United States MORE RESTRAINTS ON MEDICAL COSTS

433

example, the General Medical Council de-recognised in 1975 all undergraduate medical qualifications from Indian universities. Doctors wishing to enter the country for work had to pass a special examination for registration. Many foreign graduates believe that the standard and the pass rate of that examination are determined by supply-and-demand factors for doctors in the United Kingdom. These actions by the GMC led the Indian Medical Council to reciprocate and to de-recognise British qualifications. As a result memberships and fellowships of the Royal Colleges are no longer registrable by the IMC, thus deterring some Indian graduates from coming to Britain. The decision of the British Government to impose restrictions on the entry of foreign doctors from April 1, 1985, was a final blow to the hopes of graduates wishing to enter the country for work. Similar difficulties existed for Indian graduates in the USA. Where they had been welcomed by American hospitals and even had their fares paid at one stage, they found that by the late ’70s the situation had deteriorated and the welcome had all but disappeared. By 1985 things had reached a crisis, with American medical students graduating at the rate of approximately 17 000 per year. The number of new medical jobs available annually is almost 20 000, so only 3000 jobs are available for foreigners. Of these 2000 go to those Americans who graduated outside the US, thus leaving only 1000 posts available for doctors wishing to enter from nearly 100 different countries. Several Bills are now before the US Congress which seek to restrict foreign doctors from residency programmes. One of these stipulates that for any medical institution to become eligible for Government funds, not more than 25% of its trainee doctors should be from abroad. These deterrents in the US and the UK, together with a decline in demand for foreign doctors in the Middle East, have effectively blocked most points of exit for Indian medical graduates. Privately a number of senior medical politicians in India are pleased with this outcome, although they are reluctant to say so. Dr J. Sood, secretary of the IMA, refused to commit himself on whether or not this kind of restriction is advantageous or not for India. He did state, however, that if some doctors’ "self-respect" allowed them to go to countries where they would be discriminated against and where they would find few if any training opportunities, then they were free to make that decision. ,

Standard of Postgraduate Education Are India’s doctors being deprived of the "respected" postgraduate education available in the West? A wide consensus among Indian medical academics is that the standard of postgraduate medical education in a number of Indian institutions, such as the AIIMS, is comparable to that in the West. Furthermore, according to Professor Bhargava, fewer graduates than ten years ago wish to go abroad for training. Nevertheless she had to admit that the standard of

postgraduate

education varies

tremendously throughout

the

country, because of differences in funding and in the quality of teaching. After the de-recognition of British medical qualifications in 1976, the National Board of Examination was set up to try to standardise postgraduate education throughout India. The Board offers an examination leading to membership of the Academy of Medical Sciences in a particular specialty, and it is now not only the Government of India’s policy but also the policy of medical institutions to give preference to doctors with Indian postgraduate qualifications rather than those of the Royal Colleges so prized in the past. In view of this attitude to Western training, it is perhaps not

surprising that the Government has no policy to attract back Indian doctors working overseas. For one thing, as Dr Bhatla pointed out, doctors residing overseas are "machine oriented", and there is little need for their skills in the smaller towns and villages. Furthermore the big towns and cities are now so saturated with doctors that the assimilation of newcomers is judged likely to cause difficulties. India is now able to train more than enough doctors to meet her basic needs, and to offer some of them a high standard of postgraduate education. She is determined tcr depend no longer on the West, either for the return of her doctors working there, or for the provision of postgraduate education. PETER KANDELA

United States MORE RESTRAINTS ON MEDICAL COSTS

THE "reasonable charge" basis of American medicine has been under attack. The Government proposed amendments to the Medicare and Medicaid programmes that would, for the first time, apply limits to all items and services that are not provided through a health maintenance organisation and that are now reimbursed on an unrestrained "reasonable charge" basis. The affected services and items are estimated to be worth about$1.15 billion in the fiscal year, 1984, and were said to be rising at an annual rate of 15%. They include: durable medical equipment (eg, oxygen equipment, wheelchairs, hospital beds); ambulance services; prosthetic devices, braces, artificial limbs, and artificial eyes; portable X-ray services; and certain medical supplies used in connection with home dialysis

