Steffie Woolhandler

Care denied: US residents who are unable to obtain needed medical services.

OBJECTIVES This study analyzed data on US residents reporting that they were unable to obtain needed care. Inadequately immunized children and women inadequately screened for breast or cervical cancer were also examined. METHODS Data from the 1987 National Medical Expenditure Survey was analyzed. RESULTS A total of 6,375,000 (90% confidence interval [CI] = 6,039,000, 6,711,000) people could not get hospitalization, prescription medications, medical equipment/supplies, or emergency, pediatric, mental health, or home care. Although the uninsured were more likely to forego care unavailable, three quarters of those unable to obtain services were insured, and 46% (90% CI = 42.4%, 49.6%) had private coverage. Of those reporting the reason why they failed to obtain care, 65.1% (90% CI = 61.7%, 68.6%) listed high costs or lack of insurance, including 60.7% (90% CI = 57.1%, 64.3%) of the privately insured. More than a third of women had not had a breast examination in the previous 2 years, a fifth had not had a Pap smear within the previous 4 years, and half had never had a mammogram (ages 50-69 only). Of children 2 to 5 years old, 35.1% (90% CI = 31.5%, 35.7%) were inadequately immunized. Medicaid recipients had measures of access to care similar to those of the uninsured. CONCLUSIONS Many US residents--most of whom have insurance--are unable to obtain needed care, usually because of high costs.

Hypernatremic dehydration in nursing home patients: an indicator of neglect

In order to determine the antecedents of hypernatremic dehydration the authors reviewed the records of 56 patients with this condition at two public hospitals, one of which includes a large chronic care facility. Twenty‐nine patients developed hypernatremic dehydration while at nursing homes. All cases came from proprietary nursing homes, although proprietaries account for only 88 per cent of nursing home beds in the community studied (P < 0.05). There was a cluster of patients from two nursing homes. Sixteen patients admitted from home all showed evidence of inadequate care prior to admission. Eleven patients became hypernatremic while in acute care hospitals. No patient in the public chronic care facility developed hypernatremic dehydration during the period studied. The average serum sodium concentration of patients transferred from nursing homes was significantly higher than that of patients who developed hypernatremic dehydration at home or in acute care hospitals. It is concluded that hypernatremic dehydration in an institutionalized patient may be an indicator of inadequate care, which should prompt further investigation of the living conditions of the patient.

Patient transfers: medical practice as social triage.

We studied 458 consecutive patient transfers from 14 private hospitals to a public hospital emergency room during a six-month period. The transferred patients were predominantly male, young, and uninsured, and included large numbers of minority group members. We established criteria to identify patients at high risk for adverse effects of transfer and reviewed the clinical records of the 103 patients meeting these criteria. We judged that transfer resulted in substandard care for 33 of these patients, either because they were at risk for life-threatening complications in transit or because urgently needed diagnosis or therapy was delayed. In the community studied, transfer is a common and potentially dangerous medical intervention which appears to reinforce racial and class inequalities of access to medical care.

US emergency department costs: no emergency.

BACKGROUND Many perceive emergency department (ED) overuse as an important cause of high medical care costs in the United States. Managed care plans and politicians have seen constraints on ED use as an important element of cost control. METHODS We measured ED-associated and other medical care costs, using the recently released 1987 National Medical Expenditure Survey of approximately 35,000 persons in 14,000 households representative of the US civilian, noninstitutionalized population. RESULTS In 1987, total ED expenditures were

Who administers ? Who cares ? Medical administrative and clinical employment in the United States and Canada

8.9 billion, or 1.9% of national health expenditures. People with health insurance represented 86% of the population and accounted for 88% of ED spending. The uninsured paid 47% of ED costs themselves; free care covered only 10%. For the uninsured, the cost of hospitalization initiated by ED visits totaled

Public money, private control: a case study of hospital financing in Oakland and Berkeley, California.

3.3 billion, including

The Hospital Readmissions Reduction Program.

1.1 billion in free care. Whites accounted for 75% of total ED costs. The ED costs of poor and near-poor individuals accounted for only 0.47% of national health costs. CONCLUSIONS ED use accounts for a small share of US medical care costs, and cost shifting to the insured to cover free ED care for the uninsured is modest. Constraining ED use cannot generate substantial cost savings but may penalize minorities and the poor, who receive much of their outpatient care in EDs.

The Jackson National Health Program

OBJECTIVES We compared US and Canadian health administration costs using national medical care employment data for both countries. METHODS Data from census surveys on hospital, nursing home, and outpatient employment in the United States (1968 to 1993) and Canada (1971 and 1986) were analyzed. RESULTS Between 1968 and 1993, US medical care employment grew from 3.976 to 10.308 million full-time equivalents. Administration grew from 0.719 to 2.792 million full-time equivalents, or from 18.1% to 27.1% of the total employment. In 1986, the United States deployed 33,666 health care full-time equivalent personnel per million population, and Canada deployed 31,529. The US excess was all administrative; Canada employed more clinical personnel, especially registered nurses. Between 1971 and 1986, hospital employment per capita grew 29% in the United States (mostly because of administrative growth) and fell 14% in Canada. In 1986, Canadian hospitals still employed more clinical staff per million. Outpatient employment was larger and grew faster in the United States. Per capita nursing home employment was substantially higher in Canada. CONCLUSIONS If US hospitals and outpatient facilities adopted Canadas staffing patterns, 1,407,000 fewer managers and clerks would be necessary. Despite lower medical spending, Canadians receive slightly more nursing and other clinical care than Americans, as measured by labor inputs.

Gonadal steroids and body composition, strength, and sexual function in men.

Government support of public and private hospitals in Oakland and Berkeley, California was investigated. The private hospitals received government subsidies amounting to at least 60 per cent of their total revenues. The dollar amount of the subsidies to private hospitals was four and one-half times greater than government expenditures on the public hospital. In Oakland and Berkeley, as in many cities, public medical services have been reduced while both government health expenditures and private hospital revenues have increased sharply. The private hospitals, although all nominally non-profit, exhibit revenue maximizing behavior which results in socially unjust and medically irrational resource allocation. Funds might be found for public hospitals and clinics, and resources allocated more justly and rationally, if government expenditures in the private sector were brought under greater public scrutiny and control.

The Effects of Household Medical Expenditures on Income Inequality in the United States

To the Editor: Zuckerman et al. (April 21 issue)1 found that hospital readmissions for conditions targeted for penalties fell by 3.7 percentage points, whereas stays in observation units rose by 2.1 percentage points, yet they concluded that these two trends were not related because observation stays were rising even before the penalties were in place. Instead, the authors attribute continuously rising observation rates to hospitals’ confusion over the criteria used in audits of inpatient stays. It seems unlikely that confusion over these regulations continued to increase for many years, leading hospitals to sacrifice billions by billing for observation stays rather than for more lucrative admissions. More likely, hospital executives realized that, on balance, avoidance of readmission penalties by relabeling inpatient stays as “observation” was the most lucrative strategy. The authors also overinterpret their statistics as showing no correlation between readmissions and observation stays. In fact, they, like previous analysts,2 found a weak positive correlation (P = 0.07) — indicating a 93% likelihood that falling readmissions and rising observations were related. Finally, their analysis ignores other potential gaming strategies — for example, upcoding coexisting conditions to improve riskadjusted rates and shifting inpatient-type care to emergency departments.