AMedical Staf Conference

Refer to: The ailing health care system-Medical Staff Conference, University of California, San Francisco. West J Med 128:512-526, Jun 1978

The Ailing Health Care System These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Drs. David W. Martin, Jr., Associate Professor of Medicine, and Robert C. Siegel, Associate Professor of Medicine and Orthopaedic Surgery, under the direction of Dr. Lloyd H. Smith, Jr., Professor of Medicine and Chairman of the Department of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, CA 94143.

DR. LEE:* The central issue of this medical staff conference on the ailing health care system is rising costs. Two case presentations illustrating the complex of factors involved in catastrophic medical care costs in a university setting serve as a point of departure for a discussion of the problems surrounding the cost issue from a clinical, ethical and a policy perspective. What are some of the facts that have led to this presentation? The costs of medical care are rising rapidly. Expenses for medical care have risen from 4.6 percent of the gross national product in 1950 to 8.6 percent in 1976, when medical care expenditures amounted to $139 billion (Figure J).1 In 1977 it is estimated that these figures will have increased to $160 billion and 8.9 percent of the gross national product. Individual costs have also increased substantially, as have health insurance premiums. Persons who pay out of pocket, those who purchase health insurance, and those who pay the taxes that support government medical care programs all are becoming concerned. Hospital care is taking an increasing share of the medical care dollar, even more than profes*Philip R. Lee, MD, Professor of Social Medicine, Director, Health Policy Program.

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sional services and far more than any of the other components of medical care costs. University medical centers and teaching hospitals are accounting for a growing proportion of hospital care expenditures. An increasing share of federal and state budgets is also being spent for medical care. Federal outlays have risen from $5.2 billion in 1965, the year Medicare and Medicaid were enacted, to $39.9 billion in 1976.1 Similarly, the proportion of the federal budget devoted to medical care has risen from 4.4 percent in 1965 to 11.3 percent in 1975. This is one of the reasons politicians are searching for ways to effectively control the rising costs of medical care. The dual problems of. rising costs and regulation have become the overriding health policy issues of the 1970's. How to control rising medical costs also has become a matter of major concern to deans and other medical educators. Recently, 110 medical school deans issued a statement entitled "America's Health and Medical Costs."t I would like to quote two passages from that statement: "BetAmerica's Health and Medical Costs-A Statement from the Deans of 110 American Schools. National Fund for Medical Education. Hartford, Conn., 1977. (This statement contained the signatures of all eight California medical school deans, plus the deans of medical schools of the Universities of Oregon and Washington.)

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cause of the key role played by doctors in determining many of the costs of care, we believe the nation's health care system can be made cost conscious without compromising the quality of care delivered." We hope that this is the case. The statement. also said: "We believe all physicians must become knowledgeable about the fiscal aspects of health policy and sensitive to the economic consequences of their professional decisions." The deans went on in this short report to emphasize the need to provide physicians in training with opportunities to learn more directly about these issues. The rising individual and national expenditures for medical care have caused such distinguished economists as Victor Fuchs to raise the question, "What are we getting for our money?" Analysts have begun to raise questions about the relationship of medical care to health, the effectiveness of medical procedures and the value of medical care in general. The problem of rising costs is not only leading to more regulation of medical

care, but also has given great impetus to the idea that physicians should be at risk in terms of the costs of care generated by their behavior. This is a very old idea. It is strongly embodied in group practice prepayment concepts, and it formed the basis for national policies in the early 1970's to foster the development of health maintenance organizations. One of the newest proposals for national health insurance, designed by Professor Alain Enthoven of Stanford University's School of Business, incorporates this idea; so does the Health Security proposal supported by Senator Edward Kennedy. What would be the implications for faculty and house staff if they were at risk for costs generated by the care provided at university medical centers? Finally, the problem of the rising costs and catastrophic expenses generated in the care of many sick patients has raised the question of rationing more explicitly than it has been raised in the past. These are some of the issues that we will be discussing this morning. To do so, let us

(in billions)

Percent of GNP

tao 2

$12.0

1950

1960

197U

Fiscal years

1974

Figure 1.-National health expenditures and percent of gross national product, selected fiscal years 1950-1976. (Reprinted by permission from Gibson and Muller and the Social Security Bulletin'). THE WESTERN JOURNAL OF MEDICINE

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turn to a case summary of our first patient, which illustrates dramatically how costly, as well as beneficial, medical care can be.

Case Presentation DR. BRADLEY:* This is the first University of California, San Francisco, (UCSF) admission for this 53-year-old woman who entered with the chief complaint of diarrhea of seven months' duration. Twelve years before admission, the patient had vagotomy and pyloroplasty for recurrent duodenal ulcers with complete relief of symptoms. Three months before admission, she began to have 4 to 20 watery, dark brown stools per day. These were usually postprandial, occassionally nocturnal, and associated with intense lower abdominal pain. Five weeks before admission, the patient was admitted to another hospital with an 1 1-pound weight loss and hepatomegaly. Findings in the following tests were normal at that hospital: the antinuclear antibody, B12, gastrin, basal acid output, catecholamines, 5-hydroxyindole acetic acid, thyroid function tests, ceruloplasmin, serum immunoglobulins, amylase, stool fat, cortisol, stool ova and parasites X 12, upper gastrointestinal (GI) series with small bowel follow-through, barium enema, sigmoidoscopy, two small bowel biopsy studies, a cholecystogram (using an orally given contrast agent) and a computerized tomography (CT) scan of the abdomen. The following tests gave abnormal findings: elevated liver function tests; slightly elevated eosinophils; mildly low folate; and a carcinoembryonic antigen of 5.0 mg per ml (normal less than 5.0 mg per ml). Selected films from a celiac angiography were said to show a blush in the tail of the pancreas. The patient was given intravenous hyperalimentation, and she was transferred to this hospital. On physical examination the patient was seen to be thin and in no acute distress; vital signs were within normal limits. The abdomen was nontender with the liver edge palpable two fingerbreadths below the right costal margin. Admission laboratory values included the following: hematocrit of 30.5 percent with normal indices and 2.3 percent reticulocytes; leukocyte count of 7,800 with 4 percent eosinophils; platelet count of 355,000; normal SMA-6, prothrombin time, SMA-12, electrocardiogram (EKG), urinalysis, and chest x-ray. *William Bradley, MD, first-year

