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Acute Hospital Care of the Elclerly: Systems Resources and Constraints I. Alexander McMahon T was asked to talk about system resources and constraints from the ~ point of view of the hospital, but ~ found it somewhat difficult to do because ~ am not at all sure that my cohorts among the elderly do not need representation as weU. I would not hold myself out as especially qualified to speak, because I have been neither a provider nor a user of long-term care services. H. L. Mencken, the sage of Baltimore, was wont to say, "It is not what we don't know that hurts us; it is what we do know that is wrong." Nevertheless I am going to address myself to some aspects of the issue of caring for Be sick elderly from the hospital perspective that bear touching on. We should anticipate what errors of commission and omis- sion are going to be made so that Hey can be challenged, at least on the acute care side. ~ tried to anticipate the way He conversations at this forum might go and ~ thought about the sick elderly patient. In the actuality of the discussions, however, ~ became quite confused. In the first session of this meeting we spent a good deal of time talking about some elderly people. ~ was not sure whether we were talking about elderly patients or, in the social work lexicon, elderly clients. We did not draw a very good line between medical care and social services care, and maybe this is an area for some research. If we do not make a distinction, we are going to get ourselves all messed up. We may mess up a very good sickness system, if we try to ask too much of it, but as I thought of the sick elderly, I recognized rather quickly that there are all kinds of sickness and all kinds of elderly. So, we must avoid stereotypes in this area, and I think Hat we need to disaggregate He group being discussed. 114

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ACUTE HOSPITAL CARE: SYSTEM RESOURCES AND CONSTRAINTS 115 RESOURCES FOR ACUTE CARE ~ am not sure about resources for long-term and community care, but there are plenty of resources in the acute care world lots of money, lots of people, and lots of facilities. We spend a higher percentage of the gross national product than any other country in the world. Do we spend it wisely? Do we use the resources wisely? That is the issue, and it is not only a matter for the elderly. The federal government says that we spend too much. So do other payers, particularly business. They are critical, ~ think appropnately, of what we are doing. The providers, as you have heard, often say that we spend too little. We could do such a much better job if we just had more money. The courts often say, `'You didn't spend enough. Therefore, the plaintiff is entitled to a judgment." No wonder people are confused. Some of He confilsion is brought on by people outside the hospital world, but we do add our contribution to Me confusion. POSSIBLE SOLUTIONS The issue is multifaceted, and the solutions vary accordingly; there just is not one solution. To providers ~ would say that the resources could be used more wisely, with sharper attention to different uses of resources without changes in outcome, with more attention to care instead of to cure, and with more doctor time instead of more procedures. The provid- ers have got to get away from the "we need more" approach. It "ain't" there. It is not there from government. It is not Were from business. We are going to have to use what we have better. With all of its faults (and some have been pointed out), people from other countries still seek our system out, and ~ say, "For heavens sake, don't mess it up for me when ~ need it." Every problem really does not have a solution; this has been suggested by a number of forum participants. It is another way of suggesting that we must avoid He errors of the militate strategists who always prepare for the last war. To borrow again from Mencken: for every complex problem, there is a solution that is neat, simple, and wrong. Now, to those ready to offer a quick solution, both on the provider side and on the health-care system side, ~ offer some advice: don't just do something, stand there. The health care system and the environment itself are changing very rapidly and, remember, a moving target is hard to hit. It has adequate resources, a SUIplUS of physicians, and, it is said, a surplus

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116 J. ALEXANDER McMAHON of hospital beds; patients have a choice. We are moving from shortage to "overage"; and competition in turn win motivate much better than gov- ernment direction, and it will encourage more appropA ate behavior. CONSTRAINTS I have suggested that the constraints are not financial, and I truly believe it. ~ think, instead, that there are six constraints. You can make your own list, but ~ have identified six. First is attitude. Caregivers must focus on how they can do better. A market-dAven environment is going to sharpen that focus remarkably, rewarding those who do better and eliminating from the scene those who do not. The second constraint is expectation. Patients and Heir families must become much more realistic. AU medical problems cannot be cured. Insistence on more procedures and on a malpractice suit when something does not work out as wed as someone might have hoped are two engines that dAve costs up. The third constraint is emotional. We see the tendency to blame someone, the view that "there ought to be a law," and the belief that for every problem there is a solution. '`Tain't necessarily so." A fourth constraint is ethical. How do we focus on what is light when there are choices, and the patient and He family and He provider community, particularly the physicians, may differ on which choice they think is most appropA ate? Our lack of attention to this issue poses, suggest, a real constraint. The fifth constraint is governmental in nature. Lawmakers should become a little more cautious. They cannot solve every problem, par~cu- larly win their strong tendency to overpromise and underfund. Business and He market are modifying the health care system today much more effectively than law and regulation, and the U.S. Congress and the gover- nors of Florida and Massachusetts might pay close attention to that. One might note that Medicare's emphasis on paying only for acute care services is part of our problem in the care of the sick and ache elderly today. Think back 22 years to 1965 acute care was then the preferred solution. There was no objection to it, except by those who did not want any program at all, and acute care was what was needed. We did not have the life expectancy in 1965 that we have today; this is due not so much to the Medicare program itself as to other changes In life style. Nineteen eighty-seven is different, and we have some new solutions, and ~ suggest that 1997 is going to be different too.

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ACUTE HOSPITAL CARE: SYSTEM RESOURCES AND CONSTRAINTS ~7 Finally, there is a constraint imposed by some of the mathematical and statistical models that we are offers. Both mathematics and statistics are based on the past, and ~ ten you that Me present is different. The studies that ~ have seen that were printed in the early part of 1987 or 1986 were often done on 1983 data, and We world is different. Diagnosis- related groups, business, modification of benefit packages, and what people are doing for themselves in me weUness area (better diets, not smoking, lower drinking habits) are changing things remarkably, so that earlier mathematical and statistical models are inadequate, misleading, and occasionally just dead wrong. ~ suggest to you that the lessons that might be drawn from an analysis of these constraints, if ~ am right, are not the obvious ones reduce costs, increase quality of care, improve access. They are complex; they are changing; they will be different tomorrow, and they suggest caution and not boldness. POLICY ISSUES AND RESEARCH OPPORTUNITIES I do not see a single issue and, therefore, see no single solution. We did, however, explore and come to agreement that attention to the non-heal~-care needs of the non-sick or not-so-sick elderly~he long- term care issue~probably are the biggest issues that face us. We need to disaggregate, as ~ suggested at the outset, the sick elderly. Their solu- tions, their homes, their communities are as different as their conditions, and we need to understand that very thoroughly. We need to track the resources in the private sector. I think I am right in saying that mat is where a lot of very useful experimentation is taking place, and more quickly than through hidebound government agen- cies. It win not be not sexy, but we need to track those activities and evaluate them. We win see some solutions, and by publishing those different kinds of approaches, we will offer more help for local decisions, where ~ am sure many of our problems will be solved. T Wink that we need to recognize He limits of research. When a piece of research is finished, it is likely Hat already the environment has changed, so let us be careful. Finally, we need to recognize He limits of some of the new policies proposed, when me present is not fully under- stood. I am amazed how often people who offer a solution for the future cannot describe adequately and accurately the present. Once again, I suggest: don't just do something, stand there.