delivery systems. The proposal

tied reimbursements to the economic index restraint mechanism now in place for physicians’ services. Medicare payments for clinical diagnostic laboratory tests would be frozen for 15 months and thereafter fees would be set. Medicare deductibles (the portions of medical costs borne by the patients themselves) would be raised annually, tied to the rate of inflation. The most significant change would be the abolition of the Medicare-Medicaid patient’s freedom to choose a physician or other health professional for non-mandatory services and supplies. There is some evidence that medical costs are being controlled. In California, the rate of increase in hospitalisation cost dropped to less than a half of what it was 3 years ago. Hospital costs were climbing by 20% in 1981 and 1982, but the first half of 1985 showed an increase of only 9.1 % over the previous year. Charges for a hospital stay of about a week still averages$5948 in California, where hospital costs have long been the highest in the country. But, starting in 1982, the state has been negotiating rates with hospitals for patients on Medi-Cal, the state’s health-care provision for the poor. Almost 15% of the patients in hospitals are Medi-Cal recipients. Another 40% of the patients in Californian hospitals are on Medicare, the Federal health programme for the aged and the disabled. Private insurance companies are also allowed now to negotiate rates with hospitals. Before this triple assault by the state, Federal, and private insurers on hospital expenses, hospitals were paid simply for their cost, which were rising almost uncontrolled. In recent years, however, fewer patients have been entering hospitals and their stays have become shorter. Competitive pressure has forced hospitals to cut staff and equipment. It is not known whether these changes are detrimental to patients; and research on the effects of cost-cutting on health is hard to achieve. Some critics complain that the changes forced the early release of patients who would benefit from a longer stay in hospital. It would take only one well-publicised incident attributed to the action of a cost-cutting bureaucrat to rekindle the flames of the controversy over cost and poor patients’ health. ORGAN TRANSPLANTS: PREFERENCE FOR THE WEALTHY ?

CONGRESSIONAL hearings in Washington showed that large numbers of foreign nationals are travelling to this country for kidney transplants at a time when 8000 Americans are awaiting kidneys. The Government of Saudi Arabia told Senator Gore (Tennessee) that 114 of its citizens had received transplants here in the past three years. In some cases there is a strong suggestion of preferential treatment. Reportedly, some US surgical services charge a higher fee for kidney transplants, as much as five times higher, when the patient is a wealthy alien. A representative of the End-Stage Renal Disease Network related an incident where a dialysis patient was told to stand by because two kidneys have become available. The patient was considered a good match. Later, it was discovered that both kidneys had gone to nonimmigrant aliens. It is impossible to determine whether the person in question was the best match or whether he was passed over for financial reasons. Washington Hospital Center data show that the foreign recipients have approximately one-third the waiting time of American recipients before a transplant takes place. Almost 50% of the kidney transplants in this Centre were received by foreign

434 nationals in 1983 and a similar ratio was found at New York’s Downstate Medical Center. Another finding was that hundreds of donated kidneys are wasted every year in this country-or sent overseas when matches cannot be found here. Abroad, they fetch$8000-$12 000 in procurement costs. For example, 575 kidneys obtained by the Southeastern Organ Procurement Foundation from 1982 to 1984 were sent overseas or were "wasted" because of lack of match with US

recipients. A financial issue that surfaced at the hearings was that the number of patients that could receive transplants may be kept artificially low. Dr Paul Terasaki, director of the Southern California Organ Procurement Agency, estimated that 30% of the patients on dialysis could benefit from a transplant, but only 10% are awaiting one. He said that doctors now taking care of the dialysed patients are reluctant to transfer control of the patient to a specialty that is more oriented toward transplantation. Some nephrologists own dialysis centres in the US.

In

England Now

FOR a short time Giles was known by a nickname which recently has become quite common. His sobriquet was earned some years ago when he moved into the modern development which has now become part of our village. The houses were new and every family had the unenviable task of creating gardens out of clay and builders’ rubble. Top priority was given to making a front lawn. This required the ground to be cleared of bricks and stones and, after levelling, the admixture of copious amounts of sand. It became the habit of many to wheel a barrow in the evening down towards the site where further houses were being built. And when the watchman was off for his unofficial but regular visit to the local tavern, to load the aforesaid barrows with sand. In fairness, I suspect the contractor knew of the practice but in the interests of good community relations and the economics of having adjacent dwellings with attractive gardens, turned a blind eye to the situation. When Giles’ new neighbour arrived he surveyed his frontage mournfully. "Not to worry," said my friend, "I know where there is sand aplenty. Come along with me." And so saying they made their way to the site where together they hid behind a hut until the caretaker disappeared. Quickly Giles loaded up his barrow and, united in crime, they returned to their respective gardens where Giles demonstrated the art of mixing earth and sand to form the basis of a green sward. "Now," he said. "It’s your turn. I think there is just about time for another load." His new-found friend hesitated. "Don’t worry," said Giles. "We all do it. This is how we make up our lawns." His comrade still demurred. "Well," said Giles, "Tomorrow then. But bring your own barrow and make sure the wheel is well oiled." Next morning Giles chanced to glance out of the front window while dressing. He was just in time to see his new neighbour, in the full uniform of an assistant chief constable, step irto a police car to be driven to work. For some months, thereafter, Giles was known in the village as "supergrass". *

