Who Provides Neurologic Care?

At the Intersection of Health, Health Care and Policy Cite this article as: Darryl C. De Vivo, Marvin A. Fishman, Mark L. Dyken, Sid Gilman, Joseph B. Martin, Ludwig Gutmann, David H. Hubel, William M. Landau, Elliott L. Mancall, Roger N. Rosenberg, Lewis P. Rowland and Jack P. Whisnant Who Provides Neurologic Care? Health Affairs, 8, no.4 (1989):197-199 doi: 10.1377/hlthaff.8.4.197-a

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Letters

Publishing at its best can be a lively exchange between a journal’s authors and readers. We encourage your responcesto what you read in Health Affairs. Counting Uninsured Americans To the Editor: Eugene Moyer’s analysis of the March 1988 Current Population Survey (CPSs)indicates that 31.1 million Americans lack health insurance-six million less than estimates from the 1987 CPS indicate ("A Revised Look at the Number of Uninsured Americans,” Health Affairs, Summer 1989). It is not clear, however, that this is the correct estimate because of major difficulties in interpreting the responses given to questions changed in the 1988 survey. The changes in questions, which Moyer briefly describes, have the unfortunate outcome of contradictory answers (within an interview) for 14 percent of all children under agefifteen, and 13 percent of all children agesfifteen to seventeen. The total unduplicated count of children (under ageeighteen) affected by these inconsistent responses is 4.3 million. Moyer chose to accept any positive answer about health insurance in these casesand to consider all the children with contradictory answers asinsured. Why do so many people describe a child as both covered and not covered in response to different questions about the same type of health insurance? Because of the confusion, the Bureau of the Census is expected to release a public use data tape with all answers so that users can apply their own analyses to the inconsistent responses. Survey question changes. The March 1988 CPS questions on health insurance coverage differ from the previous March CPS questions in two ways. First, the previous questions on types of health insurance

were reworded. Previously, five groups of questions on types of health insurance had been asked each year: Medicare, Medicaid, CHAMPUS/VA or military health care, and two types of private health insurance. The interviewee for the household was asked if anyone was covered by each type of insurance and who else was covered by the policy if anyone had either type of private health insurance. The uninsured were then estimated as the residual-that is, those who did not respond that they had any type of health insurance. None of these questions, it should be noted, asked an interviewee directly if anyone did not have health insurance. In the March 1988 CPS questionnaire, the two questions related to private health insurance were collapsed into one question. The interviewee was asked whether anyone in the household age fifteen and older was covered by a health insurance plan other than Medicare, Medicaid, or military health care. Previously, the first private health insurance question referred only to employer/union group health insurance and was asked only of people age fifteen and older who had worked during the previous year. The wider universe of people captured in the new private insurance question yields at least 609,000 and as many as 767,000 responses indicating private health insurance for those ages fifteen to seventeen whose parents do not indicate that they have private insurance policies that cover the children. The difference of 158,000 between these two numbers comprises those agesfifteen to seventeen who are said to have policies in their own name. There is no way of

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corroborating that such children may have coverage from someone who does not live in the household. Second, at the end of the 1988 CPS interview, the interviewee was directly asked how many of the children under age fifteen in the household had Medicare or Medicaid.* The 1987 CPS did not do so. This question was followed by a second asking how many of the children under age fifteen in the household were covered by a health insurance plan, excluding Medicare and Medicaid. If the response to the second question was that all or some of the children had coverage, the interviewee was asked how many of these children were covered by the health insurance plan of someone not residing in the household. The intent of the third question was to determine the number of children with health insurance from an absent parent. These new questions lead to inconsistent Medicare/Medicaid responses for about 4 percent of the children and inconsistent private insurance responsesfor about 9 percent.’ We thus find that as many as 3.6 million children (under age fifteen) who might otherwise be uninsured could be counted as insured if a positive response to any of the above questions is accepted at face value (see Exhibit 1). We are skeptical that all of

the positive responses should be accepted. The patterns of conflicting responsesto the first set of questions and the new questions are not random across other characteristics that describe the families of the children with inconsistent responses.4 Private health insurance inconsistencies. Among the children with inconsistent

responses to private health insurance, 31 percent have a “yes” on the first question and a “no” on the second, more direct question on health insurance coverage other than Medicare and Medicaid (group one), while 69 percent have the reverse (group two). The children in group one are more frequently in the higher end of the income distribution than are group two children. Moreover, the distribution of family income relative to the poverty level for the first group of children is very similar to that of children who have consistent positive answers to both questions. Similarly, children in the first group are far more likely to live with both parents and to have at least one parent employed than are children in the second group. The family type and parent’s employment status distributions of children in the first group are almost identical to the distributions of the children with consistent positive responses. Thus, it appears that the interviewees for

Exhibit 1 Children Under Age Fifteen Affected By Differences In Editing That Can Yield Various Estimates Of The Uninsured From The March 1988 CPS

1988preliminary estimatefrom CensusBureau Children with coveragefrom someoneoutside household (q. 81 A) Children given Medicaid (q. 80) Children given private coverage(q. 81) Children given coveragefrom outside (q. 81A) but not indicated by q. 81 Children with missingresponsesto q.80 or q.81 who wereimputed private coverageor Medicaid Mover’s estimate

35.4million - l.lmillion 34.3million - 0.8 million 33.5million - 1.6million 31.9million - 0.1 million 31.8million - 0.6 million 31.1million

Note: These estimates may contain rounding errors. These numbers are from the March 1988 Current Population Survey (CPS) research file and may differ from the final, edited public use tape.

