Health Services Research and Health Policy Issues Determination of health policy for a society is a complex matter. Analysis of policy issues should deal with factors viewed from both the macro and micro levels. Analysis of health policy issues usually begins at the macro level with consideration of such matters as long-term population trends, organizational forms for health care delivery, total expenditures for health care, number and distribution of care givers, role of government in health care, and so on (see, for example, refs. 1-4). These topics are then discussed in terms of current issues such as how to meet health care needs of the elderly and how to finance their care. More often than not, discussion that begins at the macro level remains general and does not relate policy issues to the problems faced by individuals as they obtain and pay for health care. Another approach to analysis of health policy issues begins with a micro event such as one person's experiences in the health care delivery system. Examination of the care and treatment of a single person over time raises important policy questions about the overall system. This article illustrates how policy issues are seen in a different perspective if one begins with a micro event. One important result of such an approach is that issues often discussed separately have to be examined jointly. Further, the difficulties of translating policies into effective programs of care for individuals are made explicit. To illustrate the importance of analysis beginning at the micro level, this article deals with the last 18 months in the life of a chronically ill but mentally alert 70-year-old man. He lived alone and had no close relatives. His savings were modest, and his income consisted of Social Security payments and a small pension. His primary care physician was a board certified internist who had a reputation for providing excellent care to older patients. The Address communications and requests for reprints to David H. Stimson, Ph.D., Veterans Administration Hospital (lIB), 4150 Clement Street, San Francisco, CA 94121.
Fall 1976
221
Stimson & Stimson
Table 1. Chronology January 2, 1973 to July 12, 1974 Type of
Number of days 28 days 50 days 26 days 36 days 31 days 74 days 9 days 123 days 28 days 63 days 13 days 74 days
Dates
care
Hospital ................... Home care ................ Hospital ................... Nursing home .............. Hospital ................... Nursing home .............. Hospital ................... Nursing home .............. Hospital ................... Nursing home .............. Hospital ................... Nursing home ..............
1/2 to 1/30 1/31 to 3/21 3/22 to 4/17
4/18 to 5/23 5/24 to 6/23 6/24 to 9/5 9/6 to 9/14 9/15 to 1/15 1/16 to 2/12 2/13 to 4/16 4/17 to 4/29 4/30 to 7/12
physician was in private practice and had a staff appointment at a prestigious community hospital. He had been treating this man on an ambulatory basis for a number of years. The 18-month period analyzed in this article begins with the man's admission to a hospital in January 1973. The clinical diagnoses were chronic bronchitis, emphysema, atrial fibrillation, arteriosclerotic heart disease, and edema. The period ends in July 1974 with the man's death in a nursing home. Table 1 presents in chronological order the 18-month period classified into the number of days the man spent in his apartment on home care, in a hospital, and in a nursing home. It shows how the medical problems of the patient and the way in which services available to him were organized resulted in his being moved 12 times in the 18-month period. Of the 555 days covered in Table 1, 50 were spent in his apartment on home care, 135 days in a general acute hospital, and 370 days in a nursing home (skilled nursing facility). Total payments to physicians, hospital, home health agencies, nursing home, pharmacy, and ambulance services amounted to $47,200. Funds for these payments came from three sources: Medicare, the patienfs Blue Cross/Blue Table 2. Summary of Expenditures January 2, 1974 to July 13, 1974 Expenditure Expenditure
Total expenditures Physician charges Hospital charges Nursing home charges Drugs and medical supplies (outside the hospital) Other medical expenses
222
Amount in
~~dollars
47,200 4,700
24,200
16,200 1,000
1,100
Health Services Research
VIEWPOINTS
