168

Profits, pay, and perks

Health care in the US has becomedominated by businessmen who areoften more concerned about pay-

cheques, profits, and "perks" thanpatient care, said witnesses at a Con-gressional hearing on the financial

practices of the US health-care indus-try held by the Subcommittee on

Oversight and Investigations of theCommittee on Energy and Commerce.One witness, Graef S Crystal, an

expert on executive compensation, re-ported on the earnings of the chiefexecutive officers (CEOs) of 26 majorUS health-care companies. Thelowest paid CEO in the group earned$700 000 in 1992, Crystal said, whileone executive, profiting from stockoptions, earned more than$127 mil-lion. Crystal found that the medianCEO in his sample earned between$2.5 million and$2.9 million in 1992,depending on whether statistical out-liers were excluded, and that pay ofexecutives was rising far faster thanthat of other health-care workers. In :

1985, for example, the median CEOpay was 54 times that of a staff nurse-

by 1992 it was 85 times.: Auditors from the US General

Accounting Office (GAO) told the

committee that the cost of care nowincludes some questionable expenses.At the committee’s request, the GAO

investigators examined the$2.1 mil-lion administrative and office ex-

penses filed by the Hospital Corpor-ation of America (HCA) in itsMedicare costs report and found that

$1.1 million were either "unallowable,questionable, or unsupported".Among the costs that GAO judged tobe unallowable were$17 755 for alco-holic beverages served at employeefunctions and$51013 for enter-

tainment, including$14 225 for a

"theme party",$3500 for a singinggroup, and$1710 for a sailing regatta."While Medicare costs principles donot specifically discuss these type ofentertainment costs", the GAO said,"such costs, in our opinion, are not

related to patient care". HCA officials disputed the GAO’s

conclusions, pointing out the Medi-care reporting rules were vague anddid not expressly forbid these types ofexpenditure. HCA officials added thatemployee meetings where such enter-tainment costs are incurred boost

company morale and increase staffeffectiveness.

It would be better, said Mr JackBovender, HCA executive vice-

president and chief operating officer,if Congress spent its time trying toreduce unnecessary paperwork, citinga recent study that estimated that theadministrative costs of health care in1991 cost$125.6 billion-17% of thenation’s total health-care expendi-tures.

Commenting on his committee’s

investigations, chairman John DDingell, a Michigan Democrat, con-cluded, "Too many in the medicalmarketplace have been only too willingto take financial advantage of theabsence of a comprehensive nationalhealth policy".

Michael McCarthy

Prophylactic tamoxifen

The Department of Health has approvedthe tamoxifen trial in healthy women athigh risk of breast cancer. 15 000 womenwith a 1 in 6 lifetime risk of breast cancerwill be recruited from the autumn. Womenhave to meet one of the entry criteria. Forthose aged 45-65 these criteria are: a first-degree relative aged under 50 with breastcancer; a first-degree relative with bilateraldisease; two affected first or second degreerelatives; nulliparity and an affected first-degree relative of any age; biopsy-confirmed lobular carcinoma in situ

(LCIS) or atypical aplasia; or biopsyfindings of proliferative disease and breastcancer in a first-degree relative of any age.In women aged 35-44 the criteria are: afirst-degree relative with bilateral diseasediagnosed at less than age 40; two first-degree relatives diagnosed at less than age50; or biopsy-proven LCIS. No teratoge-nicity studies have been done for tamox-ifen, so women pregnant or at risk of

pregnancy will not be recruited. :At a press conference on July 9, the main

trialists (Prof M Baum, Dr T Powles, Dr JCusick) said that for the 85 women whohave become pregnant while on tamoxifenno fetal abnormalities have been reported.The trialists believe that the risk of livertumours (see Lancet April 24, p 1086) is .

unlikely to be significant in man. Powlessaid that although 2 cases have been re-ported, the women were on twice the dose(40 mg daily) to be used in the UK trial.About 6 million women worldwide havereceived tamoxifen, and he felt that the lackof reports of liver carcinoma was reassur-

ing. The trialists admitted that there is

probably a small undefined risk of endome-trial cancer, but pointed out that thisdisease is treatable and preventable.Furthermore, tamoxifen reduces mortality(see Lancet 1992; 339: 1-15 and 71-85) andhas protective effects of the drug in heartdisease and osteoporosis.

: Approval for the trial has not beenwithout controversy. The MedicalResearch Council withdrew its support onthe grounds of liver toxicity in rats and theethical issue of giving an anticancer drug tohealthy women (see Lancet 1992; 339: 735).The trial has, however, been approved bythe Committee on Safety of Medicines andby a large ad-hoc national ethics com-mittee. Local ethics committee approvalwill be sought by the individual recruit-ment centres. The trial is double-blind,placebo-controlled, and randomised andsimilar trials are underway in Australia andthe USA. Switzerland, France, Nether-lands, Austria, Spain, Germany, Finland,and Denmark may participate, and the .

trialists hope that about 50 000 women will veventually be recruited world wide.

Stephanie Clark

Crisis cards

The House of Commons Select Committeeon Health has rejected proposals by theRoyal College of Psychiatrists for introduc-ing community supervision orders for

mentally ill patients being treated out ofhospital.l The committee has instead

expressed interest in crisis cards, a form ofadvance directive or treatment contract

which the patient makes when well.The committee believed that, as pro-

posed by the college, the consent thatwould be obtained from the patient for acommunity supervision order would not be"real" and that the proposals focused toomuch on medication as treatment. Thecommittee was also concerned about theextent to which a person’s freedom mightbe limited by the proposals and by insuffi-cient support from other groups for the

college’s proposals. The committee doesacknowledge, though, that there are manyimportant legal and philosophical issuesabout advance directives that have to beaddressed.

Vivien Choo

1 House of Commons Health Committee.

Community supervision orders. London:HM Stationery Office. 1993: Pp 36. £10.ISBN 0-10-021-243-3.