HEALTH CARE CRISIS IN AMERICA, 1971 HEARINGS BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE UNITED STATES SENATE NINETY-SECOND CONGRESS FIRST SESSION ON EXAMINATION OF THE HEALTH CARE CRISIS IN AMERICA APRIL 15, 1971 HEMPSTEAD, LONG ISLAND, N.Y., AND MOUNT KISCO, N.Y. PART 8 Printed for the use of the Committee on Labor and Public Welfare / a iS 1/ A to Ads / ba 5 la f Je / /t ¢ ol C Keg lth RACY ly Vv. 85-1 HEALTH CARE CRISIS IN AMERICA, 1971 HEARINGS BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE UNITED STATES SENATE NINETY-SECOND CONGRESS FIRST SESSION ON EXAMINATION OF THE HEALTH CARE CRISIS IN AMERICA APRIL 15, 1971 HEMPSTEAD, LONG ISLAND, N.Y.,, AND MOUNT KISCO, N.Y. PART 8 Printed for the use of the Committee on Labor and Public Welfare 2 U.S. GOVERNMENT PRINTING OFFICE 59-661 O WASHINGTON : 1971 COMMITTEE ON LABOR AND PUBLIC WELFARE HARRISON A. WILLIAMS, Jr.,, New Jersey, Chairman JENNINGS RANDOLPH, West Virginia CLAIBORNE PELL, Rhode Island EDWARD M. KENNEDY, Massachusetts GAYLORD NELSON, Wisconsin WALTER F. MONDALE, Minnesota THOMAS F. EAGLETON, Missouri ALAN CRANSTON, California HAROLD E. HUGHES, Iowa ADLAI E. STEVENSON III, Illinois JACOB K. JAVITS, New York WINSTON PROUTY, Vermont PETER H. DOMINICK, Colorado RICHARD S. SCHWEIKER, Pennsylvania BOB PACKWOOD, Oregon ROBERT TAFT, Jr. Ohio J. GLENN BEALL, JRr., Maryland STEWART E. McCLURE, Staff Director ROBERT E. NAGLE, General Counsel Roy H. MILLENSON, Minority Staff Director EUGENE MITTELMAN, Minority Counsel SUBCOMMITTEE ON HEALTH EDWARD M. KENNEDY, Massachusetts, Chairman HARRISON A. WILLIAMS, Jr., New Jersey PETER H. DOMINICK, Colorado GAYLORD NELSON, Wisconsin THOMAS F. EAGLETON, Missouri ALAN CRANSTON, California HAROLD E. HUGHES, Iowa CLAIBORNE PELL, Rhode Island JACOB K. JAVITS, New York WINSTON PROUTY, Vermont RICHARD S. SCHWEIKER, Pennsylvania BOB PACKWOOD, Oregon J. GLENN BEALL, Jr., Maryland WALTER F. MONDALE, Minnesota LeERoY G. GOLDMAN, Professional Staff Member JAY B. CUTLER, Minority Counsel My 8 aw KFb L3S4% 197), CONTENTS v. 8-1 PUBLIC HEALTH LIBRARY CHRONOLOGICAL LIST OF WITNESSES TUESDAY, APRIL 15, 1971 HEMPSTEAD, LONG ISLAND, N.Y. Page Lenz, Sanford, director, Bi-County Consumer Alliance of Health Con- sumers and chairman, Personal Health Services of Nassau, Compre- hensive Health Planning Council 2 a ot fe opm itm mss immo Conlin, Theodore P., project director, countywide emergency food and TEA Cl BOT VICE DIOTDIIIIIN ... ouch om ion mim mmo me es ee mere we i i Anushu, Medio, aide, Hicksville Center, countywide emergency food and IEAICAL SEL VIER PROB TTI is em om ren me om ever toto en ee tt ge Ingram, Mrs, Dorothy, resident, Freeport, N.Y... mo eee memes meme Betly, Cornelius, health and nutrition aide, emergency food and medical SEV IO LAIN, WO LY i ei ss ir mts Sm omit ee Se pg ip i yemee Cohen, Mrs. Norma, social worker, Family Association of Nassau County, Hammer, Abe, consumer and resident, Freeport, Hempstead, N.Y________ Bernstein, Lewis, administrator, Bartenders Union welfare and pension BN Bl on. resets iss Sart rio hm eA es re ete te ar pag ee re Campanera, Rocco, executive director, Long Island Federation of Labor___ Safian, Dr. Harold, vice president, United Medical Services, Inc., Greater New York’s Blue Shield Plan, accompanied by Antonio Favino, second X00 DY STAN Ce pling vo on loins Sas sg es Sp te of ee SHR ee ages te Rese Kravitz, Dr. Sanford, dean, School of Social Welfare, State University of NOW A OX Ku of rmsicests milion i ie DE Bt erro SE EI EAA I AR Se ei mo res Kunken, Leonard, and son, Kenneth Kunken, of Oceanside, N.Y________ Kunken, Kenneth, son of Leonard Kunken, Oceanside, N.Y______________ Rogatz, Peter, M.D., associate Director for patient care services, Health Sciences Center, Stony Brook, Long Island, State University of New York; director, University Hospital and professor of community medi- cine at the Health Sciences Center ; vice chairman, Nassau-Suffolk Com- prehensive Health Planning Council; and vice president, Health and Welfare Cottitil of Nassau COUNLY, N.Y i. cu mom ies pst sssbioy phamints mr ssispinmom nose Glaubitz, Dr. John, acting president, Nassau County Medical Society_____ MOUNT KISCO, N.Y. Peck, Jerome F., administrator, Northern Westchester Hospital. _______ Brew, Dr. Harold T., chairman of medical board and chief of surgery, Northern WestoheSter HOSDIAL.. . crews car damm sme EL ye f ra Pruyn, Dr. Morgan F., member, Mount Kisco Medical Group-___________ Hall, Dr. E. Franklin, first deputy commissioner of health, Westchester COUILY, NY iver mic rie fe ee PS SE FT te ere Boal, Mrs. Lyndal, director of social services, Northern Westchester OD I Ts hr iimmmmes rieP E eloe ee op es Epo Bre gears Curry, R. Eugene, chairman, Citizens Committee on Aging and Chronically TI of Westchester COUNEY, N.Y om co em pref esr me Bight ar it mee Fra Hausner, Mrs. Stowe W., resident, Mount Kisco, N.Y __________._________ Sanchos, Mrs. Blanche, community worker, Community Action Program, XONEROPE, WY ili opr mi pop sim i om or HE pa fie imme Pagar Maisel, Albert, writer, Readurs Digest. oo Munley, Mrs. Joan, director of health services, Bedford central schools, Mount Kisco, N.Y 1728 1753 1756 1759 1762 1769 1771 1776 1779 1821 1838 1841 1868 1873 1889 1896 v Page Marcus, Mrs. Clair, witness from the floor of the hearing________________ 1927 Harris, John, witness from the floor of the hearing eee 1927 Garrison, Joseph, administrator of nursing home, Peekskill, N.Y __________ 1928 Gurgenheim, Mrs., witness from the floor of the hearing________________ 1929 Kidd, Stephen, resident, Yonkers, N.Y. dimming ek en's: 1930 Zwick, Fred D., president, Council of Social Agencies, Westchester County, OE RE rE ERAN SIC SN WE.” JOC MR. J STE 3 ld SEP WL oh NLT 1931 Parcall, Dr. Pleasantville, NY... et cc Ce i tm dn pre pm Thy ml 2.2 1973 Bogen, Hal,planning eonsultant. ... oo ose ito 1974 Smith, Samuel, coordinator, New Rochelle Community Action Agency and chairman, New Rochelle: Welfare Rights... 2 eee 1974 Lorentz, Mrs. Elizabeth, witness from the floor of the hearing ___________ 1975 Contiere, Mr., assistant administrator, St. Agnes Hospital, White Plains, NY ee Et te ee gn OR A od i st re 1976 STATEMENTS Anushu, Medio, aide, Hicksville Center, Countywide Emergency Food and MeaiCh] - Sor VCORE PT OB TAIN ith ce ot he cre bon ese pie sve os ea me bo peg rs 1753 Bernstein, Lewis, administrator, Bartenders Union Welfare and Pension FUNERAL 0 re is mE ei 1771 Betly, Cornelius, health and nutrition aide, Emergency Food and Medical Services Program, WeSC i a im mie ib em im mie 1759 Boal, Mrs. Lyndal, director of social service, Northern Westchester TE ORDA EAN. cic roti gd ie ic oi a re oe ri on poi oe ee eng et arb mv 1903 Prepared SEATCINONE . « oi pe mein SPs sages oon i ri os Sm gat oe wo te 1906 Bogen, Hal, planning ConSUITant. .. cio ee esr on wisn mimi mes om mi me 1974 Brew, Dr. Harold T., chairman of medical board and chief of surgery, Northern WeStCheSter HOSPITAL... oo fim mi wm em mews gr im sw oh os sm ambi ioe so mp me om mmm on 1889 Prepared Stat CIENT oe i im ms wit sm mp ot rs i ee a 1892 Campanera, Rocco, executive director, Long Island Federation of Labor__ 1776 Cohen, Mrs. Norma, social worker, Family Association of Nassau County, EA TE Al TE let I CS AC RNG, St Tab. J: NE is JI el 1762 Prepared STalOMONT = oe oe oe cin oie moss pid nim ins i om mg oe om sn SS nt 1768 Conlin, Theodore P., project director, Countywide Emergency Food and NM CA CRT = SOT VCO Pr OET ANN... i ton mre se mir messes eb mors 8 io om gi nk me ppp 1750 Contiere, Mr., assistant administrator, St. Agnes Hospital, White Plains, NO mie arn a te ioe pe ep a em 1976 Curry, R. Eugene, chairman, Citizens Committee on Aging and Chronically TIL of WW estehesSier County, NX cc ad oe ii mh yb i mie mm me 1912 PO CO SE LO INGIIL cme mers 5mm spr es sonst Es i i li me 1914 Dominick, Hon. Peter H., a U.S. Senator from the State of Colorado______ 1747 Fishel, Dr. Leo, president, Nassau County Medical Society, prepared state- BOI a ce Bi dio mbt pri a i i Ba i 2 i om i Cg it i 1869 Garrison, Joseph, administrator of nursing home, Peekskill, N.Y_________ 1928 Glaubitz, Dr. John, acting president, Nassau County Medical Society____ 1868 Hall, Dr. E. Franklin, first deputy commissioner of health, Westchester CC OTIIIEY , TIN N H0s ce ssipin b i t ri d e e ee mers 1900 Hammer, Abe, consumer and resident, Freeport, Hempstead, N.Y_________ 1769 Harris, John, witness from the floor of the hearing________________-____ 1927 Hausner, Mrs. Stowe W., resident, Mount Kisco, N.Y__________________ 1916 PrRDATER SETTOINICIIL .. om mo oo evr ss mom ie 055 ire i cp ml 1917 Ingram, Mrs. Dorothy, resident, Freeport, N.Y_________________________ 1756 Kidd, Stephen, resident, VONKErS, N.Y... worms tenis mie mmm sie 1930 Kravitz, Dr. Sanford, dean, School of Social Welfare, State University of Prepared statement Kunken, Kenneth, son of Leonard Kunken, Oceanside, N.Y______________ 1838 Kunken, Leonard, and son, Kenneth Kunken, of Oceanside, N.Y__________ 1832 Lenz, Sanford, director, Bi-County Consumer Alliance of Health Con- sumers and chairman, Personal Health Services of Nassau, Compre- hensive Health Planning Couneil. me ome oie ee ci im mim mnie 1728 Lorentz, Mrs. Elizabeth, witness from the floor of the hearing____________ 1975 Maisel, Albert, writer, Refers IDIZOSE.. . o.com ummm mn mim otra oto sr se sho oe Marcus, Mrs. Clair, witness from the floor of the hearing _________ Munley, Mrs. Joan, director of health services, Bedford central schools, Mount Kisco, N.Y ix com comm mm mimi wm esi rr ere en ro Poy Be Peck, Jerome F., administrator, Northern Westchester Hospital_________ Prepared SEtOmIONT ws oie mmm myn oti fis St mrs Gym i Bh te Pruyn, Dr. Morgan F., member, Mount Kisco Medical Group____________ Rogatz, Peter, M.D., associate director for patient care services, Health Sciences Center, Stony Brook, Long Island, State University of New York ; director, University Hospital and professor of community medicine at the Health Sciences Center; vice chairman Nassau-Suffolk Compre- hensive Health Planning Council ; and vice president, Health and Wel- fare Council of Nassau County, N.Y i «al i ie 50 ce mn cn te sis st gos on Prepared StatOIMBTII- Cc ce ite crise se mio sbi i me ici si i io oo sii pv mm Safian, Dr. Harold, vice president, United Medical Service, Inc., Greater New York’s Blue Shield Plan, accompanied by Antonio Favino, second Vie PROS AON ee ioe Sot emt Heol Sanchos, Mrs. Blanche, community worker, Community Action Program, NO TE NN cs i hips 0 wm eve ge me poco SE FE A EM aa Smith, Samuel, coordinator, New Rochelle Community Action Agency and chairman, New Rochelle Welfare Rights_________________________ ___ Gurgenheim, Mrs., witness from the floor of the hearing________________ Parcell, Dr., Pleasantville, NX oo oc Be me iim iti mn nm aE, Fred D., president, Council of Social Agencies, Westchester County, ADDITIONAL INFORMATION Articles, publications, ete. : Board of directors, United Medical Service, Inc., submitted by Dr. Harold Safian, vice pregi@ent. common moe cn oi cm mii “Comprehensive Health Goals and Objectives for New York State,” by New York State Health Planning Advisory Council ___________ Fact sheet on Health Service Resources for Westchester County, WWIRILE PUOUININL, INT com rics soon oso os i “Information Please”’—Annual Report 1969; senior information and referral services conducted by Westchester Council of Social AROTONOR cco ig imi sp ii sis sors i me roe ime Ae fe em ase nt 8 “Role for the Consumer,” by Peter Rogatz, director, University Hos- pital, State University of New York at Stony Brook; and Marge Rogatz, past worker for CORE, Headstart In-Service Training, and Organization for Social and Technical Innovation________________ “UMS Utilization Review in 1970 ” submitted by Dr. Harold Safian, vice president, United Medical Service, Inc __________________ “What's Going On.” Bulletin No. 19, sponsored by the Westchester Council Of SOCIAL ABCIICIES. cv isin ios ts i os i ok at 2 Communications to : Kennedy, Hon. Edward M., a U.S. Senator from the State of Massachu- setts, from : Meyerhoff, Gordon, R., M.D., Roselyn Heights, N.Y______________ Munley, Mrs. Joan, director "of health services for Bedford public schools, Mount Kisco, N.Y. (with attachment) ..c..me vem mew 1841 1853 1779 1918 1974 1929 1973 1931 1932 1794 1733 1934 1952 1847 1782 1937 ra. Bas IL Yay. PR, say Sit. “ sob al, La - : 3 3 LT A de = PET HEALTH CARE CRISIS IN AMERICA, 1971 THURSDAY, APRIL 15, 1971 U.S. SENATE, SuBcoMMITTEE ON HEALTH OF THE COMMITTEE oN LiaBor AND PuBric WELFARE, Hempstead, Long Island, N.Y. The subcommittee met at 9:30 a.m., at Hofstra University, Hemp- stead, Long Island, Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present: Senators Kennedy and Dominick. Committee staff members present: LeRoy G. Goldman, profes- sional staff member to the subcommittee; Jay B. Cutler, minority¢ counsel to the subcommittee. Senator Ken~epy. The subcommittee will come to order. America is in the midst of a health care crasis. This subcom- mittee has left Washington to hear how this crisis affects the people in evéry walk of life across this great land. Millions of Americans live in communities like Hempstead. Like Americans in our cities and rural areas, they depend for their very health and happiness on a system of care which charges enormous fees for inconvenient service whose quality is uncertain. The subcommittee has come to Hempstead to hear the people of suburban America. We know you feel the crisis. You feel the crisis when you pay your bills. Doctor bills are 60 percent higher today than 10 years ago, and hospital bills are nearly three times what they were. You feel the crisis when you are ill in the evening or on week- ends, and end up driving long distances to a hospital emergency room. You feel the crisis when you realize that being “laid oft” from a job also means losing your health insurance and being left com- pletely unprotected—just when you need it most. You feel the crisis when you realize a friend or relative is sicker and a lot poorer because the doctor made a bad diagnosis. Several weeks ago I asked a well known pediatrician whether you could feel confident your children were getting good care if you could afford it. His answer was no. He insisted the quality varies tre- mendously from physician to physician and there is no way for the people to know what they are getting. These problems need not exist. The providers of health care, together with the people, can change the system to serve us better. But the people must take the lead. We cannot ask the same doctors and organizations who profit from health care to set the fees—or assure the quality—or plan for our convenience without any influence from the people who buy their (1727) 1728 services. That is simply not the way we do business in this country. We look forward today to hearing both consumers and providers testify on the nature and extent of the health care crisis in this suburban community and how we might correct these problems. Before beginning, I would like to extend the subcommittee’s special thanks to Hofstra University for their hospitality. We appreciate very much their courtesies and kindnesses which have been extended to us and to the members of the subcommittee, and we are appreciative of their hospitality. Our first witness this morning is Mr. Sanford Lenz. He has some consumer witnesses with him. He is director of the Bi-County Con- sumer Alliance, regional director of IUI, chairman of Personal Health Services of Nassau, Comprehensive Health Planning Council. Mr. Lenz. STATEMENT OF SANFORD LENZ, DIRECTOR, BI-COUNTY CONSUMER ALLIANCE OF HEALTH CONSUMERS Mr. Lenz. Good morning. My name is Sanford Lenz, and I am executive director of the Bi-County Consumer Alliance of Health Consumers, which is a not-for-profit corporation of neighborhood health committees, local unions, civil rights groups, and other or- ganizations of health consumers. I intend to summarize my remarks and request the right to expand my remarks in print later and not hold up this meeting. We are primarily concerned—both with respect to the unions and consumers generally—that in the turmoil that is currently going on in health care services settles, we want to make sure that the consumer of health services is not the one who becomes victimized by the system for which he is footing the bill. We think if we do that we have failed in our responsibility as labor leaders to our members, failed in our responsibility to our commitment to work with the disadvantaged, and in our role as a progressive organi- zation force. We think we have been down that dangerous road before. We think we have been down the Defense establishment road which has been turned over to the professionals. There the cutting off of the citizenry from the decisionmaking process has resulted in essen- tially a failure in the mission of the department itself. If the mis- sion of the Department of Defense was to bring peace, we are now in a war not in every generation, but in every half-generation. And the second result has been a major polarization of the citizenry fighting over what the experts are doing. We have gone through it in education as well. We surrendered the system to the professionals, we watched the educational establish- ment fail in its mission and polarize the country as well. The educa- tional establishment now measures its successes by the number of active Ph. D’. and has failed in its basic mission to bring education 1729 to the community. The system is geared to serve those who are mov- ing on to the next level of education and the devil takes the student who gets off in the process. The ex-student realizes that whatever he knows of the world he learned outside the classroom, and what he knows of his work he learned after he left school. In fact, there was a quote in Newsday this week to the effect if the school undertakes to teach sex education as they have taught literature they will kill off the sex drive in 3 months. We don’t want to see that happen in health services, and we are afraid we are headed precisely there. We view a national health security program with great hope and with great trepidation—with hope because we are thoroughly aware of the fact that we must have new financing methods for health care in the form of national health insurance immediately. But we view it with trepidation because we are afraid that once again we will see a massive infusion of meney to health providers without any real change in the delivery system. That process can only cause inflation, can create an empire like defense and education with tre- mendous activity and little result; and most important, it will add another level of isolation between the consumer of health services and the provider, leaving the consumer helpless to do any more than to foot all the bills. The present system of health care services is chaotic enough in the delivery of health care, but it is thoroughly organized in the distri- bution of the proceeds of the process. It has completely severed the consumer of health services from the decisionmaking process. When a family physician existed, the patient was close to the de- cision about what he needed and could negotiate the cost. When hospital based medicine took over he became one step removed from that process. Group insurance promised to give the consumer cost and quality control, and instead the consumer was given no voice in the in- surance program. No quality control was ever exerted, and cost increases were handled on in the form of rate increases; so the con- sumer, the buyer found himself battling with the carriers, notably Blue Cross and Blue Shield, at public hearings through a commis- sion instead of being on the insurance boards negotiating with the hospitals. In addition, stress was placed on hospital based medicine to the exclusion of dental, optometrie, psychiatric, psychological, and social services. In addition experience rating of employee groups became ‘ fashionable and the cost of insurance to anyone became prohibitive. As a result the system precluded those who needed it the most—the old, the unemployed, the retarded child, the emotionally disturbed, the addict, the alcoholic, the poor, the husbandless mother, the chronically ill. All the concentration-was on the horizontal patient. More patient days, more and better tests. But those who needed care for unidentified pains and unusual symptoms or emotional problems, short of breakdown, had no access whatsoever to the system. The system gave lip service to the need for preventive and 1730 diagnostic treatment and then refused to pay for it. And the real villains, the environment, poor housing, poor transportation, poverty, and factory safety, were all considered outside the scope of health services. And federal and state dollars did nothing to help. It shifted the center of the health universe to the medical school, brought new and advanced research in hospital techniques, but the health of the man in the street has declined. A man who is walking in the street looking for a job and he feels chest pains or short breath, he will brush it off as indigestion because he must. He can’t afford a doctor, he can’t afford a hospital. And going into the hos- pital means he will miss his appointment for an unemployment check, for an unemployment interview, and therefore lose his check. What really does he care that high up in the medical center he is passing there is a heart transplant operation going on or a brand new machine has been delivered. Or the child that is losing interest in school because all she can think about all day is her teeth hurt and she can’t see the blackboard, or an emotional problem has gone unchecked because the school psychologist was the victim of the last budget slash. Match the amazing medical advances against the things that matter to us, the citizenry and the consumer—increasing venereal disease, increasing alcoholism, increasing drug addiction rates. Doctors’ offices that have signs that say that don’t take medicaid, or worse, signs that say they charge $3 per page to medicaid patients to fill out the forms. Three-page forms cost the medicaid patient $9 to have the forms filled out. The insurance poliey steadily costs more, but they seem to exclude those items of care that one really needs. The fault, we believe, has been the steady avoidance of real con- sumer authority that directs the course of health care. Most legisla- tion provides for consumer advisory groups that have little or no power. RMP funds today are still designated by medical schools. Hospital facility funds are still divided up by hospital administra- tors. Consumer participation is far too limited to be effective, and in any case, the consumers are never involved in the planning process, but are only given the right to review proposals planned by providers. Even in CHP where the consumers have effective voice, no money has been allocated, no real power is allocated, and it is ignored generally by the providers. ; In the belief that this time around the Federal Government might be sincere in its promises, the founders of the Bi-County Alliance of Health Consumers set about pulling together the disparate ele- ments of the community to a single cohesive consumer voice. We started at the county and bicounty levels of organizations. Labor organizations were asked to stop moving in separate directions. Minority and poverty advocate groups were asked to hold back on confrontation tactics. Social activity groups and even the League of Women Voters were requested to subordinate their separate pro- 1731 grams, and religious based groups like the Council of Churches were invited to join forces. That group incorporated as the Alliance and operated for a year on a purely voluntary effort, including the typing the the petty cash for the stamps. During that year the Alliance negotiated on CHP Council 18 seats, which is a third of the total consumer seats. CHP staff then engaged in the next phase, the development of community health councils, and the Bi-County Alliance received a small grant for CHP for a part time director and all time secretary to coordinate and educate community groups in health care plan- ning and to seek all the national forms of funding for them. There are currently 15 such local neighborhood community groups existing in Nassau and Suffolk. The next phase of the program was to have Bi-County Alliance assume responsibility for the Economic Opportunity Commission over its 11 emergency food and medical service aides. The coopera- tion from the EOC has been excellent, and as recently as the last 2 weeks those KFMS aides were transferred over to become staff to health committees, which brings us to the point we are now and the great trepidation with which we are expressing our concern. We have the aides in the field, we have organized consumer groups ready to cooperate and work in the planning conference. We have people involved currently in outreach in working day to day with people in the community who have had no contact with the health care services field, who are bringing them into that system, finding them the emergency medical services, ready to participate in the planning: The question comes, when this legislation is passed will the Fed- eral Government again walk away from its promises. Will it walk away from the EFMS aides that we have trained, that we have pre- pared for health career services, and leave them hanging and un- employed as EOC drops its EFMS program? And more important, for what purpose have we brought these groups together ready to participate in the health planning process if the Health Security Act at this point does not have safeguards in it to provide consumer participation and to insure consumer participation, and to provide the incentives for the providers to make absolutely certain that they know the consumers are going to participate. Then those neighbor- hood health groups, understanding the frustration and having been walked away from by the Federal Government again, are going to have to go some place else, do something else. We are holding the groups together because we feel that in part- nership with the Federal Government utilizing Federal legislation we can accomplish much in the way of solving community needs. We have decided this morning to try to demonstrate what kinds of problems are going out there even in a suburban community like Nassau County. And so I have asked this morning for Mr. Ted Conlon, who is the supervisor of our emergency food medical service aides, to bring some of those aides to you and to indicate just within the past few months what kind of problems those aides are seeing 1732 in the field. The kind of information you hear today, of course, is being logged, gathered by EFMS people, turned over to the Neigh- borhood Health Committee. But it 1s going to be no use if our Health Committee has whole dossiers on problems, whole dossiers on needed solutions, and the Federal Government ends up sending checks to providers and leaving us entirely out of-the process. At this point I would like to introduce Mr. Ted Conlon, super- visor of the EFMS program, and some of his people. Senator Dominick. Before we continue. I was very interested in Mr. Lenz's testimony. I would like to ask to have a statement of my own put in the record at the beginning of the hearing. Senator Javits, the ranking ER member of the whole Com- mittee on Labor and Public Welfare, regrets that he cannot be here with the Health Subcommittee, but he is out of the country on official business by order of the U.S. Senate to attend a meeting of the OAS in Costa Rica. At his request, Mr. Chairman, I ask unanimous consent that the report, “Comprehensive Health Goals and Objectives for New York State,” by the New York Health Planning Council be made part of the hearing record. Senator KexnNepy. So ordered. (The information referred to follows:) 1733 COMPREHENSIVE HEALTH GOALS AND OBJECTIVES FOR NEW YORK STATE os A; 7 New York Sate Health Panning Advisory Courd anuary 15, 1971 Walter W harrison Firve ¥orton D. ¥iller, 7.6.2 New Tork City Jags H. Abott Dewitt Felix Acevedo Yew York City Jospeh S. Barbaro East Meadow James Barwick New artford Bloneva Pride Bond Niaoara falls Gordon £. Brown New York City John Burne!) New Yorh City Bruge £. Chamberlain n.D Syre Gordon Chase New York City William P. Collins Canton 3. Jouglas Cotman Scarsdale A. Colston, Ph.D. New York City Tyrone W. Crabb Newburgh Alida C. Dotley New York City James J. Daly uffa Davies,Ph.0. ns McDonald Of xon Rome. Charles 8. Dorf pw York City Hazel Dukes Roslyn Theodore B. Eden, Pod.D. Brightwaters Merri) Efsenbud, Sc.D. Tuxedo George A. Englert, 3rd, 0.0.5. Poughkeeps te Thomas C. Field Syracuse Maron 5 Johor Roche Mice Fordyce New York City 1734 New York § Health Planning Favisory Council KONISORY COURCIL MEMCERS an, New York State Health Planning dir Tear Counc 11 - Chairman, President and Chief Executive officer, Dictaphone Ccrporation + VigeChatrar, hen York State Health “Fanning Kdvisory Council ~ Senior Vice-Fresicent and Chief Actuary, Touitable Life Esurance Society of the United States - Rdninistrator il Vice-President for Hospital Affe State herity Rptea, Medica’ 14 Pres drt, Hospital Association of New York State - Vice-President, New York City Taxt Driver's Union - Executive Secretary, Catholic Charities, Diocese of buchvitle « Member, ¥ Trustees and Review oop Long Island Health and Hospital Planning Council ' - Comissioner of awning Oneida County + Program Director, Wid-siate Comittee Wealth Planning - Naga! St Department of Social Services NAACP. Niagera Falls Branch - Executive Director, New York State Communities Ald Association - Merber, Mew York State Public Mealth Council -Direcyar, Civi) Rights and Neighborhood Com iy TI Vor'¥ ork x: Central Labor Council ~Citfzens' Committee, Boucin Task Force, City University Open Enrol - Private Practice - Chairman, Health Manpower Committee, New York State Medical Society Heath Services Aduintstrator, "The City of ew - Probation Director, St. Lawrence County - Past-President, Kew York State Mental Health Association - rastiane, Angin ty Service + visti, Cosetiay aevt ow and Plann! ing Council, State of New York - President, Bronx Community Coll - Committee on the Disadvantaged, - ot Ora Heal ates, ommittee, tre aah - Former tor of Nurses, Harlem Hospital - Netto! Towner of Negro Women - President, Seymour, Inc - Corirman, FeEatiey Comittee American ncer Society, Erie County Division - New York State Criit for Children - Past President, York State Association of Soctal ten = Revere S6over and Brass, Inc - Oneida County Community Action Agency - Vice-President, Dorf International Ltd. - Chairman, Sub-Committee on Health Legislation, Community Service Society - Dffice of Manpower Development, ssau County ~ President, N.AA.C.P., Great Neck Branch 2 rtwate practice, County Community Planning Council - Professor of Environmental Medicine, New York University Medical Center - Former Adninistrator, Environments Agency, City of New York t, Ninth District Dental Society, State of New York ~ Department of Forest Zool State univers ty Coll Forestry - Governor's Counc! of Environmental Advisors - Genesee Regional Comprehensive Health Council - Former Secretary, U.S. Jesartnent of Hesith, Education and Welfa = Co-Cha‘rman, J York State ttee Against Wental 11ines! or - = Vice-Pres ide “tert and we ry Lusver Foundation Fobert J Mager. 0 Bucher ter Robert ). Kodason nawands Frederics © Jaffe Ossint George James, ¥.0. Garden City David v. Jer Syrac C. Aadison Keeler ur. Einthanton James R. Kimey, M.0. New York City Eleanor C. Lambertsen, £4.0. New York City #12narder Livine, M.D. New Tork City C. David Loeks New Paltz John JA. Lygns, M.D. Bus Feura Berwyn F. Mattison,W.p. Lake George John Howard McE1heny Huntington Thomas McLoughlin Floral Pai Harold Miles, N.0. Rochester alter A. Miller New York City Norman 5. Moore, M.D. Ithaca James H. Willalay Syracuse Francis J. 0'8rien,Ph.0 Albany Pediatrics, ry New York Sit Pesioed Coridren orld “ation, Inc. v, Board, Nations! Council er !Mleaitimacy ert and Dean, Yt. Sef Ve<'za) Center, 2} is toe es tun cletec vactcal Schacls of Greuter Mog York - Vice-tresident and Geve=al Counsel, arr ier Corporatio - Trecsarer, kreawide en2 Local Barring for kealtr Action ~ Attorney - President, KY-Penn Nex taunci), Inc. - atutia Director, Arerizar Public Health Association Former Tractor. Comurity Kealth, Inc. - Dean, Correl) University, New York Hospital Schoo] of Nurs: ~ Health Te - Private Tonle | Practice - Chairman, New York state Legs Cont 11 on Mental wer Force, urtan Coalition - President and Chief Executive Wericer, ¥id-kudscn Pattern for Progress, - Past President, Averican Soritute of Pammers - Comnissioner of Health, Albany County pay - Vice-Chairman, Sotutyd bapa Ontsens Associatior - District Health Officer, New York Si Departrent of oleh Sem i ih Bitten rector, Execut |: Health Aotoctation = Assistant Vice-President for Personnel, Yor! ephone Company - Board of Directors, Y.M.C.A.of Greater New York rector, Division of Health and Hospitals, Earner Charities, Archdiocese of New York - Health and Hospital Planning Coweth of Southern New York - Former - Director, Comunity Mental Health Services “onroe County Department of Mental Mealth - Att s foe Federation of Jewish Philanthropies of New York - Director of Scientific Activities, Medical Society of the State of = Chairman, New York State Public Meslth Council - Public Relations Counsel - Exctivy Director, New York State Nursing Home Associati ~ Dean Emeritus, Albany he ot of Pharmacy - Mew York State Board of Phat Edad A Jeri. 0.- Wightrestdant for the Health Sciences and Mary E. Robinson New York City Adria M. Rubd Emirs Wiliam J. Taylor New York oh Jacob Thompson Nedrow Father Tirathy Weider Perkinsville Jerone Wilkenfeld Fresh Meadows Andrew Wi111s Buffalo LA Lib ».0. Bronsy Willan H. Wisely Scarsdale tor of ie perio Sciences Center, State Universi! Brook - Committee on Al fi i ore 1s, Amer can Medica) Associa ~ Maton] Training Coordinetor National Urban League - Mayor's Organizational Task Force,City of New York - Director-at-large, New York State Heart Assen] ~ Cheung County Comunity Chest - Secreta aTrsatuner. Lo Local 1199 Kew York Central on ——" ARLCI0 - Burns Bros. Company = President, Oneida Indian Kation of New York State - Executive Director, Project REACH Secular Mission of Steuben = Executive Board, New York State Center for Migrant Studies ~ Director, Environmental Health, Hooker Chemical Corporation - New York State Envirommerts] Board + Desuty Director, Buffalo Urben League, Inc. ‘ hairrar, Board of Direct tt hens fve Health Planning Council of western New York - Chairran, Board of Troitees, Medical Society cf the State of New ¥ = Fourder and Vet'rre dur, Adootion Service of Westchester ~ Executive Director, Americar Society of Civil Engl neers igéneering Foundation 1735 New York State Health Planning Advisory Council COMPREHENSIVE HEALTH GOALS AND OBJECTIVES FOR NEW YORK STATE Introduction The overall comprehensive health goal in New York State is: To attain optimum conditions conducive to social well-being; to attain optimum personal health; and to attain a favorable ecological balance between man and his physical and social environment. Few statements on human affairs can be considered absolute. Nevertheless, those which follow reflect the collective judgment, experience and belief of the broadly representative membership of the Advisory Council. They are presented as valid health goals and objectives during this decade for the citizens of the State of New York on the basis of present knowledge. Optimum health for all New Yorkers will be achieved when the State attains a rational, humane system of personal health care in a healthful natural and social environment. The close interrelationships between health and social well-being are forcefully documented in many sources including the Health Planning Commission's study of Health Needs of the Disadvantaged. : In order to deal most logically with the immense and diverse problems of health, the totality has been broken into three spheres for consideration -- social well-being, personal health and environmental health. Some of the goals chosen by the Advisory Council can primarily be met through the activity of agencies and individuals not ordinarily thought of as health-related. Some require the active commitment of all elements of our population. Others bear directly upon the providers of health services. While it is necessary to select priorities among objectives and goals, reaching the state of optimum health for all New Yorkers requires active attention to each goal. The emphasis must shift away from the present tendency to define personal health care solely in terms of facilities, finances and personnel, and toward that of the individual in need. 1736 Those aspects of the social environment which contribute positively towards health are: housing, employment, food, education, transportation, human dignity, social identity and aspiration, constructive attitudes toward health, positive personal health behavior, recognition of urban-rural-suburban differences, and attention to the needs of socially under- privileged groups. The aspects of the natural and physical environment meriting major attention were defined by the Committee on Environment of the American Public Health Association as follows: "The Environment is considered the surroundings in which man lives, works and plays. It encompasses the air he breathes, the water he drinks, the food he consumes and the shelter he provides for his protection against the elements. It also includes the pollutants, waste materials, and other detrimental environmental factors which adversely affect his 1ife and health." The terms goal, objective and priority have different definitions to different users. For the sake of consistency the following definitions have been utilized: Goal is an expression of a desired state to be achieved, prescribing the direction and intent toward achieving the desired state. Objective is the tangible division of goals toward which specific activities can be aimed, including desired end results or specific accomplishments to be sought on the way to achieving the goal. Priority is a rating applied to goals and objectives representing the realistic ordering of choices with respect to time, the allocation of resources and other constraints. The priority rating which the Advisory Council has assigned to each objective is indicated in parenthesis in the text. In the preparation of this statement there was full awareness of the resource constraints on the attainment of many of the goals and objectives. Yet, viewing this statement as an avowal of intent and direction, long-range goals and objectives, as well as those that are more immediately achievable, are both set forth for this decade. 3+ 1737 THE PROBLEMS WE FACE The attainment of a healthy society is dependent upon the physical, emotional and social well-being of its members. Poverty, unemployment, underemployment, inadequate housing and related social conditions create mental and physical health problems. The large magnitude of these problems among the poor, as compared to the more affluent, is particularly evident in the Health Planning Commission's study of the Health Needs of the Disadvantaged. Society has failed to recognize its responsibility for the health of its members. Pervasive apathy and collective insensitivity have served to inhibit the public's awareness of the relationship between the individual's well-being and the well-being of the community. Neither individuals nor the community have been made aware of their responsibility for the maintenance of optimum personal, family, and community health. There is a cause and effect relationship between socio-economic pathology, and health dysfunction. However, this relationship has not been adequately recognized in the allocation of resources. Criteria for the allocation of resources (i.e. manpower, facilities, financing, technology, and knowledge) are concentrated on illness rather than health. This problem has been recognized by a number of authorities and studies, among them the Report of the National Advisory Commission on Health Manpower; Dr. George James in his article,"Life, Liberty and the Pursuit of Quality"; and the Fortune article by Dan Corditz entitled, "Better Care at Less Cost Without Miracles." Individuals with special health needs have not been integrated into society as a whole. Minority and ethnic group membership, economic status, geographic location, age, crippling physical or mental handicap or disability are frequently the basis for isolation from the mainstream of health services and society. Society's attempts to promote social well-being have been shortsighted and crisis-oriented and have tended to disregard the whole range of social, economic and environmental factors which impinge upon the health of the individual. In the delivery of personal health care there is a lack of comprehensive preventive, diagnostic, treatment and rehabilitative services readily available for emergency, acute and chronic situations. The recent Carnegie Commission report on Higher Education and the Nation's Health discusses the uncoordinated proliferation and self- perpetuation of increasingly specialized and discrete professionals and institutions, This adds to the difficulties of caring for the total individual along with his family and the community. f= 59-661 O - 71 - pt.8 - 2 Failure to adopt preventive medical procedures and to identify potential medical problems in poverty areas has led to a higher incidence and prevalence of many diseases. It is also precisely in these areas that health services are often unavailable, unaccessible, unacceptable to recipients; costly; frequently of poor quality; fragmented; and lacking in continuity. Health services are seldom integrated with health-related supportive services, and they are not offered in a family-centered context related to community needs. These negative factors increasingly apply to the population at large which has less and less primary care resources: available for entering and moving through the present maze of health care. These problems are well developed in many studies. There is a serious deficiency in fully utilizing available manpower, facilities, financing, and technology in providing better health services and restructuring their delivery. This has been shown by major studies such as works by Somers and Somers, the Report of the Task Force on Medicaid, and the Report of the National Advisory Commission on Health Manpower. Utilization based on conventional delivery methods and ability to pay, rather than on consumer need, makes health resources appear more limited than they are. In relating health and social problems there is an inadequate application of behavioral science knowledge to the delivery of services and to the education and training of all members of the health team. The increased demand for health services created by Medicaid and Medicare; the escalating costs of hospitalization; and the rapidly changing technology of modern care, have resulted in increasingly higher expenditures which are borne by the consumers of health care services. The mounting concern over these problems is reflected in the extensive coverage provided by every leading national magazine within the past few years. Disregard for the consequences of the impact of man on the environment and the influences of the environment on man has resulted in serious deterioration in the quality of modern life. Paramount among his problems is incomplete understanding of what constitutes a healthful environment, and what attitudes and practices unfavorably alter the environment and thereby threaten his mental, physical and social well-being. Now that the pervasiveness of environmental factors is becoming more and more evident, man is faced with the necessity of examining his fundamental attitudes and behavior. As the U.S. Department of Health, Education and Welfare's Task Force on Environmental Health and Related Problems has pointed out in its 1967 report, entitled "A Strategy for a Livable Environment," more needs to be known as to 1739 what constitutes the optimal setting for human health. There needs to be an examination of present attitudes and practices, both individual and social, which, based on present knowledge, alter or affect negatively the health environment. Also required is an examination of present mechanisms for applying already acquired knowledge to determine whether they are adequate or in need of strengthening. Specific attention must be given to the development of a far broader time perspective with regard to actions which may alter irreversibly the environmental balance or require great future remedial expenditures. =6= 1740 THE SOLUTIONS WE PROPOSE THE GOAL FOR SOCIAL WELL-BEING To provide opportunity for a standard of living adequate to ensure the dignity of every New Yorker; to provide opportunity for productive employ- ment and education relevant to the needs of both the individual and society; and to develop both within the individual and the community a sense of responsibility for the maintenance of optimum personal, family and community health. OBJECTIVES: 1. To advocate the design and construction of substantially more new housing, and the rehabilitation and maintenance of existing housing. Priority No. 9) - Strive vigorously for greater private investment in housing for low and moderate income groups. - Provide innovative public programs to meet housing needs which are not satisfied by private investment. - Promulgate and consistently enforce housing standards which will ensure decent living conditions for all New Yorkers. - Seek new construction methods which provide housing at costs reasonably related to other sectors of the economy. To provide an education which will enable all New Yorkers to realize their potential to the fullest, and provide training for productive and satisfying employment. (Priority No. 15) To stimulate full employment in all areas of the State.(Priority No.21) To ensure all New Yorkers continuous access to food sufficient in quantity and nutritional value to maintain physical well-being and promote the healthy growth and development of the young. (Priority No.13) - Establish and enforce quality standards and labeling requirements for all food products in relation to nutritional value as well as freedom from contamination and adulteration. - Disseminate information on nutrition which will enable the consumer to choose wisely in the selection, preparation, and consumption of food. 10. 1741 To relate population growth and distribution to the development of those resources needed to permit social well-being. (Priority No.17) - Make family planning information and services widely available. - Create conditions to promote a more rational distribution of the State's population. To strengthen and make more effective social service programs so that they will enhance social well-being and health. (Priority No.19) - Provide adequate financing for social service programs to enable families to live in dignity. - Facilitate access to all social and health services. - Disseminate information on the availability of social and health services. To ensure consumer involvement in health and social planning through- out New York State in order to make community agencies, institutions and services more responsive to the needs of those they are designed to serve. (Priority No.18) To develop within the individual a commitment to personal, family and community health; the environment and its relationship to health; concern for persons with special health needs; and participation in the health planning effort and community programs. (Priority No.2) - Encourage the continuous self-examination and adjustment of attitudes and actions by every New Yorker so that the apathy and powerlessness of so many of our citizens is eliminated. - Develop during childhood and maintain throughout life attitudes and behavior which will enable individuals to play a more effective part in safeguarding their own health. To increase our knowledge of the interrelationship between man and his social environment and its effect on health. (Priority No.26) - Promote research into the effects of the urban, rural and suburban environments on the physical, emotional and social well-being of the individual. To develop interrelationships between health planning and social, economic and environmental planning. (Priority No.14 - Coordinate the programs and planning efforts of all health-related public and private agencies in the State. 1742 THE GOAL FOR PERSONAL HEALTH CARE To develop a responsive system, free of financial barriers, that provides continuous and comprehensive quality health care which is accessible and appropriate as well as acceptable to recipients and providers. OBJECTIVES: n. 12. 13. 14. 15. To ensure that the health care delivery system meets the special needs of urban and rural populations. (Priority No.6) - Explore the feasibility of various new delivery models to meet the special needs of urban and rural populations. To encourage manpower recruitment, training, placement, utiliza- tion and retention, especially of minority groups. (Priority No.20) - Investigate various new means of licensing health personnel. - Train and better utilize paramedical personnel. To make full use of existing technology and potential resources. (Priority No.22) - Develop objective, quantifiable measures of health status. - Develop health and management information systems for the delivery and utilization of health care. To encourage the testing of innovative health care delivery systems. (Priority No.7) - Develop innovative primary care programs for populations with limited access to care. To eliminate the financial barriers to health care. (Priority No.l) - Develop alternate methods of financing innovative primary care programs. To maintain the health of those who are well. (Priority No.8) - Prevent the occurrence and progression of human ailments. 18. 19. 20. 21. 22. 23. 24, 1743 To provide care for people with emergency, acute or chronic health conditions as they utilize a full range of preventive, diagnostic, treatment and rehabilitative services. (Priority No.3) - Improve and extend the full range of comprehensive services. - Encourage the fluoridation of all water supplies. To support continuing medical research aimed at reducing the incidence of mental, physical and emotional disorders.(Priority No.11) - Develop specific epidemiologic studies to reduce mental, physical, and emotional disorders. - Encourage applied clinical and basic research. To encourage continuing education for professional groups, especially physicians without hospital affiliations.(Priority No.25) - Explore feasibility of re-licensing physicians based on examinations. To promote the development of a physicians' service corps. (Priority No.31) - Utilize physicians to make health services more accessible through a service corps. To promote the development of facilities centrally located within the community to provide the health care services and health- related social services needed. (Priority No.16) - Improve knowledge of availability of specific health services. To encourage health services that are fully responsive to the needs and dignity of the patient. (Priority No.12) - Develop programs for the reduction of special health problems such as drug abuse and venereal disease. - Develop innovative approaches to special health problems related to age. - Change the attitudes of health personnel regarding patients and needed services. - Train health personnel in patient psychology. To promote broad community involvement in decisions concerning local health services. (Priority No. 27) To extend meaningful school and community health education programs aimed at developing an understanding and sense of responsibility for the individual's own health. (Priority No.10) <10= 1744 THE. GOAL FOR ENVIRONMENTAL HEALTH To attain a favorable ecological balance between man and his physical and social environment that will be conducive to optimum health, safety, and comfort and that will protect this generation, and coming generations as well, from the deterioration in the quality of life caused by uncontrolled environmental factors. OBJECTIVES: 25. 26. 27. 28. To develop a personal and societal responsibility for an environment conducive to health. (Priority No. 23) - Promote community and school health education programs designed to foster individual understanding of human ecology and environmental protection. - Increase public awareness of the frequent conflict between demands for a healthy environment and luxury or convenience products. To reduce air, soil, water, food, drug, radiation and noise pollution. (Priority No. 5) - Promulgate and consistently enforce standards to reduce environmental pollutants. - Provide economic incentives that would encourage industry and local governments to reduce pollution. Develop sewage treatment, air pollution control, and solid waste disposal systems. - Minimize human exposure to harmful radiation. To reduce environmental hazards. (Priority No. 24) - Diminish vehicular, home, ogcupational and recreational accidents and resulting injuries. To develop and maintain healthful conditions in residential environments. (Priority No. 28) - Eliminate rats, lead poisoning and other dangers from the dwellings of the poor. - Explore the relationship between residential density and health. - Support the establishment and enforcement of housing maintenance and occupancy codes. 1% 29. 30. 31. 32. 1745 To develop and maintain healthful conditions in occupational environments. (Priority No. 39) To develop and maintain healthful conditions in recreational environments. (Priority No. 32) To acquire knowledge upon which a workable technology can be based. (Priority No. 29) - Develop knowledge and technology to make greater use of reclamation and recycling of material from solid waste. - Develop an on-going ecological information system. - Secure basic information on pollution, to improve monitoring and to determine long-range effects on health. - Consider long-range implications, as well as immediate benefits, in the planning of programs and activities which affect the physical environment. To assure the rational allocation of resources so that they will be of most benefit to the mental and physical health of both the individual and society. (Priority No. 4 - Reduce "crisis rhetoric" in discussion of the environment so that proper priorities can be assigned. - Encourage the provision of adequate manpower, facilities, financing and technology to implement the reduction of environmental hazards and unhealthful residential environments. -12- 1746 Senator Dominick. Mr. Chairman, before we continue I think it would be of interest to some of the people who are here today if I could just quote a few statistics from statements that I have ob- tained. I won’t take long. Having been at most of the hearings we have had in Wash- ington—and I plan on being at most of the field hearings—one would get the impression that the United States is providing second rate medical care in many cases because it is said that other countries have lower infant mortality rates. In truth, infant mortality is for the most part a social rather than a medical problem. Factors such as poverty, malnutrition, poor housing, poor education and racial or ethnic differences are much more highly correlated with infant mor- tality than such factors as the number of physicians or hospitals. It has been said, “In the analysis of the health care crisis, there is an acute and worsening shortage of all kinds of health personnel, especially doctors.” The truth is that we have one of the highest ratios of doctors per capita in the world, and the number of physi- cians is growing at a rate faster than our population. In 1950, the population to physician ratio was 711 to 1. Now it is 630 to 1. The number of medical schools and medical students is showing unparalleled growth. In the school year 1966-67 there were 89 medi- cal schools and just over 33,000 medical students. It is anticipated that by next year—just 5 years later—there will be 114 schools and over 43,000 medical students—an increase of 25 schools and 10,000 students. This is not to say that we don’t need more medical schools and more doctors. We do. But the basic problems are maldistribution— too few doctors in crowded urban slums and in rural America—and a tendency to specialize. Steps are being taken by the medical pro- fession, by the States and by the Federal Government to counter this trend toward specialization, to deal with the maldistribution problem, and to take some of the load off of doctors by training more allied health personnel. I think this fits both with Mr. Lenz’s statement and also the need which has been expressed by many of the witnesses before our com- mittee. Listening to the hearings in Washington, one could almost conclude that we are about to come apart at the seams and that we are a nation that is ill-clad, ill-fed, ill-housed, and ill-cared for, whether it is in Maine, California, North Dakota, New York, or Florida. But infant mortality, for instance, has been reduced 66 percent in this country since 1900, and life expectancy is up 45 percent in the same period. In the United States we have virtually— some remains, unfortunately—but virtually no polio, no smallpox, diphtheria, nor typhoid fever, and we do have the means at hand to eliminate measles. And so despite the problems we have—and we have them, and might as well recognize them—America is, in gen- eral, healthier than ever. I am hopeful that in these hearings we will start discussing some solutions. For instance, when we are speaking of infant mortality, I believe it would be useful to identify the reasons for the difference between the death rates of whites and blacks. Last year the national infant mortality rate declined as it has every year for some years The black rate was not only higher than the white rate; the black 1747 rate increased slightly. A perceptive comment on this fact was made by Dr. Rowland Scott, Professor of Pediatrics at Howard University in Washington. Speaking of that city’s infant mortality ficure—in a city which is about 73 percent black—Dr. Scott said, “This high mortality is not taking place in the hospitals—they are not too bad. It’s what happens when these babies go home to the ghetto.” So, better medicine is not the only answer. An effective solution is going to require broad—and I emphasize that—broad socioeconomic changes. What I am trying to point out is that health problems are com- plex, and it would be unrealistic to place too much faith in simple solutions. Certainly we have made great progress. Certainly much more progress must be made. But there is no simplistic answer; no one scheme or program can do it all. In the words of H. L.. Mencken, “For every human problem, there is a solution that is simple, neat, and wrong.” That is about as simplistic a statement as one can get on health care problems that we have around the country. And I am hopeful that the press in reporting on these hearings and the ones in Washington will report on the health care programs that have been proposed by the administration and by many others, including the chairman, and that it can help in our effort to promote a national discussion based on facts rather than on myths. We need such a discussion if we are to continue to improve the quality and accessibility of health care for all Americans. This problem is so monumental, and this is a quote from a Wash- ington Post editorial of a few weeks ago— The health care problem is so monumental in scope and so intricate in detail that every idea is entitled to a full hearing on its own merits. Somewhere, out of such a free debate, a national consensus must develop, a consensus that rests on facts and solid theory, not on the whims of doing something to improve the situation or on notions of reaping political credit for the final product. And I would like to have my full statement put in the record, as I said at the beginning, if IT may. Senator Kexnepy. The full statement will be included in the record. (The prepared statement of Senator Dominick follows :) StaTEMENT oF Hon. PETER H. DoMINICK, A U.S. SENATOR From taE STATE 0F COLORADO Mr. Chairman, as the Health Subcommittee begins its field hear- ings on the subject of “The Health Care Crisis,” I believe it is important to point out to the witnesses that the jurisdiction of this subcommittee is quite broad. The rules of the Senate provide that legislation will be referred to the parent Labor and Public Wel- fare Committee if it involves the public health. In fact, this means that the Health Subcommittee has jurisdiction over the Public Health Service and also over a wide range of Federal health pro- grams. In the last Congress under the chairmanship of Senator Yarborough, this subcommittee acted on a wide range of health legislation. Much fine legislation was enacted into law which will help immeasurably in providing better facilities and more man- 1748 power to meet our problems. The subcommittee recommended and the Congress enacted legislation which provides grants to schools of public health, assistance for migrant agricultural workers health programs, Federal aid to community mental health centers, Federal assistance to medical libraries, Federal dollars for vaccination programs, an extension of the regional medical program which funds projects across the country in health education and delivery to control heart disease, cancer, stroke, and now kidney disease. This subcommittee also acted on legislation during the last Con- gress to extend and strengthen comprehensive health planning, to provide additional aid to fight mental retardation and help chil- dren with developmental disabilities, to extend and improve the training programs for allied health professions, to establish a land- mark program for prevention and treatment of alcoholism, and to authorize the use of Public Health Service personnel in areas where there are shortages of physicians. ' Additionally, we acted on legislation to provide help to persons desiring family planning ‘information, and the Congress passed occupational health and safety legislation, Clean Air Aet amend- ments, the Child Protection and Toy Safety Act, and the Federal Coal Mine Health and Safety Act, as well as the Lead-based Paint Poison Prevention Act and the Air Pollution Control Stand- ards Act. In this Congress, some 30-odd bills and resolutions covering a broad range of health matters have already been referred to the Labor and Public Welfare Committee for initial consideration by this subcommittee. Some of the most important of these deal with urgent problems related to the shortage and maldistribution of health manpower. For example, the Health Professions Educa- tional Assistance Act, which provides Federal assistance to schools and students of medicine, dentistry, osteopathy, podiatry, phar- macy, optometry, and veterinary medicine, will expire July 1 this year. Several bills which would extend and modify that authority are pending action before this subcommittee. Also pending is legis- lation to assist in the training of acutely needed nurses and other allied health personnel. As everyone knows, several national health insurance proposals have been introduced this Congress. These raise significant issues because they represent the first comprehensive approach to improving the quality and accessibility of health care in the United States. Several weeks of this subcommittee’s time this year have been spent listening to testimony directly related to these proposals. While such testimony is undoubtedly helpful to this subcommittee, I think it should be kept in mind that the various national health insurance proposals are not before us. Since they have revenue- raising features they have been referred to the Finance Committee. In summary, this subcommittee has pending before it considerable legislation dealing with urgent problems which fall within its broad jurisdiction. For that reason, I think the scope of these field hearings should be confined to those problems. As we go into these field hearings, 1 think it is important to put a few facts into the record and to comment on some misconceptions 1749 which have been apparent in previous hearings or in the discus- sion of the health care situation in the country. Let’s look at the use of statistics by some of the witnesses who have appeared before this subcommittee. Some would have us be- lieve that the United States is providing second-rate medical care because other countries have lower infant mortality rates. In truth, infant mortality is for the most part a social rather than a medical problem. Factors such as poverty, malnutrition, poor housing, poor education, and racial or ethnic differences are much more highly correlated with infant mortality than such factors as the number of physicians or hospitals. Moreover, comparisons of international statistics on infant mor- tality are not very meaningful. The Demographic Yearbook of the United Nations spends five pages pointing out why statistics from one country are not necessarily comparable to statistics from an- other country, especially in the field of infant mortality. There also seems to be a popular misconception that the United States is the only major industrial nation in the world that does not have national health service or a program of nationalized health insurance. This claim was made last month on the floor of Congress, and the idea is widely shared, even among some health “experts.” Those who hold this view seem to have in mind the British and Eastern European model in which health services are not the typical Western European model. In fact, continental health insur- ance schemes are predominantly financed by employer-employee contributions and operate within the framework of national stand- ards. It has been said, “In the analysis of the health care crisis, there is an acute and worsening shortage of all kinds of health person- nel, especially doctors.” The truth is that we have one of the highest ratios of doctors per capita in the world, and the number of physi- cians is growing at a rate faster than our population. In 1950, the population to physician ratio was 711 to 1. Now it is 630 to 1. The number of medical schools and medical students is showing unparalleled growth. In the school year 1966-67 there were 89 medical schools and just over 33,000 medical students. It is an- ticipated that by next year—just 5 years later—there will be 114 schools and over 43,000 medical students—an increase of 25 schools and 10,000 students. This is not to say that we don’t need more medical schools and more doctors. We do. But the basic problems are maldistribution— too few doctors in crowded urban slums and in rural America— and a tendency to specialize. Steps are being taken by the medical profession, by the States, and by the Federal Government to counter this trend toward specialization. to deal with the maldistribution problem, and to take some of the load off of doctors by training more allied health personnel. While it is clear that this country has critical health problems, I think we should keep the magnitude of those problems in some sort of perspective. Listening to the hearings in Washington as I have day after day, I could almost conclude that we are about to come apart at the seams and that we are a nation ill clad, ill fed, 1750 ill housed and ill cared for from Maine to California and North Dakota to Florida. Therefore, I would like to point out that infant mortality, for instance, is down 66 percent in this country since 1900. That male life expectancy is up 45 percent in the same period. That in the United States we have virtually no polio, smallpox, diphtheria, typhoid fever, and have the means in hand to eliminate measles. Despite the problems we have, America is, in general, healthier than ever. Having had the problem areas in health care identified repeatedly to this subcommittee, I am hopeful that in these hearings we will start discussing some solutions. For instance, when we are speaking of infant mortality, I believe it would be useful to identify the reasons for the gap between the death rates of whites and blacks. Last year the national infant mortality rate declined as it has every year for some years. The black rate was not only higher than the white rate, the black rate increased slightly. A percep- tive comment on this fact was made by Dr. Rowland Scott, pro- fessor of pediatrics at Howard University in Washington. Speaking of that city’s infant mortality figure—in a city which is about 73 percent black—Dr. Scott said, “This high mortality is not taking place in the hospitals—they are not too bad. It’s what happens when these babies go home to the ghetto.” So, better medicine is not the only answer. An effective solution will require broad socio- economic changes. What I am trying to point out is that health problems are com- plex, and it would be unrealistic to place too much faith in simple solutions. Certainly we have made great progress. Certainly much more progress must be made. But there is no simplistic answer; no one scheme or program can do it all. In the words of H. L. Mencken, “For every human problem, there is a solution that is simple, neat, and wrong.” In conclusion, I think the press has a special and constructive role to play, reporting on these hearings and reporting on health care programs. It can help in our effort to promote a national dis- cussion based on facts rather than myths. We need such a discus- sion if we are to continue to improve the quality and accessibility of health care for Americans. If IT may quote from a Washington Post editorial a few weeks ago on health care programs: The health care problem is so monumental in scope and so intricate in de- tail that every idea is entitled to a full hearing on its own merits. Somewhere, out of such free debate, a national consensus must develop, a consensus that rests on facts and solid theory, not on the whims of doing something to improve the situation or on notions of reaping political credit for the final product. Senator Kexnepy. Mr. Lenz. Mr. Lenz. Mr. Conlin, one of the supervisors, will introduce some of the aides. ' STATEMENT OF THEODORE P. CONLIN, PROJECT DIRECTOR, COUNTY- WIDE EMERGENCY FOOD AND MEDICAL SERVICES PROGRAM Mr. CoxuiN. Senator, I have a brief statement before I intro- duce my aides, if I might. 1751 If nobody has taken the occasion at this point I, as a former undergraduate of Hofstra and an alumnus, welcome both Senator Kennedy and Senator Dominick to our campus. I am going to address myself to concerns of the mentally disad- vantaged this morning, and Senator Dominick asked for some solu- tions, and I am going to attempt to give both Senator Dominick and Senator Kennedy some solutions as the consumers down in the local communities see them. State mental asylums were deemed archaic and obsolete better than 100 years ago by the founding fathers of the psychiatric com- munity here in America. State mental asylums were frowned upon as reminiscent of the 17th century pesthouse by these same men. And yet today, when one nation such as ours, can bend its will, resources, and planning commitment to the end of achieving in a single decade, that which most men, at the time, considered to be possible only in fantasy or science fiction, the goal of moon ex- ploration by earthlings, we still allow for the ugly spectre of the 17th century pesthouse to haunt our asylumized mental patients. And I would like to remind the Senators that here on Long Island we have three of the nation’s largest institutions, one of which is the world’s largest, Pilgrims State Hospital. It is indeed time that this same will, coupled with commitment of resources and planning, be applied towards the end of phasing out State mental asylums before the end of the decade. We are on the Moon. We are already reaching for Mars. If we can get our earthlings to such distant planets, why, then, can we not liberate the mentally incarcerated and have them treated in community oriented facilities where opportunity for expedited successful reentry into the mainstream of American life becomes more immediate, more promising, more hopeful. The community is where these brothers and sisters can, and do, belong, and where they can, in the words of world famous psychia- trist Dr. Karl Menninger, become “weller than well.” Towards achieving this end, we would do well to advance the following concepts, concepts which could easily be translated into meaningful community action upon the part of health consumers geared towards implementation of same. Ideally, the community should stress seven points: (1) Treatment available in the community. (2) Provision for early intensive treatment. (3) Hospitalization near or in each person’s community. (4) A program during hospitalization directed towards the pa- tient’s family, friends, relatives, et cetera. (5) Availability of outcare for acute epidodes. (6) Provision for a wide range of services. (7) Interagency cooperation in supporting therapeutic programs. Ideally, the community should have: (1) Psychiatric clinics for diagnosis, treatment, and rehabilita- tion of children and adults. (2) Psychiatric services in schools, courts, and prison systems. (3) Day care centers and residential services for disturbed chil- dren and the retarded. 1752 (4) Intensive treatment facilities and services. (5) Halfway houses. ( 5 Suicide prevention services. (7) 24-hour psychiatric emergency service. ( a) Psychiatric beds in general hospitals. (9) Day care and night care in hospitals for adults. (10) Rehabilitation and aftercare services. (11) Community education. (12) Advocacy for the mentally ill in cases involving civil and criminal conflict. (13) Programing for preventive medicine, rehabilitative medi- cine, supportive medicine, and followthrough medicine; and let’s get away from this crisis-oriented medicine. Mr. Lenz has indicated what my position is. I am Nassau County field director for the countywide emergency food and medical serv- ices program. I have aides working in all of the poverty pockets in Nassau County who are encountering great difficulty in obtain- ing those immediate services for the people that are needed. The three major constraints appear to be the lack of adequate staff to take care of our people; No. 2, the fiscal constraints are fantastic; and No. 3, we have absolutely no transportation facilities. In regards to the first item I would just like to point out in my own community of Westbury we have 108 medical professional people in residence in my community. Of the 108 doctors who live in Westbury only one doctor is available for emergency calls. This man is an elderly man, he is a sickly man. The other 107 doctors are not available for emergency calls in their own com- munity. At this time I would like to call on one of my aides, Medio Anushu (phonetic), who is servicing the Hicksville center of Nassau County. Following Medio I have three other aides. I would appre- ciate it if you could give them a little bit of your time this morning. Senator Dominick. Could I just ask one question? We found out in the process of the Drug and Alcoholism Subcommittee, on which T also serve, that courts in some areas of the country, par- ticularly out west, have been experimenting with the idea of taking the alcoholic or drug abusers and turning them over to locally based community organizations rather than throwing them into the jails. This approach is certainly an improvement on the encouraged re- cidivism policies of the past. Are the courts in Nassau County or the courts in New York as far as you know going along with that same type of idea? Are they turning alcoholics, for example, over to Alcoholics Anony- mous or the drug abusers over to something like Sinon or Sina- core or anything of that kind ? Mr. Coxrin. We had a gentleman in this county, George Mec- Carthy, who recently retired from an organization here in Nassau County that lends itself to the problem of the alcoholic, and he was the only man that I had ever known that would go into the courts and intercede on behalf of the alcoholic. 1753 i! all honesty, I really cannot answer that question. I wish I could. Senator Dominick. As far as you know, the courts themselves have not initiated any ? Voice From THE AUDIENCE. No! No! Senator Dominick. That’s all. Mr. Conrnin. The next speaker will be one of my countywide emergency food and medical service program aides based at the Hicksville Center. Hicksville is a white community, predominantly middle class, very conservative. My aide is Medio Anushu. STATEMENT OF MEDIO ANUSHU, AIDE, HICKSVILLE CENTER, COUNTYWIDE EMERGENCY FOOD AND MEDICAL SERVICES PROGRAM Mr. Axusau. Thank you, Mr. Conlin. Good morning, Senator Kennedy, Senator Dominick. I just want to briefly describe a few cases which I have run into in the last week. I had one client, a senior citizen, that was threatened with the loss of doctor care because the last medical bill of $10 was rejected by medicaid. This same individual is no longer able to receive pharmaceutical supplies from the local pharmacy only two blocks away because that pharmacy is no longer accepting medicare or medicaid payments. The client is 68 years old and unable to travel great distances for drugs and medical care. The closest pharmacy is on the west side of Hempstead. In this particular case I would cite inefficient operation of medic- aid and medicare and the providers’ concern with money rather than health care are two main problems. I have another client in his 70’s, and the husband in question has become #eriously ill on a number of occasions due to his age, and they have not been able to get a doctor to make a house call, and they are in an apartment facility. There are four doctors within four blocks of the apartment, and they tried another two in the local community, and nobody would make house calls. I have a 9-year-old girl. I talked with her parents last Monday. She is an asthmatic child. The father is working for the post office. They have financial difficulty and they are unable to pro- vide the child with an air filter for comforting her sickness. They applied through medicaid and they were told that many appliances do ease a patient’s condition but they have no medical value, therefore, they cannot assist the family. Senator Kexxepy. Who told them that? Mr. Axusnu. I called personally the doctor in charge of the medicaid office at the Department of Social Services, and after he hung up I called back and it was his secretary, and this has been recorded. It was his secretary that told me, and that is a quote, that many appliances do in fact ease a patient’s condition but they are of no medical value. That was their statement. There is a 22-year-old woman that is about to enter the hospital. After going through two miscarriages last year within the last 8 59-661 O—T71—pt. 8 3 1754 months the attending physician said that they did not use the usual treatment in cleaning which usually accompanies a miscar- riage. The present service “she will receive is a D and C, due to the miscarriage and not being taken care of at that time. And the operation will cost between $300 and $400. This couple is not medi- cally insured and they will have to foot the cost. I can continue on and on, but I am sure you have heard all kinds of problems like this. The thing I would like to say is if the U.S. Congress is sin- cerely interested in effecting meaningful health legislation they must constantly keep in \mind that the segment of our society, mainly the medical establishment, which has the greatest amount of power and finances available for the provision of meaningful and effective health care. It is the very same segment which has shown the least amount of interest and least amount of concern in attempting to resolve the health crisis which is at present plaguing our Nation. If they in fact keep this in mind, then the people of this country may finally see an improved health system. Senator Kenxepy. Could you tell us a little about yourself? Are you trained in the Mr. Axusnu. Yes, at present I am finishing a 2 months extensive community organizing course at the State University of Old West- bury. And basically my field is emergency food and medical service. The food problem is acute and emergency medical service is acute. Therefore, many of the aides are going into community organizing as well as the emergency food distribution service. Senator Kexxepy. How long have you been working in this? Mr. Axvsmu. Three months. Senator Ken~epy. We are interested obviously in trying to get some kind of a better feel about the nature of the health crisis in the suburban area. Are there any general comments you would like to make about it? T think most “people assume that in more middle-class suburban areas that we have got very few problems. I would be interested, from your limited kind of experience over 3 months but working rather intensively in this area, whether you would have any comments you would like to make. Mr. Axvusnu. Well, T might say that the existing hospitals—for instance, we have a county hospital which provides health care for the county. My four areas are closest to this particular area, yet due to the dispersion of housing and the area that my four communities encompass, it is difficult for these people to get to this hospital. Transportation is another problem, but I guess in this particular case it relates. But there is poor transportation in our area. Doctors are not making house calls. I para not been able to find a physician that will make a house call. Sev enty percent of the people T deal with do not have anyone they can call a family doctor. The clinic is providing the best care possible, but it is over- crowded. Many of my clients wait 2 or 3 hours to be treated in the clinic unless it is a dire emergency—and I mean you have to be dying to get treated immediately. Otherwise there is a long wait. We have a pediatric clinic located in Plainview which is com- pletely distant from any type of services. 1755 Senator Kexnepy. What sort of group are you talking about? Are you talking about the medically indigent, are you talking about the middle class? Mr. Axusau. I am talking about marginal income and middle class as well as, of course, the poor. Senator Kex~epy. Can’t middle class people get a doctor to come to the house when they need one? Mr. Axusau. Not usually. The family doctors of middle class families will sometimes come out to the house. I know of one doctor, for instance, on the edge of Iicksville who has a number of patients that have been with him for 10 or 15 years. Rather than make the house call he will say “okay, meet me at my office.” But his office happens to be attached to his house. Now why he can’t get in his car and go to the house I don’t know. But I have krown people to go there as late as 10, 11 o’clock to receive health care, and they have to go to his office. Senator Dorvicx. Have you had any medical training? Mr. Axusuvu. No, sir, I haven't. Senator Dominick. In the group that you are working with do you have what we call allied medical helpers—in other words, corpsmen who come out of the service, or people who have been trained to be nurses’ aides, assistants to pediatricians, and so forth? Mr. Axusuu. As I understand it, right now the State legislature is having a big to-do as to whether they are going to allow any type of paraprofessionals of this nature pr actice in the State of New York. I, myself, am interested in the physicians’ assistant program which was supposed to start at Stonybrook this fall, and it is still doubtful of ever starting. Senator Dominick. It has not started as far as you know in the medical schools that are around or here at the university? Mr. Axusau. No. Senator Dominick. We have to give the doctors a boost here be- cause they have been cut up pretty badly. I don’t know anything about the doctors in Hempstead, but I guess they are all overworked and pushed hard. We have had a lot of evidence that house calls, even though they are necessary with a bedridden patient, create a problem as to the number of people that may be treated. It is more difficult to make house calls than for people to come to them. In other words, they can take care of a lot more people at clinics. Have you any comment on that? Mr. Axusuu. I would say that in most cases—there are areas in this county, for instance Glencove, which have,one doctor for every 125 people. Most of these people do not have any trouble getting house calls. In the town where I have lived for 15 years when we called our doctor he was there on the double. In an area like Levittown there is one doctor for every 500 people. That is an existing problem. In Uniondale there is one doctor with a very small caseload. There is another doctor with a very heavy caseload. Yet neither of the doctors make any attempt to exchange patients nor to coordinate with each other. As I understand it, most of the doctors in our area when they hear the word group practice, which would serve more people in a given area, shun away from this idea. I think possibly the doctors 1756 in the present state could in fact service more people and possibly make provision for house calls if there were some type of co- ordination made available. For instance, at a hospital they always have, say, an orthopedic surgeon—they have one of the surgeons on call for a 24-hour period. The next day another surgeon will take that spot. IT think the doctors in a community should be responsible to each other as well as to the consumers in a given area, and I see no rea- son why a group of seven or eight doctors in any one small area, say, serving 20,000 people could not make some type of arrange- ment to have this type of service made available to the people in that area. Senator Dominick. In other words, what you are saying is that in this area there is nothing comparable to what we have in Colo- rado. For example, a program now being developed in Denver en- titles patients to complete health care coverage for a set, prepaid amount. T understand that doctors foundations organized under this concept are being created throughout the State of Colorado. é Mr. Axusnu. As far as I know, there is no such thing. Senator Dominick. Do you know of any group program of doctors in this area or elsewhere which does make house calls? Mr. Axusuau. No, sir. Senator Dominick. That's all T have. Senator Kex~epy. Thank you very much. Mr. Axusuu. Thank you. Mr. Conrin. Senators, my next speaker will be Dorothy Ingram. Dorothy Ingram is from Freeport, N.Y. Freeport is a racially inte- grated incorporated village. It has a very high density of poor people, welfare people. 