Shield insurance that supplemented Medicare, and the patient's personal inand savings. The patient's savings were almost gone at the time of his death. Had he lived three or four months longer he would have had to go on welfare to become eligible for care under Medicaid. The main categories of expenditures are shown in Table 2. Most of the $4,700 paid to physicians went to the internist for primary care. However, $990 was paid to an orthopedic surgeon and $198 was paid to an assistant orthopedic surgeon for repair of a hip broken when the patient fell in the nursing home. In addition, $125 was paid to a plastic surgeon for suturing a cut on the patient's forehead caused by another fall in the nursing home. The $24,200 paid to the hospital covered not only the daily service charge but also such items as drugs, diagnostic X rays, use of the operating room, inhalation therapy, and physical therapy. Payments to the nursing home covered the daily service charge including skilled nursing care, special diet, and routine supplies. Drug charges were not covered and were billed separately by a pharmacy. Other medical expenses included diagnostic X rays and physical therapy in the nursing home and ambulance fees for transportation of the patient to and from the hospital. Attempts to resolve the complex medical, financial, and emotional problems of long-term chronic illness involve several policy issues. In this article we have chosen to concentrate on only two issues: ways of meeting health care needs of the elderly and methods of financing their health care. Four points raised by the micro event described in this article illustrate the interaction of these two policy issues, the difficulties in translating policies into programs that resolve specific problems, and the effects of policies on the health care of individuals. Other points might be made and other policies addressed, but for purposes of this discussion the following are noted. 1. Present policy makes it difficult to provide and assure good quality of care for elderly, chronically ill patients. Many practitioners and agencies are required to provide the range of services needed for care of the chronically ill. Relationships among the primary care physician, community hospital, nursing home, home health agencies, and other providers are complicated and affect the quality of care a patient receives. Assurance of good quality care, difficult enough in a hospital, is even more difficult outside the hospital. Although the primary physician is ultimately responsible for planning, managing, coordinating, and monitoring the care of the patient, the private practitioner, with rare exceptions, has neither the time nor the resources to carry out effectively all of these responsibilities. Current health policy, which emphasizes the importance of maintaining the independence of practitioners and of hospitals and other health care agencies, makes integration of services very difficult. In effect, no one is really in charge of putting all of the pieces together for the individual patient. 2. Present policy tends to overlook that there are two components to care for elderly, chronicaUy ill patients: the medical and the nonmedical. Medicome
FaIl 976 Fall 11976
223
223
Stimson & Stimson
care policies of the federal government have been strongly influenced by the medical model, which emphasizes acute hospital care, medical treatment, and definition of patients' problems in terms of clinical diagnoses-no one ever dies of old age. In consequence, Medicare will pay for active treatment as specified by current regulations but will not pay for supportive care that does not include medical treatment or skilled nursing care on a daily basis. In the Medicare view, the nursing home patient is a temporary, transient resident on his way to recovery. However, as Shore [5] points out, the reality is that the nursing home becomes the permanent residence of the chronically ill patient who cannot care for himself. It is the base from which all services are provided for his living. In this view of care for the chronically ill, social and psychological services are as important as and perhaps even more important than medical treatment and skilled nursing care. 3. Government policy must deal with the reality that medical care for elderly, chronically ill patients is costly. Table 2 shows that the cost of care for this patient was indeed high-$47,200 from January 1973 until the patient's death in July 1974. As the costs of medical, hospital, and nursing home care increase, and as the amount the government pays for that care increases, the control of costs may become a more important goal of government than good patient care. In the translation of these goals into operating programs, economic considerations and humanitarian impulses clash, and economic considerations reinforced by prevailing attitudes toward the elderly [6] often win. Further, efforts to control costs seem to be carried out in ways that are administratively convenient, such as placing a ceiling on program expenditures, without paying adequate attention to how programs are operated and to what is required for good care of elderly, chronically ill patients. 