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The patient's three-month hospital course featured a combination of diagnostic and therapeutic maneuvers. Hyperalimentation was accomplished with a left subclavian line followed by placement of a Broviac catheter, and, finally, a left internal jugular line. When the patient neither ate nor drank, she still had three or four watery stools per day, high in sodium. On a gluten-free, milk-free, low-residue diet, she had 10 to 20 stools per day. Shortly after admission, the celiac angiogram was reviewed extensively and findings were thought to be normal. Upper gastrointestinal series, a barium enema study, colonoscopy and a cholecystogram (with an orally given contrast agent) were all repeated, and again showed no abnormalities. Another biopsy study of the small bowel failed to show Giardia. Results of a biopsy study of the liver were read as nondiagnostic. Sonogram of the pancreas was normal as was another CT scan of the same area. Serum vasoactive intestinal peptide was equivocal at a level of 18 (normal is less than 10). Many antidiarrheal agents were utilized during her hospital stay. Maximal doses of paregoric and Lomotil® (diphenoxylate hydrochloride with atropine sulfate) were found to have a small but beneficial effect. Several therapeutic trials were attempted. Two ten-day courses of tetracycline were given for presumed bacterial overgrowth; metronidazole was given for presumed occult giardiasis; indomethacin was given for presumed prostaglandin-mediated diarrhea secondary to a presumed medullary carcinoma of the thyroid; steroids were given for presumed atypical inflammatory bowel disease. None of these therapeutic trials was found to have a beneficial effect, and it became increasingly obvious that an exploratory laparotomy might be necessary. During a total hip replacement several years previously, it had been noted that the patient's blood contained an unidentified antibody and could not be cross-matched. Her blood was sent therefore to multiple blood banks, but attempts at cross-matching were all unsuccessful. Crossmatch was then attempted between the patient's three children and five siblings. One brother was compatible. Unfortunately, this brother, who lived in North Dakota, was scheduled for an elective aortic aneurysm repair two days later. This was postponed, and he donated one unit of blood toward his sister's operation. At the last minute, her blood was typed as Vel negative, a rare blood type found in one of 5,000 people;

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$0

1966

1968

1970

1972

1974

three more units were located in the San Francisco Bay area. Exploratory laparotomy was carried out. No obvious masses were found, and 70 percent of the pancreas was resected. The pathology report showed islet cell hyperplasia. She was discharged well three weeks later with only three or four loose stools per day. At follow-up examination the week before this conference, she continued to do well with only two to three bowel movements per day. The final diagnosis was pancreatic cholera; her hospital bill at UCSF was

$46,500. Medical Costs-The Clinical Perspective DR. SCHROEDER: * I will present preliminary data from a current research project on high cost medical cases, discuss the costs of medical care at teaching hospitals (with emphasis on the use of laboratory and x-ray tests) and examine differences among hospitals and physicians in their use of costly medical services. The decision of how far to pursue diagnosis and treatment of patients in hospital is one that we all face daily. As hospital costs continue to climb dramatically, questions are being asked about how these decisions are made and what are the cost implications to the patients, to the hospital and to society. Approximately 40 percent of all health care expenditures occur in hospitals. The rise of hospital costs outstrips every other component of medical care. National health expenditures rose 17 percent from 1974 to 1975, 15 percent from 1975 to 1976.1 Per diem rates at UCSF have climbed proportionately during the past ten years (Figure 2). *Steven A. Schroeder, MD, Associate Professor of Medicine, Associate Professor of Ambulatory and Community Medicine.

1976

Figure 2.-University of California, San Francisco, Hospital inpatient charges, selected fiscal years, 1966-1976.

The case just presented shows the degree to which excellent, meticulous medical care in combination with new medical technologies can produce an outstanding patient care outcome. Recently, the newspapers reported the story of a 44-year-old Army mathematician who was admitted to hospital in Washington, D.C., for 270 days. This patient had chronic pancreatitis that was resistant to medical and surgical therapy. His hospital course was even more heroic than that of our patient; prolonged paralysis resulted from administration of curare, given in an attempt to stabilize pancreatic inflammation. The patient finally died after a stormy and complicated course. Two factors made this patient newsworthy: the attempt to treat him with curare, and his hospital bill of $250,000. How typical are these cases? Are they likely to increase in frequency? Questions such as these have inspired proposals for national catastrophic health insurance that would cover only high cost medical care, such as cases in excess of $5,000 per person per year. A research team at the Health Policy Program, UCSF, is currently working with me to investigate the frequency and the characteristics of hospital patients with high medical expenses in order to judge the need for and the likely impact of a national catastrophic health insurance plan. This study, which is funded by the National Center for Health Services Research and the Henry J. Kaiser Family Foundation, involves 17 acute care hospitals in California's San Francisco and Alameda counties. We define high cost cases as those equal to, or greater than, $4,000 per patient per year. Since $5,000 is commonly discussed as a deductible level for a THE WESTERN JOURNAL OF MEDICINE

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AILING HEALTH CARE SYSTEM TABLE 1.-Characteristics of Sample of Patients Who Incurred Yearly Charges of $4,000 or More at University of California, San Francisco (UCSF), Hospital and a Community Hospital UCSF Hospital

Number of patients ........ 127 Age (years) Mean .................. Median ................. Sex Men .4...................7% Women .................3% Primary Insurer Government (Medicare, Medicaid) 43.7% Nongovernment .........3% Ethnic Group White ..................3% Nonwhite .1...............7% Discharge Status Alive .9...................5% Dead .................. 9.5%

Community Hospital

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Hospital (Percentages) UCSF Hospital

104

67.5 71.5

40.4% 59.6% 73.0% 27.0% 94.1% 5.9%

84.6% 15.4%

national catastrophic health insurance plan, we judge that adding physician charges would bring the average case over the $5,000 level. Our data will probably underestimate patient yearly costs to the degree that it excludes care outside of the hospital, long-term care, psychiatric care, and hospital admissions at other hospitals, such as occurred with this patient. It also excludes inpatient physician and surgeon charges. So far we have analyzed 12 acute care hospitals in these two counties. The percentage of patients with bills in excess of $4,000 per year in 1976 ranged from a low of 4 percent at one small community hospital to 22 percent at UCSF. The percentage of patients with bills in excess of $10,000 varied from less than 1 percent at another small community hospital to 6 percent at both UCSF and a referral pediatric hospital. Let us compare the experience at UCSF with a general community hospital in the San Francisco Bay area. UCSF is a large hospital (560 beds) with multiple specialty units; it receives referrals from a wide area. The community hospital is moderate in size (175 beds) and receives referrals from a relatively small area. Annual patient charges at UCSF are about $50 million, as compared with $10 million at the community hospital. Mean patient charges are $3,100 at UCSF and $1,960 at the community hospital. At UCSF approximately 22 percent of the patient population incurred one-year charges equal to or greater than $4,000. These patients ac516

TABLE 2.-Comparison of Chronicity and Purpose of Admission for Sample of High Cost Patients at University of California, San Francisco (UCSF), Hospital and a Community

Number of Patients ......... Chronicity Acute ................... Chronic ................. Purpose of Admission Palliation ................ Restore to normal function Improve to previously impaired status .......... Diagnostic ...............

