasize the rence of psychiatric episodes. In contrast, the current distribution of poverty and psychiatric problems in a de- study uses longitudinal data to examine (1) whether per- fined geographic area. sons not experiencing a recent psychiatric episode are at Beginning in July 1980, New Haven ECA interviews greater risk for a future psychiatric episode if living in pov- were obtained from a multistage probability sample of erty, and (2) the prospective effect of poverty on mental 5034 adults aged 18 years and older living in a 13-town status while controlling for respondents' reports about region of the greater New Haven community. The meth- prior psychiatric episodes. ods used in the ECA project have been described in greater detail elsewhere. 17,18 The initial interview had an overall Accepted for publication May 31, 1990. response rate of 77%. Approximately 6 months following From the Department of Epidemiology and Public Health, Yale the first interview, 81% (4068) of the original sample were University School of Medicine, New Haven, Conn (Drs Bruce and Leaf); and the National Research Center for Asian-American Mental reinterviewed. Individuals who did not complete the sec- Health, UCLA (Dr Takeuchi). Dr Leaf is now with the Department ond interview did not differ from those included in these of Mental Hygiene, The Johns Hopkins University, Baltimore, Md. analyses by sex, age, race, or psychiatric status; they were, Reprinted from Archives of General Psychiatry (1991;48:470-474). however, more likely to be missing income information at 122 Caring for the Uninsured and Underinsured the first interview or to report incomes less than $5000 per Table -Distribution of Poverty in Greater New Haven year. Among those without income information and Community* among low-income respondents, completion of the sec- ond interview did not differ by psychiatric status. Sample Size The number of respondents used in the current analyses In Poverty, was further reduced from 4068 to 3497 for two reasons. No. % % of Total First, we considered only black and non-Hispanic white Total 3495 100.0 7.9 respondents in the ECA (n=3958). By restricting the anal- Demographic variables yses to these two groups, we maintained sufficient num- Sex bers to differentiate the effects of poverty from race on Male 1486 47.6 5.0 mental health. An additional 462 respondents were elim- Female 2009 52.4 10.6 inated from the analyses because they did not report in- Age, y formation on their 1980 household income. Individuals 18-44 1242 55.3 7.7 excluded from the analysis for lack of income information 45-64 607 30.9 6.1 did not differ from those included by race, current psy- 65+ 1646 13.8 13.2 chiatric status, or welfare status; they were, however, more likely to be female and older than 45 years. Race White 3154 89.0 5.2 Measures Black 341 11.0 30.3 Poverty status at the first interview was determined by Psychiatric status comparing each respondent's reported total 1980 house- No recent DIS Axis I hold income and household composition with the 1980 disorder 3064 85.2 7.1 poverty guidelines. 19 The US poverty standard identifies Any recent DIS Axis I families with inadequate economic resources to meet the disorder 431 14.9 12.8 daily demands of living. The poverty index uses a series *DIS indicates Diagnostic Interview Schedule. Data are from New of income thresholds set in relation to need, determined Haven (Conn) Epidemiologic Catchment Area. Sample numbers are by family size, number of children, and age of house- unweighted. Percentages are weighted to the local population, not the holder. 20 These income thresholds are updated each year total sample number. to correct for inflation. Total 1980 income (ie, when first interviewed) was assessed retrospectively at the second of any of the disorders refers to meeting criteria (as defined interview by asking respondents their "household's total above) for at least one of the psychiatric disorders at the income before taxes for the past year (1980), including sal- second interview. To examine the effect of poverty at the aries, wages, Social Security, welfare and any other in- first interview on subsequent psychiatric episodes among come." Retrospective reporting allows for assessment of healthy people, individuals who met criteria for a psy- the total year's income (eg, from income tax forms) rather chiatric disorder within 6 months of their first interview than asking for income at the first interview during the were omitted from the analysis of each respective disor- middle of that year. In contrast to the poverty guidelines, der. Among the remaining respondents, history was which are exact to the dollar level, the ECA respondents coded as having reported an episode of the respective dis- were asked their income at the nearest $1000 level (income order at any point in one's lifetime before the 6-month levels substantially above poverty levels were rounded at period before the first interview. In the analysis of the ag- larger increments); individuals were classified "in pov- gregate disorder variable, anyone reporting an episode of erty" if their household income was below the poverty any of the eight DIS disorders within 6 months of the first guidelines level for their age and number in household, interview was omitted from the analysis; history refers to rounded up to the nearest $1000. past episodes of any of the disorders assessed. Psychiatric status was assessed by the DIS, a semistruc- tured interview administered by lay interviewers. 12,13 The Analysis DIS assesses the presence, duration, and severity of symp- We first examined rates of each outcome variable strat- toms and excludes symptoms due to physical illness or ified by poverty status. Next, multivariate logistic regres- medication use. Computer algorithms use the data from sion compared the risk of an episode between interviews the DIS to generate psychiatric diagnoses consistent with for those in poverty with the risk for those not in poverty, the DSM-III.¹⁶ These analyses examine eight Axis I psy- controlling for demographic factors and psychiatric his- chiatric disorders or disorder groups assessed by the DIS tory. Demographic factors included sex, age (18 to 65 years and using DSM-III criteria without exclusions: alcohol vs 65 years and older), and race (white or black). The age abuse or dependence, bipolar disorder or mania, drug categories were determined based on preliminary analy- abuse or dependence, major depressive disorder, ses. In the multivariate analyses, two-way interactions obsessive-compulsive disorder, panic disorder, phobia, were tested between poverty and each demographic vari- and schizophrenic disorders (ie, schizophrenia or schizo- able and with psychiatric history only on the effects of the phreniform). most prevalent outcomes (ie, major depression, alcohol Our outcome measures of the eight DIS/DSM-III psy- abuse, phobia, and the aggregate measure of psychiatric chiatric disorder groups refer to meeting criteria for the status). Population-attributable risk percent (PAR%) was DIS/DSM-III disorder at some point in the respondent's calculated using the adjusted odds ratio (OR) as an esti- lifetime as well as reporting DIS symptoms for that dis- mate of relative risk (RR) and disorder-specific estimate of order in the period between the first and second inter- poverty in each at-risk group (p) in the following formula: views (approximately 6 months). An aggregate measure PAR% =p(RR-1)/[1+p(RR- 1)]. Poverty and Psychiatric Status 123 Table 2. Effects of Poverty on 6-Month Rate of Specific DIS/DSM-III Disorders or Disorder Groups* Cases Adjusted OR At Risk All Poor Not Poor A B C PAR% Any DIS Axis I disorder No. 3064 246 35 211 Estimate, % 9.4 15.2 9.0 1.82+ 1.92+ 6.0 SE/95% CI 0.7 3.1 0.7 1.14-2.54 1.12-3.28 Alcohol abuse/dependence No. 3389 66 9 57 ... Estimate, % 3.0 5.7 2.8 2.10 2.25 2.41 9.7 SE/95% CI 0.5 2.5 0.5 0.82-5.42 0.98-5.16 0.99-5.89 Bipolar/mania No. 3465 26 5 21 ... Estimate, %, 1.0 1.9 0.9 2.15 2.13 2.73 11.3 SE/95% CI 0.2 1.0 0.2 0.61-7.54 0.41-11.07 0.55-13.52 Drug abuse/dependence No. 3461 14 2 12 Estimate, % 0.7 1.0 0.6 1.52 2.82 3.27 14.5 SE/95% CI 0.2 0.7 0.2 0.31-7.40 0.70-11.30 0.77-18.16 Major depression No. 3404 133 24 109 Estimate, % 4.3 7.9 4.0 2.06+ 2.29+ 2.51# 10.4 SE/95% CI 0.5 0.2 0.4 1.05-4.04 1.19-4.43 1.32-4.78 Obsessive-compulsive No. 3382 22 5 17 Estimate, % 0.8 2.0 0.7 2.83 3.70 4.39 20.1 SE/95% CI 0.2 1.0 0.2 0.86-9.34 0.70-19.48 0.87-22.15 Panic disorder No. 3402 12 1 11 Estimate, % 0.3 0.4 0.3 1.27 1.17 1.23 1.7 SE/95% CI 0.1 0.4 0.1 0.17-9.50 0.09-15.81 0.09-17.53 Phobia : No. 3232 102 19 83 Estimate, % 3.1 4.4 3.0 1.49 1.77 1.98t 6.7 SE/95% CI 0.04 1.3 0.4 0.82-2.73 0.97-3.22 1.07-3.65 Schizophrenia No. 3467 4 3 1 Estimate, % 0.1 1.5 <0.1 79.84$ SE/95% CI 0.1 0.9 <0.1 7.79-818.4 *DIS indicates Diagnostic Interview Schedule; OR, odds ratio; PAR%, population-attributable risk percent (proportion of new episodes in the at- risk population resulting from poverty); and CI, confidence interval. Sample numbers are unweighted; estimates are weighted. Under adjusted OR, column A includes unadjusted OR; column B, OR adjusted for age, sex, race, and history of outcome diagnosis; and column C, OR comparing specific psychiatric disorder with disorder-free (DIS Axis I) respondents, adjusted for age, sex, race, and history of outcome diagnosis. tP<.05. #P<.01. $P<.001. The data were weighted in all these analyses to com- RESULTS pensate for household size and nonresponse and to reflect As noted in the "Subjects and Methods" section, the more accurately the age, sex, and race of the greater New subsamples used in these analyses omitted respondents Haven community. 21,22 The complex sampling design and who at the first interview met criteria for specific DIS/DSM- weighting strategy were considered in estimating SEs and III disorders and reported symptoms within the previous conducting statistical tests by using Taylor Series Linear- 6 months (ie, recent cases). Before any respondents were ization with the RTILOGIT program. 23 When used with omitted from the sample (n = 3495), the poverty rate for the complex survey data, Taylor Series Linearization generally greater New Haven community was estimated as 7.9%, yields more conservative estimates of statistical signifi- comparable with the published poverty rate of 8% for the cance than do procedures that assume simple random State of Connecticut in 1979.2⁶ sampling.24,25 The demographic characteristics of respondents and 124 Caring for the Uninsured and Underinsured Adjusting the ORs to account for demographic factors Table 3. -Percentage of New Cases Meeting Criteria for and reported history of each disorder (column B) generally Any Subclinical Symptoms (SCS) at First Interview* increased or minimally affected the observed relationship Poor Nonpoor with poverty. The effects of poverty on alcohol abuse or dependence approached statistical significance Total Total 2.25; 95% confidence interval, 0.98 to 5.16), and the Cases % SCS Cases % SCS effects on major depression remained significant. Alcohol abuse/dependence 9 0.0 57 17.5 In the discussion above, the outcome measures compare Bipolar/mania 5 20.0 21 28.6 individuals with a specific psychiatric disorder with the Drug abuse/dependence 2 50.0 12 16.7 rest of the community, ie, with individuals who were ei- ther disorder free or who reported a different type of psy- Major depression 24 12.5 109 11.0 chiatric disorder. This approach is comparable with many Panic 1 0.0 11 18.2 epidemiologic reports in the psychiatric literature and is, Schizophrenia 3 0.0 1 0.0 therefore, useful for comparative purposes. But because *Data are unweighted; SCS for each disorder defined in text. our findings indicate that poverty increases the risk of a variety of psychiatric disorders, our inclusion of disor- corresponding poverty rates are displayed in Table 1. Con- dered individuals into our comparison groups is likely to sistent with state and national trends, 19 poverty was not provide conservative estimates of the effects of poverty equally distributed across demographic groups. Women, status on psychiatric illness. Column C of Table 2 presents the elderly, and blacks had high rates of poverty; blacks the effects of poverty status on each disorder compared in the New Haven ECA are almost six times more likely with meeting criteria for none of the other DIS/DSM-III to be in poverty than whites. Psychiatric status at the first disorders assessed; the ORs adjust for age, race, and sex interview was differentially distributed by poverty status, as well as history of the disorder. As expected, the ORs with 12.8% of all recent cases falling within the poverty increase. The table shows that poverty increased the OR status, compared with 7.1% of noncases (P<.01). for each disorder to approximately 2.0 or more, with the Table 2 presents results from weighted logistic regres- exception of panic disorder (OR=1.23, not significant). sion models predicting the effects of poverty on each of The effect of poverty on major depression and phobia was the specific DIS/DSM-III disorders and on the aggregate statistically significant; the OR for alcohol was marginally measure of psychiatric status. The table presents the significant. between-interview rates of each disorder for individuals We questioned whether these observed effects of pov- in the poverty and nonpoverty groups (among those who erty status on subsequent psychiatric episodes were con- did not report an episode of the relevant disorder during sistent for subgroups as defined by sex, age, race, or psy- the 6 months before the first interview). For each disorder, chiatric history. It was statistically feasible to test for such the risk of each episode by poverty status was compared interactions only on the more prevalent disorders (ie, using ORs; column A gives un-adjusted ORs, and column >2.0%): alcohol abuse or dependence, major depression, B adjusts the odds for demographic factors (age, sex, and phobia, and the aggregate measure. We observed no sta- race) as well as history of the disorder. tistically significant interaction between poverty and any Among individuals who did not meet criteria for any of of the demographic factors with any of the four outcomes. the eight DIS/DSM-III Axis I disorders at the first inter- A statistical interaction between history and poverty view, 9.4% reported at least one of the disorders at the proved significant only for phobia (P<.001). In this case, second interview. Respondents who met poverty status the effect of poverty in the group reporting prior episodes guidelines at the first interview were 1.82 times more likely of phobia was greater than twice that observed in the than the nonpoor (P<.05) to meet criteria subsequently for group without a history. a |new DIS episode (column A). Adults in poverty were The impact of poverty on rates of new episodes of each 1.92 times more likely than the nonpoor (P<.05) to report psychiatric disorder is estimated in the final column of a new episode of at least one of the psychiatric disorders, Table 2 using the PAR%. For the aggregate measure of controlling for demographic factors and history of a dis- disorder, 6% of all new cases occurring in the 6-month order (column B). period to the at-risk population were a consequence of With the exception of schizophrenia, the unadjusted OR poverty in the population. Among the other disorders in for the effect of poverty on the specific disorders ranged which the effect of poverty approached significance, ap- from 1.27 for panic disorder to 2.83 for obsessive- proximately 10% of new episodes of major depression, compulsive disorder (column A). Two of the relationships 10% of alcohol abuse, and 7% of phobia in the respective reached statistical significance: major depressive disorder at-risk populations could be attributed to the effects of = 2.06, P<.05) and schizophrenia (OR=79.84, poverty. These figures indicate, for example, that during P<.001). Although statistically significant, the number of the 6-month interview period, more than 1200 new epi- new schizophrenia cases (four) was so low that the esti- sodes of major depression in the greater New Haven adult mate of risk was viewed as preliminary and adjusted ORs population were a result of poverty. were not estimated. Several of the other ORs, while not Although persons who reported a recent psychiatric ep- significant, exceeded 2.0, suggesting that low prevalences isode at the first interview were excluded from each anal- may have decreased the power of our observations: al- ysis, it may still be possible that the poor included in the cohol abuse (OR=2.10), bipolar disorder or mania analysis were initially in worse mental health. We exam- (OR=2.15), and obsessive-compulsive disorder ined this question by comparing by poverty status the pro- (OR=2.83). portions of new cases who reported recent subclinical Poverty and Psychiatric Status 125 symptoms at the first interview (Table 3). Subclinical con- support for the social causation hypothesis in the relation- ditions were defined as meeting criteria for at least one ship between socioeconomic status and mental illness. relevant DSM-III symptom group (bipolar and major de- Particularly important in this context is that poverty guide- pressive disorders) or DSM-III criteria (drug and alcohol lines indicate more than personal income of an individual abuse, panic, and schizophrenia) for the respective dis- but also environmental and economic conditions for an order within 6 months of the first interview. Subclinical entire household. A next step for future research is to in- conditions were not determined for phobia or obsessive- vestigate the aspects of poverty that affect psychiatric sta- compulsive disorder because a single symptom in the DIS tus. As noted recently by Dohrenwend,25 an important is sufficient to meet diagnostic criteria. goal of such research is to understand the linkages be- In general, most new psychiatric episodes did not occur tween the social phenomenon of poverty and individual to individuals reporting symptoms at the first interview. experiences. Studies of individual processes are needed, With the exception of drug abuse, where the single sub- for example, to determine the extent to which poverty in- clinical case represents half the new cases, 20% or less of creases the risk of mental disorders by increased exposure the new cases in the poverty group reported subclinical to negative events¹⁴,³ and whether the risk is greatest dur- symptoms at the first interview. These figures are com- ing the transition into poverty. Family studies³¹ are needed parable with, if not lower than, the nonpoor group, where to determine whether our results are a by-product of gen- 28.6% or less of the new cases reported subclinical symp- erational drift of vulnerable families into poverty. toms at the first interview. Although these analyses indicate that poverty affects COMMENT the risk of a variety of psychiatric disorders, these findings Longitudinal analyses of the New Haven ECA data in- might also be interpreted in light of the poor validity be- dicate that individuals who meet poverty status guidelines tween the DIS and clinicians' diagnoses for many specific are at increased risk for new episodes of psychiatric illness. disorders and the relatively higher agreement for aggre- Furthermore, the effects of poverty on psychiatric status gate psychopathologic condition. 32,33 It is possible that are generally nonspecific; the poor are at increased risk for many of the DIS symptoms reported by the poor are in- each of the specific disorders assessed except panic dis- dicative of a single syndrome related to the stress of living order, although not all of these relationships reach sta- in an impoverished environment. For example, the repet- tistical significance. Nevertheless, the direction of effects itive behavior of persons diagnosed by the DIS with is comparable, and the estimates reach a minimal mag- obsessive-compulsive disorder, a disorder with particu- nitude. These increased risks remain even when control- larly poor validity, may reflect an attempt to remain safe ling for history of episodes. in a dangerous neighborhood. Investigation into the na- The effects of poverty on mental health are equally se- ture of psychiatric problems for poor individuals assessed vere for the young and old, men and women, and blacks by the DIS as cases would further our understanding of and whites. Our analyses of the aggregate measure of psy- psychiatric nosology and processes. chiatric status and alcohol abuse, major depression, and These analyses have addressed only one side of the phobia revealed no statistical interactions between pov- question in the socioeconomic status-mental illness co- erty status and age, sex, or race. Although the effects of nundrum. The effects of psychopathologic condition on poverty on mental health are comparable across sub- socioeconomic status continue to merit further investiga- groups of the population, the risk is far from equitable. tion. Such an analysis is beyond the scope of this study, Poverty is more prevalent among women than men, the in part because our poverty measure may be inappropriate old than the young, and blacks than whites. These anal- for this kind of investigation. Poverty status is a household yses indicate that beyond the economic hardships, pov- measure, affected by earnings of all family members and erty also puts these groups at increased risk for mental or by household composition. The effects of psychiatric prob- emotional problems. lems on an individual's socioeconomic status are better Since lifetime diagnoses using the DIS have been the assessed by using individual indicators such as personal subject of criticism, 27,28 we have not presented the effects income, educational attainment, job loss, or marital of poverty status on first incidence of psychiatric disor- change.34 These might change, yet poverty status could ders. We are confident that by omitting individuals who remain unaffected if the individual remains or becomes report recent episodes at the first interview, we were ex- financially supported by other household members. amining the effects of poverty on a group of individuals This study demonstrates that individuals with incomes who at the time they reported poverty status were also below the federal poverty level are at increased risk for a reasonably healthy. Because of evidence of some under- number of psychiatric disorders. Since 1980, the percent- reporting of past episodes,²⁸ however, the effects of pov- age of adults living in poverty has not changed signifi- erty on new episodes of each of the disorders while con- cantly. 35 What has changed is the availability of state- trolling for history may be exaggerated. We did omit all financed mental health services for the poor. In an effort persons with any reported lifetime history of each respec- to conserve scarce resources, states have targeted mental tive disorder; the estimated ORs for the effect of poverty health services to individuals with severe and prolonged on each disorder except phobia are comparable with those psychiatric illness at risk for hospitalization. While ad- reported in Table 2. The reduced effect of poverty on pho- dressing an important public health need, this policy has bia is consistent with the interaction between poverty and also resulted in the de facto dismantling of many of the history of phobic episodes reported earlier. mental health services previously available to low-income This study takes advantage of advances in psychiatric individuals. Our findings indicate that poor populations epidemiologic case identification and of a precisely de- would benefit from access to a full range of mental health fined indicator of socioeconomic status to generate further prevention, early intervention, and treatment programs. 126 Caring for the Uninsured and Underinsured Furthermore, the utility of these programs will necessitate 17. Eaton WW, Kessler L, eds. Epidemiologic Methods in Psy- a better understanding of the role of poverty in precipi- chiatry: The NIMH Epidemiologic Catchment Area Program. tating or exacerbating psychiatric disorders. Orlando, Fla: Academic Press Inc; 1985. 18. Leaf PJ, Myers JK. Procedures used in the epidemiologic The Yale ECA is supported by grant MH40603 from the National catchment area studies. In: Robins L, Regier D, eds. Psychiatric Institute of Mental Health, Rockville, Md. The ECA program was Disorders in America. New York, NY: Free Press; 1991:11-32. established as a series of five epidemiologic research studies per- formed by independent research teams in collaboration with the Di- 19. Characteristics of the Population Below the Poverty Level: vision of Biometry and Epidemiology, NIMH. The five sites and their 1980. Washington, DC: Bureau of the Census; 1982. US Dept of Com- NIMH grants are Yale University, New Haven, Conn, U01 MH34224; merce Current Population Reports series P-60 publication 133. Johns Hopkins University, Baltimore, Md, U01 MH33870; Washing- 20. O'Hare WP. Poverty in America: trends and new patterns. ton University, St Louis, Mo, U01 MH33883; Duke University, Popul Bull. 1989;49:1-45. Durham, NC, U01 MH35386; and UCLA, U01 MH35865. This study 21. Holzer CE, Spitznagel E, Jordan KB, Timbers DM, Kessler was also supported in part by NIMH training grant MH15783, grant LG, Anthony JC. Sampling the household population. In: Eaton MH44331, and NIMH FIRST award MH44984 (Dr Bruce). WW, Kessler LG, eds. Epidemiologic Field Methods in Psychi- References atry: The NIMH Epidemiologic Catchment Area Program. Or- 1. Patterson JT. America's Struggle Against Poverty: 1900- lando, Fla: Academic Press Inc; 1985:23-48. 1980. Cambridge, Mass: Harvard University Press; 1982. 22. Holt D, Smith TMF. Poststratification. J R Stat Soc A. 2. Waxman CI. The Stigma of Poverty: A Critique of Poverty The- 1977;142:33-66. ories and Policies. 2nd ed. Elmsford, NY: Pergamon Press Inc; 1983. 23. Shah BV, Folsom RE, Harrell FE, Dillard CN. RTILOGIT: 3. Dohrenwend BP, Dohrenwend BS. Social Status and Psy- Procedure for Logistic Regression on Survey Data. Cary, NC: chological Disorder: A Causal Inquiry. New York, NY: John Research Triangle Institute; 1987. Wiley & Sons Inc; 1969. 24. Freeman DH, Bruce ML, Leaf PJ, Berkman L. Sampling 4. Faris REL, Dunham W. Mental Disorders in Urban Areas. strategies for studying older populations. In: Wallace RB, Wool- Chicago, III: University of Chicago Press; 1939. son RC, eds. Methodological Issues in the Epidemiologic Study 5. Hollingshead AB, Redlich FC. Social Class and Mental Illness: of Elderly. New York, NY: Oxford University Press. In press. A Community Study. New York, NY: John Wiley & Sons Inc; 1958. 25. Bruce ML, Freeman DH, Leaf PJ. Use of SAS procedures 6. Holzer CE, Shea B, Swanson JW, Leaf PJ, Myers JK, George for estimating design based logistic regression variances by bal- L, Weissman MM, Bednarski P. The increased risk for specific anced repeated replication. In: SAS Users Group International psychiatric disorders among persons of low socioeconomic sta- Proceedings of the Twelfth Annual Conference. Cary, NC: SAS tus. Am / Soc Psychiatry. 1986;6:259-271. Inc; 1987:1066-1070. 7. Langer TS, Michael ST. Life Stress and Mental Health. New York, NY: Free Press; 1963. 26. Background Material and Data on Programs Within the 8. Leighton DC, Harding JS, Macklin DB, MacMillan AM, Leighton Jurisdiction of the Committee on Ways and Means. Washington, AH. The Character of Danger: Psychiatric Symptoms in Selected DC: US House of Representatives, Committee on Ways and Communities. New York, NY: Basic Books Inc Publishers; 1963. Means; 1989. US House of Representatives Committee on Ways 9. Link B, Dohrenwend BP. Formulation of hypotheses about and Means publication WMCD 101-4. the true prevalence of demoralization in the United States. In: 27. Parker G. Are the lifetime prevalence estimates in the ECA Dohrenwend BP, Dohrenwend BS, Gould MS, Link B, Neuge- study accurate? Psychol Med. 1987;17:275-82. bauer R, Wunsch-Hitzig E, eds. Mental Illness in the United 28. Eaton WW, Kramer M, Anthony JC, Dryman A, Shapiro S, States: Epidemiologic Estimates. New York, NY: Praeger Pub- Locke BZ. The incidence of specific DIS/DSM-III mental disor- lishers; 1980:114-132. ders: data from the NIMH Epidemiologic Catchment Area Pro- 10. Myers JK, Bean LL. A Decade Later: A Follow-up of Social gram. Acta Psychiatr Scand. 1989;79:163-178. Class and Mental Illness. New York, NY: John Wiley & Sons Inc; 1964. 29. Dohrenwend BP. Socioeconomic status (SES) and psychiatric 11. Srole L, Langer TS, Michael ST, Opler MK, Rennie TAC. Mental disorders. Soc Psychiatry Psychiatr Epidemiol. 1990;25:41-47. Health in the Metropolis: The Midtown Manhattan Study. New York, 30. Kessler RC, McLeod JD. Sex differences in vulnerability NY: McGraw-Hill International Book Co; 1962. to undesirable life events. Am Soc Rev. 1984;49:620-631. 12. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National 31. Weissman MM, Merikangas KR, John K, Wickramaratne Institute of Mental Health Diagnostic Interview Schedule: its P, Prusoff BA, Kidd KK. Family-genetic studies of psychiatric dis- history, characteristics, and validity. Arch Gen Psychiatry. orders: developing technologies. Arch Gen Psychiatry. 1981;38:381-389. 1986;43:1104-1116. 