1 think Dorothy might have some very interesting things to say about her community in Freeport. STATEMENT OF MRS. DOROTHY INGRAM, FREEPORT, N.Y. Mrs. Ingram. Welcome to Nassau County. It’s good to see some Democrats on the scene again. [ Laughter. ] Senator Kex~xepy. How do you think that makes Senator Domi- nick feel ? Mrs. Ingram. Well, he’s in good company. He looked like a Democrat. Senator Kex~epy. We're working on him, but Mrs. Inagram. Very good. Senator Kex~NepY (continuing). It’s a pretty tough job. Senator Doaixick. I grew up in Connecticut and moved to Colo- rado. Mrs. Ingram. Oh, TI see. First T would like to address my attention to the fact that Nassau County is the richest county in the country, perhaps in the world. And unlike the cities or unlike the rural areas, our poverty is hard to find. So perhaps one of the first priorities, Senators, is to estab- lish Nassau County in a category so that it can get some special attention, because everything is directed to the urban areas or the 1757 rural areas, and suburbanites you like to think of as people who are living the life. Perhaps some of them are. But here in Nassau County we have 11 poverty areas which exist on the fringes of the more affluent areas. We are exploding with problems. We are exploding with prob- lems of poor housing, unemployment and underemployment, in- creasing welfare rolls. And all these things we know contribute to poor physical and mental health. Senator Dominick. You sound like a Republican at that point. Mrs. Ingram. Do I really? They are working on me. [ Laughter. ] But IT would like to address myself to the infant mortality rate. Perhaps the infant mortality rate is not as high here in Nassau County as in other areas, but if you will check the records you will see that in these 11 poverty areas and in some other areas infant mortality rate is much higher than the overall county rate, and this is attributed directly to social ills. Whether it is because of ethnic background or other problems of poverty—but it is there because of the social ills. Consequently we have doctors who do make house calls, and I think the young man said in his community there is one doctor for every 125. But in the area where I come from does not have that many at all. For instance, last week there was a family who had a youngster who was ill and the mother tried to get a doctor out, the doctor said, “Well, bring him in.” It was said this was a doctor who makes house calls. The youngster wasn’t feeling well at all, but the mother got him up and dragged him to the doctor, and the doctor diag- nosed his case as having a fever and sore throat—as pharangitis, and prescribed some medication. The youngster went back home, and in about 6 hours he seemed to have gotten progressively worse, and after the mother looked and saw that this youngster was becoming delirious she took him to the county hospital, which is Meadow- brook. Luckily this family had a car. The mother took this youngster to Meadowbrook, and his symp- toms had become so intense that the doctors immediately diagnosed this as meningitis. A youngster with meningitis. And it was through prompt diagnosis and treatment that this youngster was saved. But here again we have perhaps a mother who was somewhat sophisticated and could recognize these symptoms. The majority of the people in areas such as I live, and the other 10 areas, they are not sophisticated; they can’t recognize it even if they were where they could get a doctor. So that kid in perhaps an unso- phisticated family would have stayed home and died because here is a mother that thinks he has just got a sore throat and the fever will come down, has no transportation to get to the hospital, and he could have been “caput.” Okay, they were able to get there, the doctors were good and gave good care. And the family was somewhat concerned because this youngster was really in a bad way. And you know that hospitals are understaffed. The parents felt that since this youngster would be in a crisis situation for the first 24 hours that they would like 1758 to get a private duty nurse. So the doctor said, “Well, I don’t know whether we will be able to get one because it is so hard to get nurses to take meningitis cases.” And I understand that efforts were made on the part of the hospital staff to get a private duty nurse. All the registries were called in Nassau County, and not one nurse, not one nurse. The same nursing association is fighting the train- ing of paraprofessionals as physicians’ assistants—the people who after being trained will come out and make house calls, will take on meningitis and other infectious disease cases, which nurses won’t do. Now I ask you are we going to continue these things, are we going to continue to let these things exist. The same physician who says “oh, I don’t think it is a good -idea to have physicians’ associates because malpractice suits may occur.” Suppose this person would make a wrong diagnosis. And this mother says well, a simple thing like this, you are saying pharangitis, why couldn’ a paraprofessional be able to diagnose and treat the same thing. And couldn’t this parent say the same thing. Here is a physician who made a wrong diagnosis, who per- haps may not even have taken this youngster’s temperature. But I think this is a parent who is concerned about the welfare of all and would not want to involve herself in such an entrapment as lengthy court cases and that sort of thing. So we come down to some recommendations. It was said that you are looking for recommendations about what can be done. And I say could we first of all establish Nassau County as a priority crisis area because we know we have these problems of poor health, and so forth, where the help can be a special something. You need to do as you have done in the cities, the urban areas. You have set them up as crisis areas. So that would be the first thing. Secondly, we would like to see funds from the Federal level that would generate positions for persons in high level health positions to develop and implement more and adequate health services. We have available only a few people in this county who are truly concerned about getting health care and improving health care and the delivery of services for all of the people of Nassau County, people who are not so provider oriented, or people who can work with both the provider and consumer. We need more of these types of individuals because, believe me, the few of us who are here and who are working with consumer interest, we are fragmented. You start out from 7 in the morning and you go until past midnight. How can you last? You can’t last that long. So help is greatly needed in providing manpower at that level, and this manpower will in turn be able to generate some of these other paraprofessional jobs that are needed, people to come in to assist the doctor, who will tell you we can’t expand your services because we can’t get a physician or we can’t get a trained nurse. We have people, many of these people who are sitting right here, our aides, our EFMS aides, our family planning aides—these are paraprofessional people who have gone out in the communities in less than 6 months, and they have covered numerous cases like 1759 the young man from Hicksville told you about; the case that I told you about. We could go on and on. But the thing is something must be done, and these are two— I think two of the main solutions for this problem. Senator Kenxnepy. Thank you very much. Senator DomiNtck. Just one question. Mrs. Ingram, you stated that nurses were fighting the medical assistant program. Now the evi- dence we have from the Nursing Association is to the contrary. It shows they have been pushing for this. It is certainly true judging from the witnesses we have had in Washington. Now maybe there is something different here in Nassau County, I don’t know. But as an association, as a profession, they are the first ones to admit that they need more help. So do you have any background on this? Mrs. Ingram. There was an ad in the New York Times about 8 weeks ago, I think, and it was the NLN—National League of Nursing—trying to discredit this. They were asking for support not to go along with this training of paraprofessionals in the physicians’ assistant positions. Senator Dominick. I don’t happen to know that particular group, but the American Nursing Association is moving just the other way, and have been working hard to obtain more paraprofessionals who might be of assistance. I just wanted to make that point. Your information then is based on this ad from this particular group, right? Mrs. Inara. Yes, and also the fact that it also was uncovered when this family was trying to get a private duty nurse. At the only county facility only RN’s are permitted to do private duty nursing. So, of course, this places a damper. It limits nursing services. Why can’t a LPN be able to do private duty nursing? It is done vn. viol and certainly it is done at Johns Hopkins Hospital, which is one of the greatest in the world. Why not Nassau County ? Senator Dominick. I agree. You ought to ask Nassau County. Senator Kenx~epy. Thank you very much. Mr. Conxnin. Dorothy, thank you very much. Senators, IT understand that your time is running short. We will present one more speaker. Senator Kex~xepy. Well, we have got a 2-hour frame. We have about eight more witnesses. So we are going to try and make sure everyone gets a chance. This is very interesting. We would appreciate it if you could have the next witness and then maybe you could summarize your observations. Mr. Conrnin. I think I would like to work it, Senator, if we could have one more witness, and then I think Mr. Lenz would like to do a wrap-up. I think we could do this within 5 minutes. My next aide will be Cornelius Betly from Westbury. STATEMENT OF CORNELIUS BETLY, HEALTH AND NUTRITION AID, EMERGENCY FOOD AND MEDICAL SERVICE PROGRAM _ Mr. Berry. Good morning, Senators. My job is health and nutri- tion aide under the emergency food and medical service program. It is to deal with the three communities of Westbury, Call Place, 1760 and Newcastle. And the way TI see it now, the problem is not so much we have poor health services or poor ecological conditions, the problem is the society. If the society was not the way it is today we would not have these problems. So I think that is the main thing that has to be changed. People say, okay, transportation does not relate to health. I look at the problem on the Island and I see if T can’t get to the hospital because of transportation that relates to health, or if someone talks about infant mortality and says it is a social problem—the prob- lem is that, well, if you are in a certain economic level this is one of the reasons why once they get home the children die or some- thing like that. But I see it as a problem of the society because if the society was right they wouldn’t have to go home to this type of situation. This is supposed to be the richest nation in the world, and why do we have these problems? When I was in Vietnam I lived like a king. I looked over there, I saw everything they have. And I go home and TI see people living in motels. And IT want to know why do we have people living in motels with five and six people living in one room, now how is that a housing problem? When you have roaches and rats running all up and down how is that a housing problem? Or when you have 10 percent -cut in your welfare checks or something, that is a social service problem. Okay. But how are you going to buy food, and as it stands now you don’t have enough money now to buy food. And then they give you these food stamps where you can get X amount of dollars for this, but what can you really get with the food stamps? Depends on the limit, you know. But the maximum you could get free, I believe, with food stamps is $14 worth of free food, in comparison to the other system they have where they used to give food to people. Or even better, why not have food stamps and give them the food also, because I am quite sure you are burning a lot of food, you are throwing a lot of food away, you are wasting a lot of food. I can remember when I was in basic training in the service I used to see them throw away a lot of food. And, you know, why? Getting back on food, part of my job is emergency food. Why do we need emergency food? This country is supposed to be, you know, so hip as such—you know. But we have people starving, and this relates to health, directly on health, because if you are starving, you see, you can’t make it. You can’t go to school because how are you going to make it in school. You are starving. And then one of the programs they got in school in my par- ticular school district that I am involved in is the free food pro- gram, and I imagine that is for everybody. But the way it is set up it is so evasive that they say okay, you can obtain free food, but they practically put a sign on you saying “okay, here are all the people who are getting free food,” so you can be harassed and everything. So people don’t utilize it. And then the argument they give is “well, it’s not our fault.” But it is their fault, you know. The system, you know—change it. 1761 Another thing is the hospitals, the clinics. In my particular com- munity we don’t have clinics. We need clinics. And you talk that the hospital might be good, but if you can’t get to the hospital or if you can’t pay once you are at the hospital what good is it, or once you get to the hospital you have to wait 3 hours or 4 hours “to get some type of service. One example, I picked up a lady and took her to the hospital. She didn’t even have a dime to call me back. And then when I did pick her up she had a form to pick up some drugs at the drugstore for medicaid. She had the medicaid form, they gave her the medicaid form, but she doesn’t have a medicaid card. What good 1s that? Another problem we have is venereal disease. And the society, as it is now, pictures venereal disease, like a social problem. And this is what was presented to me in Westbury and in a sense by the Health Commission in Nassau County, was that it is like, you know, they don’t want to start an uproar because it is a social- type disease. But a disease is a disease no matter how you look at it. They just keep putting names on it, they keep labeling different things. And another problem that we have Senator KexNepy. We are going to have to really sum up be- cause we have seven more witnesses to go, and I want to give them a chance to talk, too. I want you to complete your thought, but we are getting into a time bind. We want to be fair to the other witnesses. Mr. BerLey. Well, really summing up, the only thing IT can say is we need to start trying to meet the needs of poor people, just really see what is going on with poor people. And the only way you really get at the problem is to try to put yourself in their posi- tion, and then if you were in that position would you just sit around existing, or would you try to do something about it. That’s all. Senator Kex~Nepy. Thank you very much. Senator Dominick. Did you have medical corpsman training in the Army? Mr. Berry. No, I didn’t. T had a brief training before I went overseas and a brief training that everybody had to go through. Senator Domixick. But you weren’t a medical corpsman or any- thing of that kind? Mr. BerLy. But really I don’t need to be a medical corpsman to see the problem. If you walk in Senator Dominick. I am not talking about that. IT just wondered whether that was what led you into what you are doing. Obviously it was not. You got in this rather recently. That’s fine. Mr. Berry. Well, yes. IT guess. Senator Dominick. That's fine. Senator Kexxepy. Mr. Lenz, we are really in a time bind. Mr. Lexz. T understand. T can sum this up in about 30 seconds. The point we are trying to make is that obviously this tremen- dous frustration—behind me there are at least four other consumer 1762 aides who thought they were going to be able to speak today, and we have told them they cannot. The frustration comes from the fact that there is a system in which the consumer has no voice. He thought he had an opportunity today, and he has. We ap- preciate it. Much of this material will be given to you written. We are summing our responsibility in the Bi-County Alliance for holding together the groups. We have asked the advisory group not to engage in confrontation. We have asked unions not to sign separate contracts with providers. Consumers want into the system. CHP has given us that chance. HMO is about to take it away; health maintenance organizations be set up directly contracting between Federal Government and provider, and no consumer input. Consumers even in this legislation are only on an advisory basis. The consumers are demanding a policy voice in the delivery of health care services, and they have got to have it; and if this legislation cuts it out then there are none of us who can speak for what might happen. What we need is not reform in health care delivery, but revolu- tion in health care delivery, and it has got to be returned to the hands of the people who are hurting. Thank you very much, Senators. [Applause.] Senator Kenxxepy. Our next witness is Mrs. Norma Cohen. Mrs. Cohen is a professional caseworker for Family Service Association in Nassau County. STATEMENT OF MRS. NORMA COHEN, SOCIAL WORKER, FAMILY HEALTH ASSOCIATION OF NASSAU COUNTY, N.Y. Mrs. Comex. I brought with me today two elderly ladies who are interested in talking about the difficulties that they have and the anxiety they have about their medical care. I was going to ask them to speak first, but I have reversed it because of some- thing that happened on the way over. The fear in our aged today is so tremendous, the anxiety I have seen in the last 2 weeks with the threats of the cuts in medicaid and with President Nixon’s announcement that he may cut medi- care to the 14 days. I have seen people really getting ill from the anxiety. Now, one of the ladies who came with me today very bravely to tell her story is now frightened that the press may use her name, and as a result she may be cut off from medicaid entirely anyway. If so, I don’t know how she would manage. But if the press has her name in the paper giving testimony today will this hurt her with medicaid? Are there doctors in the room? This is the State many of our old people are in. I work primarily with the aged, and the fear is tremendous. One of the ladies who came with me today was in the dental chair ready to get dental care from a dentist who used to take medicaid. He changed his mind. She didn’t know this. This very dignified lady was told, “Up, out, I don’t take it any more.” Some 1763 old people are so devastated by that they never go back. I had asked this woman if she would tell that experience today. She thought she might be able to, but then again she might be too frightened with the doctors here. There are too few doctors who are accepting the New York State Medicaid, and the whole New York State Medicaid is in a big mess right now anyway. Senator Kennedy, you had asked one of the young men about the middle class and how they are managing with health care. I do work with middle class elderly as well as the poor. They are also in a state of anxiety. I see people who have Medicare and who also have private insurance plans, and they feel then they are going to have adequate coverage. When the medicare allow- ance is nowhere near what the doctor’s fee was, and very often between medicare and their private insurance they are really cov- ered for 50 or 60 percent, and not that 80 percent for medicare and 20 percent for their private plan they thought they were going to have, many of them literally fall apart. I was delighted to see number 4 up there in that health security act. T have seen people released from hospitals who really did not need the beds any more for medical reasons but who needed custodial care. Many of the people T work with are old enough that their children are senior citizens, and many of them have outlived their children. Two years ago I was working with an elderly woman who had outlived her whole family. She was in the hospital in this county and was ready to be released because medically she didn’t need treatment. But she lived alone. She could not stand on her own feet to prepare a meal. So some plan had to be made. We do have one marvelous home in the county to care for elderly people. I had an opening for her coming in 3 days. The hospitals say, “That bed costs $86 a day for this county, we can’t wait 3 days. She has to go to the State hospital for the mentally ill.” I said, “Do you think she is psychotic?” “Oh, no, she is not psychotic. But we can’t wait for 3 days. We need the bed.” Now I fought, she didn’t get booted out before her 3 days were up and she did get into a decent nursing home, but what happens to the older person who doesn’t have someone to fight for them? Many times I see them come out of the hospital not needing the hospital care, but go home, not have anyone to help, get ill again and go back. RN Several times today people have mentioned the shortage of doc- tors, which I think 1s very acute. I think if we didn’t have such a shortage we might have many doctors more cooperative about the medicare and medicaid. But it is a seller’s market right now. There are many other services that the elderly need, too, and I am hoping that that is also in that “4” there. Oftentimes I see elderly people who have some minor problem that could be taken care of in an early stage, sometimes with homemaker service when they are having a temporary illness, sometimes with social workers, sometimes with nursing care. But this service exists for so few elderly people in this country that the problem often does have 1764 to reach a crisis state where we are using the doctors who are in too short supply. We need that preventive kind of setup with the auxiliary services before someone has to end up in the hospital, and certainly afterwards. I see many elderly people who wait months to get approval for dentures on medicaid. Now the ones who waited months turn out to be lucky because it looks like they won’t even be on medicaid pretty soon. As we all know, medicaid does not cover glasses, hearing aids, and it doesn’t cover dentures. Now if there is one time an old person is apt to get depressed and break down emotionally and physically it is when they are isolated. How do you get a woman to go out and socialize 1f she doesn’t have her teeth and can’t hear? She has no choice but to be isolated. There are so many gaps in that medicare bill that I strongly hope will be considered soon. Now I do have the two women with me who were brave enough to come and say what their health problems are and how they are managing at this point. Could I ask for the lady who is frightened that ‘she not have to give her name? Senator Kenx~epy. That’s right. Mrs. Comen. All right, fine. My nameless friend, will you come up, please? Senator Kennepy. We will call her Mrs. Jones, I guess. Mrs. Conn. May I sit here with each one? Senator Ken~epy. IT wish you would. Mrs. Jones. Good morning. Senator Kennepy. We want to welcome you, thank you very much for coming. You have been very kind to do so. Mrs. Jones. Thank you. Senator KexnNepy. And we appreciate your reluctance, but we are just interested in your story and we would very much value it if you felt you could share your story with the members of the subcommittee. We want you to feel completely at ease, as much as you can. Mrs. Jones. Well, T have been a widow now since I was 51 years old. I had to go fo work, and 1 worked for about 18 years—a widow without “anything. I had no insurance to speak of. T had to depend totally on my little income from work. And paying my doctor bills and everything else took all of it during the years I worked, all of it. T did manage to get along until about 4 or 5 years ago, but since then I have earned absolutely nothing, and T am very concerned about medicaid because this is the only secure thing that I have to keep my health and well being, and I have had trouble with getting my dental work done. I have cone from one to another. Senator Kennepy. What sort of trouble have you had? Mrs. Jones. Well, T have been going to the same dentist that T had been going to when T paid my bill years ago, and he told me that I couldn’t have it any more because they had no medicaid when I got on medicaid. And T got the same story from another one. And the last one I went to got called and he told me to 1765 come down—the young lady told me to come, and I did go, and I walked up the stairs. When I got up there he had me in the chair and was speaking about medicaid—he immediately said, “I can’t touch you, I won’t touch you, you will have to go.” And, of course, I felt—well, you can imagine how I felt. And TI have been embarrassed many times with medication and things like that in spite of medicaid. But still medicaid has been a wonderful thing for me, and IT imagine many more like me. Mrs. Conen. If it is taken away from you in the next few weeks how will you manage? Mrs. Jones. Then 1 wouldn’t know what to do. IT don’t want to go to welfare, but what else can a woman like me do if she don’t get health care? T would be desperate. Just desperate. Mrs. Conen. Mrs. Jones is not on welfare at this point. She is managing on her social security and does very nicely. She is an excellent manager, except for the health care. But without medicaid now she would have to apply for welfare. Senator Ken~epy. You take care of most of your other responsi- bilities, Mrs. Jones, your food? TI know it is terribly difficult under social security in any event. Mrs. Jones. It is, because my social security is quite low. Senator Ken~Nepy. But at least you have been able to meet these responsibilities with the exception of your health needs, is that right? Mrs. Jones. Yes, that is the important thing. That is very im- portant. Senator Kex~epy. Why do you think the dentists said that they wouldn’t provide the services? Mrs. Jones. Well, T was told there was some kind of association, or something or other, that got together and agreed not to take medicaid patients. Recently T had a very wonderful dentist. Senator Kp~x~epy. Could I ask you, Mrs. Jones, have you lived out here your whole life? Mrs. Jones. Almost 50 years. Senator Kenx~Nepy. In this county ? Mys. Jones. In Freeport. Senator Kennepy. Did you work out here before, too? Mrs. Jones. Well, T worked in Hempstead and 1 worked in Marick and I worked in Rusco Field. Senator Kexxepy. You most probably have some friends. Do vou find that they are concerned about health. too? Mrs. Jones. Oh, very much so, sir. Very much so. It is the things that keeps you going, 1 think. Senator Kex~epy. Thank you very much. Senator Dominick. Mrs. Cohen Senator Kexnepy. I’m sorry. Just one minute. Senator Domintox. Mrs. Cohen, just to substantiate the things you have been saying, on March 19 there was a report in the New York Times—it is not a paper that I quote all the time, as Senator Kennedy knows—which has an interesting article which says that 8.3 percent of the beds in 50 representative hospitals are occupied by patients who no longer needed hospital care, but who had no place to go for the convalescent care that they required. 1766 Obviously, again, if one has a hospital problem and someone else who is desperately ill needs that bed, one has the same situation with the person needing treatment as one has in trying to find a con- valescent home for the person who is already there. Mrs. Comex. I was not placing blame. I am just saying this is the situation we have to look at. We shouldn’t use hospital beds for people who don’t need hospital care. We must have more nursing homes and adult care facilities. I think it is a horrible thing to send an elderly citizen to a State hospital for the mentally ill who is not mentally ill. Senator Dominick. I would agree. T gather that the medicaid problems to which you arg referring is a cutback in the allowable amount put in by New York State, is that right? Mrs. CoHEN. Yes. Senator Dominick. And it is a $500 cutback, from $5,000 to $4,500, or something of that kind. Mrs. Couen. Well, it is up in the air right now. I was on the phone with medicaid this morning. If someone here knows some- thing more recent I would be delighted to know. We really have not known what to tell the people what the cuts will mean. The statement in the paper where people will be cut off unless they are on welfare concerns me. I had one elderly gentleman yester- day who askd his landlord to increase his rent which would then make him eligible for welfare. He could get along fine with his social security, but he needed that medicaid. He can’t afford to lose it. He is partially paralyzed, his wife is blind and diabetic. We are turning a lot of our older people into liars and cheats in order to be eligible. And the number who will be applying for welfare on May 15 if they really are taken off medicaid will be fantastic. As Mrs. Jones said, she has never wanted this, and she worked until quite a remarkable age. But she would have to do it now. Our other witness would be forced to do the same thing. Senator Dominick. Thank you very much. You have been very helpful. Mrs. Comen. If Mrs. Delling could come up, too. Mrs. Denning. That’t all right. T think you have said it rather well for me, too. T am very worried about the medicaid. I am a widow. All my savings were taken up in my own illness and my husband’s illness. And T just couldn’ see being dropped from medicaid. I was going to say I live in the senior citizen’s project, and T know what Mrs. Jones is going through there. Others are going through the same thing—torment. They are so afraid of being dropped off medicaid, those who have it. And it isn’t only the doctors, it is the medications that they get. T mean it is very hard for them. Well, that’s all I wanted to say, that we are all afraid of being taken off the medicaid. It may not be the best, but it’s the best we have right now, and that’s all T got to say. Mrs. Comex. May I add a little something to Mrs. Delling’s. Mrs. Delling has been managing on social security and a son who contributes, and he is a blue collar worker with his own family 1767 and it is not easy for him to make that monthly contribution, but he wants to. However, he can’t cover the very extensive medical bills that his mother has. Now if she has to be dropped from medicaid her only choice is to ask her son to refuse to make the contribution. At that point she would be eligible for welfare. He doesn’t want that and she doesn’t want that. But they may be forced to do this. Mrs. Dering. You see, I worked as long as I could, and IT am not able to work any longer. I have disability due to a stroke. That’s all T have to say, and I just hope that things will be a little better than they have been. Senator Kexnepy. Thank you very much. We appreciate it. Mrs. Conen. May I just add one thing? Both of these ladies have testified about their anxiety with the medicaid. The majority of the people I see have just a little too much income to be eligible for medicaid and they are in a worse position. They are so-called middle class and cannot afford the medical care with the cost of it today, and I really feel I have to put in a plea for them. One of the worst things that happens to them—and I have learned to expect this for myself some day—is eventually if you live long enough you have to give up driving. In suburbia to get to that doctor or that hospital after you have had to give up driving is desperate. We had one 82-year-old woman last year who needed X-ray treatment for cancer and had to have this 6 days a week for 3 weeks. Her friends didn’t drive any more, she had outlived her son and daughter. We arranged volunteer drivers. Every day she worried was the volunteer going to find the house, were they going to be late. She shouldn’t have had to go through that in addition to her own cancer and two recent deaths. And T think transportation has to be considered in areas like this when you consider medical care. And I thank you for the opportunity. Senator Kexnepy. Just one point. You mentioned these indi- viduals who were just above the middle class, so to speak. What are their real fears in this? I think we have heard a bit about it this morning, but could you just elaborate on that a bit? Mrs. Conan. Yes. It is the size of the cost of medical care today. I see many middle class people who could really afford to be living decent lives, could take some trips, and they are afraid if that big illness strikes. They all know someone who was in the hos- pital for months who ended up in a nursing home for recuparative treatment, and they know the cost and they are afraid to spend and enjoy what they do have, because God forbid the children have to pay and many times there are no children. We have to remember we have a lot of spinsters and bachelors, too. I can think of one lady at this point who is 87 who manages on a pension and social security. She was once an editor for a magazine. She has a collapsed lung and asthma. Her medical bills this year were fantastic. Another year and the woman will have nothing. Going on medicaid, of course, and welfare, also makes people think about insurance. We heard earlier people have to turn over insur- 1768 ance, and they wonder then what kind of a funeral is going to be up for them. This is a pretty horrible state. Senator Kex~epy. Thank you very much. Mrs. Coren. You are very welcome. (The prepared statement of Mrs. Cohen follows :) PREPARED STATEMENT OF MRS. NORMA COHEN, SOCIAL WORKER, FAMILY HEALTH ASSOCIATION OF NASSAU COUNTY I am Norman Cohen of 125 Woodhill Lane, Manhasset, a professional social worker with Family Service Association of Nassau, a non-sectarian social work agency supported by voluntary contributions. My work is primarily with the aged. I have brought two ladies with me today to testify about their difficulties in securing adequate medical care. In addition to the problems these ladies have mentioned, there are many others. 1 frequently see people who can manage to live on their social security or private pension or a combination of the two, but who cannot afford medical care. For many, the drugs prescribed cost more than the doctor's service and drugs are not included under Medicare. Many do not go to the doctor because they feel it pointless when they cannot buy the medicine. Often I see people deteriorate emotionally and physically when they experience that Medicare may pay only 40 or 509% of the medical bill instead of the 809% they expected. There is often a large discrepancy between the doctor’s bill and what Medi- care considers an allowable fee. Those who have private insurance in addition to Medicare still find themselves not properly covered for medical bills. Senior Care private policies usually offer to pay 209% of what Medicare has decided was allowable. This may leave a large margin for the individual to pay. I see many elderly people who live alone and have no one to care for them. When such a person is hospitalized they frequently are held in scarce hospital beds longer than is medically necessary because they cannot afford custodial care that may be necessary for the recuperative period. When the hospital cannot or will not tolerate this the patient is often sent home unable to pre- pare meals, ete., and gets ill again. People who are not mentally ill are often sent to State Hospitals for the Mentally 111 for custodial care. In suburbia, transportation is a big problem in securing medical care. Many elderly persons must use taxis to get to doctors or hospitals. I am reminded of one woman who needed x-ray therapy five days a week for three weeks and had to go three towns away to get a radiologist who would accept Medicaid. She could not pay the transportation costs and volunteer drivers were secured. If she had not been known to a social worker or some other person who would have arranged this? Her elderly friends had been forced to give up driving. As these ladies have testified, the anxiety for many about losing Medicaid is tremendous. Even for those who will continue to have it there are many problems. I have seen people wait months to get approval for dentures and literally shop for a doctor who will accept Medicaid. Some are emotionally tough enough to do this and many are not. I know many who even under the old law had very small incomes but could not qualify for Medicaid and still could not afford the care needed. I have seen individuals do without hearing aids or glasses and thus have their social ac- tivities restricted. The isolated older person is most apt to be depressed and suffer emotional or physical breakdown, but if he cannot afford the aids to see or hear what option does he have except isolation. The drastic shortage of doctors certainly underlies many of the problems stated above, but in addition to this we have no adequate plan to pay for auxiliary services. Frequently a homemaker, meals on wheels, a social worker, nursing care, etc., could prevent physical and emotional problems from reach- ing a crisis or could shorten the duration of the problem, but these services exist for very few of our elderly. Many of the persons I see have outlived their children, have children who are themselves Senior Citizens or have children who are unwilling or most often, unable to help because of their own problems. It doesn’t take much for a relatively healthy older person to feel threatened in some way and start the emotional and physical breakdown. In the last two weeks I have seen the havoc caused in the increase in anxiety for my elderly 1769 clients with the cuts in Medicaid and the President’s proposed cut in Medicare. Even those who are healthy are afraid to spend the little they have because they live under the shadow of not being protected in the event of extensive medical costs. Senator Kex~epy. Our next witness is Mr. Abe Hammer, resident of Freeport, Hempstead, does volunteer work for older Americans. STATEMENT OF MR. ABE HAMMER, CONSUMER AND RESIDENT, FREEPORT, HEMPSTEAD, N.Y. Mr. Hammer. Senator Dominick, Senator Kennedy, members of the Subcommittee on Health. I have been asked to make a state- ment on medicare. But before I do I would like to pass on some information about the state of the nursing problem in the State of New York. At present there is a bill being introduced in the State legislature which is being backed by the ANA which requires nurses who have been RN’s who are staff graduates to go back to get a bacca- laureate degree, and if they don’t cet that baccalaureate “degree they will not be. recognized as registered nurses, and that is causing a great deal of problems. In speaking to some of the administrators in hospitals they say they can’t get nurses now, and if these girls or women who have been nurses for 25 or 30 years resign, as they threaten to, it is going to be catastrophic. If you would like to get the name of the bill, it is the Parenian bill. In fact it is going “to be debated in Garden City at Adelphi tonight by the assemblyman who introduced the bill. Senator Dodinick. Doesn’t sound to me like he has a very good wicket to play with. Mr. Hammer. 20 million older Americans will seriously be af- fected if the medicare benefits are reduced. In addition, the chil- dren and relatives of these senior citizens will feel the pinch. It is estimated that each person on medicare has a family of approxi- mately 214 persons. Multiply the 20 million by 214, and you have a total of 50 million persons who will be made to suffer. Health, Education, and Welfare estimates that 60 to 70 percent of the 20 million medicare clients are wholly dependent on their social security payments. We will therefore have a large segment of the population, 12 million to 14 million, that will not be in a position to pay for their health care. The older citizen is not in an enviable position today. He is living on a fixed income and is caught in a squeeze. Rents have gone sky high. Food prices have skyrocketed. Now they are threatened with reduced interest on their meager savings accounts. We, the older Americans, vehemently oppose the proposed re- duction in medicare. We suggest that waste be eliminated and those funds should be used for health care of the golden ages. We would like to suggest an investigation of wasteful services which are not producing satisfactory care for the aged. Number one, duplication of services in hospitals. When a gen- eral practitioner calls in a consultant there isn’t any reason why two fees should be paid for each day the patient is hospitalized. 59-661 O—T71—pt. 8—4 1770 Number two, admittance to hospitals. Most hospitals have a set hour when they start counting the time of admittance. For exam- ple, let us say the hour of admittance is 10 a.m. If the patient checks in between 7 and 10 a.m. medicare is charged for 48 hours for the first day in the hospital. The patient should not be brought in before 10 a.m. unless an emergency exists. The same applies on day of discharge. If the discharge hour is 11 a.m. and the patient is picked up by the family that hour medi- care is charged for another day hospitalization. Number three, blood tests and X-rays. Most hospital labs don’t function on Saturday and Sunday. In many cases patients are admitted on Friday or Saturday and medicare is billed for 2 or 3 extra days. "Number four, doctors don’t order all lab work at one time. It is therefore necessary to make additional tests which also extend the hospital stay. Number five, utilization committees. After 12 days the committee makes its review and decides whether or not a patient requires additional time in the hospital. These committees are influenced by the patient’s doctor when he is a member of the committee. An M.D. should disqualify himself if he happens to be on the review board and his patient’s case comes up for examination. Number six, outpatient basis. A goodly number of X-rays, blood tests, chemistry and work-ups can be done in an outpatient clinic, thereby saving the cost of a hospital room. Number seven, in foreign countries they furnish free medical services to their people. You may check England, Israel, Denmark, and Sweden. Not only do they furnish this care to their own people, but also to anyone who visits their country. Number eight, in New York State the United Medical Service makes the claims for medicare in this area. It is our understanding that they get a percentage of the funds disbursed. If this is so, it should be looked into. Why can’t the Federal Government absorb the slack in unemployment and use these people to handle claims without paying on a percentage basis? I have some late figures from the 1970 census. In Nassau County the figure is 1,422,905. It is estimated that 10 percent of these people, 142,290, are eligible for medicare. ~The town of Hempstead, where we are right now, has a popula- tion of 800,684, and 80,068 are on medicare. In this new proposed bill in the House Ways and Means Commit- tee it has been suggested that medicare patients will no longer be entitled to extended-care facilities, nursing homes. It may also elimi- nate home health care for which they are now supposed to receive 100 days. Thank you very much. Senator Kex~epy. Thank you very much, Mr. Hammer. The sug- gested cutbacks I know are of concern to the senior citizens, as well they should. We have heard a great deal of comment about those. Our next witness is Mr. Lewis Bernstein, who is the administrator of the welfare and pension funds for the Bartenders Union. Mr. Bernstein. 1771 STATEMENT OF LEWIS BERNSTEIN, ADMINISTRATOR, BARTENDERS UNION WELFARE AND PENSION FUNDS Mr. BernsteIN. Good morning, Senator Kennedy, Senator Domi- nick. I am the administrator for the Bartenders Union Welfare Trust Fund and have been the administrator for 23 years. Since 1957 the fund has been self-insured and is a provider of benefits for over 4,000 members and their families. We provide a long range of benefits for the members and families of the union, amongst them being surgical, medical, and hospital benefits. I should like to address myself particularly to the cost of hospital benefits. For our covered members we provide a hospital plan which pro- vides the full cost of hospitalization for 21 days and half the cost for 180 days thereafter. We have a great concern that these benefits shall not be reduced or terminated ; “for if this were to happen, our members and their families would be compelled to turn to the com- munity for assistance in time of illness. Yet, at present, we are faced with this very real possibility. In the allotted time it is not possible to present in great detail the tremendous increase in the cost of hospital care—care that is all too often of a mediocre quality, but I should like to particularize some of the growing abuses in the delivery of hospital care and pre- sent to the committee some of the more flagrant examples of grossly excessive charges which have come before me. I have here a bill for 44 days of hospitalization—a length of stay during which the average cost should be considerably lower than the cost of a short-term acute illness. The bill in question totaled $18,728.50; an average of over $425 per day. Laboratory charges alone amounted to $7,663, an average of almost $175 per day. I have another bill involving a 714 day stay without surgery— the bill totaled $3, age daily cost of $425. There are many more, but I should like to cite one more particu- larly flagrant case. The hospitalization was for the removal of a cyst on the buttock—a procedure which can be done in the surgeon’s office. The patient was kept in the hospital for 2 days at a cost of 1 per day. The operating and recovery room charges were $243. I can no longer accept the statement so commonly tossed at us by the hospital administrators and physicians, “If you want good medi- cine, you must pay the bill.” Of what use is the very best ‘of medical care if it is out of the reach of all exc ept the very wealthy. Now it is not alone the cost of hospital care but the daily increas- ing arrogance of the hospital heirarchy. We are now being told that we dare not question the accuracy of the bills submitted to us. To paraphrase the poet, “Theirs is the right to say—ours but to weep and pay.’ I should like to read from three letters recently received from three different hospitals in New York City. In the first case we had asked for an itemization of the bill so hos we could determine acuracy and our liability for discount days. quote : 1772 It is not our policy to show a total recapitulation of charges by date order and it is not our intention to do same. If our breakdown is not acceptable to the Bartenders’ Union Welfare Trust Fund and the payment of said claims is not expedited, we will have no other choice but to request that the patient being admitted to Hospital with this coverage pay their account in full before discharge. In the case of the cyst of the buttock at $317 per day, when we tried to negotiate with the hospital we were first offered a $50 re- duction and then the hospital sent a letter to our member which said in part: It took them over 1 year to make an “offer” which we were obliged to reject, because it represented less than 50 percent of our bill, and they insisted that it would have to be accepted as full payment. By law we cannot do this. The union official is fully aware of this and has, in effect, requested us to act in an underhanded manner. It is now underhanded to ask for a reduction of an excessive bill. We have informed the Bartenders’ Union that we will no longer deal with them—and future patients will be asked for a deposit. All of this in spite of the fact that over a period of years we had paid many bills to this hospital and this was the first time we had questioned a bill. In still another case, a 39-day stay, billed at over $8,300, when we had the temerity to suggest that we negotiate the charges our mem- ber was informed that: Upon submission of this hospital bill to the Bartenders’ Union Mr. Lewis Bernstein, administrator of the trust fund, refused to pay the bill as sub- mitted. Again this is almost in the nature of criminal activity. We didn’t refuse to pay the bill; we refused to pay it as submitted. And fur- ther on: We no longer wish to deal in any way, form, or manner with the Bar- tenders’ Union and request that you either pay the bill yourself or demand your rights as a union member and make the union pay in full. So, it has now come to this—we are told by the hospitals either pay our bills without question or we will not accept your members— and this from hospitals that send us bills for $10 for a quart of water. Of course, they called it H.O. They probably didn’t think we knew what H,O was. And when we called the hospital and said “how come the charge for a quart of water,” instead of saying “we probably made a mistake,” they said “well, we have to pay for it, too.” I don’t know how much they pay for water, but I don’t pay for water. We are all familiar with the newspaper and periodical articles which tell us that the cost of hospitalization is rapidly approaching the $150-per-day range. I can certify that the true picture in the metropolitan area is that hospital costs are about to reach an average of $200 per day. I was interested when I heard—I believe it was Senator Kennedy who cited the statistics that hospital costs over the past 10 years have increased 60 percent. Our actual costs—and in spite of a drop of 20 percent in membership, our actual costs went from $128 in 1961 to $275 in 1970. Now that is an increase of about 120 percent, and I don’t think that this applies just to our fund. I think that this is more universally true in this area. 1773 Some hospitals are presently being reimbursed by medicaid at that amount, meaning in the $200 range, and I have recently received a bill from a Brooklyn hospital for a flat inclusive fee of just under $200 per day. "This condition cannot be permitted to continue. It is imperative that something be done to check the continued rapid spiral of hos- pital and medical costs. Cost should be standardized so that every patient pays the same amount. Half a bill paid by a welfare fund should not be double the half paid by Blue Cross as is often presently the case, and a person who has no coverage at all should not be penalized by having to pay more than anyone with coverage. Bad administration should not be rewarded by receiving a larger rate of reimbursement from Blue Cross, medicare, and medicaid than a similar hospital with good administration. Hospital accounting procedures must be reviewed and changed to eliminate charges which are not justifiably chargeable to the patient. Delivery of health care must not be given over to the private sec- tor. This will only result in the further enrichment of those who are already greatly enriclied by medicare and medicaid, and not in the improvement of hospital care for the individual. Adequate hospital and medical care is no longer a luxury. It can- not be dealt with as a luxury. Adequate hospital and medical care is something that is the right of every citizen of this country. He should get it, and he should get it at a cost that he can afford. Thank you very much. Senator Kex~epy. Thank you very much. I would be interested—in your program do you have deductibles? Mr. BernsTEIN. Not on hospitalization. Senator Kex~epy. Not on hospitalization ? Mr. BerxstEIN. No; we pay the full bill for the first 21 days and we pay half the bill for the next 180 days. Senator Kexxepy. What do you have deductibles for? Mr. Bernstein. Well, not strictly a deductible, but, for instance, on our surgical program we offer it on a dual basis. If the member uses his own surgeon there is a schedule of payments which, of course, would not meet the entire fee, but we also have our own panel of surgeons which will provide the service, the surgery, at no cost to the member because they have agreed to accept our schedule. Senator Kex~epy. Do you find that your members abuse the sys- tem at all in terms of overutilization of it? Mr. Bernstein. I don’t think the members abuse the system. I find sometimes the doctors and surgeons abuse the system. Senator Kex~epy. There has been a great deal made about this cost consciousness and deductibles in the various programs that have been suggested to the Congress, and I am always interested in the experience of a group like yours or other groups that don’t have deductibles, and whether there is overutilization. Mr. Bernstein. IT wouldn't say anybody tries to cheat on it. But I would say most people—and this doesn’t go only for bartenders— most people don’t cheat, whether it comes to medical care or any- thing else. T am a firm believer—even though I am an old man and 1774 should be cynical, IT am not. I think the average person is a decent, honest individual, and if he gets sick he is interested in getting well and not making a profit out of his illness. Senator Dominick. Mr. Bernstein, you set up this trust fund by deduction from union members is this correct ? Mr. Bernstein. No; that is not correct. Senator Dominick. From their wages. Mr. Bernstein. It is financed entirely by employer contributions. Senator Dominick. By employer contributions? Mr. BernstEIN. That’s right. Senator Dominick. Now, as administrator of this particular trust jand, do you contract with specific hospitals for care for your mem- ers ? Mr. Bernstein. We don’t contract with specific hospitals. Our members are at liberty to go into any hospital, but we do have agree- ments with some hospitals for a special rate, you might say. Senator Dominick. And in those hospitals you have not had this problem, is that correct ? Mr. Bernstein. We haven’t had it to the same degree. But I can tell you that only yesterday one hospital called me that a few years ago started off with us at a rate of about somewhat under $100 and told me that the new daily rate was going to be $176 per day. Senator Dominick. IT was interested in that because, again quot- ing the New York Times, it says that the average hospital cost in all the voluntary and proprietary hospitals in the area averages out at about $105.71 a day, of which, interestingly enough, 70 percent is payroll. One of the things that has been of interest to me, having been in the hospital, as has Senator Kennedy, in the last few years, is the concern which many of the people have over the escalating costs which you have specified. Many of the doctors have been saying that the problem is caused in part by malpractice suits. In other words, they have to go through a much more elaborate set of tests than they ordinarily would in order to avoid this. I know that this was true in my particular case. This is one of the things. Have you run into this problem? Have you had any conversation with doctors along that line ? Mr. BernsteIN. We have our own doctors, and we speak about it. But before I go to that I would say that with regard to that $105 a day figure, I would right now today be willing to sign with every hospital in the metropolitan area and agree to pay $105 a day for any of our patients that are admitted to that hospital. And, of course, any over amount, the Times would pick up whatever goes above $105 maybe, so everybody would be satisfied. Senator Dominick. I want to make sure that is not my statement. That comes from the New York Times. Mr. BernstEIN. That’s why I said if they would pick it up. Not you, Senator. With regard to malpractice Senator Dominick. We had testimony given to the staff yesterday which indicated the big city hospitals are close to $111.86 a day; the teaching hospitals are $102; community hospitals are down to $77.54; 1775 and suburban hospitals, $73.98, this would indicate that there is a real discrepancy. Mr. Bernstein. There is a discrepancy. Senator Dominick. The testimony we had yesterday concerned the particular hospitals you have been dealing with. You did chal- lenge these bills, I gather. Mr. Bernstein. Oh, we continually do that. As a matter of fact, we have become known as mavericks. But with regard to those there is a schedule of medicaid reimbursements that are made to all the hospitals, and to date, this very day, some of those reimbursements, particularly for the voluntary teaching hospitals, run at $200 per day. This 1s what the city or the State combined are now reimburs- ing these hospitals for medicaid and indigent patients. Now they run on down from that. But the voluntaries are high. Some of the others are lower. But I haven’t had a total bill in some time that ran less than about $140 or $150 a day. Senator Dominick. Let me ask you just a couple more questions, and T will be very brief because I know we have other witnesses here, we want to get to their testimony. We want to hear it. When you provide this service for your membership is this an all-inclusive type comprehensive care for them? In other words, it takes in hospitals, doctors, drugs, outpatient care, things of that kind ? Mr. Bernstein. Very comprehensive. We don’t include the cost of drugs. But aside from that it is very comprehensive. Senator Dominick. Does that patient have the right to go to any doctor ? Mr. BernsteIN. In some situations, yes, in others, no. Senator Dominick. So you have an option for your membership to go to any doctor that they choose or they can go to a closed panel system of doctors that you have also established, is that right? Mr. Bernstein. That is for surgery. Senator Dominick. That is for surgery only? Mr. Bernstein. Right. For ordinary medical care, therapeutic care, they don’t have that choice. We have a medical center to which they can go and secure treatment at no cost, and this includes every- thing, everything that is possible to render in a doctor’s office. We also have a dental center where they can get treatment. Senator Dominick. Concerning therapy, that is a closed panel? Mr. BerxsteIN. Closed panel. Senator Doainick. Now I don’t happen to know this—probably many of the ladies in here do. Do you have any lady members? Mr. BernsTEIN. Some; not so many, but we have some. Senator Dominick. Do you have any objections from them due to the fact that therapeutically they must go to a closed panel? Mr. Bernstein. We haven’t had any great degree. I won't say we have never had an objection. Some of our people who live in out- lying areas have asked us about the possibility of getting medical care in their areas. But since most of our members work within an inclosed area most of them manage to reach our centers. Our medical, dental, optometrical. 1776 Senator Dominick. On these particular hospitals that have been charging you up to $425 a day, were these specifically difficult cases or—I know you cited the one was a cyst on the buttock. But were the others particularly difficult case? f Mr. BerxstEIN. The one with the $18,000 bill was—it was a circu- latory case and it was a terminal case. But it didn’t involve anything like the use of heart machines or cobalt therapy or anything of that nature. It did not. We find that in most cases today the laboratory bills are running exceedingly high, and we find that our highest bills today come from ward service cases as opposed to private or semiprivate. And I think that what is responsible for that is that a ward patient goes in and every resident or every intern that comes in orders some more tests. Everybody wants to get into the act and learn a little bit. But they send us the bill for that. T don’t mind if they learn—they have got to, but please don’t send us the bill for it. Senator Dominick. I felt the same way when I was in the hospital. Thank you, Mr. Bernstein. Senator Kexnxepy. Thank you. Our next witness is Mr. Rocco Campanera, who is the executive director of the Long Island Federation of Labor. STATEMENT OF ROCCO CAMPANERA, EXECUTIVE DIRECTOR, LONG ISLAND FEDERATION OF LABOR Mr. Campanera. Senator Kennedy, Senator Dominick, I am the executive vice president of the Long Island Federation of Labor. The preservation of health, prevention of disease, the curing of illness 1s our country’s responsibility. Every American is entitled to comprehensive quality health care. Today’s method by which medical care is delivered to the Ameri- can people is inadequate. Symptoms of this crisis are the escalation in cost, unavailability of physicians when they are needed, the dis- torted distribution of health manpower and facilities. Patchwork solutions will no longer do. Only a complete recon- structing of the delivery system will do the job. This can only come about with the enactment of a national health insurance program. Let me state some vital facts. Under existing private health insur- ance programs 200 million Americans have no dental health insur- ance coverage at all; 186 million Americans have no nursing home coverage; 126 million Americans have no out of hospital prescribed drug coverage; 122 million have no private duty nursing care; an- other 122 million have no coverage for doctor and dentist’s office and home visits; 115 million have no provisions for visiting nurse serv- ices at all; 107 million have no coverage for X-ray and laboratory examinations; 77 million have no coverage for in-house visits; 59 million have no surgeon’s fees coverage; 53 million have no hospital care coverage at all. Senator, today’s high cost of medical care places good care beyond the reach of the recognized poor and the unrecognized or so-called middle income Americans. I would like to cite an example of what happened to me when I was hospitalized in December 1969. My hospital bill for 6 days, 1777 semiprivate accommodations, was $1,378.50. This is roughly $229 a day. Of course, this included use of the operating room and other sundry inhospital medical costs. I want you to bear in mind this was in 1969. We are now in 1971. In addition, I received an additional bill of $100 for anesthesia, and a $500 surgeon’s fee, for a total of 6 days of $1,978.50. It is roughly $2,000 for that 1 week I was ill. Now I was lucky. My organization covered over 90 percent of the expense involved through insurance. However; this type of insurance is very expensive. The present rate is $59.75 a month, or on a yearly basis $717 a year. Who can afford this? In addition, Senator, we are having economic problems in Nassau and Suffolk Counties. The figures quoted are, I believe, 7-percent unemployment in Suffolk County, 6-percent unemployment in Nas- sau County. According to our members, the figure is closer to 10 percent. What this means to us is that an employed member, after 30 days unemployment he is no longer covered by any insurance. So you are faced with a serious problem in that area. Also under current major medical coverage today if you have a family of three or four and are unfortunate to have three members ill at the same time in the hospital your $10,000 coverage will go by the board very rapidly. In closing, Senator, I appreciate very much the opportunity which you have given me to comment on a national health insurance pro- gram. We in the Long Island Federation of Labor are well aware of the strong fight you are making on behalf of a good health pro- gram. We will be glad to cooperate with you in every way, and we can assure you that we want a strong, effective law. Thank you, Senator. Senator Kenxepy. Could you tell us how aware the members of your union fee} about the health issue generally? Mr. Camranera. They are very concerned, because the program I mentioned where I was covered personally is a good program. Most of the unions cannot afford that type of coverage. It is too expensive. And most of the members would like to see a national health pro- gram enacted. But a good program. I have seen some of the programs that are being talked about. They are weak, ineffective. We are not talking about that. We want a real comprehensive program, and our members are all for it be- cause they face a danger. When they lose their jobs after 30 days— even if it is limited coverage they don’t even have that. Senator Kex~epy. Why don’t you talk about that point, because there are great numbers of people, skilled people, professional people, I know up in our State now, as well as other workers, and when they are separated or lose their jobs, what happens to their health insur- ance for the most part? Mr. Campanera. For the most part it does not go beyond 30 days. They are covered for 30 days after termination of employment with their employer, because most contracts have a clause that the em- ployer contributes to a fund, and in turn that purchases the insur- ance that covers the member. When he stops contributing—he makes 1778 his last contribution the week the employee is laid off. So the union will cover him for 30 days beyond that. After that if he doesn’t have any savings, he will have to get the State to pick up the bill. And this situation involves what we consider middle income people, and that is why I called them the unrecognized poor. Senator Ken~epy. What is the average income of the members of the union or the federation? Mr. Campanera. I would say the average income is about $9,500. Senator Ken~epy. And this is a group that is very much con- cerned about the escalation in cost. Are they concerned about avail- ability of health care as well? Is it easy for you to get Mr. Campanera. Well, ‘it is not easy. But we must face one fact. When hospitals or doctors are aware that you are covered by an insurance fund they readily are agreeable to take you in and make room available. They know they will have on trouble getting their fees. So we don’t face that unfair problem that IT know people that are not protected by union contract face. Senator Kexnepy. Do you find it more readily available to union individuals? Mr. Campanera. Right. Once the hospital and the doctor are aware you are covered by a labor agreement, they are very happy to take you on. Senator Kenney. Do you hear about the quality of health care at all from your members? Do they know whether they are getting really good quality health care? Do they just assume that they are? Do you hear this talked about at all? Mr. Campanera. Well, we hear some dissatisfaction. But I am not an expert in that area. All T can say is we do have the coverage and the funds to pay for good medical care. So in most cases they are getting it. It is because the money is there they are getting good medical care. Of course, you get involved in a situation where a hospital wants to gouge you, and the doctor also—his fee. But aside from that, if you have the money to pay you get it. It is when you don’t have the money to pay you don’t get medical care. Senator Dominick. Mr. Campanera, just for the record I have got to say once again, as I have said many times before, and it would be of interest here, that this subcommittee on health, and in fact our full committee, does not have jurisdiction over the national health insurance program. S. 3. It is before the finance committee. So al- though we can take turns on what the problems are, we can’t do anything about that particular piece of legislation. I might say I am not throwing any kind of a jab at Senator Ken- nedy simply because I have a bill of my own which is designed to help the health problems of prepaid care programs for Federal em- ployees which went to the Post Office and Civil Service Committee. I didn’t get anywhere with that either. The thing that was of interest to me was that I gather from what you are saying that most of the people that you represent have hos- pitalization and comprehensive care programs built into their union contracts which are in turn backed by insurance programs. Is that correct, ? Mr. Campanera. Correct. 1779 Senator Doaintck. And it is now established by agreement be- tween the unions and the employers? Mr. CampaNEerA. Right. Senator Dominick. Thank you. Senator Kenxxepy. Thank you very much. Dr. Harold Safian. Dr. Safian is a graduate of Columbia Univer- sity, Long Island College of Medicine, and the vice president of United Medical Service. We appreciate your appearance. STATEMENT OF DR. HAROLD SAFIAN, VICE PRESIDENT, UNITED MEDICAL SERVICE, INC.,, GREATER NEW YORK’S BLUE SHIELD PLAN, ACCOMPANIED BY ANTONIO FAVINO, 2d VICE PRESIDENT Dr. Sarian. Senator Kennedy, Senator Dominick, I am Dr. Harold J. Safian, senior vice president of United Medical Service, Inc., Greater New York’s Blue Shield Plan. Accompanying me today is Mr. Antonio Favino, second vice president. As an individual and responsible citizen I am very concerned with the stories and statements we have heard today, and agree that these problems are critical and must be resolved. My statement, however, relates to what we are doing in Blue Shield for Blue Shield subscribers in the area of costs involved and utilization. We serve a 17-county area and currently provide medical-surgical protection for 6.1 million persons under our regular programs, and an additional one million under Medicare and CHAMPUS. Thus, Blue Shield in this area is serving 54 percent of the people in this heavily populated area. Last year we paid out $266 million in benefits under our regular program and medicare. For each dollar we received from subscribers, we paid out 89 cents. Considering the large volume of small claims that we process, we think this is quite good. United Medical Service is a community-oriented organization. We consider it a major obligation to make coverage available to the whole community without regard to health status, employability, or hazards of occupation. We consider it our responsibility to give the public the most for its health care dollar. I think it is important to emphasize that in our inflationary econ- omy United Medical Service has not had a rate increase since 1952. And T am talking about Blue Shield, which is coverage for physi- cians’ services, not Blue Cross which is coverage for hospital serv- ices. And within this time frame, we have expanded benefits, decreased some rates, and continued our policy of open enrollment. As to cost control, while most health insurance organizations now recognize the importance of meaningful utilization review, United Medical Service more than 10 years ago decided that our most im- portant subscriber service was to maintain controls over the use of contracts and benefits. We knew that this was the only way to assure the subscriber that his funds were properly used. During the late 1950’s we formalized and implemented an effective utilization review and control program. Our early responsiveness in creating a program that would help assure our subscribers the high- 1780 est quality of health care at the most reasonable cost—and our con- tinuing refinements of activities in this vital area—had led to na- tional recognition from both private and governmental sectors. Indeed, many of our utilization control techniques served as models for regulations and directives issued by the Social Security Admin- istration for medicare. ; Today, the need for sophisticated methods of controlling misutili- zation and outright abuse of health insurance coverage has become obvious. We responded to this need by further improving our own program, and expanding our Utilization Review Department. Methods involved in effective utilization review include detection and investigation of possible abuse. This includes case finding tech- niques of possible error or misuse which could lead to, or have re- sulted in, unwarranted payments. Detection involves investigations of many avenues of information relative to physicians’ patterns of practice. This physician profile is obtained at UMS as part of an ongoing prepayment review of phy- sicians claims as well as a post-payment analysis of practice patterns of reporting claims. : Our prepayment controls may be summarized as follows: 1. Unusual services or charges are referred for medical review during processing; 2. Randomly selected claims are verified by mailing questionnaires directly to the patient for verification of service, date rendered and charge; 3. A cross-check comparison is made of reported services rendered in a hospital with an audit of the hospital records; 4. A random review of a subscriber’s entire claim history is made in relation to a new claim; 5. An explanation of benefits and the payment provided is sent directly to each subscriber for every service claimed by a provider; 6. Questionable services are queried directly with the physician; 7. Hospital charts are audited if it appears that services were not rendered ; 8. Computer screens routinely regulate payment for certain pro- cedures and services; limits are set and payment cannot be made without additional information from the doctor. During 1970, $341,000 was disallowed on prepayment review of claims for services not verified after UMS audits of hospital records. An additional $359,000 was disallowed as a result of prepayment limitations by computer screens. Post-payment controls are also used with particular emphasis on computer-generated data. Under our system approach, a comparison is made of the physician’s pattern of practice with the practices of physicians within his own peer group in the same geographical loca- tion. Norms have been established for each procedure and service within a specialty. Individual physician norms are then compared to the group norms. In a comparison approach, data relating to the doctor’s total medicare and Blue Shield earnings, the number of patients, number of services and dollars paid per service are analyzed. Statistics are then developed from this data for each physician and a comparison is made with the peer group. 1781 Hospital audits of patients’ records are conducted on a continuing basis. Forty-four hospitals were audited during the past year. The Social Security Administration, the Senate Finance Commit- tee and the House Ways and Means Committee called upon UMS in this area during the past year to furnish them with an analysis of the medicare billings of certain physicians thought to have un- usual practice patterns. As part of this analysis, our - Utilization Re- view Department compared the practice patter ns of 5,200 individual physicians. When the doctors were compared in this manner, it was possible to detect those doctors who were overutilizing services. They constituted less than one percent of the doctors in our area. Two hundred and nine physicians had patterns that demonstrated excessive utilization of physician services. UMS representatives held individual meetings with 34 physicians in this group with medicare incomes in excess of $75,000. As a result, $244,000 was refunded by these physicians during the past year. Our investigation of another 175 physicians, including a review of over 51,000 claims, hospital records and medicare beneficis ary questionnaires, resulted in refunds of $82,000. In short, our utilization review efforts last year produced some striking results—more than $2 million in savings from refunds, amounts in process of recovery, and disallowed charges. For the in- formation of the committee and for the record of these hearings, I am attaching as an exhibit a document entitled “UMS Utilization Review in 1970.” I think it is important to emphasize that our utilization review program has had the support and cooperation of our local medical societies. Without the firm stand of the county medical societies on utilization review and the cooperation of their peer review commit- tees, we could not have the degree of effective cost control that we have been able to document. In closing, I would like to again emphasize our dedication to meeting community needs in the financing of health care. We are currently participating with prepaid, ¢ group practice on an experi- mental basis, we are continuing to upgrade our contracts and we are working to provide better subscriber service. While we recognize that much needs to be done to improve the delivery and financing of health care, we believe that locally United Medical Service has made valuable contributions. We pledge our efforts to do an even more effective job in the future. Thank you. (The material supplied by Dr. Safian follows:) 1782 UMS UTILIZATION REVIEW IN 1970 While the importance of meaningful utilization review and controls in health insurance plans is now recognized by the medical profession, Government, and community organizations, United Medical Service, more than a decade ago recognized its corporate responsibility to maintain controls over the use of contracts and benefits to assure that subscriber funds were properly expended. The responsibility of UMS in utilization review is directly related to its fiduciary role, commensurate with the public's trust in placing many millions of dollars annually with the Corporation to help prepay necessary health care costs. During the late 1950's UMS formalized and implemented an effective Utilization Review and Control Program. Reports and papers prepared at that time present- ing the specifics of the UMS program are still being used as source documents by other health insurance plans in implementing their own utilization programs. Our early responsiveness in creating a utilization review program and our con- tinuing refinements of activities in this area, have led to national recognition from both private and governmental sectors. Many of the utilization control regulations and directives issued by the Social Security Administration for Medicare Part B have their origin in essential features of the UMS program. The need for even more sophisticated methods of controlling mis-utilization and outright abuse of health insurance coverage, especially in government programs has become obvious. UMS responded to this need by improving its own program and expanding its Utilization Review Department to assume greater responsibilities. The objectives of UMS's utilization review are: 1. To promote the effective use of health care services; 2. To conserve and encourage the efficient use of health care dollars; 3. To create equity among providers and the consuming public; 4. To serve its members, the medical profession, all levels of govern- ment and other community organizations actively concerned with problems associated with ineffective utilization. 1783 Mechanisms involved in effective utilization review include detection and in- vestigation of possible abuse. This includes case finding techniques of possible error or misuse which could lead to, or have resulted in, unwarranted payments for an unnecessary medical service or for services reported, but not in fact rendered. Detection involves investigation of many avenues of information relative to physicians' patterns of practice. This information is obtained at UMS as part of an ongoing prepayment review of physicians' claims as well as a postpayment analysis of practice patterns. Prepayment controls: 1. Unusual services or charges are referred for medical review during processing; 2. Randomly selected claims are verified by mailing questionnaires directly to the patient for verification of service, date rendered and charge; 3. A cross-check comparison is made of reported services rendered in a hospital with an audit of the hospital records; 4. A random review of a member's entire claim history is made in relation to a new claim; 5. An explanation of benefits and the payment provided is sent directly to each member for every service claimed by a provider; 6. Any allowed charge under Medicare in excess of $1,600 is reviewed by a staff physician prior to payment; 7. Questionable services are queried directly with the physician; 8. Hospital charts are audited if it appears that services were not rendered; 9. Computer screens routinely regulate payment for certain procedures and services; limits are set and payment cannot be made without additional information from the doctor. 1784 During 1970, $341, 000 was disallowed on prepayment review of claims for services not verified after UMS audits of hospital records. An additional $359, 000 was disallowed as a result of prepayment limitations by computer screens, Post Payment controls: 1. Computer—includes an analysis of statistically based computer generated reports which provide objective, impersonal, unbiased data concerning utilization patterns, trends and variations. The following are some types of reports produced from UMS's paid claim history; a. The System Approach—this involves a comparison of the physician's pattern of practice with the practices of physicians within his own peer group in the same geo- graphical location. Norms have been established for each procedure and service within a specialty. Individual physician norms are then compared to the group norms; b. Comparison Approach—data relating to the doctor's total Medicare and Blue Shield earnings, the number of patients, number of services and dollars paid per service are analyzed. Statistics are then developed from this data for each physician and a comparison is made with the peer group. 2. Hospital Audits—hospital charts are audited on a continuing basis. Forty-four hospitals were audited during the past year; 3. Random Questionnaire Techniques—the Utilization Review Depart- ment routinely sends out various types of survey questionnaires to both patients and physicians to assure the verification and necessity of paid procedures and services. The Social Security Administration, the Senate Finance Committee and the House Ways & Means Committee called upon UMS during the past year to furnish them with an analysis of the Medicare billings of certain physicians thought to have unusual practice patterns. As part of this analysis, our Utilization Review Department compared the practice patterns of 5, 200 individual physicians. When the doctors were compared in this manner, it 1785 was possible to detect those doctors that were overutilizing physician services. Two hundred and nine physicians had patterns that demonstrated excessive utilization of physician services. UMS representatives held individual meet- ings with thirty-four physicians in this group with Medicare incomes in excess of $75,000. As a result of these meetings, $243,772.83 was refunded by these physicians during the past year. Our investigation of another 175 physicians, including a review of over 51, 000 claims, hospital records and Medicare beneficiary questionnaires, resulted in refunds of $82, 000. Late last year, our Utilization Review Department detected serious abuse re- lating to the billing by attending physicians for services in teaching institutions that were actually rendered by interns and residents without personal involve=- ment by the supervisory physicians. As a result of these findings, the Social Security Administration in Intermediary Letter #372, set forth guidelines in- tended to clarify the criteria for reimbursement in the teaching setting. Similar criteria for reimbursement in the teaching setting had been established by directives issued by UMS to the teaching institutions early in the Medicare program and meetings were held with representatives of these institutions but it subsequently developed there was lack of compl.ance. Subsequent to the distribution of Intermediary Letter #372, UMS representatives again met with thirty-eight hospital groups and more than one hundred physicians to reaffirm the Government guidelines and to assure compliance with SSA regulations. In addition, hospital audits were completed by the UMS staff in 34 of the 66 accredited teaching hospitals in our area in 1970. These audits disclosed past improper Medicare billings in excess of $1, 250, 000 primarily in four institutions as follows: Teaching hospital A $ 35,472 refunded B 58,215 refunded Cc 720,000 agreement reached with institution and in process of recovery D 474,000 as in "C" It was apparent that both the doctors and the institutions involved did not follow the criteria and guidelines that had been carefully prescribed by UMS and discussed with them prior to the implementation of SSA policy in the teaching setting program. More than that, when SSA originally proposed guidelines that would provide reimbursement for these services, UMS identified the dangers inherent in this policy and the abuses that could occur. UMS indicated in writing to officials of the Bureau of Health Insur- ance our concern that if this policy were to be implemented, it could lead to abuse and increased costs to the Medicare program. These opinions were 59-661 O - 71 - pt. 8 - 5 1786 unheeded and the difficulties that were anticipated have since materialized. This matter subsequently led to an extensive inquiry by the Senate Finance Committee and the House Ways & Means Committee. The Committee reports, which include UMS testimony and identification of prior concern, indicate that UMS' original reaction to the teaching setting policy enunciated by SSA has proven to be correct. Disposition—depending on the results of the review and, as the facts warrant, every attempt is made to resolve a utilization problem where one exists with individual physicians. 1. If a determination has been made that a possible utilization problem exists, the doctor is asked to appear personally and discuss the matter with a UMS staff physician; The problem is referred to the appropriate peer review committee of the physician's medical society. During the past 12 months, 500 cases have been referred to peer review committees for review and recommendation. During the year, liaison between these committees and UMS was established to provide support to these committees and resolve developing problems. Meetings were arranged between the Chairman of each committee and UMS Medical Affairs representatives. This past year we met with fourteen societies' peer review committees or their Chairmen to better acquaint them with our own program, to offer statistical and information assistance wherever possible, and to establish a close working relationship between the medical society and our organization. While all peer review committees have expressed an eagerness to participate in this type of case review, most committees are as yet not prepared to handle, within a reasonable period of time the volume of cases presented to them by our Utilization Review Department. Further, some of the recommenda- tions that follow this review still reflect an unwillingness by peer review committees to comment on another physician's manner of practice. In particular, questions involving the medical necessity of services are often regarded as an intrusion into the doctor's right to practice as he desires. It is hoped that our continued assistance to these committees with data on patterns of practice and reporting will help them arrive at more prompt and appropriate recommendations; The subscriber's employer is notified regarding member abuse of contract benefits; 1787 4, The Social Security Administration is notified in matters per- taining to Medicare; 5. The State Education Department, Division of Professional Conduct could be notified in certain problems; 6. The District Attorney's Office could be notified (after review by UMS legal counsel) of any case involving fraud. Summation The UMS Utilization program during the past year has resulted in savings primarily to the Government in amounts exceeding $2.1 million. To a lesser extent, UMS has also benefited from the program. The $2.1 million savings includes approximately $325, 000 in actual monies refunded. An additional $900, 000 is in the process of recovery as an offset against future claims and $700, 000 has been disallowed on cases prior to final disposition. Our ex- perience indicates that there has been a significant reduction of unnecessary services performed by those doctors whose UMS and Medicare records have been under review because of previous misutilization practices. We are aware that the activities of our Utilization Review Department have not passed unnoticed by the medical profession and other providers of medical services and we have been identified as one of the few Plans with an effective on-going utilization review and control program. 