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LETTERS children in the first group may have thought that the second question was referring to health insurance beyond what had already been acknowledged in the answer to the first question. This is, of course, only a guess. The children in group two do not look like the children with consistent negative responsesto both questions in terms of family income, family type, and employment status of at least one parent. In this case,we wonder if interviewees were including student accident insurance or other minor insurance policies that we would not consider as hospitalization/physician insurance. Clearly, this group of children is the most confusing group for CPS users to analyze. In looking for further clues to this puzzle, we focused on the children in the second group who also have a positive response to the question of whether the coverage comes from someone not residing in the household. There are 1.46 million children in this subgroup, of whom 235,000 also show coverage from Medicaid on the basis of the first set of questions on types of health insurance. Another 100,000 in this group also indicate coverage from someone not residing in the household in spite of the fact that their response to the preceding question on other coverage is negative and therefore the interviewer should not have asked the question about coverage from someone outside the household. The family income distribution of the 1.46 million children looks similar to that of children with consistent negative responsesto both questions. It is quite plausible that children whose only health insurance is from an absent parent may be from poorer families. On the other hand, given what is known about the low proportion of court-ordered child support payments that are actually paid, we wonder how many of these children actually have health insurance from the absent parent. A further source of confusion arises from the fact that many judges have the choice of ordering the absent parent to pay all the children’s medical bills or provide health insurance. Paying for a child’s medical bills is not equivalent to insurance for hospitalization. Probably the 100,000 chil-

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dren who have a positive response to the question of coverage from someone not residing in the household but negative responses on the other two questions should not be considered insured. This leaves just over a million children who may have coverage from an absent parent and no other source of insurance. Medicare/Medicaid

inconsistencies.

The children with inconsistent Medicare/ Medicaid responses are almost evenly divided between children with positive responsesto the first questions on Medicare/ Medicaid and negative responsesto the second question on Medicare/Medicaid, and children with the reverse pattern of responses. We suspect that the 0.8 million children who could be counted as insured via Medicare/Medicaid solely on the basis of a positive response to the second question are receiving Medicaid or some type of public assistance for health care. We do not understand why the interviewee does not state that the children have such coverage in response to the first question. Perhaps the second question causes people to think of state-financed assistanceprograms. Comparisons with the 1987 CPS. Using the March 1987 CPS, a number of researchers have estimated that 37.1 million nonelderly people were without health insurance; When the Census Bureau released its preliminary March 1988 CPS public use data tape in August 1988, it contained only the responsesto the first set of questions on types of health insurance coverage. With these responses,the estimate of people without health insurance is 35.4 million. The biggest declines were for those ageseighteen to twenty-four (- 1.8 million) and agesfifty five- to sixty-four (-675,000). Uninsured children under age eighteen increased by 250,000, and uninsured adults ages twentyfive to fifty-four by 400,000. The number of uninsured people ages eighteen to twenty-four may have decreased in part because some universities now require proof of health insurance coverage of students. But another explanation for the dramatic decline among both those ages eighteen to twenty-four and those agesfiftyfive to sixty-four is that the interviewee is

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now asked to respond to the private health insurance question for anyone age fifteen and older. In the past, the interviewee was asked to respond about employer group health insurance only in reference to people who had worked during the previous year. We chink that if this type of question had been used on the March 1987 CPS, the numbers of uninsured people ageseighteen to twenty-four and ages fifty-five to sixty four would not have been significantly different than the 1988 numbers. Exhibit 1 illustrates how Moyer reached his estimate of 31.1 million uninsured. We believe the number of people without health insurance from the 1988 CPS, however, is about 33.5 million. We lean toward assuming that there are about 1.1 million children with coverage only from someone not residing in the household. Our reason for this assumption is that some children do have health insurance provided only by an absent parent. This number, however, should not be interpreted as a real decline in the number of uninsured but rather the result of the 1988 question changes. Similarly, we lean toward assuming that there are 0.8 million more children with Medicare/ Medicaid based on the new question. Historically, the CPS has suffered from underreporting of Medicaid recipiency. Presumably, therefore, had this question been asked in 1987, it would have generated the same estimate of children with Medicaid as in 1988. We do not think the vast majority of the remaining children should be included in the insured counts. We believe almost all of the 1.6 million children whose only claim to private insurance is from the new question are not insured. Similarly, we do not think the 100,000 children who have positive responsesto coverage from outside the housed hold and negative responses to the other two questions on private insurance should be counted as insured. Nongroup insurance policies for children are extremely rare, and school sports accident insurance is not general health insurance. Because the census imputation procedure is built on the assumption that all of the above categories of children are insured, we are wary of believ-

ing that all of the remaining 700,000 children with imputed positive answers are insured. We do not believe there has been a dramatic decline in the real number of people without health insurance based on the 1988 CPS. We think the confusion generated by the changes in the 1988 questionnairewhich are also present in the 1989 CPS and probably in the 1990 CPS-presents a strong argument for additional changes in the CPS questions on health insurance coverage. For a number of years, many of us have argued that the answers co the questions about coverage refer to the time of the interview rather than the previous calendar year. We also think it would be easier to compare estimates of the uninsured (and insured) from different surveys if the wording of the questions were more consistent. In sum, the 1988 (and 1989) CPS public use data tape should be used with caution. Researchers and policy analysts will need to state their assumptions as to which children were counted as insured. Katherine Swartz ResearchAssociate The Urban Institute Senior

Patrick J.Purcell ResearchAssociate The research reported herein was performed pursuant to a subcontract between The RAND

Corporation and the Urban Institute under a contract from the U.S. Department of Labor. The opinions and conclusions expressed herein are solely those of the authors and should not be construed as representing the opinions or policy of The RAND Corporation, the Urban Institute, or the Department of Labor The authors

thank Paul Johnson and Margaret Moore for their computer assistance. NOTES 1. The questions are grouped in two sets and come at most about two minutes apart in the interview. 2. The new questions, which are asked at the end of the interview, appear on the cover-sheet of the questionnaire. CPS users reading the questionnaire may think these questions are asked at the beginning of

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LETTERS the interview, but they are not. The questions are asked in the sequence of the question numbers. We therefore refer to the cover-sheet questions as the “second” questions. 3. We only compared the responses of the children for whom responses were made; that is, we did not include the 9 percent of all children with blank answers to the second set of questions. Ordinarily the Bureau of the Census imputes answers for the nonresponses by matching children who have similar characteristics and using the responses of the “like” children to fill in the missing responses. Moyer chose to impute positive responses to about 700,000 children who were missing a response for either Medicare/Medicaid or private insurance. 4. Detailed tables of these response patterns are available from the authors. Contact Katherine Swartz, the Urban Institute, 2100 M Street, N.W., Washing ton, DC. 20037.