4. Present policy results in a complicated, costly, and problem-ridden mechanism for paying for medical care of the elderly. The way in which the federal and state governments pay for care of the elderly under Medicare and Medicaid creates problems for the patient. In the case cited in this article the primary care physician and the other physicians charged more for their services than Medicare would pay and billed the patient directly. Hence the patient had to pay the difference in addition to doing the paperwork necessary for reimbursement by Medicare and by Blue Cross/Blue Shield. In general, the ability of many elderly patients to deal with the reimbursement procedures of Medicare, Blue Cross/Blue Shield, and other third-party payers is limited. In addition, actions by third-party payers including errors, delays, communications that are difficult to understand, and so on may cause a patient to cease his efforts to obtain reimbursement. As a result, part of the cost of care is borne by the patient unable to cope with "the system." Another example of problems that the financing mechanism causes patients is the method of paying for nursing home care. If a patient meets five conditions he may receive Medicare payments to cover some of the costs of care in a skilled nursing facility for up to 100 days in a benefit period. However, uncertainty over a patient's eligibility for Medicare payments creates prob-
224
Health Services Research
VIEWPOINTrs
lems for patients and nursing home administrators alike. In order for Medicare to pay some of the costs of care, it must be demonstrated that skilled nursing care is required on a daily basis throughout the period of payment. Medicare will not pay if a patient needs skilled nursing care only intermittently. Further, the difference between skilled nursing care and other kinds of nursing care is not clear cut and the determination that skilled nursing care is needed on a daily basis is not unambiguous. After payments by Medicare stop, either because it is determined through utilization review that the patient no longer needs skilled nursing care or because the patient has been on Medicare the maximum allowable time, the patient who still needs nursing care in the same type of facility must pay for that care from his own resources. Given the high cost of care, it doesn't take long to spend many thousands of dollars. If the patient's money runs out, he may turn to Medicaid for continued support. In California this means he must go on welfare and be certified eligible for care under the Medi-Cal program (the name given to the Medicaid program in California). Because operators of skilled nursing facilities in an urban area like San Francisco consider the amount Medi-Cal pays for care (approximately $22 per day) totally inadequate, patients who are not able to pay the daily charge ($68 for a private room, $34 for a 2-bed room, and $32 for a 3-bed room) have to be moved to homes that will accept what Medi-Cal will pay. This means that patients usually have to be moved to homes some distance from San Francisco. In terms of patient care, patients moved from the city have to find new physicians. Moreover, these patients suffer the trauma of leaving familiar surroundings and of being cut off from family and friends who have difficulty visiting them. In conclusion, beginning the study of health policy issues with a micro event such as one person's experiences in the health care delivery system, rather than at the macro level, where the constructs considered by policy makers are remote from patients and their pain, enables one to see at least a part of the outcome of a set of policies and procedures often developed at different times and for different reasons. The micro approach to analysis of health policy issues also enables one to see that the quantitative, efficiencyoriented approach characteristic of much health services research is limited and needs to be augmented. This is especially true in studies of long-term care of the chronically ill because the problems of home care and nursing home care are not so much technical as social. -David H. Stimson and Ruth H. Stimson REFERENCES
1. Somers, A. R. Some basic determinants of medical care and health policy: An overview of trends and issues. Health Serv Res 1:193 Fall 1966. 2. Kissick, W. L. and S. P. Martin. Issues of the future in health. Ann Am Acad Polit Soc Sci 399:151 Jan. 1972. 3. Bums, E. M. Health Services for Tomorrow: Trends and Issues. New York: Dunellen, 1973.
Fall 1976
225
Stimson & Stimson 4. Edwards, C. D. The federal involvement in health: A personal view of current problems and future needs. New Engl J Med 292:559 Mar. 13, 1975. 5. Shore, H. Long-term care regulations: Counterproductive and costly. Hospitals 49:57 Oct. 16, 1975. 6. Butler, R. N. Why Survive? Being Old in America. New York: Harper & Row, 1975.
226
Health Services Research
Fall 1976
221
Stimson & Stimson
Table 1. Chronology January 2, 1973 to July 12, 1974 Type of
Number of days 28 days 50 days 26 days 36 days 31 days 74 days 9 days 123 days 28 days 63 days 13 days 74 days
Dates
care
Hospital ................... Home care ................ Hospital ................... Nursing home .............. Hospital ................... Nursing home .............. Hospital ................... Nursing home .............. Hospital ................... Nursing home .............. Hospital ................... Nursing home ..............