1788 Senator KenNepy. Thank you very much. I am familiar with the efforts which you have been trying to initiate in terms of the peer review group in the hospital. We hear constantly that much of the medicine that is practiced in suburbia is practiced out in doctors’ offices, and what can you say can be done to insure that an individual is going to receive quality care from a solo practitioner? Dr. Sarranx. Well, T believe that the doctors practicing in their community are qualified. They have to maintain certain standards within the hospital. They cannot practice only within their office. They need hospital backup, and T think they are judged as to their ability when they are taken on the staff of a hospital, and I think in general that doctors are well qualified and do a good job within the limits of their capability. Senator Ken~xepy. You are not just suggesting that once they get their license, so to speak, you are not going to have a review of the kinds of services and procedures that are going to be performed? I mean this is a very dynamic profession in terms of changes and techniques, various drugs, and all the rest, and I suppose the con- sumer ought to have some kind of assurances that the person Dr. Sarran. IT am not a practicing physician, but I am aware that many of the societies, not only the specialty societies, but the Acad- emy of General Practice, do require that doctors keep up with newer techniques and newer methods of medicine. Senator Ken~epy. What is the situation if they don’t? Dr. Sarian. I believe really there is nothing done. In this State if you get a license to practice medicine you can practice medicine. There is in fact very little control over the individual. Senator Kenxepy. If you have review of quality in terms of the hospitals why shouldn’t you have it in terms of the doctors’ offices as well ? Dr. Sarian. I think you should. T think one relates to the other. Senator Kexnepy. Do you think that would be worthwhile? Dr. Sariaw. I think it is very worthwhile. Senator Kex~epy. How can that be done? Dr. Saran. I really don’t know. I haven’t given much thought to it. I think it has to be done by peer groups of these physicians. T think it should be done by other doctors who are practicing in the same community with this physician. Senator Kexnepy. Do you really want other doctors in the same community. Isn’t there a lot of backscratching, so to speak? You know I am going to look at your work today and you are going to look at my work tomorrow. It has been suggested that in those in- stances you have almost a conflict of interest. Dr. Sarian. You are suggesting that it should be done by a physi- cian from another community or another area perhaps. Senator Kennepy. Perhaps. Dr. Saran. Perhaps. T think in a large community you can do it, or in a large metropolitan area. When you get off into some of the rural areas where you have a county with 10 or 15 physicians I think it is impossible to do it there. I think in a large metropolitan area or large community you can do it, and I think doctors are harder on some of the individuals in their profession than other people 1789 might be. IT found it in some of the problems we have had in utili- zation review. Senator Kexnepy. But in these larger communities you would favor doctors reviewing other doctors’ work that don’t have any- thing to do with these doctors? Dr. Saran. Yes, I would. Senator Ken~epy. You prefer that kind of setup rather than where one doctor reviews Dr. Sarran. I think it’s important to know what is going on in the community, and I think there is an advantage to a doctor prac- ticing in the community reviewing another doctor’s qualifications within that community. Senator Kexnepy. Well, as long as the other doctor isn’t going to review the other person’s in turn. Dr. Saran. As long as there is no self-interest or buddy-buddy systems. Senator Kex~Eepy. Just finally, if you favor the kinds of review, even in solo practice type of medicine, can’t Blue Cross and Blue Shield do something about trying to implement this kind of a suggestion ? Dr. Sarran. Well, in Blue Shield while we have no legal authority to do anything, we in some way control some of the money that goes to physicians, and it is possibly through the control of funds that we might be able to do something. But since we have no legal au- thority I think it becomes more a matter of legislation. Senator Kexnnepy. Well, the funds are a pretty good start. Dr. Saran. That’s a good start. We found that to be true, too. Senator KENNEDY. Sometimes that’s even better than utilization. Dr. Sarran. Well, most of our utilization problems—it is not the doctor collecting the money from the patient that causes the utiliza- tion; it is the doctor who 1s collecting the money from a third party and using the third party. Senator Kex~epy. Why is it that you haven’t had these increases since 1952? Practically every other group has had enormous in- creases. Dr. Sarran. Well, Blue Cross has had large increases because the hospitals’ costs have gone up so much. But our contracts are on schedules so that the payments have been fixed. When we have insti- tuted a new contract and improved the benefits in that particular contract both in the scope of coverage and in the allowance we paid, then that particular new contract is rated, and the rate has held up. Some of our older contracts that go back to 1952 where the coverage is inadequate and payments are low, those contracts are now losing money. But we have reserves which are able to cover all our contracts so that we don’t need a rate increase. Where we are losing in some we are gaining in others. Senator KENNEDY. Senator Dominick. Senator Dominick. Doctor, T want to congratulate you on your statement. I think it is excellent, and T think it shows some of the things that can be done with peer review and cost control. I think you have really done a tremendous job. 1790 I would presume that the $2 million-plus which you provided in the way of savings is simply absorbed by the physician who is in- volved, is that correct? Dr. Sarran. That is correct. Senator Dominick. In other words, he doesn’t charge the patient for it or anything of that kind ? Dr. Sarian. Well, as I indicated, for example, under medicare you have the assignment and the doctor has to accept the payment from medicare. And we find that in the assignment cases where the money has gone directly to the physician, whether it be a Blue Shield con- tract or medicare, these are the doctors who are overutilizing and causing this problem. It is where the doctor is collecting the money from the third party. We can control this doctor by restricting the amounts of money we pay him and determining the medical neces- sity of the services, and he cannot go back to the patient for the additional funds. Senator Dominick. Now we have had a lot of comments in previ- ous testimony in Washington about the TIMO’s and foundations backed by insurance companies. What is your thought on this? Is this comprehensive care setup done by health maintenance organiza- tions, under a foundation—is it pretty effective from your observa- tion ? Dr. Saran. Well, we don’t have very many foundations, or any, in this area. We don’t have any in this area, and most of them are out on the west coast and California. Senator Dominick. Don’t forget Colorado. Dr. Sarian. That’s right. We are just getting interested in them now and are holding various meetings to discuss foundations. They can be useful in the delivery and financing of medical care. Senator Dominick. Now there isn’t any particular reason why you have to worry about cost control, you are a nonprofit organization to begin with, isn’t that correct ? Dr. Saran. We are nonprofit, yes. Senator Dominick. There have been implications that the increased cost, utilization of doctors, and so forth, has been brought about by mismanagement by the insurance industry or overgreediness by the insurance agency. Have you had any feeling that way at all? Have you figured that this has been a part of the problem? Dr. Sariax. Well, IT think this is an individual problem in a local plan or local commercial organization. IT think we can demonstrate what we have done in our area and it must reflect good management; and I am sure that in anything, any industry, you will have good management in some companies and bad management in others. Senator Dominick. What you are saying in effect is a lot of these costs are really effective if you really go out after them with the aid of the medical society ? Dr. Sarran. Yes, sir; I think so. Senator Dominick. Now what happens when you get, as Mr. Bern- stein did—I believe it was Mr. Bernstein—a $10 bill for H,O? I think even for a bartender that’s a little high. Dr. Sarian. Especially with nothing in it. 1791 Senator Dominick. Especially for a bartender. What do you do when you get complaints like this? Do you have a chance of looking into them at all? Do they come to your attention? Dr. Sarian. Well, they happen to be under Blue Cross, and in the New York area the Blue Cross and the Blue Shield organizations are separate. They have two separate boards and two separate man- agement staffs and are in different areas. So that this would be purely a Blue Cross problem which we wouldn’t get involved in. Senator Dominick. You would not get involved in it? Dr. Sarian. No. Senator Dominick. Wouldn't the Blue Cross get involved in that? Dr. Saran. I would hope so. . Senator Dominick. But you don’t know ? Dr. Sarran. I don’t know. Senator Dominick. Well, IT frankly was a little—not a little, but a great deal upset over the cost figures which he quoted, which I am sure are accurate because he has to pay the bill. It just seems to me that isn’t necessary. I wonder what kind of a system one should have in order to be able to control this. Now the medical society, for example, is cooperating with you on controlling a lot of these costs. Are they not cooperating with the Blue Cross? Is this the problem ? Dr. Sarian. Well, IT think what they are doing is identifying their costs to Blue Cross, and as these costs go up, whether they are labor costs or equipment or X-ray or anything else, Blue Cross is just picking up the cost and in a reimbursement formula reimbursing them as their costs increase. I don’t really know how much control or what efforts they try to make in controlling the hospital costs. Senator Dominick. Well, maybe we better get some more testimony on what the Blue Cross is doing on some of this. But again I just want to congratulate you on what I think is an excellent statement, which does show that costs are controllable as least as far as Blue Shield is concerned. Do you get into teaching hospitals at all? Dr. Sarran. We have been involved in teaching hospitals, reim- bursement of teaching hospitals under Medicare. Senator Dominick. Do you find any overutilization in teaching hospitals where residents are coming in and ordering lab tests all the time? Dr. Saran. Well, T was in a meeting last night over’ at Cornell Medical College where some of the attendees were objecting to the fact that in the residency teaching programs, the resident really wants to control the care of that patient when he comes into the hospital, and one of the internists expressed the feeling that—as one of the previous speakers here I believe made the statment—that in the teaching and in trying to learn they do a lot of excess laboratory services, some which may or may not be necessary. I think it is one of the problems of the teaching program and the control of the patient by the resident. Senator Dominick. So you have found that some of the lab tests and costs that are involved are really for the purpose of medical 1792 education as far as the internist or whomever it is that may be in- volved, as opposed to patient care? Dr. Saran. Yes, and I think research and education is one of the problems we have in trying to put this into insurance, whether it is Blue Cross or Blue Shield or a commercial carrier. I think that this shouldn’t be funded by the people who have this insurance. I think it has to be funded outside that mechanism in other areas. Senator Dominick. By increased support of the medical schools or something ? Dr. Sarran. That’s right. T think research and education is a part of the hospital bill. As somebody mentioned to me a few days ago— I don’t know the correctness of the statement—it could go as high as 26 percent, or something like that. Senator Dominick. Have you found in your process of talking with the doctors about the controllable cost problem that this prob- lem of malpractice suits comes into play ? Dr. Sarian. It does. The malpractice rates have risen very sig- nificantly, and doctors are paying what I feel are real high premiums in malpractice insurance, and what they try to do is justify because of malpractice they have to do this or they have to do that, and they just want to protect themselves, and they do have a point. Senator Dominick. Do you have any thoughts on how this might be handled? T know in the President’s message—and I am happy to say I put a lot of input in it through the Secretary of HEW—that they have established a Malpractice Commission in order to try and take a look at this problem. Do you have any ideas on that? Dr. Saran. No; but I think that in some way if there is malprac- tice the awards that are given should be in some way controlled. I think it is the excessive awards. IT don’t know how you can control anybody from bringing a malpractice suit. I think he has that right. But I think the problem has been in the very excessive awards that people have been getting in malpractice suits. Senator Dominick. Would you give us your thoughts on the ques- tion of deductibles or coinsurance as factors in cost control or cost consciousness ? Dr. Saran. Well, what the deductible and coinsurance does, it reduces the premium rate for all the people and it puts on the per- son who needs the medical care at that particular time some par- ticipation in the cost of that care. All it really does is reduce the premium rate for the general group that is buying the coverage. I would prefer to see programs without deductibles. Senator Dominick. What do you have to do about utilization? Have you had any comparison or any ability to compare one pro- gram with coinsurance or deductibles and one program without it? Dr. Sarian. I haven’t had any real involvement in that. All IT know is that it is cheaper to buy a program with deductibles and coinsurance. Senator Dominick. Thank you. That’s all T have. Senator KennNepy. Just finally, could you tell us who is on your board ? Do you have a board? 1793 Dr. Sarran. We have a board of 26 members. Thirteen are phy- sicians and 13 are lay people. Some of the lay people are in the city or State programs that we have. We have a State representative. We have people from labor on our board. Senator Kex~Nepy. So you have 13 physicians, half of them are physicians, half of your board are physicians? Dr. Sarran. Half and half, 50-50. Senator Ken~epy. What is the makeup of the other 13% Do you know ? Dr. Sarian. The lay people? Senator Kennepy. Yes, what are their occupations? Dr. Sarrax. Two or three of them represent labor unions. One represents the New York State Civil Service Employees Association. One 1s an executive director of a teachers’ annuity fund, which is some type of an insurance fund. One is with one of the banks. That would be the general. We could make it available. Senator Kexxepy. Could you make it available? Dr. Sarran. Yes. Senator Kex~Nepy. Are they elected or appointed ? Dr. Sarian. They are elected through a nominating committee of the board. Senator Ken~epy. Of the board itself ? Dr. Sarian. Right. Senator Ken~epy. Do you have any school teachers or engineers? Dr. Sarian. No, but I am just reminded that we have a woman on the board also. Senator Kex~epy. Is there only one woman on it? Dr. Sarran. One woman, yes. Senator Kennepy. If you could give us a bit of a profile on the board I would appreciate it. Dr. Saran. We will do that. Senator Kennepy. Thank you very much. Dr. Sarran. Thank you. (The information referred to subsequently supplied follows :) (3) m (2) (3) (3) (1) (2) [01] (2) " 1 (2) (2) (2) (2) 1) 3) (3) [$Y] (2) (1) (2) 3) (3) wn) 1794 BOARD OF DIRECTORS OF UNITED MEDICAL SERVICE, INC. Carl R. Ackerman, M,D.. ++eeee. United Medical Service, Inc., Two Park Ave. , N.Y., N.Y. 10016 (340-5291) John Beck, M.D........ tttressiaseetatttaatenenaas 24 Carlton Place, Staten Island, N.Y. 10304 (GI-2-8709) Charles M. Brane, M.D......... “estressasssaenas.. 169 Park Avenue, Yonkers, N.Y. (Area Code 914-YO-3-5475) John T, Burnell... .ossivs sons inseini testes saesseassas Area Manpower Director of the Human Resources Development Institute, AFL-CIO, 386 Park Ave. South, Room 601, New York, N.Y. 10016 (MU 5-9125) C. Joseph Delaney, M.D...unvsssnsionsvnsssvvens . 118 East 60th Street, New York, N.Y. 10022 (PLaza 3-7798) Robert M. Duncan......... tesssassessasesssesassss Executive Vice President and Actuary, Teachers Insurance and Annuity Association of America, 730 Third Avenue, New York, N.Y. 10017 (OX 7-7600) Samuel Z. Freedman, M.D....vvvvrvess .. 541 East 20th Street, New York, N.Y. 10010 (YU 6-5757) | Harold Glasser... vsvwsnnisins sessassessasaaenassaa. Director, Employee Benefits Department, Glen Alden Cor- poration, 888 Seventh Ave.,N.Y.,N.Y.10019 (357-8740) Patrick Gle@SOn. vu ve vs ves vans esssssssvasesaes ss. President, Retail Food Clerks' Union, Local 1500, R.C.I.A., AFL-CIO, 221-10 Jamaica Avenue, Queens Village, N.Y. 11428 (479-8700) Elvin E. Gottdiener, M.D............. rereraraens ..100 A Fulton Avenue, Poughkeepsie, N.Y. 12603 (Area Code 914 - GL 4-0350) Alfred P. Ingegno, M.D...vvvvnnnnns « sus sina owe ves 27 Eighth Avenue, Brooklyn, N.Y. 11217 (NEvins 8-5455) veteesessaa...Graduate School of Public Administration, New York University, 4 Washington Square North, N.Y., N.Y. 10003 (598-3726 or 3727) .. 61-34 188 Street, Flushing, N.Y. 11365 Herbert E. Klarman, Ph.D.. Norton M. Luger, M.D... (GL 4-8700) Robert A, Moore, M.D.uvsvvsesesensnsnsssanensssas 445 Lenox Road, Room 3-490, Brooklyn, N.Y. 11203 (270-2597) Frederick H. Morris....... vole aes sae vs ee se ..Executive Vice President, Empire Savings Bank, 221 West 57th Street, N.Y., N.Y. 10019 (CI 7-6400) ULV. MUSCIO itu vtnnnssnnnnssnnnsssnsnnnans ++....President, Muzak Incorporated, 100 Park Avenue, New York, N.Y. 10017 (889-1330) . 157 East Main Street, Huntington, N.Y. 11743 (Area Code 516 - HA 7-8530) NOPMAN BACKS wats viv wivim atu w wim Sea nn a akin a ew os Deputy Director, International Operations, Administration, The Reader's Digest Association, Inc., Pleasantville, N.Y. 10570 (Area Code 914 - 769-7000) William C. Porter, Jr., M.D.. Lawrence Ravich, M.D......cvnuunesn asin Sea 4277 Hempstead Turnpike, Bethpage, N.Y. 11714 (Area Code 516 - WE 8-2130) Louis ROINICK oui sivivivin vive wisinivn misma sim wie win aie ...... Director, Welfare & Health Benefits Dept., ILGWU, 1700 Broadway, New York, N.Y. 10019 (CO 5-7000) Juan SanChezZ....cieivieeesennssennrnancneeseeesnes Manager, Latin-American Dept., Tampax Inc. , 5 Dakota Drive, Lake Success, N.Y. 11040 (N.Y.C. 895-2270 Lake Success (516) 437-8800) Elizabeth T. Schack... sus ievnnss srssiaaseareannan .845 West End Avenue, New York, N.Y. 10025 (254-8900 Ext. 313) Leo J. Swirsky, M.D..v.cvsveserenasesenasesasesessa.ll5 Remsen Street, Brooklyn, N.Y. 11201 (MA 4-2212) ' John D. Van Zandt, M.D...sssesssresnnvesis .....Route 17, Tuxedo Park, N.Y. 10987 (Area Code 914 - EL 1-4761) Theodore C. Wenzl, Ed.D.....vvevvueunveeannsans.. President, N.Y.S, Civil Service Employees Assn., Inc., 33 Elk Street, Albany, New York 12224 (Area Code 518 - 434-0191) Benjamin Weme.......covtivnerencnnensnnnnns «+... 122 East 42nd Street, New York, N.Y. 10017 (986-3040) Elected to serve until the Annual Meeting of Voting Members in the year 1973 Elected to serve until the Annual Meeting of Voting Members in the year 1974 Elected to serve until the Annual Meeting of Voting Members in the year 1972 As of March 18, 1971 1795 Carl R. Ackerman, M.D. Carl R. Ackerman, M.D., is chairman of the board of directors of United Medical Service, Inc. Dr. Ackerman previously served as chairman of the board of UMS from 1959 to 1963. In 1959 he became a member of the board of directors of the National Association of Blue Shield Plans and was elected vice chairman in 1961. He became chairman of the board of NABSP in 1966 and held that office until April, 1970. A graduate of Columbia College, Columbia University, Dr. Ackerman received his M.D. from The College of Physicians and Surgeons, Columbia University, in 1930. He has practiced general surgery in New York City since 1933. He also served as attending surgeon and director of surgery at St. Francis Hospital, Bronx, New York. He is presently consulbing surgeon at Meret Hospital and St. Joseph's Hospital, also in the Bronx. Dr. Ackerman is a member and past president of the Bronx County : Medical Society, a member of the Bron Surgical Society, and a Fellow of the American College of Surgeons. He is also co-chairman of the Carrier Advisory Group to the Social Security Administration. He resides in Glen Cove, Long Island. 1796 March 31, 197% JOHN BECK John Beck, M.D., is currently radiologist at Brooklyn Veterans Administration Hospital and Sea View Hospital and Home, Staten Island. He is consulting radiologist at the Public Health Service Hospital, Staten Island. Dr. Beck was Chief Radiologist at Staten Island Hospital from 1941 to 1970. He also serves as Vice president of UMS. A native of Brooklyn, New York, he received his B.S. degree from New York University and his medical degree from the University of Geneva, in Switzerland. He was licensed in the State of New York in 1937. In 1941 he received a Certification in Radiology from the American Board of Radiology. From 1943 to 1946 he served with the U.S. military, including 28 months in the Mediterranean Theatre during World War II. He is a member of the Richmond County Medical Society, American College of Radiology, the New York Roentgem Society, and the Radiological Societies of North American and the State of New York. 1797 arch 31, 1971 CHARLES M. BRANE, M.D. Charles M. Brane, M.D. is attending surgeon at St. John's Riverside Hospital, and consultant in surgery at Yonkers General Hospital and Dobbs Ferry Hospital. He is past chairman of the board of directors of United Medical Service, Inc., and continues to serve as a director. A past president of the Westchester County Medical Society and of the Yonkers, Academy of Medicine, he is also honorary director and past president of the Yonkers Family Service Society, serves as a director of se Westchester County Council of Social Agencies, and is past president of the United Givers Fund of Yonkers. He is a diplomate of the American Board of Surgery. Dr. Brane serves as a delegate to. the American Medical, Association and is chairman of the Medical Review Committee of the Medical Society of the State of New York. Born in 1908, he received his B.S. from Cornell University in 1928 and was graduated from Cornell Medical College in 1931. Dr. Brane served in World War II, entering the Army Medical Corps as a captain in 1942 and Was discharged as a major in 1945. He was awarded the Bronze Star for meritorious service. Dr. Brane resides in Yonkers, New York. 1798 John T. Burnell John T. Burnell i§ Area Manpower Director of the Human Resources Development Institute,AFL-CIO. He is also chairman of the New York City Central Labor Council's youth corps committee and secretary of its Black Trade Unionists. A native of Brooklyn, New York, he attended C.C.N.Y., Columbia and Cornell Universities, -and the New School of Social Research. In addition, he serves as a board member, advisory committee, Queens College Parent and Teachers Association and the New York City Board of Education's cooperative education committee. He is a member of the Regional Planning Board for Queens District #26. Mr. Burnell is a former chairman of the human rights committee of The United Parents Association. Among other activities, he is chairman of the Labor Advisory Committee of the Red Cross of Greater New York. 1799 March 31, 1971 C. Joseph Delaney, M.D. c. Joseph Delaney, M.D., is Attending Surgeon at Knickerbocker, Colurbus, Flower-Fifth Avenue, Doctors, and Metropolitan Hospitals. He is Consultant in Surgery at Misericordia Fordham and Hackensack Hospitals. Dr. Delaney is also Clinical Professor of Surgery at New York Medical College and Chief,Division of Pediatric Surgery, New York Medical College. vom in Woburn, Massachusetts, he received his B.A. degree from Boston College and nis M.D. os Georgetown University Medical School. He served with the U.S. Navy in World War II and presently holds the rank of Captain (Ret.) in the U.S.N.R. Medical Corps. Dr. Delaney is Trustee and Past-President, the Medical Society of the donathy of New York. He is a member of the New York Academy of Science, the Board of Directors of The International Center in New York, and a Fellow of the Busvlonn College of Surgeons and the New York Academy of Medicine. He is a member of the University Club. Dr. Delaney is Senior Medical Officer, New York Maritime College, Fort Schuyler, New York. . He is an alternate delegate of the American Medical Association. . 1800 ROBERT M. DUNCAN Rooert M. Duncan is executive vice president and actuary, Teachers Insurance and Annuity Association of America. He has been associated with TIAA since 1948. He formerly spent 14 years with the Home Life Insurance Company of New York. He is also executive vice president and actuary of College Retirement Equities Fund, which is a companion organization of TIAA. Born in New York City, he received his B.S. degree from New Yprk University in 1932 and his M.A. from Columbia University in 1933. Mr. Duncas is a Fellow of the Society of Actuaries. He is also currently serving on the Actuarial Advisory Committee to the Comptroller of the State of New York for the State Employees' Retirement System and the Policemen's and Firemen's Retirement Systems. ; A resident of Port Washington, Mr. Duncan is married and has two sons 1801 April 2, 1971 Samuel Z. Freedman, M.D. Samuel Z. Freedman, M.D., is the Director of the Division of Standards of Medical Care of the Medical Society of the State of New York. Doctor Freedman is a consulting genito-urinary surgeon at Beth Israel, Polyclinic, and Peninsula General Hospitals. ‘He is a former director or urology at Gouverneur Hospital. He was president of the Medical Alliance from 1938-1941. He is also past president and trustee of the Medical Society of the County of New York. He is a past treasurer of the Medical Society of the ‘State of New York. 59-661 O - 71 - pt.8 - 6 1802 March 31, 1971 HAROLD GLASSER Harold Glasser is Director of Employee Benefits, Rapid American Corporation, elon Corporation, and Glen Alden Corporation. Born in Chicago, Illinois, he studied at University of Chicago and Harvard University. He was formerly Director of Yonwiary Research for the United States Treasury, Director of the Institute of Overseas Studies of the Council of Jewish Federations and Welfare Funds, and a Fellow of Brookings Institution of Washington D.C. 1803 Patrick Gleeson Patrick Gleeson is president of the Retail Food Clerk's Union, Local 1500. A native of Canada, he resides in Brooklyn, New York. He has studied at the Cornell School of Labor Relations and the Xavier Labor School, New York City. oo Married, Mr. Gleeson has one son. 1804 March 31, 1971 ELVIN E. GOTTDIENER, M.D. Elvin E. Gottdiener M.D., is in the private practice of radiology. He is also consulting radiologist at the Veterans Administration Hospital, Castle Poiht, and Northern Dutchess Hospital, Rhinebeck, N.Y. Born in Brooklyn, New York, he now resides in Poughkeepsie. He received a degree in medicine from the University of Maryland School of Medicine in 1937. Dr. Gottdiener is a member of the American College of Radiology, the Radiological Society of North America, and the Radiological Society of New York State. He is a Past President of the Dutchess County Medical Society and delegate to the Medical Society of the State of New York. Married to Dr. Florence Harris Gottdiener, he has three daughters. 1805 April 1k, 1972 Alfred P. Ingegno, M.D. Alfred P. Ingegno, M.D., is attending physician and Chief of the Division of Gastroenterology at Long Island College Hospital, Brooklyn, New York. He is a Consultant Gastroenterologist at Brooklyn Veterans Administration Hospital, Wyckoff Heights Hospital, and the New York Board of Education. He is Clinical Professor of Medicine at State University of New York, Downstate Medical Center, and Visiting Physician at Kings County and University Hospitals. Dr. Ingegno received his B.S. degree from Columbia University and his M.D. from the Long Island College of Medicine in 1933; he served his internship and residency in Internal Medicine and Radiology at Long Island College Hospital. He is past president and trustee of the Kings County Medical Society, chairman of its publication committee and editor of its Bulletin. He is also a delegate to the Medical Society of New York State. He is also an active member of the American ————— Association, Fellow of the American College of Gastroenterology, Diplomate in Internal Medicine and Gastroenterology, and Life Fellow of the American College of Physicians. . Dr. Ingegno is a member of the Executive Committee of UMS. He resides in Brooklyn with his wife and two sons. 1806 3-24-71 HERBERT E. KIARMAN Herbert E. Klarman is professor at the Graduate School of Public Administration, New York University. His former professorial appointments, in fields related to Public Health, include John Hopkins University; Downstate Medical Center, State University of New York; Columbia University; and Brooklyn College. Dr. Klarman has also served as a consultant to the World Health Organization; Social Security Administration; National Institute of Mental Health; U.S. Department of Defense; White House Task Force on Facilities for the Aged; and Department of Health, Education and Welfare Committee on tonprelensive Services for children. Dr. Klarman is a graduate of Columbia University and holds a Ph.D. degree from the University of Wisconsin. 1807 Norton M. Luger, M.D. Norton M. Luger, M.D., is assistant clinical professor of medicine at Cornell Medical College. He is also assistant physician at New York Hospital and a consultant in medicine at Booth Memorial Hospital. Dr. Luger was director of the department of medicine at Booth Memorial from 1956 to 196k. A graduate of Brooklyn doling, he received his M.D. degree fren St. Louis University. Dr. Luger is a fellow of the American College of Physicians and the New York Academy of Medicine and a diplomate of the American Board of Internal Medicine. He is also a member of the Medical Section of the New York Board of Trade, the New York Academy of Science, and the Board of the Association of the Study of Abortion, Inc. He is past president of the Medical Society, County of Queens, and a delegate to the Medical Society, State of New York. 1808 March 31, 1971 ROBERT A. MOORE, M.D. Robert A. Moore, M.D., is an internationally known educator and medical lecturer.. He is Medical Director of the National Mund for Medical Education and past honorary consultant in pathology to the Surgeon General of the United States Army and past Senior honorary consultant to the Surgeon General of the United States Navy. A native of Chicago, Dr. Moore received his B.S., M.Sc., and M.D. degrees at Ohio State University. He holds a Ph.D from Western Reserve University. In addition, he has received honorary degrees from Union, Miami, Long Island, Washington and Ohio State Gulveriiites and Waynesburg College. He is also currently SEURTEeD of pathology at the deliege of Medicine of New York State. He is former president of the Downstate Medical Center and former dean of the College of Medicine in Brooklyn State University of New York. Dr. Moore is a former member of the National Advisory Cancer Council, the United State Public Health Service, and the National Advisory Council in health research facilities. Now retired, he remains active in the medical field and maintains his memberships in state and county medical societies. Married, Dr. Moore has two children. He resides in Brogl . 1809 , Frederick H. Morris Frederick H. Morris is senior vice Im of the Empire City Savings Bank, New York. He has been associated with Empire City since 1943. Born in Albany, Mr. Morris studied at New York University, Hofstra College, Rutgers and Northwestern Universities, and Dartmouth College. He now resides in Katonah, New York. Mor Sort participates in various community endeavors both in Katonah and in New York City. Active in the Investment Officers Forum of the State of New York, he is a former president of the New York State Savings Banks Life Insurance Council. He is a member of committees of the National Association of Mutual Savings Banks and the New York State Savings Banks Life Insurance Council. In addition, Mr. Morris is on the faculty of the summer Graduate School of Savings Banking at Brown University in Providence, Rhode Island. Married, he has three children. 1810 3-2k-71 U. V. MUSCIO U. V. Muscio is president of Muzak Incorporated. He is also on the board of directors and executive committee of Fedders Corporation. Mr. Muscio is a former treasurer and vice-chairman of the National Better Business Bureau, and former director of ’ the National Electrical Mfgr. Association. In 196k, he was awarded the McGraw Edison Medal for "Contribution to Improvement of Business Ethics." Long active in community affairs, Mr. Muscio serves on the Council of Fordham University. He is also a former trustee of the National Leukemia Society. Mr. Muscio was educated at Fordham University and New York University Law School, where his degrees include an LL.M. in Labor Law. 1811 WILLIAM C. PORTER, M.D. William C. Porter, M.D., is a specialist in urology. He is on the staffs of Huntington, Meadowbrook, and King Park State Hospitals. He is a consultant in urology to the Veterans Adminis- tration Hospital. Dr. Porter studied at Colwibia and Princeton Universities. He received his M.D. degree from Cornell Medical School in 1950. He is a fellow of the American College of Surgeons and a diplomate of the American Board of Urology. Dr. Porter is a meuber of the American Medical AeToatalon, the American Urological Association, ‘American Fertility Society, Suffolk County Medical Society, the Suffolk County Multiple Sclerosis Society Medical Advisory Board, and the New York section of the American Urological Association, Inc. He is a delegate to the New York State Medical Society. Born in St. Petersburg, Florids, he now resides in Huntington, Long Island. Dr. Porter is married and has two childern. 2 HHHE 1812 3-2L-71 NORMAN RACUSIN Norman Racusin is deputy director of international operations for The Reader's Digest Association, Inc. Prior to this position, Mr. Racusin was with the RCA Corporation for twenty years. At various times, he served as president of RCA Records; executive vice president of the National Broadcasting Company, Inc.; and staff vice president for operations planning of RCA Corporation. Mr. Racusin is a member of Phi Beta Kappa Associates; past chairman of the Music Division, Greater New York Fund; former vice-chairman of the United Nations Annual Dinner; and recipient in 1969 of the Ed Wynn Humanitarian Award of the Pexiinson's Disease Association. Mr. Racusin was educated at Pennsylvania State College and Sarvs Business School, where he received an MBA with distinction. 1813 Lawrence Ravich, M.D. Lawrence Ravich, M.D., a urologist, is on the staff of Six Nassau County hospitals. He maintains an office in Bethpage and Hicksville, New York. A graduate of C.C.N.Y., Dr. Ravich received his M.D. degree from the Chicago Medical School. He served with the U.S. Army from 1945 to 1946 and the U.S. Air Force from 1954 to 1956. He was consulting urologist with the Third Air Force in England. Dr. Ravich is a fellow of the American College of Surgeons and the International College of Surgeons. He is a diplomate of the American Board of Urology. | | He is also a member of the New York State Medical Society, the Nassau County Medical Society, the New York and Nassau County Urological - og 4 Societies, The American Urological Association, and the Associatio or the Advancement of Science. Married, Dr. Ravich has three children. ge He is a delegate of the American Medical Association. 1814 March 31, 1971 LOUIS ROLNICK Louis Rolnick has been the director of the welfare an health benefits department of the International Ladies’ Garment Workers' Union since 1962. He has studied at the College of the City of New York, Jonn Marshall and New York Universities. His work experience includes employment as a staff industrial engineer and engineering consultant. He served abroad as an employee of the Mutual Security Agency. At the I.L.G.W.U., he has been a staff member and assistant director of the management engineering deparinent and west coast director of the management engineering department. Prior to his present position, he was assistant Siactur of the welfare and health benefits department of the I.L.G.W.U. In addition, Mr. Rolnick supervises the activities of the various health centers located Garou the country. He also functions as administrator of the following manage- ment, labor jointly controlled national garment industry funds: Sugpienaniany Unemployment Benefits Fund, ILGWU, ILGWU National Retirement Fund and ILGWU Health Services Plan. Mr. Rolnick has recently been reappointed to serve as a member of the Medical Assistance Advisory Council to “he Secretary of the Department of Health, Education and Welfare. 1815 Juan Sanchez Juan Sanchez is manager, Latin American Department, Tampaz, Inc. Mr. Sanchez was born in Puerto Rico. He has lived in New York since 1931. A graduate of the Gomez Business College of Mayaguea, Puerto Rico, he also attended Columbia University. Mr. Sanchez served with the U.S. Navy during World War II. Ti Appointed to the New York City Commission on Human Rights, he also serves on the New York City Board of Correction and” on Local No. 3, Panel A. Selective Service System. Mr. suliven is a member of the boards of directors of the Community Council of Greater New York and the Manhattan Council of the Boy Scouts of America. He has served on the Board of Education's Commission on Integration, the White House Conference on Education, New York State, and the Governor's Committee on the Minimum Wage. . Mr. Sanchez is co-founder and past president of the Federation of Hispanic Societies, Puerto Rican Social Services, Inc., and the Puerto Rican-Hispanic Parade. 1816 March 31, 1971 ELIZABETH T. SCHACK Elizabeth T. Schack is employed by the department of public affairs, Community Service Society, as a researcher. She is past board president of the New York State League of Woman Voters and past president of the New York City League of Women Voters. A native of Chattanooga, Tennessee, Mrs. Schack attended the University of Chattanooga, Hunter College, and the School of General Studies, Columbia University. Mrs. Schack has been appointed by Mayor Lindsay to the Mayor's Committee on the Judiciary. She is a member of the Committee on Mental Health Services for the Family Court and the Association of the Bar of the City of New York's Centennial Committee on the decentralization of New York City's government. Mrs. Schack has three children. 1817 Leo Swirsky, M.D. Leo Swirsky, M.D., has been a general practioner since 1941. He is past president of the Kings County Chapter of the New York State Academy of General Practice. Dr. Swirsky is a graduate of the Royal Colleges of Scotland. He served in the armed forces from 1942 to 1946. He is also a delegate to the New York State Medical Society House of Delegates and serves on several committees of the Kings County Medical Society and the New York State Academy of General Practice. Dr. Swirsky is active in various civic projects, including the Brooklyn Museum, the Brooklyn Academy of Music, and the Brooklyn Philharmonic. 59-661 O - 71 - pt.8 - 7 ’ 1818 Jonn Douglas Van Zandt, M.D. John Douglas Van Zandt, M.D., is a general practioner. He is also chief of staff at Tuxedo Memorial Hospital, Tuxedo Park, New York. Dr. Van Zandt completed his undergraduate training at New York University. He did post graduate work at Harvard, Cornell, Duke and New York Universities. During World War II he served as a lieutenant in the Pacific. President of the Orange County Heart Association, he is past president of the Orange County Medical Society. Dr. Van Zandt is also a fellow of the International College of Surgeons, a member of the American Academy of General Practice, the New York Academy of Medicine, the American Medical Association and the World Medical Association. He is currently health official of the Village of Tuxedo Park and Tuxedo Hamlet. Married, he has two children. 1819 hy THEODORE C. WENZL Theodore C. Wenzl is president of the Civil Servic Employees Association in Albany, New York. Previously, Dr. Wenzl was with the State Education Sepmrunaid for twenty-four years and served as director $ of the Division of School Financial Aid. For four years, he was assistant executive director of the New York State Teachers Retirement Board. Dr. Wenzl has been a public school teacher and has taught at the University of Maryland, University of Buffalo and Alfred University. At the present time, Dr. Wenzl is president of the Bethlehem Public Library; trustee of the Upper Hudson Library Federation; and trustee of Capital District Chapter National Multiple Sclerosis Soeteiy, New York Arthritis Foundation, and United Fund Campaign Advisory Committee. Dr. Wenzl was educated at Rensselaer Polytechnic Institute and received his doctorate in education at Columbia University. 1820 Benjamin Werne Benjamin Werne is a lawyer specializing in industrial relations and collective bargaining. He is a professor of industrial relations at New York University School of Business Administration and a lecturer at Columbia Sniviestiy School of Administrative Medicine. He is also editor of the Industrial Relations Law Digest. Dr. Werne received his law degree from St. John's University and " his J.S.D. degree from New York University. Chairman of ‘the American Bar Association Committee on Wage and Salary Stabilization, he is also a member of the New York State and New York City Bar Associations, the American Arbitratio ssociation, and the Commerce and Industry Association. Dr. Werne has also authored several books in his field of speciali- zation. 3 1821 Senator Kexnepy. The next witness is Dr. Sanford Kravitz. Dr. Kravitz is dean and professor of social welfare of the State Uni- versity of New York, Stonybrook, since 1969. He received a Ph. D. in social welfare at the Heller School of Social Welfare of Brandeis, serves as consultant to numerous governmental agencies, has written extensively in many of these areas. STATEMENT OF DR. SANFORD KRAVITZ, DEAN OF THE SCHOOL OF SOCIAL WELFARE, STATE UNIVERSITY OF NEW YORK, N.Y. Dr. Kravitz. Senator Kennedy, Senator Dominick, as you have al- ready stated, IT am dean of the School of Social Welfare at the State University of New York at Stonybrook. I come with a background of experience. I think as you know, Senator Kennedy, I was Associate Director of the community action program in the Office of Economic Opportunity, in whose office the neighborhood health center program was developed. And I am also a member of the Citizens Board of Inquiry into Health Services for Americans. And more directly related to your presence here, 2 years ago I was director of a study in Nassau County which looked at the relationship of transportation and housing location to poverty and the availability of health and social welfare services to the poor. I would like to make several general points about health services which I believe are totally applicable to the suburban communities of Nassau and Suffolk Counties. One, as you have already heard, there are thousands of people in this area who do not receive adequate health care; at best only sporadic care. The system is in disarray. It doesn’t need a minor shift or minor changes, it is in disarray. And it is draining resources of government at all levels, corporations, labor organizations, and individual citi- zens. We have innumerable organizations operating at large profits on the disarray of the system—the insurance companies, the drug companies, the for-profit institutions, the hospitals, and the fee-for- service practitioners, few of whom have any interest in the more effective operation of the system, but do in fact oppose programs which might contribute to more effective organization, and demon- strate incredible arrogance, as we have already heard. Consumers have no effective role in health service delivery. And consumers, particularly the poor, have few meaningful options in health care today. I have seen the worst of this system in places like Lee County, Ark., and Stone County, Ark., as you have already heard in your Washington testimony from the Citizens Board of Inquiry and as your committee will see when you travel to these places. But you can be assured that even in sophisticated areas like Nassau County and Suffolk County physical access to adequate health care is a serious problem for the poor and near poor. Health services in these areas have been highly centralized, and with the incredibly medieval public transportation system that serves the counties of Nassau and Suffolk you can hardly get there from here. Health care is almost inaccessible for many of the poor and 1822 near poor. Health services are organized for the convenience of pro- viders, and there are literally no incentives to do anything else. I shall submit for the record maps detailing travel times to major health centers and their relative inaccessibility, and maps showing the location of physicians’ offices in this area and their relative in- accessibility to the poor, and maps showing the location of physicians who as of 1968, when the study was done, were participating in the medicare and medicaid program. The bills, more which will flow into this system from some new Federal legislation, will only have meaning if it is inextricably linked to pluralism and to competition in improving the delivery system. We need in suburbia conveniently located comprehensive care centers that are accessible to all who wish to use them. If you are healthy, mobile, and you have some money and some awareness, sophistication about the system, you can get with it and the system can deal with you, albeit inadequately. If you are poor, black, and you lack a car and you are relatively unsophisticated, you are caught in the middle of this chaos. Let me cite a homely example which I think most of you who have children would be familiar with. If you are an upper middle class mother and you have a regular pediatrician and your child has an ache or a rash you phone the pediatrician and the answering service says the doctor will call you back at 9 o’clock. And I submit that about 90 percent of the medical care that middle class and upper middle class families get for their children is over the phone from physicians at no cost fairly regularly, the 9 o’clock consultation. If you are poor and you have no regular pediatrician you get yourself on the bus to Meadowbrook Hospital with a baby in your arms and two by the hand, and you ride for an hour with two changes to get that information, and then you wait several hours before you get it. We have not developed any systems within this industry for deal- ing with these issues. We are at the mercy of providers and pro- fessionals who design the service system in terms that maintain their professional or institutional needs. The private insurance operations have made no effective contributions to these broad system needs. We have problems in the area of manpower. We have problems in the area of control in institutions. We have problems in the area of accessibility. We have problems in the area of quality of care, prob- lems in the area of distribution of resources. There is no reason to expect that a new windfall in terms of a Federal program will provide the extra incentive. A federally con- trolled program with incentives for innovation in delivery could conceivably do this. I think in large measure your bill, Senator, pro- vides for this. But I think any Federal program we get must provide the incentives for innovation and for access and for quality in the program. What we have done so far has done none of this. If T may, Senator Dominick, I would like to comment on your opening remarks. You did cite the maldistribution of physicians, and the maps that I will submit to the committee will show this maldistribution in Nassau County. But the statistics, these statistics 1823 about the number of physicians and how well we are doing can be compared to the man who drowned in a lake with an average depth of 3 inches. We have had an incredible expenditure of funds in the health in- dustry in this country, far higher than other countries on a per capita basis, and we have not forced providers or professionals to act in a socially responsible manner. I would hope that this legisla- tion will. This is not a new problem. Anybody who has been concerned with this field knows that the discussion about health care and health in- surance has been going on in this Nation for 50 years. Some of you may remember that President Truman in 1948 proposed a health care program. The reason we haven’t had one is because of the, again I say, almost incredible arrogance and opposition of the health in- dustry, the providers, who have absolutely no reason to try to im- prove the system unless the flow of funds forces them. The way in which the funds are expended by the Federal Government has to force them to respond to what people who are ill or people who may become ill may need. Thank you. [ Applause. ] Senator Kexxepy. Thank you very much, Dr. Kravitz. Could you direct your attention a little bit to the question of quality of health care in suburbia? There is a general kind of feeling in terms of middle America that if they have the resources, they can get to that hospital or call their doctor, that their sort of health needs are being met, and we have heard questions raised in terms of what that quality really is in suburbia, and should the middle income people really be concerned about the health crisis or is this really only a problem of the poor? Dr. Kravitz. Well, again several witnesses have cited personal ex- periences. I consider myself a relatively sophisticated person in this area, and I know that I have no adequate way of judging for myself the quality of care which I get. IT happen to be in a fortunate posi- tion of being in an institution which has a large number of well- qualified physicians, so I can, as a friend and colleague, call for responsible judgments. IT am at a loss to know how someone who is not in that fortunate position knows whether or not they are getting quality care. And I am talking about the middle class, upper middle class, higher income person, who has the capacity to go out and purchase the care, has a car to drive, is physically able to do so. If you are poor or if you are in a lower income category, if you have not had any kind of sophisticated background or education, you are at the mercy of the system. It is only when we begin to educate consumers as to the kinds of things they should appropriately know about and ask about—the witness from Blue Shield testified on the kind of criteria which they internally use within that system. Well, people outside the system ought to know this. Consumers ought to know what represents an overexpenditure of funds, misuse of time, too many drugs being given, and so forth. T am sure that information is not generally shared with the public about those people who do misuse these pro- grams. We ought to make public those institutions, those individuals 1824 who misuse these programs in this way so that they can be held up for public condemnation and can be avoided by the consumer. The professions protect themselves, and all professions—my own included—operate in the system maintaining waste, do not rock the boat. And until we begin to educate the public as to what are reason- able and responsible expectations that we can demand of profes- sionals and institutions the public will not know what is good quality care. Senator Kenx~xepy. Do you think that in terms of any kind of re- form of the system that we ought to be able to institutionalize the question of quality care for middle income and upper income people? Dr. Kravrrz. I think, as you may know, the concept of the neigh- borhood health center presented a model for health care that some of us would believe is a model for middle class and upper middle class people because of the possibility of providing comprehensive quality care that is not fragmented. T think the same kinds of things that we had hoped might be provided for all the poor ought to be provided for all people. Unfortunately, we are not doing it any- where near what we both, I think, hoped would happen. } Senator Kennepy. Do you think middle income people and upper a ought to be concerned about the health crisis in this country today ? So Kravitz. They ought to be. Of course they ought to be, and 1 think a lot of them are becoming: Senator Ken~epy. Not only in terms of their interest and their concern for less fortunate people, but just in terms of their own self-interest. Dr. Kravitz. The middle or upper income person has no reason to expect that they would get any better quality care in dealing with an individual practitioner or an institution than a poor person. The chances are they might. They just might because they have some- what more choice available to them. But they have no guarantees that this system will provide them with quality care. Senator Kexnepy. Do you think they really understand that? Dr. Kravitz. No; I don’t think they understand that, Senator. Senator Kennepy. I couldn’t agree with you more. Senator Dominick. Senator Dominick. Doctor, for a long period of time every time we tried to do anything in our area of the world we were constantly told that you shouldn’t do it in the outlying areas, you shouldn’t get group practices going in the outlying areas, and you should centralize everything around a major teaching school, because if you didn’t do that the doctors were going to have a lack of quality and you were not going to get good medical care, and so forth. This was backed for practically the entire decade of the sixties by HEW and by the respective administrations that were going on. And I gather from what you say that you want to decentralize medical schools and medical facilities rather than centralize them, is that correct? Dr. Kravitz. Not entirely. What IT am saying is a comprehensive system of care would provide for primary care located within easy access of every family who needed health service; decentralization to 1825 provide primary care at the level of the community hospital which would take care of those nonserious, noncritical kinds of illnesses which can well be handled at the community hospital level. We have tertiary care which is the medical school teaching kind of treatment. We don’t need to replicate these resources wherever a group of people decide they want to establish a medical school or a hospital. There has to be some system, and as I repeat, I think the system is in disarray, and it is in disarray because special interests have con- trolled where these services should be located, and rarely is the con- cern of the consumer or the user or the poor person ever figured into that system. Senator Dominick. Well, let me get back to my question, and let’s for a moment try to get away from the question of whether people are doing it for ulterior motives or something of that sort. I have been a strong supporter of decentralization of medical care at the primary level ever since I can remember, and I have been in more trouble trying to press this than anything I can think of. Under the administration program they do have under the medical student loan provision a forgiveness deal which is much larger than under the NDEA to get them to work in the rural areas, in the urban ghetto areas, and so forth. Do you have any feeling that this will work? Dr. Kravitz. I think it can work; yes. I think the medical students today are more and more interested in moving into those areas if they can be helped with the cost of their medical education. I see no reason why it can’t be made to work. We have had demonstration of interest on the part of people going into the Peace Corps, into VISTA. The best medical care that we encountered in the citizens board of inquiry study in the horrible setting of Lee County, Ark. was being administered by a VISTA physician. So IT do think it can work, and I agree with you whole- heartedly about the need for decentralization. Senator Dominick. And you also support the administration’s proposal on health education centers which would be distributed around the country ? Dr. Kravitz. I am not familiar with the detail of the concerns about health education centers. But since you raised the issue whether I am supporting a particular administration program, the admin- istration may be proposing that, on the other hand right now the administration in some of its cost-cutting efforts is grossly reducing the opportunity to train health professionals through the current cuts in a large number of scholarship and fellowship programs. And so at the same time we are proposing legislation which is to create this brave new world and these large groups of professionals, on the other hand currently in Washington we are reducing the number of fellowships and scholarships available to students in the allied health fields, in the nursing field, in the dental field, and in the medical field, to do that. Those two things are Senator Dominick. Doctor, let’s get the record straight. They are putting per capita cost of five times over what it was before for the 1826 medical students who are going to school, and if you can get him through medical school sooner he would still get the same amount of money ; so you are going to get more people in the field presumably, which is the idea behind it anyhow. So on a per capita basis the support of medical school, the administration has pretty strong sup- port behind it. Dr. Kravitz. Is it what is, or is it what is coming ? Senator Dominick. In the 1972 budget. Dr. Kravitz. In the 1972 budget ? Senator Dominick. Yes. Dr. Kravrrz. Delighted to hear it. Senator Dominick. Do you believe that in the time span within which we are working, that is, before July 1972, a varied program of health services should be developed ? Dr. Kravrrz. Oh, T certainly do think it is important. T think the legislation which emerges from these hearings should provide for a variety of options to be available, linking those options to their capacity to meet the kinds of needs that are uncovered by these hearings. Senator Dominick. And not just one single system ? Dr. Kravitz. Not just one single delivery system at the local level. The method of financing at the Federal level could conceivably obviously be one system. It is the delivery system at the local level that ought to provide for choice. Senator Dominick. But you ought to have a choice of whether you want to go to an HMO or private physician’s office or closed panel or Dr. Kravitz. Yes; whichever could deliver the best care. Senator Dominick. All right, thank you. Senator Kex~epy. Thank you very much, Doctor. We appreciate it very much. (The prepared statement of Dr. Kravitz follows :) 1827 TESTIMONY BEFORE THE SENATE SUBCOMMITTEE ON HEALTH ON 8-3 & H.R: 22 by Sanford Kravitz, Ph.D. Dean School of Social Welfare State University of New York Stony Brook, New York Hofstra College at Hempstead, Long Island, New York 1828 Senator Kennedy, Senator Dominick, my name is Sanford Kravitz. I am Dean of the School of Social Welfare in the Health Sciences Center at the State University of New York at Stony Brook. I come with a background of experience as the Associate Director of the Community Action Program Office of Economic Opportunity in whose office the Neighborgood Health Center Program was developed, as a member of the Citizen's Board of Inquiry into Health Services for Americans and more directly related to your presence here as the Director of a study On Nassau County two years ago which looked at the relationship of transportation to poverty and the availability of health and social welfare services to the poor. I would like to make several general points about health services which I believe are totally applicable to the suburban communities of Nassau and Suffolk Counties. 1. There are thousands of people in this area who do not receive adequate health care - at best only sporadic care - as you have already heard. 2. The system is in disarray and drains the resources of government at all levels, corporations, labor organizations and individual citizens. 1829 3. We have innumerable organizations operating at huge profits on the disarray of the system. The insurance companies, the drug companies, the for-profit institutions, the hospitals and the fee for service practitioner. Few of whom have any interest in the more effective operation of the system, but do in fact oppose programs which might contribute to more effective organization and demonstrate incredible array in such opposition. Consumers have no effective role in health service delivery. Consumers, particularly the poor, have few meaningful options in health care today. I have seen he worst of this system in places like Lee County, Arkansas and Stone County, Arkansas =- as you will when your committee travels to these places. But you can be assured that even in sophisticated and erudite Nassau & Suffolk County, physical access to adequate health care is a serious problem for the poor and near poor. Health services have been highly centralized and with an incredibly medieval public transportation system in this 1830 County and Suffolk cdariey - you can't hardly get there from here. For many poor or near poor health care is almost inaccessable. Services and facilities are organized for the convenience of providers and there are literally no incentives to do anything else. I shall submit for the record, maps detailing travel times to major health centers and their relative inaccessability. Maps showing the location of physicians offices in this area, and their relative inaccessability to the poor. The billions mere which will flow into this system from some new federal legislation will only have meaning if it is inextrically linked to choice, pluralism and to competition in improving the delivery system . We need in suburbia, conveniently located comprehensive care centers that are accessible to all who wish to use them. If you are healthy, mobile and you have some money and some awareness, the system can deal with you, albeit inadequately. If you are poor, black,lack a car and are relatively unsophisticated, you are caught in the chaos. Let me cite a homely example. You are middle class mother with a regular pediatrician. Your child has an ache or a rash so you get on the phone. At 9 AM you get a free pediatric consultation and you get 90% of your pediatric consultation over the phone. If you are poor, and have no regular pediatrician, you get yourself on the bus to Meadow- 1831 brook with one baby in your arms and two by the hand and ride an hour with two changes to get the information. We have not developed any systems within the industry for dealing with these issues. We are at the mercy of providers and professionals, who define the system in terms of main- taining their professions or institutional needs. The private insurance operations have made no effective contri- butions to solutions in the areas of manpower, control, accessibility, quality of care, or distribution of resources. There is no reason to expect that a new windfall will provide the extra incentive. A federally controlled program with incentives for innovation in delivery could conceivably do this: 1832 Senator Kennepy. Our next witnesses will be Mr. Leonard Kunken and his son, Kenneth. Until 5 months ago Kenneth was a junior in engineering in Cornell University, and last fall he suffered a tragic, devastating injury on the football field. Mr. Kunken, would you be kind enough to come up? I believe your son is here? Mr. KunkeN. Yes, sir. He is in the process of being taken out of the car, Senator. Senator Kennepy. Maybe you could tell us a little bit about your- self and what your business 1s and also tell us what you could about this accident to your son. STATEMENT OF LEONARD KUNKEN, AND HIS SON KENNETH KUNKEN, OF OCEANSIDE, N.Y. Mr. Kunken. First of all, gentlemen, I want to thank you very much for the opportunity to allow me to talk before you today. I feel that I do have a message of great import, and since it happened in my family, to me personally, of course, I can speak with authority. Ken was a junior in Cornell in the engineering school and was a member of the 150-pound football team. In a game against Columbia this past October 31 he made a tackle of the Columbia ball handler and instantaneously broke his neck and severed his spinal cord. Now most of the articles that have appeared in the various publications have been rather kind by just saying his neck was broken. But be- cause of the fact that my son has retained all his faculties it wasn’t until the other day that his doctor who initially performed the operation told him that he felt that the spinal cord had been severed. As a result of Kenny having the spinal cord severed on the fourth and fifth vertebrae he is now a quadraplegic. He cannot move any- thing beyond his neck, his head, and a slight shoulder movement. But has absolutely no function of his arms, his limbs, nor can he perform the normal body functions that we all do every day. The situation is such that the doctors haven’t been too hopeful for any change in his medical prognosis. And as such we are look- ing—I shouldn’t say we are looking forward to—but unfortunately the prognosis they gave is that there won’t be any substantial change in his future situation as far as being able to do anything on his own. I might say at the outset that it was rather touch and go for the first week, and, of course, the chances of his survival were quite re- mote. But he was able to pull through as a result of the excellent care that he received from the doctors up in Elmira where they trans- ferred him after the accident, and subsequently after remaining there for a month he was brought down to South Nassau Community Hospital in Oceanside, which is the local community hospital where we reside. While at South Nassau—he remained there for 3 months, and due to the fact that he was a local boy and the knowledge of the various physicians about his physical condition, I think that the medical staff both at South Nassau and also at Arnett Ogden Hospital in El- mira bent over backwards to minimize their bills. But even though they reduced their fees, I can tell you quite frankly, Senators, that 1833 as of the moment, which is now five and a half months today since the accident, our medical costs have been somewhere in the neighbor- hood of $40-odd-thousand, and presently are running at the rate of about $6,500 a month or better. IT say or better, because he is pres- ently at the Institute for Rehabilitation Medicine in New York City, which T believe you are familiar with, and the costs there are more or less on an entirely different basis than they were heretofore at the local community hospitals. Now how long he will remain at the Institute is problematical. The doctors are trying to perform certain rehabilitation procedures which they think may lend toward Kenny resuming a normal life. Since he has all his faculties and his mind is as sharp as ever, it is a question as to what they will be able to do that can make my son once again useful to society. Now unlike most types of catastrophic situations, there is no end to the medical costs involved. And projecting the medical expendi- tures in Kenny’s behalf IT daresay it is going to be a minimum of anywheres from $75,000 to $100,000 a year. But even on a basis such as this, if you knew once you had reached a certain amount of moneys that were to be expended that that would be it, you could say well, this is the problem, we will have to face it. But I don’t see how anybody can cope with such a situation as this, because frankly it is endless. There is no end in sight with all the medical bills. We have been told—and it is very obvious after you will see him—that he will need constant medical attention 24 hours a day for the rest of his life. He is presently—I think he will be brought in here in a wheelchair. But he cannot remain too long in a wheel- chair because of the fact that he is still not that stable that he can take any length of time without being able to be in a reclining position. I do have a major medical policy with my company, and ironically enough, I am in the insurance business. So it is something that IT feel T know firsthand. I have been in the business going on 25 years, and I have sold a great deal of major medical and life insurance during that period. But to my knowledge there is no plan that is being underwritten by any insurance company that in any way would personally cover all of Kenny’s medical expenses. I have a $25,000 policy with my company, which is the maximum coverage that the company would provide, and it wasn’t until just the beginning of this month that they added an additional $15,000, making a total of $40,000 coverage in toto which is the maximum amount that he will ever be able to have for the rest of his life. I have already used up about 40-odd-thousand and the chance of him ever being rehabilitated to the point where he would be self- sustaining or physically fit is out of the question. He is ineligible for ever obtaining more health coverage. We are talking about a young boy of 20 years of age; one moment his whole life in front of him, and the next moment nothing. Now my son does not want to become a social charge on the com- munity. He had every indication of becoming an engineer, and if not pursuing an engineering career, possibly an actuarial career with 59-661 O—71—pt. 8——S8 1834 my own company. As a matter of fact, he was to have taken the actuarial exam the week after the accident happened. Cornell has no coverage. They have never experienced any type of calamity in all their years of existence, and to my chagrin I find that most of the other schools are in the same position. Heretofore if a boy or a young female student were injured or ill they would utilize the facilities of the local medical center at the university and the college would assume all the costs. But suddenly out of nowhere they are faced with a devastating bill which is endless. T don’t think they know how to cope with it any more than I do. In addition to that, their first thought was that since they con- sidered there was no liability on their part that they should make a token gesture of some moneys to cover his initial medical expenses, which they did. And they have contributed at the moment some $12,000, which has been exhausted. Another fund instituted by the university from a special commit- tee also brought forth an additional 10,000. But, Senators, we are talking about amounts that run into the hundreds of thousands. So these are—if you will pardon the expression—peanuts. They don’t amount to anything after all is said and done because the situation still exists. } On the other hand, because of his age, 20, he wasn’t covered by social security even though he did have a social security number— and this is an ironic twist of fate. The last two summers he had been working as a lifeguard for the county, and since that’s more or less of a civil service position they are not covered by social security. In turn because they felt that these young boys who were working as guards at the beach clubs were just of a temporary nature they were ineligible for civil service status. So he had no social security, he had no civil service coverage. And in applying for disability benefits under social security I have a letter in my possession from the Government indicating that they are very sorry, but that he did not meet the necessary quarters; and yet while he was employed he was earning far in excess of the amount of moneys needed to be eligible for social security qualification. True, he is eligible for medicaid when he reaches the age of 21. But in order to be eligible for medicaid, as T understand it, he must more or less make himself destitute, that he will not be able to have income of more than approximately 180-odd dollars a month and divest himself of any personal assets that he may own over and above $1,600, which in this day and age is absolutely ridiculous. How do they expect a young man to be able to face society with this particular dilemma and be absolutely destitute and at the mercy of the world? I think I better stop now. You might have some questions. Senator KexnNepy. What is your reaction to the system of health in this country that burdens you not only with the enormous personal tragedy in terms of your son, but confronts you with financial ruin? Mr. Kunken. The local community where I reside, Oceanside, felt they had a personal well-being in Kenny and they went all out to institute a drive, which is currently in effect, whereby from the schoolchildren on up are running raffles, they are going from door 1835 to door and canvasing, they are doing everything humanly possible in order to raise funds to offset Kenny’s medical expenses. Now 1 say this to you, sir, advisedly, because if they are fortunate they will raise about $15,000, which at the present rates won’t last more than about two and a half months for us. I can’t expect these people to constantly shoulder my obligation. And let’s face it, being realistic, time has a way of making people forget. At the moment you might say he is good copy. Tomorrow the situation remains, but other than his immediate family there is nobody going to be there. Now my next step then is to divest myself of all my own personal assets and in turn become destitute in order to qualify for the system. Since I sell major medical insurance individually and in groups, as good as some of the coverage may be that the companies offer it is meaningless, because as fast as the companies offer a certain limit the medical costs that are incurred far exceed the limits of the various policies that are being written, and I don’t think that they will ever be able to cope with it because it is like the tail wagging the dog. And although I believe in free enterprise and I don’t feel that T am talking out of both sides of my mouth, I don’t really feel that the insurance companies—I am talking about the private car- riers—can actually be able to take care of the health problem that the people are being confronted with in the United States. And I might say parenthetically, sir, IT am not destitute. But by the same token, when you are talking about sums in excess of a hundred-odd-thousand dollars it doesn’t take very long to become destitute. Senator Kennepy. Do you know of any insurance policy by any private company in this country that could meet the kinds of obliga- tions and responsibilities that you have? Mr. Kunken. Well, since this accident came about, Senator, I have heard of one or two where they, let’s say, have a deductible of the amount of insurance that I currently have in force and that there is what they commonly call the piggyback. That would be the deductible, and where that leaves off the other commences. But to my knowledge I never had heard of it until this thing became a reality. Senator Ken~NEDY. You are in the business. Mr. Kunken. I am in the business, and I never heard of it, be- cause strangely enough—and I feel that T wrote one of the first major medical plans when it initially came out some years ago, and at that time they considered it a fairly large amount—I wrote a $5,000 major medical plan that was a cancellable plan by the com- pany, with the understanding that the company would have the right to cancel if they felt they had too many claims. And in one of the first policies I wrote the man did have a thousand dollar claim. And I thought this was out of this world—a thousand dollar claim. Now it is true everything is relative. But now, of course, most of the plans that are being written are being written on a noncancellable basis, but there is a lifetime maximum that the individual will be entitled to. And in my son’s situation there wouldn’t be any coverage. And also it was a known fact that you could not have duplicate coverage. In other words, you could have a small medical plan or a 1836 major medical policy with one company, and even if they only offered some $10,000 of coverage and you wanted to supplement it with a similar plan with another company you wouldn’t be allowed to do it. There was an unwritten law they wouldn’t allow you to have two plans in effect. Senator Kenney. You live out here in this community ?¢ Mr. KunkeN. Yes, sir; I live in Oceanside. Senator Kex~epy. How far is that? Mr. KunkeN. From Hofstra ? Senator KENNEDY. Yes. Mr. Kunken. Oh, about 6 miles. Senator Kexnepy. You have lived out here for some time? Mr. Ku~nkenx. Well, T have lived out here most all of my life, Senator. Senator Kex~epy. How far away do you work? Mr. Kunken. My office is in Queens County. This is Nassau County. But my principal place of operation is in Nassau County, further out on the Island which is Suffolk County, and in New York City. I work all over except possibly where my office is. Senator Kex~epy. This kind of tragedy which has affected your family and your son could really happen to anybody, couldn’t it? Mr. Kunken. After being at the institute for the past month and a half and seeing young boys, primarily, that are brought in from all parts of the country, and to see the devastating effects, I know now what people mean when they say “there but for the grace of God go LI.” Of course, it happens all over the country. And I am just wondering what the average person has been able to do who doesn’t have the major medical coverage that I had or some of the so-called benefits that they gave me, which in this instance is still meaningless because I will have used them all up very shortly. So I don’t think that the average person has even as much coverage or as little coverage as I have. Senator Kex~NEpy. What is the life expectancy of your son? Mr. Ku~nken. I have been told by the doctors that if Kenny gets through the first year his normal life expectancy is the same as you or I with maybe the exception of 1 or 2 years. Senator Kexnepy. And your best judgment is that that will be in terms of cost—what do you think it will be ? Mr. Kunken. Well, T am projecting it on the basis that at the moment the costs are running over 200-odd dollars a day at the institute. That does not include special apparatus that may from time to time be needed which I automatically give authorization to the institute to obtain for my son’s behalf. That’s why I gave you a figure of anywheres from $6,500 to $8,000 a month. Senator Kexnepy. Now, there’s no private insurance program, there’s no State program that you know of Mr. Ku~xkexn. Not for a boy Kenny’s age, because he is not yet 21. Now if it had happened 4 years earlier, when he was 17, it would have been that much worse. Senator Kex~epy. There is no Federal program ? Mr. Kunken. To my knowledge; no. 1837 Senator Kexnepy. Even the suggested recommendation by the ad- ministration in the President’s health message which puts the cutoff at $50,000, you would have run through that pretty quick, too, wouldn’t you? Mr. Kunken. I can answer you by telling you when people ask how is your son, I say, “well, quite frankly, he is a quadraplegic.” They say “that’s awful, but, of course, he can move his hands, can’t he?” Most people don’t even know what the term quadraplegic is. So when they are thinking in terms of $50,000, that in itself is as- tronomical. But what is 50,000 if you spend 51,0007 It is nothing. Senator Kennepy. Well, IT think once again perhaps it is a dif- ferent feature, but it is still an essential part of our health crisis in this country where you can have this kind of devastation upon you and your family and your whole future. Mr. Kunken. I can only look at my immediate family, and having always been what I thought was a good breadwinner in my own right, to suddenly be confronted with such a situation of this magni- tude, how can a person who supposedly didn’t have the where- withal that T have have been able to cope with this. Impossible. And he is my son. And it doesn’t make any difference how bad his situation is, I must protect him. Now costs at a stage like this are meaningless. You will do everything because you only have one life. But you see, I am still faced with the problem—so supposing I do divest myself of all my assets. So what? T am still going to be faced with the problem 1 month after it is all over, and I will still need the same medical attention, and then what am I supposed to do? Senator Dominick. Mr. Kunken, I just want to say I think you have great courage, and secondly, this 1s the type of situation which these hearings specifically hope to develop so we can see if we can’t get some program which will be of assistance to you. You are not alone in these kind of problems, as you know from having been to the institute yourself. Hopefully we will be able to work out some- thing. Now when this will come about or what the magnitude is, no one knows at the present time. But certainly this is one of the things that we must as a committee consider. If a person with your ability and your knowledge of the whole industry finds himself faced with this, there are many others around the country that must be in similar positions. Mr. Kunken. It was rather coincidental, Senator, that this article appeared in an editorial of Newsday the other day, which T assume prompted my being called to talk with you today, and I find that as a result of being here—I was just in the process, believe it or not, of contacting Senator Javits and Congressman Lent, who is my local Congressman, to see if some special law could be passed in Congress that could be of some help to my son. Now as a result of my having this opportunity to appear before you, if anything that my son has ever been able to accomplish in his short life would be to show people the catastrophic consequences as to what is happening to Kenny, I think he has done a tremendous service for the whole United States. And I don’t feel this could have been obtained in any other fashion than appearing before you representatives of our Government. 1838 Senator KEnnepy. Kenneth is here. He came out from New York. We didn’t want to burden him, but I understand he feels quite comfortable in talking about this. You are his father. You have told the story marvelously well. We are glad to have Kenneth comment, but I will follow whatever guidance Mr. Kunken. I don’t tell my son what to say. He is almost 21. Senator Kex~epy. Okay. We will hear from him. Mr. Ku~nkeN. Do you want me to stay here? Senator Kex~epy. Why don’t you? If you would be good enough to stay there. Mr. Ku~xkeN. Pardon me, Senator. My son may feel a lot freer if maybe I wasn’t here in the immediate vicinity. So I would rather go in the back. Is that all right with you? Senator KENNEDY. Yes, it is. Ken, we appreciate very much your coming out from the Rusk Institute. As you know, this is the Senate Health Subcommittee. We are interested in health legislation, and we have been holding hear- ings in Washington and now around the country. And, of course, we are terribly interested in the kinds of catastrophic health needs of the people of this Nation. There have been different suggestions which have been made in terms of recommendations to the Congress and the Senate, but we really haven’t responded to this kind of a problem in a really meaningful way. And you are good enough to come here today. Your father told us a bit about your experience earlier, and I think has dramatized perhaps as sadly, but as effectively as possible the unmet needs of this Nation in terms of meeting the kinds of problems which are suggested by your case. So you are really providing a great service, I think, to this committee and to the Senate, and I think to the Amer- ican people, in coming and talking with us today, and IT want to ex- press my very deep sense of appreciation on behalf of the committee for doing it. Mr. Kenner Kunken. Thank you. Senator Kexnepy. I thought if you might just tell us a little bit about yourself now and how you are getting along, and perhaps tell us a little bit about the accident itself, it would be very helpful. STATEMENT OF KENNETH KUNKEN, SON OF LEONARD KUNKEN, OCEANSIDE, N.Y. Mr. Kunken. I got hurt playing in a football game up at Cornell University, and that was October 31. And since I was hurt I have been paralyzed from the neck down. And that was instantaneous with the injury. It was after a tackle. Then I had a bone fusion done in my neck about 9 days later, and after about a couple of weeks I did get a little return back in my left arm. And I have the use of my shoulders, but very little else. So there is really nothing that I can do for myself now, or for the last 23 or so weeks that it has been since T have been hurt. So, what has been happening is I have had aides and attendants and nurses pretty much around the clock that have had to feed and dress me and turn me, say, every 2 hours to prevent my getting bed 1839 sores or to aid circulation. And I have been undergoing a lot of different sorts of therapy hopefully trying to get some movement back if it is possible. And I have been taking different sorts of breathing treatments because I don’t have the full use of my chest cavity, and it is really only my diaphragm I understand that is working to keep me breathing. So there have been a lot of different things that have been happen- ing since I have been hurt, and depending on each hospital I have been, where I have been moved to, I have had to go to a different schedule. Senator Kex~epy. How many different hospitals have you been to? Mr. Ku~nken. Well, T guess you could say it was four. I was originally brought to a hospital in Ithica, Sage Hospital, where they took x-rays of my neck and cut off my uniform. But from there I was transferred almost immediately to a hospital in Elmira, N.Y., which was the Arnett Ogden Hospital. 