Cut Hospital Costs and Doctors' FeesAn article...

THE BALTIMORE SUN

Cut Hospital Costs and Doctors' Fees

An article attributed to the New York Times News Service and printed in The Sun and The Evening Sun May 11 states that Medicare pays for the health care of 32 million elderly and 3.6 million disabled people. Apparently, the new federal administration seeks to restructure the health care system in a more comprehensive, sweeping and ambitious manner.

Repeated attempts to provide proper medical management have been made since the 1930s. Any number of alphabet agencies aimed at giving therapy to the rich and the poor have been devised.

This era, inaugurated by the advent of the anti-bacterial compounds, has been extended by the numerous examples of highly technological forms of diagnosis and treatment.

The linchpin of any drive to provide adequate medical care for all Americans must be a reduction in total cost. Equally important is that the freedom of patients to choose doctors must be protected. Rationalization to adopt these ideas will be difficult.

James Stacey, who works for the American Medical Association, has presented his thoughts about reduction of the projected $211 billion in federal outlay in 1993 in a recently published book:

* If patients would pay for a part of their care, the use of out-patient and hospital facilities would decrease dramatically.

* Cost-sharing and deductible limits should be linked to income.

* Health maintenance organizations should be used in preference to hospital emergency rooms as they are much less expensive. The HMO also affords the opportunity of seeing the same doctor if return visits are necessary.

* Inasmuch as certain cancers have a notoriously poor prognosis at the time of the first visit, patients should not be subjected to extended surgical procedures or prolonged chemotherapy once the diagnosis has been made.

* Much of the terminal care given in hospitals may be given at home or in a hospice.

* Cutbacks may be made in hemodialysis, as many patients with kidney failure have so many complications that their lot is most unhappy.

* Coronary bypass procedures have become commonplace in medical practice. A study in 1988, however, suggested that 50 percent of those 200,000 operations might have been unnecessary.

* At the moment, further installation of high-cost equipment in hospitals should be stopped.

Unrest is found not only among patients as to who will pay for unexcelled care but also among doctors. To many of them the cost of malpractice insurance is more than unreasonable and the reasons are quite clear. Multi-million dollar claims and payments are now commonplace. The practice of defensive medicine is wasteful.

Most human beings long for eternal life or at least for a prolonged period of good health. As the alchemists brewed their elixirs to capture immortality, so Western civilization is rightly seeking to extend healthful years by its new medicines and technology. Those individuals who are seriously ill and about to die, however, should not have a few days or weeks added to their lives by the use of ultra-expensive therapy.

The money spent in these endeavors would better be used to care for the young and to feed the hungry. Society, as a whole, however, is reluctant to acknowledge that life should be permitted to end in many instances without heroic, high-priced methods, if a third party will cover the cost.

In general, the public does not realize that money recaptured above and beyond the actual premium must be taken from some other source. Higher premiums will result for all insured.

At the present time, the "working poor" and a substantial number of middle class families would face tremendous financial difficulties if they had to be hospitalized for any period of time. Few of the laity realize that the basic cost of room, board and ancillary services approaches a national average of over $700 per day.

In a country where medical care is the best which can be given, many are denied such treatment because of the inability to pay. The answer does not reside in increasing the amount allotted, as this course has experienced repeated failure.

Reduction in the cost of every item in hospital life along with reduction in physician fees is perhaps the only source of correction remaining. More money allotted and a new acronym will prove worthless in solving the health care problem.

Joseph M. Miller, M.D.

Timonium

Toilet Bowl Logic

Investing money on education is like flushing money down the toilet, if we are to believe the recent article by Douglas Lamdin ("Money and Schools," April 22). Mr. Lamdin sets up his own straw man and then proceeds to disassemble it with misleading information.

No credible educational reformer asserts that money, no matter how spent, will result in the improved quality of schools. Money can be spent wisely or poorly. This is a trite and obvious conclusion.

But to admit that money does not automatically result in educational improvement is far from saying that more money cannot help schools if spent wisely. Nor does it refute the strong evidence that certain children need additional services to succeed academically.

Throughout the country, researchers have developed initiatives which substantially raise the achievement of even the most troubled students. The most promising include the Comer Model, the Accelerated School Program, Reading Recovery and Success For All, developed in Baltimore City.

But they all cost money above and beyond what the typical school has. Trained teachers tutor children in small groups. Social workers visit students in their homes. Computers provide individualized instruction. The schools start when the children are a very young age, often a year or two before traditional programs.

Effective programs counteract the obstacles faced by children from low income environments or with learning disabilities. These obstacles are severe, and without additional support, few disadvantaged children are currently able to overcome them. The best predictor of achievement in a Maryland school is the socio-economic status of the student body.