1/2 to 1/30 1/31 to 3/21 3/22 to 4/17
4/18 to 5/23 5/24 to 6/23 6/24 to 9/5 9/6 to 9/14 9/15 to 1/15 1/16 to 2/12 2/13 to 4/16 4/17 to 4/29 4/30 to 7/12
physician was in private practice and had a staff appointment at a prestigious community hospital. He had been treating this man on an ambulatory basis for a number of years. The 18-month period analyzed in this article begins with the man's admission to a hospital in January 1973. The clinical diagnoses were chronic bronchitis, emphysema, atrial fibrillation, arteriosclerotic heart disease, and edema. The period ends in July 1974 with the man's death in a nursing home. Table 1 presents in chronological order the 18-month period classified into the number of days the man spent in his apartment on home care, in a hospital, and in a nursing home. It shows how the medical problems of the patient and the way in which services available to him were organized resulted in his being moved 12 times in the 18-month period. Of the 555 days covered in Table 1, 50 were spent in his apartment on home care, 135 days in a general acute hospital, and 370 days in a nursing home (skilled nursing facility). Total payments to physicians, hospital, home health agencies, nursing home, pharmacy, and ambulance services amounted to $47,200. Funds for these payments came from three sources: Medicare, the patienfs Blue Cross/Blue Table 2. Summary of Expenditures January 2, 1974 to July 13, 1974 Expenditure Expenditure
Total expenditures Physician charges Hospital charges Nursing home charges Drugs and medical supplies (outside the hospital) Other medical expenses
222
Amount in
~~dollars
47,200 4,700
24,200
16,200 1,000
1,100
Health Services Research
VIEWPOINTS
Shield insurance that supplemented Medicare, and the patient's personal inand savings. The patient's savings were almost gone at the time of his death. Had he lived three or four months longer he would have had to go on welfare to become eligible for care under Medicaid. The main categories of expenditures are shown in Table 2. Most of the $4,700 paid to physicians went to the internist for primary care. However, $990 was paid to an orthopedic surgeon and $198 was paid to an assistant orthopedic surgeon for repair of a hip broken when the patient fell in the nursing home. In addition, $125 was paid to a plastic surgeon for suturing a cut on the patient's forehead caused by another fall in the nursing home. The $24,200 paid to the hospital covered not only the daily service charge but also such items as drugs, diagnostic X rays, use of the operating room, inhalation therapy, and physical therapy. Payments to the nursing home covered the daily service charge including skilled nursing care, special diet, and routine supplies. Drug charges were not covered and were billed separately by a pharmacy. Other medical expenses included diagnostic X rays and physical therapy in the nursing home and ambulance fees for transportation of the patient to and from the hospital. Attempts to resolve the complex medical, financial, and emotional problems of long-term chronic illness involve several policy issues. In this article we have chosen to concentrate on only two issues: ways of meeting health care needs of the elderly and methods of financing their health care. Four points raised by the micro event described in this article illustrate the interaction of these two policy issues, the difficulties in translating policies into programs that resolve specific problems, and the effects of policies on the health care of individuals. Other points might be made and other policies addressed, but for purposes of this discussion the following are noted. 1. Present policy makes it difficult to provide and assure good quality of care for elderly, chronically ill patients. Many practitioners and agencies are required to provide the range of services needed for care of the chronically ill. Relationships among the primary care physician, community hospital, nursing home, home health agencies, and other providers are complicated and affect the quality of care a patient receives. Assurance of good quality care, difficult enough in a hospital, is even more difficult outside the hospital. Although the primary physician is ultimately responsible for planning, managing, coordinating, and monitoring the care of the patient, the private practitioner, with rare exceptions, has neither the time nor the resources to carry out effectively all of these responsibilities. Current health policy, which emphasizes the importance of maintaining the independence of practitioners and of hospitals and other health care agencies, makes integration of services very difficult. In effect, no one is really in charge of putting all of the pieces together for the individual patient. 2. Present policy tends to overlook that there are two components to care for elderly, chronicaUy ill patients: the medical and the nonmedical. Medicome
FaIl 976 Fall 11976
223
223
Stimson & Stimson
care policies of the federal government have been strongly influenced by the medical model, which emphasizes acute hospital care, medical treatment, and definition of patients' problems in terms of clinical diagnoses-no one ever dies of old age. In consequence, Medicare will pay for active treatment as specified by current regulations but will not pay for supportive care that does not include medical treatment or skilled nursing care on a daily basis. In the Medicare view, the nursing home patient is a temporary, transient resident on his way to recovery. However, as Shore [5] points out, the reality is that the nursing home becomes the permanent residence of the chronically ill patient who cannot care for himself. It is the base from which all services are provided for his living. In this view of care for the chronically ill, social and psychological services are as important as and perhaps even more important than medical treatment