13. Robins LN, Orvaschel H, Anthony JC, Blazer DG, Burnam 32. Anthony JC, Folstein M, Romanoski AJ, VonKorff MR, A, Burke JD. The Diagnostic Interview Schedule. In: Eaton WW, Nestadt GR, Chahal R, Merchant A, Brown H, Shapiro S, Kramer Kessler LG, eds. Epidemiologic Field Methods in Psychiatry: The M, Gruenberg EM. Comparison of the lay Diagnostic Interview NIMH Epidemiologic Catchment Area Program. Orlando, Fla: Schedule and a standard psychiatric diagnosis. Arch Gen Psy- Academic Press Inc; 1985:143-170. chiatry. 1985;42:667-675. 14. Brown G, Harris TO. Social Origins of Depression: A Study of 33. Helzer JE, Robins LN, McEvoy LT, Spitznagel EL, Stotlzman RK, Psychiatric Disorder in Women. New York, NY: Free Press; 1978. Farmer A, Brockington IF. A comparison of clinical and Diagnostic 15. Kessler RC, Cleary P. Social class and psychological dis- Interview Schedule diagnoses. Arch Gen Psychiatry. 1985;42:657-666. tress. Am Soc Rev. 1980;45:463-478. 34. Mullahy J, Sindelar J. Life-cycle effects of alcoholism on 16. American Psychiatric Association, Committee on Nomen- education, earnings, and occupation. Inquiry. 1989;26:272-282. clature and Statistics. Diagnostic and Statistical Manual of Men- 35. Poverty in the United States 1987. Washington, DC: US tal Disorders, Third Edition. Washington, DC: American Psy- Bureau of the Census; 1989. US Dept of Commerce Current chiatric Association; 1980. Population Reports series P-60 publication 163. Mental Health Needs of the Uninsured Grayson Norquist, MD, MSPH, Kenneth Wells, MD, MPH As many as 37 million Americans have no medical insur- Study. Because Hispanics were oversampled in the Los ance, but no data exist on the mental health needs of com- Angeles site, we were able to separately estimate the ef- munity samples of the uninsured. Using interview data from fects of insurance status and ethnicity on the probabilities a household sample in Los Angeles, we found that the un- of having a psychiatric disorder and of using mental health insured had a higher prevalence of serious psychiatric dis- services. This presented an important opportunity, as pre- order (16%) than those with private health insurance (12%), vious studies have shown Hispanics to be less likely to use but had a prevalence similar to those with Medicaid (18%). specialty mental health services than non-Hispanics, and Access to mental health services among those with a psy- recent Hispanic immigrants would be expected to consti- chiatric disorder was similar in the uninsured (14.5%) and tute a large segment of the Los Angeles uninsured pop- those with private insurance (18%) but was less than those ulation.6 with Medicaid coverage (42%). These results indicate that MATERIALS AND METHODS the uninsured have a great potential need for mental health services and that access might be improved through insur- Sample Data were obtained from the first wave of the Los An- ance plans such as Medicaid. However, further study is needed to determine the adequacy and quality of services geles NIMH Epidemiologic Catchment Area survey con- provided under Medicaid and whether such a plan would ducted in 1983; the characteristics of this site have pre- improve access for an uninsured population such as the one viously been described. 7,8 Sampling was perfomed with a studied here. two-stage probability design with a final sample size of 3057 respondents. The completion rate for the survey was 69%, a response rate comparable with those in previous A ccording to recent studies, approximately 7% to 13% surveys conducted in Los Angeles.9 of the US population (22 to 37 million people) are not We determined insurance coverage through responses covered by any type of health insurance, 1,2 and as many to five items and categorized respondents into four in- as 43 million may be uninsured for some period during the surance groups: Medicare enrollees (Medicare); members year.3 The employed uninsured and their dependents of private fee-for-service plans and health maintenance make up the largest component of the uninsured group, organizations (HMOs) (Private); those in public- and young, poor workers are the most likely to be unin- supported entitlement plans (Medicaid); and the unin- sured.⁴ Recently, some states have proposed and imple- sured. A hierarchical system prevented overlap in groups mented plans to provide health coverage for the uninsured by placing an individual in one and only one group. If a based on mandatory insurance coverage for all workers. respondent was a member of an HMO (n=410), then he Studies from the late 1970s at the National Center for or she was placed in the Private group; after classifying Health Statistics (Hyattsville, Md) indicated that unin- those respondents, enrollees in Medicare were placed in sured persons were more physically ill than those with the Medicare group (n=328); next, the Medicaid group insurance.³ Others have shown that the loss of health in- was composed (n=221); then, those with private fee-for- surance benefits (eg, Medicaid) can result in a worsened service insurance (n=1400) were added to the Private physical health status for those who previously had health group; finally, the remainder of respondents were placed insurance.⁵ However, no community-based studies have in the uninsured group (n=698). Thus, the privately in- estimated the extent of psychiatric disorder among the un- sured group (Private) used in the analysis reported here insured. Such estimates would be useful in designing ben- consisted of all those with private fee-for-service insurance efit packages or planning services for the uninsured. In and all HMO enrollees. addition, estimates are needed on the use of mental health The present study focuses on the uninsured and com- services by the uninsured, particularly those with psychi- pares them with those with private insurance (fee-for- atric disorders, as a proxy measure of the extent of unmet service combined with HMO enrollees) and with those need in this population. with Medicaid coverage. The Medicaid group was in- In this article, we address these issues using data from cluded for two reasons: first, they represent those under the Los Angeles (Calif) site of the National Institute of a government plan that has been suggested as a potential Mental Health (NIMH) Epidemiologic Catchment Area way of covering all uninsured who are unemployed; and second, previous reports have shown them to have a Accepted for publication February 14, 1991. higher prevalence of psychiatric disorder. 10,11 The Medi- From the Division of Applied and Services Research, National In- stitute of Mental Health, Rockville, Md (Dr Norquist), and the De- care group was not included because we wanted to com- partment of Psychiatry and Behavioral Sciences, UCLA School of pare the uninsured population with a population of similar Medicine (Dr Wells). age. Some data presented here for the privately insured Reprinted from Archives of General Psychiatry (1991;48:475-478). and those with Medicaid have been reported previously.¹ 12 128 Caring for the Uninsured and Underinsured Sources of Data The Diagnostic Interview Schedule (DIS), 13 a structured Table 1. Demographic Characteristics of Each Group* questionnaire using lay interviewers to collect data from Private Medicaid Uninsured respondents, was used to determine the presence of psy- (n=1810) (n=221) (n=698) chiatric disorders comparable with those defined in the Age, y 37 (0.9) 39 (2.5) 34 (1.3) DSM-III. A Spanish language version was available for subjects whose primary language was Spanish. 14 All di- Women, % 50 (1.2) 64 (3.8)+ 49 (2.1) agnoses reported here were present in the 6 months pre- <12 y Education, % 46 (1.1) 79 (2.7)+ 72 (1.6)+ ceding the 1983 interview. Good to excellent health, % 85 (1.0) 60 (4.1)+ 77 (1.8)+ Not all diagnoses listed in the DSM-III are covered by % Hispanic 42 (1.3) 68 (3.2)+ 72 (1.5)+ the DIS. Disorders identified by the DIS differ in their se- verity (ie, impact on functioning or presence of psychotic *Values are means (±SEs). symptoms) and in the potential for response to treatment. +P<.001 compared with the Private group. Because we were particularly interested in examining dif- ferences in prevalence of serious and highly treatable dis- Table 2. - Proportion of Enrollees Within Each Group orders, prior to data analysis, we developed an indicator With a Serious Disorder, Any Disorder, or Any Physical of such serious disorders. We categorized schizophrenic Limitation* disorders, all affective disorders, alcohol and substance abuse, obsessive-compulsive disorder, and panic disorder Serious Any Physical as serious and treatable disorders. We excluded antisocial Disorder Disorder Limitation personality disorder, cognitive impairment, and phobia. Private, % 12 (0.7) 17 (0.9) 11 (0.9) Although we recognize that phobias can be both serious Medicaid, % 18 (2.8)+ 29 (3.3)# 29 (3.3)$ and treatable, many of the common phobias identified in Uninsured, % 16 (1.6)+ 21 (1.8) 14 (1.3) a general population by the DIS may be mild. Because previous reports from the Epidemiologic Catchment Area *Values are means SEs). study have used a summary variable for any DIS psychi- tP<.05 compared with the Private group. atric disorder, the findings for that variable were also an- #P<.005 compared with the Private group. $P<.001 compared with the Private group. alyzed and reported here as "any DIS disorder" to allow comparison with previous reports. We used scores obtained through the Center for Epi- panic. The Medicaid respondents were similar to the demiologic Studies Depression Scale as a measure of psy- uninsured, but were more likely to be women. Although chopathologic severity. 15 This scale is considered by some not shown in Table 1, we also analyzed employment data as an indicator of general "psychological distress," rather for respondents. Of those respondents with a serious psy- than a discrete measure of depression.¹⁶ chiatric disorder, 81% of the Private, 54% of the uninsured, The following categories of places used for outpatient and 27% of the Medicaid groups were employed. Over mental health services are defined by type of provider, as 85% of employed respondents with serious psychiatric described by Shapiro et al¹⁷: (1) specialty mental health disorders in the Private and uninsured groups were work- resources (psychiatrists, psychologists, psychiatric social ing full time, but only 67% of the employed Medicaid re- workers, mental health counselors, mental health centers, spondents with serious psychiatric disorders were full- and drug treatment centers); (2) general medical resources time employees. (medical care practitioners and hospital emergency de- The majority of Hispanic respondents in the Medicaid partments); and (3) other human service resources (clergy, group were US-born, while Hispanics in the uninsured family service agencies, crisis centers, spiritualists, and group were more likely to be foreign-born. As an indicator natural therapists). of acculturation, we determined the percentage of respon- Statistical Analysis dents whose primary language was Spanish. Six percent Data were weighted to account for differential sampling of the privately insured respondents spoke primarily probabilities and adjusted for age and sex (the Private Spanish, but 12% of the Medicaid and 12% of the unin- group was used as the reference). The utilization data were sured respondents used Spanish as their first language, generated using SESUDAAN, a computer program that indicating less acculturation in the latter two groups than estimates standard errors of proportions and means for in the Private group. complex sample surveys. 18 We used a logistic regression Prevalence of Psychiatric Disorder model to examine unique associations between insurance Table 2 reports the proportion of respondents with a types and either prevalence of psychiatric disorder or use significant and treatable DIS/DSM-III psychiatric disorder of mental health services while controlling for other fac- (serious disorder) and the percentage of respondents tors. Because the logistic regression model assumes simple random sampling, the x² values obtained with it were cor- within each group who had any DIS/DSM-III psychiatric disorder (any disorder) within the preceding 6 months. rected for the clustered sampling design by using values Medicaid respondents had a higher prevalence of any obtained from a survey regression program. 19,20 DIS/DSM-III psychiatric disorder, but both the Medicaid RESULTS and uninsured groups had a significantly greater preva- Demographics lence of serious psychiatric disorder than the Private Table 1 lists the demographic characteristics of the Pri- group. Nonetheless, the majority (54%) of respondents vate, Medicaid, and uninsured groups. Uninsured re- with a serious psychiatric disorder had private insurance, spondents were primarily young, uneducated, and His- 17% were insured through Medicaid and Medicare (10% Uninsured Patients 129 Table 3. Proportion With Serious Psychiatric Disorder That Used Each Sector* General Medical Specialty Mental Health Human Services General Medical or Sector Sector Sector Specialty Sector Private, % 5.5 (1.6) 15.0 (2.3) 6.2 (1.5) 18.1 (2.8) Medicaid, % 4.1 (1.9) 38.7 (7.8)+ 9.6 (5.7) 41.8 (7.9)+ Uninsured, % 8.1 (3.1) 9.9 (3.1) 8.8 (3.0) 14.5 (3.5) *Values are means (±SEs). +P<.005 compared with the Private group. Table 4. Number of Visits to Each Sector by Those health services than those in the Private group. With a Serious Psychiatric Disorder* Table 4 shows the mean number of outpatient visits for mental health care among subjects with a serious psychi- General Medical Specialty Mental Health atric disorder who used services. We have previously re- Sector Sector ported that enrollees with serious mental disorders in pri- Privatet 3.6 (0.5) 10.3 (1.3) vate fee-for-service plans and HMOs do not differ in their access to mental health care but do differ in the mean num- Medicaid 3.6 (2.0) 14.0 (4.8) ber of visits to providers of mental health care. 12 Therefore, Uninsured 5.3 (2.2) 6.5 (2.0) when we compared the mean number of visits between *Values are means SEs). the groups we broke down the Private group into the fee- tExcludes HMO enrollees (see text). for-service and HMO subgroups to determine if that af- fected the comparison with the uninsured. In Table 4, the and 7%, respectively), and 29% were uninsured, indicat- Private group consists only of the fee-for-service enrollees. ing that a large segment of those with significant and treat- There was no statistically significant difference between able psychiatric disorder were uninsured. Consistent with them and the uninsured in the mean number of visits to the "health" variable reported in Table 1, the Medicaid either the general medical sector or the specialty mental group was more physically limited. health sector for mental health care. When the uninsured When the effects of other factors (sex, age, ethnicity, were compared with HMO enrollees (6.5 visits for general employment, education, and physical health) were con- medical sector and 1.6 for specialty sector), there also was trolled by using multiple logistic regression, the Medicaid no statistically significant difference. and uninsured groups still had a significantly greater prev- alence of serious psychiatric disorder than those with pri- COMMENT vate insurance (x² for Medicaid, 6.26, df=1, P<.01; x² for To our knowledge, data from our study represent the uninsured, 7.53, df=1, P<.01). Among those in the Pri- first community data on the prevalence of psychiatric dis- vate or uninsured groups with a serious psychiatric dis- order and use of mental health services in the uninsured. order, there was no significant difference in the level of Our findings are consistent with those of previous reports psychological distress (ie, severity) as assessed by the Cen- describing the uninsured population as primarily young, ter for Epidemiologic Studies Depression score. However, minority workers. 1-4,21 Although previous reports have es- the Medicaid group had more psychological distress than timated that as many as 13% of the population may be those two groups combined. Twenty-six percent of the uninsured, in this Los Angeles sample 23% were unin- uninsured/Private sample scored 16 or more, indicating sured.¹ One explanation for the larger number of unin- psychological distress, while 67% of the Medicaid sample sured respondents in the Los Angeles Epidemiological scored at this level. Catchment Area site sample was the inclusion of a large number of recent Hispanic immigrants. Utilization Data Because some states are considering mandatory health Table 3 presents utilization data for outpatient mental benefits for all employees, we thought it particularly im- health services by insurance groups for those respondents portant to describe employment status of the uninsured. with serious psychiatric disorder. The proportion of those Other studies have shown that 39% of the uninsured are who used either the general medical or specialty mental full-time employees and 17% are part-time employees. 4,22 health sector within the preceding 6 months (last column) We found that a large segment (54%) of the nonelderly did not differ between the uninsured and the Private uninsured population with serious mental illness would groups. However, the Medicaid group had more than remain without insurance if plans to cover them required twice the proportion of respondents who had used an out- full employment, and about 46% would be uninsured even patient mental health service within the preceding 6 if part-time employment were sufficient to obtain health months. When the different sectors were considered in- coverage. Thus, in areas such as Los Angeles, providing dividually, use of the specialty mental health sector ac- mental health coverage to the uninsured with psychiatric counted for this finding in the Medicaid group. Ethnicity disorders will require strategies in addition to mandated and other factors (sex, age, education, unemployment, insurance coverage for employees. These options might and psychiatric disorder) known to affect the use of the include extension of Medicaid benefits to those who are specialty mental health sector were controlled by using unemployed and uninsured. multiple logistic regression, and those with Medicaid re- We found that the uninsured population had a higher mained the only group more likely to use specialty mental prevalence of serious psychiatric disorder than those with 130 Caring for the Uninsured and Underinsured private insurance, but had a prevalence similar to those icaid coverage to the uninsured might be a reasonable pol- with Medicaid. These findings indicate that the uninsured icy option for meeting the needs of the uninsured with population has a potentially greater need for psychiatric psychiatric disorders, especially those who are unem- services than those with private insurance and emphasize ployed. 25 However, the quality and adequacy of mental the importance of including psychiatric benefits in any health services delivered under the Medicaid system may plans to provide insurance coverage for the uninsured. not be sufficient, and future studies will need to address However, our findings also suggest that severity of illness, this issue. as measured by the Center for Epidemiological Studies This research was supported by the Epidemiologic Catchment Area Depression Scale, is somewhat lower for the uninsured Program, Los Angeles, Calif. The Epidemiologic Catchment Area is and Private groups than for the Medicaid population. a series of five epidemiologic research studies performed by inde- Thus, one might not necessarily anticipate the same level pendent research teams in collaboration with the staff of the Division of use of mental health services in the uninsured as was of Biometry and Epidemiology of the National Institute of Mental observed here for the Medicaid population if the unin- Health (NIMH), Rockville, Md. The NIMH principal collaborators sured were to be covered under a Medicaid program, but were Darrel A. Regier, MD, MPH, Ben Z. Locke, MSPH, and Jack D. Burke, Jr, MD, MPH; the NIMH project officer was William J. further studies with better measures of severity are Huber. The principal investigators and coinvestigators from the five needed. sites were as follows: Yale University, New Haven, Conn (supported Some have questioned the validity of the DIS. 23 If the DIS by cooperative agreement MH-34224): Jerome K. Myers, PhD, Myrna improperly estimated psychiatric diagnoses, then our M. Weissman, PhD, and Gary L. Tischler, MD; The Johns Hopkins prevalence data might be incorrect. However, others have University, Baltimore, Md (MH-33870): Morton Kramer, ScD, and Sam Shapiro; Washington University, St Louis, Mo (MH-33883): Lee shown it to be valid for most psychiatric disorders it es- N. Robins, PhD, and John E. Helzer, MD; Duke University, Durham, timates, and it remains the best instrument available for NC (MH-35386): Dan Blazer, MD, PhD, and Linda K. George, PhD; field studies of psychiatric epidemiologic disorders. 24 and UCLA (MH-35865): Marvin Karmo, MD, MSPH, Richard L. We expected the uninsured group with serious psychi- Hough, PhD, Javier I. Escobar, MD, M. Audrey Burnam, PhD, and atric disorders to have less access to mental health care, Dianne M. Timers, PhD. but the proportion who used either the general medical or This study was also supported in part by the NIMH and by the Health Care Financing Administration through the RAND Corp specialty mental health sectors was not significantly dif- (Santa Monica, Calif)/Health Care Financing Administration (Balti- ferent from that of those who had private insurance. This more, Md) Policy Center. was true when we controlled for ethnicity and for other The opinions expressed in this article are those of the authors and factors (sex, age, education, unemployment, and psychi- do not represent the opinions or policy of any agency of the US Gov- atric disorder) known to affect the use of mental health ernment. services. Even when we looked at the mean number of References visits to the specialty mental health sector for those with 1. Wilensky GR. Viable strategies for dealing with the unin- serious psychiatric disorders, there was no statistically sig- sured. Health Affairs. 1987;6:33-46. nificant difference between the uninsured and those with 2. Weisfeld VD, ed. Robert Wood Johnson Foundation Spe- cial Report. Princeton, NJ: Robert Wood Johnson Foundation private insurance (regardless of whether the Private group Communications Office; 1987;2. was split into fee-for-service and HMO enrollees). How- 3. Davis K, Rowland D. Uninsured and underserved: ineq- ever, our precision was relatively low for the comparison uities in health care in the United States. Milbank Memorial Fund of use among those with a psychiatric disorder who were Q. 1983;61:149-176. uninsured or privately insured. There could have been a 4. Monheit AC, Hagan MM, Berk ML, Farley PJ. The employed moderate difference in access that we were not able to uninsured and the role of public policy. Inquiry. 1985;22:348-364. detect statistically. 5. Lurie N, Ward NB, Shapiro MF, Brook RH. Terminations What we do not know from our study is the type of from Medi-Cal: does it affect health? N Engl J Med. 1984;311:480-484. mental health service or the adequacy of the service re- 6. Hough RL, Landsverk JA, Karno M, Burnam MA, Timbers ceived by the uninsured. Los Angeles County at the time DM, Escobar JI, Regier DA. Utilization of health and mental of the survey had a network of clinics that provided mental health services by Los Angeles Mexican Americans and non- health services at reduced fees or no cost to those without Hispanic whites. Arch Gen Psychiatry. 1987;44:702-709. funds. Thus, if publicly funded mental health services had 7. Eaton WW, Holzer CE, Von Korff M, Anthony JC, Helzer not been available, it is possible that the uninsured would JE, George L, Burnam MA, Boyd JA, Kessler LG, Locke BZ. The have shown less use of mental health services. This is a design of the Epidemiologic Catchment Area Surveys. Arch Gen particularly important issue to address in future research, Psychiatry. 1984;41:942-948. 8. Burnam MA, Hough RL, Escobar JI, Karno M, Timbers DM, since Los Angeles County has recently decreased the men- Telles CA, Locke BZ. Six-month prevalence of specific psychi- tal health services provided in public clinics. atric disorders among Mexican-Americans and non-Hispanic Medicaid recipients were almost twice as likely to use whites in Los Angeles. Arch Gen Psychiatry. 1987;44:687-694. mental health services as either those with private insur- 9. Frerichs RR, Aneshensel CS, Clark VA. Prevalence of de- ance or those without insurance, and differences re- pression in Los Angeles County. Am J Epidemiol. 1981;113:691- mained even after controlling for differences in prevalence 699. of psychiatric disorder. Those with Medicaid may have 10. Shapiro S, Skinner EA, Kramer M, Steinwachs DM, Regier fewer barriers to access. Alternatively, we may not have DA. Measuring need for mental health services in a general pop- ulation. Med Care. 1985;23:1033-1043. sufficiently controlled for differences in severity of illness. 11. Taube CA, Kessler LG, Burns BJ. Estimating the probability Future studies should compare these groups using more and level of ambulatory mental health services use. Health Ser- (comprehensive measures of severity of illness. vices Res. 1986;21:321-339. If Medicaid does increase access to mental health ser- 12. Norquist GS, Wells KB. How do HMOs reduce outpatient vices, as others have also reported, then extension of Med- mental health care costs? Am / Psychiatry. 1991;148:96-101. Uninsured Patients 131 13. Robins LN, Helzer JE, Croughan J. National Institute of Holzer CE, Myers JK. Contact with health professionals for the Mental Health Diagnostic Interview Schedule. Arch Gen Psy- treatment of psychiatric and emotional problems. Med Care. chiatry. 1981;38:381-389. 1985;23:1322-1335. 14. Burnam AM, Karno M, Hough RL, Escobar JI, Forsythe AB. 21. Ries P. Health care coverage by age, sex, race, and family The Spanish DIS: reliability and comparison with clinical diag- income: United States, 1986. Advancedata. 1987;139:1-8. noses. Arch Gen Psychiatry. 1983;40:1189-1196. 22. Baldwin MF. Who will pay indigents' bill? Mod Health 15. Radloff LS. The CES-D scale: a self-report depression Care. 1987;12:26-35. scale for research in the general population. Appl Psychol Meas. 23. Anthony JC, Folstein M, Romanoski AJ, Von Korff MR, 1977;1:385-401. 16. Vernon SW, Roberts RE. Measuring nonspecific psycho- Nestadt GR, Chohal R, Merchant A, Brown H, Shapiro S, Kramer logical distress and other dimensions of psychopathology. Arch M, Gruenberg EM. Comparison of the lay Diagnostic Interview Gen Psychiatry. 1981;38:1239-1247. Schedule and a standardized psychiatric diagnosis. Arch Gen 17. Shapiro S, Skinner EA, Kessler LG, Von Korff M, German Psychiatry. 1985;42:667-675. PS, Tischler G, Leaf PJ, Benham L, Cottler L, Regier DA. Utili- 24. Burke JD. Diagnostic categorization by the Diagnostic In- zation of health and mental health services. Arch Gen Psychiatry. terview Schedule (DIS): a comparison with other methods of 1984;41:971-978. assessment. In: Barrett J, Rose RM, eds. Mental Disorders in the 18. Shah BV. SESUDAAN: Standard Errors Program for Com- Community: Findings From Psychiatric Epidemiology. New puting of Standardized Rates from Sample Survey Data. Re- York, NY: Guilford; 1986. search Triangle Park, NC: Research Triangle Institute; 1981. 25. Taube CA, Rupp A. The effect of Medicaid on access to 19. Holt MM. SURREGR: Standard Errors of Regression Co- ambulatory mental health care for the poor and the near-poor efficients from Sample Survey Data. Research Triangle Park, NC: under 65. Med Care. 1986;24:677-686. Research Triangle Institute; 1977. 26. Ginzberg E. Medical care for the poor: no magic bullets. 20. Leaf PJ, Livingston MM, Tischler GL, Weissman MM, JAMA. 1988;259:3309-3311. The Dilemma of the Uninsured and Underinsured Marvin Young, MD Providing care for the more than 30 million uninsured and with the values of American society to obtain wide public more than 25 million seriously underinsured Americans is an acceptance. urgent problem of great dimension that demands innovative The physicians of Washington State have been working thought and commitment to solution. The Journal of the with a collaborative group of large and small businesses, American Medical Association will publish a special theme hospitals, and insurance companies in response to a leg- issue dedicated to this topic on May 15, 1991, which will con- islatively mandated Commission on Health Care Cost and tain a series of proposals concerning access to medical ser- Access, which is seeking a solution to the dilemma. Un- vices, financing methods, and sources of revenue for the derstood by all involved is the fact that each group must delivery of care. All of the nine American Medical Association relinqish some autonomy to attain a solution. The process specialty journals, functioning as a consortium, also contain has not come to closure as yet, but the rest of this article articles and editorials in their May issues. This editorial was describes the changes that physicians would like imple- mented in our state. written by Marvin Young, a Seattle dermatologist and pres- ident of the Washington State Medical Association. These Since society apparently does not wish to provide ev- views are those of the Washington State Medical Association erything for everyone, the proposed health care system as presented to the private sector working group, a medicine, would be divided into four tiers, with different financing for each section. The first, the "wellness" tier, would con- business, and insurance group dedicated to preserving a pri- sist of low-cost, outcome-proved measures to be applied vate solution to the problems of health care access and cost. across the entire state population. Immunizations would Kenneth A. Arndt, MD be an obvious example. Editor The second tier would include primary access to a phy- sician for emergency care, simple diagnosis and treat- T he difficulties of the medically uninsured and under- ment, and those services that are considered most basic insured are only one part of a greater problem evident by the public. Prenatal care would fit in this category. A to anyone in the United States today. People simply feel catastrophic coverage package would also be included af- that medical care costs too much, despite the fact that most ter an income-related deductible. Covered services in this Americans have much of their health insurance paid by tier would optimally be those found most cost-effective by their employers. More and more the media tell us that our outcome-proved research, such as defined in the Guide to infant mortality, longevity, and other measures of health Clinical Preventive Services.