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In his argument that neurologists should be prohibited from providing continuing care to patients with chronic neurological diseases,Menken’s concern is primarily one of cost. He seemsto blame specialty care for what he calls the “American Health Care Syllogism,” which he defines as follows: “Nothing but the best for all; we cannot provide the best for all; therefore, nothing for millions of people. The popularity of this viewpoint finally seemsto be lessening in the face of thirty-eight million uninsured Americans, the result of doing nothing but the ‘very best’.” We are not prepared to argue about the allocation of funds for health care as op posed to funds for the military, education, schools, housing, or other societal needs. Who Provides Neurologic Care? We are, however, prepared to comment on To the Editor: what we believe are the needs and rights of In a recent Commentary (“Generalism the people of the United States for highand Specialism Revisited: The Case of Neu- quality medical care, and to discuss some of rology,” Health Affairs, Winter 1988), Mat- Menken’s views. thew Menken put forward the position that Number of neurologists, Menken is conpatients with chronic neurological diseases cerned that the ratio of neurologists to should receive care from family physicians population is much higher in the United and other general practitioners rather than States than in Great Britain or Canada. He from neurologists. We take issue with this believes that the greater number is wasteful position, since we believe that patients will excess. We disagree for five reasons, all rereceive better and, in the long run, less ex- lated CO the broader scope of activities of pensive continuing care from neurologists. U.S. neurologists. Undoubtedly, there are people in the First, American and most Canadian neuneurological community who would agree rologists routinely provide continuing care with Menken’s views, but for the most part, for patients with chronic neurologic disease. he speaks only for himself and not for any Second, neurology is oriented toward reorganization. We respond as members of the search. This emphasis on research is a reNeurology Intersociety Liaison Group, a sponse to the challenge of major public neuprofessional association composed of sev- rologic health problems that have such eral organizations that represent practicing tragic consequences for patients and their and academic neurologists, including those families: Alzheimer’s disease, stroke, epiwho train neurologists for clinical activities lepsy, Parkinson’s disease, cerebral palsy, and research. In our organizations, there and mental retardation. In these times of have been numerous discussions of the na- wondrous advances in the scientific basis of tional need for neurologists.’ That need de- medicine, these diseases and other neuropends, in large part, on what neurologists logical disorders remain formidable chalactually do in their practices. lenges. The participation of physician/sciWe believe we represent the consensus of entists in the assessmentand investigation of U.S. neurologists on these issues. We arrive patients with these disorders is essential. at this conclusion not out of self-interest, Neurologists have taken seriously the imbut out of a firm belief chat patients deserve perative to support research in these areas more than Menken’s recommendations will by encouraging the training of physician/ provide. investigators.

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Third, we are wary of predictions about impending shortages or oversupply of phy sicians. There is continued demand for the services of neurologists throughout the country. Fourth, neurologists are needed as teachers of neurology for medical students and residents in primary care specialties. Finally, comparisons with Canada and Great Britain have limitations. For instance, a rep resentative of British neurology has urged a 50 percent increase in the number of neurologists there, and a representative of Canadian neurology has urged training more clinical investigators for neurology.’ In other words, both nations may be underserved. In any case, patterns of medical practice differ in the three countries. Quality of care. The core of our argument with Menken is the question of the quality of continuing care for patients with chronic neurologic disease. Menken believes that generalists of one kind or another can adequately take care of most of these patients. On the contrary, we believe that their care is best provided by neurologists. The proposed interdiction against continuing care ignores the historical evolution of clinical neurology in the United States. A generation ago, there were few neurologists, and those few served primarily as consultants. In hospitals, the neurology service was often a division within medicine or psychiatry. As neurology developed to become an independent specialty, neurologists were required to be trained in internal medicine or pediatrics before starting a neurology residency. They were equipped to be the physicians responsible for the acute care of patients with neurologic disease. That sequence naturally evolved to neurologists’ provision of continuing care for patients with chronic neurologic disease. The neurologist not only works as an individual, but also coordinates the patient’s care with other relevant specialties, including neurosurgery, psychiatry, ophthalmology, medical subspecialties, and rehabilitation medicine. The neurologist may also coordinate the roles of social workers, nurses, and other health care workers. In many parts of the country, this integrative function has led to the formation of

multidisciplinary centers of care for patients with Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, chronic pain, epilepsy, childhood developmental and behavioral disorders, stroke, muscular dystrophy, or amyotrophic lateral sclerosis. These comprehensive centers are almost always organized and coordinated by neurologists, not by primary care physicians. To prohibit neurologists from providing continuing care for patients with chronic neurological diseaseswould therefore stem a tide of activity that patients and affected families have come to appreciate and expect. Although it may be debated whether clinical outcomes actually improve when a neurologist provides continuing care, we believe that serious errors of diagnosis and management are more likely to occur when someone not trained in neurology attempts, without consultation or guidance, to provide continuing care-including chronic medication-for patients with neurologic disease.These errors cannot be justified on any grounds, and they are costly. There is no evidence to support the contention that it is more expensive for neurologists to provide continuing care. Moreover, neurologists have now acquired the skills to conduct the appropriate studies to assessoutcomes. Even so, there are measures that go beyond clinical outcomes-helping families who are faced with tragic and complex problems, or carrying out clinical research to find effective therapies for untreatable diseases. Menken states that “ . . . the self-referral of patients to a subspecialist should be discouraged.” We agree; referrals to a specialist should come primarily from other physicians. However, we are wary of gatekeepers whose sole function is to discourage needed consultation because of cost. The hallmark of the great academic medical centers has been the easeof obtaining consultation. At any rate, self-referral is not a major issue in this debate. We are not, however, oblivious of the need to control costs. As have other specialties, neurologists, through their professional associations, have initiated programs to de-