and skilled nursing care. 3. Government policy must deal with the reality that medical care for elderly, chronically ill patients is costly. Table 2 shows that the cost of care for this patient was indeed high-$47,200 from January 1973 until the patient's death in July 1974. As the costs of medical, hospital, and nursing home care increase, and as the amount the government pays for that care increases, the control of costs may become a more important goal of government than good patient care. In the translation of these goals into operating programs, economic considerations and humanitarian impulses clash, and economic considerations reinforced by prevailing attitudes toward the elderly [6] often win. Further, efforts to control costs seem to be carried out in ways that are administratively convenient, such as placing a ceiling on program expenditures, without paying adequate attention to how programs are operated and to what is required for good care of elderly, chronically ill patients. 4. Present policy results in a complicated, costly, and problem-ridden mechanism for paying for medical care of the elderly. The way in which the federal and state governments pay for care of the elderly under Medicare and Medicaid creates problems for the patient. In the case cited in this article the primary care physician and the other physicians charged more for their services than Medicare would pay and billed the patient directly. Hence the patient had to pay the difference in addition to doing the paperwork necessary for reimbursement by Medicare and by Blue Cross/Blue Shield. In general, the ability of many elderly patients to deal with the reimbursement procedures of Medicare, Blue Cross/Blue Shield, and other third-party payers is limited. In addition, actions by third-party payers including errors, delays, communications that are difficult to understand, and so on may cause a patient to cease his efforts to obtain reimbursement. As a result, part of the cost of care is borne by the patient unable to cope with "the system." Another example of problems that the financing mechanism causes patients is the method of paying for nursing home care. If a patient meets five conditions he may receive Medicare payments to cover some of the costs of care in a skilled nursing facility for up to 100 days in a benefit period. However, uncertainty over a patient's eligibility for Medicare payments creates prob-
224
Health Services Research
VIEWPOINTrs
lems for patients and nursing home administrators alike. In order for Medicare to pay some of the costs of care, it must be demonstrated that skilled nursing care is required on a daily basis throughout the period of payment. Medicare will not pay if a patient needs skilled nursing care only intermittently. Further, the difference between skilled nursing care and other kinds of nursing care is not clear cut and the determination that skilled nursing care is needed on a daily basis is not unambiguous. After payments by Medicare stop, either because it is determined through utilization review that the patient no longer needs skilled nursing care or because the patient has been on Medicare the maximum allowable time, the patient who still needs nursing care in the same type of facility must pay for that care from his own resources. Given the high cost of care, it doesn't take long to spend many thousands of dollars. If the patient's money runs out, he may turn to Medicaid for continued support. In California this means he must go on welfare and be certified eligible for care under the Medi-Cal program (the name given to the Medicaid program in California). Because operators of skilled nursing facilities in an urban area like San Francisco consider the amount Medi-Cal pays for care (approximately $22 per day) totally inadequate, patients who are not able to pay the daily charge ($68 for a private room, $34 for a 2-bed room, and $32 for a 3-bed room) have to be moved to homes that will accept what Medi-Cal will pay. This means that patients usually have to be moved to homes some distance from San Francisco. In terms of patient care, patients moved from the city have to find new physicians. Moreover, these patients suffer the trauma of leaving familiar surroundings and of being cut off from family and friends who have difficulty visiting them. In conclusion, beginning the study of health policy issues with a micro event such as one person's experiences in the health care delivery system, rather than at the macro level, where the constructs considered by policy makers are remote from patients and their pain, enables one to see at least a part of the outcome of a set of policies and procedures often developed at different times and for different reasons. The micro approach to analysis of health policy issues also enables one to see that the quantitative, efficiencyoriented approach characteristic of much health services research is limited and needs to be augmented. This is especially true in studies of long-term care of the chronically ill because the problems of home care and nursing home care are not so much technical as social. -David H. Stimson and Ruth H. Stimson REFERENCES
1. Somers, A. R. Some basic determinants of medical care and health policy: An overview of trends and issues. Health Serv Res 1:193 Fall 1966. 2. Kissick, W. L. and S. P. Martin. Issues of the future in health. Ann Am Acad Polit Soc Sci 399:151 Jan. 1972. 3. Bums, E. M. Health Services for Tomorrow: Trends and Issues. New York: Dunellen, 1973.
Fall 1976
225
Stimson & Stimson 4. Edwards, C. D. The federal involvement in health: A personal view of current problems and future needs. New Engl J Med 292:559 Mar. 13, 1975. 5. Shore, H. Long-term care regulations: Counterproductive and costly. Hospitals 49:57 Oct. 16, 1975. 6. Butler, R. N. Why Survive? Being Old in America. New York: Harper & Row, 1975.
226
Health Services Research