127

Community Hospital

104

47.2 52.8

52.0 48.0

4.7 20.5

2.0 13.7

40.9 33.9

44.1 40.2

counted for two thirds of the total charges of $50 million. At the community hospital 10.5 percent of patients had charges equal to or greater than $4,000, accounting for 40 percent of the total hospital charges. The difference between the two hospitals is even greater when $10,000 is used as a cutoff point. Of the cases at UCSF, 6 percent had charges in excess of $10,000, accounting for 34 percent of the total charges; at the community hospital these figures were 2 percent and 4 percent, respectively. A more detailed comparison of high cost cases at the two hospitals comes from a sample of 127 patients from UCSF and 104 from the community hospital who were randomly selected from patients with costs over $4,000. As shown in Table 1, patients at the community hospital were much older, suggesting that younger patients are more likely to be referred to a university hospital. The differences in primary insurers reflects the large percentage of community hospital patients covered by Medicare. In addition to describing routine demographic and clinical data, we made two clinical judgments for each high cost case. First, after a medical record review we divided the cases into acute or chronic, based on duration of illness. Second, we placed each case into one of four categories according to purpose of admission. The two hospitals were not significantly different with respect to chronicity of disease or purpose of admission (Table 2). Table 3 shows the mean yearly charges by discharge service of the UCSF high cost patients. It is of note that three services had particularly high mean costs: the transplant service, the infant service (which reflects activity in the neonatal

AILING HEALTH CARE SYSTEM TABLE 3.-Mean Yearly Charges by Discharge Service of Sample of High Cost Patients at University of California, San Francisco, Hospital Discharge Service

Mean Number Percent Charge

Percent Total Charges

Pediatrics ........... Infants ............ Pediatrics .......... Pediatric surgery ....

15 6 6 3

11.8 9,685 4.7 15,345 4.7 6,133 2.4 5,467

13.0 8.2 3.3 1.5

Medicine ............ Dermatology ....... Medicine .......... Neurology .........

39 3 32 4

30.8 10,421 2.4 4,910 25.2 11,632 3.2 4,866

36.2 1.3 33.2 1.7

Surgery ............. 73 Ear, nose and throat . 2 Neurological surgery. 16 4 Obstetrics-gynecology Orthopedics ....... 17 Surgery, general .... 12 Thoracic surgery .... 7 Transplant ........ 5 Urology ........... 4 Vascular surgery ... 6

57.4 7,828 1.6 7,674 12.6 7,154 3.2 5,235 13.4 8,010 9.3 7,343 5.5 7,777 3.9 15,574 3.2 6,721 4.7 6,201

50.8 1.4 10.2 1.9 12.1 7.8 4.8 6.9 2.4 3.3

8,844

100.0

TOTAL

............

127

100.0

intensive care unit) and medicine. Surgical cases constituted almost 60 percent of the high cost cases at UCSF, as compared with about 35 percent at community hospitals. These data suggest that high cost cases are not only common, but that they account for a large share of hospital charges and revenues, particularly at a university hospital. Comparison of the high cost cases at the two hospitals suggests that selective referral to university hospitals of younger patients and those with surgical conditions is occurring to a substantial degree. Some estimate of the likely growth of high cost cases can be made by noting that 50 percent of all patients had chronic disease (present for more than one year) and that population projections estimate an increasing proportion of elderly persons. It is not yet clear what outcomes ensue from high cost cases such as these. One report examined outcomes of 226 consecutive critically ill patients who entered the recovery room/acute care unit at Massachusetts General Hospital. Almost 90 percent of these patients were postoperative and required intensive physician and nursing care. In all, 54 percent died within a month, and 73 percent were dead within 12 months of hospital admission. Of the 62 sur-

vivors, 27 (12 percent) recovered fully. Hospital charges in 1972-1973 dollars averaged $14,300.2 In discussing the role of cost considerations in clinical decision making, the authors of this study argue that it is not appropriate to consider withholding care once the patient has been admitted to an intensive care unit. However, they hint at a cost containment strategy whereby admission to intensive care units would be rationed. Teaching hospitals are special cases in terms of medical costs because of their different referral patterns as well as their educational functions. Attention is now beginning to focus on the extent to which teaching hospital costs are high because of the teaching function. The question appears to be a straightforward one that could be answered by two accounting techniques. First, what proportion of the hospital budget is attributable to house staff salaries and to teaching activities of clinical faculty? And second, to what extent does teaching alter the process of care, for example, by increasing the length of hospital stay or by increasing the use of consultative and diagnostic services such as laboratory and x-ray tests? The question is made a great deal more difficult, however, by the problem of case mix. Most university hospitals care for an unusually large percentage of relatively complicated cases or provide special services such as renal transplantation. Because it has not been possible to control the case mix issue very well, most attempts at measuring teaching hospital costs have not been definitive. Nevertheless, interesting preliminary data are available. At the University of Rochester, Griner found that laboratory and x-ray tests accounted for 25 percent of the bills of hospital medical patients. During five years at that hospital, costs attributable to laboratory tests increased twice as much as overall hospital costs. Griner also described specific patterns of laboratory overuse, including complete blood counts, serum electrolytes, and blood urea nitrogen (BUN) determinations. X-ray studies of the chest and sputum cultures were ordered as routine daily procedures on all patients in the intensive care unit, and serum glutamic oxaloacetic transaminase (SGOT) was routinely determined on patients with acute myocardial infarction.3 In another study, expenditures for patients with acute pulmonary edema were compared before and after opening of an intensive care unit (icu). While mortality rates did not THE WESTERN JOURNAL OF MEDICINE