1 was there for 4 weeks. That’s where the operation was performed. When they felt I was well enough I was transferred to South Nassau Hospital in Oceanside. And I spent just a little over 13 weeks there, and then I was moved to the Institute of Rehabilitation Medicine in New York, where I am now. Senator Kexnepy. You were studying, as T understand, engineer- ing at Cornell. Mr. Ku~nken. That’s right. I was majoring in industrial engineer- ing. I was in my junior year. Senator Kennepy. You wanted to be an engineer ? Mr. Kunkexn. I did at the time. But I understand it may not be feasible for me to go back into engineering with the movement that I have or my ability to move around. I also hear engineers in the field have a little trouble at the moment, too. Senator Kexxepy. What kind of activity can you undertake now ? Can you read? : Mr. Kunken. Well, they are working on a page turner for me so that T may be able to read. They would have to prop a book on to the page turner and I would be able to work, say, a button with my chin. But as of yet we haven’t come up with a device that works well enough to read without getting really frustrated, because the page turner doesn’t work all the time and sometimes it turns more than one page, other times doesn’t even turn one page. So since I have been injured I have read very little. Senator KennEepy. Did you use to read a good deal before? Mr. Kunken. Well, I did a good deal as far as my studies went. Outside of my studies, a few magazines—you know, one or two books. But not really a great deal. Senator KEnnepy. As I understand, you never lost consciousness. Mr. Kunken. That is correct. Senator KENNEDY. So in terms of your mind or your ability, it has never really been affected at all by this accident, has it ? Mr. Kunken. Well, not as far as any type of injury done to it. But I think it has affected me a lot mentally as far as realizing the present condition that I am in now and the possibilities that I have for recovery, you know. There was no damage done. 1840 Senator Kenney. Are you looking forward to trying to go back to school some time in the future? Mr. Kunken. Yes; I am. But I am really not sure how that is going to work out, though, once IT do go back. IT understand I will always need an attendant with me for getting dressed, getting around, feeding, one thing or another. T am not even sure what I would like to study now, too. But I would like to go back to school. Senator Dominick. Ken, how many people are there in the Insti- tute with the same type of situation in which they need attendants all the time. Do you have any idea, or are you alone pretty much? Mr. Kunken. Well, T don’t really have any figures, any real num- bers. IT have yet to see someone there that has as little movement as I do. T understand there have been quite a number of people that were there that had very little movement. Right now, though, I haven’t seen anyone with this little movement. I know there are people, though, that do have some movement more than I do, but they still need attendants and they still need to be fed because the movement they have isn’t great enough to allow them to do it them- selves. Senator Dominick. Are they younger people down there with you or are they older people? Mr. Kunken. Well, they are mostly people right around my age group, I would say. I know they do have a pediatrics part to the hospital that I haven’t seen, so I know that there are a lot of young kids there. Sengkor Dominick. Are these mostly from accident cases, do you know ? Mr. Ku~nken. The people that T have seen have been mostly from accidents. Senator Dominick. Automobile or motorcycle ? Mr. Kunken. A lot of them have been from automobile accidents. A lot of them have been swimming and diving accidents. Those are the two accidents I think I have seen most commonly since I have been there. Senator Dominick. Well, I think both Senator Kennedy and I are extremely impressed with your willingness to come up and testify. I think it is going to be extremely helpful in our trying to work out something that will be of value to you, but also to the rest of the country. Mr. Kunken. Well, I hope so. Senator Dominick. And we really appreciate it. Mr. Ku~xgen. Thank you. It is my pleasure. Senator Kexnepy. We want to thank you. T think all of us have been enormously impressed by the tremendous advances in terms of research on injuries, particularly from the war in Vietnam. Mr. Ku~nken. Right. Senator Kex~Nepy. And I think great progress is being made. So we want to wish the best for you in the future, and we admire your determination. Mr. Kunken. Thank you. Senator Kexnepy. Keep up the good work. Thank you very much. 1841 Our next witness is Dr. Peter Rogatz. Dr. Rogatz is Associate Director for Patient Care Services at the Health Institute, State University of New York at Stony Brook. Is he here? Doctor, you have been extremely kind and patient in waiting, and our hearings are starting in northern Westchester at 2 o’clock so we are really under a time limit, but we want to hear from you. So you could file your testimony that you do have and we will make it a part of the record. Perhaps you can summarize briefly. We would certainly appreciate it. STATEMENT OF PETER ROGATZ, M.D., ASSOCIATE DIRECTOR FOR PATIENT CARE SERVICES, HEALTH SCIENCES CENTER, STONY BROOK, LONG ISLAND, STATE UNIVERSITY OF NEW YORK; DIRECTOR, UNIVERSITY HOSPITAL AND PROFESSOR OF COM- MUNITY MEDICINE AT THE HEALTH SCIENCES CENTER; VICE CHAIRMAN, NASSAU-SUFFOLK COMPREHENSIVE HEALTH PLAN- NING COUNCIL; AND VICE PRESIDENT, HEALTH AND WELFARE COUNCIL OF NASSAU COUNTY, N.Y. Dr. Roearz. Thank you, Senator Kennedy, Senator Dominick, my name is Peter Rogatz. I am associate director for Patient Care Serv- ices at the Health Sciences Center being developed on the Stony Brook, Long Island, campus of the State University of New York. I am director of the university hospital and professor of community medicine at the Health Sciences Center, vice chairman of the Nassau- Suffolk Comprehensive Health Planning Council and vice president of the Health and Welfare Council of Nassau County. It is a privilege to be invited to offer this testimony to your com- mittee. These views are my own. I am not speaking as a representa- tive either of the State university or of any other organization with which I am associated. Long Island, comprising the two counties of Nassau and Suffolk, represents a total area of approximately 1,400 square miles and a population exceeding 2.5 million. Because Long Island contains a variety of urban, suburban, exurban, and rural communities, it is in some respects a microcosm of the United States. The problems of health and medical care in Long Island exemplify those of our country as a whole. At the risk of oversimplification, IT would say that, in general, Suffolk County is primarily exurban and rural in character, while Nassau County is more typically suburban, with some significant urban concentrations. It is my understanding that this hearing is concerned chiefly with “suburbia,” and T will there- fore concentrate my comments on Nassau County. Economic levels in the county range from extreme affluence in some of the suburban “bedroom communities,” to bitter poverty in urban slums and in small, depressed “poverty pockets” that are scattered throughout Nassau. Hospitals, some of very good quality, are dispersed throughout the county. There is only one public hospital in Nassau County—the 1842 Nassau County Medical Center—and none in Suffolk. Distances from many parts of Nassau to the county medical center are con- siderable and the problem is compounded by serious deficiencies in public transportation. Two years ago, the one-way bus fare from Port Washington (on the north shore of the County) to the county medical center was $1.20 and travel time was approximately 1 hour and 15 minutes. Thus, for a mother to make that trip with two children would have cost $7.20 round trip and she would spend 214 hours just in travel time. Furthermore, for a person in pain or a mother with a sick child, a bus may be impractical or impossible; many people do not live within reasonable walking distance of bus routes; in some areas of the county, bus service is discontinued after 10 p.m. I was told recently of one person who found it so difficult to get to the Medical Center by public transportation that, despite a very limited family budget, she traveled by taxi, at a round trip cost of $10.50. Physicians’ offices are, of course, distributed more widely than hos- pital facilities. Although the ratio of physicians to general popula- tion is highly favorable (one physician to 527 people) by comparison to the U.S. average, physicians’ offices are heavily concentrated in affluent areas of the county; in poor areas the number of physicians is extremely small and, by almost any criterion, grossly inadequate. The County Medical Center operates a neighborhood health center in southwestern Nassau, and North Shore Hospital operates one in the northwest. In many situations, however, poor people lack reason- able access to primary health care services. Those who cannot utilize the Nassau County Medical Center, because of distance, tend to utilize the clinic facilities of the seven voluntary hospitals or the four centers operated by the County Health Department, but the range of services at many of these facilities is limited. Since the hours at which service is available are also limited, persons tend to present themselves at hospital emergency rooms, which were never designed to handle the heavy demand for primary health services now being placed upon them. Disease and death rates—for example, infant mortality and prevalence of tuberculosis—are high in those areas where the supply of physicians is low. This phenomenon is not due primarily to a shortage of physicians, but rather to the underlying factor of poverty which, itself, is the key reason for these areas being undersupplied with doctors. I believe that Long Island—perhaps because of its proximity to New York City—has attracted physicians who are above average in terms of professional qualifications. Where the number of physicians is adequate, middle- and upper-income patients are able to secure relatively good medical care. T have already commented on some of the difficulties that beset the poor. The low-middle- and low-income families who have cars and are thus not dependent upon public transportation often find their access to medical care limited by financial barriers. Many have little or no health insurance; those who do commonly find that their “coverage” is riddled with gaps and leaves them more “exposed” than “covered.” Even under the best of conditions, for the relatively affluent pa- tient, delivery of medical care in Nassau County suffers from the 1843 same kinds of problems observed elsewhere in the country. Utiliza- tion of hospital facilities, as elsewhere, is distorted by the benefit structures of available Blue Cross and commercial insurance plans. Coordination of services among different sources of care is poor; there is duplication of some services and absence of others. Mental health services, including prevention and treatment of drug abuse, are woefully lacking. Solo practice of medicine is the prevailing pattern and the potential advantages that group practice has to offer—both to patients and to physicians—are yet to be tapped on a large scale. The problems I have mentioned cannot properly be laid at the doorstep of the physicians or the hospitals in the area. One can cite any number of instances in which a particular doctor has extended himself in the most extraordinary ways to help patients—poor as well as rich; and instances in which hospitals have undertaken pro- grams to aid communities despite the lack of available financing. 1 believe the difficulty resides more in the fact that all providers of health care—physicians, dentists, nurses, hospitals, departments of health—are functioning within an archaic system, recognizing the defects of the system but almost powerless to modify it significantly because its nature is determined by factors that are essentially na- tionwide in character. Until there is a rational system established in which the individual elements can be properly coordinated and can function effectively, I think we shall continue to have serious dis- crepancies and inequities in the level of care available to different elements of our population, and serious inefficiencies in many of our health care programs. I consider the following to be fundamental premises upon which any effort to rationalize our health care system must be based: (1) There must be full entitlement to comprehensive health care for all persons. We must not continue to tolerate different standards of health care for different people, based on economic status. Wel- fare medicine cannot be good medicine. Medicaid, despite initial hopes, has proven to be nothing but welfare medicine in a poorly disguised form, and is being cut back step-by-step, until it has be- come no more than a grotesque caricature of its originally stated intentions. I think it is clear that universal health insurance is an essential first step. (2) Universal entitlement to health care will not, by itself, solve the problem. Reference is often made to our health care “delivery system.” Unfortunately, health services cannot be delivered in the same sense that milk, groceries, or newspapers are delivered. The patient who needs a gastrectomy cannot decide for himself when it is needed or if it is needed, and cannot have it delivered to his home. He must have access to a system that will stress maintenance of good health, prevention of disease, early detection and prompt treatment—whenever practical, on an ambulatory basis—and prompt referral to any needed source of specialized care. (3) A rational system can best be described by classifying health care into several levels: “Primary care” represents care rendered at the first point of contact. For minor conditions, definitive diagnosis can often be established and definitive treatment can sometimes be rendered at this point, but primary health care should not be de- 1844 signed chiefly to accomplish this. Its major purpose should be to en- able every person to receive prompt and easy access to the health- care system, with assurance either that definitive care will be rendered at the primary source or that he will be referred elsewhere for such care. Primary care may be provided by physicians in solo practice or in group practice, by hospital clinics or emergency rooms, by health department clinics, neighborhood health centers, and a variety of other sources. “Secondary care” encompasses diagnostic or treatment services requiring knowledge, skills, equipment or other resources not avail- able at the primary level. In addition to referrals for hospitalization, this would include referrals to consultant physicians—in solo prac- tice, group practice, or on salary at a hospital—as well as referrals to hospital clinics or free-standing clinics and referrals for radiologic or laboratory procedures under either private or institutional aus- pices. “Tertiary care” includes highly complex diagnostic and treatment services not available in most community hospitals, for which pa- tients must be referred to major centers—for example, nuclear medi- cine, super-voltage radiotherapy, kidney dialysis, and cardiovascular surgery. (4) If the system can be visualized as having these three major elements, we can clearly see the importance of developing close functional interrelationships among these elements. Such relation- ships should include procedures for the prompt referral of patients from one source of care to another; prompt transmittal of clinical data on each patient; efforts to establish reasonable uniformity of recordkeeping among all health-care agencies in a given area; and procedures designed to facilitate discussion of patient care problems and administrative problems among various sources of care. The recording and transmittal of clinical data in an organized and care- fully structured format can be a key tool in maintaining a rational system of health care. The “problem-oriented medical record” pioneered by Dr. Lawrence Weed at the University of Vermont offers the promise of a major breakthrough in this area. (5) Primary health care is the area where the need is greatest and where existing arrangements leave most to be desired. In the effort to improve primary health services, stress should be placed upon the following : (a) Special programs should be developed for those areas that are otherwise inadequately supplied with health services. A reasonable pattern might be neighborhood health centers staffed along group practice lines by teams of physicians, social workers, nurses, phy- sician assistants, and other allied health personnel. (b) Hospital clinics, health department clinics, neighborhood health centers and other such sources of primary health care should provide service during evening and weekend hours. In situations where hospital emergency rooms are not readily accessible, limited staffing should be provided in clinics and health center facilities, 24 hours a day, 7 days a week. (¢) A significant problem is the tendency for some physicians to become relatively isolated from the mainstream of current scientific and medical practice. Lack of a hospital staff appointment can repre- 1845 sent an almost insuperable obstacle to a doctor’s keeping abreast of new developments. Every physician should have a hospital staff ap- pointment. Those who cannot meet the standards for staff appoint- ments should have access to continuing education programs and in- centives should be developed—for example, periodic relicensure—to strongly encourage participation in such programs. (d) Physicians should be encouraged to develop group practice arrangements, through such means as support for construction of facilities, special grant support for effective experimental or demon- stration projects, and provision of reimbursement incentives to re- ward demonstrated efficiency. (e) More imaginative and more extensive use should be made of nonphysician health-care personnel. New roles for existing cate- gories and the development of completely new categories of per- sonnel—for example, physician assistants—must be explored. Let me stress that I believe it would be an error for educators and admin- istrators to create training programs for new types of personnel or to establish experimental staffing patterns in isolation from the professional groups concerned and from the community-at-large. For example, I believe that physician assistants will be able to play a useful role only if plans for their training and their future roles are developed in concert with practicing physicians, who will be their supervisors; with practicing nurses, who will be their co- workers; and with representatives of the community-at-large, who will be consumers of the services they will provide. (f) The emphasis, in primary care, must be upon maintenance of health, prevention of disease, and early detection of disease. Such emphasis can be expected only if health insurance benefits are de- signd so as to encourage ambulatory services in general and preven- tive services in particular. (9) Medical care should be given at that level within the system which can handle the problem least expensively, consistent with the needs of the patient. (2) The rights and feelings of every patient must be protected. A doctor cannot treat effectively any patient whose personal dignity he disregards, whether that patient be elderly, black, non-English- speaking, or a long-haired youth. (¢) Multiphasic screening can be a valuable element of the pri- mary health-care network, provided that all patient information re- quired by such a screening unit is transmitted to an appropriate source of medical care for follow-up and for incorporation into each individual’s permanent clinical record. (6) In giving attention to the health services that I have classified as primary, secondary, and tertiary, we should not overlook such institutions as skilled nursing homes, convalescent homes, rehabili- tation facilities, and domicilliary facilities, which do not fall logi- cally into the categories outlined above. These institutions represent vital elements in the health-care system and must be tied effectively into any network of health services. Physicians, nurses, and other personnel working in these institutions should have some type of affiliation with community hospitals and medical centers. The tradi- tional isolation that has made intermediate and long-stay institutions unattractive to professional personnel must be ended. 1846 I want to close with three general observations which I believe are of fundamental importance in any efforts toward improving health services in this country. First, medical care is not an end in itself, but is only one of the methods by which society seeks to secure the maximum degree of health for its citizens. There are other vital determinants of health. Broad social reforms, such as protection and control of our environment, adequate housing for all, adequate em- ployment for all, and adequate education for all will do more to secure the health of our citizenry than the doubling of our medical care manpower and capital plant. This does not mean that I regard the issues I have addressed in this statement as trivial, but rather that I believe they should be seen in the broadest possible perspec- tive. Second, I believe that consumers of health care must be seriously involved in developing overall policy directions for health. I am not referring to scientific and technical decisions, but to broad policy issues. I believe those of us who hold professional positions make a serious mistake when we seek to establish policy in line with our own concepts of what is needed, without sufficient regard for con- sumers’ perceptions of their own needs. Thus, although the pro- posals IT have outlined in this statement represent my personal views, I would want to see them tested in the fire of consumer participa- tion. The comprehensive health planning agencies that have been established in States and regions throughout the country under Pub- lic Law 89-749 are a significant step in the direction of consumer pazieipaiion and should, in my opinion, be encouraged and sup- ported. Third and last, when one endeavors to outline a program involv- ing significant organizational change, there is always the danger that it will appear oversimplified and will be interpreted as a plea for a rigid, monolithic system. This is certainly not my intention. For example, although I believe that group practice and develop- ment of new ways to utilize supporting personnel will permit sig- nificant improvements in the delivery of health care, I do not believe that physicians now in solo practice can be expected to abandon over- night the professional patterns to which they have been accustomed throughout their careers and to conform to new patterns with which they are unfamiliar. However, incentives can and should be devel- oped that will encourage physicians newly embarking on their careers—as well as those already in practice—to examine the ad- vantages that group practice can offer to themselves and to their patients. Whatever the defects in our medical care system—and they are many—there is also much that is good, and this can be lost to us if we attempt to impose Utopia through bureaucratic or legislative mandate. Utopia will always be out of reach—as it should be—but we will approach it best through a process in which providers and consumers share the responsibility for major policy directions and in which thoughtful legislation, making reasonable use of incentives, represents the vehicle for change. Thank you. (The following information was subsequently supplied for the record :) 1847 The consumer—the patient or his advocate—must begin to have a voice in planning and policy-making if we are to. obtain comprehensive health services. ROLE FOR THE CONSUMER PETER RoGATZ AND MARGE ROGATZ PETER ROGATZ, M.D., is Professor of Community Medicine and Director of the University Hospital at the State University of New York at Stony Brook. MARGE ROGATZ worked for CORE, Head Start In-Service Training, and, most recently, the Organization for So- cial and Technical Innovation (OSTI). 52 Until recent years, the hospital with the most prestige and the greatest ability to confer prestige upon those as- sociated with it (administrators, physi- cians, trustees) was the hospital offer- ing the largest number of beds, the most elaborate radiologic facilities, and the most spectacular surgical proce- dures. With this prestige comes power —power within professional organiza- tions and within the political environ- ment of the community—and, more often than not, monetary rewards. In the past few years we have seen some modest changes in the system of rewards and approvals, so that the most elaborate hospital is not always viewed as “the best”; and often the administrators, physicians, and trustees of the very elaborate hospitals bear the onus of explaining whether the hospital has been overnourished at the expense of sound community planning, whether it has become a source of ego gratification for its leaders at the ex- pense of self-restraint and interinstitu- tional cooperation that might better serve the interests of its community. Although the new trend has not been dramatic, we can perceive today that some of the rewards of profes- sional prestige, community approval, and federal funding are beginning to go to those administrators, physicians, and trustees who have committed their institutions to a more balanced pro- gram, one more cognizant of, and re- sponsive to, community needs. There is a slowly dawning awareness, for ex- ample, that a comprehensive mental health center may be more valuable than a unit for open-heart surgery, a neighborhood outreach program more worthwhile than a supervoltage radio- therapy unit or a hyperbaric chamber. But these new values need to be in- corporated into an incentives system. Accrediting bodies and third-party payers, along with public information media, have the power to reward those institutions and programs that enable middle- and low-income consumers to participate actively in policy-making. Clearly, this will not happen merely because consumers say it should. It can, and should, happen as a conse- quence of a dialogue among con- sumers, professionals, and trustees. If such a dialogue does not develop, or if it fails to produce a working con- sensus on involvement of consumers in an effective way, then consumers must take their case to third-party payers, accrediting bodies, and public information media, which represent the most effective points of leverage. PLANNING AND POLICY-MAKING Until recently, "opportunities for consumers to play ‘a meaningful role in the development of national policy for health care have been distinctly limited. Except for occasional “blue SociaL Poricy ribbon” advisory panels and occasional testimony before Congressional com- mittees and at other public hearings, there are no channels for consumer in- put at the national level. Some believe that the recent establishment of state- wide and regional comprehensive health planning agencies, with no less than 51 percent consumer membership mandated, will represent a new chan- nel for affecting national policy. This view may be prematurely optimistic. We do not know yet whether such re- gional and state groups will be gen- uinely representative or how much power they will acquire; nor do we have any indication thus far that the chaotic and fragmented process by which national health policies are de- veloped in the executive branch and in Congress will be responsive to in- puts from these groups. Simply mandating a technical ma- jority of consumers offers no assurance that the decision-making processes will not continue to be dominated, directly or indirectly, by professionals. First, many individual consumers are uncon- sciously under the spell of the profes- sional. Second, professionals have both an economic and an emotional stake in the decisions of these agencies and usually are able to attend meetings with greater regularity than the lay person. Third, there is always the pos- sibility that even a majority of con- sumers at a given meeting may be out- Janvary/FeBrUARY 1971 1848 maneuvered by the professionals who, after all, are operating on their own turf. In recent years, consumers have dealt with this by using the tactics of confrontation, boycott, and packing of meetings. Such tactics may spread, but must sooner or later be replaced by ongoing, effective interaction if ade- quate care is to be regularly provided and received. This interaction is most necessary at the local level, and it is locally that the greatest opportunities exist for con- sumers to assume a directive role in planning. Organization to obtain repre- sentation, accountability, and respon- siveness is more feasible at the local level than at higher echelons. The financial and time commitment re- quired to attend even local meetings regularly is difficult for many consum- ers, but it is less of an obstacle when the meetings are near home. Once the local planning agencies and boards of trustees have been altered to reflect the economic, ethnic, and age compo- sition of the communities they serve, comparable action at regional and na- tional levels may be facilitated. What of the frequent argument that the poor are “not ready” for major roles on boards of trustees because they lack experience in such matters as fi- nancial management? In fact, lack of such experience is less of a handicap than that faced by an affluent white banker who is knowledgeable in the preparation of budgets but has no ex- perience with deficiencies in the de- livery of health care to the poor. Mem- bers of the upper middle class, of course, have been serving on the boards of health agencies and boards of education for generations. Not sur- prisingly, the question of “readiness” was raised only when low-income Blacks and Puerto Ricans began to assert their determination to direct the institutions in their own communities. The question is prejudiced and self- serving. Since consumers, directly or indi- rectly, must foot the bill for abuse of hospital facilities, are they not en- titled to information about the deliber- ations of the utilization committees charged with preventing unnecessary use of hospital beds and/or ambula- tory facilities? Should this not extend “Criteria for the selection and evaluation of students, staff, and faculties of professional schools must be reex- amined in the light of consumer needs and experiences.” beyond mere information to actual participation in the deliberations of such committees? Although this raises questions of confidentiality and tech- nical competence, the former issue can be resolved, and the latter is prob- ably not a valid concern. There is no reason why a lay person cannot under- stand the matters dealt with by a hospital utilization committee and con- tribute constructively to its delibera- tions. There is no reason, for that mat- ter, why consumer-established stan- dards should not be included as criteria in every aspect of health program evaluation. MEDICAL EDUCATION One further area that might, at first glance, seem totally outside the pur- view of the consumer is professional education. Yet herein lies one of the most critical keys to a reorientation of the health-care system in this country if it is to attain greater responsiveness to the needs of users. Consumers must be included in decisions affecting this crucial element of the macrosystem. Criteria for the selection and evalua- tion of students, staff, and faculties of professional schools must be reex- amined in the light of consumer needs and experiences. The same is true for the design and content of curricula and materials. Traditional models— such as the goal of “scientist-practi- tioner”—need fresh scrutiny, with ac- tive participation by consumer spokes- men. New models being developed at a few schools, such as Case Western Reserve (Cleveland, Ohio), stress early relationships with patients. These models need encouragement and sup- port. . Until recently, the idea that a pa- tient might have some useful ideas 53 about the education of a doctor, nurse, or social worker would have been in- conceivable. The patient has always been utilized essentially as an inani- mate object in the teaching process. He is a subject for tion; and if he is invited to speak at all, it is only for the purpose of reciting his symp- toms so that the student can evaluate his illness. However, students can also learn much from patients about provider- user relationships. It is time for the consumer—the patient—to become a teacher as well. Some police depart- ments, recognizing the need for police- men to better understand those with whom they are so often in confronta- tion, have asked students and repre- sentatives of the poor to participate in training seminars. Why shouldnt pro- fessionals in the health field show at least as much enlightened self-interest in exposing themselves, in their own education, to those who are, or will be, their clients? Implicit in the preceding discussion is the unsettling thought that there may actually be something inherent in the training of the professional that helps to build a barrier between him and his patients, blurring communica- tion, making him resistant (perhaps subconsciously) to certain of his pa- tients’ demands, and making the pa- tient pici of the professional's ability or willingness to provide the care that is needed. Often when a member of the indigenous poor secures access to a provider role—even as an aide or a paraprofessional—he is sub- ject to many of the same symptoms of professionalism that afflict physicians, nurses, and social workers. Can we learn how best to encourage the nurse's aide, as well as the physician, to resist adopting the mystique of the profes- sional? This would involve both be- havioral scientists and community groups in designing and implementing new patterns of training. Neighbor- hood health centers, from Mississippi to New York, have used such training and have established promising mod- els. References here to the consumer's need to speak for himself and confront the professional establishment should not obscure the fact that the consumer 54 59-661 O - 71 - pt.8 - 9 1849 : does have allies in the professional world who are addressing themselves seriously to his needs and concerns. Far more active than established pro- fessionals are the students. Increasing bers of medical stud for exam- ple, are telling their deans and profes- sors that, although they are confident of being well educated scientifically and technologically, they want their schools to be concerned with the ap- plication of and technology in the day-to-day delivery of personal health care. Students learn at least as much by example as by precept, and role mod- els are of great importance in forming future attitudes. It does little good to tell students about a hospital's respon- sibilities to its community if they ob- serve in the emergency room of their university hospital that patients with conditions that do not satisfy the intel- lectual interest of their staff or faculty are shunted away to other hospitals. Nor is there much value in lecturing about the dignity of the individual when students observe the predisposi- tion of doctors and nurses to patronize patients from minority groups and those of low income by addressing them by first name (while the patient, of course, is expected to use formal terms of address when speaking to a doctor or nurse). These examples have a fund tal impact upon the atti- tudes of students in medicine and nursing. Many medical schools reserve their highest rewards (in terms of promo- tion, tenure, and salary) for those faculty members who are concerned primarily with research, rather than for those concerned with patient care. Students, can hardly fail to be in- fluenced by such practices. This is not to say that medical schools should stop doing research or that they should admit to the hospital any patient who presents himself to the emergency room and demands admission regard- less of valid clinical indications. It is to say, however, that many of the practices and procedures followed in our professional schools and university hospitals offer an example of indiffer- ence to patient care that belies the stated purposes of these institutions. Consumers and their allies among stu- “The more local the focus of a particular program, the more critical it is that con- sumers participate actively in it.” dents and professionals must be lis- tened to and heeded in these respects. PROGRAMS AND SERVICES This nation is just beginning to give lip service to the point of view that the delivery of health care is suffi- ciently important and complex to re- quire the development of a carefully designed network of coordinated pro- grams. Such programs must range from health promotion and maintenance, through prevention, screening, and early detection, to an integrated net- work of primary, secondary, and terti- ary centers for diagnostic and treat- ment services. Well-informed professionals, with good intentions, have persistently and self-righteously resisted the obvious fact that consumers must have a sig- nificant role in the design, implemen- tation, and evaluation of health-care services. Indeed, some programs (for example, those for the prevention of venereal disease or lead poisoning) can be successful only insofar as residents of the community participate in their development, in disseminating infor- mation about them, and in their staffing. The more local the focus of a par- ticular program, the more critical it is that consumers participate actively in it. A graphic example is the recent “hijacking” by the Young Lords of a mobile tuberculosis screening unit op- erated by the New York City Depart- ment of Health. The Young Lords be- lieved that a change in the location of the unit would produce a substantial increase in utilization and, through the dramatic “hijacking,” they effec- tively demonstrated this point. The problem is not that professionals are trying to put something over on their patients, but that the perceptions of providers differ substantially from those of consumers. More importantly, underlying assumptions of providers and consumers differ significantly. | SociaL Poricy The professional sees himself as the central or pivotal figure in the pro- vider-user equation: it is he who pos- sesses the vital knowledge and who must perform numerous tasks within a limited period of time in order to care for a large number of patients. They, after all, are the ones in need; and if they wish to have their needs met, they must make themselves available to him at the times and places and under circumstances that make it possible for him to function with the greatest economy of effort. The consumer, on the other hand, sees it differently: he needs relief from pain, disability, or anxiety; and he sees it as the provider's responsibility to help him obtain that relief. Poor con- sumers are beginning to come to the point of view that affluent consumers have long held—that optimum health care can be provided only under con- ditions that protect the dignity and convenience of the patient as well as of the physician and the nurse. This latter view is gradually coming into vogue among professionals; but, here again, it is one thing to give lip service to this point of view and quite another to function under conditions that are determined by this premise. Professionals will find it difficult and irksome to function under consumer surveillance and will be quick to charge that this will result in unwar- ranted and dangerous interference with medical practice. Consumers and professionals will have to confront a host of questions, ranging from minor procedures to fundamental policy. Shall the outpatient department be organized primarily along departmen- tal lines, or shall each clinic be ori- ented toward comprehensive health services, with consultants on call at every clinic? Many physicians believe that conversion to comprehensive clinics will make it more difficult and time-consuming to treat patients with common specialty problems. Con- sumers seem to feel that a patients total needs are more likely to be met by a comprehensive clinic than by a series of isolated specialty clinics. Pro- fessionals argue that if specialists do not have ongoing involvement with concentrated pools of patients, their specialized skills will atrophy and will January/Fesruary 1971 1850 G6Luecic] and bitterly disturiing.’? —Publishers’ Weekly “Blur the issue if possible. And never give a direct answer.” That's the advice the old pros gave a young pediatrician, Dr. Arthur Levin, when he joined HEW (Department of Health, Education and Welfare. Annual budget: $15,000,000,000). They made him an instant expert on child care, clued him in on “satisficing” (*do just enough to get by), and, above all, they urged him, “Don’t rock the boat.” The satisficers—as Levin quickly discovered— were everywhere. Heading up government agen- cies. Letting grave decisions be made by default. Slowing down programs to a snail's pace. Taking iteasy while vital reports went unread. Getting by—while people died because of the plans HEW didn’t make and the action they didn't take. This is a bold, highly personal and inflammatory record. It tells you about: El The big wheel who was totally unaware of a crucial research project funded by his agency. | How officials dealt with the embarrassing discovery that thousands of Americans die each year from lack of an artificial kidney machine that government researchers have known how to build for a decade. 0 The case of the Budget Committee's secret meeting and the $1,000,000 research report they ignored although it gave crucial information about a cancer vaccine and an artificial heart. And much more... - This book could never have been written before the recently enacted Truth in Government law, because many of its episodes are substantiated by transcripts and memoranda that would have been classified “ADMINISTRATIVE CONFIDENTIAL.” It's a hair-raising, incredible story of the questions that are never officially asked—and the ones that are blandly satisficed. THRE SATISEFICERS® k Official Washington's unwritten rule: Do just enough to get by. An appalling first-hand account by ARTHUR LEVIN, I'.D. with an introduction by Senator George McGovern $5.95, now at your bookstore Ris 55 no longer be adequate to serve the needs of consumers. Consumers coun- ter that the main advantage of spe- cialty clinics is to serve the academic curiosity and ego needs of the special- ist. Consumers assert that nursing pro- cedures, such as waking patients at early hours for temperature-taking and baths, are designed for the con- venience of the nursing personnel. Nurses and hospital administrators re- spond that the realities of staffing pat- terns and the multiplicity of the es- sential procedures to be carried out throughout the day make it impracti- cal to allow each patient to wake at his own convenience. Consumers com- plain that mealtimes are set for the convenience of the staff; the profes- sionals counter with arguments relat- ing to the demands of personnel sched- ules and the complexity of overall hospital operations. Consumer participation in the plan- ning process is likely to result in serv- ices’ being brought to neighborhoods where consumers work and live, rather than the construction of facilities that require people to travel unreasonable distances to obtain primary health care. When communities have been permitted to join in planning for their own services, many have proposed such measures as greater use of mo- bile health units and the placing of facilities in stores, housing develop- ments, and other outreach sites. In addition to improved physical access for users (leading to improved utiliza- tion and, one hopes, improved health), such outreach arrangements increase the likelihood that professionals will become better acquainted with the living and working conditions of those they serve. Hospitals and other agencies that establish outreach facilities may find that staffing advantages result. The chronic shortage of personnel that af- flicts large, centralized facilities may be substantially ameliorated when fa- cilities are decentralized and thus are * accessible to potential pools of em- ployees. This assumption, of course, rests on the premise that hospitals and health-care agencies are prepared to draw upon indigenous groups as sources of manpower for jobs beyond 58 1851 the menial ones to which they have been traditionally confined. The combination of readiness to train and employ indigenous persons for semiprofessional and professional jobs and decentralization of formerly centralized facilities offers the promise of very significant improvement in the nation’s ability to meet its health man- power needs. This solution can be effective only if there is cooperative planning among provider agenci professional schools, and communi- ties. There must be arrangements that assure that a steady supply of indige- nous applicants will be accepted by the professional schools and that, when they subsequently return to their own local communities, they will be reasonably sure of employment by the provider agencies. PATIENT-ADVOCATES In the final analysis, there are few unassailably “right” answers; and dif- ferences of opinion will be resolved in favor of whichever side holds an edge in terms of power. What must be sought is a reasonable balance of power between providers and con- sumers—a balance that will persuade each to listen to the other with some degree of restraint, respect, and at- tention and that will, in the long run, enable both points of view to be worked into a series of compromises that will best serve the needs of the communily of which the professional, too, is a po Special arrangements will have to be made if consumers are to partici- pate to the extent proposed here. Day- care programs, which should be pro- vided for employees who need them, should be available also for those con- sumers who, as patients, as visitors, or as members of boards and committees, require such services. Additional as- sistance may also be necessary for travel subsidies, for example, to en- able consumers to attend meetings. Until programs and services receive enough consumer input to be reason- ably responsive to consumer demand, there will be a continuing need in almost every program for a patient- advocate, or ombudsman. Such a per- son, selected by the community, should be particularly sensitive to, and have the ability to intervene on behalf of, consumers whose needs are not being met. Introduction of a patient-advocate raises complex and sensitive issues. If the advocate is to function effectively, he must be able to report his findings to the community—that is, to a body representing the community, Neither the administrator nor any group made up lusively of professional matter how well motivated—can serve as his sole channel of reporting. Al- though it is vital that the professional (including administrative) staff be aware of what the ombudsman learns, his authority must derive from the community, or he will be essentially impotent to effect change. If the board of trustees is broadened to include low-income consumers, it may be able to serve as the ombudsman’s line of reporting. A community advisory board can serve this function, but its effectiveness will depend on the ex- tent to which it (the advisory board) has access to, and influence upon, the board of trustees. The matters ‘that will concern a patient-advocate range from mundane to fundamental. Is there a faulty air conditioner in a patient’s room that has not been repaired? Are outpatient clinic hours set without regard for patient needs? Are patients who seek abortions subject to unreasonable de- lays? Because of the wide range of problems with which he must deal, the ombudsman must have access to lines of communication that will as- sure prompt repair of the air condi- tioner as well as lines of communica- tion that will affect long-range policy issues. ’ Consumers in policy roles and non- professionals in service roles represent a long-overdue invasion of the health field on two fronts. This invasion may ultimately produce important changes in the attitudes of providers and users, rich and poor. In the process, there will undoubtedly be innumerable con- frontations and severe upheaval. But health services will not become con- sumer-responsive until consumers in all economic groups are accepted as full partners in directing basic reform of the total health system. m : "Soci Poricy 1852 Senator Kennepy. Thank you very much. Senator Dominick I think has some questions. Senator Dominick. I have just one question, Doctor. We have an effort going in our city of Denver to provide linkage between the primary, secondary, and tertiary care system by electrograph com- puter bank which is community based supported by three of the principal proprietary hospitals, not voluntary hospitals, and linked in with outlying areas, so that a doctor can call up and say, “look, I have got the electrodes on this guy, this is what it shows,” it goes into the bank, and out this comes on the panel. Now the cardiologist goes over to make sure the computer hasn’t made a mistake, which I think is necessary in a community center. I think this is the type of thing which seems to me to be on its way. Do you know many places where this is going on? We had Dr. Schwartz, I believe it was, testify. Dr. Weed has testified. Are there other places that are doing this? Dr. Rogarz. There are experimental demonstration efforts along this line. It happens that electrocardiography lends itself well to this type of computer analysis. And I do believe in fact that except in very, very rare kinds of electrocardiography the computer is as good as the physician in interpretation. There are other kinds of medical services that do lend themselves to the use of modern tech- nology. Multiphasic screening, which is a way of testing large num- bers of apparently well people for evidence of latent disease, is an- other important example. Laboratory procedures can be now handled extremely well by computer. And I think while every once in so often we get a little bit con- cerned that the computer 1s going to mechanize and dehumanize the patient’s care, in fact if we recognize it as a tool, and .as a tool which we control rather than allowing that tool to control us, we can really greatly facilitate patient care and at the same time leave profes- sionals more time and leave them more free to deal with the direction personal doctor-patient contact, and 1 think that this kind of tool is one that we should use and exploit. Senator Dominick. Thank you, Doctor. I look forward to reading your full statement, and I think you have been very helpful. T really appreciate it. Senator Kennepy. Thank you very much. (The prepared statement of Peter Rogatz, M.D., follows:) 1853 TESTIMONY BEFORE SENATE SUB-COMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE April 15, 1971 Hofstra University, Hempstead, New York by Peter Rogatz, M.D. Mr. Chairman, my name is Peter Rogatz. I am Associate 3 Director for Patient Care Services at the Health Sciences Center being developed on the Stony Brook, Long Island campus of the State University of New York. I am Director of the University Hospital and Professor of Community Medicine at the Health Sci- ences Center, Vice-Chairman of the Nassau-Suffolk Comprehensive Health Planning Council and Vice-President of the Health and Welfare Council of Nassau County. It is a privilege to be invited to offer this testimony to your Committee. These views are my own. I am not speaking as a representative either of the State University or of any other . organization with which I am associated. Long Island, comprising the two counties of Nassau and Suffolk, represents a total area of approximately 1,400 square miles and a population exceeding 2.5 million. Because Long Island contains a variety of urban, suburban, exurban and rural communities, it is in some respects a microcosm of the United 1854 States. The problems of health and medical care in Long Island exemplify those of our country as a whole. At the risk of over-simplification, I would say that, in general, Suffolk County is primarily exurban and rural in character, while Nassau County is more typically suburban, with some significant urban concentrations. It is my understanding that this hearing is concerned chiefly with "suburbia," and I will therefore concen- trate my comments on Nassau County. Economic levels in the County range from extreme affluence in some of the suburban "bedroom communities," to bitter poverty in urban slums and in small, depressed "poverty pockets' that are scattered throughout Nassau. Hospitals, some of very good quality, are dispersed through- out the County. There is only one public hospital in Nassau County -- the Nassau County Medical Center ~-- and none in Suffolk. Distances from many parts of Nassau to the County Medical Center are considerable and the problem is compounded by serious defi- ciencies in public transportation. Two years ago, the one-way bus fare from Port Washington (on the North Shore of the County) to the County Medical Center was $1.20 and travel time was approximately one hour and fifteen minutes. Thus, for a mother to make that trip with two children would have cost $7.20 round trip and she would spend two and a 1855 half hours just in travel time, Furthermore, for a person in pain or a mother with a sick child, a bus may be impractical or impossible; many people do not live within reasonable walking distance of bus routes; in some areas of the County, bus service is Shseanttrund after 10:00 pm. I was told recently of one person who found it so difficult to get to the Medical Center by public transportation that, despite a very limited family budget, she travelled by taxi, at a round trip cost of $10.50. Physicians' offices are, of course, distributed more widely than hospital facilities. Although the ratio of physicians to general population is highly favorable (one physician to 527 people) by comparison to the U.S. average, physicians' offices are heavily concentrated in affluent areas of the County; in poor areas the number of physicians is extremely small and, by almost any criterion, grossly inadequate. The County Medical Center operates a neighborhood health center in southwestern Nassau, and North Shore Hospital operates one in the northwest. In many situations, however, poor people lack reasonable access to primary health care services. Those who cannot utilize the Nassau County Medical Center, because of distance, tend to utilize the clinic facilities of the seven voluntary hospitals or the four centers operated by the County Health Department, but the range of services at many of these facilities is limited. 1856 Since the hours at which service is available are also limited, persons tend to present themselves at hospital emergency rooms, which were never designed to handle the heavy demand for pri- mary health services now being placed upon them. Disease and death rates -- for example, infant mortality and prevalence of tuberculosis -- are high in those areas where the supply of physicians is low. This phenomenon is not due primarily to a shortage of physicians, but rather to the under- lying factor of poverty which, itself, is the key reason for these areas being waleresipplied with doctors. I believe that Long Island -- perhaps because of its proximity to New York City =-- has attracted physicians who are above average in terms of professional qualifications. Where the number of physicians is adequate, middle-and upper-income patients are able to secure relatively good medical care, 1 have already commented on some of the difficulties that beset the poor. The low-middle and low-income families who have cars and are thus not dependent upon public transportation often find their access to medical care limited by financial barriers. Many have little or no health insurance; those who do commonly find that their "coverage' is riddled with gaps and leaves them more "exposed" than "covered." 1857 Even under the best of conditions, for the relatively affluent patient, delivery of medical care in Nassau County suffers from the same kinds of problems observed elsewhere in the country. Utilization of hospital facilities, as elsewhere, is distorted by the benefit structures of available Blue Cross and commercial insurance plans. Coordination of services among different sources of care is poor; there is duplication of some services and absence of others, Mental health services, includ- ing PRESEN and treatment of drug abuse, are woefully lacking. Solo practice of medicine is the prevailing pattern and the potential advantages that group practice has to offer =-- both to patients and to physicians -- are yet to be tapped on a large scale. The problems I have mentioned cannot properly be laid at the doorstep of the physicians or the hospitals in the area. One can cite any number of instances in which a particular doctor has extended himself in the most extraordinary ways to help patients -- poor as well as rich; and instances in which hos- pitals have undertaken programs to aid communities despite the lack of available financing. 1 believe the difficulty resides wore in the fact that all providers of health care -- physicians, dentists, nurses, hospitals, departments of health -- are func- tioning within an archaic system, recognizing the defects of the system but almost powerless to modify it significantly because 1858 its nature is determined by factors that are essentially nation- wide in character. Until there is a rational system established in which the individual elements can be properly coordinated and can function effectively, I think we shall continue to have serious discrepancies and inequities in the level of care avail- able to different elements of our population, and serious in- efficiencies in many of our health care programs. I consider the following to be fundamental premises upon which any effort to rationalize our health care system must be based: 1. There must be full entitlement to comprehensive health care for all persons. We must not continue to tolerate different standards of health care for different people, based on economic status. Welfare medicine cannot be good medicine. "Medicaid, despite initial hopes,has proven to be nothing but welfare medicine in a poorly disguised form, and is being cut back step-by-step, until it has become no more than a grosesqia caricature of its origin. ally-stated intentions. T think it is deer ghat ‘universal health insurance is an essential first step. 2, Universal SuEiEIenent to health care will not, by itself, solve whe problem, Reference is often made to our health care "delivery system." Unfortunately, health 1859 services cannot be delivered in the same sense that milk, groceries or newspapers are delivered. The patient who needs a gastrectomy cannot decide for himself when it is needed or if it is needed, and cannot have it delivered to his home. He must have access to a system that will stress maintenance of good health, prevention of disease, early detection and prompt treatment (whenever practical, on an ambulatory basis), and prompt referral to any needed source of specialized care. 3. A rational SSE can best be described by classifying health care into several levels: Primary care represents care rendered at the first point of contact. For minor conditions, definitive diagnosis can often be established and definitive treatment can sometimes be rendered at this point, but primary health care should not be designed chiefly to accomplish this. Its major purpose should be to enable every person to receive prompt and easy access to the health care system, with assurance either that definitive care will be rendered at the primary source or that he will be referred elsewhere for such care. Primary care may be provided by physicians in solo practice or in group practice, by hospital clinies or emergency rooms, by health department clinics, neighborhood health centers, and a variety of other sources. 1860 Secondary care encompasses diagnostic or treatment ser- vices requiring knowledge, skills, equipment or other en sources not available at the primary level. In addition to referrals for hospitalization, this would include referrals to consultant physicians (in solo practice, group practice, or on salary at a hospital), as well as referrals to hospital clinics or free-standing clinics and referrals for radiologic or laboratory procedures under either pri- vate or institutional auspices. Tertiary care includes highly complex diagnostic and treatment services not available in most community hos- pitals, for which patients must be referred to major cen- ters (e.g., nuclear medicine, super-voltage radiotherapy, kidney dialysis and cardiovascular surgery). 4, 1f the system can be visualized as having these three major elements, we can clearly see the importance of devel- oping close functional inter-relationships among these elements. Such relationships should include procedures for the prompt referral of patients from one source of care to another; prompt transmittal of clinical data on each patient; efforts to establish reasonable uniformity of record-keeping among all health care agencies in a given area; and pro- cedures designed to facilitate discussion of patient care os 1861 problems and administrative problems among various sources of care. The recording and transmittal of clinical data in an ranted and carefully structured format can be a key tool in maintaining a rational system of health care. The '"problem-oriented medical record" pioneered by Dr. Lawrence Weed at the University of Vermont offers the promise of a major breakthrough in this area. 5. Primary health care is the area where the need is greatest and where existing arrangements leave most to be desired. In the effort to improve primary health ser- vices, stress should be placed upon the following: (a) Special programs should be developed for those areas that are otherwise inadequately supplied with health services. A reasonable pattern might be neigh- borhood health centers staffed along group practice lines by teams of physicians, social workers, nurses, physician assistants and other allied health personnel. (b) Hospital clinics, health department clinics, neigh- borhood health centers and other such sources of pri- "mary health care should provide service during evening 1862 10. and weekend hours. In situations where hospital emer- gency rooms are not readily accessible, limited staffing should be provided in clinics and health center facili- ties, 24 hours a day, seven days a week, A (c) A significant problem is the tendency for some phy- sicians to become relatively isolated from the main- stream of current scientific and medical practice. Lack of a hospital staff appointment can represent an almost insuperable obstacle to a doctor's keeping abreast of new developments. Every physician should have a hos- pital staff appointment, Those who cannot meet the stan- dards for staff appointments should have access to con- tinuing education programs and incentives should be de- veloped (e.g., periodic relicensure) to strongly encourage participation in such programs. (d) Physicians should be encouraged to develop group practice arrangements, through such means as support for constructién of facilities, special grant support for effective experimental or demonstration projects, and provision of reimbursement incentives to reward demonstrated efficiency. (e) More imaginative and more extensive use should be made of non-physician health care personnel. New roles 1863 11, for existing categories and the development of completely new categories of personnel (e.g., physician assistants) must be explored. Let me stress that I believe it would be an error for educators and administrators to create training programs for new types of personnel or to estab- lish experimental staffing patterns in isolation from the professional groups concerned and from the community-at- large. For example, I believe that physician assistants will be able to play a useful role only if plans for their training and their future roles are developed in concert with practicing physicians (who will be their supervisors), with practicing nurses (who will be their co-workers) and with representatives of the commmity-at-large (who will be consumers of the services they will provide). (£f) The emphasis, in primary care, must be upon mainten- ance of health, prevention of disease and early detec- tion of disease. Such emphasis can be expected only if health insurance benefits are designed so as to éncour- age ambulatory services in general and preventive services in particular. (g) Medical care should be given at that level within the system which can handle the problem least expen- sively, consistent with the needs of the patient. 1864 12, (h) The rights and feelings of every patient must be protested, A doctor cannot treat effectively any patient whose personal dignity he disregards, whether that patient be elderly, black, non-English-speaking, or a long-haired youth, 1) Multiphasic screening can be a valuable element of e primary health care network, provided that all patient information required by such a screening unit is trans- mitted to an appropriate source of medical care for follow- up and for incorporation into each individual's permanent clinical record. 6. In giving attention to the health services that I have classified as primary, secondary and tertiary, we should not overlook such institutions as skilled nursing homes, con- valescent homes , rehabilitation facilities and domiciliary facilities, which do not fall logically into the categories outlined above. These institutions represent vital elements in the health care system and must be tied effectively into any network of health services: Physicians, nurses and other personnel working in these institutions should have some type of affiliation with community hovplinls and medical centers. The traditional isolation that has made intermed- iate and long-stay institutions. unattractive to professional personnel must be ended. 1865 13. I want to close with three general observations which I believe are of fundamental importance in any efforts toward im- proving health services in this country. First, medical care is not an end in itself, but is only one of the methods by which society seeks to secure the maximum degree of health for its citizens. There are other vital determinants of health, Broad social reforms, such as protection and control of our environment, adequate housing for all, adequate employment for all and adequate education for all will do more to secure the health of our citizenry than the doubling of our medical care manpower and capital plant. This does not mean that I regard the issues I have addressed in this statement as trivial, but rather that I believe they should be seen in the broadest pos- sible perspective. Second, I believe that consumers of health care must be seriously involved in developing overall policy directions for health. I am not referring to scientific and technical deci- sions, but to broad policy issues. I believe those of us who hold professional positions make a serious mistake when we seek to establish policy in line with our own concepts of what is needed, without sufficient regard for consumers" perceptions of their own needs. Thus, although the proposals I have outlined in this statement represent my personal views, I would want to 59-661 O - 71 - pt.8 - 10 1866 14, see them tested in the fire of consumer participation. The comprehensive health planning agencies that have been established in states and regions throughout the country under Public Law 89-749 are a significant step in the direction of consumer par- ticipation and should, in my opinion, be encouraged and supported. Third and last, when one endeavors to outline a program in- volving significant organizational change, there is always the danger that it will appear over-simplified and will be inter- preted as a plea for a rigid, monolithic system. This is cer- tainly not my intention. For example, although I believe that group practice and development of new ways to utilize support- ing personnel will permit significant improvements in the de- livery of health care, I do not believe that physicians now in solo practice can be expected to abandon overnight the profes- sional patterns to which they have been accustomed throughout their careers and to conform to new patterns with which they are unfamiliar. However, incentives can and should be developed that will encourage physicians newly embarking on their careers -- as well as those already in practice ~-- to examine the advantages that group practice can offer to themselves and to their patients. Whatever the defects in our medical care system =-- and they are many -- there is also much that is good, and this can 1867 15. be lost to us if we attempt to impose Utopia through bureau- cratic or legislative mandate. Utopia will always be out of reach ~- as it should be =-- but we will approach it best through a process in which providers and consumers share the responsibility for major policy directions and in which thought=- ful legislation, making reasonable use of incentives, represents the vehicle for change. 1868 Senator Kennepy. Our final witness was to have been Dr. Leo Fishel, president of the Nassau County Medical Society. I under- stand that Dr. Fishel is ill, and I believe that Dr. Glaubitz is here with his statement. STATEMENT OF DR. JOHN GLAUBITZ, ACTING PRESIDENT, NASSAU COUNTY MEDICAL SOCIETY Dr. Grauvsrrz. I am Dr. John Glaubitz, speaking for the Nassau County Medical Society. Senator Kennepy. I again apologize to you for the lateness of the hour and the difficulties we are having. But I would appreciate it if you would submit your statement, it will be printed in its entirety, and perhaps you could make any comments you care to. Dr. Grausrrz. Fine; I would like under that circumstance to make two comments. We have been very interested in peer review. We have had an ac- tive committee for the past 12 to 18 months. We are involved in setting up a medical services foundation. It is the nature of our problem in medicine that our story doesn’t get around very well, and certainly that was made evident to me today. I think those are the two areas in which we in Nassau County have been working to try to answer some of the problems of access to the medical care system, the quality and the cost. Senator Kennepy. What about the peer review in terms of solo practice ? Is this something that you Dr. Grausrrz. Yes, sir; we are involved with peer reviewed in the solo practice. In the past 12 months we have submitted two cases to the district attorney, one to the State department of education, and thas cases to the Board of Censors of the Nassau County Medical ociety. Senator Kennepy. And are there other societies that you know in the State that have this kind of a Dr. Grauerrz. Yes; but even in our own situation this is only a beginning. We get cases from insurance companies, from people who have a complaint. We are interested in a larger input. But for that we need electronic data processing. We would like to expand our endeavors. Senator Ken~epy. What about the peer review of one doctor, this sort of backscratching kind of effect? Does this concern you? Would you rather have peer review of doctors reviewing other doctors’ work that are outside the community, or at least maybe within the com- munity but have very little kind of association ? Dr. Grausrrz. Well, we thought about that, and with the answer that I gave of some of the cases that we have actually turned over to various authorities, actually the doctor is hardest on himself. We have at least six to 12 cases a month in which recommendations are made on reduction of fees. We have actively gotten into this and feel that the local scoiety man is best able to do it especially in a society with at least several hundred members. Senator KENNEDY. Senator Dominick. 1869 Senator Dominick. Doctor, I am glad you brought these points up because previous testimony would indicate that none of this stuff was going on, and I was wondering what had happened in the Nassau County Medical Association. I am glad to hear it is alive and on its feet. This is very encouraging. And I have no real ques- tions. I look forward to reading the testimony when you can get it in to us. I just have perhaps one point. The experience we have indicates that the doctors as a whole in our city, where we are trying a foun- dation supported by an insurance company with peer review, are coming in without any problems at all. Is this true in your situation, or are you having some problems? Dr. Grausrrz. Not completely; there is a segment of physicians resisting this particular effort, and we are not sure whether it should be translated to a resistance to the peer review aspect or the fee aspect. We are not sure. We believe that we will have a viable foundation and it will be participated in by a majority of the physicians, but by no means will it be the entire society, from where we can see at this point. Senator Dominick. One other question which I think has not been covered in previous hearings. It is my understanding that if you find a doctor who has been misbehaving, as we find lawyers, nurses, or engineers or any other profession Senator Ken~epy. Politicians. Senator Dominick. Politicians—do you have any authority to pre- vent them from practicing medicine? You don’t, do you? Dr. Grausrrz. No, sir. Senator Dominick. It has to be done by the State, does it not? Dr. Grausrrz. Yes; and this is why I say we referred two cases to the district attorney, one to the State department of education, and so forth, because we really have no authority as a medical society to prevent the man from practicing. This has to be done by the State. Senator Dominick. And that is taken before a court if the district attorney accepts the case? Dr. Grausrrz. I presume that that is the proper mechanism. Senator Dominick. And then would his license to practice be taken away at that point? Dr. Grausrrz. Then the recommendation would probably go to the State department of education, and I believe that decision is made up at that level. Senator Dominick. I see; all right, fine. Now that is true, gener- ally speaking, of medical associations around the country ? Dr. Grausrrz. Yes, sir. Senator Dominick. Fine. Thank you, Doctor. (Prepared statement of Dr. Fishel follows:) PREPARED STATEMENT OF DR. LE0o FISHEL, PRESIDENT, NAsSAU County (N.Y.) MEDICAL SOCIETY, PRESENTED BY DR. JOHN GLAUBITZ, PAST PRESIDENT, NCMS I am Dr. John Glaubitz speaking for Dr. Leo Fishel, President of the Nassau County Medical Society. I am a past president of the NCMS and a member of its executive committee. First, let me thank you for the opportunity you have extended to me as a practicing physician, to speak to you about some of the 1870 unique problems of medical care in this large suburban county. The fact that you are here today would indicate your awareness that the problems of this county are not the same as those of the core cities, or even the same as other counties. The fact that you have invited me as a practicing physician indicates that you are willing to listen to those most intimately involved, on a day to day basis, with the provision of medical care. What is the nature of this County? Nassau County is unique in New York State, and, indeed, in much of the nation. We have more practicing physicians here than in any other suburban county in the United States. We have 7 voluntary hospitals, 10 proprietary hospitals, 1 large County medical center, and several Health Department clinics. We have, therefore, an elaborate health care delivery system—one which is constantly changing, constantly being expanded to meet the changing needs of our citizens. Is everything perfect then? No. We have problems . . . but they are related to the nature of this suburban area. We have poverty, but it is not throughout the county. There are poverty pockets—often close to affluent areas. There are problems of the large middle class in this county, many of whom have been hit by unemployment. There is the problem of the cost of catastrophic illness. There is the problem of transportation to free medical facilities for those in need. In this county, we have the facilities, the manpower and the incentive to make fuller use of the health care systems which we now have, and to build upon them. How have we worked to solve these problems? We are most fortunate in this county in that for many years, the County Medical Society—its commit- tees and its members—have had an excellent relationship with government. We have worked closely with the County government in developing programs and facilities to provide for this growing area. In the 30s, even before the county began its tremendous growth, the Medical Society saw the need for a County hospital to care for the indigent. The Medical Society was a driving force behind the creation of that hospital, and has continued to work closely with the hospital. Our members give of their time and effort to provide free care for the indigent, with one of every four doctors giving their services free of charge to the Nassau County Medical Center. Our doctors, through their Medical Society, were instrumental in bringing about a unified County Health Department to serve the needs of the entire county. The Medical Society was one of three co-sponsors instrumental in establishing a Cancer Detection Center. The Society was responsible for a county-wide polio immunization program several years ago. In recent years, we have actively supported and participated in Regional Medical Planning and Comprehensive Medical Plan- ning. We are not boasting of this. We believe it is our responsibility as doctors and as citizens to look to the constant improvement of health care delivery systems. Most recently we have spent a great amount of time on the development and establishment of a Medical Services Foundation, with the purpose of ob- taining better use of our health care delivery systems, of improving quality, and of making full use not only of our larger facilities, but also of the thousands of physicians’ offices which are on the firing line of medical care. After extensive planning, we will shortly be initiating two pilot projects under the Nassau Medical Services Foundation. One will be designed as a special program to provide adequate care for the needy, the other involving a program of comprehensive insurance. A key element in the Foundation plan is the use of Peer Review, in which doctors assure the maintenance of quality care and the improvement of health care delivery systems. Through all this, one thing clearly emerges. A good health care deliverv system must be constantly changing, responsive to the needs of the area. Above all, it must be flexible. If there is one thing I can get across today, it is the importance of this flexibility. I would ask you gentlemen to give serious consideration to avoiding rigid formulas which put every area into a unified mold. Medicine is constantly changing. The ways of medical care are constantly changing. If the hearing was held thirty years ago, one of our main concerns would be how to improve our sanitorium facilities for tuberculosis. Today we look to the solution of other problems, and any legislation which you develop should 1871 take into account the need for flexibility and experimentation with multiple systems of health care. Our experience in Nassau County shows us something else. [he importance of consu tation between the practicing physician and government. We have had it here, and we hope that this type of communication will be fostered on all levels of government. In our direct dealings with our patients and in our broader activities, we have seen something else. Money alone for medical care will not eliminate disease. Many of the most serious health problems are related to nutrition, housing, and environment, and these can only be corrected through education, experi- mentation and other non-medical programs. Yes, we must improve our health care delivery system. But this is only part of tbe story, and, as you gentlemen are well aware, the health of our nation is related to many other factors and subjects of concern. As physicians, as members of a olcal medical society, we will continue to work and respond to the ever-changing rhalienges related to health care in our communities and our county. We appreciate the opportunity you have given us to speak with you today. We hope that there will be more opportunities like this, more meetings designed to constructively work out solutions; more oppor- tunities for the local areas to be heard. We share a common concern . . . the health of our citizens. Towards the improvement of the health of our citizens, we offer the energies, the expertise and the cooperation of the practicing physicians of Nassau County. Senator Ken~epy. Doctor, I want to thank you very much. And just before we conclude we want to welcome Mrs. Dominick, who has been with us all morning long. We want to welcome you, and we appreciate your coming. We again want to thank Hofstra University for their kindness. We will stand in recess. (Whereupon, at 1:30 p.m., the subcommittee recessed, to meet in afternoon session at Mount Kisco, N.Y.) 1 . + - 1 Sa d Ha 1 . I Ss = a E) ey : Sy “2 : 3 oR ie Lg RPE i Sale =n anal fo a a Fall i : Lo | = v . = I: 2" » ip Ea LT he 4! a, WA Ey . La wd . hr Ce ' N fen } - Ss 4 A I 0d is 5 oe io we HE El Ta SE . v fi tal VARI kar Teed RET Er TT LS ER He [Li rt i An Tred Pot ie gi air: 0 Sp in A HL ER, ky . : © YT 3 :. 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E wr Hs gr) ¥ we - tt ty " th i Poargpin Fre hal wt? is a i pe } TUR pve ell IE g tll 4 hh It ai a ha . n 43 I o 2 eae ¥ oe eel 4 e { ba Fw og Fit gfe Yaa ln Hip soi 441 ig 37 FT de oy ha ln Tale 1 SE ean Si a I iy = a -% ] alld ¥ = i’ Jon a en =n Fo pal a on a LT . Re Cn SL Soa i gy * ba, Fh ah a ’ poten at . , Ee i r= al 2 | 3 oe : mr J alee Liha a IFS ) | me 3 - Wl Ze TH y= Alle es hd SW te Fe Tan | Ee ww gE Ey? Fremfa a i, —% a la B = be 5 ) 3 N wt ll 5 . ff - ¢ wo ay Ta . . IN I : # 1 RE hl . i ’ 3 ils 1 Fo : i gi B = x - RE i gd =m LE = CI ih . al Ly ug! ru we 3 I i 5 a i Cela tw LE mE ey fp yale 7 et #3 “ay RT = Ln Ea gitel B10 x i - S 3 say 1 ? § ¥ I ae eT -— rr = . s W a hs =r W awl | = lo EL ; ; o, = i 2! $ I - 1 - I Lat p - al = re Fe = ) oe El ta i peli Se LS wih + 25 ~) qi id a = | I - 9 aly x = = = N te ISL i HEALTH CARE CRISIS IN AMERICA, 1971 THURSDAY, APRIL 15, 1971 U.S. SENATE, SuscoMMITTEE ON HEALTH OF THE COMMITTEE oN LaBor AND PuBrLic WELFARE, Mount Kisco, N.Y. The subcommittee met at 2:45 p.m., at Northern Westchester Hos- pital, Mount Kisco, N.Y., Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Also present: Congressman Ogden Reid, Representative in Con- gress for the 26th District of New York. Committee staff members present: LeRoy G. Goldman, profes- sional staff member to the subcommittee; Jay B. Cutler, minority counsel to the subcommittee. Senator Kennepy. We are delighted to have Congressman Reid join with us here at the start. Would you like to make a comment? Mr. Rem. No; I am just very happy, Senator Kennedy, that you can be here with the Senate subcommittee. I think this is a vital subject, and I think the country is very grateful to you for your leadership in this field. Senator Kennepy. You usually don’t get Members of the Congress and Senate making such brief statements. [Laughter.] We are getting started late, and we want to apologize to our wit- nesses and to the others who have been kind enough and patient enough to wait. We are going to have to conclude the hearing a little before 5 o’clock, so we have about an hour and 45 minutes. We have four scheduled witnesses and a panel. Then we would like to open the hearing for any comments that any of you would like to make. We try to do this at each of the hearings. Therefore, we will try to conclude the more formal statements at 4 :30. Our first witness is Mr. Jerome F. Peck, Jr., administrator of Northern Westchester Hospital for the past 25 years, a member of the American College of Hospital Administrators, and director of the Northern Metropolitan Hospital Council. STATEMENT OF JEROME F. PECK, ADMINISTRATOR, NORTHERN WESTCHESTER HOSPITAL Mr. Peck. Mr. Chairman and members of the subcommittee, I am the administrator of the Northern Westchester Hospital. I am ac- companied by Mr. Thomas McCance, chairman of our board of trustees, Dr. Harold T. Brew, the chairman of our medical board and chief of surgery, Mrs. Lyndall E. Boal, our director of social (1873) 1874 service, and Dr. Morgan F. Pruyn, a member of our staff and a part- ner in the Mount Kisco Medical Group. First of all, Mr. Chairman, I would like very much to welcome you and the subcommittee to Mount Kisco and to the Northern West- chester Hospital. We are extremely pleased that you have chosen to visit this area as part of your hearings on health care in America, and we appreciate the opportunity to testify this afternoon. The Northern Westchester Hospital is a nonprofit, community hospital serving approximately 130,000 people of northern West- chester County. Our community is both growing and changing. Population pressures are bringing more and more people into the northern part of the county and what was once generally an area of scattered, single-family houses is becoming a mixture of apartment houses, garden apartments, and housing developments. Moreover, new highways and new industries have assured the area’s continued growth in the future. By 1985, the population is expected to increase by 65 percent. In light of this projected growth, we at Northern Westchester consider ourselves very fortunate to have a progressive, forward- looking board of trustees which has always been careful to plan for the future health care needs of the area. As has been seen on your brief tour—briefer than we hoped, and perhaps you can do it again, Senator—we are now in the process of replacing, rehabilitating, and adding to our physical plant. The overall goal of the Northern Westchester Hospital is to pro- vide quality medical care at an economically feasible cost. Unfortu- nately, this noble goal is very easy to state, but extremely difficult to achieve. In fact, this goal cannot be achieved using conventional methods of hospital construction and hospital operation. Consequently, our new facility, to be known when completed as the Northern Westchester Hospital Center, will incorporate several new and innovative design concepts. It is our expectation that the incorporation and utilization of the new concepts will enable us to achieve our goal of providing quality care at a reasonable rate for all the people in our community. Perhaps the most interesting and illustrative of these new con- cepts is our plan to construct single occupancy rooms only. While at first glance this may seem to be an unnecessary and expensive luxury, in reality it will result in significant cost-reduction as well as a significant increase in the quality of patient care. Studies have shown that the occupancy rate of two-bed, semi- private rooms cannot exceed 85 percent, because the mix of male and female patients seldom matches the available room. Other difficulties occur in placing patients of different ages, in handling the extremely ill, and in isolating potentially infectious patients. Two-bed rooms are thus often only half occupied. In Northern Westchester, patient preferences require moves from doubles to singles, when available. Each move costs the hospital $35 to $45. In sharp contrast, a nursing unit of only single-bed rooms is faced with none of these difficulties. And it can function effectively at a 95-percent occupancy rate. The savings resulting from this 10-per- cent differential in occupancy rates far exceeds the higher construc- tion costs of single-bed rooms. 