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needs and the relationship of generalists and medical specialists. As I indicated in my Commentary (Health Affairs, Winter 1988), my perspective is that of a practicing neurologist in thecommunity, asare most of the 8,000 neurologists in the United States.’ Of the clinical neurologists who wrore the NILG letter, most are neurology residency training program directors (active or emeritus), and all practice in teaching and referral centers. None represents community hospital practice. Thus, it is not surprising that the NILG Membersof the Neurology IntersocietyLiaison viewpoint regarding the neurologist’s role is Group: entirely on target for teaching hospitals. Darryl C. De Vivo and Marvin A. Fishman, Neurologic patients in teaching hospitals Child Neurology Society; Mark L. Dyken, are a highly filtered group of people with American Board of Psychiatry and Neurology; acute, serious, complex, and esoteric disorSid Gilman and JosephB. Martin, American ders rarely encountered elsewhere. Clearly, Neurological Association; Ludwig Gutmann, for this group of patients, the provision of IntersocietyCommitteeon Necrologic Resources; care by a narrowly focused subspecialist Dawid H. Hubel, Societyfor Neuroscience; neurologist is necessary. William M. Landau and Elliott L. Mancall, AsBy way of contrast, neurologists in officesociationof University Professorsof Neurology; based practice spend roughly half their RogerN. Rosenbergand Lewis P.Rowland, time treating headaches, backaches, and American Academy of Neurology;and Jack P. epilepsy; 24 percent of office encounters inWhisnant, American Board of Psychiatry and volve psychiatric disorders and ill-defined Neurology conditions and symptoms usually associated with the scope of primary care pracNOTES tice.* Given this case-mix, it seems entirely appropriate to question whether the special 1. E.M. Marcus and K.D. Wickmann, “How Many skills of a highly trained neurologist are Neurologists?” Neurology 36 (1986): 383-388 and always necessary in standard and typical w-804; M.L. Dyken, “The Continuing Undersituations. supply of Neurologists in rhe 1980s: Impressions The NILG representatives are not correct Based on Data from Three Studies,” Neurology 32 (1986): 1576-1582; and J.F.Kurtzke et al., “Neurolowhen they say that my concern is primarily gists in the United Srates-Past, Present, and Fuone of care cost, rather than care quality. I ture," Neurology 36 (1986): 1576-1582. would suggestthat they reached this conclu2. M. Menken et al., “The Scope of Neurologic Pracsion by making a number of highly questice and Care in England, Canada and the United States: Is There a Better Way?” Archives of Neurology tionable assumptions about medical care, 46 (1989): 210-213. unsubstantiated by peer-reviewed evidence. First, they assume that the quality of care is necessarily higher when provided by a The Role Of The Neurologist: The subspecialist rather than by a generalist, Author Responds even for the most common neurologic disorders (headache, backache, dizziness, and so on), which the generalist may be expected To the Editor: to encounter frequently. The representatives of the Neurology Second, they assume that the explosion Intersociety Liaison Group (NILG) are correct when they note that I speak only for of knowledge and technology since World myself, notwithstanding that other neurolo- War II makes it unrealistic for a generalist to gists share my views about future neurology be competent to treat a wide range of comvelop standards, evaluate outcomes, and assesstechnology. These evaluations should improve care and simultaneously decrease fruitless expenditures. Matters of cost and affordability will, in the end, determine what health care the American people receive. As a nation, we may receive what we can afford. What we can afford, however, is a matter of debate. However “afford” is defined, we must strive for the best possible care for all people in the United States.

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mon disorders, and that, therefore, the dysfunction of each organ system should fall within the domain of an appropriate medical subspecialist. Third, and arguably most important, they assume that primary care provided by neurologists is just as good as that provided by primary care physicians, even though neurologists have virtually no postgraduate preparation in such essential primary care fields as disease prevention, health promotion, practice management, nutrition, domiciliary care, and occupational medicine. Although cost is, or should be, an important issue for all physicians, my primary concern is the quality of care for all people with neurologic (and other) disorders, including those who fall through the ever-increasing number of cracks-especially the poor and chronically ill-in communities that lack a sufficient number of practicing generalists. Hence the paradox of the syllogism I employed, which calls attention to the lack of care for many patients with undifferentiated problems amidst a surfeit of highly specialized providers. Who should provide continuing care for patients with chronic neurologic illness? Clearly, it is preferable to formulate an answer based upon evidence rather than unsubstantiated assumptions. There is no known difference in neurologic illness and death rates in the United States and the United Kingdom, as the NILG authors imply. Therefore, I would suggest that the NILG provide the peer-reviewed evidence necessary to support their assumptions and assertions by demonstrating the importance of neurologist intervention in specific situations through studies of care outcomes. The question is not whether neurologists have a role here, for they certainly do, but whether the role of neurologists (and other medical subspecialists) should be delineated by a processof consensus among each group of subspecialists on a specialty-by-specialty basis. With some exceptions, I have difficulty with the notion that patients have sufficient medical knowledge to determine which symptoms call for what medical interventions performed by whom.