¹ status rank us lower than other industrialized nations of The third tier would include most of the remaining med- the world, even though we spend more of our gross na- ical services that we now deliver. Many dermatological tional product on health care than any of these same coun- services that I would call "quality of life" would be here. tries. Paradoxically, we are also the foremost exporter of Those strictly cosmetic services would be in a fourth tier, new medical information and technology to the rest of the probably not covered in most plans, as at present. The first world. requirement for the plan is improvement in cost control, The problem of access to care is viewed by the public so the obvious questions are "Where is the savings and simply as one of cost. Our population is conditioned to who pays for it?" The biggest saving is from the acceptance believe that modern technology will substitute for un- that society will not have to pay for all services for ev- healthy life-styles, abuse of drugs and alcohol, and a mul- eryone, but only for those termed most "basic." titude of social problems. Furthermore, society believes The first tier would be tax supported by the state. The that all Americans have the right to have unlimited access state would use its purchasing power to buy vaccines or to lifesaving care. other supplies at the best price and distribute them to phy- Imposition of a Canadian-style, single-payer govern- sicians, health departments, or other groups to administer mental system of health care is seen by many as the ap- to the public. The cost of the "work" component of this propriate solution to these problems. Yet the average care would not change significantly, but cost of the "tech- American's trust of government seems to fade when we nical" component would decrease with the economies of mention the savings-and-loan debacle, the postal service, volume. Similarly, the benefits of the prevention would and the less than dynamic behavior of our Congress. increase as the service is applied to all the population, Whatever health care solution we adopt, it must conform rather than only to those now insured. The second tier of "uniform health care benefits" would Accepted for publication March 12, 1991. be paid for by employers for their employees, by individ- From the Washington State Medical Society, Seattle. uals who are self-employed, and by state government for Reprinted from Archives of Dermatology (1991;127:712-713). the indigent. Existing federal COBRA regulations would The Dilemma of the Uninsured and Underinsured 133 allow the temporarily unemployed to continue their in- care, with physicians the rationers. Another option, which surance. In our state, this premium would probably be in removes incentives for excellence, is all physicians being the range of $60 to $90 per month. All citizens would be salaried as employees of the state or a megacorporation, required by law to have this coverage. These benefits with additional utilization review. A third option is ex- would be identical in all insurance policies. tensive physician rate regulation, coupled with utilization The third tier could be purchased by individuals, em- review, our current situation, and exemplified by Medi- polyers, governmental agencies, or unions, and could be care. negotiated by collective-bargaining agreements. Any Public opinion research in our state indicates agreement group, or individual, could purchase whatever additional with the concept of a multitiered health system, but it also limits they desire. The cost would be negotiable and cov- indicates a desire to tightly control physician and hospital erage tailored to individual groups. The fourth tier could be purchased similarly. fees as a simplistic solution to skyrocketing costs, unless Applied across all these tiers would be uniform appli- some other solution is found. The desire to provide basic cation of practice parameters, mandatory utilization re- services to all, regardless of income, is strongly felt, but view linked to these parameters, and uniform data col- "Don't tax me more than $300 per year to pay for it" is the lection on claims frequency, costs, and outcomes. Because unrealistic public answer for the cost. of mandatory coverage for "uniform health care benefits," And how does all this apply to dermatology?I think that preexisting disease exclusions would be eliminated. In- we must decide what constitute "basic dermatological ser- surance companies would only be allowed to use "com- vices," recognize that not all we do should be insured in munity rating," instead of "experience rating." the same way, and that some services should not be in- To provide immediate eligibility information and dras- sured at all. The management of pigmented lesions is our tically reduce physician and hospital billing costs, each forte, both diagnostically and therapeutically, but, cer- person would have a uniformly coded credit card and a tainly, the treatment of melanoma is more "basic" than single clearinghouse would be used for billing and claims that of seborrheic keratosis, once the diagnosis is estab- management. High-cost services requiring preauthoriza- lished. Other examples abound. tion would be standardized for all plans, with such de- This change in what is insured is already occurring. Pay- cisions made by a private Health Care Quality Foundation ment for treatment of "nonirritated" seborrheic keratoses (already in existence in Washington State). That same is not covered under many plans, including Medicare. As quality foundation would be the data bank for all services. more charges become the patient's responsibility, less ser- The cost savings realized would come from a combi- vices (and, possibly, fewer physicians) may be required. nation of the following factors: reduction in administrative The penalty for not prioritizing what is always insured, costs, payment for only appropriate utilization frequency optionally insured, or self-paid is the continued inclusion (as determined by peer professionals in combination with of all services under a single premium. If that global pre- payers), coinsurance by the users themselves, and ulti- mium is not high enough, the fee for each service must mately supply-demand economics. Fee controls should decrease, the utilization frequency must fall, or some ser- not be imposed, because moving away from the free mar- vices will not be covered. Medicare and Medicaid are clas- ket would again produce the current cost shift that got us sic examples where the total premium is inadequate. into this mess. In a truly free market, the ultimate worth Those who pay for private health insurance say the pre- of goods and services is defined by what the buyer is will- mium is already too high. ing to pay. If that value is too low, suppliers (physicians) The American Academy of Dermatology has a task force will leave the market, increasing the demand and the fee beginning to look at "basic dermatological services." Cre- paid. In the long run, patients will decide what our ser- ative and innovative solutions must come from derma- vices are worth. tology and all of medicine if we are to retain our profes- What are the alternatives to this system? Canada's so- sional autonomy and maintain our position of trust as the lution is a global budget applied to all health care, with an advocates for our patients. A profession cannot ethically inflation-adjusted increase each year. This means that do less. changing numbers of physicians, changing demographics Reference of the population and the increasing application of new 1. US Preventive Services Task Force. Guide to Clinical Pre- technology with a capped budget produce rationing of ventive Services. Baltimore, Md: Williams & Wilkins; 1989. The Underinsured and the Uninsured Maria D. Allo, MD T he so-called crisis in health care speaks to a situation sisters' keepers. Our ultimate satisfaction as physicians is whose solution is overwhelming the most ambitious as caretaker and healer. among us. As in other "larger than life" crises, it is easy If fiscal realities preclude pro bono care of the medically to separate ourselves from the problem, leaving its solu- indigent as part of daily practice, we can be supportive of tion to apparently mightier powers. Often we stand back those physicians who have chosen to provide this care. We from the issues; rarely do we identify ourselves as part of can be sensitive to the increasing number of patients and the problem. We are numbed into complacency because decreasing funding allocated for care of these patients, our life and practice are not directly touched; or, if they many of whom are the working poor who defer seeking are, it is in a way by which we can shamelessly dismiss care until their treatable disease approaches end stage. We the problem as society's, or the public hospital's, or some- can respect the human dignity of all who call our offices body else's (whoever that is!). In some practices, the wallet and provide alternative care sources when we cannot ac- biopsy is the first procedure performed, and "greenope- commodate an individual seeking our help. nia" is the diagnosis justifying transfer to the public fa- The present medical care system reflects attitudes and cility, or the "teaching service." values of our individualistic, affluent society, which Most of us became physicians because we wanted to speaks poorly for us as a community. Certainly "the med- care for other people. Changes in the practice of medicine ical establishment" does not bear responsibility for all of have subverted the system so that one can easily lose sight society's ills. In fact, like the education system, it has been of this. Medical linguistics reflect this change. We are no assigned responsibility for larger societal problems not tra- longer physicians caring for patients; we are "providers ditionally the domain of medicine. Nevertheless, our re- servicing clients." Nonetheless, our "clients" still need our sponse ought to be as role models rather than as part of care, our skill, and our compassion. Looking past the in- the problem. We need to be advocates for all of our patients surers' code number, the medical assistance card number, and strive to make a system that provides a just and com- or the look of despair when asked for the card that is not petent level of care to all those who need it. This entails possessed, we see in the "client" a patient with the needs defining essential care, lobbying for means to provide it, that we were trained to care for. We are our brothers' and and, if necessary, restricting expensive or unnecessary services until the basic needs of the population at large have been served. There is indeed unrest resulting from Accepted for publication March 3, 1991. From the Department of Surgery, Santa Clara Valley Medical Cen- the ills of our medical system, but there can be no peace ter, San Jose, Calif. until there is justice. We must be responsible to see that Reprinted from Archives of Surgery 1991;126:551). justice is done. Surgical Care for the Uninsured and Underinsured Claude H. Organ, Jr, MD T he American Medical Association and its family of public education, compared with 4.8% in Japan and 7% in journals, including JAMA, are focusing this month on Sweden; and (4) The percentage of our gross national health care for the uninsured and underinsured in the product spent on the health care system in 1989 was 11.1%, American society. This complex socioeconomic problem compared with 6.8% in Australia. has troubled our nation for many years. The number of These increased health care costs are multifactorial in underinsured and uninsured Americans continues to in- origin and generally attributed to increased utilization of crease at an alarming rate. It has become a serious national medical services; phenomenal technologic developments; concern and fosters continuing dialogue. Our national ef- inflation; increased hospital personnel costs; an aging fort for resolution of this problem continues to be terp- population, including the chronically ill; and the growth sichorean. While we are experiencing a soaring deficit and of insurance coverage and other third-party payments. a deepening recession, the costly war in the Persian Gulf The lingo in the health care industry has become saturated has expanded the roles of the unemployed and underin- with terms such as "macroallocation" and "microalloca- sured. tion." Society, while confronting the reality of our limited Surgeons trained in the United States during the last 50 health care resources, simultaneously raises the complex years are intensely aware of existing practices in many of questions of allocation, rationing, and financing.¹ our hospitals that complicate health care for the poor. Sig- Several special projects recently funded by the National nificant parts of our surgical training have occurred in pub- Science Foundation and the National Institute of Mental lic hospitals where there are often long waiting lines, Health are a reflection of our national priorities: (1) a study equipment shortages, poor staffing, and underfunding, of the cause of rudeness, cheating, and lying on tennis coupled with high patient cancellation and no-show rates. courts that received $2500; (2) a study of why people fall These are factors that affect, but are not directly related to, in love that received $84 000; (3) a study of how long it takes our discipline. The United States has a gifted surgical com- to cook eggs that received $46 000; (4) a "study of sexual- munity. We are in many ways confronted with a dilemma looking, classical conditioning of sexual arousal, and im- of our own research and patient care successes. Although provement of copulatory performance of Japanese quail" the financing of health care is a global concern, the surgical that received $107 000; and (5) construction of a 10-story disciplines are not immune from the effects of this prob- replica of the great pyramid of Cheops that received lem. We are not a sui generis group. While responsibility $500 The military-industrial complex has been no less for our concern may best be left to our informed national a participant in utilizing a significant segment of our gross surgical leadership, we can no longer ignore this continu- national product. ing national problem with the aphorism, "We have always Back in the trenches, we should develop an agenda taken care of the poor." within the discipline of surgery that governs our attitudes In our system of health care, costs attributable to surgery and practices in caring for the surgical needs of the poor. are driven by increased pressure for aggressive surgical This agenda need not await a consensus on global funding intervention, society's reluctance to accept death as a nat- mechanisms. How then do we take care of the surgical ural event, a system of resident training that encourages needs of the underinsured and uninsured during this pro- "high-tech" and critical care surgery, and the threat of lit- tracted national dialogue? Observations herein are not in- igation, which increases the use of diagnostic tests and tended to ignore the contributions of those who fulfill their influences management decisions. Even so, within our responsibilities to indigent patients in their practices. The complex society, surgeons should accept the challenge pro bono work of surgeons would be a difficult figure to and rise to new standards of accountability regarding care document. of the poor. Reflect back for a moment, however: Would your sur- Our national priorities are poorly focused and need se- gical training have been possible in the absence of indigent rious realignment. These data serve to emphasize our con- patients? Did they contribute to your learning experience? cerns: (1) In the last 44 years, we have had only seven Do you feel any professional and/or personal obligation balanced national budgets, the latest being in 1969; (payback) to those who contributed to your early surgical (2) More than $100 billion will be spent in 1991 to protect training? Fairness does not dictate that a surgeon accept Japan and Western Europe from military threats; (3) Only and treat only the uninsured or underinsured. This re- 4.1% of our gross national product in 1989 was spent on action begs the question. A better question is: Have you Accepted for publication April 4, 1991. done your fair share? There are dignified ways to exercise From the Department of Surgery, University of California-Davis, such a commitment to this segment of our health care pop- Oakland. ulation. Reprinted from Archives of Surgery (1991;126:549-550). I recently made a personal appointment to see a pro- 136 Caring for the Uninsured and Underinsured fessional colleague. After identifying myself, the first bit value-oriented and moral obligations and not be a carpe of information requested by the receptionist was the name diem. Such a reproachment must be taught beginning at of my insurance carrier. This is not an unusual occurrence. the undergraduate level of medical education. Such contretemps serve to confirm that our practices are Surgeons are no more guilty of "skimming" pay patients economically driven.³ Have we developed a two-tier sys- and avoiding indigent patient care than any other group tem of surgical care in which the poor receive inferior and within our profession. Practitioners who skim feel this less attentive care than patients who can afford to pay? Too procedure is justified because those who can pay are sub- often the poor are considered lower class and disruptive ject to an informal tax which permits the cost of providing to our practices and hospital system. Can we neglect or defer care for this group of less fortunate patients while care for those who cannot pay (the Aunt Emma test). The transfer of the underinsured or uninsured patients from a global funding strategy is being developed? By our vol- untary actions we can assist the underinsured and unin- private to public hospitals because there is no method of sured segment of society in maintaining their sense of dig- reimbursement is institutional skimming (abandon- nity. Such posturing is not designed to be sententious. ment?). Surgeons are often blamed, instead of the hos- Economic considerations seem to play an inordinate role pital, for these transfer decisions. Surgical problems, in driving our moral obligations on this issue. when they exist in those unable to pay for needed services, Humane attitudes do not require legislation, are cost- are not the sole province of university, county, or VA hos- effective, and have been the cornerstone of our love affair pitals, but rather, as Spinoza said, "Care of the poor is with patients for centuries. Our regard of the indigent pa- incumbent upon society as a whole.' Laws have been tient during professional contact is reflected in the manner passed to discourage "dumping." These federal guide- by which we obtain informed consents, interpret the need lines serve to "encourage" hospitals to assume responsi- for an operation or its results, supervise residents, and bility for their share of care for the poor, particularly in return phone calls. Our body language and attitudes speak emergency situations. Health maintenance organizations louder than words. The 1977 observation by Egbert and and private clinics are no less guilty of these same prac- Rothman⁴ that blacks were 2.2 to 4.3 times more likely than tices. However, these guidelines are not uniformly en- whites to be under the care of surgeons in training forced. Some hospitals have a fixed percentile ceiling on (P<.001), although widely criticized at the time, continues the level of charity care they underwrite and prorate this to haunt our system or nonsystem. We should reassure pernicious policy throughout the year on a monthly basis. ourselves and society that indications for operative inter- These personal and institutional practices suggest that we vention are not governed by the economic status of pa- have a crisis in our value system. tients. What are our reasons for not admitting Medicare We have sat on the sidelines too long watching this rev- and Medicaid patients to our practices? We must offer our olution and hoping that someone else will take care of the surgical services to individuals in Appalachia, rural Amer- problem. Today we must exhibit greater concern for hu- ica, and the inner city, and, yes, even to the incarcerated mane than for monetary values. The significance of the Rip within our criminal justice system. No patient should be van Winkle story was not that he slept for so many years denied needed emergency or elective surgery because of but that he slept through a revolution. To hope that the monetary considerations alone. problem of health care for the underinsured and unin- Surgeons could do more to control their own destinies sured will go away or does not exist is to depart from re- by taking care of the uninsured and underinsured. These ality. actions must go beyond mere public relations rhetoric. Many of our colleagues will counter that we do better than References others, which again begs the question by comparing us 1. The Price of Life: Ethics and Economics. Minneapolis, with noncomparable occupations. It is a rare occasion at Minn: Minnesota Coalition on Health Care Costs; 1984. surgical meetings where ethical issues are discussed, that 2. Federal Budget, 1990. Federal Register. 1990;60. the agenda includes surgical care of the poor. 3. Shames L. The Hunger for More-Searching for Values in the Age of Greed. New York, NY: Times Books; 1989. Surgeons serve as role models to surgical house officers 4. Egbert LD, Rothman IL. Relation between the race and eco- whose lives we influence. To what extent is our manage- nomic status of patients and who performs their surgery. N Engl ment of the poor patient exemplary for our residents? The J Med. 1977;297:90-91. profit motive must be placed within the context of other 5. Spinoza B. Ethics. Part 1. Proposition LXX. Caring for the Uninsured The Oregon Experience Richard Allen, MD A commission was appointed by the governor of Oregon To provide care for this growing number of uninsured, to develop strategies to increase health care access for the providers found themselves shifting the cost of care to the estimated 400 Oregonians who were without health in- insured. However, those who were providing health care surance. Because of real or perceived financial barriers to to their employees became increasingly unwilling to bear access, these uninsured usually had more expensive, acute, these costs, thereby creating an ever-widening gap. The and episodic care that resulted in the shifting of cost to the Commission found three main reasons for the limitations insured and in higher health care costs. After studying the in access to health care: first, there were the obvious fi- problem for 6 months, the commission made specific rec- nancial barriers to those unable to afford care; second, ommendations that, if fully implemented, would ensure ac- there were the limitations to Medicaid imposed by the cess to health care for virtually all uninsured Oregonians. state legislature; and third, there were problems of avail- The recommendations support existing medical and insur- ability of services, mainly in rural areas. ance systems, foster public and private partnerships, and provide for the leveraging of federal Medicaid dollars in a THE SOLUTION favorable ratio to the state. The implementation of these The Commission's first recommendation was that the recommendations should ultimately reduce costs and at the state of Oregon adopt a mission statement saying that it same time provide more care. had "an obligation to ensure equitable access without ex- cessive burdens to an adequate level of health care for all P roviding health care for the uninsured is a difficult Oregonians." This obligation should be balanced by peo- problem that the state of Oregon has been making ple's obligation to provide for their own needs. 1 Toward attempts to solve. The author's involvement in this con- that end, any recommended strategies needed to include tinuing perplexing process dates back several years. The the maintenance of public and private partnership, the governor of the state was persuaded in 1988, his second leveraging of private and federal dollars, the traditional year in office, to appoint a special task force to deal with employment-based insurance system, and that the most this problem. The task force, named the "Governor's Com- cost-effective methods and equitable approaches be uti- mission on Uncompensated Care," was convened in Feb- lized. The following recommendations were made. ruary 1988, with a reporting deadline of 6 months, so that legislation could be drafted in the fall of 1988, for sub- Employer Tax Credit mission to the 1989 state legislature (which meets bien- Legislation was recommended (and passed) that would nially). The author, who at the time was president of the give a tax credit of $25 per employee per month to small Oregon Medical Association, was the only physician ap- businesses with fewer than 25 employees (the bulk of the pointed to the 18-member Commission. The other com- employed uninsured). The program would be voluntary, missioners included business and insurance executives, but if compliance were poor, it would become mandatory teachers, sociologists, hospital executives, and public in 5 years' time. The Commission encouraged the use of health nurses and legislators. managed care systems to regulate utilization and provide THE PROBLEM cost containment. This program is now in force, and com- Oregon has 400 000 citizens under the age of 65 years pliance has been slow but steady. who do not have health insurance coverage. Sixty-five per- cent were employed workers and their families. Since the The plight of the tens of millions of us citizens who have no, Oregon legislature has allocated funding for Medicaid to or inadequate, health insurance is of increasing concern to the only 58% of the federal poverty level (FPL), the remaining public and physicians alike. In an effort to stimulate discussion one third of the uninsured were those either unemployed about this vital issue, JAMA is devoting the May 15, 1991, issue or earning more than 58% of the FPL. A small number, to "Caring for the Uninsured and Underinsured." The nine approximately 15 000, were high-risk individuals who AMA specialty journals are also publishing articles dealing with were largely considered uninsurable. this same topic in their May 1991 issues. This special article on Accepted for publication March 15, 1991. the approach being taken by the state of Oregon provides one From the Department of Obstetrics and Gynecology, Oregon potential solution to this problem. Our readers are encouraged Health Sciences University, Portland. to seek out the May 15th issue of JAMA and the May issues of Reprinted from Archives of Pathology and Laboratory Medicine the other AMA specialty journals for additional articles on this (1991;115:437-439). important topic. - THE EDITOR. 138 Caring for the Uninsured and Underinsured High-Risk Pool Cost-Containment Strategies Legislation was proposed (and subsequently passed) to Because of the concerns over the rising cost of health create a state-run high-risk pool for the "uninsurable." It care, the Commission stressed the importance of contin- is funded by a surcharge on insurance companies doing ued monitoring to keep the cost per unit of care level and business in the state, with any necessary additional fund- neutralize the shifting of costs. It was thought that man- ing provided by the state's reserve fund. aged care systems, which, in turn, would be monitored by the Office of Health Policy, could best ensure proper uti- Medicaid Expansion lization and cost control.