1875 Moreover, patients prefer single-bed room and get better care in such rooms. The human animal, like other animals, likes to be alone when he is ill. They appreciate not being disturbed by the presence of a roommate with different waking and sleeping, TV watching, and talking patterns. They appreciate being able to discuss their problems in privacy with visitors, nurses, doctors, and religious coun- sellors. They appreciate the convenience of having shower, washing, and toilet facilities unshared with anyone else. They appreciate being able to have heating, ventilating, and lighting adjusted to their own desires and needs and being able to have their room door closed or left open as they prefer. Nurses and physicians, on the other hand, can perform all required services for their patients without disturb- ing room sharers. Even an orthopedic patient need not be moved for a change of cast. This long procedure can be carried out at his bed- side if he occupies a single-bed room. Mr. Chairman, I have described this single-bed concept in some detail to make two points. The first is that the best care need not be the most expensive care, as I think my description has shown. The second point is that careful planning can uncover such economies as the single-bed concept. At the outset of our planning phase, a private financial contribution enabled a team from Northern Westchester Hospital to visit more than a score of outstanding new hospitals in this country and in Europe to become familiar with recent innova- tions which might be adaptable to our situation. We feel that no other hospital ever built has had the benefit of such extensive studies of the success and failures of other hospitals’ designs. Another innovative feature of our hospital center will be a “service base” of four floors with a capacity for vertical and horizontal ex- pansion which will be economical and which will not interrupt the normal functioning of the rest of the hospital, and meet the needs of the future. A new management engineering system for the nursing service has been built into our plans. This system has two principal advantages: (1) The nurse staffing patterns will be set in accordance with the needs of the individual patients; and (2) the handling of material will be accomplished in such a way as to free the nurses from having to leave the patient areas. In other words, we keep the nurses by the patients. We get the supplies and other things to them so they don’t have to leave the patient. Other services new to our hospital will include ambulatory care for minor surgery, extended care, minimal care, expanded outpatient services and home care services, and a psychiatric unit. With some additional beds, the increased utilization of beds, shared services with other hospitals on a regional basis, and the new empha- sis on ambulatory care, we are confident that we will be able to handle our community’s projected 65 percent population increase with only a 35 percent immediate increase in beds. I would like to say just a few words about a subject of immediate concern to your subcommittee : health manpower. We at Northern Westchester share your concern about the shortage and maldistribution of health professionals of all types. The esti- mated current shortage of 50,000 physicians, 150,000 nurses, and over 1876 a quarter of a million allied health professionals (including 105,000 environmental specialists) is staggering enough. But the projected shortage figures for 1980—26,000 physicians, 210,000 nurses, and almst a half million allied health professionals—is truly frightening to a hospital center such as ours. The excessive competition for scarce specialists has two major adverse effects on a hospital : staff shortages and increased costs resulting from the large salaries which have to be paid to meet the competition. Unfortunately, both of these ad- verse effects have to be passed on to the patient in the form of less complete care and higher per diem charges. Fortunately, our enlarged facilities will make possible a greatly expanded teaching and training program. Within the next few years the present New York Medical College will move out of that city and relocate at the county’s Grasslands Hospital, near White Plains, to become the Westchester Medical College. Arrangements have already been made for an extremely close affiliation between the Northern Westchester Hospital and this new institution. Many of its undergraduate and postgraduate students will come to our hospital for clinical, bedside training coupled with instruction in our classrooms. A number of our senior physicians will receive appointments as professors or adjuncts in their respective specialties. Senator Kennepy. Does it concern you, Mr. Peck, that more and more doctors are moving out of the urban areas into suburbia, and it appears now that the medical schools are doing likewise? Perhaps it is good for the people that are served by this hospital, but what is your feeling about the general problem that is suggested by this movement ? Mr. Peck. Certainly, as you say, we are in a favored position. With us it is more a matter of distribution. Dr. Brew, our director of surgery, is sitting on my left and, of course, we have talked about it. Are there enough surgeons or are there too many, and do we need more primary physicians? Not very far from here, over in Sullivan County, there is a woeful lack of all physicians. So I hope that through the centering of hospitals we will attract doctors who can provide better distributed services. Hopefully by working with insti- tutions like the new college coming up we will be able to have some more effective answers to that. Senator Kennepy. Well, I was more interested in the general movement that is beginning, of teaching medical schools away from urban areas where they have been established traditionally. They seem to be following the flight of the more skilled health manpower, into the suburban areas. This really complicates and adds to the maldistribution problem rather than remedying it. Mr. Peck. Well, I think it will help. Dr. Brew, our chief of staff, and I were talking about how to adapt the curriculum of medical schools which Senator Kennepy. I don’t doubt that it is good for Northern West- chester or Mount Kisco. I wonder, however, if New York City can afford to lose the NYU Medical School. I know you are interested in this particular problem. Perhaps there is very little that you can really do about it. But I am just interested in how you view this. 1877 Mr. Peck. Well, we certainly view with great relief the coming of a medical school. Somebody asked me if it was true that in all of Westchester County there is no American-born, American-trained intern or resident. I think that is true. If you grant that you must have medical education to have high quality of medical care then we need it in Westchester. I know there are dreadful problems in New York, and while we are concerned about that, we have the feeling that people in the suburbs have problems just as real and need solutions to them just as much. Let’s go back a little to this hospital. The most recent expansion of our facilities took place approximately 10 years ago, when a $3 mil- lion addition was constructed. This project added 89 new beds, two cafeterias, a diet kitchen, one of the country’s first intensive care units, plus some other much needed space. A substantial amount of this project was financed by a Federal Hill-Burton grant. Unfortunately, in 1971, when we face the need for still more space, the Hill-Burton program is no longer a likely source of assistance. As you know, the grant program has been cut back to the point where, for fiscal year 1972, the administration is requesting an ap- propriation of just $58.3 million for such grants to be allocated among the 50 States. The cost of our construction project alone is $30 million—more than half the amount the Federal Government proposes to make available for the entire Nation. A construction grant program of reasonable proportions is clearly needed if the health care needs of the country are to be met. I heard you say on the elevator and I agree completely—that if there is a new system of financing health care with the demand that is already there, then the resources that are part of that delivery system have to be improved, too. Continued reliance on loan programs alone, either direct loans or guaranteed loans, will result in prohibitive construction costs in many instances and excessive per diem costs in others, since mort- gage payments must come out of operating revenue. In this particular hospital a 50-percent mortgage, or in this case 15 million, would mean that the interest and principal payments would be $14 per patient per day the first year. That’s pretty close to prohibitive. I think a grant program is the only answer. We at Northern Westchester have developed our plans in close cooperation with the New York State Department of Health and, until very recently, we were confident of receiving a mortgage loan under section 28B of the New York Public Health Law which would cover half the cost of our project. We were prepared to raise the other $15 million from private contributions. In fact, we had ac- cumulated gifts and pledges totaling nearly $10 million. However, on March 24 of this year, we were informed by the New York De- partment of Health that the maximum mortgage loan permitted for our construction program had been administratively reduced from $15 to $10 million. This decision was based on a statewide “review” of all projects requesting mortgage loans. We were subsequently informed by the department that we should be able to construct our new facility for $16 million instead of the 1878 $30 million which had previously been agreed to. Later on we were told that perhaps our project could be constructed for $24 million if we conduct an “indepth architectural review” of our current plans. We are now in the process of appealing this rather arbitrary and, we feel, unjustified decision. I raise this point only to illustrate the extent to which hospitals often find themselves at the mercy of various government agencies. In a peculiar sense we were perhaps fortunate that the Hill-Burton program had already been sharply cut back by the time we were ready to arrange financing, since we were at no time counting on support from that source. Hence, our plans were not disrupted by any Federal funding decisions. The New York State problem, of course, is another matter. It is our hope, however, that we will be able to clear the matter up with no loss of either construction time, money already spent on the project—you can see the hole out there, steel is on order and being fabricated—or, and this is the point— the innovations which will make possible our goal of quality care at a feasible cost. This concludes my testimony, Mr. Chairman, but I would like Dr. Brew to briefly discuss the patterns of medical care as seen from the physician’s eye in this community, especially as it relates to our own. Then Mrs. Boal will give you a brief rundown on the problems in the area of social services faced by our community and Dr. Pruyn will say a few words about the Mount Kisco Medical Group. Thank you once again for this opportunity to testify, and we, of course, will be pleased to answer any questions. Senator Kex~Nepy. Thank you very much, Mr. Peck. (The prepared statement of Dr. Peck follows:) 1879 Testimony Statement cf Jerome F. Peck, Jr., F ACHA Administrator, Northern Westchester Hospital befecre the Subcorrmiittee on Health cf the U. S. Senate Committee on Labor and Public Welfare April 15, 197] 1880 Mr. Chairman and members of the mubcommittee, my name is Jerome F. Peck. I am the Administrator of the Northern Westchester Hospital. x am accompanied by Mr. Thomas McCance, Chairman of our Board of Trustees, Dr. Harold T. Brew, the chairman of our Medical Board and Chief of Surgery, Mrs. Lyndall E. Boal, our Director of Social Service, and Dr. Morgan F. Pruyn, a member ‘of our staff and a partner in the Mt. Kisco Medical Group. First of all, Mr. Chairman, I would like very much to welcome you and the subcommittee to Mt. Kisco and to the Northern Westchester Hospital. We are extremely pleased that you have chosen to visit this area as part of your hearings on Health Care in America, and we appreciate the op- portunity to testify this afternoon. Northern Westchester Hospital . The Northern Westchester Hospital is a non-profit, community hospital serving approximately 130,000 people of northern Westchester County. Our "community" is both growing and changing. Population pressures are bringing more and more people into the northern part of the county and what was once generally an area of scattered, single-family houses is becoming a mixture of apartment houses, garden apartments, and housing developments. Moreover, new highways and new industries have assured the area's continued growth in the future. By 1985, the popula- tion is expected to increase by 65% In light of this projected growth, we at Northern Westchester consider ourselves very fortunate to have a progressive, forward-looking Board of Trustees which has always been careful to plan for the future health care needs of the area. As you have seen on your brief tour of our facilities, we are now in the process of replacing, rehabilitating, and ~ adding to our physical plant. The overall goal of the Northern Westchester Hospital is to provide quality medical care at an economically feasible cost. Unfortunately, this noble goal is very easy to state, but extremely difficult.to achieve 1881 In fact, this goal cannot be achieved using conventional methods of hospital construction and hospital operation. Consequently, our new facility, to be known when completed as the Northern Westchester Hospital Center, will incorporate several new and innovative design concepts. It is our expectation that the incorporation and utilization of the new concepts will enable us to achieve our goal of providing quality care at a reasonable rate for all the people in our community. Perhaps the most interesting and illustrative of these new concepts is our plan to construct single occupancy rooms only. While at first glance this may seem to be an unnecessary and expensive luxury, in reality it will result in signi- ficant cost-reduction as well as a significant increase in the quality of patient care. Studies have show that the occupancy rate of two-bed (semi-private) rooms cannot exceed 85%, because the mix of male and female patients seldom matches the available rooms. Other difficulties occur in placing patients of different ages, in handling the extremely ill, and in isolating potentially infectious patients. Two-bed rooms are thus often only half occupied. In Northern West- chester, patient preferences require moves from doubles to singles, when available. Each move costs the hospital $35 to $45. In sharp contrast, a nursing unit of only single-bed rooms is faced with none of these difficulties. And it can function effectively at a 95% occupancy rate. The savings resulting from this 10% differential in occupancy rates far exceeds the higher construction costs of single-bed rooms. Moreover, patients prefer single-bed rooms and get better care in such rooms. They appreciate not being disturbed by the presence of a roommate with different waking and sleeping, TV watching, and talking patterns. They appreciate being able to discuss their problems in privacy with visitors, nurses, doctors, and religious counsellors. They appreciate the convenience of having shower, washing and toilet 59-661 O - 71 - pt. 8 - 11 1882 facilities unshared with anyone else. They appreciate being able to have heating, ventilating, and lighting adjusted to their own desires and needs and being able to have their room door closed or left open as they prefer. Nurses and physicians, on the other hand, can perform all required services for their patients without disturbing room sharers. Even an orthopedic patient need not be moved for a change of cast. This long procedure can be carried out at his bedside if he occupies a single-bed room. Mr. Chairman, I have described this single-bed concept in some detail to make two points. The first is that the best care need not be the most expensive care, as I think my description has shown. The second point is that careful planning can uncover such economies as the single-bed concept. At the outset of our planning phase, a private financial contribution enabled a team from Northern Westchester Hospital to visit more than a score of outstanding new hospitals in this country and in Europe to become familiar with recent innovations which might be adaptable to our situation. We feel that no other hospital ever built has had the benefit of such extensive studies of the success and failures of other hospitals’ designs. Another innovative feature of our Hospital Center will be a "service base" of four floors with a capacity for vertical and horizontal expansion which will be economical and which will not interrupt the normal functioning of the rest of the hospital. A new management engineering system for the nursing service has been built into our plans. This system has two principal advantages: 1883 1. nurse staffing patterns will be set in accordance with the needs of the individual patients; and 2. the handling of material will be accomplished in such a way as to free the nurses from having to leave the patient areas. Other services new to our hospital will include ambulatory care for minor surgery, extended care, minimal care, expanded outpatient services and home care services, and a psychiatric unit. With some additional beds, the increased utilization of beds, shared services with other hospitals on a regional basis, and the new emphasis on ambulatory care, we are confident that we will be able to handle our community's projected 65% population increase with only a 35% immediate increase in beds. Health Manpower I would like to say just a few words about a subject of immediate concern to your subcommittee: health manpower. We at Northern Westchester share your concern about the shortage and mal-distribution of health professionals of all types. The estimated current shortage of 50,000 physicians, 150,000 nurses, and over a quarter of a million allied health professionals (including 105,000 environmental specialists) is staggering enough. But the projected shortage figures for 1980 -- 26,000 physicians, 210 000 nurses, and almost a half million allied health professionals -- is truly frightening to a hospital center such as ours. The excessive competition for scarce specialists has two major adverse effects on a hospital : staff shortages and increased costs resulting 1884 - B= from the large salaries which have to be paid to meet the com- petition. Unfortunately, both of these adver8e effects have to be passed on to the patient in the form of less complete care and higher per diem charges. Fortunately, our enlarged facilities will make possible a greatly expanded teaching and training program.Within the next few years the present New York Medical College will move out of that city and relocate at the county's Grasslands Hospital, near White Plains, to become the Westchester Medical College. Arrangements have already been made for an extremely close affiliation between the Northern Westchester Hospital and this new institution. Many of its undergraduate and post-graduate students will come to our hospital for clinical, bedside training coupled with instruction in our classrooms. 2 number of our senior physicians will receive appointments as Professors or Adjuncts in their respective specialties. While these young physicians and physicians-to-be will be coming to us primarily to receive clinical training, their presence on duty here will permit us to provide more skilled services to our patients and, at the same time, their questing minds will serve as a constant stimulus to all our staff. Many will remain with us, after they win their medical degrees, to serve their internships or residencies. And the very best among them will undoubtedly join our permanent medical staff and settle in our community to share in serving its medical needs. 1885 Similar affiliations with the Nursing and Technicians- Training Schools of the Medical College will also be made possible by our new teaching facilities. Financing Health Care Facilities The most recent expansion cf our facilities took place approximately ten years ago, when a three-million dollar additicn was constructed. This project added eighty-nire new keds, two cafeterias, a diet kitchen, cne of the country's first intensive care units, plus scrme other much-needed space. A substantial amount of this project was financed by a Federal Hill-Burton grant. Unfortunately, in 197), when we face the need for still more space, the Hill-Burton program is no longer a likely source of assistance. As you know, the grant program has been cut back to the point where for Fiscal Year 1972, the Administration is requesting an appropriation of just $58.3 million for such grants to be allocated among the fifty states. The cost of our construc- tion project alone is $30 million -- more than half the amount the Federal Covernment proposes to make available for the entire Nation ! A constructicn grant program of reasonable prcportions is clearly needed if the health care needs of the country are to be met. Continued reliance cn loan programs alone, either direct loans or guaranteed loans, will result in prohibitive construction costs in many instances and excessive per diem costs in others, since mortgage payments must come out of operating revenue. We at Northern Westchester have developed our plans in close cooperation with the New York State Department of Health and, 1886 until very recently, we were confident of receiving a mortgage loan under Section 28P of the New York Public leelth Law which would cover half the cust of our project. We were prepared to raise the other $15 million from private contributions and, in fact, had accumulated gifts and pledges totaling nearly $10 million. However, on March 24 of this year, we were informed by the New York Department of Health that the maximum mortgage loan permitted for our construction precgram had been administratively reduced from $15 millicn to $10 million. This decision was based cn a State-wide "review" of all projects requesting mortgage loans. We were subsequently informed by the Department that we should be able to construct our new facility for $16 million instead of the $30 million which had previously been agreed to. Later on we vere told that perhaps our project could be constructed for $24 million if we conduct and "in depth architectural review" of our current plans. We are now in the process of appealing this rather arbitrary and, we feel, unjustified decision. I raise this pole only to illastrate the extent to which hospitals often find themselves at the mercy of various government agencies. In a peculiar sense we were perhaps fortunate that the Hill-Burton program had already been sharply cut back by the time we were ready to arrange financing, since we were at no time counting on support from that source. Hence, our plans were not disrupted by any Federal funding decisions. The New York State problem, of ccurse, is another ratter. It is our hope, hcwever, that we will ke ekle to clear the m~tter up with no loss of either construction time 1887 money already spent on the project, or the innovations which will make possible our goal of quality care at a feasible cost. This concludes my testimony, Mr. Chairman, but I would like Dr. Brew to briefly discuss the patterns of medical care in this community, especially as they relate to our hospital. Following that, Mrs. Boal will give you a brief rundown on the problems in the area of social services faced by our community, and then Dr. Pruyn will say a few words about the Mount Kisco Medical Group (a private group practice in our community). I thank you once again for this opportunity to testify. We will be happy to answer any questions you may have. 1888 Senator Kennepy. We hear a great deal about the health crisis that we are facing generally in the country. President Nixon has identified the crisis and Secretary Richardson has talked about it, as well as others in the Congress and Senate. Do you have a health crisis in Northern Westchester ? Mr. Peck. I think there is a crisis, but I don’t believe it is gen- erally recognized. Certainly the first side of it we see is economic— it is not possible to provide quality care, as we now do it, at a cost that can be afforded. So we must come up with innovative methods of some kind. The status quo won’t do, and I think that’s the dimension of the crisis. There is a crisis, not everybody recognizes it, but they know it when Blue Cross premiums come due. There are other aspects to the crisis that Mrs. Boal will tell you about. But I see it first as a finan- cial crisis. Senator Kennepy. Do you think perhaps the crisis is not quite as apparent in a community such as this as it is in the urban areas? But I would agree with you that the crisis is just as present in sub- urban communities as it is in urban areas where it is more pressing and obvious. Could you tell us how the hospital room cost has increased, say, in the period of the last 5 years and what you can see down the road in terms of the next 2 or 3 years? Mr. Peck. Yes, sir; I can. Presently our cost of daily patient care is $80 on the audited reimbursable cost. However, in intensive care or coronary care it is about $140 per day there, although we still receive the same $80. Compared with 5 years ago, this percentage increase fits in with all the figures you are familiar with. It has gone up more than average, higher than I guess anything except the con- struction industry. Senator Ken~epy. It has gone up even higher than that. Mr. Prox. As for our projections for the future, if we talk about traditional care as delivered—put everybody in the same kind of bed— I think we will be at crisis proportions very quickly, and $150 a day in 1974. That is the financial measure of the crisis. Senator Krennepy. Now what does that mean generally to the people that live within this community ? Mr. Peck. The great majority, 80 percent, have their bill paid by somebody else—medicare, medicaid, Blue Cross, and so forth. So it is a deferred kind of economic problem. As TI said, Mrs. Boal will tell you what it means to some individuals. Senator Kennepy. Before we hear from Mrs. Boal, what can you tell me about the quality of health care in a community such as this? Mr. Peck. I think it is superb. T think it is first rate. One of our problems is being able to provide that top level of care to the total population consistently, not just to the intensive care, coronary care, but to the areas of preventive medicine, home care and psychiatry. I think the more serious and obvious the problem the more clear it is that the level of care is superb. As you know, the flight of doctors to the suburbs—I think our medical staff is outstanding, and you couldn’t have this superb care without superb doctors. Senator KKenNEDY. Do you have peer review here? Mr. Peck. Yes; I think we do. 1889 Senator Kennepy. Could you tell us a little bit about it ? Mr. Peck. I think we were one of the very first to start it. Morgan, this is where you ought to come in, because it began 15 years ago when the medical board had Dr. Pruyn and Dr. Dan Brown on it. They were one of the very first to start peer review, which didn’t make them the most popular individuals around, but it did improve the quality of care. Senator Kennepy. Could you tell us a little bit about the peer review ? Mr. Peck. Harold, you have the microphone right here. You have been up to your neck in it the last 5 years. : Dr. Brew. Senator Kennedy, within the hospital itself we hav review by departments—specialty departments. We do have review, sir, within the hospital by departments, as to the caliber of work performed, the nature of the disease, requirements of treatment, and a critique of the quality of medical care. We also have an ongoing utilization review to insure this. Senator Kex~epy. What kind of peer review do you have of the solo practitioner in a community like this? Do you have any review? Dr. Brew. In the doctors’ offices? No, sir; we do not. Senator KENNEDY. Say outside the doctor’s office. Do you have any kind of review of this kind of practice? Do you think it would be useful or helpful? Dr. Brew. In terms of the community at large outside of the hos- pital, which has the review mechanism I mentioned, to my knowl- edge, no. I think ongoing review is inevitable in evaluating what we are doing in the quality of medical care. I might touch on that in my prepared remarks. Senator Kennepy. OK, fine. STATEMENT OF DR. HAROLD T. BREW, CHAIRMAN OF THE MEDICAL BOARD, AND CHIEF OF SURGERY, NORTHERN WESTCHESTER HOSPITAL Dr. Brew. If I might before testifying, in response to your com- ment about the transposition of a medical school from one area to the other, it would seem to me that this only highlights our need to increase our educational facilities for training medical personnel of all categories. I think the point of the transfer of schools creating a void is well taken, and we just need more training facilities. In brief, the Northern Westchester Hospital provides a broad spectrum of inpatient, outpatient care to the people of Northern Westchester County. It is staffed by 140 physicians practicing in the communities in the hospital district. The majority of these are spe- cialists. They practice privately in solo, association, partnership or multispecialty groups. Within the hospital they are grouped by spe- cialty with responsibilities to patient care, continuing education, re- view of caliber of medical care and teaching responsibilities at all levels, be it interns and residents, various nurses and technicians programs, or community forums for the dissemination of medical information to the community at large. Parenthetically, IT might add that in spite of what might seem to be an abundance of physicians, there are communities within this district that lack primary physicians. 1890 Additionally, the hospital is presently well staffed with competent nurses and technicians; also with ongoing educational program. In- tern and residency training program under the full time director of medical education is well established and has added to the caliber of patient care over all, and to the ongoing medical education pro- gram. We have an active social service department and home care pro- gram which help with patient problems prior to, during hospitaliza- tion, and are invaluable in discharge planning and disposition of patients when their hospitalization needs are over. In an acute care institution discharge planning and disposition is a very vital func- tion. A county health center adjacent to the hospital provides multiple outpatient services, clinics and nursing services. Our commitment for the future is in our plans for an inpatient psychiatric unit and an extended care unit underscore a current lack in providing these services to this community. The problems of our existing physical plant you have heard about, and in spite of a very thorough review and utilization study of in- hospital patients, our occupancy rate continues to climb. As providers of medical care, we are well aware of the increasing costs of hospital beds and the need for efficient utilization of the same. The increase in demands on providers of medical care by a growing population will require changes in the delivery system to include specially trained paramedical personnel to relieve the strain at both the physician and hospital level. The long successful experi- ence of the military with this concept, as well as more recent inter- ests and implementation in a limited way in several areas of the country, should encourage us to avail ourselves of this now, and to implement the training programs necessary to meet the needs. Any discussion of medical care problems, be it distribution or financial, must take into account the needs and desires of the con- sumer of these services, namely the patient. As a surgical specialist in practice for 12 years in this community, I am more firmly con- vinced than ever before that what most patients want is the avail- ability of competent professional care in a competent medical facility, whether it be physician’s office, outpatient area or an inhospital set- ting. To most people this implies an ongoing relationship with their physician, and this is the keystone. This cannot be rendered by as- sembly line techniques or by itinerant personnel. It’s true that as more paramedical personnel are involved in patient care of all types physician time with an individual patient may be shortened. How- ever, if this results in more medical care for more people, we will have moved in the right direction. Senator Kennepy. Thank you very much. You hear that surgery is really sort of the prestige specialty of the medical profession. Because it is viewed this way, more medical students are getting into surgery. Do you think perhaps we have too many surgeons ? Dr. Brew. I would say this—I can’t answer that question intelli- gently. I think probably by specialty designation there are more general surgeons certainly in this country than there are other cate- gories in which there are substantial shortages. How much is too 1891 many ? If we are still not delivering a good product I am not sure I can say we have too many of anything at this time. Senator Kexnepy. But if you have too many, then they have to make a living and I suppose they have to perform more surgery. This raises the question of whether you can maintain continuing quality with an oversupply of physicians in a specialty. I would be interested in what your general reaction to this is. We hear many charges made about this problem, and T am interested in how you view it in terms of this community and generally in terms of sub- urbia. Dr. Brew. Yes. Specifically locally T think the surgical staff here undertakes a volume of surgery that they can handle very adequately, and I think as one has more and more well-trained people at any level of hospital, be it suburban or large center, who are continuing their education, who continue to review their own work in confer- ences, I think anyone not doing things by the book would stand up. I think the review mechanism we have is a protection for this kind of thing. So that T would view that locally at least as not a problem. Senator Ken~nepy. Well, how many surgeons do you have on the staff ? Dr. Brew. We have approximately 20 surgeons of various spe- cialty interest on our staff. Senator Ken~Nepy. What is the most that any one of them might operate a week and what is the least? Dr. Brew. Conceivably one might do 10 cases a week, not speci- fying by days or hours, and one might do two or three cases a week. Senator Kexxepy. Can a surgeon maintain competency by doing two or three a week? Dr. Brew. I think so. I think we also—— Senator Kennepy. Obviously there is a great distinction between different types of surgery and there are different levels of skill needed. But what number of surgical operations would be necessary to maintain competency ? Dr. Brew. Well, that gets into the business of numbers, and I am not sure that the numbers are total answers. There used to be a great emphasis years ago on going to a place where you could do every- thing. I think doing everything is fine, but if you are doing it with- out proper instruction or supervision in your formative time I am not sure that this is any benefit in the longrun. I think we do have the mechanism whereby all major surgery at least, two surgeons of equal training partake. So there is a great deal of give and take. These men are more active than their own individual practices might indicate. They also have appointments at other hospitals where they may be supervising residents. So that their hands are in, as it were. They are actively engaged in the prac- tice of surgery in some way. Primary physician, assisting physician, teaching physician. Senator Kennepy. You have an interesting group practice situa- tion here. We hear group practice talked about a great deal. Most of the programs that we have heard about or looked into are prepaid group practice. You have a different kind of situation here. IT wonder if you could describe it briefly to us. (The prepared statement of Dr. Brew follows:) Testimony Statement cf Harold T. Brew, M. D. Chairman of the Medical Bcard and Chief of Surgery, Northern Westchester Hospital befcre the Subcommittee on Health of the U. S. Senate Committee on Labor and Public Welfare April 15, 197} (1892) 1893 wile The Northern Westchester Hospital provides a broad spectrum of In Patient-Out Patient care to the people of Northern Westchester County. It is staffed by 140 physicians practicing in the communities in the hospital district. The majority of these are specialists, They practice privately in solo, as- sociation, partnership or multi-specialty groups. Within the hospital they are grouped by specialty with responsibilities to patient care, continuing education, review of caliber of medical care and teaching responsibilities at all levels, be it interns and residents, various nurses and technicians pro- grams, or community forums for the dissemination of medical information to the community at large. Parenthetically, I might add, that in spite of what might seem to be an abundance of physicians, there are communities within this district that lack primary physicians. Additionally, the hospital is presently well staffed with competent nurses and technicians; also with on-going educational programs. Intern and residency training program under the full time director of medical education is well established and has added to the caliber of patient care over all, and to the on-going medical education program. We have an active social service department and home care program which help with patient problems prior to, during hospitalization and are in- ’ valuable in discharge planning and disposition of patients when their hospitalization needs are over. In an acute care institu- 1894 wD tion, discharge planning and disposition is a very vital function. A county health center adjacent to the hospital provides multiple outpatient services, clinics and nursing services. Our commitment for the future in our plans for an inpatient psychiatric unit and an extended care unit, underscore a current lack in providing these services to this community. The problems of our existing physical plant you have heard about and in spite of a very thorough ‘review and utilization study of in-hospital patients, our occupancy rate continues to climb. As providers of medical care, we are well aware of the increasing costs of hospital beds and the need for efficient utilization of the same. The increase in demands on providers of medical care by a growing population will require changes in the delivery system to include specially trained para- medical personnel to relieve the strain at both the physician and hospital level, The long successful experience of the military with this concept, as well as more recent interests and implementation in a limited way in several areas of the country, should encourage us to avail ourselves of this now, and to implement the training programs necessary to meet the needs. Any discussion of medical care problems, be it distribution or financial, must take into account the needs and desires of the consumer of these services, namely the patient. As a surgical specialist in practice for 12 years in’ this community, I am more firmly convinced than ever before, that what most patients want is the availability of competent professional care in 1895 3 a competent medical facility whether it be physicians office, out patient area or an in-hospital setting. To most people, this implies an on-going relationship with their physician, and this is the key stone. This cannot be rendered by assembly line techniques or by itinerant personnel. It's true, that as more para-medical personnel are involved in patient care of all types, physician time with an individual patient may be shortened. However, if this results in more medical care for more people, we will have moved in the right direction. 1896 Dr. Brew. Dr. Pruyn, who is one of our partners, is there with that specific purpose. STATEMENT OF DR. MORGAN F. PRUYN, MOUNT KISCO MEDICAL GROUP Dr. Pruyn. Senator, I was asked by you to present the reasons for the formation of the medical group and what the advantages were to professional members, and also to say what are the advantages of the patient, to everybody, of a service medical group. The Mount Kisco Medical Group was formed in 1947 when it became legal in New York State to have a partnership for the prac- tice of medicine. From a start of five physicians, it has grown with the demand for its services to full-time board certified specialists, a business manager, clinical laboratory, and limited diagnostic x-ray. It relies on outside specialists for services not represented in the group. There is very little referral of patients to the group by local physicians. The group physicians comprise a sixth of the hospital medical staff. Professional advantages of a service group practice of medicine are: 1. The assurance of having talented and reliabile associates. 2. The assurance that the quality of medical care will be enhanced by the day-to-day example and influence of physicians working under the same roof, the democratic principle of policymaking, and the exchange of information. 3. The assurance that his patients will be well taken care of by other group physicians when he is unavailable. 4. The security a new member has in being needed in the commu- nity, in rapidly having his own practice, and in not having to make an immediate capital investment and yet being assured of an im- mediate income. 5. To be relieved of day-to-day managerial, personnel and financial matters. The advantages that patients derive from group practice are: 1. The availability of a physician at all times. 2. The unit medical record which affords a continuity of medical care by all involved physicians in a sequential manner, and is avail- able to all group physicians at all times avoiding duplication of tests and pitfalls. 3. The obtaining of informal or formal consultations under the Je roof, and often simultaneously with their initial visit for that illness. 4. The fact that fees are not determined by the whim of any one physician or physician assistant, but by the group as a whole. 5. No means test is required of a new patient. It is important to point out to your committee that because of our availability on short notice, and because this is a wealthy community and there is widespread third-party payment of sickness benefits, we care for a good deal of inconsequential illness as well as perform a large volume of so-called periodic health examinations. This is luxury medicine and is not what primary physicians have been 1897 trained for, nor is it what they expect after intensive postgraduate medical training. It is certainly the antithesis of what a comparable group would be performing or could afford to perform in a low- income area under existing methods of medical economics. Nonethe- less, it is what sophisticated Americans have been led to believe is a necessity and are willing to pay for. z I should add also that in this community is a younger medical group consisting of 12 physicians, of which this hospital is duly roud. P Senator Kexnepy. Do they have a group practice association? Dr. Pruyn. Similar, but younger. Senator Kexnepy. How do you differ from them, other than ex- perience ? Dr. Pruvn. I suppose basically there’s very little difference. Senator Ken~xepy. What can you do to assure quality control? Dr. Pruyn. I think it is the built-in peer review. The record of a patient is the property, you might say, of the medical group, and if T were not to be in the office today and one of my patients came in, that patient’s records would be reviewed by the physician who was going to look after the patient. If it wasn’t considered a good record I would be called on the carpet about it. The very fact that I know my work is going to be reviewed is an incentive to the lazy doctor who might ordinarily cut the corner. And TI think these are all the advantages of working in unison with people. It has a profound influence on the quality of care, and also on the urge to try and keep up with the young fellows that are com- ing along after you. Senator Kexnepy. Of course, that wouldn’t exist in solo practice, would it? Dr. Pruyw. No. Senator Kennepy. And there really is very little peer review done for solo practice across the country, as T understand. Dr. Pruy~. Well, it is hard to see how it could be done. Private records are not reviewable by any person who wants to do such a thing. You could subpoena them, I suppose, but you certainly couldn’t just walk in the doctor’s office and review records because they are privileged communication. Patients would raise the roof. Senator Kex~epy. Well, how do you address the problems of qual- ity? How can people know when they go to a doctor and he pre- scribes X, that X is really the best in terms of their problem? They can’t shop around and look for someone else. They have confidence in this doctor, but do they have to just take it on faith? Dr. Pruyn. I think the only place you Senator Kenxepy. You have given us two of the advantages of some kind of peer review. You have made that case, and quite effec- tively, in terms of your own kind of group. We can perhaps be as- sured of a higher quality in terms of this kind of a group, but some consumers have asked how they are going to be sure that their child is getting the best from a doctor when there has been no one really taking a look at his record over the last 15 or 20 years. Dr. Pruyn. I suppose the hospital is the only place where there is any review of what a man is performing. 59-661 O—T71—pt. S——12 1898 Mr. Rem. Well, Dr. Pruyn, is there any problem in the patient waiving the right to privileged communication, and in fact asking the solo practitioner to have the records reviewed from time to time? Dr. Pruyn. Well, this would mean showing records which you don’t usually do. You see, if you keep records only for yourself you can be pretty sketchy and you can say you will do it tomorrow. If you have partners who may need the record tomorrow you can’t put it off, and I think this is what I said. Certainly, in a hospital they make tremendous efforts to keep good records. I don’t think you can do that in solo practice. Senator Kexnepy. Well, let me ask this. If you pay high cost in terms of health care—does that necessarily mean that you are getting good care? Dr. Pruyn. That’s a loaded question. [ Laughter. ] I don’t think they bear any relationship, Senator. Mr. Rem. Let me ask the other side of that question. What are the incentives in group practice to lower the fees so that the average patient can more nearly afford the best care ? Dr. Pruyn. I think the incentive other than local competition would be a moral, shall we say, philosophical one. Mr. Rew. Do you find that is a strong sanction ? Senator Kennepy. I feel that the doctors for the most part are caught up in the system. I don’t know how much we can expect from the kind of health system that we have in this country, and from doctors that obviously are enormously committed, dedicated, and compassionate individuals on the whole. How can we expect that the burden would fall to physicians to devise a program that is going to drive the cost down. I think that is obviously demanding too much. What we are trying to find out is what is happening in terms of cost, in terms of quality, and in terms of shortage of manpower. It is my own feeling that the cost of health care and quality don’t neces- sarily run together. I think there are an awful lot of people that assume that because they are paying high premiums on their insur- ance or expensive medical bills, they are necessarily getting quality care. We are trying to decide what role we should be playing at the level of the U.S. Senate to find ways that can insure quality and control costs. Obviously we need the input from doctors on these questions. Could I ask you, Mr. Peck, do you have any shortage of manpower here at the hospital ¢ Mr. Peck. We work very hard and very industriously, and I think are able to say that we have the manpower shortage in better con- trol than most. But in order to say that we would be able to make thas Satoment 2 years hence we do have to go to any number of engths. I think the major one in what I was talking about before in man- agement engineering; that is, nurse staffing so that we don’t have nurses, who are going to be in even shorter supply in the future, doing nonnursing duties. By doing that and recruiting well-trained nurses overseas we are in pretty good condition. We also try to use the best management techniques to minimize shortages, so I think we are in very fortunate shape. 1899 Senator Kex~epy. Would you say that you have a shortage but it is manageable ? Mr. Peck. I think we are better off than that. For example, we were able with the help of a joint program with the board of coop- erative educational services, local school district, to educate practical nurses, so that there are enough practical nurses to fill our jobs. I think there would have been a shortage had those programs not been in existence. Likewise Pace College has a registered nurse school here, so they produce some. I think the area is so fortunate in having industries like Readers Digest and IBM and others coming in, where the young wives might be nurses or that kind of personnel, that has helped. Plus trying to minimize the use of unskilled people. So that I would say it is a little better than manageable. I think we have met it quite well. But it is just again the status quo wouldn’t take care of the future. Senator Kennepy. Do you have difficulties in getting doctors at nighttime to provide services in the hospital ¢ Mr. Peck. Staffing our emergency room has been one of our per- plexing problems, but I think we do it very well. And this was an- other example of how quality of care demands medical education because it needs our intern program, our residency program. We have a full-time director of medicine who has among his duties the handling of the emergency room, and the fact, as Dr. Brew said, 140 doctors on our staff do give wonderful backup coverage. So that that exists. I am sure we could hear from people who say no, I can’t get a doctor at night. Senator Kenxepy. What about nighttime? Can a person in this community call a doctor at night and get him to come out to their home? Say a mother has a sick child. Mr. Peck. Senator, we do have here the president and president- elect of the Westchester County Medical Society. They have a countywide program designed to meet that, so I am sure they would be able to speak to that, and then we have some consumers. I don’t know what they are going to say, but I am sure they can testify about it. Senator Kexnepy. We visited a number of the emergency rooms in New York City the other night, Elmhurst, Kings County, Lin- coln, Roosevelt, Mount Sinai, and a number of the other great hos- pitals. I saw as we went through a little placard about the minimum cost of $12.50 that is charged for use of the emergency room. Could you tell me a little about that? Is that needed in terms of balancing your books? Do you find that it discourages people that might other- wise come because they are concerned about it? What is really the effect of such a charge? Mr. Peck. I am sure that it does not discourage, no, sir .We don’t enforce that—for example, the collection rate from that kind of service is about 50 percent, whereas the collection rate for the hos- pital in general is something like 98 percent. Certainly there is an economic one. We do, as I know you can appreciate, having looked at other emergency services, lose a lot of money in emergency room services. Our unit cost is approximately 1900 $20 per visit, so that the $12 charge is a little bit more than half. On the total per year that costs us probably $300,000 to run the emergency room. We receive an income of about $150,000. So yes, it is a factor, we do lose money. It is also one of the most rapidly growing departments of the hospital. You are well advised to consider it a significant part of any hospital. Senator Kexnepy. Dr. Franklin Hall, the first deputy commis- sioner of health, secretary of Westchester County Board of Health, long experience in public health in State and county departments. STATEMENT OF DR. E. FRANKLIN HALL, FIRST DEPUTY COMMISSIONER OF HEALTH, WESTCHESTER COUNTY Dr. Haut. Honorable Members of this Senate Health Subcommit- tee, I am pleased to be invited to participate in this hearing. Due to the extremely short notice to our department of this meeting (con- firming telegram received Apr. 14), it is impossible for the Commis- sioner of Health, Dr. Jack Goldman, to be present due to prior commitments. For the same reason, it was not possible to prepare a broader in-depth statement to present to the subcommittee at this time. The Westchester County Health District, with a population of 816,024 people, presently includes all municipalities and towns of the county, with the exception of the city of New Rochelle. Our county executive, Edwin G. Michelian, having early recog- nized the importance of health in the lives of the citizens of this county, has provided the leadership which our health department wants to recognize here and now as the impetus for the generally excellent level of health care in this county. In fact, in his last annual message delivered on January 18, 1971, he pointed the path to the future in the health disciplines in this county by stating, and I quote: I venture to forecast that delivery of quality health care will become the most talked of subject in our country. Just as the welfare system and its reform, the environment and environmental controls, and drug abuse were topics eof the day throughout all of 1970, quality health care and its availa- bility to every American, irrespective of socio-economic status will be the order of the day in the 70's and 80's. That is the reason why, as the head of this government, I place such great emphasis upon development of a medical center in Westchester County and the necessity to affiliate all of our voluntary and nonproprietary hospitals therewith. We must also stress the necessity of protecting the economic viability of these hospitals to insure their serving the medical needs of the people of their area. In the not too distant future, 1 believe our county will witness the establishment of what has heretofore been called a ‘storefront’ operation to bring health care to the people rather than vice versa. Strong clinical departments, hospital organizations and practi- tioners in the various disciplines of medicine, public health and mental health are vital for the delivery of medical treatment of substance and quality to our population to assure their good health. Besides, the topics to which I referred earlier, are tied to health care—the environment, drug abuse, the welfare syndrome and the economic health of our country. Hence, the great emphasis upon the Medical Center, which, when it comes to fruition, in my opinion, will be the most important forward step for Westchester County in the last half of this century. Many of our citizens have an increasing concern relating to the availability of high quality health services for all in the community. 1901 Accordingly, our department has attuned itself to the many impli- cations and possibilities inherent in this concern. Faced with this mandate, it has been necessary for our department to shift its empha- sis to the extensive community involvement in the planning, estab- lishment, and execution of public health programs designed to im- prove upon previously inadequate systems of delivering health care to the grassroots of our communities. Although not unique to Westchester County, the problems of pov- erty with its associated substandard health findings, are present in well-established pockets of poverty areas throughout the county. Many people who are not familiar with Westcheser County are quite surprised that we have 58,000 individuals being served by the de- partment of social services. I am not referring only to the areas of poverty of the southern tier, but also to the rural suburban poverty of northern and eastern Westchester County. The problem of poverty and its health evils are only a part of the total health crisis in Westchester. We have long been aware of the growing middle income health deficiencies with delivery of health services becoming more difficult due to one of or a combination of factors: (1) high cost of services; (2) poor accessibility of services; and (3) unavailability of services—or a combination of these—there are many combinations. Perhaps the family is not even motivated to seek health services and then again perhaps they may be ignorant of what health services are available and where. One of the greatest bugaboos to public health people has been and still is the splintering of health services and the fragmentation of health services and, of course, there is always the duplication of health services, which seems such a waste in any society. Sometimes we defeat our own purpose by dividing the patient into so many parts, into so many specialty clinics, that as he functions he feels like a machine. One could continue almost indefinitely listing the problems attend- ant to the delivery of health services. The important factor we be- lieve is that we concentrate on the more effective delivery of health services for most of the people—all of the people, if possible. Although this county is blessed with a significant number of assets in terms of its health manpower and facilities, inclusive of approxi- mately 2,200 highly trained, skilled and dedicated physicians result- ing in a ratio of approximately one doctor per 400 people, or twice the national average, along with an equally proportionate share of dentists, nurses, therapists, technicians, 16 accredited and quality- oriented general hospitals, coupled with above-average nursing home and rehabilitative facilities, it is of interest to note that the steering committee on comprehensive health planning has clearly discerned the existence of significant gaps in the availability of general medical care to target groups in various communities of our county. As a result of these and related studies, the county health department has intensified its efforts to make high quality care available to everyone who is disadvantaged in not receiving high quality health care for himself or members of the family unit. The cause for this apparent anachronism in a county like West- chester can be stated in simplistic terms, and it is believed that the Federal level can most directly lead to its solution. 1902 In such an action, it is modestly submitted that the cause of this top priority problem results in the basic inability of our present old- fashioned health care system to respond effectively to the health needs of today’s society. Briefly, a few of the things we have done during the recent past and a few of the things we are in the process of doing and propose doing are as follows: The merging of the Mount Vernon City Health Department into the county health department was finalized on January 1, 1970. The coordination between the county and city officials was most effective and resultant action has already attested to the success of such agreement. A similar merger was completed for the city of Yonkers in Janu- ary of this year, 1971, and it is anticipated that this merger will broaden the base for health services into Yonkers. Health Guide Program—Initial programs were established in Mount Vernon and Port Chester and additional programs for White Plains, Greenburgh, and Peekskill are now being formulated. Other programs, such as unwed mother services, family planning services, and rubella immunication programs have been initiated. A lead screening program for children 1 to 6 years of age is pending approval of the New York State Department of Health. Facilities have been improved with the latest being our new health and social services center to open next month in White Plains. Previ- ous such facilities have been built in Mount Kisco and Peekskill. Another major item is the support and encouragement given by the county to promote the New York Medical College’s move to Westchester, with the ultimate coordination and improvement of services in the county, due to the development of a large medical complex in Valhalla. We in this county are working hard to achieve the desired solu- tion, and this is coming about through the partnership that is de- veloping among the health professionals of the official voluntary and private sectors in the coordination of the leaders of the various con- sumer groups who are increasingly addressing themselves to the health problems of the people at the grass roots of our community. The solution that we are talking about concerns itself with the need for the establishment of community comprehensive health care centers that will be available to provide a total health care package for everyone’s service by such system, inclusive of screening, diag- nosis, preventive, therapeutic and rehabilitative care, inclusive of general and specialized outpatient and inpatient hospital care. The county health department, working cooperatively with the appro- priate citizen groups, hospitals, physicians, dentists, mental health interests, et cetera, is striving desperately to achieve such goals in such areas as Fairview-Elmsford section of Greenburgh Town, and the city of Mount Vernon. Similar interest is now germinating in the city of Yonkers. It is believed that these proposed programs will not only do the indicated job, but it is maintained that existing resources will pro- vide more services at lower unit cost than at present. This will be accomplished through a program improved in the utilization of exist- 1903 ing services. For example, a private practitioner cannot benefit from all the paraprofessionals that could be available to him in a group practice. In comprehensive care program, he need perform only the tasks for which he was trained at medical college. Based on the belief that the Congress will move forward on the high priority health delivery programs that the President is pre- senting, we on this local level will continue exploring and imple- menting new and innovative programs to accomplish the goals we need. We need early and significant funding approval on ‘the part of the Congress to accomplish our purpose. Thank you. Senator Ken~epy. Thank you very much, Dr. Hall. Mrs. Boal. STATEMENT OF MRS. LYNDALL E. BOAL, DIRECTOR OF SOCIAL . SERVICE, NORTHERN WESTCHESTER HOSPITAL Mrs. Boar. I will try to be brief because I think the main bulk of the people we want to hear from are the consumers that are here. I appreciate being asked to testify before this Committee because I care very deeply about the provision of good comprehensive health care to the people of our community. The | provision of basic medical services to the entire population of our community is in a precarious position. Good medical care is a commodity available in our sub- urbs, semirural and relatively affluent community, but there are seri- ous breakdowns in the delivery of this care to all people. Severe individual tragedies result. Patients frequently fall between various programs and plans, regardless of their economic level. There is a grave need for a basic foundation of guaranteed health care to be provided by a Federal system, regardless of State and local varia- tions. Preventive services in particular are lacking for many residents. Medicare will not pay for the routine physical examinations so essen- tial for the proper health care of the old and medicaid recipients frequently have difficulties obtaining this kind of care. Clinic facili- ties, where good medicine can be provided at lower cost for those who cannot afford private care, are woefully lacking. Northern West- chester Hospital provides the only treating clinics in the whole of Northern Westechester and southern Putnam counties. These consist of a prenatal-gyn clinic and a medical clinic, each held only once a week during the working day. The population in these two clinics has been increasing markedly: It is clear that both expansion and the addition of new clinics i 1S necessary. There is no pediatric outpatient treatment facility, other than pri- vate care, in the area. The nearest pediatric clinic is situated in the county hospital, 16 miles to the south and accessible by public trans- portation—only with great difficulty. Tt takes approximately 1 hour and 45 minutes one way, including a wait to change buses, which is impossible for a mother with a sick child. Transportation i is a prob- lem peculiar to this area, and one which makes medical care virtually inaccessible to many. There is no public transportation in this com- munity except for one north-south bus line through Mount Kisco. 1904 Patients without their own automobiles are dependent on costly taxis or friends and neighbors. The emergency room of the hospital is frequently used as a source of primary medical care for those patients unable to afford private care. This results in a lack of continuity of care and the provision of emergency treatment only. This hospital is currently attempting to rectify this gap by incorporating a viable ambulatory care unit into its new structure. Preventive dental care covered by third party payment is also im- possible to obtain. Virtually no dentists accept patients covered by New York State’s medicaid program, a service which has been dras- tically cut in recent weeks. Medicare does not provide coverage and, again, there are no dental clinics. There is only crisis care which could and should have been avoided. Patients living on close to a welfare-eligible level have severe problems in obtaining medical care. They represent one of the most vulnerable groups needing medical care. A married couple, under 65, receiving welfare benefits, who become eligible for social security disability benefits go off welfare, thereby losing that health care coverage. They are not yet old enough to receive social security coverage under medicare and are therefore without any medical coverage whatsoever. Even to qualify for coverage under the cata- strophic illness clause of the New York State medicaid program, their medical expenses must equal 25 percent of their income. Med- icaid will only cover medical expenses incurred 3 months prior to the date of application—it frequently takes a longer period of time to reach a total equal to one-fourth of income. A disabled father living in our hospital area supports his wife and two young children on combined social security and Veterans’ Administration benefits of $449.10 per month. He has a surplus in- come of $24.60 per month over the eligibility level for full medicaid assistance. He must therefore pay the full $24.60 toward medical ex- penses each month plus 20 percent of all medical costs. Under the medicaid cutbacks, he will be required to pay $66.60 per month, plus 20 percent of all medical costs. The family is totally drained financially and emotionally by this constant financial struggle. This man with metastatic cancer knows that in order to pay his medical bills, he must leave his wife and young children with nothing for their future. It is my feeling that any individual receiving disability benefits under social security should be eligible for medical coverage. He should not have to wait until he reached the age of 65—he may not live that long. I also feel that payment for drugs should be included under social security benefits. Not to do so is rather like building a house without a roof—in many instances, if the patient does not hays access to prescribed medications the total treatment plan is utile. In this State, patients between the ages of 21 and 65 with marginal incomes are ineligible for medicaid but their medical expenses fre- quently cause them to enter the welfare program. When they do ap- ply for welfare, debts have accumulated and they have frequently delayed seeking care due to the cost or failed to follow medical 1905 recommendations for the same reason. This has then affected their employment situation, family relations and general level of funec- tioning. A husband and wife, in their late 50%, are slowly approach- ing this. The husband has had a lengthy illness, suffering from metastatic carcinoma with many hospitalizations and extensive home care. The wife has recently been hospitalized. They must sell their house, their only child may not be able to go to college, and they may eventually slide onto welfare solely because of their medical expenses. I would like to mention that we do have someone in the audience who is a representative of the welfare rights group from this area who can speak even better to these points than T can. Two other quick points, and IT will eliminate the rest—equipment, which may seem like a small item, is no longer provided under the auspices of a home health agency unless the patient meets the cri- teria of skilled nursing care. The patient usually cannot pay for the equipment prescribed by his physician and therefore is not able to have it. Frequently the patient is unable to manage at home and must be transferred to a nursing home or rehospitalized with conse- quent disruption to the family and greatly increased cost to the community. We struggle constantly with the question of nursing home care for patients. Payment for nursing home care has also been a victim of cutbacks in allowed benefits, as you all know. Many families have been experiencing retroactive denials of medicare benefits, some several months after the patient has entered the nursing home by which time the bills have reached unmanageable proportions. It was interesting the national influential American Nursing Home As- sociation has recently requested that all member nursing » homes with- draw from participation in the extended care program, medicare program, which would be a disaster for the individuals needing this kind of care. Human tragedies such as these should not occur. I feel very strongly that it is within our power to prevent them. Medical care is a basic right that should be guaranteed to every citizen whether rich or poor, black or white, well or ill. We must have the basic foundation of a national health insurance program available to all. Thank you very much. (The prepared statement of Mrs. Boal follows:) 1906 Testimony Statement of Lyndall E. Boal, M.S.S.W., Director of Social Service Northern Westchester Hospital before the Subcommittee on Health of the U.S. Senate Committee on Labor and Public Welfare April 15, 1971 1907 STATEMENT OF MRS, LYNDALL E, BOAL TO U.S. SENATE SUB-COMMITTEE ON HEALTH ‘My name is Mrs. Lyndall Boal. I hold a Master's Degree in Social Work, and am licensed to practice as a social worker in the state of New York, I am currently Director of the Social Service Department of Northern Westchester Hospital, Mt. Kisco, New York. I appreciate being asked to testify before this committee because I care very deeply about the provision of good comprehensive health care to the people of our community. The provision of basic medical services to the entire population of our community is in a precarious position. Good medical care is a commodity available in our suburban, semi-rural and relatively affluent community, but there are serious breakdowas in the delivery of this care to all people. Screre individual tragedies result. Patients frequently fall between various programs and plans, regardless of their economic level. There is a grave need tor a basic founda- tion of guaranteed health care to be provided by a federal system, regardless of state and local variations. Preventive services in particular are lacking for many residents, Medicare will not pay for the routine physical examinations so essential for the proper health care of the old and Medicaid recipients frequently have difficulities obtaining this kind of care. Clinic facilities, where good medicine can be provided at lower cost for those who cannot afford private care, are woefully lacking. Northern Westchester Hospital provides the only treating clinics in the whole of Northern Westchester and Southern Putnam Counties, These consist of a Pre-Natal-Gyn Clinic and a Medical Clinic, each held only once a — during the working day. The population in these two clinice has been increasing markedly. It is clear that both expansion and the addition of new clinics is necessary. There is no pediatric out-patient treatment facility, other than private care, in the area. The nearest pediatric clinic is situated in the county hospital, 16 miles to the south and accessible by public transportation - only with great difficulty. It 1908 takes approximately one hour and forty-five minutes one way, including a wait to change buses, which is impossible for a mother with a sick child. Transportation is a problem peculiar to this area, and one which makes medical care virtually in- accessible to many. There is no public transportation in this community except for one north-south bus line through Mt. Kisco. Patients without their own automobiles are dependent on costly taxis or friends and neighbors. The emergency room of the hospital is frequently used as a source of primary medical care for those patients unable to afford private care, This results in a lack of continuity of care and the provision of emergency treatment only. This hospital is currently attempting to rectify this gap by incorporating a viable am- bulatory care unit into its new structure. Preventive dental care covered by third party payment is also impossible to obtain. Virtually no dentists accept patients covered by New York State's Medicaid program, a service which has been drastically cut in recent weeks. Medicare does not provide coverage and, again, there are no dental clinics. There is only crisis care which could and should have been avoided. Patients, living on close to a Welfare--eligible level have severe problems in obtaining medical care. They represent one of the most vulnerable groups needing medical care. A married couple, under 65, receiving Welfare benefits, who become eligible for Social Security disability benefits go off Welfare, thereby losing that health care coverage. They are not yet old enough to receive Social Security coverage under Medicare and are therefore without any medical coverage whatsoever. Even to. qualify for coverage under the catastrophic illness clause of the New York State Medicaid program, their medical expenses must equal 25% of their income. Medicaid will only cover medical expenses incurred three months prior to the date of application =- it frequently takes a longer period of time to reach a total equal to one-quarter of income. A disabled father living in our hospital area supports his wife and two young children on combined Social Security and Veteran's Administration benefits of $449.10 per month, He has a surplus income of $24.60 per month over the eligibility level for 1909 full Medicaid Assistance. He must therefore pay the full $24,60 towards medical expenses each month plus 207% of all medical costs. Under the Medicaid cutbacks, he will be required to pay $66.60 per month, plus 207% of all medical costs. The family is totally drained financially and emotionally by this constant financial struggle. This man with metastatic cancer knows that in order to pay his medical bills, he must leave his wife and young children with nothing for their future. It is my feeling that any individual receiving disability benefits under Social Security should be eligible for medical coverage. He should not have to wait until he reaches the age of 65 - he may not live that long. 1 also feel that payment for drugs should be included under Social Security benefits, Not to do so is rather like building a house without a roof - in many instances, if the patient does not have access to prescribed medications the total treatment plan is futile. In this state, patients between the ages of 21 and 65 with marginal incomes are ineligible for Medicaid but their medical expenses frequently cause them to enter the Welfare program. When they do apply for Welfare, debts have scsumalted and they have frequently delayed seeking care due to the cost or failed to follow medical recommend- ations for the same reason, This has then affected their employment situation, family relations and general level of functioning, A husband and wife, in their late 50's, are slowly approaching this. The husband has had a lengthy illness, suffering from metastatic carcinoma with many hospitalizations and extensive home care. The wife has recently been hospitalized. They must sell their house, their only child may not be able to go to college, and they may eventually slide onto Welfare after all these sacrifices. Families just able to move off Welfare frequently return to the rolls if they are unfortunate enough to incur medical expenses within the first few months. Families in which the wage earner is self employed and those who are not covered by Social Security are also vulnerable to similar economic pressures. We have been finding that employers are hiring on a contract basis to avoid paying benefits such as health insurance, 1910 : This community also has a high proportion of families in which the wage earner would be classified as a junior executive or in a middle-management echelon. Many of these families spend to the limit of income, with little savings or in- surance, Medical expenses, even of a relatively minor nature, cause a dispropor- tionality high dislocation of family functioning. The recent cutbacks in coverage by both Medicare and Medicaid have resulted in severe problems for many residents in need of health care. Benefits are no longer extended under Medicare unless the program's criteria of "skilled nursing care" is met, Our local District Nursing Association is currently seeing a patient who has had progressively crippling multiple sclerosis for over thirty years. Her husband recently had surgery for cancer, and has a colostomy which needs care, When Medicare coverage was denied, the nurses continued to provide highly skilled nursing care free. Their sound nursing evaluation indicated a need for this, and the family was unable to pay. However a small nursing agency is obviously unable to continue to do this in- definitely. Equipment is no longer provided under the auspices of a home health agency unless the patient meets the criteria of "skilled nursing care". The patient usually cannot pay for the equipment prescribed by his physician and therefore is not able to have it. Frequently the patient is unable to manage at home and must be transferred to a nursing home or rehospitalized with consequent disruption to the family and greatly increased cost. } “ Payment for nursing home care has also been a victim of cutbacks in allowed benefits. Many families have been experiencing retroactive denials of Medicare benefits, some several months after the patient has entered the nursing home by which time the bills have Foadtiad unmaneagable proportions. A spouse of an institutionalized patient is frequently reduced to a subsistence level even with state and county aid for the nursing home bills, The inf tial American Nursing Home Association has recently requested that all member nursing homes withdraw from participation in the extended 1911 care program, with the consequent human suffering involved. Human tragedies such as these should not occur. It is within our power to prevent them, Medical care is a basic right that Should be guaranteed to every citizen whether rich or poor, black or white, well or ill, We must have the basic foundation of a national health insurance program available to all. 4/15/71 1912 Senator Kenney. Thank you very much. A splendid statement. Mr. Eugene Curry, who is chairman of the Citizens Committee on Aging and Chronically Ill of Westchester County. STATEMENT OF R. EUGENE CURRY, CHAIRMAN, CITIZENS COM- MITTEE ON AGING AND CHRONICALLY ILL OF WESTCHESTER COUNTY Mr. Curry. Senator, I was certainly heartened by your picture of the person who had saved during his lifetime and was in full ex- pectation of being able to remain independent and able to care for himself and what has happened. I think the words yesterday at the White House conference where we are getting ready for the large meeting on the 27th spoken by those leaders of the seven counties, agreed that inflation unless stopped will dissipate anything that may be done for the older citizen. So if I may, I will carry your point about the lifetime of saving to the next step, and I think something should be done. There are many people who could be retained in their own home—who want to be retained in their own home. Their great fear is that they will not be able to stay there because of their health or because they can’t afford it. And these supportive services would cost so much less than to put them into any form of institution care. We have already in our committee and under the Northern Metro- politan Council granted permits for the health related facilities and nursing homes that we believe are adequate. Now we need the ex- tension of the hospital so that these people staying in their own homes, in the nursing home and in the health related facility can have a place to go immediately in, and then back to their proper place. So we need balance and we need, of course, the new hospital enlargement. The tragic fact is that costs of supporting services and per diem rate for care, as you have pointed out, have risen rapidly, out of all proportion to past savings and present income of older citizens. They have lived frugally and carefully, with every expectation of being self-supporting, independent members of society to the end. Their savings can be wiped out in a very short period of a few weeks with any prolonged illness. Of course, it is hard for us to believe, but the savings of these older people of the 1930’s, when many of them were in their prime, are two-thirds wiped out by inflation. The savings of 25 years ago are half wiped out, and even since 1967 the value of savings and pensions have been decreased by one-sixth. That is 314 to 4 years. Now as we come into this nice new health insurance of the United States, I hope you and Mr. Reid will listen to the words of good old Lord Beveridge, about 82 years old. He was here a few years ago as our guest in this community, and he said two things that happened in financing in Great Britain—First, the actuaries in the Govern- ment underestimated the cost, and second, inflation underestimated the building up of the benefits. We have already had the underesti- mation, as you well know, in medicaid and medicare, and we have 1913 the inflation. So I hope we are not repeating those great mistakes which Great Britain went through. We must get this balance back between savings and the cost of care. Now let’s go further. As a Nation we are not facing up to our problems of inflation but have turned to subsidies in construction and belated increases in social security, never going to the causes of our problems. We have got to begin with the Federal Government, where infla- tion has had its greatest impetus. We must have cooperation from and control over those with monopoly power to force increases in wages and profits far exceed- ing increases in the cost of living, and all too often without increased productivity or changes to permit it. That could be enlarged upon, but this is not the time or place to do so. It is not in the national interest to have the powerful and the well organized exploit the worker and it is reprehensible to see the help- less older citizen robbed of his life savings. Unless and until we as citizens in our various capacities, and our representatives at every level of Government, understand and attack the causes of inflation there cannot be any security for the older citizen in the health or any other field. Senator KenNEDY. Good statement. Do you live out here, Mr. Curry ? Mr. Curry. Yes, sir. Senator Ken~epy. You have lived out here how many years? Mr. Curry. Forty years. Senator Kennepy. And you have been a part of this community for that period of time ? Mr. Curry. Yes, sir, I have. Senator Kennepy. We have been hearing this afternoon, as we have over the period of the last 7 weeks in Washington and yesterday in New York City that we have a real health crisis in the country in many areas. You point out what is happening in terms of the suburban communities, and how individuals who live out in a com- munity such as this are disadvantaged. Thank you, Mr. Curry. (The prepared statement of Mr. Curry follows:) 59-661 O—71—pt. 8——13 1914 PR Eugene Curry 21 Mead Bond Amant, N.Y. 10504 Wl. (913) AR 3.3004 Statement for U.S.Senate Sub Committee on Health Care in America Northern Westchester Hospital, Mount Kisco, New York, April 16,1971 By R. Eugene Curry, Chalrman, Westchester Citizens Committee on the Aging and Chronically Ill, and Chairman of the Advisory Committee on Nursing Homes, Northern Yetnopaiiten Healt and Hospital Planning Council; btlme did no of this statement to these bodies for approval or change. The greatest threat to the older person 1s the loss of the home or the ability to live in it by reason of failing health or insufficient income under soaring costs of living. Supporting services could keep many older citizens in their own or similar residential quarters at a fraction of the cost of health related, nursing home or other institution. Health related and nursing home facilities are important in the total program, and permits for the estimated needs have been granted in this area. It 1s essentlal that we bulld adequate, accessible and complete hospital services for those in their own homes and for those under group care. permit ea ston The tymgic fact 1s that costs of supporting services and per diem rates for care have risen rapidly,out of all proportion to past savings and present income of older citizens. They have lived frugally and care- fully, with every expectation of being self supporting independent members of soclety to the end. Their savings are wiped out rapidly in the event of prolonged illness; thls great imbalance between past savings and present costs is the terrible toll of inflation. The savings of the 1930's have lost two thirds of thelr value, those of 25 years ago half, and even savings and pensions of 1967 have lost one sixth of their value. As we approach our own national version of Health Insurance, it is evident that we are repeating needlessly the mistakes of others. Lord Beveridge, sponsor of the National Health Service of Great Britain, was our guest ln this community a few years ago; he stated that thelr great effort had suffered two great blows : Underestimate of costs by the actuarles in government, and the inflation. We see that here, in the underestimates for Medicare and Medicald and the excessive infldtlon of recent years. We must reestablish a balance between savings and nl 3,to cover health costs; this 1s vitally important to those over fifty, ad well as to those already in retirement. | 1915 21 Wad Koad Amank, N.Y. 10508 Page 2 Statement Ii (914) A? 3.3008 of April 15, 1971 Sub Committee on Health in America As a nation we are not facing up to our problems of inflation but have turned to subsidies in construction and belated ; increases in Social Security, never going to the causes of our problems. We must begln with the federal government, where inflation has had 1ts greatest impetus. We must have cooperation from and control over those with monopoly power to force increases in wages and profits far exceeding 1lncreases in the cost of living, and all too often ‘with- out increased productivity or changes to permitg 1t. It is not in the national interest to have the powerful and the well organized exploit the worker and it is reprehensible to see the helpless older citizen robbed of his life savings. (Unless and until we as cltizens in our various capacitles, and our representatives at every level of government, understand ha attack the causes of inflation there cannot be any security for the older citizen in the health or any other field. 