An alternative approach is a matrix of service provision that calls for a generalist to refer a patient to a specialist for consultation or continuing care on a patient-by-patient basis-a key feature of the British and Canadian health systems. Moreover, the effects of a gatekeeper mechanism are not uniform across all medical and surgical subspecialties, and, in one small survey, did not appear to have a marked effect on the workload of neurologists3 When the role of the generalist is clearly defined and carried out in practice, the dimensions of specialty medicine are automatically clarified as well. A consensus is emerging that the U.S. health system, dominated by the several subspecialties, has a fragmented and poorly coordinated framework of service provision, and that changes in postgraduate training are needed to increase the absolute number and proportion of primary care physicians to meet the needs of the entire population.’ At the same time, there is a consensus that changes are needed in the medical school curriculum to provide all students, regardlessof their subsequent field of specialization, with the general knowledge, skills, values, and attitudes needed by all practicing physicians.5 Successful implementation of these programs at schools and teaching hospitals is unlikely without the support of the several specialized departments that collectively exert the most powerful influence upon the educational programs of the modern academic medical center.

MatthewMenken Clinical Professorof Neurology RobertWoodJohnsonMedical School NOTES 1. M. Menken, “Postgraduate Training in Neurology: Education for What?” Archives of Neurology 40 (1983): 329-332. 2. L.P. Garrison, Jr., “Physician Requirements-1990: For Neurology” (Seattle: Battelle Human Affairs Research Centers; 1982); and C. Nelson, “Office Visits to Neurologists: 1985.” Advance Data from Viral and Health Statistics 158, DHHS Pub.’ no. (PHS)88-1250 (Hyattsville, Md.: U.S. Public Health Service, 1988). 3. M. Menken, R. Behar, and P. Lee, “Patterns of

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LETTERS Neurologic Referrals in a Health Maintenance Organization,” HMO Practice (forthcoming). 4. A. Gellhorn, New York State Council on Graduate Medical Education: First Annual Report (Albany, N.Y., 1988). 5. Association of American Medical Colleges, “Physicians for the Twenty-First Century,” Journal of Medical Education 59, no. 2 (1984): 11.

Clarifying Canadian Physician Payment To the Editor: The article “Paying Physicians in Canada: Minding Our Ps and Qs” by Jonathan Lomas and colleagues (Health Affairs, Spring 1989) contains some interesting information concerning medical fee negotiations in Canada. However, we fear that lack of clarity (or, in some cases,factual errors) may lead many readers to misinterpret the situation in Canada. Drawing on our experience working with provincial departments of health as well as with medical associations, our response focuses on only a few areas. First, we address the factual errors in the description of the Manitoba utilization (hence volume) mechanism and the evaluation of its effects (one of only two such evaluations in the article). Next, we focus on a broader concern. Although the authors purport to present the “different ap proaches” our provinces are using to control volume and to discuss their impact on the utilization of medical services, they ignore the (long-standing) main ones. Factual errors. In their Exhibit 4, Lomas and colleagues analyze the three-year effects of a putative Manitoba volume-control system that deducts the cost of the previous year’s “excess” volume increases (that is, utilization increases in excess of an allowed threshold) from the proceeds of the current year’s fee increase. Their tentative conclusion is that the fee-adjusted billings per physician behveen 1984 and 1987 are “consistent with the impact of controls” (page 94). This analysis of the impact of threshold controls is, in fact, erroneous. Manitoba has never had any system of volume recoupment since the publicly funded provincial medical care system was introduced in 1969.

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The fee-for-service (master) agreement in 1985-1986 and 1988-1989 did contain a requirement that volume increases be reviewed and divided into two categories: the portion attributable to seven factors listed in the contract (“attributed volume”) and the portion, if any, that was not (“unattributed volume”).’ The only financial repercussion for unattributed volume was trivial-the current fee increase would not apply to the previous year’s unattributed volume. In other words, to calculate the dollar value of the current year’s fee award, the previous year’s payout base would be reduced (solely for purposes of this calculation) by the cost of the unattributed volume and then multiplied by the percentage fee increase. The 19861987 arbitration award illustrated the mechanics of this volume-review mechanism. The arbitration board awarded a 5.7 percent fee increase in 1986-1987 and decided that $3.5 million of the $183.5 million pay out in 1985-1986 was unattributed. Although the board agreed that the Manitoba Health Services Commission’s (MHSC’s) method of volume attribution was more consistent with contract language than the Manitoba Medical Association’s (MMA’s) interpretation, it deemed these results “regrettable” and sympathized with the MMA’s contention that the method “will consistently and erroneously attribute too little." 2 Since the 5.7 percent nominal fee award was applied to the adjusted base of $180 million instead of to the actual base of $183.5 million, the volume mechanism reduced the yield of the award from $10.46 million to $10.26 million and lowered the effective fee percentage increase, relative to the actual base of $183.5 million, to 5.6 percent. The MHSC was solely responsible, under the agreement, for funding for 19861987 volume increases that would raise the commission’s increase in expenditures above $10.26 million. It would be naive to suggest that the $200,000 financial impact of the mechanism would have any effect on the billing pattern of fee-for-service physicians in Manitoba (approximately 1,500). Also, the timing of

