- Email: [email protected]
United States REASONABLE AND CUSTOMARY
1310 anyone who charges more than the basic medical fee. To the dismay of the medical profession, this law has been upheld by a Federal Appeals Court,and the matter will go to the US Supreme Court. If upheld, the decision is not likely to be confined to Massachusetts. Similar legislation is under consideration in many other States, although some have already rejected such a law. Somehow, Medicare costs must be cut, and with stricter controls being
Round the World From
our
Correspondents
Italy
spring of last year restrictive legislation on tobacco was proposed by the then Minister of Health, Signor C. Degan.! It included: total prohibition of smoking in hospitals, schools, public and private offices open to the public, restaurants, and cafes (whenever separation of smoking and non-smoking areas was not feasible), urban public transport, and national airline flights; a total ban on cigarette promotion by sponsorship (which is particularly widespread in Italy, since direct advertising is forbidden); health warnings and indications of tar and nicotine yields of cigarettes; and health education campaigns. The attitudes to this legislation were investigated in a survey of 1515 individuals aged 15 or more, living in towns of over 30 000 inhabitants from various parts of Italy, conducted by a marketing research institute. The findings were published in a national daily newspaper.2 76% of the whole sample (and 70% of smokers themselves) were in favour of the legislation. 97% of those interviewed approved total prohibition of smoking in hospitals or schools, 86 % in public offices, 83 % in aircraft, 66 % in restaurants and cafes, and 61 % in private offices. Widespread popular support for this proposed legislation could not prevent the transfer of Signor Degan to another Ministry in July, 1986, and complete abandonment of the proposal. One of the first public statements of the new Minister was that smoking did not constitute a health priority in Italy.3 Consequently, no action against smoking has so far been undertaken by the new Minister. Although the economic and political implications of smoking are largely different in Italy (where tobacco products are manufactured and sold only by the State monopoly), there is a similarity between this Italian anecdote and what happened to the former US Secretary of Health, Mr Califano, and to the British junior Minister at the Health Department, Sir George Young. This can well be summarised in a sentence by Sir George himself: "Smoking is in every sense a political issue, and those politicians who concern themselves with it find themselves unexpectedly promoted or IN the
demoted."4 Istituto di Ricerche Farmacologiche Mario Negri, 20157 Milan
CARLO LA VECCHIA SILVIO GARATTINI
United States REASONABLE AND CUSTOMARY
SUCH
are
the fees that
physicians expect
to
be
paid
for their
services. The trouble comes when the reasonable and customary fee
by those third parties now paying most of the costs of medical This is of especial concern to the patient covered by the Medicare programme for the elderly. Physicians may charge Medicare patients as much as they like but the system will only cover 80% of a "reasonable" charge. To encourage physicians to treat Medicare patients (and many refuse to accept them) the doctor receives 80 % directly and agrees not to charge the patient for more than the remaining 20%. If the doctor charges for more than this, payment is made to the patient and the doctor has to collect from the patient. Many physicians think that the Medicare fees are unrealistically low, and that doctors have the right to set their own fees. The law in Massachusetts denies this option and penalises is
on hospitals, the obvious target for additional cost reduction is the fees paid to physicians. Of course the profession will resist furiously and there are threats that many physicians will refuse to treat the elderly or give inferior treatment. But this threat may prove idle. Too many doctors are graduating and medical schools have been urged to reduce numbers. Many doctors have moved into the health maintenance organisations and similar bodies. Meanwhile, in view of the budget deficit, the pressure to reduce cost is immense and growing. Some specialist groups, such as radiologists and pathologists, are under particular pressure. Haematology has largely fallen into the hands of haematologists, chemical pathology and microbiology are increasingly open to PhDs, and only histopathology is being left to pathologists. Many residents in pathology are wondering whether it is worthwhile sitting for the national boards in clinical pathology. Others seek different specialties. It looks as if the golden days for clinical pathologists are over. Radiologists are likely to be next to feel the squeeze. Some internists who do not have a mass of diagnostic gadgetry are likely to be affected. It seems as though big changes must meet what is certainly a crisis. Congress set up a physician payment review board, headed by Dr Philip Lee. He has said "there is a grass roots consumer movement now developing around National Health Insurance". But it is not only happening at the grass roots. If the profession finds itself faced with a national health insurance system forced on it, after all its opposition to "socialised" medicine, the blame will surely fall on the profession itself.
imposed
ATTITUDES TO LEGISLATION ON RESTRICTION OF SMOKING
set
care.