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change, length of hospital stays increased by 2.3 days and expenditures increased by 50 percent. The use of arterial blood gas studies increased sevenfold coincident with the opening of the ICU.4 Dixon and Laszlo studied laboratory tests on the medical service of the Durham Veterans Administration Hospital. They judged the usefulness of each test, based on four criteria: Did it generate an order for medication or the need for other care? Were the results considered in planning for subsequent patient care? If findings were abnormal, was the test repeated? If they were normal, was it evident that the test ruled out diagnostic considerations? For a set of randomly selected medical patients, only 5 percent of laboratory tests yielded a positive answer to any of these four criteria. They then arbitrarily limited the house staff to eight laboratory tests per patient per day and found that the percentage of appropriate tests increased to 23 percent.5 Schroeder and O'Leary compared the experience of 450 hospital patients of 13 faculty internists who admitted patients jointly at two hospitals, one a major university teaching center, the other a community hospital. After controlling for type and severity of illness, duration of hospital stay was equivalent at the two hospitals. This was somewhat at variance with other published reports and probably reflects the fact that case mix was controlled. The frequency of consultations, laboratory tests and x-ray studies was significantly higher at the university hospital. Of the 54 different types of tests and procedures ordered for these patients, 21 were carried out much more often at one of the two hospitals; 19 of those 21 were done more often at the university hospital, and virtually all of those were blood tests. The increased frequency of laboratory testing at the university hospital accounted for 56 percent of the differences in hospital charges between the university and the community hospitals.6 Just as differences in intensity of laboratory use occur among hospitals, differences also exist among physicians. Several years ago, we looked at differences in use of laboratory tests and x-ray studies among similarly trained faculty internists practicing in a university medical clinic. We found huge differences in the costs due to the laboratory tests-as great as 17-fold on one occasion, 20-fold on another, with very large standard deviations.7'8 We could not attribute these differences to in518

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creased severity of cases in the more expensive physicians' practices, nor to characteristics of the patients. Neither could we find any correlation between the increased use of tests and increased quality of care or productivity.8 In other words, increased cost of practice was not translated into increased quality or efficiency, at least using the measures studied. Similar practice variations have been reported in other settings.9-11 In conclusion, five points should be emphasized. First, the increase in medical technology available for patient care and proportion of the population with chronic diseases will almost certainly result in increasing numbers of high cost cases. These cases are likely to account for an increasing proportion of patient care, especially at university teaching hospitals. Second, use of laboratory and x-ray tests is an important component of medical expenditures, and amounts to approximately 25 percent of hospital charges. Third, there is increasing concern that excessive use of laboratory tests occurs in teaching settings. Fourth, great variation exists in the costliness of physicians' medical care, without an obvious translation of these increased costs into improved efficiency of practice. Finally, because of all of these factors, there has been increasing attention to the process of clinical decision making. Articles have recently appeared in major clinical journals that attempt to define in quantitative terms the issues involved in decision making.12-15 This methodology, sometimes called cost-benefit analysis, means that the financial value of services, care and, ultimately, of patient life is measured in quantitative terms. The problem of how to value a human life is a good point at which to introduce the next case.

Case Presentation DR. LUBIN:* This is one of several UCSF admissions for a 69-year-old white woman with probable hepatic coma. She has had a history of multiple medical problems: postnecrotic cirrhosis, status postportacaval shunt in 1973, adult onset diabetes mellitus with a neurogenic bladder and multiple urinary tract infections. She had weekly episodes of pre-coma treated at home by her daughter with lactulose, protein restriction, and dioctyl sodium sulfosuccinate (Colace®). Between October 1973 and July 1977, the patient had nine admissions for hepatic encephalopathy. Six days before admission, she became confused and *Craig

Lubin, MD, first-year medical resident.

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fell. She became progressively lethargic in spite of home therapy and was brought to the emergency room. The patient was obese, obtunded, moaning and responded only to deep pain. Positive findings included bibasilar rales and a II/VI systolic ejection murmur. The abdomen was obese and nontender, bowel sounds were active and there was no organomegaly. Right gaze preference was noted, her pupils were equal and reactive to light, and she moved all extremities in response to pain. Asterixis was present, deep tendon reflexes were 3 + and symmetrical in the upper extremities, absent in the lower extremities. Pertinent laboratory data included the following: hemoglobin, 12 grams per dl; hematocrit, 35 percent; leukocyte count, 3,400 per cu mm, platelet count, 33,000 per cu mm; prothrombin time, 19.6 seconds; partial thromboplastin time, 41.9 seconds; BUN, 74 mg per dl; creatinine, 2.6 mg per dl; sodium, 138 mEq per liter; potassium, 5.7 mEq per liter; chloride, 104 mEq per liter; bicarbonate, 14 mEq per liter; uric acid, 9.4 mg per dl; normal levels of serum glutamic oxaloacetic transaminase (SGOT) and lactic dehydrogenase; total protein, 5.7 grams per dl; albumin, 2.3 grams per dl; alkaline phosphate, 131 iu per liter; cholesterol, 107 mg per dl. The urine was positive for bile and negative for glucose, ketones and protein, with 10 to 25 leukocytes and 5 to 10 red blood cells per high power field. On the first hospital day, obtundation persisted in spite of therapy for hepatic encephalopathy. Lumbar puncture showed xanthochromic cerebrospinal fluid (CSF) with 780 red blood cells, 95 leukocytes with 92 percent polymorphonuclear leukocytes per cu mm and a protein value of 133 mg per dl. CSF glucose was 230 mg per dl with a serum glucose value of 470 mg per dl. CT brain scan was negative for intracranial bleeding. On the second day, blood and urine cultures were positive for Gram-negative rods. The patient was treated with chloramphenicol and gentamicin. Oliguria, sepsis and hypotension developed, and the patient was transferred to the intensive care unit. On the fifth hospital day, the patient's condition was improving with a rising urinary output and improved mental status, but two days later, liver function tests began to worsen. On the tenth hospital day, urine output began to fall, and findings on liver function tests continued to worsen. On the 12th hospital day, mental status

began to deteriorate, and the patient became more icteric. She became increasingly obtunded, with worsening hepatorenal failure, and she died on the 15th hospital day. The hospital bill was $13,836.