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the award itself was sufficient to render the mechanism impotent for changing physician behavior. The award was issued at the end of what would have been the succeeding year’s volume-review period and was retroactively implemented fifteen months after its effective date. To top it all off, the MHSC prematurely terminated the agreement-thus killing the volume-review mechanism after only one application. Hence, the volume provisions in the agreement had a financially insignificant, ex post facto, one-shot financial impact on physicians’ incomes and no discernible effect on physicians’ billing behavior in Exhibit 4. The real upshot is that, in the absence of threshold controls, average volume per phy sician decreased cumulatively over the fiveyear period of the analysis. This decrease occurred in spite of the fact that Manitoba’s fee schedule increasesfrom the start of Canada’s Medicare to 1985-1986, before the arbitration, were the second lowest in the country, resulting in decreases of over 20 percent in real fees and over 15 percent in real average payments to physicians.’ The authors have erred not only in their interpretation of how the mechanism worked but also in the number of years in which it applied and the application lag to which it was subject. Their account of the terms of the subsequent agreement also contains inaccuracies> Neither party achieved its key objective in the ensuing negotiations. The MHSC was unwilling to accede to the profession’s demand for reinstituting binding arbitration, and the MMA was unwilling to concede threshold-type volume controls. A compromise was reached on a negotiated three-year settlement that provided physicians with fee increases of 3.48, 3.90, and 4.53 percent for each year plus compensation for increasesin liability insurance premiums. The volume-review mechanism contained in the previous agreement was dropped entirely without any argument from the MHSC, which remained wholly responsible for volume increases. Approaches to controlling volume. The authors create the false impression that the physician payment component of health

care expenditures in Canada has lacked controls, thus justifying setting threshold-type controls and capping-both drastic measures that erode the fee-for-service system upon which Canadian Medicare was founded. At several points the authors note that there are two types of control on physician services in Canada-the “threshold ap proach,” which allows some volume increases, and “capping,” which sets a total, inflexible amount of expenditures. They also note that (with the exception of Quebec) controls are a mid-to-late 1980s phenomenon that applies in a minority of provinces (pages 85, 93, and 98). Later, they contradict themselves with the observation that the presence of other controls hampers analysis of the effectiveness of thresholds and caps (page 96). However, they reinforce the incorrect impression that controls are few and something new (page 98). Provincial health ministries in Canada have limited options in restraining volume increases because three of the cardinal principles upon which national health insurance is founded prevent them from using many of the heavy weapons found in the costcontrol arsenal of private insurers. First, the principle of universality of coverage eliminates the option of excluding high-risk individuals. Second, the required comprehensiveness of coverage for all medically necessary physician and hospital services prevents health ministries from excluding services and placing artificial annual ceilings on individuals’ entitlement to benefits. Third, the accessibility principle-subject to different interpretations before the Canada Health Act-now effectively prevents provincial health insurance plans from imposing user charges for compulsory services and limits the scope for employing impediments to access,or at least blatant ones. Despite these limitations and in addition to thresholds and caps, provinces do impose a variety of controls on fee-for-service volume. We concentrate on three such controls-restrictive wordings in physician manuals, medical review of physician practice profiles, and supply-side restrictions to accessibility. While specific restrictions in physician

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LETTERS manuals do vary from province to province, provincial governments are becoming more imaginative and are pressing medical associations harder to secure new, negotiated, manual-based restraints. The most pervasive constraints are limitations on how frequently a physician can be paid for rendering certain services to a patient, tough criteria to limit claims of remunerative services, and various maximums or fee-reduction formulas for multiple services delivered to a patient within a certain time span. Other restrictions include protocols for certain services, the elimination of catch-all tariffs to force “a la carte” ordering of lab tests,and incentives for general practitioners to function in a British-style gatekeeper’s role (that is, controlling and directing patients’ accessto specialists). An entirely different layer of volume control is provided through medical review, a peer review process that exists in various forms in every province. Even if physicians strictly abide by the provisions of the physician manual and, therefore, comply with its controls, a Medicare review panel could find them guilty of overservicing and force them to reimburse the plan. Medical review and restrictive manual wordings mainly affect visits; other methods of control focus on procedures. Through their control of hospital budgets, provincial health ministries increasingly are using British-style supply-side constraints such as restrictions on additional hospital beds, outpatient facilities, and high-technology equipment. The resulting artificially created bottlenecks limit fee-for-service throughput for those services requiring these complementary inputs. There are other emerging supply-side constraints, the general purposes of which are to increase patients’ accesscosts or to counteract (weaken?) fee-for-service physicians’ incentives to increase volume. These constraints include limiting geographic diffusion of high-technology services; regulating expansion of private laboratory capacity; arbitrarily restricting some services to the controlled hospital sector; and experimenting with salaried and capitation remuneration in health service organizations,

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community clinics, and other related systems to reduce fee-for-service exposure. In recent years, provincial governments have pursued additional supply-side constraints through restrictive physician resource policies, but their most promising and powerful tool-the restriction of billing numbers-was struck down in the courts in British Columbia. Current methods of control are to reduce government-funded residency positions, control the immigration of physicians, and try to persuade Canadian medical schools to decreasefirst-year enrollment. Limitations of thresholds and capping. Although the authors state at the outset that their article will discuss the impact of different approaches to controlling utilization, their evaluation deals only with threshold and capping systems in Manitoba and elsewhere (pages 81, 93-97). The existence of at least some other controls is acknowledged only in passing as a reason, along with the recent advent of thresholds, for their inability to draw clear empirical conclusions about the impact of thresholds and capping on overall expenditure growth (pages96-97). The authors indicate that this lack of clear empirical evidence prevents them from providing lessons in “structural elements of a program of maximum impact on expenditures” and means that the intellectual foundations of thresholds and capping are “hope,” “faith,” and “intuitive appeal” (page 97). We do not find any intuitive appeal in the notion of embracing thresholds and capping without solid evidence, which the authors do not provide, that increasesin volume and physician expenditures are inordinate; that physicians are engaging in a significant degree of churning out medically unnecessary services for financial gain; that, if tighter controls are necessary, these are the best alternatives; and that these controls will not have a major disruptive effect on the health care system. Also intuitively unappealing is that thresholds and caps penalize both overservicers and physicians practicing an “acceptable” standard of medicine. Finally, we have little “faith” that provin-