1. Ciuffa V. II tabacco al bando. Corriere della Sera May 18, 1986, 2. 2. Clerici S. La guerra al fumo. La Repubblica May 25-26, 1986, 4-5. 1. 3. Anonymous. Donat Cattin assolve i fumatori. Corriere della Sera Sept 27, 1986, 4. Bjartveit K. Legislation and political activity. In: Zaridze DG, Peto R, eds. Tobacco: a major international health hazard. Lyons: IARC, 1986: 285-98.
In
England Now
As I have said before, I am none too sure about private homes for the elderly. The whole idea of making a business out of caring for people who are, almost by definition, dependent seems rather unsatisfactory. Such homes are sold as going concerns-with their residents thrown in, like cattle in a farm sale. It is even less satisfactory when large sums of public money are spent on maintaining old people in such homes because they are believed to be cheaper than provision by the State. How many old people allow themselves to be persuaded (perhaps when judgment is clouded by illness or a bereavement) into going into a home "just to give it a try"-only to find that their environmental niche has been securely closed behind them? In my experience, old people need only be in a home for a couple of weeks to find their personal possessions distributed round the neighbourhood, their tenancy terminated, even their house actually sold, before they know what is happening. Trying to restore matters can be impossible, especially for a defenceless frail person. I vividly recall the indignation of a village vicar when I threatened him with the police if old Mrs X’s television set was not returned to her house forthwith-one of our nurses had seen him departing with it the day after she had been admitted. I have recently experienced a new variation on the "just give it a try" theme. One elderly retired professional lady decided she would see what a new residential home could offer. She made it clear that she was only going in on a trial basis, and, following our advice, took every precaution to protect her environmental niche. She was delighted with the little suite she was given in the home-a sitting-room, with bedroom off, gave her privacy when she wished, a communal life if she felt the need of company. After a month’s trial, she put her house on the market and announced she was staying for good. The day after she signed the contract of sale on her house she was moved out of her suite. She now shares a pokey bedroom with three other residents, all complete strangers and one of them incontinent. She is trapped.
Round the World From
our
Correspondents
Italy
spring of last year restrictive legislation on tobacco was proposed by the then Minister of Health, Signor C. Degan.! It included: total prohibition of smoking in hospitals, schools, public and private offices open to the public, restaurants, and cafes (whenever separation of smoking and non-smoking areas was not feasible), urban public transport, and national airline flights; a total ban on cigarette promotion by sponsorship (which is particularly widespread in Italy, since direct advertising is forbidden); health warnings and indications of tar and nicotine yields of cigarettes; and health education campaigns. The attitudes to this legislation were investigated in a survey of 1515 individuals aged 15 or more, living in towns of over 30 000 inhabitants from various parts of Italy, conducted by a marketing research institute. The findings were published in a national daily newspaper.2 76% of the whole sample (and 70% of smokers themselves) were in favour of the legislation. 97% of those interviewed approved total prohibition of smoking in hospitals or schools, 86 % in public offices, 83 % in aircraft, 66 % in restaurants and cafes, and 61 % in private offices. Widespread popular support for this proposed legislation could not prevent the transfer of Signor Degan to another Ministry in July, 1986, and complete abandonment of the proposal. One of the first public statements of the new Minister was that smoking did not constitute a health priority in Italy.3 Consequently, no action against smoking has so far been undertaken by the new Minister. Although the economic and political implications of smoking are largely different in Italy (where tobacco products are manufactured and sold only by the State monopoly), there is a similarity between this Italian anecdote and what happened to the former US Secretary of Health, Mr Califano, and to the British junior Minister at the Health Department, Sir George Young. This can well be summarised in a sentence by Sir George himself: "Smoking is in every sense a political issue, and those politicians who concern themselves with it find themselves unexpectedly promoted or IN the
demoted."4 Istituto di Ricerche Farmacologiche Mario Negri, 20157 Milan
CARLO LA VECCHIA SILVIO GARATTINI
United States REASONABLE AND CUSTOMARY
SUCH
are
the fees that
physicians expect
to
be
paid
for their
services. The trouble comes when the reasonable and customary fee