Medical Costs-The Ethical Perspective DR. JONSEN: * The onset of an ethical problem, like the onset of influenza, starts with headaches, pains, and malaise, and sometimes nausea. These problems that we call ethical problems are literally headaches. We find that it hurts to think about them. A medical student said to me the other day, after a class in medical ethics, "These problems make my head hurt." The conclusions we reach after thinking about these so-called ethical problems are sometimes so repugnant to us that they cause a kind of moral nausea. Finally, there is malaise, that vague discomfort and dis-ease, and the inability to mobilize our resources to come to direct grips with the problem. The problems of the high costs of care and of cost containment are already beginning to cause these symptoms. I feel them myself when I participate in discussions of cases in which ethical problems arise. The first patient discussed today might not require what we are now calling, somewhat pretentiously, an ethical consult, but the second patient might need an ethical consult fairly early. Rather than discuss these particular patients, I will make some general comments. Examples of the kinds of problems that I am beginning to see are the following: The Medicaid (Medi-Cal) consultant at a major institution starts to challenge and deny charges for certain procedures and days in the intensive care unit because these patients are judged terminal and therefore should not be treated. The criteria for candidacy for renal dialysis are carefully scrutinized by accountants from the Department of Health, Education, and Welfare in terms of quality of life that will result from that procedure. The outcomes of graduates of neonatal intensive care units are carefully analyzed for cost effectiveness. The State Department of Health in California is now asking what is appropriate critical care for the mentally infirm persons confined to institutions. These are ominous points. The most common reaction to these symptoms is beginning to take place, namely *Albert R. Jonsen, PhD, Associate Professor of Bioethics, Medicine, Pediatrics, and History of Health Sciences.

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the formation of committees and the calling of conferences to deal with ethical problems in the allocation of scarce medical resources. This outbreak of acute ethics, however, should not blind us to the fact that this ethical problem, like a low-grade infection, has been part of medicine since its beginnings. The Hippocratic Oath declares "Into whatever houses I enter, I will come to help the sick." The oath did not oblige the Greek physician to enter every house in which there was sickness. Today we may ask whether some houses cannot be entered because it is not cost effective to do so. Throughout medical history, persons have received care only when they could pay for it, when others (friend, family, the state) would pay, or when a charitable physician would donate care at cost to himself. The finite time of the physician, the limited availability of medicines, and the plethora of sickness and pain all dictated some distribution of medical care in terms of costs. In fact, the scarcity of sanitoria for patients suffering from tuberculosis and other respiratory diseases in the 19th century was a major stimulus toward the establishment of the German health insurance system, the oldest in the world. Some of you remember well the rationing of penicillin in this country, and even more of you recall the rationing of renal dialysis in the mid-1960's. If any event can be credited for the ethics explosion in medicine, it was the effort in the 1960's to give access to hemodialysis on the basis of social and personal qualities. Forgetting that cost has long been the rationing device in medicine, people were outraged by the thought that social status, which of course is often associated with ability to pay, would become the explicit criterion for admission to a lifesaving technology. Yet a committee was established in Seattle to parcel out admission to dialysis on the basis of something more than medical criteria, namely, a set of social worth criteria. Subsequent debates about federal support of the dialysis program and about national health insurance asserted the right to health care based on need alone. However, it has become patent that need is, on the one hand, a concept of infinite elasticity, and, on the other, a mighty expensive proposition. An ancient ethical question which is part of the debates about the nature of justice is "Should benefits be distributed in terms of merit or need?" We find it repugnant to provide medical care on the basis of merit, as in the Seattle pro520

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gram. Yet we find it impossible to provide it on the basis of need. Impossible because, if we take the need criterion seriously, we find that its costs will withdraw resources from many other necessary and worthwhile endeavors that may have equal claim upon those resources. That is one ethical dilemma about the problem of high costs of medical care. A second centers on the question "Should cost be a consideration at all in clinical decisions?" We say "Life is priceless," that is, you cannot put a price on life. We speak of "cure at all costs"; we speak of the sanctity of life. Of course, we know that these are metaphors, but they are mighty metaphors with a great deal of symbolic power over our motivations, our own self-image, and our cultural mores. How should these metaphors affect decision making? Cost has always been a consideration in clinical decisions. But is this merely a matter of expediency? Is it in fact an appropriate ethical consideration when making a clinical decision to ask "How much will this cost?" For the sake of an example, I wish to make reference to one tradition, which over many, many years has maintained a strict and demanding position with regard to the sanctity of life and at the same time has a long tradition of considering the problems of medical ethics. I speak of the Roman Catholic tradition, which has always stated that there was a moral obligation to preserve one's health by ordinary means. One of the principal authors in that tradition, Father Gerald Kelly, defines extraordinary means of care in this way: Extraordinary means are medicines, treatments, and operations that cannot be obtained or used without excessive expense, inconvenience, or, which if used, provide no reasonable hope of benefit.'6

That is certainly not the definition of extraordinary means that is common in medicine, which looks at the state-of-the-art rather than at the costs or the inconvenience of the treatment. Yet, in this tradition, which has maintained a conservative view of the sanctity of life, excessive cost is admitted as an ethical consideration relevant to clinical decisions. This tradition looks principally, however, to the very private kind of relationship among physicians and patients and families. The authors did not explicitly propose how these considerations can be lifted to the level of social concerns. Are cost considerations permissible when clinical decisions are being made in view of social costs

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rather than to costs to the individual person? How can we apply these principles to broad social policy? When some persons who are accustomed to having authority over certain decisions find that authority being taken away or threatened by others, a classical ethical problem emerges. In the 19th century, the two major ethical problems facing Western civilization were problems of that sort. The first was the problem of the relationship between the aristocracy and the people. The revolutions of the 19th century all centered on the problem of authority: Where should it lie? This problem has been solved in fundamental ways by the establishment of modern democracies that provide a very different sharing of authority than existed in the beginning of the 19th century. The second major problem of that century was the problem of the relationship between labor and management. The authority over production and the conditions of work were fought over until finally it was settled that employers have no legitimate authority over the lifestyle of their workers, while they do have legitimate authority over the distribution of dividends. The question of the conditions of labor would have to be negotiated between labor and management. This resolution of the problem essentially redistributed the authority over the conditions of work and the relationship between management and labor. I mention these things in order to suggest that the question of the locus of authority in medicine with regard to clinical decisions is in the same place that the problems of aristocracy and democracy, and labor and management, were in the 19th century. In medicine, we have not yet begun to parcel out and to discern who ought to have the legitimate authority to do what. It seems to me that the current struggle in which patients' rights are asserted on the one hand, and the involvement of government on the other, with physicians in the uncomfortable middle, is the beginning of a process of parceling out who ought to really make what sorts of decisions. In clinical decisions themselves, which issues should be handled by one with medical knowledge and licensure? One of the major studies of the influences of decisions relative to intensive care, Diana Crane's book The Sanctity of Social Life, shows the immense influence of social factors in clinical decisions