⁴ In addition, tort reform legis- It was strongly believed that the state should fund Med- lation was proposed to reduce the costs of "defensive med- icaid to at least 100% of the FPL and up to 185% of the FPL icine." for pregnant women and children. Federal matching funds are available to those who return to employment but RESULTS are still below the FPL. A demonstration project was pro- posed that could then use federal dollars to leverage fund- The total expenditure in state general funds to accom- ing. It was also believed that it would be desirable to use plish all of the preceding solutions was estimated at $28.2 these funds to purchase health insurance instead of having million, which, in turn, would generate $67.5 million in the State Welfare Department reimburse providers. This matching federal funds. There would be some loss of rev- enue due to the small business tax credits estimated to be would remove the "welfare stigma" and improve access. Access would also be improved by reducing the paper- in the range of $26 million per biennium if there was 100% work and the "hassle factor" as much as possible (at least enrollment. This would hopefully be offset by a healthier at the level of managed care competition). population as a result of the increased access with earlier Because federal matching funds of up to 185% of the FPL preventive care and, ultimately, a cost saving. To date, the are available to pregnant women and children, special em- small business insurance plan has enrolled 1730 employer phasis was placed on access to prenatal care. Since the cost groups, with employees and dependents totaling 7012. of low-birth-weight babies is excessive (up to $250 000 per There are seven commercial carriers that are participating infant), it was thought that each dollar spent on prenatal in the program; they are offering a basic package that care, which would help to prevent a low-birth-weight in- ranges from a minimum premium of $53.33 per month to fant, would produce a saving of $2 to $11. Figures have a more standard package that pegs its rates to a large suc- ranged from a saving in neonatal intensive care costs of cessful health maintenance organization. $1.70 to $2.60 for every $1 spent on prenatal care² to a To expand the Medicaid eligibles, a waiver application multiplier of 3.33.3 In other words, the dollars spent on needed to be obtained from the Health Care Financing preventive care would result in long-range cost savings Administration to set up the demonstration project for fed- eral funds. Since there needed to be some constraints in and ultimately a reduction in expenditures, not to mention potential improvements in the quality of life of these in- terms of what the legislature would budget, a special com- fants. mission (the Health Services Commission) would be cre- ated to prioritize services to provide the most efficacious care for the dollars spent. Also, to see whether or not such Continuation of Benefits for the Unemployed a "list of services" could be developed and prioritized, a Oregon law, similar to the federal COBRA (Consoli- research grant was obtained from a local charitable trust, dated Omnibus Budget Reconciliation Act) legislation, and the Oregon Medicaid Priority Setting Project was es- provides for continuation of benefits to those individuals tablished. The participants were divided into several focus who have recently become unemployed and as a result groups to broadly prioritize care so that actuarial costs have lost their health insurance benefits. Unfortunately, could be estimated. 5 When this was completed, state leg- most of those who are eligible to continue their insurance islators were provided with the information to assist in benefits have elected not to do so because of the cost. Thus, drafting legislation. It is important to emphasize that the it was proposed that a surcharge be placed on unemploy- funding for care would then be the responsibility of the ment insurance in order to provide continued coverage. legislature (and thereby of the public, through their The amount of the surcharge needed to accomplish this elected representatives). was figured to be $0.00263 and would amount to an 8.5% Legislation was proposed and enacted in 1989 with the total increase in the average unemployment tax. passage of three different bills: (1) Medicaid Reform (SB 27), (2) Uninsurable High-Risk Pool (SB 534), and, (3) Emphasis on Primary Care Small Business Insurance Pool (SB 935). It is the author's The state, through county health departments and some opinion that the latter bill is the most important of the nonprofit clinics, currently provides a great deal of pri- three, but it is the first bill (SB 27) that has gained all of mary care and preventive medicine to the uninsured. the media attention. 6 The section of SB 27 that calls for a These clinics operate with minimal funds and yet provide demonstration project requires a waiver in the Medicare/ a maximum amount of service. It was proposed that $2 Medicaid rules, and failure to obtain this waiver in order million be provided by the general fund (a minimal figure) to proceed with the demonstration project has kept the to the State Health Division and local-county public health entire proposal from becoming operational. departments for this purpose. By improving access to the Currently, the state has not formally applied for the nec- generally high-risk populations that use these clinics, and essary waiver and is awaiting the results of the Health thereby providing early and preventive treatment, it was Services Commission work. The Commission is close to hoped that long-range improvement in health care, with completing its work and made a first draft public in March accompanying decreases in expenditures, would ensue. 1991 so that the legislative session currently convening Caring for the Uninsured 139 could make its budget deliberations. If this can be accom- were within state budget resources. The only "outside" plished in late spring of this year, the waiver application help needed would be a waiver from the Health Care Fi- will be submitted. If the waiver is obtained, the program nancing Administration for the Medicaid demonstration could be in place by July 1992. project. However, even without this, it was thought that CONCLUSIONS a basic health care package could be defined and that the To provide health care for the estimated 400 000 of its other recommendations could be acted on. Ensuring ac- citizens without health insurance, the State of Oregon ap- cess for better health care should ultimately reduce costs pointed a commission to study the problem and make rec- and result in a healthier population. ommendations. The Commission arrived at six recom- References mendations that, if enacted, would solve the problem of 1. Governor's Commission on Health Care. Report to Gov- ernor Neil Goldschmidt on Improving Access to Health Care for equitable access without excessive financial burden. They all Oregonians. Salem, Ore: Office of Health Policy, State of were (1) an employee tax credit for small businesses; Oregon; September 1, 1988. (2) a state-run high-risk pool; (3) an expansion of Medicaid 2. Kornbrot C. Risk reduction in pregnancies of low income to 100% of the FPL; (4) a plan for continuation of benefits women. Mobius. 1984;4:34-43. to the recently unemployed; (5) increased funding for pri- 3. National Academy of Science Institute of Medicine. Pre- mary clinics, especially in the more rural areas of the state; venting Low Birth Weight. Washington, DC: National Academy and (6) various cost-containment strategies, particularly Press; 1985. managed care programs and tort reform. 4. Brook RH, Kosecoff JB. Competition and quality. Health Aff (Milwood). 1988;7:153. Currently, a newly created state agency, the Health Ser- 5. Golenski JD, Blum SR. Oregon Medicaid Priority-Setting vices Commission, is completing its work to prioritize ser- Project. Portland, Ore: Medical Research Foundation of Ore- vices and the administrative structure to deliver these ser- gon; December 1988-March 1989. vices. All of the above recommendations could be carried 6. Allen R. Why the Oregon plan deserves your support. Med out within existing medical and insurance systems and Econ. 1990; 16:18-26. Prioritization of Health Care Services A Progress Report by the Oregon Health Services Commission Harvey D. Klevit, MD; Alan C. Bates, DO; Tina Castanares, MD; E. Paul Kirk, MB; Paige R. Sipes-Metzler, DPA; Richard Wopat, MD The Oregon Health Services Commission is composed of Bill (SB) 935 required all employers to provide health insur- a group of 11 consumers and health care professionals. It was ance for the 260 000 uninsured working Oregonians above appointed by the governor as required by the "Oregon Basic the federal poverty level either directly or indirectly through Health Services Act" to produce a prioritized list of health a state-run pool. SB 534 established a mechanism for pro- services ranked on the basis of their relative importance to viding coverage for the 20000 individuals with preexisting populations served. Following actuarial analysis, the legis- conditions that are often excluded by commercial health in- lature will determine the extent to which the "list" of ser- surance. The third, SB 27, was the most controversial. It has vices can be funded to provide health care access for Med- been widely publicized as "Oregon's plan for rationing icaid recipients earning up to the 100th percentile of the health care" and was designed to increase the eligibility for federal poverty level. Prioritization will be based on a cost- Medicaid coverage to 100% of the federal poverty level from benefit formula applied to each treatment/condition unit the current 67% (an additional 116000 recipients) by limiting and assignment of each of these to a general category, which the number of health services the state would cover. The itself has been ranked on the basis of "public value." benefits covered for Medicaid recipients would also serve as a minimum package employers would be required to pro- vide under SB 935. I n 1988 it became necessary for Oregon, like other states, This legislation has remained controversial. Work is still to address a budgetary shortfall in the funding of health in progress to establish a required list of prioritized ser- services for Medicaid recipients. The Oregon Legislature vices, and it appears that the decision at the federal level, determined that it would no longer pay for most organ whether to grant Oregon waivers for Medicaid mandates, transplants, but instead would use the money recovered will be postponed at least until the final report and pri- for maternity care for approximately 1500 women. As a oritized list of services is completed and approved by the result, a 7-year-old boy named Coby Howard was denied legislature. This promises to be a social policy issue that funding for a bone marrow transplant for leukemia; he will be hotly debated in the political arena. died $30 000 short of the $100 000 needed to obtain the An 11-member body, the Oregon Health Services Com- procedure, and became a cause célèbre in spite of the fact mission (HSC), was appointed by the governor in August that he was not in remission and thus not a good candidate 1989, and given the simple, straight forward instruction for the procedure.¹ It was pointed out by Golenski¹ that "to report. a list of health services ranked by priority arbitrary removal of one type of treatment without con- from the most important to the least important, represent- sidering the entire spectrum of care was inherently unjust. ing the comparative benefits of each service to the entire Oregon was and still is rationing health care covertly population to be served." The bill includes additional pro- through decreasing the number of individuals eligible for visions that are fundamental to the process, among which Medicaid services. Currently, only those residents with are the following: (1) active solicitation of public involve- family incomes up to the 67th percentile of federal poverty ment in a meeting process to build a consensus on the level are eligible for the Medically Needy Program. A pilot values to be used to guide health resource allocation de- study, "The Oregon Medicaid Priority Setting Project," cisions; (2) implementation through contracting with showed that a group of health professionals could rank the managed-care systems; (3) the legislature, at a time of bud- importance of general categories of care. This played an getary shortfall, would not have the authority to limit the important role in convincing the legislature that priorities number of recipients by modifying eligibility requirements could be set and helped pave the way for innovation. but would be obliged to decrease the number of available In the 1989 legislative session Oregon adopted sweeping services or make more funds available to cover the existing initiatives to reduce considerably the number of individuals services; (4) the reimbursement or capitation rates for pro- without access to health care. These bills, comprising "The viders and plans established under the contractual agree- Oregon Basic Health Services Act," were designed to com- ment could not be reduced at a time of insufficient re- plement one another by providing access to basic health care sources; and (5) Medicaid services mandated for the for the approximately 400 000 uninsured of the state. Senate elderly, blind, or disabled persons, or children in foster care would continue without prioritization. Accepted for publication March 22, 1991. The HSC is composed of five physicians (three family phy- From the Oregon Health Services Commission, Salem. sicians, an obstetrician, and a pediatrician), a public health Reprinted from Archives of Internal Medicine (1991;151:912-916). nurse, a social worker, and four laypersons, one of whom Health Care 141 was the chairman. The appointment of primary care pro- were explored as possible tools to measure the relative viders to the HSC tended to minimize pressure from special benefits of the health services under consideration. The interests thus enhancing general acceptance of the final rank- Quality of Well-Being (QWB) Scale of Kaplan and Ander- ing of services. In its brief existence, it has encountered a son² was selected as the most appropriate and thorough mixture of advice, support, and the following criticisms: (1) measure for our purposes. Simply stated, it measures how the principles on which Oregon is basing its prioritization are an individual functions independently and how he/she unethical; (2) it is impossible to rank services in a rational, feels normally and during illness. Its advantage over other logical way on the basis of a cost-benefit formula derived tools is that it will provide an interface between scientific from population health outcomes; (3) the bill itself does not fact provided by informed practitioners in terms of symp- directly address cost containment problems of the existing toms and disabilities and the public's perception of the system; (4) this social/medical experiment should not be con- relative importance of them. ducted on the Medicaid population alone, but prioritization Kaplan's QWB system is a measure of an individual's of services should be applied to everyone regardless of age, disability, state of health, personal resources, and the source or population's overall state of health at a point in time. of their health insurance; (5) the prioritization process does The method assigns a score of 1.0 to a perfectly healthy individual and a score of 0 for death (see Tables 1 and 2 not include mandated services for the elderly, disabled, blind, and mentally defective, which account for 70% of the for limitation and symptom codes with weights supplied Oregon Medicaid budget; and (6) this is yet another "Band- by the public). The severity of certain limitations in phys- Aid" approach; the nation should move with haste to a uni- ical activity, mobility, social activity, and/or the presence versal access national health insurance program modeled af- of physical or mental symptoms derived from a list of 24 ter the Canadian or British systems, or design a new plan. categories allows the calculation of the QWB score. Each These opinions have been presented in a variety of forums disability and symptom was weighed on the basis of in- from poignant personal testimony in public hearings to formation supplied by Oregon residents during a tele- broad political polemic. Through the process, HSC has been phone survey. The QWB formula is as follows: buoyed by the universal acceptance that society's expecta- QWB = 1 - [Mobility Weight] - [Physical Activity tions are on an inevitable collision course with its resources, Weight] - [Social Activity Weight] - [Symptom Weight] and that something must be done. The need to prioritize is The net benefit of a service or intervention for a par- widely accepted and legislation similar to Oregon's is being ticular condition or group of conditions was defined as the considered in 10 or more other states. It is more honest to difference between the expected QWB score resulting recognize the enormity of the individual tragedies that ac- from the condition and that following either definitive or company the absence of health insurance than to pretend that no such problem exists, so that action taken on the basis palliative treatment (net QWB). This measure was applied of that honest acknowledgment is-a priori-ethical. to a large number of treatments used for the majority of In summary, HSC has been charged to develop a list of conditions coded according to the International Classifica- prioritized services used for all illness, injury, intoxication, tion of Diseases, 9th ed. Calculation was further refined by and ascertain the effectiveness of each service applied to the applying the duration of time with QWB status persisted. A cost-benefit formula was defined as follows: target population. The legislators will then determine at what point on the list a line will be drawn below which ser- Cost, $ vices cannot be funded unless additional resources are al- = located. Net Benefit X Duration, Years This article serves as a progress report, describing some Cost, $ of the problems HSC has encountered and the process it [QWB₂-QWB₁] X Duration, Years has adopted to establish its list of services. QWB₁ = QWB Resulting from Untreated Condition METHODS Oregon SB 27 does not specify a method or approach for QWB₂ = QWB Following Treatment HSC to develop its ranked list of services. Scientific proof of relative benefit of a treatment or intervention to the pop- Cost represents charges submitted in the past to the Or- ulation served was neither specified nor implied in the egon Adult and Family Services Division as supplied by the language of the bill. A Health Outcomes Sub-Committee Oregon Office of Medical Assistance Programs as well as was formed early in the process of HSC for the purpose other payers and providers. The cost includes all services of developing an approach to the evaluation of the relative pertaining to a particular diagnosis, including laboratory and importance of each service to be considered. A subcom- imaging services, hospitalization, drugs, professional fees, mittee was also formed to explore methods to rank mental and ancillary services such as physical and occupational ther- health services that have been exempted from prioritiza- apy, rehabilitation, and social services. tion for the initial implementation of the plan. It was rec- Since virtually all medical conditions are associated with ognized that a list of ranked services is meaningless with- multiple symptoms and/or limitations, the probability of out applying each of them to specific conditions. occurrence for each symptom/limitation as well as death Moreover, HSC believed that public and professional ac- was also applied to the equation. Thus, the QWB score for ceptance would be maximized if an objective measure- an individual with a given condition with or without treat- ment tool was used in determining relative benefit of each ment is 1.0 (perfect health) less the sum of the weights of of the services considered on the basis of outcome, du- each symptom/limitation multiplied by their probabilities ration of benefit, and cost. of occurring: The sum of the probabilities of all symptom/ Methods that assess the state of health of an individual limitations must total 100%. 142 Caring for the Uninsured and Underinsured Table Oregon VS Orange County, California, Table -Oregon VS Orange County, California, Quality of Well-Being (QWB) Weights for Physical and Quality of Well-Being (QWB) Weights for Symptom Social Limitations Category Orange Orange Oregon County Oregon County Definition QWB Weight QWB Weight Condition QWB Weight QWB Weight Mobility Scale Loss of consciousness due to No limitations for health reasons 0 0 seizures, blackouts, or coma -0.099 -0.407 Did not drive a car, health Bad burn over large area -0.359 -0.387 related; did not ride in a car Drainage from sexual organs as usual for age (younger than and discomfort or pain -0.308 -0.349 15 years), health related, and/ or did not use public Trouble learning, remembering, transportation, health related; or thinking clearly -0.359 -0.340 or had or would have used Difficulty walking because of more help than usual for age paralyzed or broken leg -0.270 -0.333 to use public transportation, health related -0.045 -0.062 Pain or weakness in back or joints -0.248 -0.299 In hospital or nursing home, health related -0.044 -0.090 Pain while urinating or having bowel movement -0.289 -0.292 Physical Activity Scale No limitations for health reasons 0 0 Stomachaches, vomiting, or diarrhea -0.358 -0.290 In wheelchair, moved or controlled movement of A lot of tiredness or weakness -0.264 -0.259 wheelchair without help from Coughed, wheezed, or had someone else; or had trouble trouble breathing -0.310 -0.257 or did not try to lift, stoop, Often felt depressed or upset -0.316 -0.257 bend over, or use stairs or inclines, health related; and/ Headaches or dizziness -0.298 -0.244 or limped, used a cane, Itchy rash over large area of crutches, or walker, health related; and/or had any other body -0.288 -0.240 physical limitation in walking, Trouble talking -0.181 -0.237 or did not try to walk as far or Pain or discomfort in the eyes as fast as others the same age or had vision problems that are able, health related -0.364 -0.060 corrective lens cannot fix -0.244 -0.230 In wheelchair, did not move or Overweight or facial acne -0.204 -0.188 control the movement of wheelchair without help from Pain in ear or trouble hearing -0.212 -0.170 someone else, or in bed, Prescribed medication or diet chair, or couch for most of the for health reasons -0.119 -0.144 day, health related -0.536 -0.077 Wear glasses or contact lens -0.052 -0.011 Social Activity Scale No limitations for health reasons 0 0 Trouble falling asleep or staying asleep -0.243 0 Limited in other (eg, recreational) role activity, Trouble with sexual health related; and/or limited performance -0.255 0 in major (primary) role Unable to stop worrying -0.209 0 activity, health related; and/or Trouble with the use of alcohol performed no major role or drugs -0.421 0 activity, health related, but did perform self-care activities -0.062 -0.061 episodic treatments are considered to be 1 year in dura- Performed no major role tion. Treatments of self-limited conditions are considered activity, health related, and to have 5-year durations. Treatments such as hip replace- did not perform or had more ment that have a duration of greater than 5 years but less help than usual in than a lifetime are considered for the expected lifetime of performance of one or more self-care activities, health the treatment. One-time treatments that will not be re- related (eg, needed help peated (eg, appendectomy) are considered to have lifetime going to the bathroom or benefits. eating) -0.100 0.106 All data were entered into a computerized database, which calculated the "cost per benefit year" for each item The expected outcome results are measured at 5-year on the list and then sorted them in rank order from lowest intervals, which is the customary norm for treatment suc- to highest. When the final list becomes available, it will be cess. The duration of benefit of an individual condition- subjected to actuarial analysis. A capitation rate will be treatment pair may have one of four effects. Repetitive or computed for each item on the list representing its total Health Care 143 cost per recipient per budget year. At the point when the Public Hearings running total of the capitated costs equals available re- Twelve public hearings were held throughout the state sources nothing lower on the list will be included in the and others were planned for the future. On the average, benefit package unless further resources can be allocated. 45 formal testimonies were given at each hearing, with The legislature is not authorized to change or rearrange the some 150 in attendance. The Oregon Health Action Cam- list in any way. Nothing below the funding line may be paign, an advocacy coalition of 72 smaller grassroots or- provided unless the more "effective" items above it are ganizations, supported the process; one of its constituent also included. groups provided door-to-door canvassing to encourage at- Data Collection tendance. Testimony from providers was not infrequent, The use of a cost-benefit formula required information but the majority of contributors identified themselves as regarding health outcomes. It became evident at the start consumers. of the project that outcomes established scientifically by Principal concerns expressed at the public hearings gen- randomized trials for most of the common treatments and erally fell into one of two categories: those concerned with services delivered on a daily basis are largely not available. the prioritization process and SB 27 ("philosophical is- Morell³ reassured HSC, "In the best of all possible worlds, sues"); or those advocating that high priorities be assigned you would have clinical trials (instead of clinical judg- to certain specific categories of service ("special interest ments) to determine the efficacy of each treatment, but issues"). The tenor of the hearings demonstrated that that would take you 30 years to do, by which time the many Oregonians put health care at the top of their per- treatments would be obsolete." sonal list of priorities. To await the results of the current outcome research move- The philosophical issues most frequently articulated in- ment would postpone this project for years. It was concluded cluded health care as a right; the need to guarantee that that ranking of services could be based legitimately on a con- adequate health care be available to all; the persistence and sensus on outcomes obtained from knowledgeable experi- even institutionalization of a two-tiered system of health enced practitioners. The International Classification of Diseases, care in the United States, with "doors open for the rich, 9th ed, and Current Procedural Terminology, 4th ed, codes closed for the poor"; and the desirability of ensuring per- were used to create approximately 1600 condition/treatment sonal choice among providers and delivery systems. pairs to be prioritized for the list. The pairings often con- The special interest issues that most regularly emerged tained a "clustering" of multiple conditions and interven- concerned organ transplants, family planning, and other re- tions that were closely related and for which it was suspected productive services, and maternity care, including reim- that outcomes would be similar. bursement for midwifery. Finally, HSC's members were Most input was provided by subspecialty, specialty, and urged to give low rankings to "unnecessary surgeries," but generalist groups recruited from their respective state pro- few examples were suggested. fessional societies. In addition, dentists, osteopaths, nurse practitioners, and other alternative providers were asked Community Meetings to contribute data. Each of these groups was given con- The planning of the community meetings focused on the dition/treatment pairings for consideration that were com- aim of consensus building and solicitation of shared public monly employed in their scope of practice. In instances values. Oregon Health Decisions,⁴ a citizens' nonprofit or- where data appeared inconsistent or incomplete "second ganization, which sponsors such community discussions, opinions" were sought. conducted 47 meetings in the winter of 1990 on behalf of HSC. Members of HSC were intimately involved in the Public Participation planning and evaluation of these meetings. With respect to ensuring public participation, HSC's Volunteer facilitators and coordinators were recruited mandate was made explicit in SB 27. Testimony and in- from throughout the state, and were given special training formation were to be solicited from "advocates for seniors; to help them involve their communities. In total, 1048 Or- handicapped persons; mental health services consumers; egonians gathered together to express their values about [and] low-income Oregonians," as well as from providers health care, in essence responding to the question, "Why of health care. Public hearings were to be conducted for are certain health care services important to us?" Back- this purpose. In addition, a community-meeting process ground information on the "Oregon Experiment" was pro- was to be instituted to "actively solicit public involvement vided, exercises were completed in small groups, and [and] to build a consensus on the values to be used community consensus was articulated in the course of to guide health resource allocation decisions." each meeting. Thirteen "values" or desirable character- Efforts were initiated early to meet these objectives. Of istics for