1916 Senator Kennepy. We have now completed the formal witness list. Some individuals have given us their names, and we will hear from them now. Mrs. Hausner has to leave at 4:30, and then we will hear from Mrs. Sanchos. For any of you who want to file a statement, we will be glad to include in the record that so that your views are repre- sented. We ask those that speak if they can keep to 3 minutes or so. If we are able to get through everyone we will come back and give you another chance after that. STATEMENT OF MRS. STOWE W. HAUSNER, MOUNT KISCO, N.Y. Mrs. Hausner. I will try to speed through this. I am here as a citizen, as a consumer, someone who has lived in this community for over 20 years. You have described this as an affluent community. I really feel the description of affluence is a de- ceptive one. Our pockets of poverty remain fairly invisible to most of us. Our neighbors living in poverty include those who are post- revolutionary war settlers as well as newly arrived families. The group that is least visible to us are the seemingly middle class families, who even before this inflationary time, were barely coping on their incomes. Most of them have fed our inner cities, and now find themselves house-poor. When income is limited, health care without insurance becomes one of their postponable budget items. Medical care for many of these families, who are in every respect responsible citizens and community members, is something they al- low themselves and their families only in situations of severe or extreme illness. The use of such services frequently results in in- creased debt. I feel great concern about this situation because I, too, regard comprehensive health care as a basic right. Children within our community are the most frequent victims of their parents’ poor financial planning or lack of income. So that some are really poor and others are not visible to us as poor people. They cannot electively choose medical care. I’m sure the kids them- selves would be reluctant for their parents to use it. Medical care is possible for any family in northern Westchester despite lack of income. But let me briefly describe to you how frag- mented it can become, for children in particular. We have a well child conference available to all children from birth to 5 years of age whose families cannot afford private care. I think Mrs. Boal described to you the trek, but not the cost of $3 in just fare in order to obtain medical care. Where a family has no physician our emergency rooms have become the physician’s substi- tute. Without some type of universal health insurance within this democracy I feel we offer no free choice of medical care. This is primarily what physicians tell us—that everybody must have a choice. We are not allowing that choice. Choices exist only for those who can pay their own way. Medical care must become available to all of us. We should be able to make the judgment as to the best care we wish. This may be a private practitioner, a medical group, or a clinic. 1917 I would like to see the day when the hospital clinics and emergency rooms would be filled only with those people waiting there because this is where they believe they receive top level medical care, rather than as now exists, emergency rooms and clinics are seen by patients as the only place they can afford and frequently the only medical facility which will tolerate them. (The prepared statement of Mrs. Hausner follows :) PREPARED STATEMENT OF MRS. STowe W. HAUSNER, MoUNT Kisco, N.Y. I submit this statement as a private citizen; a resident of an area the sub- committee has described as “affluent”. The description of “affluence” is a de- ceptive one. Our pockets of poverty remain fairly invisible to most of us. Our neighbors living in poverty include those who are post-revolutionary war settlers as well as newly arrived families. The group that is least visible to us are the seemingly middle class families, who even before this inflationary time, were barely coping on their incomes. Most of them have fled our inner cities, and now find themselves “house-poor”. When income is limited, health care without insurance becomes one of their ‘“postponeable budget items”. Medical care for many of these families, who are in every respect responsible citizens and community members, is something they allow themselves and their families only in situations of severe or extreme illness. The use of such services frequently results in increase debt. I feel great concern about this situation because I too regard compre- hensive health care as a basic RIGHT. It is already axiomatic that the wealth of the nation can and should be measured by the health of its people. We readily accept that people living in poverty have a disproportionate number of health problems—due to malnutrition, lack of availability of pre and post-natal care, etc. What is less evident is that otherwise self sufficient families can become poverty stricken due to illness. This poverty is not only due to the direct cost of medical care to a family; but also to loss of income for either the husband or wife bread winner. Health care, which families cou'd afford to use freely could prevent much of this poverty. I have no question but that we have superior medical care available in our community. It is important that all our citizens have equal access to it. Children are the most frequent victims of their parents poor financial plan- ning or lack of income. They cannot electively choose medical care—I'm sure they wou'd most frequently be reluctant to. Medical care really is possible for any family in Northern Westchester despite lack of income. Let me briefly describe how fragmented it can become for children. We have a Well Child Conference available to all children from birth to five years of age whose families cannot afford private care. Beginning at the age of five a child need- ing pediatric services wou'd have to use our county hospital some fifteen miles away. If the family has no physician in the community the hospital emergency room will become the substitute. Another category of victimize children are those whose family may have marginally sufficient funds but whom mismanage their income. Without some system of insurance coverage, we allow these children to suffer from their parents distorted sense of values. We do them and our nation a disservice. Without Universal Health Insurance we offer NO free choice of medical care for those with marginal incomes. Choices exist only for those who can pay their own way. Medical care must become available to all of us. We should be able to make the judgment as to the best care we wish. This may be with a private practitioner, a medical group or, in a clinic, I would like to see the day when hospital clinics and the emergency rooms would be filled with those people waiting there because they believed that this was where they would find top level medical care—rather than the only places they can afford, who will “tolerate” them. Senator Ken~epy. Thank you very much, Mrs. Hausner. Mrs. Sanchos—just for the record, could you give us your com- plete name and address? 1918 STATEMENT OF MRS. BLANCHE SANCHOS, COMMUNITY WORKER, COMMUNITY ACTION PROGRAM, YONKERS, N.Y. Mrs. Sanxcmos. My name is Mrs. Blanche Sanchos, community worker, community action program in Yonkers; address, 138 South Broadway. I am also an active member of the Poor People’s Con- sumers Committee on Real Health Care. I don’t have a statement prepared. I do have a few points I would like to respond to. I heard mentioned before, peer review, and who does the peer review. It is impossible to think that in the medical profession this can ever be a reality, simply because standards of health care are set up by doctors, codes for standards are set up by the medical profes- sion. There is no independent body or accountability to anyone in the community at large for either service or expenditure of public funds. I say public funds because there is no such thing as private medical care. Today we have what you call a voluntary system that is quasi-public. All health care depends upon public funds in one way or another. We find that there are ways in which this can be found and the big barons of the medical empire know how to get them. There are tax exempt funds they know where to tap. Before any of the poorer communities are able to know where the Federal funds are coming from and how to obtain them for the local communities they al- ready have their grants in. I am particularly kind of keen to one of the points brought out in terms of the New York medical complex coming up here. IT am disturbed because besides losing that medical school we might lose a second one, the Einstein complex. Today there are games being played by the Montefiore medical complex to see how they can im- prove their affiliation and hook up with NYU, and this way not only - will they control the medicine in the Bronx, they will control West- chester and Rockland. But let me relate now to what I really wanted to speak about, and that is that here in northern Westchester we are talking about health care. The county of Westchester has very well people. We don’t have that in Yonkers or any of the poorer cities in southern Westchester. Yonkers, whose health care is one of the saddest things in this Nation—we talk about Lincoln Hospital—Senator, before you leave please visit Yonkers. Come to St. Joseph and Yonkers General. Come and see an emergency room that has no staff. Come and see one-third of the population who is poor, has no power—and simpler, there are no services. I heard about the department of health. We have no department of health in Yonkers. We have some well baby clinics. I heard of your comprehensive health centers. When I came here IT knew about the ghetto hospital. We were told there are no plans to expand. We have something going in Greenbury, but not in Yonkers right away. In the county of Westchester with all its poverty—and there is a lot of poverty—I am talking about Yonkers, Mount Vernon, New Rochelle, Peekskill—all over the county there are little pockets. In the county of Westchester, with all respect sir, we don’t have a lead poison program. Incredible. Twelve thousands units of substandard 1919 housing in Yonkers, and the county of Westchester does not have that program. The city of New York has had it for 2 years. Senator Kennepy. We don’t have a program at a national level. We authorized $15 million for this year, $20 million for next year, 25 the next year. But not one cent was requested by the administra- tion for lead poisoning programs. Mrs. Sancuos. Should I rephrase it then ? Senator Kenneny. OK. ; Mrs. Sancnos. I just took some notes, and I’m sorry. Senator Kennepy. That’s all right. You are doing very well. Mrs. Sancuos. I would like to refer you to the problem of the aged, one of the things that concerns me particularly with the volun- tary hospitals. At one point—that must have been about 3 or 4 years ago—there was money in the Federal Government for the extension of this service among the ambulatory. Then some funds dried up. I notice now the voluntary hospitals have been decreasing the service. I became familiar with it when TI was working for the affiliation and spent a lot of time in the emergency room. I became impressed with the home care service simply because most of the population—80 percent of it was aged. This program released hospital beds to take care of the poor. It also gave other services; in other words, it co- ordinated services that were in existence that were not being tapped, and I feel that there should be an extension of this. Senator Kennedy, the county of Westchester has got to wake up. On their doorstep is one of the greatest problems that they have turned their backs on, and that is the drug addiction. Formerly T worked in the South Bronx area and I thought nothing can be worse than this, but, T found the worst part in Yonkers—found 14-year-olds dealing in the streets. They weren't only taking the needle, they were pushing the drug in order to maintain the habit. I’m sure you go nationwide and hear this, but IT am talking about the county of Westchester. I am talking about the fourth largest city in the county of Westchester who suddenly the county has turned its back on. When I heard of such a fantastic program going on here, T thought perhaps somehow we can come up and visit with vou and see how that program could be initiated down there. We need help and we need desperate help, but I think that the only way that we can get it is at hearings like this so public attention can be brought to bear on the problems. But we have a few other people here from Yonkers, and T think they have other points to bring up. Thank you very much. Senator Kennepy. Thank you very much. Mr. Maisel. STATEMENT OF ALBERT MAISEL, WRITER, READERS DIGEST Mr. Maser. Yes, sir. Senator Kexnepy. We will try and follow the 3-minute rule. Mr. Marser. I will follow the 38-minute rule. I am a writer for the Readers Digest specializing in medical mat- ters, and particularly in social aspects of medicine. 1920 My purpose in coming here is twofold. First, I think it may be of value to you to know that there is a crisis among the middle class. That may come as an anticlimax after hearing the very acute, very desperate, very heart-rending aspects of the crisis as it affects the poor. But there is also a crisis among the middle class. The Readers Digest, for example, has for very many years main- tained an insurance program, the usual Blue Cross and Blue Shield and the major benefit program, the Digest paying two-thirds of the cost and the employees, some 2,800 of them in this area, paying one- third of the cost. When this started this was a minor fringe benefit in the total wage package, salary package of the Digest. Today, after repeated increases in cost, this has become part of the package, much more than a fringe benefit. And yet the Digest employees, who are middle class people, well paid, well salaried, are unable to get as good health services as they were able to get some years ago in spite of the fact that the cost has gone up. This is not the fault, let us say, of Northern Westchester Hospital. Here there has been great devotion, volunteer devotion by all sorts of people in the community, including many Digest people, to build this hospital and maintain it and maintain the services. But the fact is here is a plant that is in part obsolescent and that is not able as it stands, until it gets its new building, to give the same sort of service it could give 10 years ago simply because the population of the area has grown while the plant has aged. And this is happening not only here in Westchester, not only to the Digest middle class employees, but it is happening to similar groups throughout the country. I think in part because my editors see this from day to day among themselves, they feel the fact that their coverage, in spite of trying to buy the most complete coverage and the ability to buy the most complete coverage, this coverage is with deductibles Senator Kennepy. What do you think is the answer? Mr. Marser. The answer, I think—and T know our readers think, from the letters we get from them when we publish articles on this— is that we do need some form of national health insurance. As we said in an article that we published in February, the debate has largely shifted from whether to adopt national health insurance to what kind of a program we need and how big. And T think that increasingly this disgruntled middle class group is finding that it needs in its own interest, as well as a desire to help the disadvantaged—that what we need is a health program, a form of national health insurance, but beyond that it must not be a pro- gram that merely adds insurance. If you give us just insurance you will be compounding the mistake that was made in 1965 with medi- care and medicaid, the mistake of adding buying power without adding supply. A program such as this has to have imbedded in it a segment of the funds collected, however you collect, whether by wage tax or by income tax, that will go for the building of new hospitals, that will go for the building of medical schools, that will increase the supply of physicians, that will permit the peer review, and every other goal that has been mentioned here today. And I say that this is what we get in our mail, this is what T get when I interview members of the Digest staff or when I go out and interview middle class people who are the Digest readers. 1921 {Td Senator Ken~NEepy. This is what we get in our hearings, too. Mr. Maser. I am sure. Senator Kexnepy. Would you not agree with me that the hospitals alone can’t meet this problem ? Mr. Maser. No. Here is a hospital who has not been able to meet this problem, and let us say although it is struggling manfully to do so, it can’t raise the money. : Senator KenNepY. Any more than you could expect the doctors in and of themselves to try and remedy the situation. Mr. Maser. They can locally by extra efforts, or something, in the way they used to give charity and remedy the situation. Senator Kexnepy. But I think your point is that it is the system itself. When you talk about the development of some kind of health insurance you also talk about increasing the supply of services, as well as the whole question of quality and establishment of innovative and creative programs that develop competition between health de- livery systems. Mr. Maser. Without feeding them the answer, I find they volun- teer the answer—they don’t want just national health insurance. They want a national health insurance program that will increase the supply of health facilities. Senator Kennepy. Well, I appreciate your comment. I think it reinforces at least my view on it, and I think Congressman Reid has expressed it as well. It is very reassuring—Readers Digest has main- tained contact with the people, and has a real feel for what people are thinking about; I think this is an extremely important and useful comment. Mr. Marser. I don’t take any position in favor of one program or other, and I am speaking here on my own on that, but the fact is the Digest experience is part of the total experience of the middle class here and they are disgruntled over what they have today. Senator Kexnnepy. Thank you very much. Joan Munley, director of health services, public schools. I am going to have to leave. Congressman Reid has indicated that he would be able to remain for a while. Our two staff will remain, and I hope that we will continue along. I will read the transcript of He testimony very carefully. We will not recess, but continue right along. We have Joan Munley and Mrs. Claire Marcus, who is a private citizen, and Mr. John Harris, who want to make a statement. Mr. Rem. And TI hope also that anyone in the room that wants to speak for the record will do so even though we may not have the name. Senator Kennepy. I want to thank you very much for your com- ing here, and thank Congressman Reid, and thank the hospital ad- ministration of the Northern Westchester Hospital. We are asked often what you can learn from these hearings. We are only here for a couple of hours. But we spent a couple of hours out in Nassau County earlier today. We were down in the city of New York yesterday, and in the emergency rooms of some of the hospitals the night before. We have been holding hearings on this general health care crisis area for 8 weeks in Washington, and now we are going into the field. We have seen yesterday and today that 1922 none of the national experts’ testimony is more eloquent than that coming from people that have a very direct contact with health care services. It is enormously helpful to the Senate and to our under- standing of this issue. We are very appreciative for the courtesy that you have shown and the attentiveness which has been reflected at this meeting here this afternoon. We will go ahead and continue the record as long as Congressman Reid can stay. And I want to once again thank you all for your interest and your attention here. (Senator Kennedy withdrew.) Mr. Rem (presiding pro tempore). I think we will proceed, and I would like Joan Munley, as director of the health services, public schools of Mrs. Muncey. Bedford public schools. That is a central school district that serves this area. Mr. Rem. If she will proceed, and we have three or four that have asked to speak, and then we will open it up. STATEMENT OF MRS. JOAN MUNLEY, DIRECTOR OF HEALTH SERVICES, BEDFORD CENTRAL SCHOOLS Mrs. Muntey. I just want to say that we in the health services in the schools work with the so-called well child, and Mrs. Boal and Mrs. Hausner have very ably related to you how our marginal fam- ilies do and do not use health services. However, IT would like to point out most especially the mental health needs of growing youngsters. We see on a daily basis scores of children in our health services that have semantic complaints that really are related to stress, stress in their private lives and/or in their school lives. And we feel that the mechanism for promoting the mental health and protecting the mental health of growing children is very, very vital. Mr. Rem. What therapy are you able to give in that regard? Mrs. Muncey. By law the schools are forbidden to give therapy. This is not permitted. We do screening only. And we are totally de- pendent on the communities for whatever services are needed. Mr. Rem. Well, when you refer a child to whatever means that you choose what are the chances that he will get any kind of ade- quate therapy? Mrs. Mu~rey. The chances that he will get therapy when we from the school refer a youngster depend on his parents. They have the final responsibility for the care of the child. From there on Mrs. Boal has Mr. Rem. Are there a significant number who need therapy that are not getting it? Mrs. Munrtey. What I am speaking here to at this moment is the growing child and help for him in coping with the stress that he finds in his daily life. Mr. Rem. Fine. Well, thank you very much. We appreciate that comment, and we will look into it. Mrs. Claire Marcus. Thank you very much for staying. (Supplemental information subsequently supplied by Mrs. Munley follows) 1923 BEDFORD PUBLIC SCHOOLS THE FOX LANE CAMPUS, P. O. BOX 180, MOUNT KISCO, NEW YORK 10549 Area Code 914: 666-6731 ANTHONY C. SABELLA ERNEST L. HUNTER Superintendent of Schools Assistant Superintendent April 21, 1971 Senator Edward Kennedy, Chairman Senate Labor & Public Welfare Committee, Sub Committee on Health Washington, D.C. Dear Senator Kennedy, Your personal assurance, during your visit to Northern Westchester, that a spokesman for the school children of Westchester County would be heard and that a statement made would become a part of the record of the Senate Labor and Public Welfare Committee, Sub Committee on Health has motivated follow through. Repetition, in this instance, has its value. To be sure, what is written on the attached statement you have heard before. However, what is said does not come from a health agency but from public education. This view of how health care affects the lives of children and youth as they face their daily responsibilities in the school can complete the total health care picture. Rarely is one sought out by his federal government and asked to speak of the concerns in the daily lives of growing children. This is in itself an event. At the same time it was conveyed to me that what was said at The Hearing does and will have meaning toward a better life for all in the future. Thank you for making this possible. Sincerely yours, Do Npr os P2ee Je oan Munley, Direct 1th Services 1924 BEDFORD PUBLIC SCHOOLS SCHOOL HEALTH SERVICE P.O. Box 180, Mount Kisco, New York 10549 We work in the public schools with what is known as a "well child" population. Our purpose is to promote and maintain health in order that children can make the best use of their educational opportunities. Our responsibility is to guide families to health services for their children and, at times, to guide parents as well. Sometimes, children are at home to care for parents who are ill. By law, public schools are not free to render diagnostic and therapeutic services and therefore are entirely dependent on services in the community. What are those things that block children from getting the services they need? 1. Availability of diagnostic services when exceptional problems occur. A. Timing for working parents is not appropriate. Public service schedules require time off from work to obtain care for children and their parents. B. Geographic location - special services are at some distance and require private transportation. It ie unusual that parents refer themselves to these services and more than usual that they are there on referral of a physician. Such families are apt to live with their daily health problems and use the Emergency Room abt the Hospital at times of crisis or drift from private physician to private physician and there is therefore no continuity of care or a total view Page 2 point of the family and its problems and how they might affect an individual's health. This is aggravated by a great deal of mobility. 10% of our children are new to the school each year. They are from all parts of the country and of the world. T Children and parents of these middle income families depend a great deal on school medical and nursing services for health supervision. Concretely this means discovery of either acute or chromic health problems at the school. Part of this reflects the families priorities and values and part the rising cost of médical care. These families do not go to doctors unless "something is wrong". Mandated annual health inspections in the past lead to a false sense of security in that numbers precluded examination of the children in depth. Now that the mandate has been changed to 4 or 5 times during the school life of a child, we are in a better position to perform broader and more complete and more meaningful screening examinations. What are the major health problems of school children as viewed from the daily life of a child? 1. Debilitating, recurring marginal infections resulting in frequent school absence or lethargic presence in classes. ie. One stays sick until he gets well unless a crisis occurs. 2. Somatic complaints that are seemingly related to stress in the child's life at home and/or at school. 3. Dental caries: It's not unusual for a child to be at home in bed with a toothache! 1926 Page 3 What would make things better for school children and their families? 1. Oneplace where families can consistently, freely, and conveniently go with all of their problems, both health and social. 2. Total coordinated care whether under the supervision of a family ~rhreician or a public service rendered to families. 3. Services geared to needs of working parents so that they will not need to lose a days work to get them. 1927 STATEMENT OF MRS. CLAIR MARCUS, FLOOR WITNESS Mrs. Marcus. My statement is very brief. But I am rather sur- prised the point has not been made up until this moment—the break- down in amount of money that supports hospital care, medical care, research, and what have you. I feel—and many will agree with me when I say this—if the war in Vietnam were to end this money could then be channeled very usefully into all of these fields. And since we seem to be at such a crisis pitch as far as the kind of medical care that is available in this county and many other counties across the country I certainly think that this war has to stop at the very earliest opportunity. Mr. Rem. Well, I agree with you, and we also need a peace divi- dend and a change in priorities so that we can really make major amounts of money available for health care and environment, schools, and other needs. Thank you. Mr. John Harris had two questions. STATEMENT OF JOHN HARRIS, FLOOR WITNESS Mr. Harris. Thank you, Congressman. I don’t know whether they are questions or a comment. I raise them anyway. I am doing some preliminary doctoral research concentrating prin- cipally on the problem areas within the hospital and focusing on the training areas, and in some preliminary work I have been doing I find a tremendous woeful lack of training, particularly with the non- professional staff. I am not speaking about universities, and so forth, which seem to have a tremendous program. But in the area of the nonprofessional staff the hospitals seem plainly aware of the need of it, but felt their greatest problem was not just funds, but in getting people released, getting supervisors to understand. Mr. Rem. Let me ask Dr. Brew if he would like to comment on training for nonprofessional staff here. Dr. Brew. Yes, sir, we have a full-time, in-service director of on- going educational programs that relate to nurses and others, and these are not restricted only to nurses. But I think this is frequently a void. I concur with that. Mr. Harris. One of the key areas, it would seem to me, is in the area of supervisory training, and this is among the professional people. The nurses are trained very well, and other professional people, but they have had very little training in supervisory manage- ment skills which take on a whole different aspect when they are thrust into positions and frictions in human relations and employee relations areas. The other question, maybe you would comment, Congressman, on Mr. Curry’s point of inflation and the cry of many hospital ad- ministrators versus the unionization of hospital workers. By this I mean I believe as of July 1st many hospitals in the city will have a base pay for the lowest worker of $130 a week, and we know that the poverty level for a family of four in New York City is about $6,000. So the problem is how can a worker support a family and survive, and yet hospitals have the crying problem of inflation. of Zr 1928 Mr. Rem. Well, I think that inflation is very serious, and it is one of the reasons why I have supported hooking social security benefits to cost of living so that social security benefits go up automatically with the cost of living. But it is very true that many citizens have very little in the way of savings and they are wiped out almost overnight by catastrophic illness, and that’s why the legislation that we are holding hearings on today is trying to deal across the board with a whole series of needs to develop a coherent national health delivery service that we just don’t have. And it has got to reflect, in my judgment, not only inflation, but in addition provision for a shortage of—well, 150,000 nurses, 50,000 doctors, perhaps a quarter of a million health profes- sions personnel, plus increases in facilities. All of that has got to be part of this, as well as the capacity to provide the service for the individuals. But if it is just an insurance plan the individual can’t afford, with the services not available, it is not meeting the needs. So I think your point is very well taken. Mr. Harris. Thank you. Mr. Rew. Thank you. Yes? Would you give your name ? STATEMENT OF JOSEPH GARRISON, NURSING HOME ADMINISTRATOR, PEEKSKILL, N.Y. Mr. Garrison. Joseph Garrison, Nursing Home Administrator, Peekskill, N.Y. I want to bring to your attention a problem which I have run across recently which seriously affects the aged when they become nursing home patients. The State hospital code requires a nursing home patient be visited at least once a month by the physician of his choice, and, of course, more if necessary. I have run across the situa- tion where a number of doctors refuse to treat and care for nursing home patients at all. Maybe physicians who have spent many years caring for an individual, but when that individual goes to a nursing home the doctor washes his hands of the individual and says, “It is just not my policy to treat nursing home patients. It is not that I can’t care for them, I just don’t want to.” And here you have an individual late in life who has been associated with a physician for a good number of years, suddenly finds he has been tossed out. Now couple this with the traumatic experience of moving from a home or hospital into a nursing home, it is a serious problem for this person. And I don’t know how to solve it, but I think the medical associations and societies must police themselves and correct the situation. Mr. Rem. Well, that is a very important problem. I am glad that you raised it. And let me ask either Mr. Peck or Dr. Brew if they youd care to comment on that problem. Did you hear this, Mr. eck? Mr. Peck. I didn’t hear it. Mr. Rem. Well, it is a case that there are many individuals in nursing homes who are unable to have their physicians or any phy- sician visit them, and there is a requirement under the law that this be done from time to time. 1929 Mr. Garrison. It is really a problem that they cannot have a phy- sician of their choice. Their physician may say, “I'm sorry, I don’t treat nursing home patients.” Then the individual has to hunt around and try to find another doctor who will treat them. i Mr. Peck. Well, I share with Mr. Garrison the feeling that this is a problem, and 1 hope we will be able to cooperatively work it out. Mr. Garrison runs a nursing home with which we have transfer agreements. We do try to keep in close touch, and that is what Mrs. Lyndall Boal meant when she was talking about a continuity of care. I think it is important, but it is a hard thing to achieve. Dr. Brew can comment on the problem from the doctor’s viewpoint. One reason why Northern Westchester Hospital’s center program includes an extended care unit—and I am sure you don’t view that as competition, understanding that those patients are ones that need a little more doctor visiting and will get it through the new plan. I agree wih you, and we would like to try to work with you to improve it. Harold, what do you say ? Dr. Brew. No, I think the basic premise of ongoing efficient pa- tient relationship doesn’t stop at the door of entry to the hospital or door of entrance to the nursing home, so this has got to be solved. Is geography a problem ? Mr. Garrison. It is not a problem of geography. I really don’t think it is a problem that the hospitals face. Dr. Brew. I think it is something the medical profession will have to come to grips with and increase their own practitioners. Mr. Rem. Is there anything further? Dr. DeLaveaen. May I answer that? T think a part of this is— Mr. Rem. Will you give your name? Dr. DeLavenen. Dr. DeLaughen from Pleasantville. Part of the problem is we do not have that many nursing homes in our particular local area. Geography is an important point I think, and on the other hand, if there is one particular reason—so far as IT know, every effort is made that this patient is being transferred to a physician who may be much closer to a nursing home, and with proper transfer of charts and information, medicines, and so forth, and then the care will be continued there, and so there is no discontinuance of care, it may be transferred. Mr. Rem. Well, of course, I think doctor-patient relationship is terribly important, but be that as it may, I am glad you raised that point. I think Mrs. Gurgenheim is scheduled to testify and hasn’t had the opportunity to. STATEMENT OF MRS. GURGENHEIM, FLOOR WITNESS Mrs. GureenuEIM. I am very happy sitting here today, Congress- man Reid. I was going to take this up with you myself, but Mr. Curry insisted I come here this afternoon to the hearing because he is very familiar with this case. He has known my parents for as many years as he lived in town, which is over 45 years. My mother had a stroke some time ago. She is now in a nursing home which costs over $1,000 a month without any extras. The fi- nancial sacrifice many of us are facing is tremendous when we try to provide decent care for our aged and sick loved ones. 59-661 0—71—pt. 8——14 1930 My parents came here from Europe 70 years ago with nothing. They worked hard and sacrificed. After a long time they were able to build—and much of it was with their own hands—a house where they hoped to live out their days on their hard-earned savings. For most of their lives they earned as little as $3 a day, and often less, doing manual labor—farm work, cooking, cleaning, and whatever else they could find to do. Due to the inflation the earnings and sav- ings of a lifetime can now be used up in just a few months when a major illness occurs such as in the case of my mother’s recent stroke. If my parents had not saved their money and done without many things and did not have any assets such as their home my mother would today be automatically taken care of by the Government. If they had been very wealthy my mother could afford a staff of nurses and would be able to live out her days comfortably in her own home. But my parents are neither of these extremes. They were good hard- working, taxpaying middle income Americans, Now the Government tells us that if we, the children, cannot af- ford to pay this more than $1,000 a month—and we cannot much longer—to keep my mother in a decent nursing home the Govern- ment will place a lien on her home. This to me is criminal. If my mother recovers—and we hope and pray she will—where will she go and what will she live on? All her possessions and memories of a lifetime are in that house. She looks forward to re- turning to it. There must be a better system of financing convalescent care for the elderly, especially for the elderly who have contributed so much to this great country during their younger years. They have lived in this immediate vicinity for over 60 years. [ Applause. ] Mr. Rem. I appreciate your comments, Mrs. Gurgenheim, and it is our hope that the Congress will provide some better answers. Mrs. Gureenmem. Well, I know it may not help my mother, but it may help other people that are facing the same problem. Mr. Rem. Thank you for being so patient. STATEMENT OF STEPHEN KIDD, YONKERS, N.Y. Mr. Kp. My name is Stephen Kidd. I live in Yonkers. My concern has to do not so much with the bad conditions of health care in Yonkers for poor people, black, white, and Spanish, because I think that those were very well covered by Mrs. Sanchos. I think, however, that the question that has to be asked is what can be done. I think also that everybody is shying away from the central issue in the real solution. The real solution to me starts with beginning to say that no one has a right to make a profit off another human being’s misery. This is the problem—because you have a medical establish- ment that is out for its own good and can afford to put a lobby in Washington to get laws bent to their benefit while poor people suffer. When TI go to the emergency room and pull out my medicaid card it is not because I want to go to the emergency room—it is because T know that if I go to any of the private physicians in my community that they are not going to accept it, or that I am going to have to wait 6 hours while 200 other people in the same economic position as myself wait for 5 minutes of half-ass treatment. And we are tired of it. 1931 People have talked about all sorts of revolutions, but there’s going to have to be a health revolution. And if the President doesn’t do something about health then it is going to be the people who do something about health, because we are tired of dying and nobody gives a damn. And that’s really all that I have to say. [Applause.] Mr. Rem. Well, thank you for your eloquent statement. It speaks very clearly. Mr. Fred D. Zwick. STATEMENT OF FRED D. ZWICK, PRESIDENT OF THE COUNCIL OF SOCIAL AGENCIES, WESTCHESTER COUNTY Mr. Zwick. Congressman, I have a long report which I just filed with Senator Kennedy’s staff aides for the use of the committee afterward. IT am sending in a letter of transmittal as president of the Council of Social Agencies. These reports are of conferences and task force committees over a period of 6 or 8 years of private and public planning work in the county of Westchester on the sub- ject of health and health service lacks. I thank you for having this hearing today, and I am delighted to be able to help. Mr. Rem. Well, thank you. Is there anything in particular you would like to highlight ? Mr. Zwick. I think it was all done much more dramatically than I could and these words really back up much of what has been said, particularly in the field that Mrs. Boal had to speak to, Mr. Curry, Dr. Hall, from a public standpoint, and some of the people from South County. Much of the work of the Westchester Council in plan- ning, of course, does emphasize the lack of health care in the south county, so I am delighted to just put it into the record to back up what they said. Mr. Rem. How would you characterize the delivery of health care of the northern part of the county at this point? Mr. Zwick. I think the entire situation is governed by the crisis type of health care that we have through our health system. Our insurance programs, both medicaid and private, emphasize going to the hospital before you really are cared for too well, whereas what our surveys have shown for many years is that we would be far better off if we could shorten or short circuit this care in the homes or in treatment centers within the neighborhoods where the care would be more attuned to the problem of the individual and their family, more personalized, with less of a traumatic dislocation, and far cheaper. The use of the hospital as a provider of primary care is probably one of the greatest difficulties we have today, and I can understand why, because the delivery system for health care has broken down. Mr. Rem. Well, IT thank you very specifically and warmly for ap- pearing today personally. The Westchester social agency over the years has focused on the need and the importance of getting some major help in this area. Thank you very much. ( Pi information subsequently supplied by Mr. Zwick fol- lows: 1932 Wesrcnester Counce of Sociar Asencies, foc. COUNTY OFFICE BUILDING + WHITE PLAINS, NEW YORK 10601 « 914 WH 9-0370 President FRED D. ZWICK Vice Presidents MRS. GEORGE J. AMES MRS. DAVID SWOPE Vice President-Treasurer JAMES LYALL Secretary MRS, WILLIAM L. WALTER Assistant Treasurer ROBERT C. AGEE Directors GILBERT J. BLACK DAVID BOGDANOFF CHARLES M. BRANE, M.D. ROBERT H. BURDSALL R. EUGENE CURRY ROSWELL K. DOUGHTY MRS. LOUIS S. FRANK JACK J. GOLDMAN, M.D. HARVEY HOWSE FREDERICK F. HUFNAGEL EDWARD J. HUGHES MRS. JAMES N. HYNSON MRS. BOYD JOHNSON HOWARD A. JONES MRS. ALAN H. KEMPNER MRS. JOHN G. KIRK LOUIS P. KURTIS MRS. CHARLES D PEET MRS. CARL H. PFORZHEIMER, JR. ROBERT L. POPPER MRS. LIONEL ROBBINS DWIGHT S. SARGENT S. J. SCHULMAN WILLIAM 6. SHARWELL WILLIAM J. STRAWBRIDGE, JR. JOHN A. TAYLOR MRS. THOMAS M. WALLER EDWARD R. WEIDLEIN, JR. DANIEL A. WILCOX, M.D. JUDGE HAROLD L. WOOD Executive Director JOHN E. DULA TESTIMONY BEFORE HEARING OF UNITED STATES SENATE SUB-COMMITTEE ON HEALTH at Northern Westchester Hospital Mount Kisco, New York April 15, 1971 My neme is Fred D. Zwick and I live in Pound Ridge not far from this hospital. I am President of the Board of Directors of the Westchester Council of Social Agencies, the only countywide,voluntary, health and welfare planning center in Westchester. Since 1954, planning and coordinating health services has been an integral, full-time function of the Council. Through its Health Consultant Service, the Council organized meetings, conferences and studies on specific health areas and unmet needs in Westchester. Copies of reports are being submitted with this statement. To save time, I will not discuss them in detail. As one of the most affluent counties in the United States, Westchester can claim that its health and welfare resources exceed in number those of most other counties. The 1968-69 Directory of Community Services in Westchester County, published by the Council, lists 536 different programs and services —-- 227 supported by tax funds and 309 supported primarily by voluntary contributions. Not listed in the Directory are proprietary services such as two general hospitals, more than 50 nursing homes and two home care agencies. It must be noted that this impressive number of health services does not mean that all essential services are available. For example, Westchester's chronically ill psychiatric patients must be sent outside the County for long-term care. The profusion of services combined with the increasing complexity and specialization of health services create frustrating pre- dicaments to those who need health care, regardless of financial circumstances. Federal programs for the most part, have been unable to fulfill their promise. Medicare and Medicaid, for example, are mechanisms to pay for medical seryices within the current system of fragmented health care. Without relating the newly- developed payment ability to increasing the manpower supply to meet the increasing demand, the subsequent escalation of health cere costs is threatening the ability to deliver services oY-bbl 310d HEALTH AND WELFARE PLANNING SINCE 192] 1933 —l) to all segments of society. Co-insurance and deductible features of insurance plans compound the incomprehensibility of the federal programs for the consumers and add unanticipated expenses when they can least afford them. This is particularly true for the elderly. Present medical care is crisis- and institutionally-oriented, i.e., patients who are hospitalized may have their bills paid in full. Furthermore, eligi- bility for admission to a nursing home, which costs less, or for receiving nursing care at home, must follow a brief hospital admission before payments for these services can be approved. The result is emphasis and overuse of the most expensive medical service -the acute hospital- and no financial encouragement for preventive or ambulatory and home care. Based on our years of working closely with lay and professional people (now called consumers and providers of services), we believe that order must be brought to the present chaotic system. Just as incentives are offered now for the use of hospitals, there is need for the development of incentives for alternate medical services. The purpose would be to provide a greater variety of services accessible to those who need them at less cost to patients and society as a whole. Incentives should be offered for use of preventive services, such as local neighborhood health centers, which would provide primary health care within an identifiable geographic area. Such centers would provide preventive medical care and treat minor difficulties which can be handled appropriately out of hospitals. Care in the home is the second important alternative for which incentives should be provided. Sending nurses, homemakers, social workers and other therapists into homes is much cheaper and more sound psychologically than hospitalization. Finally, insurance programs which focus on payment mechanisms alone can only feed the fire of escalating costs. Manpower training programs must be set up concurrently and should include programs for ancillary personnel such as physician aides, home health aides and community aides. Thank you for this opportunity to meet with you. 1934 COMMITTEE ON COMPREHENSIVE HEALTH PLANNING FOR WESTCHESTER COUNTY 713 County Office Building, White Plains, New York 10601 FACT SHEET ON HEALTH SERVICE RESOURCES repared for Information o Workshop Leaders and Co-Leaders CONFERENCE ON HEALTH October 30, 1969 NOTE: = Following is a compilation of health and health related services available within Westchester County. The intent is to show the number and variety of such services. Many agencies provide more than one type of service and are counted under each category. This should not be considered as being a complete listing. SERVICES IN THE HOME Bedside Nursing: 10 agencies (including county and 3 city health departments, voluntary visiting nurse services, 6 combinations of the two, plus one other cover the county). Home Care: 10 voluntary hospitals, plus two other agencies, extend coordinated hospital services according to the individual patient's needs, shortening hospital stay for those discharged to the program. Home Health Aides: 7 agencies (including the 4 Health Departments and 3 family agencies) provide limited patient care under supervision of a public health nurse. Homemaker Service: 8 agencies (7 voluntary and the Department of Social Services) provide homemakers, under supervision of a social worker, to undertake household and child care duties in the temporary absence of the mother; some but not all serve the aging. HOSPITALS -- GENERAL Inpatient Care: 14 general hospitals (13 voluntary and Grasslands, the County Hospital) serve the acutely 111, with a combined capacity of 3,261 beds and 427 bassinets. Ambulance Service: Available to all hospitals largely either by number of volunteer ambulance corps or commercial carriers; very few maintain their own service. Outpatient Clinics: 11 general hospitals provide clinic service ranging in type from 5 to 40. 1935 2. DENTAL CARE 11 dental clinics are conducted, 3 by city health departments and by 8 general hospitals. MENTAL HEALTH SERVICES Emotionally Disturbed Children: 1 voluntary day school, ‘plus mandatory classes in public schools. 7 voluntary institutions; not limited to Westchester children. Inpatient Services for Adults: 5 hospitals (3 psychiatric, 2 general). 7 private institutions, licensed by New York State Department of Mental Hygiene, with combined capacity of 235 beds. Outpatient Clinics Serving Families and/or Children, Individuals: 17 (9 voluntary, including 3 general hospitals; 8 public). Convalescent Care Clintes: 2 State Hospitals conduct monthly clinics for patients on convalescent care or discharged from hospital. Outpatient Day Care: 1 psychiatric hospital (voluntary). Half-Way Houses: 2 serve a limited number of women who need a protective setting following or to prevent hospitalization. Reorientation and Retraining: 2 agencies (1 public and 1 voluntary). Retarded and Brain Injured: 2 voluntary agencies provide such services as training, education, recreation. 6 private residential institutions licensed by the New York State Department of Mental Hygiene, with combined capacity of 328, in addition to State Schools located elsewhere. NURSING HOME BED CAPACITY AND OTHER HEALTH RELATED FACILITIES -- Westchester & Putnam Counties, Public Voluntary & Proprietary -- 4,664 long-term beds to meet need by 1972. 650 beds currently under construction. 1,668 beds have been approved, pending construction. 2,188 existing beds conform to standards of which 1,420 are certified as extended care facilities and eligible to receive Medicare payments. 1936 wad PUBLIC HEALTH AND HEALTH EDUCATION Public: health departments (3 cities and the County). Voluntary: n Yolunary. agencies have health education programs and provide some patient service. REHABILITATION SERVICES Alcoholism: 3 agencies, 1 public walk-in clinic, 1 half-way house (for males, recovering and employable) and 1 information and referral. Blind: 2 agencies, 2 voluntary, 1 public. Mental Health: 3 agencies, 2 voluntary, 1 public. Narcotics: 4 agencies, 2 voluntary, 2 public -- 1 inpatient. Speech and Hearing: 3 clinics, 2 voluntary, 1 public. 1 residential and day school for the deaf. Physical Medicine and Rehabilitation: 6 hospitals provide inpatient and outpatient care (2 serve children only). Workshops : 3 agencies provide workshop programs -- rehabilitation and sheltered. TRAINING OF HEALTH PERSONNEL Schools of Nursing: 6 general hospitals have schools with Registered Nurse programs. (1 is college affiliated). 3 general hospitals have schools with Licensed Practical Nurse programs. (1 of above has both programs). Home Health Aide Training: 1 health department (county) has on-going program to train home health aides for its own program, other health departments, visiting nurse services and family agencies. Technician Training: 2 colleges offer a variety of health related technical training programs. 1937 WHATS GOING | at the Westchester Council of Social Agencies Bulletin Mo. 19 1969 CONFERENCE HIGHLIGHTS January 1970 CONFERENCE ONG HEALTH October 30, 1969 Conducted under the auspices of THE COMMITTEE ON COMPREHENSIVE HEALTH PLANNING FOR WESTCHESTER COUNTY Sponsored by Westchester Council of Social Agencies Westchester County Medical Society Westchester County Department of Health Westchester Community Mental Health Board Westchester County Hospital Association New York Medical College COMPREHENSIVE HEALTH CARE -- WHO CARES? This conference substituted fon the WCSA's Sixteenth Annual Westchester Conference of Community Services. The purpose was to pinpoint problems consumers have in puLainieg quality health care and problems providers have in delivering quality health care and to serve as a springboard for deliberations by the Committee on Comprehensive Health Planning. The Conference Program Committee aimed Zo give equal time to both sides of the health care coin -- consumers and providers. As keynote speaker, Mus. Athins graphically portrayed her first-hand experience as a consumer. And 50 did Dn. James, an eminent medical educator and provider of health services, the dinner speaker. Condensations of their addresses follow. Fourteen workshops, each Led by a consumer and a provider, addressed themselves to the same topic. Workshop summaries also §ollow. T wish to thank Mr. Robert L. Popper, Conference Chairman, and the members of the Conference Program Committee who served with him in developing this program. - = Mrs. Carl H. Pforzheimer, Jr., Chairman Committee on Comprehensive Health Planning for Westchester County 1938 COMPREHENSIVE HEALTH CARE: WHO CARES? Condensation of Keynote Address by Mrs. Ruth Atkins, Community Worker, Union Settlement and Chairman, East Harlem Health Council We're all concerned about health. I think the greatest emphasis is on health now because those who have the money to pay for good health care are finding that they, too, cannot always get it. I think that good health care is the right of all people in our country -- those who have and those who don't have. Many professional health providers seem to feel that Medicaid is a welfare program, not an insurance program for people who have limited or no income. COMMUNITY OUTREACH You know of Mount Sinai Hospital. Mrs. Ruth Ravich is the community representative. We can go to her if we have a complaint. She tries to find out if what you said is so, why it Happened and sees that it does not happen again. But many people say, "Well, the poor are not concerned with health. The poor are not interested in health. The poor do not keep their hospital appointments." But they don't take time to find out why. Way back, when it wasn't fashionable to identify with the poor, Union Settlement was concerned with Tow income people, .rggardless of color. When they wanted to discuss something that was going on in the area, they always called in some re- sidents to see what their complaints were, what recommendations they might have and then work together on the problems. STUMBLING BLOCKS My definition of quality health care is having the best service at the time you need it, in a facility close by whether you can pay for it or not. People have waited a long time for something close by them where they can walk in with their heads high. Many times, when you go to the emergency, the first thing they want to know is, who is going to pay the bil1? In the meantime, you're aching and aching. When you say you are on Medicaid or welfare, they say your pain is your imagination. You never know at what hour you're going to get sick. Many low or no income people do not get health care because of the hours. If you're a welfare client, after 2:30 P.M., you just don't get sick because if you do and you call up Social Service, no doctor comes. At a meeting, I had to let a doctor know we really didn't want to go to the emergency ward. It's only after you did your best to get your child feeling better and failed, did you go there. We know the Tong wait. We know the overcrowding. Time after time we have had wrong diagnoses. A mother has to take one child to a certain clinic because the child has asthma, and another child to still another hospital because the hospital that would take a child for asthma will not take the other children. So you'll find people going to four or five different hospitals trying to get treatment at five or six differ- ent clinics all in one day, and sometimes three clinics at the same time -- Wednes- day at 1:00 o'clock. I always have to be thankful to Mount Sinai Hospital. But for them, I would not be alive today. Someone told me to go there although it was out of my district. I went. Right away some big shot came and examined me and then wanted to know why I hadn't been to the hospital before. "What's wrong with you people? Don't «ie 1939 Keynote address - continued you believe in taking care of yourself?" I said,"1've been going to three differ- ent hospitals for five years and they kept on telling me it was my imagination. When people need health care and get it, it may be expensive the first year, but the problems that had gone unattended for years will not repeat themselves. I keep on hearing and hearing the poor are not concerned; the poor do not believe in taking care of themselves. But let me ask you, what have you or your agencies done to see that preventive health education is passed out through your day care programs, through your senior citizens' programs? What have you done when parents come in for day care and the child has a cold and tell you the house is cold? What do you do to help her out? HUNGER One of your groups can find out the extent of malnutrition. How many children in your class or your day care program are hungry? Why are they hungry? Beans and cheese are not the most appetizing but they keep you alive. And when you see poor people, it's just amazing how many big, poor women we have. But beans and biscuits kept us from being hungry, hungry. If my child can get proper food and be in a warm place, this is better for you. When my child grows up, your tax money will not have to be paid to keep him on welfare. My child then will be able to compete equally for jobs. 00DS AGAINST GOOD MENTAL HEALTH When a child is growing up seeing the mother embarrassed every three months by a different investigator who comes and says, "Good afternoon, Mrs. Atkins, how are you?" 1I'11 say, "Fine." "Mrs. Atkins, are your married?" In 1965 they knew I was married. "Mrs. Atkins, how many children have you?" "The same four I had in 1965." "Mrs. Atkins, are they all of the same father?" "No." Why is this neces- sary when they have the report? How can I have good mental health when I have to answer such unnecessary questions? How can my children function properly and feel like they're somebody? When they go to school and have a "W" on their card in or- der to get lunch? When they're not entitled to dessert because their mother is on welfare? COMMITMENT NEEDED We don't need more surveys and studies. But we do need some commitment, some follow- through, some sharing of ideas. I hope and I pray that there are enough people in America willing to stand up and be counted as committed, so this land of opportun- ity will be opportunity for all, people,"with liberty and justice for all." Those of you in this room, who are emotionally secure enough and don't feel threatened by the poor, can bring about many changes. Are you mature enough to work with the poor and not see them as a threat? Can they work with you? Can they show you how best you can spend your dollars to help them? Are you secure enough so when an extreme militant comes and yells at you, you don't jump and buy him off? On your maturity will depend the future of America. The time has come when we can no longer continue to put bandaids on problems and give people aspirin. We consum~. ers and providers must join forces to bring about change. a 1940 THE RESPONSIBILITY OF THE HEALTH CONSUMER Condensation of a Dinner Address by George James, M.D., President Mount Sinai Medical Center 1 am going to try to relate the role of the health consumer and that of the health professional. My favorite philosopher these days is Colonel Edwin Aldrin. After coming back from the moon, he said,"What this means is that other problems can be solved in the same way: by making a commitment to solve them in a long-time fashion . . . ." It is sobering to realize that one rocket launch costs more than the tuition of every medical student in the United States. CONSUMER POWER AND BETTER MEDICINE We have a crisis in medical care. Education and television have made medical care a household word and increased the demand for it. We in public health have known for a long time that medical care is a right. Democracy is more solidly in control than ever before. What do the people want? What priority do they give to their wants? What does the consumer want of the profession -- to be blind servants at your beck and call, or to contribute leadership? The rapid advancement of medical science is startling. Thirty years ago, the great- est doctor was powerless to control lobar pneumonia. Compare this with the power our youngest practical nurse has today with a penicillin syringe in her hand. An outbreak of poliomyelitis in the Buffalo area in 1944 struck 2,000, leaving hundreds of crippled children in its wake. A group of citizens was considering various projects. One might have been construction of a large chain of rehabili- tation hospitals. At the same time a man working at Harvard Medical School, John Enders, sought only a few tens of thousands of dollars to work on tissue cultures. Without professional leadership, it would have been difficult to make a case. Yet, he received the Mobel Prize because his tissue cultures were needed to develop a vaccine which was eventually to eradicate poliomyelitis, measles, German measles, and, some day, hepatitis and all other virus diseases. But such dramatic successes have left us a residue of uncontrollable disease and a residue of science inadequate at the moment for the major tasks before us. If you Took at recorded history, practically every disease that has been controlled, has been controlled because we have learned how to attack it before clinical symptoms have occurred. Work is going on now that someday will give us the keys to pre- venting heart disease, cancer and stroke. This is why we need professional leader- ship; why we need specialists and researchers. In a democracy, if people demand the care they feel they need and want, they have a right to it if they are willing to pay for it and to take the steps to get it. But the demand can only exist in terms of what is known and what is available and, at the moment, the biological needs of people are insatiable. We lack the scientific knowledge to launch effective medical care programs to solve the major killers and disablers. Not only is medical science not all it might be, but the existing system, or lack of it, has marked shortcomings, John Gardner pointed out when he was Secretary of Health, Education and Welfare. This is why we need com- prehensive health planning to develop programs to suit local needs and performances. There has never been any question that the consumers control the medical system. The question is, how? It takes the best of our scientists working together with ld = 1941 Dinner address - continued our consumers to see what can be done to develop new techniques and streamline old ones, and how the partnerships should develop. COST OF MEDICAL CARE A recent study at Mount Sinai, based on careful cost accounting, showed our per diem cost per patient at over $100. Room and board with three meals a day came to $19.88 per day and more for the more than half of our patients on special diets. This compared with well over $40 a day at the Hotel New Yorker, with room service. Why are costs so high? What accounts for the difference? We have 100 patients on the kidney machine three days a week. The cost for each is between $10 and $15,000 a year. Without it they would die. Open heart surgery costs $3,200. More than half of these patients are poor and pay nothing. Our clinics lose about a million dollars a year. No hospital like ours has to run clinics. We have a three month waiting list for private surgery and medicine. We could fill our hospital with patients who can pay and run at a profit. Would you have us deny a portion of these people the gift of 1ife? If so, which ones? Our Department of Community Medicine has walked around the area and talked with people to find out what is troubling them. This is people-oriented research. We found a large number of hepatitis cases and opened a special clinic; we found that people from the Caribbean area seem to have a higher incidence of asthma and set up asthma programs. The other day, a group from East Harlem came to see if they could involve us in a major service program to push methadone treatment throughout the city. We said yes, and have enlisted the help of about twenty of the top scientists in the city. All these programs cost money. COST OF MEDICAL EDUCATION The cost of a medical education is fantastic -- approximately $24,000 per year in New York City. This means if a medical student pays $2,000 tuition, society is certainly picking up the rest. The pressure for more general practitioners is real. People tell us we are training too many specialists and researchers. We need more doctors and more allied health professionals to extend their services. But I ask, would you really have wanted Jonas Salk to have been a general practi- tioner? He has done more for health in the ghetto than 100 G.P.'s distributing tens of thousands of pills. We have started two programs with foundation grants to take young black high school students in the summers to get them into health careers and provide tutorial help during the school year. We will make many of them physicians. All of us in the medical field train not only doctors but a host of others. My medical faculty is giving $100,000 a year of free education to train allied health professionals at Hunter College. COSTS CAN BE CUT, BUT . . . Instead of the necessary 16 tests for hypertension, would you have us do five and train M.D.'s to do just those? Kingston has never had flouridation. The dental bills are two-and-a-half times those of Mewburgh, which has it. One way to cut costs: Immunization programs are success stories of professional leadership work- ing with the consumer. Official agencies must be given the resources to be more than giant accounting and eligibility determining centers. Take Medicaid. Des- pite what some of us told them,government went into this program without doing anything about the manpower. We have only a limited amount of talent. We have to work together with consumers who will take the trouble to learn, ask questions and work with us. «Bw 1942 SUMMARY OF WORKSHOPS ARE YOU GETTING GOOD HEALTH CARE 2:77? Who controls it? Who delivers it? Who pays for it? ALL 14 workshops discussed these questions against the proposition that compre- hensive planning is essential to the delivery of quality health services for all consumers -- the wealthy, the comfortably off, the poor and the not so poor -- when needed and where needed by members of the Westchester community. Each workshop had a health service provider as Leader and a co-Leaden from the ranks of consumers. A. RECOMMENDATIONS TO THE COMMITTEE ON COMPREHENSIVE HEALTH PLANNING Master Plan: . . . Develop a master plan for the delivery of comprehensive health care that . would incorporate objectives and priorities with respect to availability, equality, quality and financing of health services, including merging similar health agencies to strengthen services and decrease costs. Undertake health planning on a sub-county as well as on a countywide basis, in view of the differing characteristics between northern and southern Eastchester. With health and mental health services clustered in the more populous localities, provision must be made to meet needs in outlying areas. . . Take immediate steps to comply with criteria to establish an agency qualified for organizational and operating funds under the Hill-Staggers Act. Health Care -- A Right: . . . Establish a patient "Bill of Rights." Equal and quality medical care is the right of everyone, regardless of who pays the provider. The right to good health is equal to rights to public education and to police and fire protection. The ombudsman principle to secure these rights was proposed. Delivery of Health Services . Establish local community health centers to provide health services around the clock, fully staffed by medical and paramedical personnel, including a system of emergency transportation, and backed up by hospitals and other facilities for specialized care. District offices of the County Health De- partment might be the nucleus of such centers; planning should be conducted in cooperation with the Medical Society, boards of health and hospital boards and implemented as soon as possible. . Modernize methods for the delivery of health services; eliminate waiting lists that seriously impair ability to return to good physical and mental health; improve the physical facilities of emergency rooms and clinics and eliminate overcrowding. . Involve greater numbers of consumers, including the poor, in all planning and decision making, e.g., as board members of hospitals and all other physical and mental health agencies. Organize parent and consumer groups to urge establishment of services they require. 1943 Worksaop recommendations - continued . Pursue with the Departments of Health ways to reduce the infant mortality rate in Westchester County. (Statistics available on request to WCSA.) Health Manpower: . Encourage government-sponsored training and subsidy for medical students and nurses to help alleviate personnel shortages. Develop part-time work-training programs for paramedical personnel so they can earn as they learn . . . Increase training of paraprofessional personnel . Recruit and train more indigenuous as health aides. . Help professionals recognize that paraprofessionals can perform essential services and accept them as helping people and colleagues. Payment for Health Care: . . Promote legislation to correct problems of individuals and families caught "in the middle" and unable to pay costs of medical care, drugs, etc. . . Make quality medical care universal through a national insurance plan. Handicapped and Aging: . . Start planning immediately to meet the needs of chronically i11, multi- handicapped young people, including those with emotional problems. . . Make total health care available for the aging, both physical and mental. Public Education and Communications: . Establish programs to instruct in basic health care and hygiene, nutrition, sanitation, symptoms of illness and available medical and social service; educate the public to want and expect good medical care. . Obtain listing of health services in Yellow Pages of telephone directory. . Develop more meaningful communication between service and funding agencies and break down resistance to joint planning. . Keep problems, needs of people and effects of legislation before legis- lators by letters and telegrams. Transportation: . Explore possibility of obtaining half-fares for elderly people in southern Westchester for public transportation system in New York City. . Investigate use of school buses in off hours for transportation to medical facilities. . Establish a coordinated countywide bus transportation system, plus special transportation where needed, to make health services more accessible. 1944 Workshop recommendations - continued B. PROBLEMS CITED IN WORKSHOP DISCUSSIONS Clinics and Emergency Rooms: . Indifferent attitudes of clinic and emergency room staff and mental harass- ment by clerks who want to know who is going to pay the bill greet the poor before care is provided. Long waits, overcrowded conditions and too few physicians in attendance are common complaints. . Taking the clinic to the people via a "Module Unit," set up as a pilot project to go into populous areas, was proposed. Hospitals: . . "Come off the business attitude," hospitals were urged. But all hospitals have difficulty in meeting rapidly rising costs. They have to operate as business does, they point out, and charges must be related to cost. . The Joint Commission for Accreditation of Hospitals was criticized for confining its attention to the physical plant, procedures and records, and not to the social needs of patients as well. Voluntary hospitals serve doctors' patients primarily and do not meet community needs. They need to be more closely related to the community. Broader inter-hospital planning would eliminate needless duplication of some types of expensive equipment making for better utilization, and more ‘efficient operation through the use of common computers, etc. . Broaden the scope of home health services to free expensive hospital beds. . A11 hospitals should review their policies against admitting patients with a diagnosis of alcoholism alone. . Practices among hospitals differ widely in dispensing drugs after hours. Most people do not realize local police know which drug store is on call. Delivery of Health Care: From one workshop leader's opening remarks: "We know there are serious problems in the delivery of health services and in the economics of the delivery of health services. The survival rate now increases the demand for services. The origins of health services were not designed to meet the medical needs of growing patient loads and chronic 11lness. Some early problems in the delivery of service in- cluded lack of funds. Where more funds became available, personnel problems became more serious . . . " . Some available health services are not used fully due to lack of community outreach. Fragmentation makes it difficult to obtain complete health care. Insufficient planning and coordination hamper delivery of comprehensive health care. "Consumers must be in on the planning, otherwise it takes years to undo the mistakes." More efficient use and further devélopment of existing health care facilities are needed, rather than more facilities. . Dental care is of major importance but too many children do not get it. In some areas, large segments of the middle class population may be just as lacking in medical and dental services as are the poor. <8 1945 Workshop discussions - continued . . More general practitioners are needed. The family physician is disappearing-- an outgrowth of medical specialization -- and physicians are not oriented to the total family. Home visits are becoming rare: "Bring your child to the office; wrap him warmly." But doctors contend, "Most home calls are un- necessary." . Physicians in private practice and hospitals alike face problems of growing patient pressure, increasing workloads and paperwork, keeping up with the rapid expansion of knowledge and slowness in reimbursement. . New technology and use of paraprofessionals and technical personnel should improve the quality of health services. . Many providers showed strong identification with consumers; some suggestions: "Go after the guys who make the Laws" "Social agencies should have Legislative committees and develop Leadership to solve these problems" "Let's stop talking and meet needs" Health Care Deficiencies: . . Lack of adequate services for the care of the sick in the home. . Lack of adequate family planning education. . Lack of rehabilitation for drug addicts and alcoholics. . Lack of facilities for disturbed elementary school children. . Lack of services for preschool handicapped children. . Lack of dental care, eye and hearing tests for children in day care centers. Health problems of children in elementary school could be prevented if they were to receive adequate preschool medical care. . Lack of comprehensive health screening facilities such as are conducted for trainees in programs at Rochambeau School, e.g., eye and hearing tests, counseling for the overweight and health education. . Lack of training in low income areas in such basics of daily 1iving as budget- ing, nutrition and where to turn for advice and assistance. Insufficient Manpower: . Severe shortages of personnel in all phases of the medical field, sometimes causing people to be placed in jobs they are not properly prepared for. . Career ladders for paraprofessional personnel should be developed, with community colleges providing the necessary training. Some college credit should be given for on-the-job training of such personnel. . . . More young people should be trained and employed in hospitals; and elderly people could be trained and used in home care programs. -9- 59-661 O - 71 - pt.8 - 15 1946 Workshop discussions - continued . . . With more doctors needed, additional federal aid for costly medical education is necessary. , With health personnel historically underpaid, the best personnel is not being attracted to the field and many leave for better paying jobs in industry. . . Nursing homes with staffing problems might look to CAP groups as recruiting sources for non-medically related personnel. p Paying for Health Care: . Only 35% of the population is covered by major medical insurance. Medicaid cutbacks are detrimental to the provision of health services and af- fect people least able to provide for themselves or make their plight known. Many physicians do not accept Medicaid patients because of delayed reimburse- ment and fee schedules allowed are unrealistic in relation to cost of care. Many pharmacists refuse to fi11 Medicaid prescriptions, while others are known to dispense less than the amount prescribed. "Remove biinders from all vendors of care so they can see the problems around them." . Even if the 20% cuts in Medicaid were restored, with payments to hospitals based on 1967, not 1969 costs, there still would be a gap between cost of care and payment per patient day. Nursing Homes: . Legislation is needed requiring all nursing homes to accept a given per- centage of Medicaid patients. . More nursing home beds are needed. Church groups should be encouraged to sponsor new nursing homes. . If mental health specialists offered help to nursing home staff in under- standing problems of the aging and in managing difficult cases, patients would benefit. Transportation: . . Lack of adequate, convenient and reasonable public transportation is a real obstacle to getting medical care. Many patients must travel for hours to reach clinics. Many others simply don't go when it means losing a day's pay . Many hospitals are moving toward preventive medicine, but if people can't get to them, it is of no avail. ; . Red Cross Motor Corps and members of hospital auxiliaries should be available to transport patients to hospitals and clinics. sy. 1947 WESTCHESTER CITIZENS COMMITTEE FOR THE AGING AND CHRONICALLY ILL T13 County Office Building White Plains, New York 10601 ” REPORT OF SUB-COMMITTEE ON COMMUNITY CARE FOR THE DISTURBED AGED April 17, 1969 PROBLEM: This is a report, with recommendations, of the Sub-Committee on Community Care for the Disturbed Aged. Many of the disturbed aged in Westchester have heretofore been cared for in state mental hospitals. The care of these elderly became critical when, on June 19, 1968, the Deputy Commissioner of Mental Health, New York State Department of Mental Hygiene, Division of Mental Health, issued Memorandum No. 68-27 to all state hospital Directors concerning the Department's policy in the screening of admission of elderly patients referred to state mental hospitals. "Sections 71, 72 of the Mental Hygiene Law . . . state that the Director of a State Hospital may receive and retain patients suitable for care and treatment. Sections 75 and 76 governing admissions . . . are even more explicit provid- ing that the need for hospitalization shall be confirmed by the receiving hospital . . . There is a clear-cut responsi- bility for the Director of the State Hospital or his medical representative to ascertain and certify that patients who enter the hospital are in need of hospitalization in order to obtain psychiatric care and treatment . . . " . . . it is the duty of the Directors of our State Hos- pitals to ascertain in the case of every patient presented to them, and especially in the case of elderly patients where we believe most abuse of this principle occurs, that a patient is most appropriately cared for or treated in a State Hospital. " . . . admission of patients whose problems are primarily physical infirmity, or social and economic difficulty into State Hospitals, places a burden on the hospital to which they are not equipped to respond. It also removes from the community the necessity for developing adequate services to solve the problems . . . 1948 oD " . . . we therefore request the Directors of State Hospitals . . . to scrutinize more closely the condition of persons who are candidates for admission . . . and to determine prior to their admission whether or not such persons are suitable for care and treatment . . . " . . . persons should not be accepted if care and treat- ment would more appropriately be given by another facility . . Patients should not be admitted when their problems are primarily social, medical or financial or for the convenience of some other care facility . . ." ' . . this may mean a considerable change in policy and will have an impact on other social and treatment agencies . " On June 28, 1968, the Deputy Commissioner of the Division of Local Services, State Department of Mental Hygiene, issued Memorandum No. 68-1k4 to Chairmen of Community Mental Health Boards and Directors of Community Mental Health Services. " , . . this policy will affect people over 65 years of age more than any other group, and it is anticipated by the Mental Hospital Division of the Department that during fiscal year April 1, 1969 to March 31, 1970 this program will have achieved a reduction in the admission of people over 65 by 50%. Since the number admitted in this age category each year is approximately 8,000, a sizable group is involved . . . " . . . the immediate effect will be that the communities will find it necessary to expand the kinds of services which such patients who are not accepted will need. Such services include general medical and nursing care, financial and welfare aid, and psychiatric services such as consultation to patients in general hospitals and other health caring facilities in the community, as direct alternatives to in- patient care in a State Hospital . . . " . . . it is rare that hospital admission of geriatric patients is a psychiatric emergency and a system of screen- ing of all patients by the county mental health services is recommended and has already been initiated in some counties.” SIZE OF PROBLEM: During the year April 1, 1966 to March 31, 1967, 325 patients in the 65 and over age group were admitted to State mental hospitals from Westchester County. This number represented 25.9% of all State mental hospital admissions from Westchester County for the same period (325 of 1,255 admissions). Since it is estimated that admissions of these individuals will be reduced by 50%, it would appear that approximately 163 of Westchester's disturbed aged who have been admitted to State mental hospitals will remain in the community and will require & variety of local services as an alternative to admission to State mental hospitals. This estimate would appear to be minimal. It does not include elderly patients who occupy beds in general hospital and nursing homes. 