made to proceed with intensive care.'7 Is this decision appropriately part of a physician's skill and ability? In conclusion, it seems to me that we need three things in this early stage of considering ethical problems raised by the high costs of care. First, we need an examination of the grounds for the legitimacy of clinical decisions, that is, what appropriately -belongs to whom. Secondly, we need clear and general application of appropriate principles for decision making. I frequently have occasion to deal with house staff related to problems of termination of care, and it interests me that even the most rudimentary considerations coming from the tradition of medicine are unknown to many of them. If we are going to teach principles of cost effectiveness to house staffs, as medical school deans suggest, we ought also to teach them ethical traditions and current considerations of the law related to termination of care. Finally, there is need for a set of procedures to say who ought to be making what decision and when. Should the clinical decision be made by a bureaucrat who is not in contact with the patient? Are features of the clinical decision legitimately influenced by bureaucrats who may have a broader view of the issues of cost than clinicians? It seems to me that we have only the most rudimentary beginnings of this kind of distribution of authority at present. In the last analysis the problem is an ethical problem because it involves a sacrifice by physicians, and when one is asked to sacrifice, ethical problems become extremely acute. The sacrifice is the sacrifice of a great and broad range of authority. The sacrifice is the sacrifice of that great satisfaction that may come with being able to deal with a variety of problems on one's own. And finally, it may be the sacrifice of an image that has always been immensely important to medicine, that is, the image of going all out. There may be times when that is not appropriate. DR. LEE: If many of the physicians in the audience think that they are in a bind, our next speaker is in a double-bind.

Medical Costs The Hospital Perspective MR. KERR: * I will assess the implications of federal and state health care cost control efforts for the UCSF hospitals and clinics, particularly from the hospital director's perspective. Most of *William B. Kerr, MHA, Director of Hospitals and Clinics, Lecturer in the Division of Ambulatory and Community Medicine.

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us now clearly recognize that some form of governmental cost control and regulation is inevitable. The exact form this legislation will take is unpredictable at this time, since several bills are pending at the federal level. A California state bill has also been introduced that proposes an inpatient reimbursement limitation quite similar to current Medi-Cal reimbursement limits for outpatient services. In the event that legislation is not enacted at one of these two levels, the issue will possibly be taken to the voters in California as a referendum initiative on next November's ballot. Previous efforts to control routine hospital costs have been unsatisfactory and soimewhat arbitrary. Legislation currently being assessed suffers from some of these same basic weaknesses. The proposed ceiling of 9 percent on total revenues tends to penalize well-run institutions that have historically curbed costs. It fails to give proper consideration to varying lengths of stay throughout the country and, perhaps most important, does not recognize variables related to patient mix and severity of illness. Further, if any cost containment proposal is to reduce hospital costs without reducing essential services, it must recognize a hospital's limited ability to influence some cost increases. General inflation and government mandated programs, for example, are beyond the control of hospitals. Other factors contributing to increases are at least partially controllable, and we must initiate programs to reduce their impact on hospital cost increases. I am not opposed to reasonable cost or rate regulation. To be successful, however, such a program must have certain essential characteristics. It must set limits on the full cost of hospital care, both routine costs and ancillary services. It must apply to all patients, not simply those whose care is paid for by the federal or state governments. It must be a stable program projected to continue into the foreseeable future. Without such stability, difficult decisions to permanently effect cost savings will not be made. It should be based on a per admission rather than a per diem rate because success in reducing length of stay will naturally result in a higher cost per patient day. There must be provisions for adjustment related to case mix, since the number of costly diagnostic and treatment outputs varies considerably with the nature of the illness. The program must have a reasonable and 522

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a timely appeal process to deal with unique situations. Last, it must be simple to administer in a cost-effective and equitable manner. If we are to secure a program with these characteristics, university teaching hospitals have a responsibility to contribute to the legislative and regulatory process. To this end, the directors of the five University of California hospitals are currently engaged in a cooperative effort to review and comment on all proposed cost containment legislation. In addition, we hope to influence the positions taken by national organizations such as the Association of American Medical Colleges and the Council of Teaching Hospitals. During the past fiscal year our cost per inpatient admission has increased by 11 percent. This represents an improvement over the rate of increase for the previous two years, which averaged 14 percent per annum, and also compares favorably with the increase in per admission cost of approximately 17 percent in the nation as a whole. I can assure you that although we will continue our cost containment efforts from an administrative level, it is highly unlikely that we will be able to operate within a revenue ceiling of approximately 9 percent without modification of clinical activity. Multiple factors contribute to the cost of patient care in this institution. Some of these factors are essentially beyond our control. Costs that I would include in this category are the following: increases in salaries and fringe benefits for current employees, which are intended to maintain at least modest pace with inflation; sky-rocketing energy costs, and inflationary increases in the costs of supplies, drugs and replacement equipment. Other cost elements can be most appropriately controlled through administrative efforts, but require the continuing involvement of the medical staff. Costs in this category include items such as malpractice insurance, the costs of which have leaped almost 900 percent in the last five years. We will continue our attempts to increase standardization of supply items and to develop joint purchasing agreements with other institutions to mitigate the increase in supply costs. Greater efficiency in some of the support areas, such as housekeeping, laundry, maintenance, billing and registration services, may also be attainable and provide modest cost relief. However, I think that most persons who are active participants in the budget process are familiar with the fact that major efforts already have been made in all of

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these areas. In fact, I would suggest that we have been able to remain fiscally viable under current reimbursement limits of Medicare and Medi-Cal primarily through the attainment of greater operational efficiency. Certainly, continuing focus on these administrative elements will be essential. But it appears unrealistic to assume that these efforts, no matter how rigorously pursued, will enable us to live within the revenue limitations likely to be imposed. A major new initiative is required. We must focus on those costs that are most appropriately controlled by the medical staff. I would like to suggest four areas, each of which represents a substantial component of our expense base, to which we might direct our attention in the future. The first area is diagnostic tests. We are paying more to diagnose illness, because more sophisticated technology is available. In addition, we are ordering more tests. For example, the number of clinical laboratory tests ordered at UCSF is increasing at an annual rate of approximately 10 percent with little change in patient volume. I might add that that 10 percent is a major improvement in contrast with the escalation of laboratory test ordering in the previous two to three years, which was ranging much closer to 15 percent. Many of our diagnostic tools are also quite expensive, both to purchase and to operate. It is often extremely difficult to balance the cost of these services against a significant improvement in patient care quality. In this regard, I am sure that you have found many of the statistics presented by Dr. Schroeder to be not only highly significant, but also alarming. The second area of interest is nurse staffing. It is being recognized increasingly that levels of required nurse staffing are influenced strongly by ordering habits of medical staff. This factor is borne out in a recent analysis of the relationship between orders and staffing requirements of our intensive care unit. That analysis showed that the work demand on nurses in the intensive care unit has indeed increased, largely due to more sophisticated patient monitoring. But there is no parallel evidence that the patient mix in the intensive care unit has changed substantially, or that our morbidity or mortality outcomes have been affected. Similarly, the increase in laboratory tests referred to earlier has occurred without objective evidence from the medical profession that patient outcomes have been significantly improved. I am not suggesting that this might not indeed have been the case. My only point is that