by those third parties now paying most of the costs of medical This is of especial concern to the patient covered by the Medicare programme for the elderly. Physicians may charge Medicare patients as much as they like but the system will only cover 80% of a "reasonable" charge. To encourage physicians to treat Medicare patients (and many refuse to accept them) the doctor receives 80 % directly and agrees not to charge the patient for more than the remaining 20%. If the doctor charges for more than this, payment is made to the patient and the doctor has to collect from the patient. Many physicians think that the Medicare fees are unrealistically low, and that doctors have the right to set their own fees. The law in Massachusetts denies this option and penalises is
on hospitals, the obvious target for additional cost reduction is the fees paid to physicians. Of course the profession will resist furiously and there are threats that many physicians will refuse to treat the elderly or give inferior treatment. But this threat may prove idle. Too many doctors are graduating and medical schools have been urged to reduce numbers. Many doctors have moved into the health maintenance organisations and similar bodies. Meanwhile, in view of the budget deficit, the pressure to reduce cost is immense and growing. Some specialist groups, such as radiologists and pathologists, are under particular pressure. Haematology has largely fallen into the hands of haematologists, chemical pathology and microbiology are increasingly open to PhDs, and only histopathology is being left to pathologists. Many residents in pathology are wondering whether it is worthwhile sitting for the national boards in clinical pathology. Others seek different specialties. It looks as if the golden days for clinical pathologists are over. Radiologists are likely to be next to feel the squeeze. Some internists who do not have a mass of diagnostic gadgetry are likely to be affected. It seems as though big changes must meet what is certainly a crisis. Congress set up a physician payment review board, headed by Dr Philip Lee. He has said "there is a grass roots consumer movement now developing around National Health Insurance". But it is not only happening at the grass roots. If the profession finds itself faced with a national health insurance system forced on it, after all its opposition to "socialised" medicine, the blame will surely fall on the profession itself.
imposed
ATTITUDES TO LEGISLATION ON RESTRICTION OF SMOKING
set
care.
1. Ciuffa V. II tabacco al bando. Corriere della Sera May 18, 1986, 2. 2. Clerici S. La guerra al fumo. La Repubblica May 25-26, 1986, 4-5. 1. 3. Anonymous. Donat Cattin assolve i fumatori. Corriere della Sera Sept 27, 1986, 4. Bjartveit K. Legislation and political activity. In: Zaridze DG, Peto R, eds. Tobacco: a major international health hazard. Lyons: IARC, 1986: 285-98.
In
England Now
As I have said before, I am none too sure about private homes for the elderly. The whole idea of making a business out of caring for people who are, almost by definition, dependent seems rather unsatisfactory. Such homes are sold as going concerns-with their residents thrown in, like cattle in a farm sale. It is even less satisfactory when large sums of public money are spent on maintaining old people in such homes because they are believed to be cheaper than provision by the State. How many old people allow themselves to be persuaded (perhaps when judgment is clouded by illness or a bereavement) into going into a home "just to give it a try"-only to find that their environmental niche has been securely closed behind them? In my experience, old people need only be in a home for a couple of weeks to find their personal possessions distributed round the neighbourhood, their tenancy terminated, even their house actually sold, before they know what is happening. Trying to restore matters can be impossible, especially for a defenceless frail person. I vividly recall the indignation of a village vicar when I threatened him with the police if old Mrs X’s television set was not returned to her house forthwith-one of our nurses had seen him departing with it the day after she had been admitted. I have recently experienced a new variation on the "just give it a try" theme. One elderly retired professional lady decided she would see what a new residential home could offer. She made it clear that she was only going in on a trial basis, and, following our advice, took every precaution to protect her environmental niche. She was delighted with the little suite she was given in the home-a sitting-room, with bedroom off, gave her privacy when she wished, a communal life if she felt the need of company. After a month’s trial, she put her house on the market and announced she was staying for good. The day after she signed the contract of sale on her house she was moved out of her suite. She now shares a pokey bedroom with three other residents, all complete strangers and one of them incontinent. She is trapped.