health care approaches emerged as the most fre- three subcommittees established at the outset, two con- quently discussed (Table 3). It is acknowledged that the cerned themselves specifically with public and consumer frequency of discussion of a topic has no direct inference input: a Mental Health and Chemical Dependency Com- as to the importance of a value. However, the information mittee, its membership actually including consumers; and garnered from community meetings and public hearings a Social Values Committee. The latter undertook to help will serve as an important qualitative determinant in the organize, facilitate, and provide HSC's first oversight of final "fine-tuning" of the list. the community meetings and public hearings processes, Each type of forum appears to have provided a quali- as well as a random telephone survey of Oregonians. The tative sense of the relative public importance of numerous public's right to attend all HSC and committee meetings factors necessary to consider in planning health policy. is guaranteed by Oregon state law requiring open meet- The HSC has expressed its commitment to examine ings. computer-generated drafts of a "prioritized list" in light of 144 Caring for the Uninsured and Underinsured Table 3. Values Developed by the Community Meeting Table 4. List of Categories of Health Services to Be Process* Ranked by Health Services Commission Prevention (very high, mentioned at 100% of meetings) Preventive care for children as defined in US Preventive Services Quality of life (very high, 100%) Task Force Report' (immunizations, well-child care) and treat- Cost-effectiveness (high, >75%) ments of those conditions when the major purpose is to prevent Ability to function (moderately high, 75%) chronic disability (eg, congenital hypothyroidism, treatment of Equity (moderately high, 75%) strep throat) Effectiveness of treatment (medium high, >50%) Preventive care for nutritional deficiencies in children at risk (eg, Benefits many (medium, 50%) iron) Mental health and chemical dependency (medium, 50%) Preventive dental care for children (eg, hygiene, fluoride) Personal choice (medium, 50%) Preventive care for adults as defined in US Preventive Services Community compassion (medium low, <50%) Task Force Report7 Impact on society (medium low, <50%) Preventive care for nutritional deficiencies in adults at risk Length of life (medium low, <50%) Preventive dental care for adults (eg, cleaning, fluoride) Personal responsibility (medium low, <50%) Vision and hearing screening for adults Health education for adults (eg, smoking cessation, alcohol abuse) *Frequency of discussion at meetings is indicated within parentheses. Health and safety education (eg, workplace) for adults Initial diagnostic screening of presenting problem Maternity care (eg, prenatal, natal, and postpartum) all public input herein described, and will make adjust- Family planning (eg, sterilization, termination, education, and ments or relocate any service or treatment on such a list counseling) if the public would be better served by doing so. In the Infertility services (eg, workup, treatment, and counseling) words of one commissioner, the final list must be "value- Treatment of acute life-threatening conditions where treatment driven, not computer-driven." prevents imminent death with a full recovery and return to previous health state (eg, appendectomy, bacterial meningitis) Treatment of acute life-threatening conditions where treatment Telephone Survey prevents death but without a full return to previous health state The telephone survey performed in conjunction with (eg, cerebrovascular accident, gunshot to the head) the Department of Psychology, Oregon State University, Treatment of acute nonfatal non-self-limited conditions with Corvallis, asked 1001 individuals to assign numeric scores return to previous health state (eg, skin diseases) Treatment of acute nonfatal conditions where treatment will to various sets of health symptoms and functional impair- improve quality of well-being without return to prior health ments, as they relate to a scale where perfect health equals state (eg, burns) 100 and death equals 0, derived from Kaplan's QWB Scale Treatment of acute nonfatal self-limited conditions where treat- (see the "Methods" section). As such, resultant-weighted ment will expedite return to prior health. state (eg, measles, values, standardized and incorporated into the mathemat- chicken pox, and viral warts) ical prioritization model, reflect Oregon specific public in- Treatment of a fatal chronic condition where with treatment one put about the health status of individuals, without refer- would return to previous health state with improvement in life span and quality of well-being (eg, major depression, trans- ence to the question of one individual's health problems plants, diabetes, schizophrenia) or needs when viewed in the context of societal resource Treatment of a fatal condition with no improvement in life span allocation. but improvement in quality of well-being (eg, stage IV cancer) The equal completion and refusal rates for the survey Treatment of a fatal condition with improvement in life span, but demonstrated sensitivity of the questions; demographic with no improvement in quality of well-being (eg, life support) One-time treatment of nonfatal chronic conditions with improve- information collected simultaneously was reassuring ment in quality of well-being (hip replacement) overall with respect to adequate representation of the pop- Repetitive treatment of nonfatal chronic (with recurrent or contin- ulation of the state. uous symptoms) conditions with improvement in quality of The telephone survey concluded with an open-ended well-being with short-term benefit (eg, epilepsy, rheumatoid question, "Is there anything you would like to tell us about arthritis) your health or about health care in Oregon?" to which 40% Treatment of nonfatal conditions with minimal or no improve- responded. Of these, 42% expressed concern about the high ments in quality of well-being or life span (eg, viral pneumonia) Comfort care for persons with less than 1 year to live costs of both insurance and health care; an additional 11% recommended national health insurance and/or other con- trols of the health care industry; and 8% cited problems of values articulated at the numerous public hearings and access including "uninsurability." community meetings held in all regions of the state. In summary, various modalities have been and continue to be employed by HSC that health services prioritization RESULTS be a public process. The public hearings and community The first test of the methodology occurred on May 2, meetings provided numerous opportunities for civic par- 1990 when a preliminary incomplete prioritized list was ticipation in many remote areas of the state. All meetings made available to the HSC as well as to the public. As are open to the public and with rare exception there are expected, numerous flaws, aberrations, and errors were questions and comments from the audience. An ongoing present; those conditions appearing at the top of the list effort to provide informative press releases has contrib- were as follows: (1) bacterial meningitis, (2) phenylketo- uted to a sustained high profile for the project in the state nuria (3) non-Hodgkin's lymphoma, (4) septicemia, (5) press and elsewhere. A representative group of Orego- meningococcemia, (6) disseminated candidiasis, (7) sal- nians provided input now integral to the formulaic pri- monellosis, (8) Wilms' tumor, (9) other bacterial infec- oritization model. Most important, HSC has committed tions, (10) autoimmune hemolytic anemia, (11) congenital itself to preparing a prioritized list that fairly reflects the adrenal hyperplasia, (12) Ewing's sarcoma, (13) Hodgkin's Health Care 145 disease, (14) insulin-dependent diabetes mellitus, and category of health care. A modified Delphi technique was (15) bacterial endocarditis. Opponents of the plan seized used to reach final consensus of the category rankings on this as an opportunity to criticize and to ridicule the based on the above public attributes. entire process on the basis of what resulted from the first This process allowed consideration of the public values test of the methodology. 5,6 Reporting of the most prelim- and attitudes that were well expressed at public meetings. inary methodology testing in an open process did little to Each condition/treatment pair was then assigned to a enhance the public image of the HSC's competence. category of care and ranked on the basis of its cost:benefit Aberrations in the preliminary list of prioritized services ratio as determined by the formula. Thus, the final ranking made it apparent that there were major deficiencies and of a service will be driven more by its category assignment inaccuracies in the data used in the cost-benefit formula. than by its formula-derived value. This was regarded as Although the continued use of the formula was chal- appropriate at this time, since so few scientifically based lenged, a number of commissioners refused to abandon health outcome studies are available. the model, agreed to upgrade the cost and outcome in- formation, and to study the effects of revision of certain CONCLUSIONS of its components. A dual approach was embarked on, one The HSC has been in existence for slightly over 1 year. "cleaning the data" and testing the formula and the other It exists for a single purpose- to provide a list of services exploring alternate methods of prioritization. ranked on the basis of relative importance to the popu- All data were revisited and modified when necessary for lation served. Simple rhetoric, daunting task. A cost- inappropriate aggregation of codes for similar morbidities, benefit formula approach, referred to as "pseudo-science" incomplete costs, and questionable outcome information. by some,5 has been tested. It has been fraught with dif- The duration of a benefit was more clearly defined for ficulties, especially the unavailability of accurate cost and treatment of chronic diseases and self-limited disorders. outcome information. It is hoped that with progress in the The group evaluating new approaches worked more outcome movement, more useful data will allow more sci- with the "soft data," the values of the public, and the opin- entifically accurate ranking and prioritization of services. ions of providers heard at open meetings, than with the With the development of a number of categories of outcomes and cost information that appeared to be elusive health care that will be ranked in importance on the basis and unreliable. The system of categorization of health care of the large amount of public testimony, the final list services proposed by D. Hadorn, MD, served as a basis should be based on clear messages from consumers of care for the fresh approach (New Jersey Health Decisions Assem- as well as the cost of producing 1 year's worth of QWB. bly. May 19, 1989). This provided a way of subdividing the large number of health services into more manageable References groupings. Hadorn's original 10 categories were expanded 1. Golenski JD Jr. A report on the Oregon Medicaid priority to a total of 26 (Table 4). Nearly half of the categories are setting project. Presented at the Cleveland Conference orl related to the care of acute and chronic diseases and the Bioethics, Cleveland, Ohio, June 2-5, 1990. other half were special categories such as preventive 2. Kaplan RM, Anderson JP. A general health policy model: update and applications. Health Serv Res. 1988;23:203-217. health care, maternity care, and comfort care. 3. Morell V. Oregon puts bold health plan on ice. Science. Once the 26 categories of care were agreed on it became 1990;249:468-471. possible to assign each of the individual treatment/ 4. Crawshaw R, Garland MJ, Hines B, Lobitz C. Oregon health condition pairs into an appropriate category. decisions: an experiment with informed community consent. The 26 categories were then ranked by HSC on the basis JAMA. 1985;254:3213-3216. of three attributes: (1) the importance to the individual; (2) 5. Budetti P. Medicaid rationing in Oregon: political wolf in the importance to society; and (3) whether the category a philosopher's sheepskin. Presented at the Cleveland Confer- was basic or essential to a health care plan. ence on Bioethics; June 2-5, 1990; Cleveland, Ohio. This was accomplished by each commissioner's rating 6. The Oregon rationing plan: inspired or misguided? Healthweek. 1990;18. of each category on a 1 to 10 scale for each of the attributes. 7. US Preventive Services Task Force. Guide to Clinical Pre- The sum of the three ratings for each category by each ventive Services: An Assessment of the Effectiveness of 169 In- commissioner served as a basis for ranking each generic terventions. Baltimore, Md: Williams & Wilkins; 1989. Overcoming the Prejudice Against Establishing a National Health Care System Richard J. Botelho, MD O ur health care system has been very successful in pro- ing health care costs that it considers economic and busi- viding the most technologically advanced medical ness approaches to address the problem of access to health care in the world to affluent and well-insured segments of care and rising health care costs. A paradoxical question society. Pride in this accomplishment has contributed to arises from this economic preoccupation: "Can the most a success-induced blind spot. Our society overlooks and affluent health care system in the world afford to provide fails to adequately respond to the most significant short- health care to all of its people?" Even though more at- comings of our health care system, namely, social inequal- tention has recently been given to the plight of the un- ity in access to health care and escalating health care insured and underinsured poor, our society overlooks the costs. 1-6 ethical dimensions of these problems. Our country spends the highest percentage of gross na- Our tunnel vision focuses our attention on economic tional product on health care and, yet, 37 million unin- options, such as financing methods and identifying new sured Americans have limited access to medical care⁷,⁸; 11 sources of revenue. Regrettably, this vision lacks an ethical million of these Americans are children, 7 million of whom perspective that would help to solve the problems of ac- go without regular medical care. In contrast, all other west- cess to health care and escalating health care costs. From ern democracies implicitly or explicitly used the moral the moral perspective of health care as a human right, the ideal, "health care as a human right," to establish different previous question now becomes "how do we pay for our types of national health care systems (NHCS). These sys- belief in this moral ideal?" For our society to address this tems provide health care to all citizens regardless of their question, we must first expand our vision and ethically ability to pay and operate under a controlled budget. Re- analyze the largely unconscious, cultural values that ham- grettably, the prejudice against establishing an NHCS pre- per our ability to solve these problems. vents our society from assuring that all Americans have Ironically, opinion polls show that most Americans fa- access to affordable health care and from controlling es- vor a right to health care and an NHCS to provide health calating health care costs. care for all. 9-12 In contrast, the Constitution of the United In effect, our society discriminates against providing States does not address a right to health care nor provide health care to the uninsured and underinsured poor. Dis- the government with any guidance on how our society criminatory health care practices arise from both economic should address the health of the nation. 13 Not surpris- and organizational barriers. The uninsured and underin- ingly, a recent court case denied that health care is a human sured poor must overcome these barriers to obtain medical right.¹⁴ care. This legal decision is consonant with the Constitution, The economic barrier is the inability of patients to pay but it certainly is not consonant with the Universal Dec- for needed medical care. This barrier has many conse- laration of Human Rights (1948), 15,16 signed by US repre- quences for patients and their families, which include the sentatives, that specifies medical care as a right. Since all following: patients' inability to pay for medications, office US citizens do not have access to basic health care, we visits, procedures, and hospitalizations; patient delays in remain in violation of article 25, section 1, of the Universal seeking health care; the psychological effects on the family Declaration. Thus, on the issue of universal access to arising from these delays in seeking health care; and bur- health care, public opinion and the Declaration of Human dening families with severe financial problems when they Rights stand in contradiction to current public policy and do seek health care. the Constitution. The organizational barriers that impede our society from Clearly, the reasons why we have inequality in access assuring universal access to health care arises from struc- to health care and escalating health care costs are not sim- tural deficiencies in our health care system; the most no- ple, and resolving these problems will not be easy. We lack table deficiencies are the poor distribution and insufficient an adequate understanding of why the moral ideal of numbers of primary care physicians and the lack of a gov- "health care as a human right" is not a part of our public erning body to control rising health care costs. policy. Most importantly, we pay inadequate attention to Currently, our government is so preoccupied with ris- the value system that underpins our actual health care policies and practices. Accepted for publication March 20, 1991. Numerous proposals have been suggested to resolve From the Department of Family Medicine, Jacob W. Holler Family the plight of the uninsured. 17-20 Before advocating any of Medical Center, Rochester, NY. these proposals, the task of successfully incorporating Reprinted from Archives of Internal Medicine (1991; 151:863-869). public opinion into public policy will be easier if one first National Health Care 147 Table 1.-A Conflict of Value Systems: Values for and Against a National Health Care System Against For Self-serving individualism Societal-serving individualism Libertarianism Health Egalitarianism Care Ethics Antisocialism Human rights Antigovernment Level 1 Democracy sentiment Health Care Politics, Business ethic Human services Law, and Policy Sovereignty of the Primary care as the foundation Level 2 biomedical paradigm of the health care delivery system Health Care Services Table 2. The Major Flaws in Our Health Care System Level 3 Basic health care is not available for all Secondary and Tertiary Care No explicit moral directives govern our health care policy Level 4 Absence of a national health care policy Primary Care No budgetary controls over health care costs Haphazard cost-shifting practices Level 5 A multitier system based on the socioeconomic characteristics of the individual Fig The structure of a national health care system Fragmented health care services Uncoordinated health care delivery conflict; the individual is simply not exposed to or encour- Duplication of health care facilities aged to consider alternative values. In addressing health care issues, this concept can clarify how our internalized No rational and equitable distribution of specialists cultural values implicitly conflict with alternative values, Covert rationing of health care resources which would assure universal access to health care (Table 1). understands the reasons for the moral hypocrisy arising This conflict of value systems is rarely made explicit in from the discrepancy between our professed belief in public discussions or articulated in policy statements. The health care as a human right and our discriminatory health uninsured and underinsured poor are the victims of an care practices. Unless our government and society are ed- unresolved conflict of value systems with regard to our ucated about the reasons why health care as a human right health care policy. Unless this conflict of value systems is is not the moral ideal governing our health care policy, no explicitly addressed, solutions focusing on uninsured and proposals are likely to put our expressed ideals into action. underinsured poor will not address the flaws of our health An analogy can be drawn from the circumstances of an care system (Table 2). alcoholic patient to address this moral hypocrisy. The al- Understanding the powerful influence of our value sys- coholic patient may agree that abstinence is in the best tem (Table 1) helps to explain why public opinion polls interest of his or her family, but the alcoholic continues to inadequately reflect society's intent to establish an NHCS, drink in spite of the unhealthy effects on the family. For why health care as a human right is not incorporated into the alcoholic patient, the "benefits" of continued drinking our health care policy, and why all US citizens do not have (relief from the pain of living) outweighs the ill effects of access to affordable health care. In contrast, all other west- that behavior on the health of the family. ern democratic countries have established different types In an analogous fashion, individuals with health insur- of national health care systems that assure universal access ance coverage have become addicted to their medical to health care. Describing the common values and features "benefits," the overuse and misuse of investigations, of these systems can help our society understand why we death-defying technological interventions, and proce- have not putithis moral ideal into practice. dures. Unfortunately, these addictions monopolize and inefficiently use our limited health care resources in a way NATIONAL HEALTH CARE SYSTEMS that is detrimental to the overall health of our nation. In Health care is a human right. This moral ideal is the making this analogy, the metaphor of addiction is in- guiding principle of the health care ethic in national health tended to highlight the discrepancy between what we say care systems (Fig 1). This ideal carries an obligation for in public opinion polls and what we do with our health governments to assure universal access to health care. care policies and practices. This analogy does not explain With the notable exception of our country, all other west- the reasons for this discrepancy. ern democratic countries use this health care ethic to guide Enculturation is a key concept to the understanding of their health care politics, laws, and policies and to estab- the discrepancy between our professed belief in health lish primary care as the foundation of the health care sys- care as a human right and our discriminatory health care tem. practices. Enculturation is the process whereby members An NHCS is predominantly a nonprofit human service of society unconsciously internalize cultural values. This operating under a controlled budget. Individuals contrib- process occurs in the absence of interpersonal and social ute to the national health care budget through general tax 148 Caring for the Uninsured and Underinsured Table -Common Characteristics of Western, ration of Independence that "all men are created equal." Democratic Health Care Systems This moral ideal simply did not apply to blacks. Subse- All citizens have ready access to a family doctor quently, the government introduced legal remedies to put this ideal into practice by outlawing slavery and giving Patients have no or nominal health care bills blacks the right to vote. In effect, racial prejudice stood in Tax revenues and/or national insurance pay for basic medical the way of making Thomas Jefferson's statement become care more of a reality. Access to high-cost technology and hospital care is regulated In an analogous fashion, our society believes that health A fixed budget controls government expenditure for health care is a human right but resists changes that would assure care universal access to health care. The value system that gov- erns our health care system stands in the way of achieving Table -Contrasting Characteristics of universal access to health care (Table 1). This value system US Health Care System is implicitly incorporated into our health care policy and Primary care has an inadequate number and poor consists of the following values: libertarianism, self- distribution of physicians serving individualism, antisocialist rhetoric, antigovern- Patients are more economically vulnerable to high medical ment sentiment, the business ethic, and the sovereignty bills of the biomedical paradigm. These values shape the char- Employers and individuals pay more for the cost of acteristics of our health care system, which sharply con- medical care trasts with other western democratic health care systems Access to high-cost technology and hospital care is (Table 4). poorly controlled This value system accounts for the economic and or- The open system of financing health care contributes to ganizational barriers that prevent the uninsured and un- its escalating costs derinsured poor from gaining access to affordable health care. This set of cultural values forms the basis of our so- revenues and/or national insurance. Then, patients have ciety's prejudice against having an NHCS. In effect, our no or nominal health care bills at the time that health care health care system institutionalizes inequitable access to is provided. health care as a consequence of this prejudice. With finite health care budgets, these democracies have Because of this prejudice, opponents of an NHCS have health care policy-making mechanisms that explicitly ad- thwarted attempts to establish such a system on several dress conflicts of interest between the individual and so- occasions in the past. 23-25 These reform failures testify to ciety and conflicts over resource allocation between pri- the power of this prejudice to obstruct the implementation mary care and other levels of care. 21,22 Administrators of of an NHCS. Our society needs to understand better how this policy-making process set priorities to allocate re- our values affect the economic and organizational aspects sources and to organize health care services that will meet of our health care system. Then, proposals advocating policy goals. These western democratic governments pro- equal access to health care, such as the National Health vide patients ready access to family doctors and controlled Program proposal, 17 will have better prospects of assuring access to high-cost technology and hospital care. Table 3 universal access to health care. summarizes the common characteristics of these national health care systems. SELF-SERVING INDIVIDUALISM AND LIBERTARIANISM These countries have established different types of na- American individualism has emphasized self-reliance in tional health care systems to assure universal access to health care matters. The doctor and patient negotiated an health care. For example, the Canadians value the prin- arrangement for the provision of medical care. Then, in- ciple of egalitarianism to such an extent that private in- surance companies became intermediaries in this process surance and private medical practice are not allowed. The to act in the best interest of the individual patient. Even public system provides equivalent health care benefits to with the involvement of third parties, the individual still all Canadians. In contrast, the British government has re- has the responsibility to arrange for health care coverage. cently encouraged the expansion of private health insur- Libertarianism endorsed "absolute freedom of choice" ance, so that increasing numbers of patients are obtaining for doctor and patient. Advocates of this value maintained their medical care independent of the National Health Ser- that doctors and patients should be free from societal and vice. Thus, having an NHCS does not preclude the pos- sibility of private insurance and private medical practice. government infringements in how they negotiate the pro- vision of medical care. Both of these cultural values have THE PREJUDICE AGAINST ESTABLISHING AN NHCS created a special kind of doctor-patient relationship. This Our society needs to understand the reasons why we do relationship became encapsulated by a sacrosanct bound- not have an NHCS and why we cannot assure that all ary and dissociated from its social context. Americans have access to affordable health care. Compar- In effect, physicians act exclusively as the sole advocates ing the Universal Declaration of Human Rights with the for patients without regard to the effects of this relation- Declaration of Independence provides a way of under- ship on society. During the cost-plus reimbursement era, standing why health care as a human right is not part of insurance companies exploited this type of exclusive our health care policy. The United States signed the Uni- doctor-patient relationship and provided physicians with, versal Declaration of Human Rights, which specifically in- in effect, an open checkbook for health care expenses. cludes medical care as a right. 