we have been accepting increases in costs of care without requiring objective evidence of increased patient benefits. As difficult as these assessments may be, the public is demanding more than assurance that care has been improved. A third area in which physician decisions have impact on the cost of patient care are those services provided at the request of physicians by other professional groups, such as physical therapists, respiratory therapists, social workers and so on. With regard to these three areas, I am not suggesting that the ordering of any required services be discontinued, merely that these three categories constitute a major portion of the expense base of this hospital. Each of you must carefully assess the benefits that will accrue to your patients by providing specific services and weigh those potential benefits against the cost of providing the service. You, the medical decision makers, must become increasingly conscious of the cost implications of the decisions you make. A fourth but somewhat dissimilar area is the manner in which clinical departments schedule patient care and educational activities. It is my strong impression that better coordination of departmental activities with those of the hospital will result in significant improvement in operating

efficiency. No discussion of cost containment in an institution such as UCSF would be complete without mention of the medical education process. Clearly, future research will be required to understand this relationship more fully. The first area that should be addressed in this regard is the hypothesis that the incidence of inappropriate utilization of ancillary services is higher in a teaching setting. To this end, we have held discussions with some members of the faculty concerning the formulation of a study to determine the reasons for which diagnostic procedures are ordered, and the extent to which overutilization occurs. If we determine that overutilization is, in fact, contributing to cost escalation, we would propose developing an educational program to make the staff familiar with our findings. Through such educational efforts and the establishment of a jointly developed monitoring and control program, we could effectively reduce inappropriate demand. These are some of the specific issues in cost containment. I believe that we all have a common goal in this regard; that is, each of us wants to avoid arbitrary restrictions imposed upon us by THE WESTERN JOURNAL OF MEDICINE

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outside forces. There is no question that we will be told that we cannot spend as much to provide our services as we have in the past. The American public seems to be in general agreement with Secretary of Health, Education, and Welfare Califano's contention that hospitals have become obese. It is clear that the health care industry, if not obese, is at least overweight. The question that remains is: Who should prescribe the diet?

Medical Costs-The Policy Perspective MR. BUTLER: * My function is to summarize what you have heard and then to talk about choices for the future, largely choices for government. You have heard from Dr. Lee that the cost problem has become the political health care issue in the United States. You have heard one case history about a set of clinical decisions with a marvelous outcome, but high expense. You have heard from Dr. Schroeder about the difficulty in assessing medical costs around the country; about the influence of the nickels and dimes, the laboratory tests and x-ray studies, and about the enormous differences in practice habits from one clinician to another. You have heard an example of the kind of case that we all know too wellhigh cost care including intensive care with a final result of death. You have heard Dr. Jonsen talk about how decisions in such cases are and always have been inevitably ethical ones. And finally, William Kerr talked from the standpoint of someone running a hospital and suggested that the end is in sight for him in cutting administrative costs. It is clinical decisions that have to be changed now. My function is to discuss what the government and others are considering doing to change clinical decision making. Up to present there really has been very little governmental interference with day-to-day clinical decisions. The primary attention of government has been devoted to gross abuse, fraud, excessive facilities, or overlapping or duplicating services in communities. A whole variety of agencies have been spawned to deal with these issues, most notably Professional Standards Review Organizations and Health Systems Agencies. But by and large, their attention has been focused, appropriately at this stage, on major cases of abuse. As you have heard today, the role of these agencies and other governmental agencies has to change. The government stake is too high; the *Lewis H. Butler, LLB, Adjunct Professor of Health Policy, Associate Director, Health Policy Program.

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TABLE 4.-Policy Options for Medical Care Cost Containment

1. Change consumer behavior Encourage purchase of more cost-effective health insurance Increase cost-sharing through deductibles and copayments Encourage healthier lifestyles 2. Direct governmental regulation of physicians and hospitals 3. Limit supply of physicians and hospital facilities 4. Change method of paying for medical care 5. Change physician attitudes 6. Total government payment for medical care

costs are too high. Without trying to be overly dramatic, it is fair to say that the great medical issue of all of our professional lifetimes will be how to deal with the question of clinical decisions, and their impact on costs. The six basic alternatives for addressing this question are listed in Table 4. The first is to influence how consumers behave. There are three ways to try to do that. One is to try to change the way consumers buy their health insurance

by making them more cost conscious and thereby making them choose the most efficient and least costly kinds of medical care. That is the essence of the recent Enthoven proposal that Dr. Lee mentioned. A quick way to understand the proposal is to look at the rising costs of health insurance for employees of the University of California. The University is paying $66 a month for a family. Comprehensive Blue Cross costs $128. Kaiser Permanente Health Plan costs $82. A small study that we have just begun shows that a number of employees of the University are now electing to move out of the comprehensive Blue Cross coverage to the Kaiser Plan because they would rather pay only $16 a month out of their pockets than $62 for the Blue Cross coverage. Essentially this is the kind of choice that the Enthoven proposal would present to the country as a whole. Another approach is to put more of a financial burden on consumers at the time that they receive care, through deductibles and copayments of one kind or another. This approach is frowned on by many because it affects people at the very time that they are in the worst shape-when they are sick and in the hospital or have lost their jobs. Yet another approach is to try to change personal behavior by encouraging people to take better care of themselves, to engage in more self-care and to follow better health habits. That is a very long process and