These successful programs not only destroy these unfair barriers, they also save millions of dollars in the long run.

Children who attend early intervention programs grow up to become stable members of their communities. They are less likely to need expensive special education services, depend on welfare, commit crimes, fill jails or hang out on street corners.

One famous preschool program for poor children netted more than $7 for every dollar spent, according to a recent study that tracked participants over a 30-year period.

Despite impressive results, these programs remain the vast exception. Schools continue to use outdated and even counterproductive strategies to deal with troubled students. The reasons are plentiful, but two major ones emerge from studies.

First, low-income students are concentrated in property-poor school districts that cannot afford to provide their students with intensive services. Maryland schools are more dependent on the local tax base than those in 40 other states. Resource disparities between schools in wealthy and poor counties have grown and threaten to become even wider.

Second, no accountability exists for schools that either succeed or fail. Successful schools are not rewarded, and chronically under-performing schools are not sanctioned.

In other words, there is no strong pressure forcing schools to develop and implement effective instructional technique. As a result, many schools misuse the money they do have and could misspend additional funds.

Current school reform efforts seek to address both issues. On one hand, state funding of schools will be based on the needs of students.

The state will guarantee that schools with disadvantaged students have the additional resources they need. But a strict accountability program will ensure that schools utilize effective programs and make substantial annual improvement toward rigorous achievement standards.

Mr. Lamdin's article is filled with numerous other inaccuracies. For example, much of the increased cost of education over the last 30 years has gone to provide expensive special education services for disabled students who were excluded from schools until the early 1970s.

Also, the suit being considered in Maryland asserts that all children are entitled to an adequate education, not equal per-pupil spending. Reformers are proposing an increased investment in education, not a reallocation of money from some districts toward others.

Still, reading Mr. Lamdin's article in the best light possible, the cynicism toward blind increases in spending is justified and healthy. Additional resources should only go to effective programs implemented by educators held accountable for producing results. Certainly major changes are needed in the way schools currently use resources.

But to do nothing, and to deprive certain children of vital services because of accident of birth, will result in something else going down the toilet besides the tax dollars which Mr. Lamdin is so determined to protect.

The continued miseducation of thousands of students severely threatens our state's economy, which will depend on the contributions of every single child in the 21st century. Mr. Lamdin's state pension and Social Security check will depend on a shrinking pool of workers, largely made up of the very children schools are failing now.

We live in the seventh most prosperous state in the union. We must invest now to enjoy the benefits of continued prosperity in the future. We must invest wisely, keep track of our investments and hold our portfolio managers accountable. But we must invest or face the bleak consequences.

Susan P. Leviton

Baltimore

The writer is the president of Advocates for Children and Youth Inc.

Baltimore's Light Rail Doing Quite Well

There you go again.

I find Barry Rascovar's title, "Heavy Criticism is Unfair to Light Rail" (The Sun, May 9), ironic. Because of such criticism, Baltimore has light rail instead of a heavy rail system that serves Towson, Waverly and Marley Station.

Here's how it goes: When San Francisco opened its Bay Area Rapid Transit (BART) in late 1973 or early 1974, its opponents didn't wait for them to open the trans-bay tube to pronounce it a failure. After Gerald Ford became president, he used the perceived failure as justification to reduce the capital appropriation for mass transit from $20 billion (over six years) to $11 billion.

Similarly, local opponents used the reports of failure to truncate Baltimore's Metro to a relative rinky-dink operation that cannot generate the kind of support where commuters in San Francisco and Washington push for the systems' completion.

If critics had understood that these new systems take time to build up their ridership, they would have welcomed rapid transit as a way to energy independence after the Arab oil embargo. Even if President Ford had tried to reduce the appropriation, he would have been stopped.

Although the light-rail advocates don't have the Ozymandias complex that heavy-rail supporters once had, they are quite arrogant themselves. Many seem spiteful. I went to a meeting where Baltimore light-railer George Tyson spoke, and he seemed unaware that the highway lobby was a worse enemy. All his criticism was directed at heavy rail. Now that light-railers are getting the same unfair criticism that derailed heavy rail, I only wish they'd acknowledge that they're not the first victims.

Paul O'Brien

Baltimore

____________

It is most unfortunate for clean air, Baltimore's economy, its commuters and their travel safety that your staff writer Peter Jensen twisted the realities so negatively in his diatribe (April 25) against Mass Transit Administration's new Central Light Rail Line. The end of the story actually did report that light rail was doing a very good job in its incomplete state.