15,16 Health insurance became a growth industry. Physicians The inability of our society to fulfill this obligation has did not have to consider how the medical expenses of well- analogies to Thomas Jefferson's statement in the Decla- insured patients affected society as a whole. National Health Care 149 This open system of financing health care persists and United States. However, such propaganda is effective contributes to escalating health care costs, 26,27 which only because it magnifies the disadvantages while mini- amount to nearly 12% of our gross national product and mizing the overall benefits of these national health care result in a health care expenditure per capita that is the systems. highest of any country in the world. Our concerns over The term "socialist" does not appropriately describe the rising health care costs will not affect this problem, as long health care systems in Canada and England, which are, as we refuse to say "no" in our "yes" society. Not sur- respectively, referred to as National Health Insurance and prisingly, in the absence of a national health care system, the National Health Service. 29-33 The key word is national, federal and state governments are severely handicapped used in the same way as in the phrase national education. in controlling health care expenditure. If we applied antisocialist rhetoric against national edu- In essence, the unchecked influence of self-serving in- cation, one would expect that the right to basic education dividualism and libertarianism created a special kind of for our children would depend on the economic resources doctor-patient relationship. This relationship clearly ben- of the parents. efited the well-insured patients, but it has had a cascade Antisocialist rhetoric is effective in persuading people of ill effects for society as a whole. These ill effects include against establishing an NHCS. The power of this rhetoric the following: the inefficient use of resources, the inap- makes us resist substantive and morally just changes in the propriate use of modern technology, wide discrepancies political and health care systems. This rhetoric is inap- in health care indexes between the rich and poor, and the propriately used to impede the goal of achieving afford- uncontrolled rise in health care costs. These ill effects arose able health care for all Americans. from the well-insured maximizing their freedom of choice, without considering how these choices would affect so- ANTIGOVERNMENT SENTIMENT ciety at large, the uninsured, and the underinsured poor. In the past, the American Medical Association (AMA) Advocates of a libertarian approach to health care con- has done its utmost to keep government out of the picture veniently overlook the fact that medical demand will al- with regard to the clinical practice of medicine. The AMA ways exceed supply and that free-market forces will not has successfully used this antigovernment sentiment to equitably resolve the conflict between the limited supply block many reform initiatives. The AMA did not conjure of and the continuing need for health care. Given this over- up this sentiment in a social vacuum. In fact, the AMA sight, these advocates tolerate or even deny the meritorial capitalized on a prevailing sentiment of society for use as system of rationing health care resources. The wealthy in- effective propaganda. dividuals are free to buy boutique medical care, and the This antigovernment sentiment still exists and contin- poor are at liberty to choose free or charitable medical care, ues to undermine the role of government in organizing a if available. national health care system. This sentiment persists in This libertarian attitude toward health care accounts for spite of the fact that all other western democratic govern- our inconsistent response in addressing the issue of access ments have successfully adopted such systems and have to health care. For example, prisoners are legally guar- insured that all of their citizens have equitable access to anteed health care, whereas the uninsured poor, impris- health care. oned by their poverty, are not afforded equal treatment. And yet, we do not use this sentiment against the gov- The poor cannot afford to pay for doctors' visits and med- ernment organizing our national defense! We entrust our ications or for medical insurance. Thus, criminals have bet- government rather than individuals to act in the public ter access to health care than the uninsured poor. Our good of society. In spite of many shortcomings, our na- society responds more favorably to criminals whose illegal tional defense is one of the best in the world and protects activities have resulted in the denial of their individual all American citizens against external threats. In contrast, liberties than to the law-abiding poor whose liberties are our aggregate health care indexes lag behind most western curtailed by their poverty. democracies. ANTISOCIALIST RHETORIC THE BUSINESS ETHIC Our society reflexively associates national health care Our society has treated health care as a commodity, systems with socialism. This mind-set accounts for pre- which has led to the primacy of the business ethic in the dictably biased evaluations when we examine other na- health care delivery system. This ethic rationalizes the dis- tional health care systems. The derogatory associations of tribution of health care resources according to the eco- totalitarian principles with socialism provide excuses for nomic characteristics of the individual. The business ethic not seriously considering the advantages of other national in health care has ended professional immunity from an- health care systems. Furthermore, antisocialist rhetoric is titrust laws and given rise to the medical-industrial used to discredit, for example, the advantages of the Brit- complex. 34-39 ish and Canadian health care systems. This ethic has also changed the health care delivery sys- Overall, these countries have equivalent or superior in- tem. For example, two economic factors have been respon- dexes of health, yet spend less on health care than does sible for closing many hospitals: the high percentage of the United States.2⁸ In spite of these documented advan- Medicaid recipients attending the hospital and the inad- tages, certain disadvantages have become modern-day equate reimbursement for Medicaid patients. These clo- folklore, such as the unavailability of renal dialysis for pa- sures have been to the detriment of the health care needs tients over the age of 50 years or the long waiting lists for of the surrounding community. hip replacements in the British National Health System. The current reliance (despite rapidly fading optimism) These disadvantages have become effective propaganda on free-market forces purports to increase competition against adopting a national health care system in the and efficiency in health care delivery, and to reduce health 150 Caring for the Uninsured and Underinsured scribed previously, the sovereignty of the biomedical par- Tertiary and Secondary Care adigm has inverted the structure of the NHCS (Fig 2). This inverted hierarchy reflects how the values of the biomed- ical paradigm have been enshrined in our health care sys- Health Care Ethics tem. These values have had a pervasive influence over the direction of medical education, health care policy, and Health Care Politics, law. For example, New York State law regulates how a Law, and Policy physician writes a do not resuscitate order. Thus, the law mandates standard treatment as patients exit the health care system but not as patients enter the system. The Health Care Services death-and-dying issues of secondary and/or tertiary care take precedence over the issue of access to health care at the primary care level. Primary Care WHY IS HEALTH CARE NOT A HUMAN RIGHT? Viewed in the context of this value system, it becomes clearer why our society cannot put the moral ideal, health care as a human right, into practice. Health as a right can be viewed from different ethical perspectives. According to one perspective, rights can be categorized as negative Fig. The inverted hierarchy of our health care system; the sov- or positive.51 ereignty of the biomedical paradigm. A negative right can be regarded as a libertarian value; the individual's liberty is protected against infringements from society or the government. Individuals are respon- care costs. 40 In fact, the for-profit sector provides less char- sible for their own health care. They can use their economic ity care, avoids high-risk patients, and is not any more resources to buy whatever health care they choose. In con- efficient than the nonprofit sector. 34,41,42 The for-profit sec- trast, a positive right can be regarded as an egalitarian tor shows no promise of alleviating the ailments of the value; the individual receives health care entitlements health care system, such as administrative waste or the from the government. Then, government is responsible poor distribution of physicians and health care re- for ensuring that all Americans have equitable access to sources. 43,44 This sector, which is at liberty to divert profits quality health care. away from the provision of health care in favor of invest- In a health care system with finite resources, the central ments in other business ventures, has no motive to restrict conflict of values affecting health care policy is the right growth or to reduce the national expenditure for health to individual liberty vs the right to equality. However, our care. This approach will not and cannot solve the problem society buys into the myth of unlimited resources. This of rising health care costs nor can it solve the problem of myth helps our society to overlook our finite resources and inequitable access to health care. to avoid this central conflict of values. This allows our so- As a consequence of how the business ethic influences ciety to place a higher value on a negative right over a the administration of health care policies and debates positive right to health care. about those policies, economic considerations override Opponents of an NHCS, when predicting the impact of concerns for the basic health care needs of the uninsured. a system predicated on a positive right to health care, por- Too much time is devoted to concerns over who will pay tray a scenario in which the health care system encourages for the rising costs of health care. Too little time is spent the individual to make inordinate demands for medical on how to set a finite budget on health care expenditure services and becomes institutionally responsible for the and on how to distribute limited resources equitably so as health of all individuals. 52 This distorted prediction over- to maximize the health of all members of society. looks the fact that demands for medical care will always exceed supply and that society can work toward setting SOVEREIGNTY OF THE BIOMEDICAL PARADIGM limits on the demands for health care. As a society, we are captivated by the successes of the The addition of "basic" to the phrase "health care as a biomedical paradigm: the achievements of specialization, human right" avoids these criticisms by setting limits on modern technology, and tertiary care. Our society places the amount of health care that an individual can reason- higher priorities on the values of this paradigm at the ex- ably expect. Then, "basic health care as a human right" pense of primary care and long-term care. These priorities could be considered a negative right as the individual be- have given rise to sovereignty of the biomedical paradigm. comes protected against an infringement created by so- As a consequence, primary care has an inadequate num- ciety, the economic and organizational barriers that block ber and poor distribution of physicians,43 and long-term the individual from gaining access to adequate health care. care is poorly organized within a two-tier system, ie, Med- In fact, categorizing this modified statement as a negative icaid and private pay. 45-47 Without a controlled health care right highlights one limitation of defining rights in this budget and without primary care physicians controlling dichotomous manner. access to more costly levels of health care, it is not sur- The classification of rights as negative or positive po- prising that cost containment measures have given only larizes the issue of responsibility for health care into two a temporary reprieve from rising health care costs. 48-50 options. Either the individual or society is responsible for Together with the influence of the other values de- health care. This classification oversimplifies a complex National Health Care 151 issue, but it does capture the either/or mentality that per- LIBERTARIANISM/EGALITARIANISM meates this health care debate. In a health care system of finite resources, egalitarianism This either/or mentality is also reflected in the way that and libertarianism are in direct competition with one an- we argue over who will pay for health care, eg, either the other. To date, the value of libertarianism has had a dom- government or the employers. This mentality sets up dif- inating influence on our health care policy at the expense ferent parties in opposition to one another, which makes of egalitarianism. these parties lose sight of the moral ideal of health care as "To what extent is an individual at liberty to use re- a human right. This situation reduces the prospects of col- sources at the expense of another individual's equality? laboration among federal and state governments, individ- And, to what extent does an individual's right to equality uals and society, and physicians and the medical profes- impinge on another individual's liberty?" sion to assure that all individuals have equitable access to affordable health care. For example, our society could es- SELF-SERVING/SOCIETAL-SERVING INDIVIDUALISM tablish an NHCS that relies on the individual to assume Self-serving individualism has been the prevailing ethos as much responsibility as possible for his or her own health of the medical profession, and this ethos has clearly ben- care, but when individuals are unable to assume this re- efited the "haves" of society at the expense of the "have nots." sponsibility, individuals and society contribute to the ef- forts of their government to assure that all citizens have "To what extent should physicians be able to select their access to quality health care. specialty choice and location of employment solely based on their self-interest and thereby shape the supply side of RESISTANCE TO ESTABLISHING AN NHCS the health care delivery system? And to what extent The argument for an NHCS often provokes a defensive should society regulate the distribution of specialists and counterargument that renders our society resistant to es- the location of their employment based on the medical tablishing an NHCS. This defensiveness arises from the needs of the society?" perception that these arguments are attacks on highly "To what extent should the 'haves' of society have ac- cherished values that are an integral part of our health care cess to the best possible medical care when the 'have nots' policy. These values prevent our society from putting the are unable to afford basic health care? And to what extent moral ideal, health care as a human right, into practice. By should the 'haves' subsidize the 'have nots' in gaining understanding the reasons for this defensive reaction, our access to health care?" society may reconsider the priorities of the values affecting our health care policy. ANTISOCIALIST RHETORIC/HUMAN RIGHTS The concept of enculturation helps to explain why this The overzealous use of antisocialist rhetoric is used to moral idea is not currently the governing principle of our maximize the individual liberties of physicians and well- health care policy. Our society has predominantly inter- insured patients at the expense of the moral ideal of health nalized a system of values that makes us prejudiced care as a human right. Unfortunately, antisocialist rhetoric against establishing an NHCS. A dialectic tension exists is used to work against our society trying to put this moral between the value systems that do and do not support ideal into practice. having an NHCS (Table 1). At present, values that do not "How can antisocialist rhetoric be appropriately used to support an NHCS hold sway in public policies. maximize the liberty of all individuals and physicians? Medical societies and associations, employers, hospital How can the moral rhetoric of 'health care as a human associations, medical insurance companies, trade unions, right' be used to appropriately regulate the practice of politicians, and society-at-large must be educated about medicine so that all Americans have access to affordable the values that could help us establish a more equitable, health care?" health care system. These values include egalitarianism, THE ANTIGOVERNMENT SENTIMENT/ societal-serving individualism, human rights, democratic DEMOCRATIC PRINCIPLES principles, human services, and primary care. The antigovernment sentiment is used to persuade so- Applying the concepts of prejudice, discrimination, and ciety that the government is incompetent to organize an moral hypocrisy to this health care debate cannot be done NHCS. This sentiment also works against the use of dem- without causing some defensiveness and discomforting ocratic principles in the provision of health care. controversy. Such a reaction will cause ethical dissonance, "Can we trust our government to be responsible for the which occurs when the values of individuals and/or so- health of our nation, as we do our national defense? How ciety are challenged by conflicting or alternative values can we use democratic principles to ensure that our gov- such that individuals and/or society reevaluate their value ernment develops a highly effective NHCS that is account- system and consider other values. Health care debates are able to the people?" needed to generate ethical dissonance in society. Such de- bates could help our society to adopt the value system of HEALTH CARE AS A BUSINESS/ an NHCS. HEALTH CARE AS A HUMAN SERVICE GENERATING ETHICAL DISSONANCE Our society regards health care delivery more as a busi- ness than as a human service. Brief comments will be made about the values that are in conflict with one another (Table 1). These comments will "To what extent should financial viability of a hospital be followed by questions that aim to generate ethical dis- or the medical needs of a community determine whether sonance. The purpose of these questions go beyond the a hospital remains open or not?" either/or debate on conflicting health care values and con- TERTIARY CARE/PRIMARY CARE sider how to blend conflicting values in a manner that will In a health care system of finite resources, community assure universal access to affordable health care. and hospital-based medical care are in direct competition 152 Caring for the Uninsured and Underinsured with one another for resources; this raises questions about spread media coverage of this educational activity to tri- the relationship between community and hospital-based umph over our national equivocation on these health care medical care. issues. 54 First, our society must sufficiently understand "Should primary care become the foundation of the and overcome its prejudice against having an NHCS. Sec- health care system with primary care physicians being the ond, the government must outlaw discrimination against first point of contact for all patients, or should patients the uninsured and underinsured poor. have free access to any physician? To what extent should To achieve these goals, this educational activity must our society regulate the allocation of resources and reim- generate massive, political support for an NHCS. All in- bursement mechanisms to influence how primary, sec- terested parties-medical societies and associations, em- ondary, and tertiary care are organized?" ployers, trade unions, hospital associations, health insur- The purpose of generating ethical dissonance is to per- ance companies, and activist groups-must lobby elected suade the federal and state governments, the medical pro- officials to overcome political inertia. Such lobbying efforts fession, employers, hospital associations, health insur- must persuade federal and state governments to initiate ance companies, and society-at-large that changing the legislative reforms that would mandate health care as a value system of our health care policy is necessary to human right. Such legislation would reduce discrimina- achieve universal access to health care. tion against the uninsured and underinsured poor. The government would then have to establish a finite CHANGING THE VALUE SYSTEM budget on health care, set priorities democratically about OF OUR HEALTH CARE POLICY what level of health care we can afford for all Americans, Advocating the values of an NHCS does not mean that and develop an NHCS compatible with our culture. Such we abandon the values that are currently incorporated into a health care delivery system may operate as a single-payer our health care ethic. Quite to the contrary, it is a matter system organized by the government or consist of a plu- of how these conflicting value systems are blended to- ralistic mix, eg, nonprofit private and public and, possibly, gether. For example, the business approach to health care the for-profit sector. Until our society substantively would become subservient to regulations based on the changes and stabilizes the value system of our health care moral ideal of health care as a human right. ethic, millions of Americans will go without adequate To achieve such a change, society must undergo a moral medical care, and the health care system will remain un- conversion to a new blend of ethical priorities. In this way, just. we will avoid patchwork reforms that incrementally change our fragmented health care system. 53 Such incre- References mental changes will never solve the problems of inequi- 1. Iglehart JK. Medical care of the poor: a growing problem. table access to health care and rising health care costs. N Engl / Med. 1985;131:59-63. 2. Hayward RA, Shapiro MF, Freeman HE, Corey CR. Ineq- Addressing this conflict of value systems will determine uities in health services among insured Americans: Do working whether our society can solve these two problems. age adults have less access to medical care than the elderly? N The solution to these problems lies primarily in the Engl / Med. 1988;318:1507-1512. moral domain: clarifying and changing the values of our 3. Curtis R. The role of state governments in assuring access health care ethic (see level 1, Fig 1). A well-articulated to care. Inquiry. 1986;23:277-305. health care ethic that has widespread support will stabilize 4. Darling H. The role of the federal government in assuring the direction of health care politics, policy, and law. Un- access to health care. Inquiry. 1986;23:295-306. fortunately, most discussion papers and debates on these 5. Ginzberg E. Medical care for the poor: no magic bullets. JAMA. 1988;259:3309-3311. problems rarely make explicit the conflict of value systems affecting our health care ethic. 6. Schmidt D. The challenge of caring for the underserved. Fam Med. 1989;21:257-260. Without understanding the conflict of values affecting 7. Cohodes DR. America: the land of the free, the land of the our health care ethic, the political, policy, and financial uninsured. Inquiry. 1986;23:227-235. debates on these two problems will continue to polarize 8. Holloman JLS Jr. Securing Access to Health Care. Wash- the various participants in health care into opposing fac- ington, DC: President's Commission for the Study of Ethical tions. These opposing factions will doom health care pol- Problems in Medicine and Biomedical and Behavioral Research; icy changes to vacillating incrementalism or stagnation, as 1983;2:83. in' the recent case of the Catastrophic Health Care Bill or 9. Navarro V. What is the popular mandate? N Engl J Med. in the current issue of who will pay for the health care of 1982;307:16-18. the uninsured. Unless we commit ourselves to the health 10. Blendon RJ. The public's view of the future of health care. JAMA. 1988;259:3587-3593. care ethic of an NHCS, reform plans will not be imple- 11. Danielson DA, Mazer A. Results of the Massachusetts mented for a period of time sufficient to solve these two referendum for a national health program. J Public Health Pol- problems and will fall victim to uninformed political de- icy. 1987;8:30-35. bate, stop-gap efforts, and haphazard changes. 12. Schneider W. Public ready for real changes in health care. :Not surprisingly, our democratic society will remain in Natl J. 1985;17:665. violation of article 25, section 1, of the Universal Decla- 13. Holloman JLS Jr. Securing Access to Health Care. Wash- ration of Human Rights. Advocating health care as a hu- ington, DC: President's Commission for the Study of Ethical man right will not convince federal and state governments Problems in Medicine and Biomedical and Behavioral Research; to assure that all Americans have access to affordable and 1983;1:33. 14. Curran WJ. The constitutional right to health care. N Engl quality health care. / Med. 1989;330:788-789. Our government and society must be educated about 15. United Nations Universal Declaration of Human Rights. the value system that supports the establishment of an New York, NY: United Nations; 1948;25:1. NHCS (Table 1). Advocates for an NHCS must gain wide- 16. Browlie 1. Basic Documents on Human Rights. New York, National Health Care 153 NY: Oxford University Press; 1981. 35. Relman AS. Antitrust law and the physician entrepreneur. 17. Himmelstein DU, Woolhandler S, and the Writing Com- N Engl J Med. 1985;331:884-885. mittee of the Working Group on Program Design. A national 36. Blythe SL. Megacorporate health care: a choice of the health care program for the United States: a physicians' pro- future. N Engl J Med. 1985;312:579-582. posal. N Engl / Med. 1989;330:102-108. 37. Bromberg MD. The medical industrial complex: a na- 18. Enthoven A, Kronick R. A consumer-choice health plan tional defense. N Engl J Med. 1983;309:1314-1315. for the 1990s: universal health insurance in a system designed 38. Schramm CJ. Revisiting the competition/regulation de- to promote quality and economy. N Engl J Med. 1989;330:29-37, bate in health care cost containment. Inquiry. 1986;23:236-242. 94-101. 39. Hillman AL, Nash DB, Kissick WL, Martin SP. Managing 19. Hirt EJ, ed. The Health Policy Agenda for the American the medical industrial complex. N Engl J Med. 1986;315:1-3. People. Chicago, III: American Medical Association; 1987. 40. Himmelstein DU, Woolhandler S. Cost without benefit: 20. The National Leadership Commission on Health Care. For administrative wastes in US health care. N Engl / Med. the Health of a Nation: A Shared Responsibility. Ann Arbor, 1986;314:441-445. Mich: Health Administration Press Perspectives; 1989. 41. Watt JM, Derzon RA, Renn SG, et al. The comparative 21. Thurow LC. Learning to say no. N Engl J Med. economic performance of investor-owned chain and not-for- 1984;311:1569-1572. profit hospitals. N Engl J Med. 1986;314:89-95. 22. Evans RW. Health care technology and the inevitability of resource allocation and rationing decisions: part I. JAMA. 42. Kinzer D. The decline and fall of deregulation. N Engl J Med. 1988;318:112-116. 1983;249:2047-2053. 23. Starr P. The Social Transformation of American Medicine. 43. Petitti DB. Competing technologies: implications for cost New York, NY: Basic Books Inc Publishers; 1982. and complexities of medical care. N Engl J Med. 1986;315:1480- 1483. 24. Califano JA. America's Health Care Revolution: Who Lives? Who Dies? Who Pays? New York, NY: Random House Inc; 44. Barnett PG, Midtling JE. Public policy and the supply of 1986. primary care physicians. JAMA. 1989;262:3064-3068. 25. Navarro V. Why some countries have national health in- 45. Health and Public Policy Committee. Long-term care of surance, others have national health services, and the US has the elderly. Ann Intern Med. 1984;100:760-763. neither. Soc Sci Med. 1989;30:887-898. 46. Kane RA, Kane RL. The feasibility of universal long-term 26. Fuchs VR. The counterrevolution in health care financing. care benefits: ideas from Canada. N Engl J Med. 1984;312:1357- N Engl / Med. 1987;316:1154-1156. 1364. 27. Relman AS. Dealing with conflicts of interest. N Engl J 47. Moon M. Taking the plunge: the arguments for a com- Med. 1985;3:747-749. prehensive long-term care system. J Am Geriatr Soc. 28. Navarro V. The public and private mix in the funding and 1989;37:1165-1170. delivery of health care systems: an international survey. Am J 48. Ginzberg E. Is cost containment for real? JAMA. Public Health. 1985;75:1318-1330. 1986;256:254-255. 29. Relman AS. United States and Canada: different ap- 49. Schwartz WB. The inevitable failure of current cost con- proaches to health care. N Engl J Med. 1986;315:1608-1610. tainment strategies. JAMA. 1987;257:220-224. 30. Iglehart JK. Canada's Health Care System, 1. N Engl J Med. 50. Ginzberg E. A hard look at cost containment. Engl Med. 1986;315:202-208. 1987;316:1151-1154. 31. Iglehart JK. Canada's Health Care System, III: addressing 51. Beauchamp TL, Faden RR. The right to health and the right the problem of physician supply. N Engl J Med. 1986; 315:1623- to health care. J Med Philos. 1979;4:118-131. 1628. 52. Sade R. Medical care as a right: a refutation. N Engl Med. 32. Lister J. General prospects for the national health service. 1971;285:1288-1292. N Engl J Med. 1988;318:1473-1476. 