dietary changes, or other alterations in life-style.4 Decreases in blood pressure, due to the "loss of the alerting response," would affect all three groups similarly and could not explain our study's findings. At regular 1-month intervals and on completing the study, interviews with control subjects indi¬ cated that they had not engaged in any aerobic exercise, which was confirmed by the lack of increased aerobic fitness. The effects of staff exposure was controlled for by the in¬ clusion of a nonaerobic exercise group. Objective, automated blood pressure measurements were obtained during mental stress testing and during daily life with ambulatory blood pres¬ sure monitoring. The consistent lackofeffectofexercise on blood pressure, across situations, including the clinic, laboratory, and ambulatory settings, suggests that the blinding procedures that we used in the clinic setting were adequate. We should note that our results were a surprise to us, but they suggest that at least one subset of hypertensive patients may not respond to an increase in fitness alone in the absence of weight loss or dietary change. James A. Blumenthal, PhD Duke University Medical Center Durham, NC William C. Siegel, MO New England Deaconess Hospital Boston, Mass Mark Appelbaum, PhD Vanderbilt University Nashville, Tenn 1. Keleman MN, Effron MB, Valenti SA, Stewart FJ. Exercise training combined with antihypertensive drug therapy: effects on lipids, blood pressure, and left ventricular mass. JAMA. 1990;263:2766-2771. 2. Duncan JJ, Farr JE, Upton J, Hagan RD, Oglesby ME, Blair SN. The effects of aerobic exercise on plasma catecholamines and blood pressure in patients with mild essential hypertension. JAMA. 1985;254:2609-2613. 3. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255\x=req-\ 3264. 4. Siegel WC, Blumenthal JA. The role of exercise in the prevention and treatment of hypertension. Ann Behav Med. 1991;13:23-30.
Hospital Resource Allocation and Insurance Coverage To the Editor. \p=m-\Bravemanet al1 very elegantly provide documentation that babies who are not covered by "adequate" health insurance have fewer resources applied to their medical problems. But is their inference that these infants are getting suboptimal care valid? They state that, "It seems reasonable that medical procedures not necessarily associated with lowering the risk of
adverse health outcomes, and even medically indicated elective procedures, would be kept to a minimum for newborns, especially sick ones." There is a different way to look at the same data\p=m-\thatof the behaviorist. Neonatologists, like all of us, are rewarded for their behaviors, which include procedures that they perform. If their compensation is enhanced (that is they get paid) for a particular behavior procedure in a particular group of patients, they are more likely to repeat that behavior. If, on the other hand, no reward results from a particular behavior, it is less likely to be repeated. The health maintenance organization experience showing that fewer (less expensive) interventions are necessary to achieve comparable outcomes for many medical problems and that fewer hospital days are required for many procedures documents that overutilization of resources has been common in the past. Part of this overutilization results from physician behavior; we do what we are rewarded for. Might this not be the case when the data of Braveman et al are viewed in this light? Rather than underutilization of resources for a particular cohort, might this not be docu¬ mentation of overutilization by another cohort? If outcomes
(mortality rate, morbidity, developmental outcome, etc) are
the same for the groups, that certainly could be the case. We should be looking at means by which we can determine what is optimal care in terms of resource allocation. At that point, we may be able to determine whether underutilization or overutilization is the problem.
Johnson, Kalamazoo, Mich Donald F.
MD
1. Braveman resource
PA, Egerter S, Bennett T, Showstack J. Differences in hospital allocation among sick newborns according to insurance coverage. JAMA.
1991;266:3300-3308.
To the Editor.\p=m-\Bravemanet al1 examine differences in hos-
pital resource allocation among sick newborns according to
their insurance coverage. The authors conclude that because length of stay, total charges, and charges per day were less for the uninsured babies, and because they could not explain these differences based on differences in medical need, that this represents "prima facie evidence of inequities that need to be addressed by policy changes." They are clearly outraged that uninsured infants do not receive the same quality of care as the infants of mothers with insurance or Medicaid. But their findings are not direct evidence of poor quality of care. What Braveman et al do not report are outcomes. We need to know if the babies without insurance or Medicaid had worse outcomes, after adjustment for medical risk, than those with insurance or Medicaid. Without these data we cannot rule out the alternative hypothesis that the babies of mothers with insurance received unnecessary care and/or full markup of charges, and that all the babies received adequate care. If one is going to assert the existence of a prima facie case, then one had better deliver unequivocal results.
Harry B. Burke, MD, PhD Medical College of Wisconsin Milwaukee
PA, Egerter S, Bennett T, Showstack J. Differences in hospital allocation among sick newborns according to insurance coverage. JAMA.
1. Braveman resource
1991;266:3300-3308.