1949 -3- LOCAL RESOURCES: Existing resources in Westchester County include medical and psychiatric services in hospitals, Community Mental Health Board clinics, visiting nurse services, social and recreational facilities, financial assistance, social services, homemaker services, home health aide services, nursing homes, homes for the aged, information and referral services, friendly visitors, and legal services. However, because of the fragmentation and skewed distributions of many of these services and facilities, elderly persons often find these services inadequate or unavailable. SERVICES NEEDED: The lack of transportation and scattered locations of many facilities often prevent full utilization. An expansion of or addition to these services would help alleviate the situation. These include housing facilities, friendly visitors, visiting nurse services, homemaker ser- vices, home health aide services, long-term facilities for the chronically ill, meals-on-wheels, outpatient clinic services, psychiatric clinic services, social and recreational programs, rehabilitation programs (physical and occupational therapies), sheltered workshops, information and referral services, and nursing home facilities. There is a need for a public information program, a geriatric screening program, a mobile crisis unit for evenings and week-ends, a geriatric- orientation program for existing services, and a foster home care program. All these services need to be coordinated. Possibly this could be done through the establishment in the County Executive's Office of a Division on the Aging. THE STATE'S ROLE: Historically, the State has carried the responsibility for and the financing of the care and treatment of the mentally ill in hospitals, including the elderly. The present emphasis of the State Department of Mental Hygiene upon the development of community care for the disturbed aged may be appropriate. However, the abruptness of the decision together with the lack of opportunity for local communities to plan to meet the changes occasioned by the Department's new directives, is regrettable and unfortunate. It is expected that Westchester County as well as other counties in the State would be willing to devote efforts to planning appropriate programs for this age group. However, the responsibility for providing the numerous services is too expensive to be borne by the local communities alone. Payments per- capita in a skilled nursing home presently range from $17 to $24, and they are expected to increase. Payments for care in health-related facilities currently range from $12 to $15 per person and are also expected to increase. Foster home care costs are estimated at a minimum of $175 per month. In general hospitals, payments are currently running as high as $100 per patient per day. Currently Westchester County is reimbursed 50% by the State of New York for community mental health services, and the proposed cut-backs would call for a reduction to 45%. In contrast, beginning July 1, 1969, the State of California will provide 90% reimbursement to local communities for mental health services for all people requiring them, including those in the 65 years and over age group. 1950 po BECOMMENDAZIIONS The State Department of Mental Hygiene should place a moratorium of at least one year, beginning April 1, 1969, upon implementing its directives of June 19 and 28, 1968, so local communities can have time to develop local resources and facilities for elderly patients who will not necessar- ily benefit from psychiatric treatment but who require special programs to enable them to remain in their own homes or special facilities in which they can receive care. During the moratorium and the program of the Geriatric Screening Unit (see number 2 below), various types of at-home and outside-home care for the disturbed aged should be considered and developed, among them the following: a. Special services to senior citizen housing programs to assist the elderly to remain at home as long as possible. b. Special hostels, possibly to be operated by the Community Mental Health Board. c. Possible utilization of a relatively new building at Harlem Valley State Hospital which is presently vacant. d. Placement and supervision in foster homes. (1) e. Strengthening and expansion of existing community services to the elderly in their own homes to help prevent mental and emotional deterioration, e.g., Homemaker Services, Home Health Aides, Friendly Visitors. For at least one year, from April 1, 1969, it is recommended that the New York State Department of Mental Hygiene provide a financial grant for a Geriatric Screening Unit in Westchester County, to be operated by the Community Mental Health Board. This Unit would evaluate the needs of those elderly patients formerly admitted to State hospitals and mobilize appropriate local resources to care for them. The Geriatric Screening Unit would be similar to one in San Francisco, California which was financed by the California State Legislature in 1963 as a pilot screen- ing program for the mentally impaired aged. The Bureau of Social Work of the California Department of Mental Hygiene was delegated the responsibility for developing the program. The primary objectives were to reduce the number of inappropriate commitments of elderly persons to State hospitals, to provide alternatives to State (1) Over the past ten years, the Veterans Administration Hospital, Montrose, New York has developed a foster home program that now serves 500 veterans in 80 selected and supervised homes. 1951 -5 hospitalization by developing and utilizing community resources, and to provide consultation and information to persons or organizations serving this age group. The Screening Unit staff consisted of a half-time internist, a part-time psychiatrist, a psychiatric social worker, a supervising psychiatric social worker who functioned as coordinator, ‘and a senior stenographer. From 1965 through 1967, 1,290 persons were screened through the project. Of this total, 44 were committed to to State hospitals, 33% were placed in nursing homes, 8% in boarding homes, 10% were admitted to county or private medical hospitals, and 45% remained in their own home with supportive services. Additional nursing home beds appear to be required, and the formula now used to allocate nursing home beds to meet the needs in Westchester County should be changed to allow for the construction of additional nursing homes for the care of the chronically ill, including the dis- turbed aged who do not necessarily require or can benefit from psychia- tric treatment. In order to foster the development of adequate services locally, New York State should reimburse localities 90%, as will California on July 1, 1969, for the development and maintenance of programs for the disturbed aged. At the same time consideration should be given to utilizing this reimbursement formula for the entire service program of the State Department of Mental Hygiene.(2) The reimbursement formula for community mental health services in New York State is only 50%, and the proposed cut-backs in the State budget would reduce this to 45%. (2) Effective July 1, 1969, in California, the Lanterman-Petris-Short Act will provide for 90% reimbursement by the State for all mental health services. The share of Counties with over 100,000 population would be 10% including care of the mentally ill in State hospitals. 1952 INFORMATION, PLEASE 1 ee is , ee ANNUAL REPORT.1969 Senior Information and Referral Services Conducted by WESTCHESTER COUNCIL OF SOCIAL AGENCIES © County Office Building, White Plains, New York 1953 WESTCHESTER COUNCIL OF SOCIAL AGENCIES, INC. (wesa) SENIOR INFORMATION AND REFERRAL SERVICES (SIRS) COMMUNITY ADVISORY COMMITTEE Dwight S. Sargent, Chairman Dobbs Ferry Mrs. Charles F. Bound Sam Scheiber Bedford Peekskill Mrs. John F. Maloney Irving Walt Chappaqua Port Chester Reverend Henry R. Brau Mrs. Leo Greenland Elmsford Otis Sanford Scarsdale Mrs. Albert Siegel Harrison Robert L. Popper Leonard Salvador Mrs. Harold L. Wood Dr. Lawrence W. Schwartz Mount Vernon Mrs. Robert S, Woolf White Plains George E, Cohron Mrs. Charles Forman Thomas F. Hammond Samson Gordon Honorable Kristen Kristensen New Rochelle Yonkers SIRS STAFF Daniel Sambol WCSA Coordinator of SIRS Miss Catherine M. Melillo SIRS Director Mrs. Ellen Cunning Assistant Director Mrs. Jean Mas Secretary 1954 SENIOR INFORMATION AND REFERRAL SERVICES Conducted By WESTCHESTER COUNCIL OF SOCIAL AGENCIES, INC. Supported by Contract #MS 3963 with the New York State Office for the Aging under the Older Americans Act of 1965 Annual Report - 1969 INTRODUCTION: The following is the final Annual Report of the Senior Information and Referral Services (SIRS) which has been conducted by the Westchester Council of Social Agencies fos) in cooperation with the New York State Office for the Aging under Title III of the federal Older Americans Act of 1965. SIRS completed its three-year demonstration on December 31, 1969. Its functions have been absorbed by the White Plains Regional Office of the New York State Department of Health, and all of its resource data and case records have been transferred. SIRS was supported by federal, state and local funds with governmental contribu- tions diminishing and local support increasing each successive year. GOALS AND FUNCTIONS: Westchester County has a great number and diversity of services and facilities scattered throughout its six cities, eighteen towns and 22 villages. .Locating an essential service at time of need is often complex for professionals and frequently overwhelming to less sophisticated lay people. To help locate essential resources quickly, especially for the aging, SIRS concentrated all known health and welfare services available to the aging in one central repository. Thus, through a single telephone call, those looking for services could find them rapidly or learn that no such service was available. In addition, recognizing that some people -- possibly through ignorance, fear, prejudice or pride -- would probably not reach out for the services they needed, SIRS' two skilled workers tried to evaluate the needs and, if necessary, active- ly assisted the callers in securing the necessary service. As a secondary goal, while providing information to the callers, the staff accumulated statistical data attempting to specify the services requested, the gaps in community resources and the characteristics of those requesting infor- mation. : METHOD OF OPERATION: Accessibility to SIRS was considered essential to its effectiveness. Westches- ter County, with 453 square miles of densely populated communities in the south and sprawling rural areas in the north, created a special problem. Public trans- portation is inadequate. As a result, it was assumed that the elderly or those interested in their behalf would make most of their inquiries by telephone. 1955 -2= To facilitate telephone inquiries, especially for the aged who live on fixed, limited incomes, a telephone network with four trunk lines throughout the county was set up so that a call could be made at no more than a local charge. NUMBERS OF CONTACTS: During 1969, SIRS served 2,347 different individuals, an average of 195.5 per month, This compares with 2,157 individuals served during 1968 (an average of 179+ per month) and 1,009 people in 1967 (an average of 8L per month). Responding to the 2,347 calls required a total of 6,704 "contacts," e.g., tele- phone calls, letters, office interviews, field visits. This meant an average of 2.8 contacts per inquiry. This compares with an average rate of 3.4 contacts per inquiry in 1968 and 5.5 in 1967. Efficiency was enhanced with increasing experience by the professional staff and greater familiarity with community resources. PERSONS SERVED: During 1969, 75% of inquiries were received from the elderly themselves or their families as compared with 66% in 1968 and 77% in 1967. On the other hand, there was a decrease in the number of inquiries received from agency personnel: 18% in 1969 compared to 22% in 1968 and 12% in 1967. In 1969, as in 1968, T4% of those who sought information used the telephone. Even so, the numbers of written inquiries increased to 417 in 1969 compared with 373 in 1968 and 60 in 1967. This was due largely, as in the past, to the West- chester-Rockland newspapers for the increasing number of letters received. These newspapers published SIRS' address in their frequent reports but generally omit- ted the telephone numbers. x For the third successive year, residents in every Westchester community were served. In addition, residents in the metropolitan New York area and from other states were helped. COMPARISON OF SERVICES REQUESTED: Significantly, housing retained its position as the most called-for resource in 1969 and increased its proportion of the number of calls: 34% in 1969, as com~ pared with 32% in 1968 and 27% in 1967. Similarly, information about nursing homes was the second most frequently re- quested service for the third consecutive year. Twenty per cent of all inquiries in 1969 requested information about nursing homes compared with 25% in 1968 and 20% in 1967. Equally consistent as the third most frequently requested service was the proportion of inquiries for care in the home (homemakers, home health aides, housekeepers, companions, etc.). Ten and one-half percent of all calls requested some form of home care as compared with 11% in 1968 and 1967. Inqui- ries about Medicare and Medicaid comprised 5% of all calls in 1969, compared with 53% in 1968 and 13% in 1967. People seem to be increasingly familiar with these programs and know where to obtain them without SIRS' assistance. COMPARISON OF MAJOR SERVICES REQUESTED IS67 1968 1969 (1009 INQUIRES) (2157 INQUIRIES) (2347 INQUIRES) LEGAL AID, EMPLOYMENT, FRIENDLY VISITING, FINANCIAL AID, NURSING HOMES NURSING HOMES 20% 9661 1957 . The four major categories noted above comprised 693% of all telephone calls received in 1969. The balance pertained to other important services, such as financial assistance, employment, friendly visiting, legal aid. Since each of the other categories comprised less than 5% of the total questions, they have been combined for convenience. Nevertheless, it must be stressed that each service was important to the individual who was calling for information. For statistical convenience, only one service was listed for each caller even though an elderly person might inquire about two or more. In such instances, for statistical simplicity, the professional staff determined the primary ser- vice according to the individual situation. COMPARISON OF NEW INQUIRIES: The chart on the following page reveals an inconsistent pattern of the numbers of inquiries received each month. Inquiries ranged from a high of 298 in April to a low of 127 in November. No seasonal pattern could be traced during 1969 or the previous two years. However, publication of news items in the newspapers invariably stimulated a noticeable increase in inquiries at that time. In the fall of 1969, the number of inquiries began to decline. When it became apparent that SIRS would no longer be able to continue under its existing aus- pice, publicity was deliberately avoided to allow the staff to complete its work and transfer the program to the Regional Office of the New York State Department of Health. THE FOLLOW UP STUDY: On the basis of their involvement with the people they served, the staff felt that the service was helpful. Nevertheless, it was agreed that a formal follow- up study could better document the effectiveness of the program. With the support of the New York State Office for the Aging, a retired profes- sional social worker was employed part-time during the early part of 1969. In three months, she extracted a sample of all even-numbered cases served during the seven-month period beginning January 2, 1968. Excluding inquiries from agencies, she called or, when necessary, wrote 442 individuals who had request- ed information. The guidelines employed in the follow-up included the follow- ing five questions: 1. Did the resource requested exist? 2. Was the information used by the inquirer? 3. If inquirer was other than client, did client find the information helpful? 4. Was this method of getting the information satisfactory? 5. If SIRS made a referral, was the person or agency to whom they referred helpful? SUMMARY OF FINDINGS: The resources requested by 90% of the people contacted existed. This is not to suggest that an existing service was available since some who were eligible were often confronted with formidable waiting lists, and others were ineligi- ble because of restrictive residence requirements. 59-661 O - 71 - pt, 8 - 16 New Inquires Per Month 34 315 30 270 255 240 225 210 195 165 150 135 120 105 0 January 1967 = nun 968 - mmm i969 - IEFE February March April Moy June July SIRS - Comparison of New Inquires nnd August September October Novemb er Per Month -1967-1969 Decenber 8961 1959 bm Out of 413 inquiries where the resources existed, the information was used in 61% of the cases, not used in 30% and not known in 9% of the cases. In the 225 situations where the inquirer was other than the elderly person himself, 44% found the information helpful and 55% found the information was not helpful. Ninety-five percent of the 349 who telephoned SIRS found this method satisfac- tory. Of the 74 who chose to write, 70% were pleased with this method, and 99% of the 29 who came to the office for personal interviews were satisfied with this approach. Out of 101 situations where SIRS referred the inquirer to another agency, 80% stated that SIRS' guidance was helpful. CONCLUSIONS OF FOLLOW-UP STUDY: It is apparent that SIRS was useful and helpful to most of those who inquired by assisting them through a maze of resources which they might or might not have found without professional assistance. Where services were available, 61% of the inquirers used the information provided. In those instances where the staff made referrals, i.e., actively arranged appointments for the clients, 80% of the callers stated that SIRS' participa- tion was helpful. What is not possible to measure is the number of situations where anxious elderly people and/or their families, upon being provided with factual information, were able to develop their own plans. In selected situations, where elderly individuals were unable to follow through, for whatever reason, the staff assumed the role of advocate in order to open doors to insure that the dependent elderly secured the help they needed. In these instances, the staff remained active until it was determined that a decision had been made by the client and the agency to which he had been referred. There is no way of evaluating the amelioration of aggravation, anxiety and expense spared the clients and their families when they were able to get by means of a single telephone call factual information about the services they wanted and needed and directions on how to secure them. Routine follow-ups as performed in the study revealed that in some cases, new problems had arisen since the initial inquiry, and in others, that secondary problems which had not been presented became more significant following reso- lution of the primary need and, finally, that some problems had not been resolved, because, for a variety of reasons, the callers did not follow through. RECOMMENDATIONS : After three years' experience in providing information and referral services for the aging, the Council of Social Agencies offers the following suggestions to those who contemplate providing similar services: 1960 -, 1. Publicity Repeated newspaper accounts, meetings with lay and professional groups, and other public relations activities are essential to publicize the service. While some elderly people save news clip- pings for possible future use, many pay little heed until they need help. Repeated news releases serve to remind the community of the service at times of need. 2. Professional Staff From the outset, the program was designed to make available the skills of professional people to all who called even though it was believed that many inquiries could be classified as "routine." Experience has reinforced the conviction that skilled professional assistance is needed. Trained, experienced and full-time personnel are the hallmarks of an effective information service. The train- ed sensitivity of professionals and the continuity of full-time staff will afford, on the one hand, more precise evaluations of the problems presented and the proper delineations of the services needed and, on the other hand, more efficient use of staff time. 3. Maintaining the Mandate As is the case all too frequently, many people procrastinate when some kind of action should be taken. By the time some people call for information, the problem has become critical and the pressures on the staff to "do something" immediately is difficult to contend with. This is particularly true when family problems require prompt amelioration but attempts at seeking relief are frustrated by waiting lists. Despite pressures and the desire to fill the vacuum, the staff must provide only those services for which the program was established. If possible, they should document the gaps in services and resources and stimulate the community to provide the needed programs. This is not to imply that the staff is to do nothing but provide infor- mation. While avoiding duplicating existing services, there are two functions which are appropriate to the Information and Referral Services and which experience has shown may be performed productive- ly. The staff could be advocates in behalf of the callers and could follow up calls which had been made to ascertain what had transpired. ADVOCACY : Unless an individual is sufficiently aggressive and persistent, he can frequent- ly fall through the cracks of the maze of services available in the community. For the timid, the unsophisticated, the insecure, the uneducated and the non- English-speaking, breaking through the barriers of rigid intake procedures can be so formidable that those in need are unable to apply for, let alone secure, the services that have been established to help them. In such instances, staff can serve as the "advocate" -- the sophisticated expert who knows which tele- phone to ring, which doors to open, which pressures to apply -- to insure that eligible applicants receive what they need at the time of need. 1961 Bu FOLLOW-UP: A planned follow-up on a systematic basis is a second activity which an infor- mation and referral program could pursue, time permitting. A planned follow-up call one month from the initial inquiry could help to ascertain whether or not the caller had followed through on the recommendations, clarify what difficul- ties had been encountered, and how they might be corrected, determine if other services might be needed and show some of the elderly that they are not isolated and forgotten. SIRS AS A PROTOTYPE: Under the title, "A Project Report on Countywide Information and Referral," SIRS was written up by the Administration on Aging, U.S. Department of Health, Education and Welfare, in its publication series entitled, "Designs for Action for Older Americans" as a prototype for an information and referral service. Ten thousand copies were printed and distributed nationally. ACKNOWLEDGEMENTS : During the three years in which it operated, the Senior Information and Referral Services served 5,513 different individuals from every community in Westchester, the surrounding metropolitan region and other states. The success for this endeavor is due to the happy combination of the support of the New York State Office for the Aging, the assistance of its staff, the ini- tiative and sponsorship of the Westchester Council of Social Agencies, the help and counsel of the Community Advisory Committee, and the patient and persistent efforts of the devoted staff. 1962 WESTCHESTER COUNCIL OF SOCIAL AGENCIES, INC. County Office Building, White Plains, New York BOARD OF DIRECTORS Fred D. Zwick President Mrs. George J, Ames Vice President Mrs. David Swope Vice President James Lyall Treasurer Christian H. Armbruster David Bogdanoff Charles M. Brane, M.D. Robert H. Burdsall R. Eugene Curry Roswell K. Doughty Mrs. Louis S. Frank Jack J. Goldman, M.D. Mrs. Kenneth W, Greenawalt Frederick F. Hufnagel Edward J. Hughes Mrs. James N, Hynson Mrs. Alan H, Kempner William G. Sharwell Vice President Mrs. William L. Walter Secretary Robert C. Agee Assistant Treasurer John R. Kibbe Mrs. John G. Kirk Louis P, Kurtis Mrs. Charles D Peet Mrs. Carl H. Pforzheimer, Jr. Robert L. Popper Mrs. Lionel Robbins Dwight S. Sargent S. J. Schulman William J. Strawbridge, Jr. Edward R. Weidlein, Jr. Daniel A, Wilcox, M.D. Judge Harold L. Wood HoH EK KK KKK John E. Dula Executive Director Daniel Sambol Associate Executive Director for Health Planning 1963 SENIOR INFORMATION AND REFERRAL SERVICES 129 COURT STREET WHITE PLAINS, N. Y. 10601 WESTCHESTER AREA TELEPHONES Southern 726-2040 Caniral 428-2818 North West 245-7050 North East 666-7930 COMMUNITY ADVISORY COMMITTEE THE CASE OF MRS. A. SLRS. harman: IWAGHT S. SARGENT (75 year old chronically ill woman) Dobbs Ferry MES. CHARLES F. Soom AND THE EFFORTS REQUIRED TO OBTAIN am ey HOSPITAL AND MEDICAL CARE FOR HER Choppig.» January 6th, Tth, 8th KEVEREND |IENKY R. BRAU (Monday, Tuesday, Wednesday) Elmsford MRS. ALBERT SIEGEL Hapriste January 1969 MES, BENJAMIN ENoe MI. HAROLD L. WOO Mount yaoo .tORGE FE, COHRON Mr. A walked into the SIRS office to request help MRS SHAPE osu in placing his 75 year old mother in a nursing New Rochelle home. He learned of SIRS (Senior Information and SAM SCHEIBER Referral Services) from a poster at the extended Poslskill care facility where he is employed as an attendant YING on weekends. He works as an attendant at a private OAD GRESLAD mental hospital during weekdays. Mr. A is a 0115 SANFORD foreign born young man with some language difficulty. Scarsdale ROBERT L. POPPER 1 EONARD 5A1 VADOR OK. LAWFLNCE W. SCHWARZ Mit. ?OBEKT 5. WOOLF BACKGROUND ite Plains —_— FOMAS | HAMMOND HON, KRISTEN KRISTENSEN onkers of Mr. A brought his mother to the United States from 55 CALHERING M. MELILLO Saal S Director her native country last July (1968) expecting to provide her with a healthier diet and proper medical WCSA care. Some years ago, Mrs. A had a stroke which OFFICERS caused partial paralysis. Subsequently, she broke FRED D_ZWICK her hip. However, she remained ambulatory. rosidont Mi. GEOKGE J. AMES Since she has been in the United States, she has WLM 5, SHARWELL received bilateral cataract surgery and dental 2 ical ridonts surgery (all her teeth extracted) at Phelps Memorial MRS. WALTER H. LIEBMAN Hospital. She was in Grasslands Psychiatric Unit Secretary for two days (12/6 to 12/8) for possible referral JAMES LYALL to a state hospital, but she was discharged. The Treasurer doctor told Mr. A she isn't "crazy". ROBERT C. AGEE Assistant Treasurer JOLIN E. DULA Executive Diracior 59-bbl 3136 conc shud by WESTCHESTER COUNCIL OF SOCIAL AGENCIES, INC. 113 County Office Bulaing, White Hai Haw York 1081. Under Contract #1M53956 with the New York Slaty Chins iat ti 7 ging under thu Whder Amcncens Act od 1965 1964 = Dr. Z had been Mrs. A's general physician in the community but he has withdrawn from the case. Mr. A showed a letter dated 12/18/68 from Dr. Z stating, 'Mrs. A requires more care than I care to undertake." The letter continued that Dr. Z is sorry Mrs, A is not in a nureing home where she belonge, but this is through no fault of his. It concludes, "do not call this office for any further medical advice or prescriptions." Mr. A made it clear that Dr. Z's care of his mother was generous while he was on the case. He made house calls even during the night and also made efforts to get Mrs. A into a nursing home, both while she was at Phelps Memorial Hospital and after she was returned home. We understand that Dr. Z was in contact with the Department of Social Services in the course of his efforts. Since Dr. Z withdrew from the case, Mr. A had tried to get another doctor for his mother. One doctor he contacted refused the case after talking with Dr. Z. As we understand it, the Department of Social Services tried to help Mr. A gecure another physician. SITUATION AT THE TIME OF INTERVIEW Mrs. A's prescription medication to control high blood pressure was exhausted three or four days ago as was her prescrip- tion for ''mervousnese'. Mr. A is also concerned about bed sores which are Jeveloping, Hie mother is no longer ambulatory, but Mr. A thinks that th proper therapy she would walk again. As Mre. A received Old Age Assistance, the matter of place- ment in a nursing home has been referred to the Institutional Placement Unit at Grasslands. ACTIVITY Summary of Contacts: In a period of three days (1/6/69 through T7755) ROE Nery 20 contacts were made involving SIRS, WCSA, Department of Social Services (Medical Assistance and District Office), Westchester County Department of Public Health; Grasslands Hospital (Medical, Social Service and Clinical Departments.) Details and Chronology of Contacts Called Worker, Institutional Placement Unit: (Mr. A still at SINS desk). The worker said she tried to arrange placement for Mrs. A but when the nursing homes learn she is ''confused,” does not speak English and doee a great deal of yelling and screaming, they 1965 refuse to admit her. Apparently the patient is Bo noisy the A's have been threatened with eviction. The worker said there was nothing more she could do. When we explained that Mrs. A is now without medical supervision and without medication, the worker responded she has told Mr. A he could get his mother into Grasslands if he would call the police during the night while she is screaming and have her taken to the hospital. In such a situation, Grasslands must admit her. Further discussion with Mr. A. Mr, A verified that his mother "cries" and calls for her children, but he said that at the nursing home where he works, old people often do the same, He went on that his mother is now incontinent. His young wife (they have been married 8 months) cannot or will not clean her up and it must wait until he comes home from work. (He is aware thia contributes to developing bed sores.) It is evident Mr. A cannot bring himself to use the police as the worker suggests. Telephone supervisor at Institutional Unit: Reviewed the situation as it now stands. After clariliying some points, she called back to say that her worker has done all that can be done about nursing home placement. Mrs. A was calm and quiet during the two days she was at Grasslands Paychiatric. With "the directive’ from the State Mental Hygiene Department, placement in a state hospital cannot be expected. We inquired about getting a doctor from Grasslands to go to the home at least to prescribe necessary medication. We were told this is not poasible. The supervisor said the best she could Fugees regarding renewal of the prescription was to have Mr. A bring his mother to the admission desk at the Psychiatric Unit. There the doctor on call would examine Mrs. A and prescribe medi- cation. She gave us the telephone extension to use in making such arrangements. Discussion with Mr. A: He felt his mother could not stand the trip to Grasslands and back just to be examined. He explained his mother weighs about 175 pounds and he cannot move her alone in any case. In the past an ambulance has been called to transport her. Supervisor: referred us to the District Office regarding calling an ambulance. (Mr. A had to go home to care for his mother and then to report to work. We promised to continue to work on the situation.) Called Supervisor, District Office: After we reviewed the situation, she expressed concern and sald she would see what could be done. *Igsued in June, 1968, stating that State Mental Hospitals will accept only those patients who can benefit from psychiatric treatment. 1966 - 4 - Call from Mr. A: at 2:00 p.m. to inquire what had happened. He was due to work at 3:00 p.m. Called Supervisor of District Office: She had been in touch with the Director of Soclal Jervices at Grasslands Hospital. They were working on getting Mrs. A admitted to the hospitel on an emergency basis. Called Mr. A and reported the above. Suggested he tell his employer e delayed. Call from Supervisor, District Office: to say, although there was no guarantee, she believed an embulance would be sent during the afternoon and she suggested Mr. A remain at home. Called Mr. A and gave above information. Called Supervisor, District Office: (as we had heard nothing further and it was close to 5:00 p.m.). She explained the only basis on which Mra. A could be admitted to Grasslands was the bed sores. However, someone would have to verify the bed sores. There- fore the visiting nurse agency had been contacted. A nurse was to have visited that afternoon if possible. If not, she would visit the following morning. When we pointed out that the patient was still without med- ication and suggested if Dr. Z knew that the community was moving towards hospitalizing Mre. A and understood that her medication was exhausted, he might be willing to write the prescription. The supervisor replied she had discussed it with the worker who eaid she thought he would not. When I pressed what might be done now, the supervisor could make no further suggestion. Called Mr. A: Let him know the visiting nurse was to come to hie home the following day. We made sure he knew how to reach the Medical Association for a doctor in an emergency. We found he already had this information. 1/7/62 Mr. A called as arranged at 9:30 a.m. He said he had heard from no one. His mother Fa spent a quiet night. Called Supervisor, District Office: She said she had been in contact with Supervisor of the local visiting nurse agency and a nurse was being sent to the home that morning. If Mr. A contacted me again, I should refer him to her. Called Mr. A Let him know the visiting nurse would be coming to his home during the morning. Also let him know that he could speak with the District Office Supervisor if he wished to do so. 1967 - 5 = Called llr. A ip early afternoon: He said two nurses had come and looked at hie A They told him they would contact him again either before he left for work or at his job, and had taken his phone number there. He was a little vague as to what they had said regarding plans, but he thought they hoped to get his mother into the hospital. Called Vipiting Nurse of the Department of Health: She told us the Family was taking rather good care of Vrs. A under the circumstances. However, Mrs. A did have bed sores, and her skin was in poor condition. The bed in which Mrs. A had to sleep waa very poor. The nurse 's supervisor was already aware of the nurse's findings. Called Grasslands Social Service: The worker there explained that the supervisor of the visiting nurse agency has been in con- tact with the Coordinator of Health Services between Grasslands and the Community. The Deputy Commissioner of Health has also been consulted, The next move would be up to him, as we understood it. When we focused on the matter of medication for Mrs. A, the worker sald she would bring it to the attention of the Deputy Commissioner of Health right away. Call from Grasslands Social Service Worker: The Deputy Commissioner of Wealth was not in his office, a note was left for him regarding Mrs. A's lack of medication. Situation at 5:00 p.m. 1/7/6%: In spite of the concern and activities of various agencies, Mre. A was still without medication, medical supervision or placement in an appropriate medical facility. Representatives of the various medical and welfare agencies con- cerned were keenly aware of the lack of facilities in Westchester County for chronically 111 patients. We were told that Grasslands gets at least one case each day similar to Mre. A. Called Grasslands Director of Social Services ard explained we felt something must be done for llrs. A. advised we call the doctor in charge of the Emergency Room. Called Chief Doctor in charge of Emergency Room: After we reviewed the situation, the doctor said Mrs. A could be admitted through the emergency room under the circumstances. However, there might be a problem of deciding which service would admit Mra. £; medical for high blood pressure or surgical for bed sores. It wae, therefore, suggested the admission should be postponed until the morning of January 8th when the chief doctor would be on duty. Called Mr. A at his job to let him know that his mother would be ud ed to Grasslands on January 8th if he would bring her to the Emergency Room. We gave him the name of the doctor to ask for, also let him know he could have her admitted during the night, {f he felt it was neceasary. Again he wae told the police would help him if he called them. 1968 -6 - 1/8/69 Mr. A called at 9:30 a.m. and wished to verify what he should do. We reviewed just what he was to do, and made aure he had the doctor's name. We stressed that Mr. A was under no circumstances to bring his mother away from the hospital once there. We told him to call if he had any question or if admission was refused. Mr. A called at 12:30 p.m. from a public telephone booth. Said he was in the Emergency Room, that he had arrived at 11:00 a.m., that his mother had been examined by the doctor, and he had been told he was to wait and speak with the doctor. Mr. A was beginning to be apprehensive about whether his mother would be admitted and also whether he would be at his job on time. Called Emergency Room: learned they still intended to admit Mrs. ut it was a question as to which section. Tried to call Mr. A Unable to reach him. At about 1:30 p.m. Mr. A telephoned. He was then in the Paychiatric Building with hie mother. He said he had been told by the doctor to wait. It was his impression they would not be admitting her. Also, he was concerned about getting to his job. Called the Emergency Room doctor who said they knew Mrs. A was in the Pavers Building and had left instructions that when they were finished with her there, she was to return to the Emergency Room. When I explained lr, A's need to get to his job, the doctor said he could leave. I explained that the doctor in the Psychiatric Building had told him to wait. The doctor said she would herself speak with Mr. A and tell him he could go home, that hie mother would be admitted to Grasslands. At about 3:00 p.m, Mr. A called again. Said he had been told Ly aE TOTES TEI HI Tories Satoppied be si Sobpasel. His mother had been sitting in a wheelchair all this time. She was terribly tired and needing to go to the bathroom. He was told there was nothing they could do about her personal needs. Mr. A's voice had become increasingly anxious from call to call. Telephone call was made to the Medical Director of Grasslands Hospital and let him know of refusal to admit Mrs. A after all. He said he would check and call back. Telephoned the Chief Doctor of the Emergency Room who stated that while the Hospital Director of Medicine had agreed to admit Mre. A, the doctor in charge of patient utilization had countermand- ed the order. 1969 Called Social Service to ask whether there was anything which could be done to make Mrs. A more comfortable. Not able to reach worker. Called Mr. A told him to be patient a little longer. Medical Director called back to say that Mrs. A is to be admitted. Director of Social Services is to follow the case and see that no dis- charge occurs without an appropriate plan for another facility. Mr. A called us at 4:30 P.M. Said he was at home and that his mother had been admitted to Grasslands and was in bed when he left. He was still somewhat upset that his mother had been so tired at the end of the day, and when I inquired if she had been given any lunch, Mr. A said she had not. He thanked us for our efforts and concluded in his broken English, "I'm hauppy". Agencies involved: 1. Department of Social Services, District Office 2. Department of Social Services, Institutional Unit 3. Local Visiting Nurse Agency, Department of Health 4, Psychiatric Institute Grasslands Hospital 5. County Hospital doctors 6. # " Social Service Department T. Department of Health, Deputy Commissioner 8/9 WCSA and SIRS (three staff members, including executive director.) Telephone calls: 8 from Mr. A. T to Mr. A 17 to and from agencies and hospital 32 different telephone contacts plus Mr. A's visit to SIRS office. Post Script: On January 28, 1969 Mrs. A was discharged from Grasslands Hospital and placed in a nursing home. 1970 WESTCHESTER COUNCIL OF SOCIAL AGENCIES, INC. County Office Building, White Plains, New York AD HOC COMMITTEE ON WESTCHESTER'S HEALTH RESOURCES AND UNMET NEEDS co-sponsored by Westchester Council of Social Agencies Westchester County Medical Society Westchester County Department of Health April 28, 1966 - ‘Since many young people display an interest in a health career-at an early age, all efforts to foster and develop their interest and desire should be intensified 1ong befure they reach high school age. To help guidance counselors in Westchester's forty-seven public school dis- tricts advise and counsel young people for careers in the health fields (medicine, nursing,dentistry, technicians, practical nursing, home health aides, etc.), the official and voluntary health agencies should prepare and distribute a packet of materials describing various health occupations. Nurse educators and school guidance counselors should engage jointly in an intensive program to recruit candidates for the nursing profession. Hospitals should provide more in-service orientation and education for all general staff nurses, particularly the newly graduated who are frequently re- quired, because of personnel shortages, to assume responsibilities for which they had not been prepared. In view of the trend toward collegiate schools of nursing, the diploma schools of nursing in Westchester should immediately develop, in concert, an appro- priate plan for future nurse education programs. The Westchester Nursing Council should take the initiative in establishing a program for training and utilizing home health aides. Such a program should draw heavily upon the experience of the District Nursing Association of Northen Westchester which has demonstrated the effectiveness of a home health aide program during the past three years. The Westchester Heart Association, together with other health agencies and appropriate organizations such as the Westchester Council of Bocial Agencies (WCSA), the Westchester Medical Society, Westchester Academy of Medicine, and the Hospital Review and Planning Council of Southern New York, should continue its leadership in developing a regional medical complex, emphasizing medical education and seeking such aid as may be available under the federal Regional Medical Programs: The Heart Disease, Cancer, and Stroke Amendments of 1965, Public Law 89-239. 10. 13. 1h. 1s. 16. 17. 18. 1971 -2 = In order to recruit and retain more American-trained interns and residents, Westchester's community hospitals should institute a system of rotation for their continued medical education and training; such a program should not wait for the establishment of a medical school as part of the Westchester Branch of the State University. A centralized information and referral service, possibly an extension of the Information Bureau of the Westchester Council of Social Agencies, should be established on a threeyear demonstration basis to meet the needs and interests of the fields of medicine and education as well as health and welfare. Because of the fragmentation of health screening programs (chest x-rays by the Westchester Tuberculosis and Public Health Association; urine tests by the Diabetes Association; glaucoma tests provided in some hospitals by some of the Lions Clubs, ete.), official and voluntary health agencies should get together to coordinate and expand such health screening programs, with follow- up incorporated in them. Particular emphasis should be placed upon developing programs providing annual physical examinations for persons over forty years of age since they are more susceptible to disease and disability. To promote the establishment of a unified Health Department in Westchester County at the earliest date possible, the Westchester Tuberculosis and Public Health Association, with the support of the Westchester Council of Social Agencies, the Medical Society, health and welfare organizations as well as civic groups, should continue its leadership towards this objective. Every free-standing nursing home in Westchester County at present is operated under profit-making auspices. Non-profit, philanthropic health (including hospitals), welfare, religious and civic groups should be urged to sponsor such programs with whatever financial assistance in the form of grants or loans as may be available from governmental sources. To assure the sound development of the county hospital at Grasslands, the Westchester Medical Society is urged to work more clesely with the Board of the County Department of Hospitals and the Medical Board of the Hospital. Grasslands Hospital is urged to continue the development of specialized services (e.g., cardiopulmonary center, renal clinic, chronic illness institute) with the full participation and support of the Medical Society. Members of the medical profession, hospital trustees and administrators should join the official and voluntary health departments and agencies in planning the health services necessary in the community. To make the services of the hospital better known to the community, to help the community better understand the needs of the hospital and to help the hospitals better understand what community needs are, workshops should be instituted by and for hospital trustees, hospital administrators, and members of medical Boards. Since social service is an essential part of the total treatment of the patient hospitals should develop social service departments, staffed by qualified grad- uate personnel who should also participate in hospital program planning, both within the hospital and within the community. 19. 20. 21. 23. 2h, 25. 26. 1972 8 There is urgent need for hospitals to make provision for the in-patient care and treatment of psychiatric patients. Hospitals should give special attention immediately to the need for improved, round-the-clock emergency services; for patient-care, from the most intensive to the least intensive, and for more adequate out-patient clinic care and treatment, Hospitals should expand their services to include skilled nursing home programs for patients who require nursing care primarily, either by the direct operation of such nursing homes by the hospital itself or by the hospital's affiliation with a skilled nursing care facility. Rehabilitation services should be expanded to assist physically, mentally and socially disabled persons to achieve a socially satisfying way of life in addition to the present exclusive requirement of potential employability. Since public transportation in Westchester County at present is inadequate, a program should be developed to transport disabled patients to appropriate rehabilitation facilities. Since most of Westchester's sixteen voluntary nursing associations constitute units that are too small to attract and retain the qualified staff required, the visiting nursing association should accelerate their efforts to consol- idate on a regional basis or to establish one countywide nursing organization. All hospitals in Westchester County should set up comprehensive home care pro- grams which have become an important segment of modern medical care. Despite indications that there is an urgent need for rehabilitation and sheltered workshops in Westchester County, the nature and extent of this need should be studied and documented more precisely, with blueprints for such workshop(s) as may be recommended being drawn up and implemented. 1973 STATEMENT OF DR. PARCELL, PLEASANTVILLE, N.Y. Dr. Pagrcerr. My name is Dr. Parcell, of Pleasantville, N.Y. Much has been said today about hospitals and everything else, but very little has been said about how this service can be delivered, and unless we have the personnel to do it it will never be available to anyone. Beautiful hospitals do not treat patients. We need the pri- mary physician, call them a general practitioner or whatever you want. T have been a general practitioner for 40 years. I am working harder today than I ever worked in my life covering my community. I am getting tired. I have no coverage. Unless you train more pri- mary doctors all this beautiful talk can go to naught. We need 70 percent of the doctors coming out of medical schools for the next 10 years, or primary doctors. We have an excess of specialists. They can serve the community for the next 20 years with only 20-percent replacement. These are the men we need. Cw We wil not need the paramedicals if we have general practitioners taking care of the patients—we do not need to train midwives or we do not need the corpsmen. They can fill a gap in between until the 70,000 general practitioners are produced, or the primary doctors. This is important, and without them, forget it. Billions of dollars will never do it. . Mr. Rem. Well, I am delighted that you have highlighted this, and I was one of those in the Congress who supported legislation that would have strengthened, I think, funds, scholarships, and others, to insure that we have more general practitioners. I was sad and upset that the White House saw fit to veto the bill. But I think the point you raise is very valid, and I hope that we will get more young men and women that will become general prac- titioners and meet the needs, and I think the Federal Government has a responsibility to help make this possible. Dr. Parcerr. Now one other thing IT would like to bring out, hos- pital costs should be divided in total, those for the maintenance of the physical structure such as salaries, for that which are mandated by the State or Federal Government, and those for medical services. I have possibly figured out a formula, that taking the average of 3 years running, what hospital costs are running, take 50 percent of that and give it as a direct contribution to each hospital. We have less than 10,000 hospitals in the United States, and by making out 10,000 checks or less, we can help keep those hospitals in the black instead of the red. Mr. Rem. And keep the cost of the patient down. Dr. Parcern. So that our insurance premiums will be less. We won’t have to pay for the maintenance of the hospital. Mr. Rem. Mr. Peck, would you care to comment on this? Mr. Peck. Well, I think three-quarters of the cost of a day in the hospital is the cost of the people. So T am not sure how you divide it, Joe. But if you divide it between the professional, say, that still has a lot of the people cost. For example, the radiologist, the Dr. Parcerr. Radiologist would be part of the medical cost, and laboratory would be. But when we have to pay for the superin- 1974 tendent who takes care of the maintenance man and the man who cleans the halls and cuts the grass outside, that should not be part of the medical cost. Those are the costs I wish to have reimbursed by the Federal Government as part of the first line of defense in health, because our physical structures are our forts, and if we don’t have those we don’t have anything. Mr. Rem. Well, T thank you for a very creative suggestion. Lyndall, would you like to say a final word ? Mrs. Boar. No, I think it has been covered amply. Thank you very much. Mr. Rem. Are there any others in the room that would like to comment ? STATEMENT OF HAL BOGEN, PLANNING CONSULTANT Mr. Bogen. My name is Hal Bogen, planning consultant. I spent a couple years planning health facilities for a New York metropolitan public agency, and there were two observations I thought might possibly be useful. You may have had testimony on the overall needs for the metropolitan area in terms of facilities. The calculation, as I recall, as of a year or so ago, was about 4.4 billion. I am not sure that is in your records, but some work has been done on that. The two points that may be of more significance and may or may not be in the record are, first, regarding the balance of attention that has been given by public funds and public programs to urban versus suburban facilities, it should be clear surely by now that the program under the Hill-Burton Act and its followup program Mr. Rem. Unfortunately that act, the funding for it has been cut back very drastically, and New York is only going to be receiving, I think, 10 million. Mr. Bogen. But over the entire length of that time, a couple of decades now, the formulas that were used for the calculation to me have not been determined by need, but by growth alone. And so this, of course, has shortchanged some areas. The second point has to do with the location of hospital expansion facilities, the most glaring example surely being the grasslands medical facility expansion to a medical school, in locations not ac- cessible to either the great bulk of patients being served or cer- tainly those who work there at low wages. And this is not a problem unique to Westchester, of course. It has occurred in other counties in the metropolitan area. And certainly those two points I think should be investigated further as your work proceeds. Mr. Rem. Thank you for those two points, and we will pursue them. Yes, sir? STATEMENT OF SAMUEL SMITH, COORDINATOR OF THE NEW ROCHELLE COMMUNITY ACTION AGENCY AND CHAIRMAN OF THE NEW ROCHELLE WELFARE RIGHTS Mr. Smita. Well, I am glad to see you, Congressman. My name is Samuel Smith, coordinator of the New Rochelle Community Action Agency and chairman of the New Rochelle Welfare Rights. What I 1975 have to say can go hand in glove with both the welfare rights and the community action agency. : ; First I would like to say, however, that we were very distressed in New Rochelle because this meeting that we are holding today was never publicized to the point where it even reached the ears of the New Rochellees, because I am sure there would be more people here to this meeting from different organizations, and what not, that would like to see Mr. Rem. Well, T am glad you had a good set of ears and were able to hear us. Mr. Smita. I am here to ask for help, Congressman. As you know, speaking as the chairman of the welfare rights, the aim of welfare is to get the people off welfare so they can support themselves and their families. And contrary to the belief of many people, we do have a multitude of welfare recipients that would like nothing better than this. Now in the community action agency in New Rochelle we have started two programs. One is a licensed practical nurse and the other is a registered nursing program. Knowing that the hospitals need help and the shortage of this type of professionalism, the programs caught fire. We have a waiting list of approximately 300 more girls waiting to go into this program. Our stumbling block is this and it is where we need the help. We have a 10-week nighttime program where students attend school for 3 hours, two nights a week. After this there is a 20-week session, and this part of the program has to do with the hospital. But our trouble lies with reception of our program by the State of New York itself. We are having difficulty getting the State to recognize our program as a legal program. Now these girls are trained by the Yonkers College, that is, the Cooperative College Center of Yonkers. They have licensed teach- ers, and what not. However, the State itself does not want to recog- nize our program as being a legal program. Mr. Rem. Well, T am glad you mentioned it, Mr. Smith, and I will be happy to intervene with the State and see what can be done. Mr. Smyrrm. Because time is growing short. The 10 weeks are almost up now, Congressman, and a lot of these girls have to know what is going to happen because the next 20 weeks are daytime sessions, all day sessions, and some of them do have menial jobs and they have to give up these jobs in order to continue in the program. This is our stumbling block, and we would appreciate your help. Mr. Rem. We will look into it promptly. Thank you. I think the lady STATEMENT OF MRS. ELIZABETH LORENTZ, WITNESS FROM FLOOR Mrs. Lorentz. My name is Elizabeth Lorentz, and IT would like to place in the record the need felt by my friends in the new careers movement for a part in the legislation that encourages people to develop guidelines for training paraprofessional personnel of all kinds. The medical centers vary greatly in the way they use para- medical personnel and have no agreement about what partnership should be developed in the medical field. 1976 As we know from the experience of Permanente—and Dr. Gar- field has written that—once you insure people you get all the people who want to talk about their health even if they are not sick—the worried well, they are called. They have a right to a hearing, too, but they do not have a right to take up the time of the busy phy- sician who is needed by a very sick person. So that three-quarters, I guess, or more, of the patients at the Permanente Foundation are handled by paramedical personnel. Now the training seems to me important. Mr. Rew. And some form of uniform guidelines. Mrs. Lorentz. Right. Dr. Brew is very interested in the para- medical field but guidelines are very hard to find for the people em- barked on careers in medicine, whether they are poor people or young people, looking for a career. We are trying to introduce high school kids in this area to the world of work to help fill their needs for a career and also to use them for health personnel. Mr. Rem. Might 1 ask whether you have looked at the Health Training Improvement Act which was signed into law last year and ascertained whether that is of any assistance to you in this regard? Mrs. Lorentz. I haven't studied the bill. But I think I would have been told whether it solved the needs IT am referring to because my friends at Johns Hopkins have recently had a meeting where this was discussed. But I am sorry, if this does cover the situation I brought up—I certainly will look it up. Do you feel that it does? Mr. Rew. It doesn’t cover it. Tt does call for a study, I am advised by counsel. But I think the point you are making is valid, because if you look at the shortage of paraprofessional personnel, which perhaps is a quarter of a million, I think there is going to have to be some understanding both as to training and as to guidelines. And if this is a gap in the pending legislation we will certainly take a look at it to see what we can do to be specific. Mrs. Lorentz. Thank you. Mr. Rew. Thank you. It is a very good point. Yes, sir? STATEMENT OF MR. CONTIERE, ASSISTANT ADMINISTRATOR, ST. AGNES HOSPITAL, WHITE PLAINS, N.Y. Mr. ContiEre (phonetic). I am assistant administrator of St. Agnes Hospital, White Plains. Mr. Rem. A very fine hospital. Mr. Contiere. Thank you. Just for the record and for the Sena- tor’s information I wanted to mention that along with catastrophic illness there is also the catastrophe of having multiple handicapped children, and I don’t know if you have heard about the plight at St. Agnes which has been recognized to some degree now. We are giving day care and outpatient services to these children, but there are many programs and many conditions, like muscular dystrophy, and so forth, where there isn’t sufficient funds to care for it. Mr. Rem. Would you care to estimate just from your own ex- perience the number of handicapped children that need care and are not receiving it? 1977 Mr. Conriere. Oh, well, presently we care for approximately 250, and I can say there’s about five times that many children in the Greater Westchester area. Now I am talking about we are the only agency that does this in Westchester County. So T would estimate about five times that number. Mr. Rem. Well, I am glad you mentioned it, and T am glad that St. Agne’s appearance has been made possible by vour appearance here today. If there are no others here I will close the hearing and merely say on behalf of Senator Kennedy and myself how grateful we are for all of you having stayed, and to express our commitment to work for creative and effective legislation to maintain the quality of our medicine, for the first time in our history make it available to all who need it, and hopefully get the cost under control, not alone for the poor, but for the middle income family that has been so badly affected as well. At this point we will insert all statements of those who could not attend and other pertinent material submitted for the record. (The material referred to follows:) 1978 Gordon R. Weyorkolf. W.D. ~ 9 Rdllaide rhuennc Roslyn Heights, Hew York 11577 Wagan 1-551 April 16, 1971 Senator Edward Kennedy Subcommittee on Health U.S. Senate Washington, D.C. Dear Senator Kennedy: Thank you for your kind invitation to present testimony to the Committee regarding medical care. It is a pleasure to see someone so concerned with such an important matter. Especially combined with wanting to see how the people feel about it. In this regard, one can easily predict that you will hear from everybody that medical care should be available to those who need it, and where it is not, this problem should be solved. The only question will be how it should bgsolved: within the ways of our cherished free society or shall we give up that way and institbte some form of government control, some form of socialism. Your proposed bill seems to say we must foresake the free way of life, not allow people to have full free choice of! physician, and we must, in essence, conscript physicians, telling them where, when, how, and for how much to perform their service. The Medicredit approach purports to solve these same problems within our cherished free way of life. It is hoped as you tour the country you will not only be tuned in on the problems, but that your own heart will be open as well to the more fundamental heartbeat of the American way of life, for which men, from its very inception, were willing to sacrifice honor, fortunes, health, become maimed, and even gave up their very lives so that cherished freedom could be preserved. It would be a tragedy for the world that if, for the sake of better health, you attempted to turn people from further cultivating this garden of freedom, to sacrificing freedom for health. The fieedom appraach shows how we can have freedom and health. It is hoped that whatever it is that is turning you, personally, away from the free way of life, that it hasn't reached the point whereby you would keep this testimony from all the other members of the committee. Sincerely yours, Gordon R. Meyerhoff, M.D. 1979 Senator Kexxepy. Thank you very much. (Whereupon, at 5:45 p.m., the subcommittee adjourned.) Oo HEALTH CARE CRISIS IN AMERICA, 1971 HEARINGS BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE UNITED STATES SENATE NINETY-SECOND CONGRESS FIRST SESSION ON EXAMINATION OF THE HEALTH CARE CRISIS IN AMERICA APRIL 19, 1971 KINGWOOD, W. VA. APRIL 20, 1971 NASHVILLE, TENN. MAY 4, 1971 CLEVELAND, OHIO PART 9 Printed for the use of the Committee on Labor and Public Welfare 2 U.S. GOVERNMENT PRINTING OFFICE 59-661 O WASHINGTON : 1971 COMMITTEE ON LABOR AND PUBLIC WELFARE HARRISON A. WILLIAMS, Jr., New Jersey, Chairman JENNINGS RANDOLPH, West Virginia JACOB K. JAVITS, New York CLAIBORNE PELL, Rhode Island WINSTON PROUTY, Vermont EDWARD M. KENNEDY, Massachusetts PETER H. DOMINICK, Colorado GAYLORD NELSON, Wisconsin RICHARD S. SCHWEIKER, Pennsylvania WALTER F. MONDALE, Minnesota BOB PACKWOOD, Oregon THOMAS F. EAGLETON, Missouri ROBERT TAFT, Jr., Ohio ALAN CRANSTON, California J. GLENN BEALL, Jr., Maryland HAROLD E. HUGHES, Iowa ADLAI E. STEVENSON III, Illinois STEWART E. MCCLURE, Staff Director ROBERT E. NAGLE, General Counsel Roy H. MILLENSON, Minority Staff Director EUGENE MITTELMAN, Minority Counsel SUBCOMMITTEE ON HEALTH EDWARD M. KENNEDY, Massachusetts, Chairman HARRISON A. WILLIAMS, JR., New Jersey PETER H. DOMINICK, Colorado GAYLORD NELSON, Wisconsin JACOB K. JAVITS, New York THOMAS F. EAGLETON, Missouri WINSTON PROUTY, Vermont ALAN CRANSTON, California RICHARD 8. SCHWEIKER, Pennsylvania HAROLD E. HUGHES, Iowa BOB PACKWOOD, Oregon CLAIBORNE PELL, Rhode Island J. GLENN BEALL, JRr., Maryland WALTER F. MONDALE, Minnesota LEROY G. GOLDMAN, Professional Staff Member JAY B. CUTLER, Minority Counsel (IT) CONTENTS CHRONOLOGICAL LIST OF WITNESSES MONDAY, APRIL 19, 1971 KINGWOOD, W. VA. Page Kemphfer, Mrs. Dolores, housewife... oem biden od 20 1983 Hess, Mrs. Wilda, staff attorney, North Central West Virginia Legal Aid Society, accompanied by Mrs. Malinda Perkins_______________ _______ 1987 Bacilett, Mrs. Grace Maries... ice ewido dd kins mn Lm ey) 1995 Michaels, Charles, pharmacist and president, Doddridge County Medical Center, West Virginia, accompanied by John Van Gilder, M.D. ; Howard Spurlock; John Droppleman; Rev. Richard Bowyar, president, Eight County Comprehensive Health Planning Board; and Dr. Robert L. Nolan, professor and chairman of the Department of Public Health and Preventive Medicine, West Virginia University, Morgantown, W. Va___ 1997 Davis, Delroy, M.D., general practitioner, Kingwood, W. Va., and public ; health officer and ‘past president, Academy of General Practice, accom- panied by Miss Iris Allsopp, administrator, Preston Memorial Hospital _ 2005 Steelman, Mrs. Emma and Mrs. Anna THRONE eo Breer ese forts or cont 2010 Cool, Mrs. Rondalyn, director, Emergency Food Program for Webster CONtY, Wo Va cc teen ee ois ilps mi Ba BE he hme sm pt wi AE Bm Fm Ao 2012 Watkins, Vernon, president, Newburg Community Organization, Newburg, WW. Va. alent inl i i dit diated mid bem NEL mm 2013 Dalton, Mrs: Shirley.cn. coy on deo iain A ee 2014 Linsky, Benjamin, professor on air pollution control, and safety engineer- Ing, University of West VILGINIa.. ... communion mk ews Sat oti etm Sm 2015 Milne, Mrs. Eloise, social worker, West Virginia Department of Welfare, ANA MES: TH «creme cs oe meio es sie mi sg om i em ar SE CR, J ITT 2015 Bory, BATE) I oc ee i Rig i Ee he 2018 Browning Preston... ita cum is mim ine mcm mola Soap LI 23 2018 TUESDAY, APRIL 20, 1971 NASHVILLE, TENN. Fletcher, Miss Mary Lynn, Knoxville, Tenn., a student of the University OF DOI SOO es oe RT Re ot mmm mri ml weet et eve Ee SR pe 2119 Vogen, Don, representing Herbert Anderson, Steelworkers representative__ 2123 Yiutz, Mrs. Francis, Nashville ToSIAeNla . . co mmo wr pape fag stim mess mom mpg aig = 2125 Young, Mrs. Mary, employee of General Hospital, Nashville, Tenn_______ 2126 Long, Mrs. Patricia, telephone operator. ________ 2128 Parsons, James, employee of Nashville Bridge Co ___________________ 2129 Smith, Mrs. Mary, public health nurse, and Mrs. Berna Lou Kaiser, county resident ee er te a SE ge ee i EE BE Sa Sm oi Sa oe 2132 Jones, Mrs. Mary, employee of Central State Hospital, Nashville, Tenn___ 2136 May, Mrs. Jean T., resident, Nashville, Tenn... _______________ 2138 Nesbitt, M.D., president-elect, American Medical Association and past president, Tennessee Medical Association____________________________ 2140 Elam, Lloyd, M.D., president of Meharry Medical College________________ 2147 Bistowish, Dr. Joseph M., director of health for Metropolitan Nashville i and DAvIASon Cou... i i nt i 2151 Lewis, Miss Gale, witness from the floor of the hearing__________________ 2154 Smith, James R., witness from the floor of the hearing__________________ 2154 Taylor, Miss Dixie, witness from the floor of the hearing________________ 2155 May, Mrs. Jean, witness from the floor of the hearing________.__________ 2155 Carley, Mr. Rob, witness from the floor of the hearing__________________ 2155 (111) v TUESDAY, MAY 4, 1971 CLEVELAND, OHIO Reiger, James, Cleveland resident ______________________________________ Dowden, John, member of Mount Pleasant Community Council, accom- panied by a panel composed of citizens of Cleveland, Ohio______________ Bilton, Joseph L., M.D., vice president, Cleveland Academy of Medicine, accompanied by Milton Lambright, M.D., past president, Cleveland Acad- CMY OF MEAICHAB Lo ee cere mei sim iid om a sem bra Sm mio i mi li DeShetler, Kenneth E., insurance commissioner of the State of Ohio______ Ganofsky, Miss Maryanne, social worker on the Division of Child Psychi- atry and Division of Pediatrics at University Hospitals in Cleveland, EO ole or rim rps iis atime at oo ab mi mem vec Smtr me ne et i A i Keller, Dr. David L., Cleveland, Ohio Craig, Tillian, Cleveland, ONO. cua =a ims nm mir —————————— DAnICIS, Mary, (CIEVCIAN, OII0% ...cm wu igo oem im mn i i goss si me oo me rn smo Rateliffe, . Walter, 2016veland, : ONI0. Lv mo mm mm sims semomen em mm 5 mre meme Bauknight, Dr. Tilman, Cleveland, Ohio, accompanied by Vallrie Bradley__ Camardese, Dr." N.:M., Norwalk Ohio... ..o-tccce JT ba Sel Xo. Barry, Mrs. Mildred, representing the Health Planning Development Com- mission of the Welfare Federation... __._________________________ Hatten, Mrs. Carolyn, HSC, Cleveland Ohio... ________________________ Brooks, Mrs. William, resident of a public housing project and presi- dent of the Seniors Of O00. 2. mimm mri moni sm mm win maimed Johnson, Karl C., vice president, Garden Valley Neighborhood House Board of Trustees, Cleland, Ohi0... ve cB meme em ms aren STATEMENTS Barry, Mrs. Mildred, representing the Health Planning Development Com- mission of the Welfare Federation... ovncivom minis denne ——— BATLIotl, MIS, Gree MATIC oc oi i bo io od oh i i os SA ip i im Bauknight, Dr. Tilman, Cleveland, Ohio, accompanied by Vallrie Bradley__ Bilton, Joseph L., M.D. vice president, Cleveland Academy of Medicine, accompanied by Milton Lambright, M.D., past president, Cleveland ACARI. OF MCA CRIN. oo cer mis ws i simi moss im io si wi en Bistowish, Dr. Joseph M., director of health for Metropolitan Nashville ANA, DDAVIASON, CONNIE hrs le Fe ction ii sm ig op tm mb BOL RY NOL I iia oe oi nm i eo sn i ml fiom mma Brooks, Mrs. William, vesident of a public housing project and president ofithe Semiors of ON IO. £m es Browning: Preston eo ice ee de UN A Nd el RLS iia Camardese; Dr. N. M., “Norwalk, OMO.... oc ea ne ae Carley, Rob. witness from the floor of the hearing_______________________ Cool, Mrs. Rondalyn, director, Emergency Food Program for Webster Daniels, Mary, Clevelanl, rORi0.. oo cdi Ce ee cre Bm ee mm sn se me Davis, Delroy, M.D., general practitioner, Kingwood, W. Va., and public health officer and Past President, Academy of General Practice, accom- panied by Miss Iris Allsopp, administrator, Preston Memorial Hospital _ DeShetler, Kenneth E., insurance commissioner of the State of Ohio____ Dowden, John, member of Mount Pleasant Community Council, accompa- nied by a panel composed of citizens of Cleveland, Ohio______________ Elam, Lloyd, M.D., president of Meharry Medical College______________ Fletcher, Miss Mary Lynn, Knoxville, Tenn., a student of the University OF TOT IOBEOO orice ot on ois gio Eh st oi a i i ar ol om ga Ganofsky, Miss Maryanne, social worker on the Division of Child Psychi- atry and Division of Pediatrics at University Hospitals in Cleveland, D0 et oD i ol rrp i lng ooh ee i eat ais snr fr ee Hatten, Mrs. Carolyn," HSC, Cleveland, Ohio. Hess, Mrs. Wilda, staff attorney, North Central West Virginia Legal Aid Society, accompanied by Mrs. Malinda Perkins________________________ Johnson, Karl C., vice president, Garden Valley Neighborhood House Board of Trustees, Cleveland, POND. 0. cco im iii wim seme sm si see smi Jones, Mrs. Mary, employee of Central State Hospital, Nashville, Tenn__ Page 2157 2161 2176 2180 2188 2192 2192 2193 2193 2194 2196 2197 2198 2199 2201 2197 1995 2194 2176 2151 2018 2199 2018 2155 2012 2192 2014 2193 2005 2180 2161 2147 2119 2188 2198 1987 2201 2136 Page Reller, Dr. David: L.; Cleveland, ODIO «ows mf mo tion bia won ey serb fring 2192 Remphier, Mrs. Dolores, OUSCWILR.. toes fie win ti mp i isp senna wm ont 1983 Kerr, Lorin E., M.D., M.P.H., director, Department of Occupational Health, United Mine Workers of America and visiting professor of public health, Howard University College of Medicine_ coo 2089 Lewis, Miss Gale, witness from the floor of the hearing _______________ 215 Linsky, Benjamin, professor on air pollution control and safety engineer- ing, ‘University of West. Virginia ou. votes wcapedi seman mmm Mmm metho 2015 Long, Mrs. Patricia, telephone operator. vem ws mie SE mm dif om sd dma = 2128 Lutz, Mrs, Francis, Nashville resident... ius oil tim ten Sli nm 2125 May, Mrs. Jean T., resident, Nashville, Tenn. tice. i. 2138, 2155 Michaels, Charles, pharmacist and president, Doddridge County Medical Center, West Virginia, accompanied by John Van Gilder, M.D., Howard Spurlock ; John Dropleman; Rev. Richard, Bowyar, president, Eight County Comprehensive Health Planning Board; and Dr. Robert L. No- lan, professor and chairman of the Department of Public Health and Preventive Medicine, West Virginia University, Morgantown W. Va.__ 1997 Milne, Mrs. Eloise, social worker, West Virginia Department of Welfare, I UTR. TU ie cat iminium whe aon igo si oS ee ee ES 2015 Nesbitt, M.D., president-elect, American Medical Association and past president, Tennessee Medical Association_._____________________.____ 2140 Parsons, James, employee of Nashville Bridge Co _______________ 2129 Rateliffe, Waller, ‘Cleveland, ONI0... ov wm emma mim se pois 2193 Reiger, James, Cleveland resident... oo UZ naan 2157 Smith, James R., witness from the floor of the hearing__________________ 2154 Smith, Mrs. Mary, public health nurse, and Mrs. Berna Lou Kaiser, county FOBIAONL ce oe cep evap oe orgs em mn ig mm ea pa tn tls mi orn fo me 4 8 i ie 2132 Steelman, Mrs. Emma and Mrs. Anna Likens__________________________ 2010 Taylor, Miss Dixie, witness from the floor of the hearing________________ 2155 Vogen, Don, representing Herbert Anderson, Steelworkers representative__ 2123 Watkins, Vernon, President, Newberg Community Organization, Newberg, WY i Vl oo tis oe lie st ns Boia we ei oti eset mets ong ev eit Ep ie pot ema A ae Sed 2013 Young, Mrs. Mary, employee of general hospital, Nashville, Tenn________ 2126 ADDITIONAL INFORMATION Articles, publications, ete.: “Doctor Rebuts New Health Plan,” from the Citizen Journal, Colum- DIS, SOMO, ADIL Dr DOT] Lacie tims mommy shisha mimes es eso sm erie mis ies 2217 Health. Care in" West VIrgInia.. ove ei ie sii ms sk simi ss mes im is 2057 “Make Health Care A Right, Not A Privilege,” by Medical Committee for Human Rights, National Health Insurance Committee ________ 2221 New Orleans District—Louisiana Hospital Association meeting, March 12; 1070, IIRULES Ofc cme ce vo wisi as ei Sm i i 2211 “Observations on Health Care Problems in North Central West Vir- ginia,” by Rev. Richard Bowyer, president, Health Planning Associ- ation of North Central West Virginia, Clarksburg, W. Va__________ 2035 “Population Change in West Virginia 1960-70—A Preliminary Study,” by the Office of Research and Development, Appalachian Center/ West Virginia Vera ye ec oie ce re mis ci ins pi pn se se a a ok 2072 “Standards for Accreditation of Hospitals, October 1969,” Joint Com- mission on Accreditation of Hospitals, Chicago, IIl_______________ 2213 “Survey—Water and Waste Disposal Systems, Rural Areas, West Virginia,” from the U.S. Department of Agriculture, Farmers Home AGMIMISIIATION Lo ib sit pssst emi sami ons gis Sa osm mtn Hw wi ig ir 2077 “The Hospital Medical Record,” published by the Health Insurance Council in cooperation with the American Association of Medical ROECOTA TAD TAIT... ci irecormmom itor i smi sis 555 mpi smite Sma me sg ld 2212 “These Joneses Are Trying To Keep Up With Themselves,” by Susan Conte, Dominion-Post staff writer, from the Dominion-Post, King- WO0A,-W. Va., 'OCLODEr 18, 1070... up wmv mins mmm nm ves sm oe seme 1994 Uniform policy for release of medical information_________________ 2216 VI Communications to: Alexius, Haller, administrator, St. Tammant Parish Hospital, Cov- ington, La., from Louis A. Gerdes, special counsel, Department of Justice, State of. Louisiana, February 25, 1971 coe Ellender, Hon. Allen J., a U.S. Senator from the State of Louisiana, from James S. McCaughan, Jr.,, M.D., April 16, 1971 ______________ Kennedy, Hon. Edward M., a U.S. Senator from the State of Massa- chusetts, from : Keith, Mrs. Patricia M., executive director, Family Service Associ- ation, Morgantown, W. Va., April 23, 1971. een Kohn, Markin I., M.D., obstetrics and gynecology, Mentor, Ohio, May 4, TOT] canada atm mma pm pm a i mb Nolan, Robert L., M.D., J.D., professor and chairman, Division of Public Health and Preventive Medicine, West Virginia Univer- sity, Morgantown, W. Va., April 28, 1971 (with enclosures) ____ Schwartz, Jerome L., Dr. P.H., visiting professor of public health and preventive medicine, West Virginia University, Morgan- town, W. Va., April 28, 1971 (with encloSures) ...........bwwmmws McCaughn, James S., Jr., M.D., 497 East Town Street, Columbus, Ohio, from : Devine, Hon. Samuel L., a Representative in Congress from the State of Ohio, April a9, 197d. 200. tn ee ee ae Samia Saxbe, Hon. William B., a U.S. Senator from the State of Ohio, APTIL TB, TOT L... cc ciio mh oicon wicsmmermoron eg cmt misn ms otamnsw coesinm et mss oii tm Taft, Hon. Robert, Jr.. a U.S. Senator from the State of Ohio, ADVIL DL, LOTT dd no Dm eg nmi ios hn Si mB A ASE Sw Wylie, Hon. Chalmers P., a Representative in Congress from the Stateiof Ohio, April 19, A007] ee ore ee er mem rere me Resolution from: Louisiana State Medical Society, May 1971... ______ Selected tables: Health-related data, Marion, Monongalia, and Preston Counties, Page 2209 2204 2075 2219 2021 2021 2206 2205 2207 2208 2210 HEALTH CARE CRISIS IN AMERICA, 1971 MONDAY, APRIL 19, 1971 U.S. SENATE, SUBCOMMITTEE ON HEALTH OF THE ComMITTEE ON LABOR AND PUBLIC WELFARE, Kingwood, W. Va. The subcommittee met at 2:10 p.m., in the Preston County Court- house, Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present : Senators Kennedy and Randolph. Committee staff members present: Stanley Jones, professional staff member ; and Jay Cutler, minority counsel. Senator Ken~Nepy. The subcommittee will come to order. First of all, as Chairman of the Senate Health Subcommittee of the U.S. Senate, I want to express my very sincere appreciation per- sonally and for the members of the subcommittee, to Judge Snyder and the people of Kingwood for the kindness and courtesy they have ex- tended to the members of our staff and to us here today. I will make a very brief comment and then I would like to ask your own Senator Jennings Randolph, who is ranking member of the Senate Labor and Public Welfare Committee and who is extreme- ly interested in the problems of health, not only of the people of West Virginia, but generally throughout the country, if he would be kind enough to make a comment. It is a pleasure for me to be here. The members of my family have always been warmly received each and every time they have come to the great State of West Virginia. Today has been no exception. We met with a number of your chil- dren outside and were greeted warmly by them. We asked them about the dentists. We learn something new everywhere we go. When I asked them how many liked to go to the dentist, practically two-thirds of the children put their hands up in the air. If we ever ask that ques- tion up in Massachusetts, everyone would hold their hand down. No one really enjoys it. We come here today as a continuing part of our study of the health crisis in the United States. During the period of the last 8 weeks we have held extensive hearings on the health crisis. We have heard from representatives of different interests in the health area. We have lis- tened to the doctors who spoke for the American Medical Association. We have heard from the Secretary of HEW. We have heard from the insurance companies. We have heard from a wide variety of differ- ent spokesmen for different interests. (1981) 1982 Then last week we went out into the field. We went up to New York City to study the problems of the health crisis in one of the major urban areas of our country. The next day we went out into the sub- urban communities. We visited some of the wealthier communities in our country, Nassau and Westchester Counties, because we believe the health crisis doesn’t only show in the quantity of service, but in the quality of service as well. We started early today in Fairmont, W. Va., and we have tried to visit both the best health services and also the poorest. We wanted a chance to see both aspects, and we have had some opportunity to do so. Of course we won’t conclude these hearings today thinking we un- derstood completely the problems of health care in West Virginia. I do feel, however, that as a result of the hearings that we have had in the Nation’s Capital, and the extensive field hearings that we are holding that we will learn enough to make significant recommenda- tions to the U.S. Senate on how to improve the quality of health care in this great country of ours. Today, at this hearing, we are interested in hearing from the people. After listening for 7 weeks to the experts and then recently listening for this last day or two to the op I must say the most eloquent testimony has really come from the people. So we are here to listen to the people of Kingwood and the sur- rounding areas describe the problems they have in health care in order that we can consider new laws which might help the people of King- wood, W. Va., and all of rural America. If the people speak and make their problems known, we are con- vinced that this country’s doctors, nurses, hospitals, and citizens together can create health services which are worthy of this great coun- try, and which offer every man, woman, and child the greatest oppor- tunity for a healthy and productive life. We have some witnesses who have indicated they want to speak. We are going to terminate the scheduled witnesses at about a quarter to 4, if we possibly can, and then open up the hearing for any of you who might have some comment on the health crisis. If individuals are here now who, in the course of this hearing, want to express themselves write your name on a card and pass it to the desk here. We will try to call on you. If anyone in the community at a later time wants to file a comment or a statement about what they think needs to be done on health, we will make that a part of the record of the Health Subcommittee. Before starting, I would like to call on Senator Randolph. Senator Raxporrm. Thank you, Mr. Chairman. Ladies and gentlemen: You will forgive me for saying that when I come into this courtroom I remember that I first appeared here 41 years ago. That is a consider- able length of time. Senator Kenxepy. I can’t say that. [ Laughter. | Senator RaxporrH. It was before Senator Kennedy was born. It was 1930. That is a long time ago. I take only 1 minute, because it is the hard facts that we are inter- ested in on this tour. I do feel that Senator Kennedy, you and the members of the sub- committee, the 14 Democrats and Republicans on your subcommittee, 1983 indicate the intense interest within the Labor and Public Welfare Committee of the work that must be done. I think when we come from Washington D.C., out into the field, we understand more than we can understand in any formal hearing in the Nation’s Capital that we must go beyond the statistics and clothe them with people. d People, their problems, that is what we are intensely interested in in these hearings here in West Virginia and throughout the country mn an effort to meet with those of you who come to testify and counsel with us. I want to conclude by saying that we not only are listening to what you say, but we are making careful notes in our minds and hearts of what you tell us, hoping that we may interpret what you have said as constructive in aiding in the passage of legislation that will help you to help yourselves to build a better America. That is why we are here. Senator Kexnepy. Thank you very much, Senator Randolph. Our first witness is Mrs. Dolores Kemphfer. She is a housewife. We want this to be an extremely relaxed session. I am afraid Sen- ator Randolph and I with these formal statements will make people feel ill at ease. We want everyone to tell their story and feel relaxed about it. It is an important meeting but an informal one. We hope everyone will feel relaxed. STATEMENT OF MRS. DOLORES KEMPHFER, HOUSEWIFE Mrs. Kempuarer. I have had five children in 8 years. I came from a very poor family. I had this one child, Cindy Robbins, she was my second. She has bronchial asthma. I just had my fourth baby. She took pneumonia. I was staying with my husband’s brother and his wife at the time. They took Cindy to the hospital. Irma stays with my little girl and she comes back and says, “Dolores, we have got to have $50 before Cindy can have oxygen.” I go to pieces. Senator Kexnepy. As I understand, when your baby went to the hospital, your neighbor came back and said to you that they needed $507 Mrs. Kempurer. Before we could get her entered in the hospital. My husband had just went back to work. I had to locate him. He was working in Marlinton. IT had to get the money from his boss. By that time, I went on to the hospital and made my phone calls. I was holding my little girl and I started crying. The doctor said, “If you can’t take care of them, why did you have them damned kids?” Those were the words. He was very disgusted with me. I am there without money and with a sick child. I said, “How do you keep from having them?” T was never told. And I was crying. So Jerry was 14 months old, and T had my last one, Peggy Sue, who is my fifth child. She is 3 now. Amanda has rheumatic fever. Senator Kex~epy. That is another child ? Mrs. Kempuarer. She is my third. It was winter before last, it de- veloped, my husband was out of work. He was on unemployment. I never asked for any aid. I canned all summer. Amanda’s medicine was $12 a week. That had to come out of the $26 on unemployment. Senator Ken~Nepy. Her medicine was $12 a week, and your husband 1984 was getting $26 a week unemployment? And that left, what, $14 for you to— . Mrs. Kemeurer. We had to ask his sister to buy fuel for the winter, and she paid our electric bill. The rest of that, we had to use what I canned from. I asked for Amanda to be on the Crippled Children’s Fund. I got a rejected letter last week. I still haven’t got her on it. She bleeds. She is not really a bleeder, but we have her taking hemophiliac because if she would be in an accident, she needs immediate atten- tion, because this rheumatic fever, she will get nosebleeds and it won't stop until she goes into shock. ] I have been kept out of the hospitals because I have no insurance, no money from the bank, to get them in. Senator KENNEDY. You can’t get them into the hospital ? Mrs. Kempurer. It is awful hard to get them in. Senator Kennepy. Do they ask you when you come down to get them into the hospital Mrs. Kempurer. If you have insurance or the money. : Senator Kexnepy. They ask you that before they treat the child. Mrs. Kempurer. We have to have $75 at one hospital and $50 at another. Senator Ken~Nepy. In the emergency room ? Mrs. Kempurer. Usually, when I go to the emergency room, yes. Senator Kennepy. Before you are able to get them in, at one hos- pital, you have to pay $50 and the other is $75. Mrs. Kempurer. That is right. After Peggy Sue, this is my fifth one, I went to this old doctor and he was real nice. My husband had started to work for a mining company which had insurance and it covers. It was a bad risk insurance coverage because of the asthmatic, and I needed an operation. So we was a bad risk. We would have to have the policy 2 or 3 years before it would do us any good. So my husband is working at this mining company, and they had insurance on us then. After Peggy Sue was born, T was supposed to have a tubligation. And the doctor that T was going to didn’t perform this kind of an operation, but he informed another doctor that I needed it. He said he accept my insurance policy. We didn’t have cash at the time. So this doctor says , “Dolores, you need it, IT will pay for your operation, and I will wait for the insurance to come through.” You know, I had Peggy Sue that night. The next morning he died of a heart attack. And the doctor came in and they gave me a hypo in the arm, and I thought they were getting me ready for the operation. Fifteen minutes later he said your source is gone, it just died, you either come up with the money or get out of the hospital. I picked my baby up the next day and left the hospital. Senator RaxporLpr. May I interrupt, Senator Kennedy ? Senator KENNEDY. Yes. Senator Raxporpn. Is this Pocahontas County ? Mrs. Kempurer. No, sir. Senator Raxporrn. I thought you said Marlinton. I am sorry. Mrs. KempaFer. I live in Aurora, W. Va. My husband worked out of Marlinton. He is on railroad construction. Senator Raxvorpu. That is what I understood. Mrs. Kempurer. He went there to work at the time. 1985 Senator Raxvorem. Yes; but the family, you and the children re- mained here ? Mrs. KempHFER. Yes. d Senator Kennepy. These have been the principal experiences with the health system that you have had? Is the only time you go to the hospital or to the doctor when you have an emergency situation? Mrs. Keapurer. I have to limit it to that. Senator Kex~epy. Have your children ever seen a dentist ? Mrs. Kempurer. No; not really. I just got my teeth last summer. All mine went with the babies. My husband is also sickly. He gets pneu- monia awful easy. Senator Kennepy. What does he do? Mrs. Kempurer. He won't go to the doctor. He gets delirious, and I drag him to the doctor, and he doesn’t know where he is. Senator Kex~epy. Why doesn’t he go to the doctor? Mrs. Kemparer. He is scared. Senator Kennepy. Is it part of the fact he will have medical bills, too? Mrs. Kempurer. Yes. He told me one time when I was pregnant, and he said, “I don’t like children.” I said, “Why ?” He says, “Ours have always been sickly; we watch them almost die with no money.” It just tears us apart, you know, to have them. Senator Raxporru. Your children are in school and have shots given to them ? Mrs. Kempurer. Yes; I do get that. Little Peggy Sue is allergic to the shots. IT have to watch her awful carefully, you know. I sponge her down or she will go into convulsions. Senator Ranporpn. What recommendation do you have for us for an improvement in, let’s say, health or hospitalization that will help people like you that face these problems? Mrs. Kemparer. I am all for this preventative medicine they have out now. After Amanda had the rheumatic fever, I went to the doctor and TI tried to take the pills many a time and I couldn’t. They worked on my nerves. This last time I broke out in a rash and swelled up. I oak them 4 months before I would give in and realize I couldn’t take them. So I said, “I can’t see having another child like this.” And I can’t take the pill. So he said, “Well, it is up to you, you will have to get the 1UD, it 1s going to cost you from $40 to $50. Can you come up with it?” I said, “Yes.” I went back home and I picked up the Journal and read where they are having a family planning clinic on June 26. I called my doctor and asked 1f I could go there. He said, “Yes.” I was th first one there. I wanted to make sure they didn’t run out of these things. Senator Kexnnepy. Do they usually run out ? Mrs. KempaFER. I don’t know. But in my case, I was going to make sure they didn’t. I didn’t run out of babies. [ Laughter. ] Senator Ranporrr. You wanted to be there oh the door opened ? Mrs. KemparER. Yes. I was there when the door opened. It wouldn't work. So I went home all upset. So I go back to the doctor. He says there is nothing you can do. We didn’t have insurance. So about a week or two later, infection set in. I went back and he wouldn’t even 1986 see me. I went on for another week until I couldn’ move. I was so sore inside I couldn’t move. So I went down and waited until his office opened up the next morning. He examined me and said : You have got acute infection. It is set in clear in your whole system. You are going to have to have an operation. You take this penicillin and call me Tuesday at 10 o’clock and I will have you admitted. I called Tuesday at 10 o’clock. He said : You have no insurance, no money, they won’t accept you. So Isaid: ‘Would you get in contact with the family planning clinic in Morgantown? They will contact a doctor for me. So he did. I went to Morgantown. That was August 19. They listened to all of my problems, all of my children, why I didn’t want any more, and I was sent up to have a Tubligation and a D & C, and in my condition I had to have a partial hysterectomy. I was on nerve medicine from the time I started having children until T had my operation. I have never taken a nerve pill, and I have seen a doctor once for my checkups. Senator Kennepy. How are your children now ? Mrs. KempuaFER. Amanda still has to take medicine for her rheu- matic fever. Senator Kennepy. How do you pay that? Mrs. KempaFER. 