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THIS week’s visit to that circular chamber in north-east London wherein the official inquiry into Mrs Wendy Savage’s obstetric practice is taking place was prompted by the warning issued by Sir John Walton, President of the General Medical Council, who declared earlier in the week that the public nature of the proceedings compromised patient confidentiality. Mr Christopher Beaumont, QC, chairman of the inquiry, had, however, already ruled that the cases under investigation were to be referred to by the patients’ initials only. So I found the same small number of the public in attendance. Luckily, I also found the same case (see Lancet, Feb 15, p 376) under scrutiny. Prof Jurgis Grudzinskas, Mrs Savage’s head of department at the London Hospital, who had set in motion the train of events culminating in Mrs Savage’s suspension, had

Further developments were the appearance of a company that coordinated kidney transplants for foreign nationals and advertised broadly in the foreign press to induce foreigners to have their organs transplanted at particular US hospitals and the emergence of a brokerage for organ donors, inviting donors to put up their organs for auction to the highest bidder. Some of these activities relating to kidneys were suppressed by 1983 but threats remain of similar enterprises coming on the scene in relation to hearts. To prevent finances ruling medicine-at least in this area-the Task Force on Organ Transplantation will recommend to Congress the use of US citizenship as a criterion for receiving donated organs. One possible option is to place a limited number of foreign nationals on organ transplant waiting lists through the use of a quota system. Once on the list, foreigners would be treated as equal to US citizens. Many Task Force members view organs as scarce national resource. Recommendations in the report will serve as voluntary guidelines for organ distribution in hospitals.

declined last week to condemn outright her management of Mrs A. U.’s delivery. Mrs Savage had agreed, in response to a family plea, that Mrs A. U. should attempt vaginal delivery, even though she had had a previous caesarean section, the infant was presenting in the breech position, and her pelvis was small. The infant died 8 days after delivery by caesarean section. The case was described this week as an "obstetrician’s nightmare", by Prof John Dennis, of the University of Southampton, who had been asked to give an expert opinion. Professor Dennis criticised Mrs Savage’s handling of the case, on the grounds that a trial of labour exposed Mrs A. U. to unacceptable risk. He argued that he would not have expected any infant to emerge undamaged as a result of her management and he also suggested that a trial of labour in such unpromising circumstances was unkind. *

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related before in this column the censoriousness of the the pecadilloes of the elderly. This spoil-sport towards young attitude extends to legal liaisons. Not so long ago I was summoned to a local authority old people’s home by a highly-agitated matron. I was told, in a voice filled with horror, that Alec had proposed marriage to Ivy, and had been accepted. This seemed to be a perfectly reasonable, indeed laudable, state of affairs. I could think of no reason for matron’s agitation-other than my private knowledge that she herself had carelessly omitted to involve either a minister of religion or a registrar before cleaving unto the man who shared her flat. So I enquired why the business of Alec and Ivy was so terrible. It was explained to me, patiently, that Alec was very fit, had been married previously, and, what was more, was an ex-naval man. Thus he would, it was felt, wish to exercise his conjugal rights to the fullest extent. Ivy was a spinster, and could not, the staff felt sure, have any idea of what was coming to her. Ignoring the implied slur on the Senior Service, I asked what I was supposed to do. It was my duty as a psychiatrist, I was told, to certify this man and, by incarcerating him in hospital, prevent him having his evil way with this inoffensive and innocent maiden. This, of course, I refused. However, I found myself manoeuvred into the position of having to find out whether Ivy knew the facts of life, and of enlightening her if she did not. I chatted to her for a while about Alec, and then cautiously-after all, she was old enough to be my mother-asked her if she realised that there was something Alec would definitely want from her beyond mere companionship and platonic friendship. Her eyes sparkled with pleasure and excitement as she answered, "Ohyes!" At this point I gave my blessing to the union and withdrew. Alas, it was not to be. Officialdom would not tolerate the situation, especially when chivvied by Ivy’s family, which saw its longawaited, if modest inheritance slipping from its grasp. Alec was moved to another home, twenty miles away, and no contact, not even letters, was allowed between the two sweethearts. A few weeks later, Ivy died, still a virgin. I

HAVE