In Reply. \p=m-\Weagree with Dr Johnson that it is important to consider how physician behavior is rewarded in interpreting our findings on resource allocation to sick newborns by insurance status. Since providers in prepaid plans (including health maintenance organizations, the predominant type of prepaid plan in California) have powerful incentives for eliminating unnecessary services, we looked separately at the records of babies covered by prepaid plans. The babies who were uninsured or on Medi-Cal consistently received significantly fewer services than those with prepaid coverage. This was true despite evidence that the uninsured and Medi-Cal babies were likely to be at greater medical risk than either the prepaid or fee-for-service private groups. Prepaid plans have been accused of cutting too many corners to suit some consumers' preferences; we are not aware of charges that their service levels are excessive. We therefore interpret our results as indicating that the babies who were uninsured or on Medi-Cal received levels of care that were below the accepted standards of necessary care, and were thus placed at risk of preventable adverse consequences. In response to Dr Burke's letter, we agree that one cannot determine from these data whether adverse outcomes oc¬ curred as a result of the differential allocation of resources. We are interested in studying the ultimate consequences of the most vulnerable groups receiving the least care. How¬ ever, we believe that the findings stand on their own as strong evidence of unacceptable inequities, with or without additional evidence regarding consequences. Our primary outcome measure was length of stay; differ¬ ences in this measure were substantial and statistically sig¬ nificant. It is highly unlikely that elective services account for
Downloaded From: http://jama.jamanetwork.com/ by a Michigan State University User on 06/14/2015
Hospital Resource Allocation and Insurance Coverage To the Editor. \p=m-\Bravemanet al1 very elegantly provide documentation that babies who are not covered by "adequate" health insurance have fewer resources applied to their medical problems. But is their inference that these infants are getting suboptimal care valid? They state that, "It seems reasonable that medical procedures not necessarily associated with lowering the risk of
adverse health outcomes, and even medically indicated elective procedures, would be kept to a minimum for newborns, especially sick ones." There is a different way to look at the same data\p=m-\thatof the behaviorist. Neonatologists, like all of us, are rewarded for their behaviors, which include procedures that they perform. If their compensation is enhanced (that is they get paid) for a particular behavior procedure in a particular group of patients, they are more likely to repeat that behavior. If, on the other hand, no reward results from a particular behavior, it is less likely to be repeated. The health maintenance organization experience showing that fewer (less expensive) interventions are necessary to achieve comparable outcomes for many medical problems and that fewer hospital days are required for many procedures documents that overutilization of resources has been common in the past. Part of this overutilization results from physician behavior; we do what we are rewarded for. Might this not be the case when the data of Braveman et al are viewed in this light? Rather than underutilization of resources for a particular cohort, might this not be docu¬ mentation of overutilization by another cohort? If outcomes
(mortality rate, morbidity, developmental outcome, etc) are
the same for the groups, that certainly could be the case. We should be looking at means by which we can determine what is optimal care in terms of resource allocation. At that point, we may be able to determine whether underutilization or overutilization is the problem.
Johnson, Kalamazoo, Mich Donald F.
MD
1. Braveman resource
PA, Egerter S, Bennett T, Showstack J. Differences in hospital allocation among sick newborns according to insurance coverage. JAMA.
1991;266:3300-3308.
To the Editor.\p=m-\Bravemanet al1 examine differences in hos-
pital resource allocation among sick newborns according to
their insurance coverage. The authors conclude that because length of stay, total charges, and charges per day were less for the uninsured babies, and because they could not explain these differences based on differences in medical need, that this represents "prima facie evidence of inequities that need to be addressed by policy changes." They are clearly outraged that uninsured infants do not receive the same quality of care as the infants of mothers with insurance or Medicaid. But their findings are not direct evidence of poor quality of care. What Braveman et al do not report are outcomes. We need to know if the babies without insurance or Medicaid had worse outcomes, after adjustment for medical risk, than those with insurance or Medicaid. Without these data we cannot rule out the alternative hypothesis that the babies of mothers with insurance received unnecessary care and/or full markup of charges, and that all the babies received adequate care. If one is going to assert the existence of a prima facie case, then one had better deliver unequivocal results.
Harry B. Burke, MD, PhD Medical College of Wisconsin Milwaukee
PA, Egerter S, Bennett T, Showstack J. Differences in hospital allocation among sick newborns according to insurance coverage. JAMA.
1. Braveman resource
1991;266:3300-3308.
In Reply. \p=m-\Weagree with Dr Johnson that it is important to consider how physician behavior is rewarded in interpreting our findings on resource allocation to sick newborns by insurance status. Since providers in prepaid plans (including health maintenance organizations, the predominant type of prepaid plan in California) have powerful incentives for eliminating unnecessary services, we looked separately at the records of babies covered by prepaid plans. The babies who were uninsured or on Medi-Cal consistently received significantly fewer services than those with prepaid coverage. This was true despite evidence that the uninsured and Medi-Cal babies were likely to be at greater medical risk than either the prepaid or fee-for-service private groups. Prepaid plans have been accused of cutting too many corners to suit some consumers' preferences; we are not aware of charges that their service levels are excessive. We therefore interpret our results as indicating that the babies who were uninsured or on Medi-Cal received levels of care that were below the accepted standards of necessary care, and were thus placed at risk of preventable adverse consequences. In response to Dr Burke's letter, we agree that one cannot determine from these data whether adverse outcomes oc¬ curred as a result of the differential allocation of resources. We are interested in studying the ultimate consequences of the most vulnerable groups receiving the least care. How¬ ever, we believe that the findings stand on their own as strong evidence of unacceptable inequities, with or without additional evidence regarding consequences. Our primary outcome measure was length of stay; differ¬ ences in this measure were substantial and statistically sig¬ nificant. It is highly unlikely that elective services account for
Downloaded From: http://jama.jamanetwork.com/ by a Michigan State University User on 06/14/2015