It said:

* "light rail generally gets high marks from people who do use it";

* "trains are comfortable, quiet, clean, virtually graffiti-free and almost always on time";

* 8,195 passengers chose to ride on the average weekday prior to the Linthicum extension. No current count was given.

The caption under the picture of John Backer "riding an empty car" that accompanied the story was dishonest. That picture clearly showed other passengers at the other end of the car. No matter how busy a transit line is, some nearly empty trips must be run to position cars for busy trips.

Baltimore's light-rail line is not very near empty. The story has 8,195 passengers on about 138 weekday scheduled trips, excluding trips to the storage yards. That is almost 60 passengers per trip, over 40 per car. That is almost a full seated load for a bus which averages only 15 passengers for the typical mile. In most cities the bus average is closer to ten.

The story could have added about 3,800 more passengers for Linthicum and 6,000 more for Glen Burnie. That will total almost ++ 130 passengers per trip and 90 per car -- far more than any bus could handle. How much better response could anyone expect than that?

Even now, the Central Light Rail Line is averaging close to 20 passenger-miles per car-mile, which is very close to the New York subway average. Look at Northern Virginia, where 1,130,000 people live outside Washington. The busiest bus line among those million people uses 25 buses to carry 9,550 weekday passengers, less than Baltimore's light rail is carrying on about 20 cars. In Northern Virginia the bus line is overcrowded whenever it is late. Light rail is not crowded and runs on time.

Look at Timonium on the first anniversary of rail service there. The U.S. Census dropped Lutherville-Timonium's population to 16,442 in 1990, and light rail is capturing almost 900,000 annual passengers there at the rate of 55 annual rides per capita, almost 40 percent more than the Baltimore area bus average of 39.7.

The problem is that there are no stations yet at Cockeysville, Padonia, Riderwood or Ruxton. These stations are needed to justify the investment.

Compare light-rail ridership in Timonium to transit ridership in Cleveland, Pittsburgh and St. Louis with similar population to Baltimore's. The riding habits in those cities is only 37 per capita per year and that includes rail service as well as bus. Baltimore, with rail included, attracts 47 annual rides per capita, much better than Cleveland or St. Louis.

The old Northern Central Railway roadbed through Timonium was not primarily a freight line. It was the main passenger railroad to Detroit, Pittsburgh and Chicago, with commuter service as far as Parkton. Commuters fought hard to retain train service, prior to the growth of Hunt Valley.

Even now, there are enough light rail passengers to overflow parking lots at Falls Road and Mount Washington stations. For walk-in travel, the Riderwood and Ruxton stations are a must. It was wrong to leave them out.

Professor J.F. Kain should not have been quoted in the article. I am not aware that he has any transit experience, but he has criticized transit for 30 years, because he thinks highway travel is free and transit costs money.

The fact is that mass transit costs less than highways where it is run right. With the full $462.5 million invested in the completed Central Light Rail Line, it will cost $28 million annually to amortize and $14 million to operate. With the Cockeysville and Glen Burnie passengers on board, that figures to $4.60 per passenger total, much less than the full cost of driving in and parking at Charles Center.

Light rail riders take longer rides than city bus riders, so the costs can not be compared per passenger. So long as highways are provided free, it just isn't possible to charge for the full cost of a parallel service, but $462.5 million for 27 miles of traffic-free urban right-of-way was a very good buy. Even now, the partially completed rail line is carrying more people in the peak hour than a lane full of automobiles can carry on Charles Street.

The reporter mentioned the Buffalo and San Jose (Santa Clara) light rail as the only two other lines with poor ridership, but he did not disclose what happened after those lines were completed.

Buffalo's ridership zoomed to over 30,000 per weekday, almost too many for their car fleet; it averages more passengers per weekday than a New York City subway car. Downtown business increased 20 percent with light rail, as it did in Portland and Pittsburgh. In Santa Clara, ridership is now 24,000 on the completed line, and it is so popular that the voters have funded countywide extensions.

Baltimore has a very good chance to emulate Portland, Sacramento and San Diego, where 65 miles of new light-rail line have been completed. They are attracting tens of thousands of new transit riders each weekday, and thousands more on weekends, with operating and maintenance costs far less than the cost of providing bus service that could not attract the revenue.

Standard diesel buses are no longer legal for future purchase. In urban areas with good electric rail service, people consume almost 150 fewer gallons of motor fuel per capita per year than they do in auto-oriented cities with extensive bus systems. That will be very important to Baltimore as it tries to comply with the Clean Air Act.

E.L. Tennyson

Vienna, Va.

The writer is a professional engineer with extensive experience in mass transit.

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