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cial governments under increasing financial pressure-from income-elastic demands for health care services coupled with incommensurate growth in federal transfer pay ments to health care-would use thresholds and caps wisely and fairly, especially when they are largely precluded from imposing controls on patients. We fear that provincial governments would, instead, exercise the monopoly power to which the authors refer, and use thresholds and caps for “maximum impact on expenditures.” Michael Loyd President Michael Loyd and Associates

Jim Tsitanidis SeniorEconomist,Department of Economics Canadian Medical Association NOTES 1. MMA/MHSC 1985/86-1988/89 Aereement. Article 9-15(b), p. 22. 2. D.G. Baizley, Chairman’s Award, Arbitration between the MHSC and MMA. p. 24. 3. MMA submission to the board of arbitration established to settle disputes between the MMA and MHSC, section entitled “Fees,” p. 8; and section entitled “In-Province Fee-for-service Payments,” p. 9. 4. Lomas and colleagues incorrectly stated that arbitration was reinstated, omitted the shoring-up portion of the increase in fees, and, mistakenly, indicated that the final year’s increase was a function of the Canadian consumer price index (CPI) when in fact it was tied with the increase in the Winnipeg CPI.

Canadian/U.S. Health Systems: Asking The Right Questions To the Editor: We commend The Commonwealth Fund for its leadership in allocating philanthropic resources toward answering some important questions about Canada’s health care financing system as reported in the Summer 1989 issue of Health Affairs (Thomas W. Moloney and Barbara Paul, “A New Financial Framework: Lessons From Canada”). Our community is very interested in those questions as well, as evidenced by the Minnesota Coalition on Health’s devoting much of its 1989 Annual Meeting in September to

presentations from Canada and a discussion of Canada’s experience. Our interest in Canada does not mean we have given up on market solutions to the problems in U.S. health care. On the contrary, the coalition was founded and continues to be supported by employers, labor leaders, providers, and health plans who believe in the positive potential of markets. Our work is based on a broad consensusthat a properly structured health care market, with strong positive incentives for both quality and economy, offers a powerful opportunity to achieve affordable health care matching the values and needs of the American public. We also know that such a market does not happen by itself and requires appropriate regulation plus vigilance and thoughtful strategies from all parties, public and private. Where our society has been ambivalent about its strategies, it has produced distortions and inequities. Our coalition is acutely aware of the problems Moloney and Paul cited to The Commonwealth Fund’s Board of Directors: continuing high and rising health care costs in the United States accompanied by diminishing accessfor millions of Americans. We feel a responsibility for addressing these concerns as part of our vision for the market. Our group has given the highest priority to finding ways to meet the needs of the uninsured and the underinsured. We believe it is important for us to look carefully at a system such as Canada’s that has successfully created universal coverage. Without careful analysis, however, we should not assumethat such a system would be either right or wrong for the United States. Both its positive and negative consequences need to be understood. We especially applaud The Commonwealth Fund for supporting studies addressing a wide range of consequences including patient satisfaction, practice styles, appropriateness and availability of care, and cost and access issues. We hope that a workable solution in the United States will draw on the best results of several experiences, preserving both for government and the private market those roles

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LETTERS that each can best play. We eagerly await the results of the work The Commonwealth Fund has initiated. Patricia Drury ExecutiveDirector Minnesota Coalition on Health JamesRing Chairman of the Board

The Health Care Electoral Paradox To the Editor: With customary resourcefulness and insight, Robert Blendon and Karen Donelan have plumbed available polling data to understand the place of health care issues in the 1988 election (“The 1988 Election: How Important Was Health?” Health Affairs, Fall 1989). Perhaps their most notable finding is that public opinion is shifting in ways that are increasing the political salience of health care problems. Dissatisfaction with our health care system has grown impressively, even since the mid-1980s; in 1988 exit polls, a respectable number of voters (21 percent) cited this issue as a significant influence on their electoral decisions. Heartening as this news should be for Americans concerned about our health care system’s enormous problems, we would do well to ponder further a fundamental paradox of the 1988 election, as noted by Blendon and Donelan. Though Americans seem to have decisively favored Michael Dukakis’s views on health care, they voted overwhelmingly for George Bush. The explanation for this finding lies partly in a kind of crude issues-arithmetic: the public simply liked Bush’s positions more than Du-kakis’s on a seriesof other important issues. However, part of the explanation for the health care electoral paradox lies in qualitative factors that polls do not adequately reveal, but to which politicians and their senior advisers must b-esupremely sensitive. Failure to take these considerations into account may lead to an overestimation of the political salience of health care issuesand of the likelihood that polling data will translate into short-term policy breakthroughs.

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Political power of health issues. The first of these factors is that, whatever the numbers show, health care has never had, and may never have, the raw political power of certain other concerns-the power to make or break an electoral campaign. Take, by way of illustration, some recent presidential debates. In 1976, President Ford crippled his campaign by fumbling a foreign policy question: Was Poland behind the Iron Curtain? In 1988, Dukakis’s effort to overtake Bush was doomed by his answer to a question concerning crime and personal values: Would he favor the death penalty for his wife’s hypothetical rapist? It is difficult to imagine a similarly devastating outcome if a candidate muffed a question on the costs of health care or the number of uninsured. Why is this the case?The answer may lie in the psychology of American voters, who seem to fear unemployment, the Soviet Union, nuclear annihilation, and the invasion of their homes and persons by criminals more than they fear inadequate health care. In other work, Blendon has demonstrated that public concern over health care seems to rise in periods of prosperity but falls in periods of economic hardship. Could it be that health care is inherently a second-tier issue in the United States?At a minimum, matters will have to get dramatically worse in ways that profoundly unsettle substantial numbers of middle-class voters before health care becomes a concern with which national politicians absolutely must deal. An exception to this generalization are drug abuse and abortion issues, which, as Blendon and Donelan note, already carry substantial political punch (cited as important issuesin exit polls by 25 and 33 percent of voters, respectively). However, the inclusion of these problems in the category of health care seemsinappropriate. They have more in common with crime (in the caseof drug abuse) and religious and personal values (in the case of abortion) than they do with catastrophic illness, Medicare, physician payment reform, or the gamut of other purely health care issues. Public ambivalence. A second qualitative factor detracting from health care as a national electoral issue is that solutions to