53. Dickman RL, Ford AB, Liebman J, Milligan S, Schorr AL. 33. lliffe S, Haines A. Developments in British general prac- An end to patchwork reform of health care. N Engl J Med. tice. Fam Med. 1989;21:169-170, 175-176, 229-230. 1987:317;1086-1088. 34. Gray BH, McNerney WJ. For profit enterprise in health 54. Levey S, Hill J. National health insurance: the triumph of care. N Engl J Med. 1986;314:1523-1530. equivocation. N Engl J Med. 1989;321:1750-1754. Universal Access to Health Care A Comprehensive Tax-Based Approach Jack A. Meyer, PhD; Sharon Silow-Carroll, MSW, MBA; Carl J. Sardegna, MBA More than 30 million Americans lack health insurance, hence greater productivity-may be worth the extra initial and millions more are "underinsured." Meanwhile, the cost investment. of health care in the United States is escalating, and some of our care is of questionable value. This article presents a BASIC PRINCIPLES health care reform strategy that addresses these three fun- To address the access, cost, and quality problems si- damental problems in the US health care system. The strat- multaneously, some type of fundamental reform is clearly egy, designed to empower consumers to make cost- needed. The following principles should guide our efforts: conscious health care choices, combines a universal tax No one should be denied access to necessary care for credit that enables all Americans to purchase basic health financial reasons. coverage; insurance reforms including pooling and reinsur- Consumers should be empowered to purchase health ance mechanisms; requirements that all employers make in- care coverage for themselves. surance available to their employees and that all consumers Cost discipline must be built into efforts to expand purchase coverage; and efforts to measure and improve the access, and consumers should share in the financial con- quality and efficiency of health care services. This strategy sequences of their choices. would help us to achieve universal health insurance cov- No one should be excluded from receiving subsidies erage, while creating the proper incentives for cost control. because of arbitrary characteristics such as family or wel- In addition, it can be largely internally financed through sav- fare status. ings automatically triggered by its implementation. Subsidies should not be "open-ended"; ie, they should not automatically ride up with health care cost es- calation. T he purpose of this article is to describe a new approach Better information about the appropriateness of med- to achieving universal health insurance coverage in ical care and the comparative performance of health care the United States in a way that also creates the proper providers must be generated and disseminated to improve incentives for cost control. The United States faces a di- our control over the quality of that care. lemma now. More than 30 million Americans lack cov- Incentives are preferable to controls as a means to ex- erage, and millions more are underinsured against the pand access, control costs, and improve quality. threat of "catastrophic" expenses. At the same time, health Risks should be spread over large groups to maintain care costs are rising sharply, and broadening coverage affordability of insurance for individuals. without making major structural reforms is likely to ac- celerate cost escalation. Furthermore, purchasers of health THE STRATEGY services are often uncertain about the value they are get- The strategy presented here uses the above principles ting for their money, as they lack adequate measures of to help achieve universal access to health care coverage, quality of care. create mechanisms for pooling risks for the millions of This article presents a strategy that addresses the prob- Americans who are uninsured, encourage cost control, lem of access, cost, and quality in the US health care sys- and establish the means to evaluate and improve the qual- tem. This strategy builds universal coverage and cost- ity of health care. The unique feature of this strategy is that control incentives into the system. It involves new it combines into one package a variation of Enthoven's¹ government spending, but the plan can be largely inter- original approach based on universal tax credits with a nally financed through a redistribution of existing re- plan for assuring that employers make a group insurance sources and offsetting savings automatically triggered by vehicle available to workers; insurance market reforms to its implementation. While the plan is not completely tax assure that no one is denied care as a result of his or her neutral, the gap between its costs and the automatic sav- current health status; personal responsibility among con- ings is manageable, and could be closed in a variety of sumers for acquiring coverage and for the cost conse- ways. Furthermore, the long-run economic and social ben- quences of their choices; and a greater emphasis on mea- efits of achieving universal coverage-better health and suring quality and rewarding providers who practice Accepted for publication March 20, 1991. medicine that is likely to produce good health outcomes. From New Directions for Policy, Washington, DC (Dr Meyer and Thus, our plan provides both the means and the mech- Ms Silow-Carroll), and Blue Cross and Blue Shield of Maryland, Ow- anisms to assure universal coverage. It does this in a way ings Mills (Mr Sardegna). that also builds cost discipline into the health care system Reprinted from Archives of Internal Medicine (1991; 151:917-922). and promotes the delivery of high-quality care. Universal Access to Health Care 155 The primary components of this strategy are as follows: would be facilitated in the long run by outcomes research Empowerment of the consumer through universal, re- and quality measurement, discussed further below. Ad- fundable tax credits for the purchase of health insurance ditional cost containment could result in the long run from Requirement that employers offer group insurance to bringing basic and preventive health care to the millions their employees of Americans who are currently not receiving these ser- Pooling mechanism to help spread risk over large vices. groups and to make available group coverage to the unem- To assure affordability of basic coverage, the subsidy ployed would be greater for low-income individuals and families. Reinsurance mechanism to protect carriers from inor- Subsidy categories could also be based on the current dis- dinately high risks tinction between "self" and "family" insurance policies. A Requirement that all consumers purchase basic health third, "self plus one dependent" category could also be coverage considered. Within these categories, age brackets would Ongoing efforts to measure and improve quality of care be established (eg, at 5-year intervals for both men and women) to reduce cross subsidies. Universal, Refundable Tax Credits The means for assuring universal coverage would be a refundable federal income tax credit for all Americans that Requirement That Employers Offer Group Insurance could be used exclusively for the purchase of health in- All employers, including small groups and self-insured surance. This approach is a variant of the tax credit pro- businesses, would be required to offer at least two "qual- posal first put forth by Enthoven.¹ The credit would be ified" group insurance plans to their employees. At least sufficient to cover a substantial portion of the premium one of the plans offered must be a low-cost, "basic" plan cost for a basic insurance plan. The refundability feature that would be limited to coverage for hospitalization, phy- means that households with no federal tax liability would sician visits, x-rays, laboratory work, and limited mental still get the credit. People who do not file federal income health benefits. Employers would not be required to fund tax forms would simply fill out a one-page form (or it could health benefits since the tax credit largely serves this pur- be a preprinted postcard) and send it to the Internal Rev- pose. enue Service. They would get a "refund" even though they The second health plan offered must include at least the paid no taxes. basic insurance package provisions. All qualified plans The tax credit would replace both the Medicaid program must include some cost sharing (deductibles and copay- (the acute care portion) and the current federal tax pro- ments) to help contain costs and a stop-loss provision to vision that allows employees to exclude from taxable in- protect consumers against catastrophic costs associated come the full value of employer contributions to health with major illness. The requirement to offer at least two insurance plans. As the current open-ended tax exclusion plans, only one of which must be limited to basic benefits, disproportionately benefits higher-income Americans permits employers to continue to offer a plan that is more and fails to provide any assistance to many lower-income comprehensive than the basic plan, rather than being re- people, while the proposed tax credit would benefit all quired to scale down their existing plan. Consumers could Americans, this strategy distributes resources more eq- then buy the more comprehensive plan as a package, in- uitably. stead of being forced to buy coverage for extra services "a In the short term, Medicare would remain in place to la carte." serve older Americans and the disabled. We may consider Requiring employers to offer a low-cost, basic plan en- incorporating the Medicare program into the overall strat- sures all workers and their families access to coverage for egy sometime in the future. Reforming the financing of the most critical health care services. This provision re- long-term care is another important challenge, but is be- quires the preemption of current state laws that mandate yond the scope of this proposal. more comprehensive and expensive benefit packages and By placing consumers in a situation in which they are that result in consumers facing an "all-or-nothing" situ- assured of the basics in health care, but must help pay the ation. The new strategy provides that no one goes with cost of additional, "extra" services using after-tax dollars, "nothing," and that consumers who want "all" or "more" this tax credit approach brings the consumer more directly could purchase additional coverage with unsubsidized into the health care picture and helps build cost discipline dollars. into the system. Consumers will be more sensitive to the Employer contributions to the cost of a group health cost implications of their choice of plans, and will pre- insurance plan would presumably drop sharply following sumably seek out and select the more efficient policies. the enactment of a universal tax credit. Employers might In addition, the tax credit would be fixed in value for any continue to contribute an amount that covers some pre- given year, and would be updated annually for general viously covered services that are not included in the basic inflation (not medical inflation). It could be adjusted for plan (eg, dental services and vision care). But consumers measurable changes in technology, labor, or capital costs, would pay the bulk of insurance premiums themselves, but would not ride up automatically with health care costs. using the tax credit to cover their costs. This would help to prevent the type of sudden cost es- To avoid cash flow problems arising from the fact that calation associated with the introduction of Medicare and their tax credits for one year cannot be claimed until they Medicaid, when public reimbursement for health care ser- file their federal income taxes in the following year, em- vices had no limits. Rather, the tax credits, held at rea- ployees could adjust their withholding allowances. This, sonable levels, would put some pressure on providers to in effect, would enable them to receive the value of the tax keep the volume of services in check and to reduce un- credit in continuous increments, reflected in higher take- necessary services and "waste" in the system. This process home pay. 156 Caring for the Uninsured and Underinsured Insurance Reform: Pooling Mechanisms and Reinsurance Requirement That Consumers Purchase Coverage One of the principles behind this strategy is that risks Once all of the above mechanisms are put in place, a should be spread over large groups to maintain afford- requirement would be enacted that all consumers purchase ability for all purchasers. To achieve this, we must set some a qualified insurance plan. This would reduce the current rules of the game for the private insurance industry. "free-rider" problem, where some people who could af- To assure that the tax credit covers most of the cost of ford coverage choose to go without it, and when they do the basic benefit package for all Americans, we propose incur high medical expenses, much of these costs are certain limitations on rating practices. Insurers would be passed on to others. Coupled with the refundable tax allowed to adjust rates for certain demographic factors credit that helps to provide the financial means, manda- such as age and gender. To preserve the incentive to main- tory purchasing should truly allow us to approach uni- tain healthy life-styles, they could also impose a surcharge versal health coverage. on premiums for unhealthy behaviors such as smoking and substance abuse. They could not, however, vary pre- Quality Measurement Efforts miums based on the health status or medical history of The twin problems of rapidly rising costs and inade- beneficiaries. quate access due to coverage gaps are interwoven with a A second aspect of spreading risks involves pooling third problem: the lack of adequate measures of quality in those people who are not part of an employer-sponsored health care. There is mounting evidence that many pro- cedures and tests are of questionable value, if not unnec- group insurance plan. Nonprofit agencies acting as bro- essary, or, in some instances, even harmful. And there are kers would be licensed to enroll the unemployed, along also indications that some doctors and hospitals are much with part-time and seasonal workers, and bring them into better than others in producing desirable health outcomes. the mainstream health system. The individuals who enroll Public and private purchasers of care often simply do not with these brokers would turn over their tax credits to know what value or results they are getting for their them when they are received. In effect, the brokers would money. loan their enrollees the amount of the tax credit, to sur- While the primary goals of this strategy are to improve mount the cash flow problems that these people, who are access to health care and control costs, the plan also in- not working full time, would otherwise experience. cludes measures aimed at improving the quality of care Broker agencies would negotiate rates for their enrollees provided. This begins with efforts to understand and mea- with carriers and choose health insurance plans, as an em- sure "quality" in health care. ployer would do. The agencies would also perform such Gaining an understanding of quality is critical, not just functions as educating those who are not familiar with to improve the kind of care being received, but also as the insurance procedures or options and then helping them key to controlling the utilization and, hence, the costs of choose an insurance plan, sign up, pay premiums, fill out medical services. Purchasers and individual consumers of claims forms, and keep appropriate records. The public care must develop the ability to discuss cost and quality sector would establish guidelines and provide oversight tradeoffs with providers, instead of just haggling over for these agencies. price. To do this, they need to understand and be able to Germany has been successful with the use of brokers gauge several distinct dimensions of quality: necessity, ap- who pool risks and negotiate rates on behalf of consumers. propriateness, effectiveness, satisfaction, and efficiency. German associations called Krankencasse are organized on To accomplish this, employers and group administra- the community, guild, and employer levels. These orga- tors need to agree on and use a uniform data system within nizations negotiate physician fees with medical societies. a community. Information on providers' cost and out- A third type of insurance reform involves reinsurance. comes, adjusted for such factors as case mix, should be States would legislate the formation of reinsurance pools, assembled and made publicly available to all payers. These to which all health insurers and self-insured employers efforts can be initiated by statewide data commissions and would contribute premiums. The reinsurance would kick supplemented by private efforts. in once medical costs exceeded a certain threshold This type of outcomes research would enable those se- amount. lecting health plans to compare the performance of doc- A cost-effective approach would involve reinsuring se- tors, hospitals, and other health care providers and to steer lected high-risk individuals in a plan that includes deduct- their group members to the most effective providers. This ibles and copayments. Other cost management techniques is not an easy or a quick process. But over time, the careful frequently used in conventional health insurance plans, collection and analysis of clinical severity-adjusted data such as case management and utilization review, should would lead to the development of medical practice guide- also be included in the reinsurance plans. lines and protocols. This should help to reduce unnec- With this reinsurance mechanism to protect insurance essary care and to improve the quality and efficiency of health care services in the long run. carriers that have relatively large numbers of high-risk en- rollees from catastrophic losses, additional insurance re- ESTIMATING THE COST OF THE TAX CREDIT STRATEGY forms could be enacted. These include mandating open The cost of the new strategy described above depends enrollment, prohibiting preexisting condition exclusions, on a number of variables- the first being the exact amount and enforcing guaranteed renewability of coverage for as of the tax credit. The credit would equal a portion of the long as a person remains in the covered group. The basic full cost of the premium for the basic plan. purpose of these reforms is to assure initial access to cov- For individuals and families with incomes below the erage for all Americans and to protect those who become poverty line, the subsidy should equal 100% of the pre- ill or disabled. mium for basic health insurance. The tax credit should Universal Access to Health Care 157 Table 1. -Estimated Cost of a Refundable Tax Credit for Table 2. Estimated Total Cost of Tax Credit Under Four the Non-Medicare Population (in Billions of 1989 Scenarios (in Billions of 1989 Dollars)* Dollars)* Basic70 Basic80 Income Group Basic70 Basic80 Sub50 85.85 98.12 Below poverty line Sub70 104.50 119.43 (100% subsidy) Individuals 4.37+ 4.99 *See "Estimating the Cost of the Tax Credit Strategy" section of the Families 16.83 19.24 text for definitions of terms. 100% to 200% of poverty line (80% subsidy) costs approximately $1400 for individuals and $2700 for Individuals 3.72 4.25 families.² Our basic plan is meant to be a somewhat scaled- Families 14.32 16.37 down, "bare necessities" version of today's average plan, Above 200% of poverty line but we acknowledge that it is the basic physician and hos- Sub50 (50% subsidy) Individuals 9.60 pital coverage that constitutes the bulk of the average plan 10.97 Families 37.01 premium. Therefore, we calculate costs under two further 42.30 scenarios: the first assumes that the basic plan would cost Sub70 (70% subsidy) Individuals 13.44 70% of the current average plan, and the second assumes 15.36 Families 51.82 59.22 that the basic plan would cost 80% of the current average plan. These assumptions are based on current examples *See "Estimating the Cost of the Tax Credit Strategy" section of the text for definitions of terms. of scaled-down insurance policies that feature significant tSample calculation: 4.46 million individuals below poverty X 100% cost-sharing, provider discounts, and managed care. We subsidy X $980. Basic70 plan = $4.37 billion. call these scenarios Basic70 and Basic80, respectively. Thus, we derive rough cost estimates under four alter- then be scaled down as income increases, until it reaches native sets of assumptions: Sub50/Basic70, Sub50/Basic80, the "standard" subsidy at a designated income level. Sub70/Basic70, and Sub70/Basic80. Subtotals for the var- There are many options for, and considerations in- ious income groups are presented in Table 1. The total cost volved in, setting the standard subsidy. It should be a high estimates for the refundable tax credit under the four al- enough proportion of the cost of premiums to assure that ternative scenarios are presented in Table 2. The total cost everyone can afford basic insurance, as this is the purpose is shown to range from approximately $86 billion to $119 of our strategy. However, as Enthoven¹ has noted, if the billion. (Additional data and assumptions used in cost cal- tax credit covers too much of the premium cost, incentives culations are available from the authors on request.) for health plans to be efficient are weakened, and pre- miums-not to mention health care costs in general- FUNDING FOR THE TAX CREDIT could soar. Funding for the refundable tax credit would come from Other considerations are the availability of funds and four sources. First, the acute care portion of Medicaid the degree to which society chooses to have wealthier would be replaced by the subsidy, "freeing up" Medicaid Americans subsidize poorer ones; eg, the subsidy could funds. Second, employer contributions to health insur- be based on a sliding scale, ranging from 100% of basic plan ance would drop sharply, increasing business profits, premium for those in poverty, down to 30% or 40% for which would result in higher tax revenues from those prof- those with incomes above $150 000. If a less "progressive" its. Third, the largest employer-the government-would system is desired, then the subsidy could be a straight save a considerable amount in direct contributions to percentage for everyone whose income is above 150% of health coverage for its employees. Fourth, the remaining the poverty line. employer contributions to health insurance premiums For the purpose of making initial cost estimates, we will would no longer be excluded from taxable income, thereby assume a 100% subsidy for those in poverty, 80% for those increasing revenues from individual income taxes. with incomes between 100% and 200% of the poverty line, In addition to these direct savings, long-run, system- and alternative scenarios of 50% and 70% subsidies for all wide efficiencies would result from (1) more prudent pur- other Americans. We will call these two scenarios Sub50 chasing of insurance plans and health care services as con- and Sub70, respectively. sumers are faced with financial incentives to reduce waste We use the figure of 80% for the near poor as illustrative and overutilization; (2) a reduction in the cost shift from of the need for a gradual phasedown of the tax credit. The nonpaying to paying consumers and from public to private advantage of picking one rate for a range such as 100% to third parties; and (3) the decrease in expensive tertiary care 200% of the poverty line is that it is not administratively resulting from better access to primary, preventive care. complex. A disadvantage is that it may impose greater To the extent that these efficiencies reduce overall health hardship on those closer to the poverty line who are not care spending, resources would be freed up for investment receiving contributions from their employers that would in other sectors of the economy. In particular, employers cover the remaining 20% of the cost of insurance. It would would have more funds available for private investment. be possible to graduate the subsidy within the near-poor The magnitude of these potential savings and economic range without significantly affecting the overall cost es- growth, however, is difficult to project, and they are not timates. counted in short-term budget estimates. The cost of the basic plan could also vary considerably, To estimate the Medicaid savings, we must separate depending on the exact levels of coverage, copayments, long-term-care outlays, which would continue. We count deductibles, and stop-loss thresholds. The "average" plan here only the savings from the acute care part of the pro- 158 Caring for the Uninsured and Underinsured Table 3. Estimated Funding for Tax Credits (in Billions of Dollars)* Sub50/Basic70 Sub50/Basic80 Sub70/Basic70 Sub70/Basic80 Medicaid savings 34.60 34.60 34.60 34.60 Business tax increases 13.71 15.67 19.19 21.93 Reduced insurance outlays for public employees 8.40 9.60 11.76 13.44 Elimination of tax exclusion 12.66 10.92 7.79 5.36 Total Funding 69.37 70.79 73.34 75.33 *Estimates of Medicaid Savings and Elimination of Tax Exclusion are based on 1989 dollars. Estimates of Business Tax Increases and Reduced Insurance Outlays for Public Employees are based on 1988 dollars. See "Estimating the Cost of the Tax Credit Strategy" section of the text for definitions of terms. gram. Moreover, about 45% of such savings will accrue to value of the tax credit. To the extent that this occurs, it will states. Thus, a mechanism must be worked out to garner reduce the amount of additional business profits emerging these savings and use them to help finance the new tax from this plan. But higher wages yield higher personal credit. One possible method is to deduct the projected income taxes. Thus, to the extent that employers' financial state savings from federal payments to states for the long- gain from this proposal is passed along to workers in the term-care portion of Medicaid. Alternatively, the govern- form of higher wages, the revenue gain will take the form ment could reduce federal grants to states for nonhealth of personal rather than corporate income taxes. programs. Developing the precise mechanism for recap- If, however, employers are able to shield more savings turing state savings for federal use is a difficult task, and from both profits and wages, the revenue would be re- the full 45% may not be captured. In the short run, federal duced, but this would not significantly affect the overall budget planners may need to substitute other funding magnitude of our total revenue estimates; eg, assuming sources. However, the purpose of this analysis is to assess that 50% of employer savings were shielded and only 50% the overall, system-wide savings, which would include sav- were taxed (as opposed to 80%), the revenues would range ings to states. From a system-wide perspective, an esti- from $9 to $14 billion. mated $35 billion would be saved by eliminating the acute care portion of the Medicaid program. The estimates of federal savings do not include the likely We cannot estimate precisely how much employer con- savings to local and state governments, which, if counted, tribution to health insurance will fall. Clearly, this would would raise overall savings considerably. Rather, we vary from firm to firm, as some employers "supplement" chose a more conservative approach, assuming that this the tax credit while others do not, and the extent of sup- "windfall" to states would further enable the federal gov- plementation would vary. Industries providing very ex- ernment to recapture the full Medicaid savings to states pensive coverage now, and their employees, would be discussed earlier. confronted with the financial costs and tradeoffs of adding The third source of savings is in direct government out- coverage "at the margin," for unlike the present situation, lays for health insurance for its employees. We would ex- these additions would be counted as taxable income and pect federal, state, and local governments, as employers, would not be underwritten by government. to reduce their contributions to employee health care cov- We can make a rough estimate of employer cutbacks by erage by the amount of the tax subsidy. While these sav- assuming that they would reduce their contributions by ings would not be seen as increased "profits" to be taxed, the amount of the tax credit. This means that employers they are direct "dollar-for-dollar" savings to the govern- who had been contributing an amount exceeding the tax ment. Again, a mechanism must be worked out to channel credit would continue to pay the difference between the not only federal but also state and local savings toward the credit amount and their previous contribution, thereby new tax credit. Under the four alternative subsidy sce- protecting workers from sudden increases in out-of- narios, estimates of these public outlay savings range from pocket costs. Under this assumption, the tax credit for the $8 to $13 billion. employed population would reduce employer contribu- The fourth source of funding for the tax credit is the tions by an amount ranging from $50 to $81 billion, de- elimination of the federal income tax exclusion. While em- pending on the subsidy scenario. This, in turn, would in- crease profits for nongovernment employers. We assume ployer contributions to employees' health care coverage will decline (as noted above), the remaining contributions that employers would shield some of these savings from taxable income, and that only about 80% would