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one that we cannot expect to save us a great deal of money in the short run. There are problems with all these approaches. The principal problem with giving people a choice in buying health insurance is that such choices really do not exist in most localities at present. The choices available to employees of the University of California are generally not available nationwide, largely because alternative methods of providing care, such as health maintenance organizations, are fairly limited in their geographical spread. Copayments strike hard at the neediest people. Personal behavior is hard to influence, and efforts to do so run the risk of excessive infringement of personal freedom. The second alternative to cost control would be direct government regulation of physicians and hospitals. That is what William Kerr talked about, and, clearly, it has been the primary emphasis of the federal government. This approach, which has been taken in most European countries and Canada, includes regulating physician fees and hospital budgets, a very difficult thing to do well. For example, if you regulate the fee for a physician visit, a natural reaction for physicians may be to expand the number of visits. Despite the difficulties, however, this approach is currently the leading contender in government efforts to control costs. A variation of this approach is to regulate the charges of insurance companies, which, in turn, would put the pressure on physicians and hospitals to control costs. This at least has the advantage of insulating physicians from direct action by governmental agencies. A third alternative, very much related to the second, is to limit the supply of physicians and hospital facilities as well as various kinds of equipment. This is a very possible and very likely alternative now because the government is paying more than 60 percent of the costs of physician training and more than 50 percent of hospital costs and, therefore, has the power to turn on or off the supply faucet. The problems are that limiting capital spending, as it is now proposed, is very hard to do equitably without freezing all the bad aspects of the system, protecting existing hospitals and facilities that may be inefficient, and keeping out more efficient ones. The problem with controlling the supply of physicians is that they tend to work where they want to work in specialties that they choose. Perhaps an even larger problem is the public conception that we have a shortage of physicians in the United States,

whereas many who have studied the issue suggest that we have overall a national surplus of physicians. A fourth option is to change the way that we pay for care. The current system is almost entirely a fee-for-service system. This system might be changed so that physicians are penalized for excessive use of procedures, such as x-rays, laboratory tests and intensive care. This change would be similar to the British system of paying general practitioners through what is called capitation payment. There are problems, of course, in switching to such a system. First, the fee-forservice system is well entrenched in this country, and, if it is changed, a new set of financial incentives would be created, including the incentive to short patients on care. We have had some examples in California, particularly in Los Angeles with prepaid systems for the poor, where that was exactly the result. A fifth alternative is to try to change the attitudes of physicians and other professionals. Over the long run this may be the most important thing that can be done. But there are also problems here. You are bucking strong professional and economic forces. A physician naturally wants to do as much as possible for the patient. Dr. Jonsen has spoken about that desire, and the cases this morning illustrate it. And there are strong financial rewards for ordering x-ray studies, laboratory tests, surgical operations and other procedures. Schroeder and Showstack have recently constructed a model to illustrate the impact of these economic forces. They indicate that internists in private practice can double or even triple their incomes through increasing their rate of carrying out office laboratory procedures."8 Finally, the sixth alternative is government control of most spending. This approach transfers most payment for medical care to governmental budgets, and the government then allocates dollars back to physicians and hospitals and other providers of medical care. Essentially, it is what is done in the British and Swedish systems, and is the approach of the Kennedy-Corman Health Security legislation. It does create the greatest possible pressure for cost control because the costs are coming identifiably out of taxpayers' pockets. The British have been very successful in controlling costs. But the Swedish parliament just keeps voting more money for medical care because of popular pressure by voters for such expenditures. Such an approach has other major THE WESTERN JOURNAL OF MEDICINE

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problems. It is hard to allocate the dollars fairly. The rich hospitals tend to stay rich; well-served areas tend to stay well-served; shortage areas tend to stay short. And, of course, there are all of the fundamental problems of any governmental enterprise-bureaucracy, stifling of innovation and lowering of productivity. In conclusion, some or all of these alternatives are coming in one degree or another. They all have problems and disadvantages. Some will interfere far more than others in the day-to-day lives and clinical decisions of physicians and other professionals. My personal view is that such interference carries such risks to the creativity and vitality of the system that we should concentrate our efforts on options 1, 3, 4 and 5, and try as much as possible to avoid direct government regulation and total governmental payment. This is going to be a difficult time of transition. Dr. Jonsen has referred to that eloquently. Authority is shifting from the physician to others. Inevitably, with effective cost control, the quality of care as some define it will decline, although I think that this eventuality can be greatly minimized by sensible and flexible approaches. There are, it seems, two great psychological hurdles that all of us have to get over. One requires accepting that we cannot do everything for infants in the neonatal intensive care nursery or for dying patients. Second, and perhaps most important, we must understand that there are no devils to

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blame, either government or physicians. We have tough choices to make, and we have to get about making them with as much good will as possible. REFERENCES 1. Gibson RM, Mueller MS: National health expenditures, fiscal year 1976. Social Security Bulletin 40:3-22, Apr 1977 2. Cullen DJ, Ferrara LC, Briggs BA, et al: Survival, hospitalization charges and follow-up results in critically ill patients. N Engl J Med 294:982-987, Apr 1976 3. Griner PF, Liptzin B: Use of the laboratory in a teaching hospital-The implications for patient care, education, and hospital costs. Ann Intern Med 75:157-163, Aug 1971 4. Griner PF: Treatment of acute pulmonary edema: Conventional or intensive care? Ann Intern Med 77:501-506, Oct 1972 5. Dixon RH, Laszlo J: Utilization of clinical chemistry services by medical house staff. Arch Intern Med 134:1064-1067, Dec 1974 6. Schroeder SA, O'Leary DS: Differences in laboratory use and length of stay between university and community hospitals. J Med Educ 52:418-420, May 1977 7. Schroeder SA, Kenders K, Cooper JK, et al: Use of laboratory tests and pharmaceuticals: Variation among physicians and effect of cost audit on subsequent use. JAMA 225:969-973, Aug 1973 8. Daniels M, Schroeder SA: Variation among physicians in use of laboratory tests: II. Relation to clinical productivity and outcomes of care. Med Care 15:482-487, Jun 1977 9. Freeborn DK, Baer D, Greenlick MR, et al: Determinants of medical care utilization: Physicians' use of laboratory services. Am J Public Health 62:846-853, Jun 1972 10. Lyle CB, Applegate WB, Citron DS, et al: Practice habits in a group of internists. Ann Intern Med 84:594-601, May 1976 11. Wright DD, Kane RL, Snell GF, et al: Costs and outcomes for different primary care providers. JAMA 238:46-50, Jul 1977 12. McNeil BJ, Keeler E, Adelstein SJ: Primer on certain elements of medical decision making. N Engl J Med 293:211-215, Jul 1975 13. Pauker SG, Kassirer JP: Therapeutic decision making: A cost-benefit analysis. N Engl J Med 293:229-234, July 1975 14. Sisson JC, Schoomaker EB, Ross JC: Clinical decision analysis. JAMA 236:1259-1263, Sep 1976 45. Shapiro AR: The evaluation of clinical predictions. N Engl J Med 296:1509-1514, Jun 1977 16. Kelly G: Medico-Moral Problems. St. Louis, Catholic Hospital Association, 1958, p 129 17. Crane D: The Sanctity of Social Life: Physicians' Treatment of Critically Ill Patients. New York, Russell Sage Foundation, 1975 18. Schroeder SA, Showstack JA: Financial incentives to perform medical procedures and laboratory tests: Illustrative models of office practice. Med Care 16:289-298, Apr 1978