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many pressing health care problems require increased governmental spending or regulation, and thus run afoul of a prevailing aversion to government. This leads to public ambivalence toward health care reform that is only revealed, as Blendon and Donelan note, by probing questions concerning the extent to which voters will sup port higher taxes or increased financial regulation of providers. When such questions are asked, voters show a marked reluctance to back up their wishes with action. (Indeed, a limitation of Blendon’s intriguing work demonstrating Americans’ interest in a Canadian-style health care system is that the relevant polling question made no reference to the need for increased taxes to sup port such a system in the United States.) Sensing this ambivalence, some political leaders currently tend to mistrust polling data demonstrating the increasing importance of health care and the public’s readinessfor dramatic change. Presidential leadership. A final factor to keep in mind in assessinghealth care polling data is the central role of the presidency in initiating major health care reforms. As Blendon and Donelan point out, polls show that most voters disagreed with candidate Bush on the importance of addressing our health care system’s ills. The public also elected an apparently reform-minded Congress.There would seem to be, therefore, an opportunity for Congress to move forward despite the president’s lesser interest in or outright opposition to certain measures. However, Congress has never undertaken major reform in our health care system without presidential leadership and support. This was true of Medicare and Medicaid and, more recently, of catastrophic illnesslegislation. These cautionary observations on the potency of health care as a national issue and the link between public opinion and shortterm health care reform should not be taken as unduly pessimistic. The shifts in public opinion documented by Blendon and Donelan are significant because they create conditions in which national legislative action is more probable (though far from certain in the short term) and are further evi-

dence of an underlying deterioration in our health care system. That deterioration is increasingly eroding the hitherto fierce op position of business and provider groups to forceful governmental action. The combination of a sympathetic public, a weakened opposition, and (sooner or later) presidential leadership may lead to determined national action to improve accessand control costs. David Blumenthal Senior Vice-President

Brigham and Women’sHospital Assistant Professor Harvard Medical School

Physician Time And Cost Of Living To the Editor: The article by Gregory Pope and colleagues entitled “Cost of Practice and Geographic Variation in Fees” (Health Affairs, Fall 1989) raised several areas of concern. The authors state that failure to include a geographic variation in fees could result in “distorting the geographic distribution of physicians.” I believe a redistribution of the current gross imbalance with which the public and Congress have wrestled for years would be welcome. The authors appear to confuse the definitions of “value” and “cost.” It is unclear why the cost of physician time should vary by geography. The cost of my time should be irrelevant whether I practice in Bismarck or Boston, but my time may have different market value in different areas.The authors justify including physician time in their index by stating that higher costs of living require physician time to be worth more in a given geographic area. Instead of calling this variable (which constitutes more than half the weight of the cost of practice index) the “cost of physician time,” it should rightly be called the “local cost of the standard of living.” It might then be harder to sell to Congress and taxpayers a proposal that they should subsidize a physician who chooses to live in San Francisco in preference to one who lives in Bakersfield. A potential side benefit would be rectifica-

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LETTERS tion of the current geographic imbalance of physicians. The simplest approach would be to eliminate any geographic index in Medicare reimbursement. Some geographic index is probably justified, however, because of higher overhead costs in urban areas. Nevertheless, physicians’ standard of living should not be a component of such an index. Frank Lawler Assistant Professor The University of Oklahoma Colleege of Medicine

Ownership Statement Statement of ownership, management, and circulation (required by 39 U.S.C. 3685) of Health Affairs, published fourtimes a year at Project HOPE, Millwood, Virginia 22646, for September 30, 1989. General business offices of the publisher are located at Project HOPE, Millwood, Virginia 22646. Publisher, William B. Walsh, Project HOPE, Millwood, Virginia 22646; Editor, John K. Iglehart, Project HOPE, Two Wisconsin Circle, Suite 500, Chevy Chase, Maryland 20815; Managing Editor, Jane H. White, Project HOPE, Two Wisconsin Circle, Suite 500, Chevy Chase, Maryland 20815. Owner is The People-to-People Health Foundation, Inc., Project HOPE, Millwood, Virginia 22646. Known bondholders, mortgagees, and other security holders owning or holding one percent or more of total amount of bonds, mortgages, or other securities: None.

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distributed: 1. Office use, leftover, unaccounted, spoiled after printing: 1,184. 2.Return from news agents: 0. G. Total: 9,523. The actual number of copies of a single issue published nearest to filing date are: A. Total number of copies printed: 12,581. B. Paid circulation: 1. Salesthrough dealers and carriers, street vendors, and counter sales:0. 2. Mail subscriptions: 8,411. C. Total paid circulation: 8,411. D. Free distribution by mail, carrier, or other means: 0. E. Total distribution: 8,411. F.Copies not distributed: 1. Office use, leftover, unaccounted, spoiled after printing: 4,170. 2.Returns from news agents: 0. G. Total: 12,581. I certify that the statements made by me above are correct and complete. Bruce Appelgren Assistant Publisher

The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes have not changed during the preceding 12 months. The average number of copies of each issue during the preceding 12 months are: A. Total number of copies printed: 9,523. B. Paid circulation: 1. Sales through dealers and carriers, street vendors, and counter sales: 302. 2. Mail subscriptions: 7,501. C. Total paid circulation: 7,803. D. Free distribution by mail, carrier, or other means: 536. E. Total distribution: 8,339. F. Copies not

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