be counted will no longer be excluded from employees' taxable in- as additional profits and taxed at a 34% corporate income come. This will provide additional tax revenues. Under the tax rate. This would result in an increase of $14 to $22 four subsidy scenarios, the estimated increase in federal billion in tax revenues. income tax revenues ranges from $5 to $13 billion. (Again, The precise response of employers and workers to a de- these are conservative estimates as they do not include cline in employer health care outlays is uncertain. It is increases in state and local income tax revenues.) likely that a significant portion of the initial increase in Table 3 summarizes the estimated funding sources un- business profits will end up as higher wages for workers. der the four subsidy scenarios. The estimates of total fund- Indeed, some workers may seek and receive higher wages ing range from $69 to $75 billion. (Additional data and to compensate them for the additional taxes they will have assumptions used in these calculations are available from to pay if they want to maintain coverage that exceeds the the authors on request.) Universal Access to Health Care 159 Table 4. - Tax Credit Funding "Shortfall" The centerpiece of the strategy is a system of universal, (in Billions of Dollars)* refundable tax credits. These credits would replace both the acute care portion of the Medicaid program and the Estimated Estimated current tax exclusion associated with employer contribu- Cost Savings Difference tions to health insurance. The tax credits provide the ma- Sub50/Basic70 85.85 69.37 16.48 jority of the funding for universal coverage. Other features Sub50/Basic80 98.12 70.79 27.33 of our plan provide the insurance mechanism and the risk- Sub70/Basic70 104.50 73.34 31.16 spreading needed to assure that all consumers can afford Sub70/Basic80 119.43 75.33 44.10 basic coverage, regardless of their current health status. *See "Estimating the Cost of the Tax Credit Strategy" section of the With these features in place, everyone would be required text for definitions of terms. to purchase insurance coverage-there would be no free rides. MEETING THE FUNDING SHORTFALL Furthermore, rough estimates show that the majority of The cost and revenue estimates presented here are in- the cost of this plan would be "internally financed" by tended to describe the general order of magnitude of the expenditure reductions or revenue increases that would refundable tax credit strategy. The reader may or may not occur as a result of the program. agree with all of the assumptions used, and may choose We cannot claim that this strategy is administratively to substitute his or her own. simple. The very elements mentioned above that would According to this analysis, 63% to 81% of the cost of the improve the health care system may also add a layer of program would be internally financed. The funding short- complexity. Yet none of the reforms is completely untried: fall ranges from $16 to $44 billion, as displayed in Table 4. subsidies based on factors such as income can be found While the majority of the cost of the program is auto- in our current tax system; consumer cost-sharing is prac- matically covered under all four scenarios, to be politically ticed in the private insurance system and in many social feasible and fiscally responsible any new major program welfare programs; and reinsurance is currently used with must be budget neutral. Accordingly, this strategy should other forms of insurance. be linked with other measures that would provide addi- Still, administrative complexity should not be ignored. tional funds to meet the new costs of the program, ie, by It should, however, be considered within the context of raising additional revenues or by reducing current expen- tradeoffs. This strategy addresses the major problems ditures. within our health care system, while maintaining a largely On the revenue side, potential sources include increas- private sector orientation. As a result, the proposal may ing marginal tax rates for individuals and corporations, be more politically feasible than a complete replacement raising the payroll tax rate or the base to which it is applied, of our current system with a national health plan. While increasing excise taxes or instituting a value-added tax, a system such as Canada's public insurance program may and applying existing tax rates to some income that is cur- be easier to administer, it would likely face greater political rently not taxed, such as portions of employee benefits and opposition in this country. retirement benefits. On the expenditure side, significant At the other end of the spectrum, proposals that are less savings could be achieved through reductions in national comprehensive than the strategy presented here may be defense outlays and entitlement programs that are not cheaper and easier to implement and may face less op- means tested. Some combination of these (or other) ap- position, but they are much less likely to achieve our goals proaches could undoubtedly provide the needed funds. of universal access and cost containment. The main point is that the funding shortfall is manage- The strategy presented here is not the only possible so- able, and appears to be a reasonable price to pay in order lution to the access problem in the United States. Yet it to extend coverage to all Americans. In addition, this up- represents one approach that would help to achieve uni- front investment will likely result in a more efficient health versal access, to control escalating costs, and to improve care system and a stronger US economy. the quality of our health care system in a fiscally respon- CONCLUSIONS sible way. This article has described a new approach to achieving References universal health insurance coverage in the United States with built-in cost discipline. It has regulatory as well as 1. Enthoven AC. Health Plan. Reading, Mass: Addison- Wesley Publishing Co; 1980. market features, and it includes important requirements 2. Gabel J, DiCarlo S, Sullivan C, Rice T. Employer sponsored for employers and consumers. health insurance, 1989. Health Aff (Milwood). 1990;9:161-175. Insuring the Uninsured Is Not Enough James E. Dalen, MD, Jose Santiago, MD M any Americans have access to some of the best health prevent these complications results in increased costs of care in the world. Others are not as fortunate. medical care and loss of productivity. Health care expenditures in the United States, already the It is clear that insuring the uninsured and underinsured highest in the world, continue to increase at a seemingly is in everyone's best interest. The May 15th issue of the uncontrolled rate. From 1980 to 1989, US health care ex- Journal of the American Medical Association and the May is- penditures increased by 128%.1 Despite this tremendous sues of the AMA's specialty journals present a wide va- investment in health care, our system is increasingly com- riety of proposals to insure the underinsured. ing under attack. The quality of US health care, as judged In reading these articles, it soon becomes clear that our by indexes such as infant mortality, does not compare well mission is far more than just insuring the uninsured. There with other countries that spend much less on health care. are overt deficiencies in health care coverage in those The May 15, 1991, issue of the Journal of the American Americans who are currently insured by Medicare, Med- Medical Association and the May editions of the American icaid, and private insurers. Just having an insurance policy Medical Association's (AMA's) specialty journals focus on is not enough. Given the magnitude of our nation's health another critical defect in our health care system-more care expenditures, our goal should be to ensure universal than thirty million Americans have no health insurance; access to quality health care to all of our citizens regardless additional millions are underinsured. Friedman¹ esti- of ability to pay or type of health care insurance. mates that the percentage of our citizens who are unin- The proposals in the special issue of the Journal of the sured or underinsured on any given day could be as high American Medical Association and the AMA's specialty jour- as 25%. Ginzberg and Ostow² estimate that we fail to pro- nals have as their goal the provision of health insurance vide effective medical care to about a third of our popu- to all Americans. Most of the proposals would preserve the lation. three dominant payers: Medicare, employer-provided pri- Of the more than 30 million Americans who have no vate insurance, and Medicaid for the poor. Medicare is medical insurance, more than 75% are workers or their retained in its current form or is expanded in most pro- families. The basic reason that so many Americans are un- posals. Nearly all plans focus on the fact that most of the insured or underinsured is that they simply cannot afford uninsured in the United States are workers and their fam- medical insurance. Our increasing health care expendi- ilies. tures drive health insurance premiums higher and higher. Most plans mandate that employers provide insurance We must address the "interdependent problems of rising to all employees or pay a payroll tax to be used to provide costs and declining access."³ insurance. The plans vary in how they would assist em- The widespread lack of adequate medical insurance has ployers, especially small businesses, by means of tax cred- important health and financial consequences. A recent its or other mechanisms, to meet this obligation. These survey of the uninsured in Arizona demonstrated that proposals stress that insurance premiums should be based they were less likely to have a primary care physician and on "community rating" rather than "experience rating." less likely to receive needed medical care than those Ar- The use of experience rating, which charges higher pre- izonans who had medical insurance.⁴ miums for those most likely to seek medical care, is one The impaired access that results from lack of adequate of the reasons that small businesses cannot afford to pro- medical insurance has a high price for society. Medical care vide medical insurance to their employees. for the underinsured is far more likely to involve care in Medicaid has failed its mission of providing health in- the emergency department than in a primary care phy- surance to the poor. Most low-income men and childless sician's office. The increased costs are borne by providers couples are excluded regardless of their poverty status.¹ as free care, or by society via cost shifting. The lack of Almost half of Medicaid expenditures are for the long-term preventive care further increases costs to society. The lack care of the elderly in nursing homes and the long-term.care of prenatal care, for example, increases the probability of of the mentally ill and mentally retarded. Medicaid's mis- care in a neonatal intensive care unit. Failure to detect and sion of providing coverage for the poor is further eroded treat hypertension increases the likelihood of hospitaliza- by the fact that each state sets its own eligibility criteria. tion and care in the intensive care unit for stroke, myo- In some states, income must be as low as 13% of the federal cardial infarction, or congestive heart failure. Failure to poverty level to be eligible for Medicaid. By 1989, it was estimated that only 40% of the population living in poverty Accepted for publication April 11, 1991. From the Editor of the Archives of Internal Medicine (Dr. Dalen) was covered by Medicaid.¹ Most of the proposals recom- and the Department of Psychiatry, College of Medicine, University mend expansion of Medicaid such that it covers all who of Arizona, Tucson (Dr. Santiago). are below the federal poverty level. Some recommend that Reprinted from Archives of Internal Medicine (1991;151:860-862). Medicaid be replaced by a new federal program for the Insuring the Uninsured Is Not Enough 161 poor6,7 or be folded into Medicare.⁸ effective than their predecessors, and they will be more Most of the proposals conclude that a restructuring of expensive! If our current spending of 12% of gross national our current three major payers, Medicare, employee- product on health care is the maximum we can afford, we based insurance, and Medicaid (or an alternative plan for must determine how to contain health care costs if we are the poor), can achieve the goal of providing all Americans to extend access to the uninsured and the underinsured. with basic medical insurance coverage. We will not be able to afford extended access unless we Two of the proposals³,⁸ suggest that our current plu- contain health care costs. ralistic approach has failed and should be replaced with a single-payer national health program, financed by taxes. Nearly all of the proposals for insuring the uninsured The obstacles to the implementation of a national health address the issue of cost containment. Some plans place program at this time are formidable. Enthoven and Kro- responsibility with the consumer, some with providers, nick9 estimate that implementation of a national health and others focus on the payers. plan would require $250 billion in new taxes. Given our Many plans suggest that cost sharing will lead to cost increasing public debt, passage of a tax increase of this consciousness by consumers. They recommend deduct- magnitude seems very unlikely. ibles and copayments to put the consumer at risk. 5,6,8,12 Implementation of a national health plan would require Deductibles and coinsurance will have little impact on the a very large bureaucracy. Many fear that a national health sick who have already exceeded their deductible limits.⁹ plan could result in rationing of health care. Such legis- Countries, including Canada, that have been more suc- lation could expect the vigorous opposition of the medical cessful at cost containment than we do not rely on cost insurance lobby and provider groups such as the AMA. sharing by the consumer. 13 It is the view of the AMA¹⁰ that most Americans are sat- Others place responsibility for cost containment with isfied with their physicians and the health care services the payers. They recommend that they control providers' they receive. fees by using the Medicare model of diagnosis related If we are able to modify our current pluralistic health groups and resource-based relative value scales. 6-8,12,14 care program such that all Americans have basic health Some recommend that payments to providers be capped care insurance, we still face two critical problems. First, we on the basis of the gross national product. 3,8,15 must be certain that in addition to being insured, all Amer- Enthoven and Kronick9 emphasize that "managed com- icans have access to all medically needed health care and petition" will allow payers to control costs. Managed com- that it be quality care. Concerns for cost may lead to a petition has had a significant impact on cost containment; "basic package" that excludes some medical care that is however, it presents the risk that quality and access to care medically necessary. Oregon's plan¹¹ to prioritize health may become less important to the provider than the gen- services, and then to cover only those conditions whose eration of profit.5 costs can be met by available resources, is de facto ration- We believe that the primary responsibility for cost con- ing. It is unlikely that this approach to define a basic med- tainment should rest with the provider, especially the phy- ical insurance package would be acceptable to the Amer- sician. Meaningful cost containment cannot occur unless ican people. A "basic package" must cover all medically we decrease the volume of services. 12 The volume of med- needed care. ical services in the United States can be decreased without Provision of health insurance to all Americans does not guarantee assured access to quality medical care. As Gin- resorting to rationing on the basis of age, ability to pay, or payer. Volume can be decreased if we eliminate un- zberg and Ostow² note, the ease of access of veterans with preferred eligibility status depends on the location of the necessary or ineffective procedures. Practice patterns nearest Veterans hospital. The accessibility of health care must be based on outcomes.⁹ We need to encourage re- to all Americans will depend on the availability of health search aimed at determining what procedures are most care facilities and providers. Due to a maldistribution of likely to benefit which patients under what circumstances. physicians, we have at least 2000 underserved areas in the In short, practice guidelines and standards of care must United States.² To assure access, we must address the be developed that result in cost-effective treatment. To ef- problem of underserved areas. Federally funded commu- fect these changes in physicians' behavior will not be easy. nity health centers show great promise and should be ex- Medical schools and residency programs must take the panded. 2,12 We clearly need additional primary care phy- lead in encouraging cost-effective practice patterns early sicians; our medical schools must address the problem that in each physician's career. Granting agencies must sup- fewer of our graduates are selecting primary care special- port research aimed at assessing the efficacy and defining ties. Ginzberg and Ostow² recommend that we revive the the indications for various medical procedures. Research National Health Service Corps to help provide primary will continue to produce new technology with increasing care services in underserved areas. Unless we can provide costs. We must determine the efficacy of each new tech- the necessary manpower to assure access to all Americans, nology and determine specific indications before we ap- the provision of health insurance policies to all Americans prove reimbursement. Since many tests and procedures will be a hollow victory. are performed as defensive medicine, meaningful mal- Second, we must address the critical issue of the cost of practice reform would lead to an additional reduction in ensuring all Americans access to quality medical care. The the volume of unnecessary medical services. escalating cost of health care is the primary reason that A second way to decrease the volume of medical ser- access to medical care has declined. Unless we ban all med- vices is to have fewer patients. We can decrease the num- ical research, each year we can expect new technology, ber of patients requiring increasingly expensive treatment new procedures, and new medications that will be more by emphasizing primary prevention and early detection. 162 Caring for the Uninsured and Underinsured Hospitalization for stroke has decreased because of effec- dler S. Liberal benefits, conservative spending: the physicians tive treatment of hypertension. Hospitalization for myo- for a national health program proposal. JAMA. 1991;265:2549- cardial infarction has decreased because of treatment of 2554. hypertension, decreased cigarette smoking, and changes 4. A Flinn Foundation Report. Health Insurance in Arizona. in diet. The decrease in health care costs due to the de- Phoenix, Ariz: Flinn Foundation; 1990. crease in just these two diseases is far greater than the 5. Bronow RS, Beltran RA, Cohen SC, Elliott PT, Goldman savings that might be attributable to consumer cost con- GM, Spotnitz SG. The Physicians Who Care Plan: preserving sciousness. Again, research is needed to determine other quality and equitability in American medicine. JAMA. 1991;265:2511-2515. methods to prevent disease rather than to deal with dis- 6. Rockefeller JD. A call for action: the Pepper Commission's ease in its final stages. blueprint for health care reform. JAMA. 1991;265:2507-2510. A third way to decrease the volume of medical services 7. Kansas Employer Coalition on Health Inc. A framework for is to reassess our approach to the terminally ill. It is clear reform of the US health care financing and provision system. that we are providing expensive, high-technology treat- JAMA. 1991;265:2329-2531. ment to many terminally ill patients who do not want these 8. Roybal ER. 'The US Health Act': comprehensive reform for treatments. 16 The widespread use of living wills and/or a caring America. JAMA. 1991;265:2545-2548. durable powers of attorney could save millions of dollars 9. Enthoven AC, Kronick R. Universal health insurance by avoiding unwanted expensive treatment of the termi- through incentives reform. JAMA. 1991;265:2532-2536. nally ill. 17 10. Todd JS, Seekins SV, Krichbaum JA, Harvey LK. Health We believe that the provision of health care insurance access America: strengthening the US health care system. to all Americans is not enough. We must ensure access to JAMA. 1991;265:2503-2506. quality health care to all Americans without regard to their 11. Klevit HS, Bates AC, Castanares T, Kirk EP, Sipes-Metzler ability to pay. This goal is attainable by modifying our cur- PR, Wopat R. Prioritization of health care services: a progress rent pluralistic health care system. report by the Oregon Health Services Commission. Arch Intern Implementation of any of these plans to increase access Med. 1991;151:860-862. will require additional expenditures for health care. There- 12. Nutter DO, Helms CM, Whitcomb ME, Weston WD. Re- fore, all plans to provide quality care to all Americans will structuring health care in the United States: a proposal for the 1990s. JAMA. 1991;265:2516-2520. fail unless we control health care costs. Meaningful control 13. Holahan J. An American approach to health system re- of costs will require us to decrease the volume of medical form. JAMA. 1991;265:2537-2540. services. The volume of medical services can be signifi- 14. Davis K. Expanding Medicare and employer plans to cantly decreased by eliminating unnecessary and ineffec- achieve universal health insurance. JAMA. 1991;265:2525-2528. tive procedures. Physicians must lead the way by utilizing 15. Fein R. The health security partnership: a federal/state practice patterns and standards of care that result in cost- universal insurance and cost containment program. JAMA. effective treatment. 1991;265:2555-2558. If we reexamine our priorities, we can ensure that all 16. Cohen-Mansfield J, Rabinovich BA, Lipson S, et al. The Americans have access to quality health care. decision to execute a durable power of attorney for health care References and preferences regarding the utilization of life-sustaining treat- 1. Friedman E. The uninsured: from dilemma to crisis. JAMA. ments in nursing home residents. Arch Intern Med. 1991;265:2491-2495. 1991;151:289-294. 2. Ginzberg E, Ostow M. Beyond universal health insurance 17. Gamble ER, McDonald PJ, Lichstein PR. Knowledge, at- to effective health care. JAMA. 1991;265:2559-2562. titudes, and behavior of elderly persons regarding living wills. 3. Grumbach K, Bodenheimer T, Himmelstein DU, Woolhan- Arch Intern Med. 1991;151:277-280. On the Care of the Poor and the Uninsured Boris M. Astrachan, MD, Donald J. Scherl, MD A ccess of the poor to mental health services is varied and further distrust. In the process, the individual relationship of in many sections of the nation reflects Medicaid pay- the practitioner to the patient, and the duty each has to the ment policies and the availability of state- and/or county- other, has been changed in ways we only poorly comprehend. supported programs. Norquist and Wells¹ demonstrate in How then are we to alter the present circumstances of these this issue of the ARCHIVES that in Los Angeles (Calif), a rel- high-risk groups? How can we better serve the poor? As atively resource-rich community with fairly extensive Norquist and Wells¹ explain, we do not yet know clearly state-supported services, those without health insurance whether services provided to Medicaid beneficiaries and may well have less adequate access to mental health care heavily used in the authors' study represent an adequate level than do poor residents who are eligible for Medicaid, yet of care, although we do know from Bruce et al² that the the Medicaid-eligible residents and uninsured residents Medicaid-eligible population is likely to have a higher preva- had similar prevalences of serious psychiatric disorders. lence and severity of illness than the general population. Ex- The poor tend to be sicker. As Bruce et al² demonstrate, tending health care insurance to all employed people does not after comparing the low-income population, which is de- solve the problem, although it might well alleviate part of it, but fined in much more precise terms than has been the case in for the unemployed who are poor and without community- earlier literature, with the general population, previously provided care, some other alternative is needed. Norquist and "healthy" poor people are almost twice as likely to develop Wells¹ suggest that Medicaid be extended to this population. mental illnesses over 6 months as their nonpoor counter- Some form of guaranteed access to health care is certainly parts. While this is no surprise, the increasing ability to doc- needed. However, we cannot expect changes in health policy ument in detail the nature of the association between poverty alone to change health status and health outcomes. We do not and mental illnesses is critically important if we are to begin yet fully understand the specific impact of the often crowded, to understand the mediating mechanisms that influence the dangerous, and unstable living conditions of many poor per- incidence and prevalence of mental illnesses among high- sons on the development and treatment of mental and physical risk populations. illness. It seems obvious that sickness destabilizes an already Our experience with chronic mental illnesses over the marginal life. Chronic illness strains the capacity of even caring last two decades provides at least one clear lesson as we friends and relatives. It does so to a much greater extent when contemplate the needs of those who lack access to care for poverty compounds illness. The poor who are ill have difficulty mental illnesses because they are uninsured or poor: while negotiating multiple service systems. While access to care may there is much that we do not know and must study at be available, it may be difficult to maintain treatment. What is length and in detail, there is much that is known, and that true of the disabling mental illnesses is equally true of chronic we do not use. More might be done had our society the physical illnesses. desire and the will. When President Bush recently said Our society has maintained a remarkable belief in the ca- that we are a compassionate people, he was surely correct, pacity of the individual: the individual can surmount difficulty but when he said we had "more will than wallet" he had and succeed despite disability. At times, it appears as if the it exactly backward. extraordinary dedication of dollars to medical care serves this We often act as though poverty, dishonesty, and dishonor societal value; fix the illness first and then free the person to were synonymous. We want to be sure that the poor merit the triumph over adversity. Unhappily, for far too many, the care that we provide them and that public support of their care model does not work. For many disabled, physically depen- is absolutely necessary. While the advent of Medicaid and dent, mentally ill, and poor people whose lives are marginal, Medicare profoundly altered the relationship of the medical we need new models. profession to the disadvantaged, societal attitudes toward the If we are to provide better care to patients, the development poor were not dramatically changed. These entitlement pro- of research and new social models that will help us understand grams made it possible for physicians to be paid for services that and deal with specific issues involving high levels of chronicity, had formerly been rendered free. The inability of individual dependency, and poverty, and the mechanisms that mediate patients to pay for care, something physicians believed they their effects seems as important as our need to better under- had to deal with individually, instead became a matter removed stand neurobiologic mechanisms. Society should have long from individuals and assigned to "society," its accountants, ago looked beyond its health care practitioners and institutions and its regulators. And Medicaid, in many states and for many to deal with the failures of social, welfare, and housing policies. services, reimbursed physicians so poorly that the patient's We need to understand that trying to change health policy in- perception of an entitlement and the physician's sense of being dependent of social policy must inevitably fail our patients and forced to do what one would rather not do conflicted, building our practices. References Accepted for publication March 18, 1991. 1. Norquist G, Wells K. Mental health needs of the uninsured. From the Department of Psychiatry, University of Illinois, Chicago Arch Gen Psychiatry. 1991;48:475-478. (Dr Astrachan), and the Health Science Center at Brooklyn, State 2. Bruce ML, Takeuchi DT, Leaf PJ. Poverty and psychiatric status: University of New York (Dr Scherl). longitudinal evidence from the New Haven Epidemiologic Catch- Reprinted from the Archives of General Psychiatry (1991;148:481). ment Area Study. Arch Gen Psychiatry. 1991;48:470-474.

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Health Care 1991 [5]

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