1 have been getting it since this fall through the health program. But I tried to get her on the crippled children’s for her blood test. She is allergic to penicillin. I can’t get her in on the crippled children. enator KenNepy. Your husband, as I understand it, was working one time and then they garnished the money from his salary. Was that to pay off medical bills? Mrs. Kemparer. He was fired from his job because we owed a hos- pital bill on one of our children. They attached his wages. The policy is you straighten it up yourself with the people or they don’t need your employment anymore. I tried to straighten it up. It had already gone through the court. It had to come off his wages. Senator Kennepy. He was fired ? Mrs. KempHFER. Yes, that is where we got our insurance. Senator Kennepy. Was he willing to pay off some of the bill ? Mrs. KempHFER. Yes, when we could, we tried to pay them off. Senator Kuexnepy. Just because you were unable to pay, he lost his job? Because of the payment of medical bills? Mrs. KeMPHFER. Yes. Senator Kennepy. I want to thank you, Mrs. Kemphfer, for coming here and telling this story. Finally, do you have friends in your neighborhood and in your com- munity that have perhaps not as dramatic kind of experience, but just find that they fear going to doctors because they are going to have to pay? Mrs. Kempurer. Yes, we have a lot of that. Senator KENNEDY. Is this something your friends and neighbors feel strongly about? Mrs. KEMPHFER. Yes. 1987 Senator KexNepy. Thank you very much for telling us your story. Mrs. Wilda Hess, staff attorney, North-Central West Virginia Legal Aid Society. She has brought several clients with her and she will introduce them. STATEMENT OF MRS. WILDA HESS, STAFF ATTORNEY, NORTH-CEN- TRAL WEST VIRGINIA LEGAL AID SOCIETY, ACCOMPANIED BY MRS. MALINDA PERKINS Mrs. Hess. I would like to say that I am very pleased to be able to appear before this subcommittee. And I hope that I will be able to offer some information, facts, and situations that will be of assistance to you in drafting legislation. There isn’t any problem that we encounter more often in our work in legal aid. To furnish a little background, the North-Central West Vir- ginia Legal Aid Society covers six counties in West Virginia: Marion County, Taylor, Tucker, Barbour, Monongalia and Preston, and there are three attorneys covering these six counties. The problem of health care and medical expenses is one which is en- countered by our clients and comes to us as a consequence. To provide a little background information, as you doubtless already know, persons who receive welfare benefits receive a medical card which will enable them to receive free hospital and medical care. In West Virginia, the legislature has decided that they will provide 52 percent of the basic minimum needs. Its basic minimum needs hav- ing already been determined. A single person on welfare will receive $79 per month. Two people, a family on welfare, will receive $99 per month. One adds $20 per dependent. Often, that medical card is the most valuable resource that the wel- fare recipient receives. However, if a person has income of, let’s say, $80 per month or $85 per month, he now has too much money to afford welfare benefits. That means that he doesn’t have a medical card. I have been given permission by seme of my clients to state their situations. Last week a woman came into my office. She is 60 years old, and she has an income of $84.20 per month from social security dis- ability. She receives these benefits because of acute arthritis in her back and leg. She has considerable difficulty in walking. She worked for 20 to 25 years as a maid, as a waitress, a cleaning woman, laundry, and her husband died fairly recently. She is a widow. In March of 1971, she had to go to the hospital for radical mastec- tomy. She now owes doctor bills in the amount of $235 and a hospital bill in the amount of $853.40. That is almost $1,100. She has an income, as I said, of $84.90 per month. She doesn’t have any medical insurance and she obviously doesn’t have any way of getting any in her situation. She came to consult with us as to what she could possibly do about this. Frankly, I don’t know a source. I really don’t. There are so many people in a similar situation who make a little too much or receive a little too much from a pension or disability to qualify for welfare and they don’t have a medical card, too young for medicare, this woman being 60. Senator Kennepy. What do you advise her to do? 1988 Mrs. Hess. What do I advise her to do? That is really a tough one. What can you do? You can write the hospital. If it has been turned over to a collection agency, you write the collection agency. If she doesn’t work, as she is unable to do, obviously, her salary can’t be at- tached. If she doesn’t own her own home, that can’t be taken away. But this is a woman who has worked hard all of her life. She doesn’t owe a single other bill to anybody. She has always prided herself on keeping her bills paid. Now there is this overwhelming expense. _ Senator Kexnepy. I suppose her disposition would be to start pay- ing that off, if she could possibly live on $87 a month. Murs. Hess. Yes, I believe so. If she received only $75 a month social security disability, then she would qualify for a $4 supplement in welfare benefits and then she would have that card, which is worth a good deal to her. She is going to need to see a doctor again. Senator KennNeoy. They can’t attach any part of her social Security ? Mrs. Hess. No, they cannot. I have with me today Mrs. Malinda Perkins, a resident of Monon- galia County, who has had considerable problems with medical ex- penses. She would like to tell you her story. Mrs. Perkins. My name is Malinda Perkins. On Easter day, about 5 years ago, a neighbor of mine asked me if I would come and baby- sit. I couldn’t go because my family was in from out of town and I hated to leave them. So she said would it be all right if Perky came. That was my third child. I said yes, but she couldn’t stay too long because I was going to serve dinner and I would like to have her eat with the family. So she goes over to the neighbor’s house. In the meantime, they had to get to the hospital because her mother-in-law was seriously ill and I felt like I was doing them a great favor to let her go over. So she went over to take care of the children. She hadn’t been there, I would say, 15 minutes, when she went up the stairs to get the baby and there was 17 steps, there wasn’t anything to keep her from fall- ing, so the oldest boy slipped upstairs and hid in a closet. Just as she got at the top of the stairs, he jumps out from the closet. He pushes her and down the stairs she goes. So she came to long enough to call me. Senator Kennepy. How old was Perky at the time? Mrs. Perkins. She was 14 years old. So then my son-in-law went up to see about her and when he got there, she was unconscious. I think that year she went to the hospital 88 times. Mrs. Hess. If T may continue for her. Perky suffered permanent brain and spinal damage as a result of this accident. This caused her to have a type of epilepsy so that she has recurring seizures and always will have as long as she lives. The hospital bills, as you can imagine, were absolutely staggering. The people who lived next door did not have any insurance coverage of any kind and the Perkins’ didn’t have any insurance coverage either. Perky has to have medication constantly and she is still subject to these seizures. The last one was on Good Friday, a little over a week ago. The ambulance costs about $16, to be added to the emergency ward costs, I believe, about $40. That is not really being admitted to a bed in a hospital, either. 1989 Mrs. Perkins has been participating in a program in the school sys- tem which has now come to an end. And her income will now be $150 in child support. She was getting about $80 a month. I believe that there are quite a few pharmacy bills, and hospital bills. Of course, after a while some of the hospitals, most of them will turn the bills over to a collection agency. Pharmacies are threatening that, too, and, of course, sometimes one borrows money to pay the hospital bills. That, of course, accumulates, too. It is a snowballing sort of thing. Senator Kennepy. What are the bills now, approximately ? _ Mrs. Prriins. I think I have paid almost $3,000 for my daughter’s injury. Mrs. Hess. Out of her $150 a month, Mrs. Perkins is paying for the house that she lives in. Of course, she is providing food. She has a younger daughter still at home. Senator Kennepy. Where is Perky now ? Mrs. Perkins. She is at home. And she didn’t feel any too well today. From time to time, as Mrs. Hess said, she does have these seizures. Senator KenNEpy. Does she go to school at all? Mrs. Perkins. Noj she is graduated now, thank God. Senator Kex~Nepy. But to the best of your knowledge, she will be staying with you for probably the rest of her life; will she? Mrs. Perkins. Ilook for her to stay, you know. Senator Raxpoorpi. How often are the seizures that you spoke of, Mrs. Hess? Mrs. Perkins. Now they are cut down. Good Friday was the last one. But before, maybe 6 or 7 times a week she would have seizures. Senator Raxporpu. Do those of the medical profession, the doctors, give you any hope for her in treatment of one type or another ? Mrs. PERKINS. Some neurosurgeons say it is possible that she may outgrow it and others think that it may be a thing that reoccurs from time to time. Senator Raxporeu. Dr. Nolan, I want to interrupt a moment, not asking you particularly, but you or some other physician, in a case of this kind, 1s there hope of outgrowing the problem ? Dr. Norax. I think it is possible that the frequency of seizures might diminish. But we won’t know in a particular case until a considerable time has elapsed and there has been an opportunity to try different medications over the period of that time. In addition, there is always the possibility that new drugs will be developed which will suppress the motor activity and thereby diminish the seizures. Senator Ranooreu. Thank you, sir. Senator KENNEDY. Your sources of income—is your husband still alive? Mrs. Perkins. I am divorced. Senator KENNEDY. Your sources of income, that $150, where does that come from? Mrs. Perkins. From him. Mrs. Hess. There was to be another lady with me today. It was only at the very last moment that we learned that she wouldn’t be able to appear. Her name was Mrs. Denver Jones. Denver Jones is in his 50’s, I believe. He has been receiving social security disability for 2 years. 1990 He has emphysema and the heart problems which result. He is con- fined to bed. He needs oxygen and various medications all the time. Mrs. Jones is in ill health, also. She has had two spinal fusions and she has to wear a back brace all the time. Mr. Jones has to have oxygen constantly, and their income is $187.30 from social security disability and he receives a pension from the Pipefitters Local of $59.15. That is a total of $246 and some cents. Last month they had to spend $166 for oxygen and $150 for medi- cation. That is a total of $316 on medical bills alone and an income of $246. This is not talking about rent, food, utilities or anything of that nature. ’ He has been in and out of the hospital many, many times. There is no hospital insurance. They have tried very, very hard. They have borrowed from finance companies, and in order to pay the hospital bills, so now they owe not only hospital bills, and doctor bills, but four finance companies. They are a Tot harder to deal with than the hospitals. They have sold everything they possibly can. When Mr. Jones is well enough to do anything, he is always bed- ridden, he paints. She takes in ironing, which, of course, isn’t easy to do in her condition, as you can well imagine. They had hoped to have someone who could stay with Mr. Jones today, but it has to be someone who understands how to administer the oxygen. Three or four people who had promised didn’t turn up in the end. So she is unable to be here. She wanted desperately to testify here today and present this situation. He is, again, too young for medicare, and their income is too great for any welfare benefits. Yes, she did tell me when I talked to her that they have told her that she can’t get Food Stamps anymore. I don’t know about that. I haven’t looked into it at all yet. I have a client in Preston County, a man 59 years old, married, four children. He worked all of his life until he was stricken with cancer early in 1969. At that time, they applied for welfare. While he was waiting for social security disability benefits, the operation removed one eye and a good portion of his jaw bone. He was on welfare for some months until the social security disability benefits came through. Now the family receives $206 a month social security disability benefits and, fortunately, all his hospital bills were paid because he was on welfare for this brief period. But now there is an operation that could be performed to restore a good portion of his face, but they don’t have the money for that. They simply don’t have the money for it. A collection agency was trying to collect one of the doctor bills which was why they came to me in the first place. Senator Kennepy. You mean the doctors that they consult have indicated to him that they could at least restore part of his face but because he lacks money, he is unable to get that? Mrs. Hess. That is correct. At first, they had a terrible time with money for medication and sterile bandages. They were receiving $206 a month and the bandages had to be changed all the time. 1991 There is a man 39 years old in Preston County, married, with five children, working regularly ; Senator KENNEDY. Are these all cases that you have had contact with as a worker and that you are personnaly aware of ? } Mrs. Hiss. These are a few I pulled out of the file the other evening. They are typical of what all of us run into. This man worked until he was injured in 1969. They are now getting Workmens’ Compensation and social security disability, $227 a month; no medical benefits of any kind. ; There is a case of a widow in her 80’s who received $69.50 social se- curity widow’s pension. That is supplemented by welfare. So this one is a little different. She was in a hospital last summer because of a heart attack. At the time she was there, she fell out of bed while un- attended in the hospital. Now that she has been returned to home for a while, there were home health aides who came at no cost through medi- care to help out ? The daughter in the family works in the 10-cent store and earns $40 a week take-home pay. Now the home health care has ex- pired through medicare. The 100 visits are over. That is it. She is now listed as chronically ill rather than acutely ill. But somebody has to be with her all the time. The daughter is paying someone, I believe, $1 an hour, to stay with her mother while she goes out and works. She doesn’t want to quit her job and lose what benefits she has accrued over 20 years work, but somebody has to stay with this woman at home. She can’t walk. Some- one has to be with her in case she has another heart attack. What re- sources does she turn to? Here, it is the home health care that is the big problem. I would like to mention that there are problems also for people who are receiving welfare. Although they have a medical card which will provide hospitalization and certain medical treatment, during the past year the welfare department was not granted the welfare com- missioner’s request for funds by the legislature. A lesser amount was appropriated. The special diet allowance has been eliminated completely. That was available to persons with, for instance, arteriosclerosis or diabetes, who have to buy special foods and follow special diets. Now there simply aren’t any provisions for that. The special telephone allowance was cut off and that was provided to people who had severe heart conditions, in case they should need to call for medical assistance immediately. That simply isn’t avail- able anymore. We encounter in another way health problems. Our transportation to reach a physician is a problem also, to get to a doctor for an exam- ination, to get to the hospital by ambulance, to get to a clinic for treatment. And I have talked to people who are on welfare, and I knew had a medical card and say they coundn’t afford to go to the doctor. So I will say, “I know you have a medical card. Why couldn’t you?” They will say, “I couldn’t afford the transportation.” I would ask if they had a neighbor to help you out. And they would say, “Yes, but Mr. Smith charges $5 or $10 to take me to the 59-661 O—T71—pt. 9——2 1992 doctor every time.” So she is paying in order to go to the doctor so that the care—it is the same as paying for medical expenses. Senator Raxvorrn. You mentioned the problem of ambulance serv- ice. It is my understanding, and if I am in error someone can correct me, but I believe that the Association of Funeral Directors has voted not to use their equipment to serve as ambulances to come in cases such as you mentioned here this afternoon. I believe that someone, individual funeral directors, or companies are still giving the service. Clan someone tell me if I am right or wrong that the Association did cut it off ? Mrs. Hess. I believe there is a special setup here in Preston County now. I am not really familiar with it. But there is some organization which is in lieu of what used to be done providing ambulance services. But it isn’t free. There is a cost for it. Mrs. Hin. Before they come out and do anything, you have to have cash money for them. If it is a DPA patient, they still have the cash. Senator Kexxepy. Before they will take you ? Mrs. Hun. It costs about $36 to come from Morgantown, for a 1-hour trip. ; Senator Raxporp. Who made the ambulance trip? Who operated the ambulance ? Mrs. Hur. It is an ambulance service in Kingwood here. There is an ambulance service here in Kingwood. It is an independent service. Senator KExnNepy. When did you pay the bill? Did you have to pay it before they would take you? Mrs. Hin. They ask you before they go if you have the money to pay them. You have to have cash. When they brought my grandmother home, we had to have the cash ready. Or they wouldn't have gone after her and picked her up. We had to get a doctor to put my grandmother in the hospital. We kept her there until Saturday. Unless we can get her into a home some- Whara else, she will have to go home by herself and nobody to care or her. Mrs. Hess. I would like to mention a couple of more things. I know time is very short. One is that we do handle bankruptcies at Legal Aid. We have only been in existence for about a year and a half. But I think that in every case that we have handled medical expenses have been one of the large expenses and sometimes there is just no doubt about it, that is the straw that breaks the camel’s back, the medical expenses. Without it. it wouldn’t be necessary to file the bankruptcy petition. I would like to refer one final case which is a Preston County case. The man is married and has three chilldren. He was injured in the Korean War and has lost one leg. He has a service-connected disability pension of $106 a month. He and his wife both worked regularly for some years until he became ill in July, 1970, and he has been unable to work since then, still under a doctor’s care. The wife worked regularly until October of 1969, when she under- went an operation for abdominal cancer. Later, complications devel- oped and she is still under treatment for a blood ailment. She has to receive treatment at West Virginia University Medical Center weekly. He has to see a doctor every other week. 1993 That is their total income, $106 a month. Some of this treatment is paid for through the VA, a fraction of it, three-quarters, I believe, but even so, hospital bills have mounted up and the medical treatments, the costs have mounted just to an extra- ordinary amount. Of course, they really don’t have enough to live on with $106 a month without the medical problems. They owe hospital bills and one hospital has turned the bill over to a collection agency. They have a car. They have to have a car, because they have to travel back and forth to the doctor and to the hospitals. They have applied for welfare. And with $106 a month, they ought to qualify for welfare, you would think, with that many children. I think it would be about 140-some dollars in welfare. But they have been turned down on wel- fare because they have a car that has an assessed value of over $2,000. They can’t sell this car because they owe more than $2,000. They can’t trade it in, because the dealer doesn’t want it, because they owe so much money on it. He doesn’t want to trade it in on a cheaper model. The bank doesn’t want to refinance at a longer period in smaller payments. We are appealing that welfare decision, by the way. But they waited all of this time to even apply for welfare because they didn’t want to. They wanted to get along as best as they could. They have gone into debt. There isn’t any source for these medical bills. This is just one of such a large number of people who don’t fit into either category, too young for medicare, and a little too much money for welfare; here, not even that. But this is just one. There are hundreds and hundreds, thousands, no doubt, across the country. Senator Raxporru. You spoke of the numbers, thousands and thou- sands. How many cases come to the attention of you and your associ- ates in the course of a year? Mrs. Hess. I thought you would ask that. And I don’t have an an- swer for you. Senator Raxvorpu. You can supply it for the record. But it would be helpful to us. Mrs. Hiss. It is really very, very difficult for me to say. I didn’t have much time to prepare for this. Maybe next week I could go through the files and really find it. These are just a few in 1 year which I thought were representative. There are many others. There is a case where we are preparing a bankruptcy petition right now. He is about to get social security disability. He needs an opera- tion. I have urged him to go quickly while he is still on welfare be- cause otherwise he will owe an absolutely staggering hospital bill. Senator Ranporpu. Mr. Chairman, with your permission, Mrs. Hess has mentioned the case of the Jones family where both husband and wife are ill. There was a rather revealing story which brings out, I think, not only the humanness of the problem, but the facts are con- tained. Dominion Post staff writer Susan Conte, last October 18, wrote a helpful story that will be of value to the committee. I ask unanimous consent that that article be included in our record of the hearing. Senator Kexnepy. Without objection. (The information referred to follows:) 1994 [From the Sunday Dominion-Post, Kingwood, W. Va., Oct. 18, 1970] THESE JONESES ARE TRYING To Keep Up ONLY WITH THEMSELVES (By Susan Conte, Dominion-Post Staff Writer) His life is regulated each day by periodic intake of “canned” oxygen, and his wife's day-to-day existence is marked by her constant surveillance of his con- dition and her worries of how to purchase more medicine and “breaths of life” for her husband. ; “p Yet they still find time to laugh, to argue playfuly over colors in a painting and to debate who is the best actor—John Wayne, Jimmy Stewart or Gary Cooper. The Denver Joneses, 235 Monongahela in Westover, are caught in a bind that many others experience when a disability causes them to have to rely on Social Security disability payments. : Jones, a pipefitter out of Local 152, has emphysema. His condition has steadily worsened over the years since about 1959 and he is now unable to go outside his home to work. His wife, Brenice, who never worked under Social Security, is not eligible for any benefits. Not in good health herself, Mrs. Jones has had two spinal fusions and must wear a brace periodically. She takes in ironings as often as possible to supple- ment the family income, sometimes ironing from dusk to dawn to be able to buy the next day’s medicine. Disability payments under Social Security, available once a person is termed disabled, total $187.30 per month for the Jones. They also received $59.15 from a union pension. To a lot of people, this may seem like a sizable amount to live on. To the Jones, bills for drugs amount to more than $150 per month, and bills to keep two large oxygen tanks in their house at all times total approximately $80 per month. These are only approximate figures and for the month of September, the bills came out to 16 cents more than their income. Jones paints and his paintings will be available for sale at the Scott’s Run Settlement House from 2 to 6 p.m. today during an open house. Mrs. Jones makes flower arangements and these will also be available at the Settlement House. They are not asking for charity. But help is welcomed from charitable organi- zations and individuals. Jones will tell you how much he hates watching his wife worry about how they will pay bills. It’s not like this man has just given up and decided to sit back and let society take care of him. He has worked throughout his life. And at the age of 53, he is still not asking but he feels there should be some type of medical program that could help him and his wife. Social Security disability carries no hospital or medical benefits. If the Jones had some type of plan or program to qualify for medical expenses, their money worries would be over. A check with the Welfare office reveals they are not eligible here. They have applied for “welfare disability” but have not received word on the application. Jones cannot qualify for Medicaid because West Virginia is one of 14 states which stipulated that if a person is not eligible for welfare, he is not eligible for Medicaid. Jones could accept some type of work in his home such as stuffing envelopes or stamping—some type of work that is not tedious and does not require precision. And he is willing to do it. They have their bad times and they have their good times. But they could be helped permanently if the Social Security laws were revised and disability pay- ments included medical benefits. Rep. Robert H. Mollohan of the First District has sponsored legislation calling for revisions. Temporary finances is necessary now to pull the Joneses out of a slump which includes their being three months behind in rent payments. Any contributions can be sent to Mrs. Violet Petso at the Settlement House in Osage. Mrs. Hess. Every person I mentioned here was eager to have the situation explained. I said to them, “This may not help your situation, but they are all anxious that it might be of use ind rafting future legis- lation to help other people in the same situation.” 1995 Senator KexNepy. Just before you conclude, tell me about yourself. Where did you go to law school ? Mrs. Hess. West Virginia University College of Law. I graduated 2 years ago. Senator KENNEDY. Are you from the State of West Virginia? Mrs. Hess. Yes. Senator Kexxepy. How long have you been associated with the legal services ? Mrs. Hess. Less than a year and a half. It just opened last Novem- ber; a few months after I graduated. T commenced working for them immediately. Senator KexnNepy. Is it better or worse than you thought it was? Mrs. Hess. It is in many ways very, very rewarding. I met so many fine people. But it is dreadfully frustrating. The Denver Jones case is one. I just don’t know. You just don’t know what to do. You can write the collection agency, you know. But they will keep after them a little bit. At any rate, they will gradually come back after the Joneses. He had a picture that he had painted sometime ago that he wanted to pre- sent today. I was working up until the last second to try to find someone to stay with him. So I didn’t have an opportunity to go over and get it. But we will get it to the committee. Senator Kexnepy. You have not only told us a good deal about health programs, but you have given us some additional reasons to support legal services. Thank you very much. Mrs. Grace Bartlett ? Mrs. Bartlett, I want to welcome you here before the committee. We are very appreciative of your kindness in coming. I understand your father just passed away yesterday. We would have understood if you were unable to be with us. We are very, very appreciative. I think it reflects once again the real sense of motivation of people like yourself who are willing to make this sacri- fice to be with us this afternoon. We want to welcome you here before the committee. STATEMENT OF MRS. GRACE MARIE BARTLETT Mrs. Barrrerr. Thank you, Senator Kennedy. I appreciate the fact that I have been able to work with Reverend Bowyar on the compre- hensive health plan. We can see a number of things that have been a great concern to me and I have been able to realize that there are so many people that are not getting what is required in the way of health services. Twenty years ago, it was determined that I had borderline Addison’s disease. At that time, of course, I quit work. I was not able to go on as I should, but I come from a middleclass family and my family was able to take care of the expenses at that time that were connected with the problem. Eight years ago, my father retired and I felt then that I was com- pelled to apply for social security disability, which I did, and T have received it. This amounts to about $125 a month. I went through my records and last year my medicine alone, just maintenance dosages, cost me $50 a month. I had hospitalization last May for 3 weeks, which 1996 costs me $2,100. That is very easy to see that you can not pay these kinds of expenses and still use what you have. With the death of my father our income will be much lower yet than it is. IT am single and I live at home. I have been so fortunate that they have been able to at least make payments on hospital bills. But today, 1 feel overwhelmed because I know that the income is much less than it will be or would have been before and so you wonder what you should do. Two of my brothers are associated with the medical field. I have had advice from both of them. I have a Baker's cyst behind both knees, and one of them is cutting off circulation into the foot. They said T must get this taken care of immediately. But believe me, when you have these kinds of expenses and you honestly hope to meet them all, you think many times before you go to a doctor or you do anything unnecessary. My father’s expenses were something terrific. He was in West Penn Hospital in Pittsburgh for 15 days. This run $68 a day. No middle- class family can reasonably expect to pay the difference there. He went to my brother's home and took treatments there for 6 weeks fol- lowing that. He came home. He was home for 8 days and was admitted to the hospital. In Taylor County, our doctor situation is certainly not what it ought to be. We are very limited. We have four specialists there. We have four doctors. No doctor was really capable of taking care of him and yet it was a matter of having somebody to order medication. Last Sunday we were told that he was much improved and could come home that day. Seeing him as a person who had been in the hos- pital a number of times, I realized that he was not this well and the doctor walked in the same day that he told him he could go home and said, “You are as bad as you could be.” We did not feel we were in a position to get him somewhere else because, as someone else has stated, ambulance service in this area is prohibitive. He went to the hospital by car. He came home from Pitts- burgh by car because we felt that this is the only way we could handle this situation and still expect to pay the people involved. So I strongly feel that somewhere, somehow, we are going to have to find some way we can reach all the people with adequate health care. Senator Kenney. Do you have any insurance at all ? Mrs. BarrLert. None at all. When I first got sick 20 years ago, health insurance was not this prevalent and the minute that they diagnosed my condition as being a borderline Addison problem, I was refused time and time again hospitalization. Senator Kex~epy. We hear these insurance companies testify be- fore our subcommittee on how they are responding to the health crisis, and how they are willing and flexible on these matters. Yet, we hear examples time and again where they are completely ignoring the problem, completely unresponsive to the health needs in this country. Yet, they are the basis for the administration’s efforts to reform the system. It is extraordinary that they should be the basis for reforming what 1997 all of us who have heard these tragic stories realize is a completely inadequate health system in this Nation of ours. } You have told the story terribly well. Once again, I appreciate your being here. . Mrs. Bartrert. IT have had several contacts with the insurance com- pany. My brother-in-law is an official with Prudential Insurance. They have told me time and time again : “Do not make an application. You may get well enough some day. If you have been turned down once, then you will not be acceptable for surance. So do not make an application. Make an inquiry, but not an application, because once you do, it is on the record and you will no longer be considered at any time.” Senator Raxporpm. Senator Kennedy, I want to be very careful in my comment, but I have made recently a speech on this subject in West Virginia. I believe there is an unconscionable gap in the insurance coverage by private firms. I believe there is a lack of comprehensive coverage that we must have. This doesn’t say that I am just a critic of private insurance pro- grams. But this gap exists. If we cannot have at least a greater reali- zation and finalization within the companies themselves, the legisla- tion which Senator Kennedy proposes is a must, and a must very soon. Senator Ken~epy. Thank you very much. Our next witness is Mr. Charles Michaels, pharmacist and president of the Doddridge County Medical Center. He is accompanied by several members of the medical center. STATEMENT OF CHARLES MICHAELS, PHARMACIST AND PRESI- DENT, DODDRIDGE COUNTY MEDICAL CENTER, W. VA.; ACCOM- PANIED BY JOHN VAN GILDER, M.D.; HOWARD SPURLOCK; JOHN DROPPLEMAN; REV. RICHARD BOWYAR, PRESIDENT, EIGHT COUNTY COMPREHENSIVE HEALTH PLANNING BOARD; AND DR. ROBERT L. NOLAN, PROFESSOR AND CHAIRMAN OF THE DEPART- MENT OF PUBLIC HEALTH AND PREVENTIVE MEDICINE, WEST VIRGINIA UNIVERSITY, MORGANTOWN, W. VA. Mr. Seurrock. We are from Doddridge County, which is a rural area of less than 7,000 people. We also live in a small town of under 1,200. The economy is based on textile factory, oil and gas production, farming and cattle raising. In the spring of 1966, the Sears, Roebuck Foundation, Aid to Rural Areas, by providing increased medical facilities, was contacted and asked to make a survey of our basic medical needs. After the survey, it was determined that this county could very easily support three physicians. And we should prepare for the future by building a medical facility. We started a fund drive of $50,000, and this was all private money. There was no Government money in- volved. It came from the citizens. We concluded this January 1, 1967. Afterward, we added another $30,000 in medical equipment. Prior to this, we did have one physician servicing the whole county. He was 62 years of age and had decided to leave. 1998 We had a public meeting with the Sears Foundation in 1966, and at that time, they gave us the impression that with this modern facility, we would be able to find us another doctor or two, as the clinic was built to take care of two physicians. : In September of 1967, we opened the clinic, and we did have a foreign graduate physician and an American lady pediatrician. They came in September of 1967, and they left in April of 1968. We spent the next 6 months pursuing all possibilities of getting another physician for the county. Senator Ranporpa. Why did they leave ? ; Mr. Spurrock. One had immigration problems, and the lady pedia- trician was following her husband who was a music professor, and moved on. We managed to get another foreign graduate in November of 1968. He stayed until November of 1969. He left. He had immigra- tion problems. So that leaves us where we are now, without a doctor. In the last 40 months, we have only had a doctor for 19 months. This means that we have been without basic medical facilities for our citi- zens, and our citizens are welfare and also middle class, and these are the people that can pay a bill but cannot get the services. So, actually, a national health bill won’t really help us right now, because transportation is a problem to the people, we are 35 minutes away from hospital facilities. We have sent people in an ambulance into Clarksburg, and we have had people die on the way in, and im- mediate medical attention could have saved some of these people. So we are up a tree. We have tried everything we now know, to get a physician. We have advertised in periodicals, medical journals, news- papers; we sent out 120 letters to medical universities all over the country and Army discharge centers. We haven’t had a direct reply from any of these. We have had people come in, but for one reason or another they didn’t want to locate there. Senator RanporpH. Are you speaking now of the county as a whole? Mr. Spurrock. I am speaking of West Virginia and the county as a whole. We have no doctor anyplace in the county, from one end to the other. We are really 35 minutes away from medical care. Senator Ranporer. How far would Parkersburg be? Mr. Spurrock. It would be farther than that. It would be about 40 or 50 minutes. Of course, we are in the middle of highway construc- tion. So even if we had a great insurance program, it won’t help us as much as it really should. Senator Raxporrem. I want at this point, Mr. Chairman, with your permission—Dr. Nolan, how many graduates come from the West Virginia University School of Medicine each year? Dr. Noran. We have now reached the level of approximately 75 in- coming students, and that is our prospective number of graduates each year, 75. Senator Raxvorrn. If 75 are graduated, how many of them do their Sok in the State of West Virginia, and what proportion go out of the State ? Dr. Noran. The school has only been graduating M.D.’s—although it has a history of over 30 years as a 2-year medical school—it has only been granting the M.D. since about 1961. So many of our young graduates are still in service or in residency training. During the last 5 years, it has not been possible to effectively 1999 measure ; and for the first 5-year period, the office of the dean has esti- mated that approximately 40 percent of those graduates for the first 5 years have stayed within the general region, which includes Ohio, Kentucky, Maryland, Virginia, and the contiguous States. However, I do not have the exact data with regard to the percentage that haye actually remained within the borders of West Virginia. Almost all of the students now admitted to West Virginia University School of Medicine are residents of the State of West Virginia. So it would only be two or three incoming this year who are out-of-State residents. ett So it is our hope that by admitting primarily West Virginians, they will remain in the State. I think the data shows that the ma- jority of them thus far have not done that. : Mr. DroppreMan. We have a young man who is completing his medical requirements and his draft material. But he is willing to come into our area in lieu of going in the service and service us. He could come as a conscientious objector, but he is not, and he has also made that statement. This is Dr. Van Gilder here. We are trying to find a way of get- ting him into an area where there are between 6,000 and 7,000 people that aren’t getting any medical service. We also feel that the West Virginia Medical School is letting us down. We are supporting the school with our taxes and our State is still primarily rural, and they should have a program to route these people back to the rural areas, definitely. Let me take a crack at something else here. This thing is a national problem in the rural areas. We think that the Federal Government ought to implement some kind of a system to speed up the education of physicians and, if the various medical societies will not go along with 1t, that they do it on their own, if necessary, and get this service on a competitive basis with all the other professional services. This might alleviate some of this. In the meantime, we are without a physician. But from observing the past, our Government, if they wish and care, could solve this gen- eral condition in a few years. If anybody has any way they can help us here on Dr. Van Gilder, we would certainly appreciate it. Senator Ranporra. Mr. Spurlock, we passed the Emergency Health Manpower Act, which, in a situation such as you are expressing, Dr. Van Gilder would prove valuable. But the problem is the implemen- tation of that legislation. I want to ask you what is the attitude when we approach the Ad- ministration with reference to this problem ? We have no indication that there will be an implementation of the act. This is difficult for us to understand. Mr. Srurrock. I spent an hour and a half Friday afternoon and I called Representative Harley Staggers’ office. Is this Public Health Law 916237 Dr. Noran. That is correct. Mr. Seurrock. I talked to two or three people there and they routed me to a Mr. Menger who worked on the bill and was going to call me back. It was Friday afternoon and T didn’t get the call back. So I heard generally that the Surgeon General had the power to draft this man, commission him and then reassign him to a rural area. 2000 But I tried the Judge Advocate Office of the Surgeon General’s office and this gentleman didn’t interpret it this way. Then he suggested I call the Surgeon Generals office of Health, Education, and Welfare. I talked with a Dr. Zapp’s office. I didn’t talk with him personally. He looked the act over and told me that it will be July 1972 before this is a funded act and in process and he could make application then. By that time, this man is gone. He really didn’t read this the same way, that they could reassign a man back to us, that had been taken into the service. He proceeded to tell me that the public health, De- partment of HEW, will commission an officer and they in turn pro- vide services for certain Federal employees like the Coast Guard, Merchant Marine. But he didn’t see anything that would help us, espe- cially right now. Senator RaxvoLru. We disagree with him. Mr. Seurrock. I hope. 3 Senator Ranporpn. I want to check this special case out. We will do it in a matter of days. Senator Kennepy. The Emergency Health Manpower Act passed the Congress. The authorization, I believe, was $10 million for the first fiscal year, but not one cent was requested by this administration for that program for the first fiscal year. We hear that they are going to make a supplemental request for 1972 of approximately $10 million. But we can try to fund that program with a fiscal year 1971 sup- plemental. I will put that amendment in. T am sure Senator Randolph would join us. Hopefully, if we can get Senator Magnuson, who is the real initiator of the program to join us, as chairman of the Appropria- tions Subcommittee on health matters, we would have a good chance of getting it. The real lesson of this experience is, I think, the extraordinary ef- forts that have been made by people in this community. We often wonder what value people in a community, in a rural area or urban area, put on decent health. What you are telling us by your story is that your community of only modest resources has been willing to make the extraordinary efforts which you have outlined here today to develop a facility and, now you are unable, because of bureaucratic rigamorale, to utilize it to get services to people. It is an additional indictment of the whole system. I commend what you gentlemen and the people in your community have done to try to get this kind of facility to provide health care. Mr. Seurrock. We had over 800 participants in this. That means we hit about every level, from 50 cents up. We anticipated our prob- lem and thought we would be ready for it. We sure haven't solved it by a long shot. Senator Raxporpa. Mr. Spurlock, you know the problem in Clay County ? Mr. Spurrock. I read about it. Senator Raxporrm. There is a nonprofit organization that has been formed where they will guarantee the salary of the physician, if he will come, $36,000 a year, the dentist $23,000 a year, and the pharmacist 2001 $18,000 a year, and provide $4,000 for an inventory with which the pharmacist can open his shop, as it were. This is a rather unusual effort that is being made there. I don’t know whether it will succeed or not. But there is no doctor in that county just as there is no doctor in your county. Would you take just one minute to tell me what has happened in Ritchie County just to the west, where they have had a similar prob- lem to yours, sir? Mr. SeurLock. Yes, but they have not been completely without a physician. They had three or four or—he will turn this over to a pharmacist, he would know more, because he writes a few preserip- tions from Ritchie. Senator Ranvorpn. The clinic is established there, as you know. We hope it was a stimulus to bringing in medical personnel. Mr. DropprLEMAN. They have been able to acquire one physician in Pennsboro and they are seeking another. There are two in Harris- ville. One of them 1s on limited practice now. So their need is great, too. Those people down there just are worked to death. This last boy is a Colombian from Colombia, South America, and doing an excel- lent job. But he is looking for help. I understand if he doesn’t get some additional help in there that he will possibly leave Pennsboro. Senator Raxporen. I want to say, Senator Kennedy, that there is no State in the Union other than Vermont, that is more rural than West Virginia. That is why you are in the correct location in West Virginia to hear the problems of rural America and the problems are perhaps in 40 of our counties, or more, out of the 55. We can repeat is story in varying degrees, but with the same intensity in all of them. Mr. Seurcock. I told you we were 35 minutes away from medical facilities. This means that we can get the patient into the hospital in 35 minutes. But it doesn’t mean he is going to see a doctor. He can be there from a half hour to 3 hours. We run into circumstances where it is almost impossible to find a physician at night or early morning. They are just not available. Dr. Vax Giwper. I would like to give my position on this. I am a native West Virginian. I graduated last year from the West Virginia University School of Medicine. It has always been my intention to return to West Virginia to practice. I had originally planned to gather more training before this. But the draft situation intervened. I am Jie concerned about the problems of rural health care in West irginia. If IT were able to go to this community, my intent would be to try to set up comprehensive health services, including possibly 1- or 2 day a week specialty services, services of home health nurses, and social services. I understand there is a good Public Health nurse there. But I think she is tremendously overworked. If I should try to get more training, I would try very hard to get a replacement, continuity of care for the people, if T were to leave. 1 also hope to involve the university in this, to hopefully make or encourage them to fulfill their obligations in the State that Mr. Spur- lock has delineated. 2002 I applied to the Public Health Service under the Emergency Health Manpower Act. I received a polite form letter last week telling me that they had no need for people with my particular level of training. T have also talked to West Virginia Congressman Staggers and Con- gressman Mollohan, to try to find out what the status of my applica- tion was. Apparently they have not been able to find anything out because I have not heard from them. I would be quite happy to go, not as part of the Public Health Service, as a private, independent physician, if this act can be imple- mented by that time. It seems to be the intent of the Congress and of the President, as he signed the bill, that physicians be exempted from military service to meet the specially demanding needs of the Nation. If the act can be implemented, I really think that it is a shame that I can’t be exempted apart from that piece of legislation to do this. Thank you. Senator KENNepy. Mr. Bowyer. Reverend Bowyer. I would like to speak as the President of the North Central West Virginia Health Planning Association, which cov- ers most of the counties that you have been in today and others, and Sei also of another county which faces similar problems, Gilmer ounty, which has attempted to meet this in a somewhat different way than Doddridge County has done. A group of consumers of medical care have formed the Gilmer County Medical Center, Inc., in an effort to seek Hill-Burton moneys and build a medical complex and thereby attract physicians. They have two elderly physicians that have almost ceased practicing now and two osteopaths who are practicing in the county that are also near retirement age. However, as we look at situations such as Doddridge County and others, we find that the total solution may not simply be a matter of having adequate facilities in order to attract doctors into a situation. The problems seem to be much more complex than this. It seems to me, too, as we have heard these comments that have been made this afternoon, describing many of the situations throughout West Virginia, that the situation of the war effort is further complica- tion of our medical problems. It is illustrated here. And secondly, in the fact we have heard many stories within our own area of experience who are wounded or injured on the battlefield and were very promptly able to receive medical care, and yet, this is unable to be done for the citizens who are here, and those soldiers, who once they have gotten out, come back home. I would like to say something about some of the problems in and the alternatives which I feel are important in dealing with this over- all situation. It seems to me, we may have to look elsewhere for solutions to the crisis than merely to doctors or to equipment or facilities. But these are complicated, in our area, for instance, by the poor nature of roads and the difficulty of travel over our State’s beautiful terrain and fur- ther aggravated by the general shortage of facilities and personnel that we have. So, practice doctors in every location are already carrying very heavy patient loads and some of our hospitals are placing patients in 2003 the hallways, which, of course, is not necessarily an indication that there is a shortage of space, so much as it indicates unnecessary hos- pitalization and the poor organization of delivery services. Oftentimes insurance programs are designed to put people in the hospital who could be treated much more cheaply and much more ef- ficiently perhaps outside. I think statistics will show that the largest amount and the largest percentage of money for health services which are spent by the West Virginia Department of Welfare goes for hospitalization, which is the highest cost to service ratio of medical services. Virtually none of it goes for prevention. The stories you have heard this afternoon I think have borne this out. It should be noted that many of our doctors are older and without the benefit of more recent training. The same is true of other health providers. Not only do they lack up-to-date training, board certifica- tion is often not attained by doctors practicing in specialties. While modern medicine is available to many at West Virginia University or at Fairmont or in our hospital, it is often effectively denied to many of our region’s residents. The tragedy of the poor and aged I think is clearly discernible but the very nature of the problem means that many who could generally afford care could not get it or cannot get to it. I am convinced that several factors must be brought to bear upon our current medical crisis. In priority is planning which must be in- clusive and regional and it must be genuine. I think Government in- centive for serious planning is imperative. A business which is wracked with inefficiency and outlandish costs must come to terms with its ways. More attention must be given to preventive care. Plans and programs must be devised which will re- duce the need to travel about to see several doctors or to make trips to labs or other ancillary services. Drug costs must be reduced. Hospitals must include the EKG departments and others which otherwise encourage profiteering by private practice physicians. There must be incentives for planning and for participation in planning, or conversely, penalties or lack of benefits for hospitals who do not. In my own county, the Fairmont Clinic and a very few local doc- tors will join in planning efforts. Other medical facilities and most of the doctors will not. This makes it nearly impossible to plan seriously and effectively. Consumer participation is mandatory. Public facili- ties and programs should be required to include on their boards and in their decisionmaking significant percentages of consumers who re- flect and represent the population of the service area. Finally, I would underscore the need for a patient-oriented or serv- ice-directed system. Probably the major weakness of medical centers associated with medical schools is their impersonality. Much of this is understandable since their primary function is education and train- ing. But service must be made more humane. If it cannot be done in the medical school setting, then doctors need to be trained out in the area where patients live, work, suffer, and die. The profit motive is basic in our society, but humanity is even more basic. The health industry must place service to patients ahead of profits, and any other approach is evidence, I think, of a truly sick society. 2004 When I look over our region and assess my own immediate com- munity and analyze my own family’s health needs, and the available services and the costs, I see the need to encourage group practice wherever feasible, and above all, to provide a system of prepayment which enables all to have equal access to equal service. I do not believe this can or will ever be achieved without active consumer participation in the planning and in the policing of the health industry. Thank you. Senator Kenxepy. It is a good statement. Mr. Michaels? Mr. MicuagLs. Senator, we want to thank you for permitting us to appear before the committee. In regard to our particular case in Doddridge County, we feel that were you to have a hearing there we could cite many cases of the inability of people to meet medical costs. However, the critical problem in Doddridge County is the lack of a doctor. Again thank you. Senator KenNepy. Senator Randolph mentioned a county that has offered a guaranteed yearly salary. That is an extraordinary effort for a county to make. I don’t think the total burden should be on one community to solve their health crisis. It is a national concern and we ought to be able to respond to it in a national manner. I think we have to offer the special incentives that have been sug- gested here to get doctors to rural areas. But the burden, I don’t think, ought to be assumed by a community in and of itself. A progressive tax system should spread the burden nationally. | But you mentioned very briefly the efforts you made trying to get some medical staff for your community. Have you said all you would like to say on that question? Mr. SpurLock. Are we talking finances? Senator Kennepy. How you are going to attract people ? Mr. Seurrock. We don’t know. We think we have tried about every- thing. If you have an idea, we will go that way. Senator Kexnepy. That brings me to S. 3. We will have a mechanism built into that system that will allow a doctor to go on out into the country and practice without being dis- advantaged financially. If a man has motivation, concern, and the desire to do so, he will be able to practice quality medicine out in rural areas. And he and his family won’t be disadvantaged financially. “Under that legislation we are not going to put the extraordinary burden on a single community to get together these resources alone. Mr. Srurrock. It is not a matter of economics in our county. The money is there, the patient load is there, they will patronize a doctor if he will come. In fact, a young doctor can start off much better there than he can in the city where it is more competitive. This is a solution to our problems right here, if you can tell us the way to get him. Dr. Van Giper. He is quite right. Physicians practicing in rural West Virginia don’t have any economic disadvantages. The things that make it unattractive are professional isolation, social isolation, 2005 things like inadequate school systems. I think people in Doddridge County assure me that the school system is fair in a general instance. This is the problem. Part of the reason I would like to involve Dodd- ridge County is not only for their benefit, but for mine. Senator Kennepy. Thank you very much, gentlemen. Dr. Davis, Delroy Davis, M.D., general practitioner in Kingwood, public health officer and past president of the West Virginia Academy of General Practice. We would like to ask Miss Iris Allsopp to also come to the table. STATEMENT OF DELROY DAVIS, M.D., GENERAL PRACTITIONER, KINGWOOD, W. VA, AND PUBLIC HEALTH OFFICER AND PAST PRESIDENT, ACADEMY OF GENERAL PRACTICE; ACCOMPANIED BY MISS IRIS ALLSOPP, ADMINISTRATOR, PRESTON MEMORIAL HOSPITAL Dr. Davis. Senator, I have been asked to give a statement as to the need of health care in Preston County. After T hear the plight of our neighboring counties in West Virginia, of Doddridge, Gilmer, and others, I feel like, perhaps, our need is not nearly as great as once I imagined. First, before 1 go on with our testimony, Mr. Senator, I have been requested to ask for a transcript of the record for the West Virginia State Medical Association. Senator Kexnepy. Fine. Dr. Davis. They are concerned with this problem. Senator Kex~epy. We will be glad to make it available. If you can indicate where you want it sent, we can get it sent to you as soon as we have a supply. Dr. Davis. Thank you, sir. T will indicate after we get through. For purposes of discussion, I would like to divide the medical needs of Preston County into two categories: First, the need of practicing medicine as far as the need of practice of medicine in the county is concerned ; the other is the need of the county from a public health standpoint. I believe Preston (founty is the fifth largest county in the State, as far as land area is concerned. It has a population of 25,000. There is a medical manpower shortage. The present doctor census consists of one general surgeon, one internist with a subspecialty in cardiology, four full-time general and family practitioners and one part-time prac- titioner. There is also a staff of resident physicians at Hopemount State Hospital for chronic disease. Five of our physicians are over the age of 50. Two are over the age of 45. In the past year, two physicians in the county have died and have not been replaced. One physician has left the county for a residency in neurosurgery. There is a need soon for at least two or three family practitioners in the county. Ideally, four or five practitioners would satisfy our needs. With this increase, we could probably support another general sur- geon and another physician in the subspecialty. 2006 Experience in looking for a partner in family practice this past year has brought approximately 100 applications from the specialists, mostly surgeons who would be willing to do general practice until they could do their specialty. We received only four inquiries from general physicians. I believe this illustrates the deficiency in the curriculum of the medical schools in not training general physicians. For this reason, I don’t need to urge you, you have already sup- ported the Yarborough-Rooney bill, but your continued support of the Yarborough-Rooney bill for the training of general physicians in the departments of family practice within the medical schools, not in divisions under another discipline of medicine. Senator Kennepy. I couldn’t agree with you more. We passed the Family Practice bill overwhelmingly—I think in the House and Senate there were only six votes in opposition to it. That would have provided a real stimulation in terms of general practitioners. Then the Congress adjourned at Christmastime for 3 or 4 days, and the Presi- dent pocket-vetoed that legislation. I think his act is unconstitutional, and we are hoping to test this constitutional question. Any fair reading of the Constitution would indicate it is only when the Congress ac- tually adjourns for the year, sine die, that he would have a pocket veto. By its pocket veto, the administration avoided giving reasons to the Congress for vetoing that legislation. It also avoided giving us a chance to express our views of this issue and to try to override the President’s veto. He didn’t give us that opportunity. Therefore, I share your sense of frustration. We are trying to test this case before the Court of Appeals. We are also attempting to have the House Appropriations Committee fund the bill and hopefully to test it before the Supreme Court. But all this means delay for those who are trying to provide addi- tional help and assistance to general practitioners. This is just a point I thought that might be of some interest to not only you, but to our friends here, who might wonder why the Congress hasn’t acted in this kind of legislation. Dr. Davis. As for legislation in the care of patients, there is a group of patients—and I can’t reiterate Mrs. Hess’ request greater—that are not now covered by medicare or any other program that needs imme- diate correction, the paraplegics, the patients in any age group, but mostly in the 40-50 plus year age group who become totally disabled from any cause, and cannot gain medical help or hospitalization for physician’s care. May I digress just a little bit from my statement? I think medicare covers an awfully lot of ground. It is not very discriminating in the people that it includes. It includes everyone past 65. There is a great number of people in this country, fortunately, past the age of 65 that remain in good health and are perfectly able to withstand their own costs. I think certainly under medicare or some other Government program there needs to be a catastrophic policy that covers people like Mrs. Hess mentioned. l ! Early experience in West Virginia just recently with the new revi- sion of the Department of Welfare into regional offices rather than 2007 county offices so far has not been good. If there are specific questions, I will be glad to answer these. I believe the consensus of our present physicians in the county is that medical care is adequate for the patients that come to our attention. _ But improvements can be made, mostly in the area of socio-econom- lcs; in the area of logistics ; and an increase in medical and paramedical personnel. We need a home nursing service. We need convalescent and nursing homes. Certainly, we also need better public relations in the education of the entire population. Under public health needs, may I say that our Public Health De- partment in the county consists of one part-time health officer with an assistant. We have one public health nurse. We have one sanitarian. We could immediately use a full-time public health director. We could immediately use an additional nurse and an additional sani- tarian. We could also use a social worker. We need expanded physical facilities. Preston County is fortunate that it is adjacent to Monongalia County and the medical center. We have tried to cooperate with them in several new programs that they have tried to put on in the county, especially one in the Bretz area. I thank Dr. Nolan for helping out with the birth control clinics in the Sounty; in the back areas which our own health department cannot reach. Dr. Wiles has included us in his maternal and infant care program at the university. This has provided the university with much needed obstetrical patients. Dr. Wiles does not need a station wagon to trans- port patients back and forth to the hospital. I have not discussed fees. I know very little about the economics of government. However, if we must continue inflation by raising the minimum hourly wage, this, in turn, raises the cost of supplies and office personnel and must eventually raise fees. I believe that concludes my statement. Senator Kexxepy. Doctor, do you consider health a matter of privi- lege or right for Americans? Dr. Davis. It is both. Senator Kennepy. If it is a matter of right, then it is total and it is comprehensive, I would assume. Dr. Davis. Yes, sir. Senator KenNepy. You might have those who for one reason or another have privileged opportunities, but it seems to me that if we say health is a matter of right, there is a responsibility on the health system to reach out into the community and find the areas of greatest distress and do something about it. Is that something that this country ought to be attempting to do, if we realize that this is a matter of right? Is that a goal we ought to be headed for? Dr. Davis. I think this is the goal we should be headed for. I think it is a goal that we have tried to get to. But to the present day, we haven’t quite reached this goal. Senator Kennepy. I would take issue in terms of whether we as a country have really tried to reach out. As a matter of fact, I am quite confident that, for example, the administration’s proposals in terms of deductibles are quite to the contrary. 59-661 O—71—pt. 9——3 2008 We hear this afternoon, of people who go on into emergency rooms and are required to pay fees before they get any service. It seems to me that rather than reaching out to find people that need help, the system as it exists today works to their disadvantage. It discourages people from utilizing the health system. That would be the conclusion I would draw from the comments we have heard today, as well as from the fact that we need coinsurance or deductibles or cutoff dates to insure people don’t use the system until they’re really very sick. It seems that the system works contrary to reaching out. It only responds to those who have emergencies, and even then, it often ap- pears to be inadequate. Do you have any reaction to my sweeping statement ? Dr. Davis. Yes; we have taken in an awful lot of ground, Senator. Emergency rooms are a problem countrywide. They are abused in many ways. I can’t say for the rest of the country. I can speak for Preston County. I know that welfare patients, or the people who are on welfare, as I told your secretary the other day, we have very little chance to do any charity work anymore. Senator Kennepy. That isn’t the point. The whole system works against the poor. The administrator of a hospital, if he is going to keep the doors open at all, can only afford certain kinds of service. They have to balance their budget and, therefore, can provide only so many services to the disadvantaged or the poor. It seems to me it is more the system than it is the motives of the people involved. e question is whether we are going to add on to that system, patch it up a little bit, and put a “Band-aid” on it and say you have reformed the system, or whether we are going to really come to grips with some significant change in the system. Dr. Davis. I think this has to come from attitudes. This is the one encouraging thing I have seen among medical students of the past year or two, that these people are more socially conscious than we have ever been before. These are freshmen and sophomore students we talked to; how they will be when they are juniors and seniors, I can’t say. Miss Arusorp. About the national health program, this is probably the route we are going to go and this is perhaps one way we can provide care for the disadvantaged and the whole population. But I think some concern must be given not only to the financing of health services, but I think there needs to be a whole new concept of how are you going to deliver health care, how are you going to reach all of these people? I think there needs to be an ideal program for the consumer, the provider, the medical staff, the whole bit. Senator KeNNEpy. I couldn’t agree with you more. Miss Arusorp. You can throw money into the fund, but if you don’t do something about the way you are going to deliver these services, if you are not going to help alleviate the shortages of medical per- sonnel—we have a shortage of doctors in the county. You have a problem in recruitment, how are you going to get these people to come here? This affects the occupancy rate of the hospital. People don’t want to live in rural areas any more. 2009 I think somebody needs to rebuild the image of the general practi- tioner and do something about family practice, because these are the people who have devoted all their lives to the maintenance of health more than anybody else I know of. Senator Kenney. That is a good observation. Miss Arsorp. In a rural area, you have the same problems as the metropolitan area in the operation of a hospital, but they are com- pounded here by many things: lack of medical personnel. If we want to get people to fill the professional jobs in our institutions, we have to provide some way to educate the people within our county, because these are the people that then have some obligation to return to the county and to work for us. So we have systems’ whereby we send people to school and also we have been connected with West Virginia University which has a telec- ture continuing education program for nursing, which has been a real asset. In this rural hospital, the things that prevent us from extending our services and having more modern equipment is the fact that in- adequate reimbursement programs with welfare and so forth, do not provide for a reserve to update our equipment. So we do have problems. We have the same problems as everybody else has. We have to com- pete with people in metropolitan areas for the personnel that we have. This is not an industrialized area, so there are no major group insur- ance programs and we have many people with no ability to pay. We also have a problem with patients in the hospital who are no longer certificated by medicare for continued care. They have no place to go. There is a great need for nursing home care, care for the elderly, and the disabled, these people who come in an age group that are not covered by medicare and are not eligible for welfare. Dr. Davis. Senator, I would like to make one comment: I don’t be- lieve you can legislate love, which is what a great number of these elderly patients need. I don’t think you can legislate social concern, unless people themselves wish to do it. Senator KexNEpy. I am sure you are right. What you can do is pass legislation that gives an advantage to young people like this girl from legal services who came up this after- noon. That gives some voice to voiceless people and some hope to people who think that there is nobody who is interested and concerned so that they raise their voices, as you raise yours, about the needs of the health crisis. It strikes me that if all Americans would just tell it as it is in health, we would get major reform overnight. But the American people are just too proud. We have problems. But it is a part of our national character, that we try and resolve them ourselves. It is only when we are just backed up completely against the wall that we seek help, whether it is from a hospital, a doctor or a Legal Services Office. So we suppress all this. Yet we will be spending more money on health next year than we will be spending on national defense and getting much, much less for it than in years past. 2010 It affects us as individuals, and we don’t want to complain about it. That is not part of our character. The greatest strength of our char- acter in this particular instance is, I think, the greatest roadblock to improvement, because if people started to holler bloody murder about it, they would get some action. Unfortunately, it is the individual that has that $5,000 medical bill, and we go ahead and pay it off for $8 or $9 a month. It is about time we started to do something about our health crisis. We have to change the system to fix it. Blue Cross said, “We can’t hold costs down.” Blue Shield says, “We can’t do it.” Hospital administrators, doctors, everyone says it isn’t their fault. In fact, it isn’t anyone’s fault. It is the whole system’s fault. And the person that is paying for it is the consumer, as we heard here today. We need your help, and Miss Allsopp’s. We can’t legislate love and affection and all the rest, but perhaps we can legislate some paramedi- cal personnel that will be interested in looking out into these hills for people that are suffering from thyroid problems and measles and pneu- monia and a lot of other things, and willing to give them a little help. I think there are tens of thousands of young Americans and old Americans who would do this. Take a look at the Teacher Corps, for example, VISTA volunteers, Peace Corps people. They are ready to go out and help. What is wrong with our health care system that we can’t encourage such people to do this work in the area of health ? Dr. Davis. You have an opportunity in legislating some new legisla- tion to take care of these people that aren’t covered now, I believe. Senator Kexxepy. You are very kind to come. We appreciate it very much. Dr. Davis. It is our privilege to be here. Senator Kexn~epy. Thank you very much. We are going to now have open hearings. I will ask everyone if they can limit their comments to 2 or 3 minutes. We have some names that have been filed. Is Mrs. Emma Steelman here, and Mrs. Anna Likens? STATEMENT OF MRS. EMMA STEELMAN AND MRS. ANNA LIKENS Mrs. SteermaN. This is Mrs. Anna Likens. She is currently a client applying for public welfare. I would like her to tell you her story. Mrs. Ligens. I am a widow. I have been a widow for the past 12 years. And I need a lot of medical attention, and I don’t have no money whatsoever to pay for any medical attention. I have been trying to get on welfare, on the medical list ever since last October. So far, I have not been able to receive one cent for medical attention. Mrs. Seeman. We talked today about people on welfare, more or less, like they have got it made. They get medical coverage. But I oy like to explain the plight of some of the people trying to get on welfare. Mrs. Likens applied for welfare in October. The type of welfare that she would be eligible for is aid to the disabled. To determine that she is Ysaliled, we have to have medical documentation that she cannot work. 2011 As you can see by looking at her, I don’t think she is someone that we would want to put out and make her go to work, but still our tax- payers, people that write welfare policy, state in order to get on wel- fare you must be considered disabled. 3 She applied in October, was able to get an appointment with the doctor, the last of November. : We received his report in December. This was sent into our State review team. It was made up of doctors, social workers and so on. The medical was not enough to state that she was completely dis- abled. They asked for an orthopedic consultation. J We were not able to get this appointment until April 13. j Mrs. Likens has just had her medical orthopedic evaluation. Now it will take another 6 weeks before we will get that medical report. Then this will be sent in to the State office. In all respects, she probably will be eligible for welfare, but look how long it has taken. Senator Ranvorpu. Mrs. Likens, how old are you? Mrs. Likexns. I am 62. Senator Raxporpu. Are you in what we call good health or are you needing medication ? Mrs. Likens. I need medication. Senator Raxporpr. How long have you been trying to receive it? Mrs. Ligens. Since last October. Senator Ranporri. And have received no assistance ? Mrs. Likexs. None whatever. Mrs. SteeLmAN. I might add that Mrs. Likens is a little bit better off than most of our pending AD applications, because her husband died leaving her with social security, or she was eligible for social security of $56 a month. : So we have many welfare clients who have pending applications that have no income, but still $56 a month is not enough to live on. Senator Ranpvorpi. Do you own your own property ? Mrs. Likens. Yes, sir; such as it is. It isn’t very good but it is a home to live in. Senator Ranpvorpr. What are the taxes a year on your property ? Mrs. Lixens. I don’t remember. Senator Raxvorpr. What is the cost of the upkeep of your property ? Mrs. Lixens. There hasn’t been no upkeep paid, because I haven’t had the money to pay any. But the valuation of my home is $1,700. Senator Raxporpm. What is the appraised value of your property ? Mrs. Laxens. $1,700. Senator Raxporpn. You have a problem. Is that problem the problem of thousands of other people in West Virginia, or would it be hundreds of other people? . Mrs. SteeLman. I would say if everybody that was in her situation or many kinds that could be eligible for welfare that applied, that are, say, 50, 60 years old that are trying to manage to live on, very, very small incomes, maybe small social security checks, some of them would be eligible for welfare. But they are too proud to apply. Some of them have medical prob- lems. They never go to the doctor. On the way up I asked Mrs. Likens if she would go to the doctor if she had money. She said yes. She 2012 has trouble bending: like scrubbing the floor, things like this, she 1s In pain a lot of the time, but she can’t afford any medication for the pain. Senator Kexxepy. I think we have a problem that we can’t better help Mrs. Likens. hank you very much. Mrs. Rondalyn Cool. Mrs. Cool is director of the emergency food program for Webster County. STATEMENT OF MRS. RONDALYN COOL, DIRECTOR, EMERGENCY FOOD PROGRAM FOR WEBSTER COUNTY, W. VA. Mrs. CooL. I am employed by the Office of Economic Opportunity, 2d ! am the director of the emergency food program in Webster ounty. I am employed by an organization called United Appalachian Poor People, which is an outgrowth of a CAP program that was in Webster County in about 1967. They were more or less run out of town. Mainly, what I would like to bring up today is that a few years ago when a new administrator took over our hospital, it was some $2 million in the red. Today, that hospital is several million dollars to the good. Tt has added a couple of extra wings. But Webster County is considered possibly the poorest county in the State, with 68 percent of the population with incomes below $3,000. When the new administrator took over, the county hospital placed a sign in the entrance room which read “Anyone wishing to receive serv- ices from this hospital must make previous financial arrangments.” That statement is really adhered to in the respect that the poor people, anyone that goes into the hospital, cannot go in without a $50 advance. Just last month, there was a case where a man came into the hospital with a stroke and was refused because he didn’t have the $50 down payment. In my work, I come in contact with several expectant mothers that go to the hospital to have their babies delivered and are refused, be- cause they don’t have the money in advance. My field workers have driven, and each month they drive two or three of these women to other hospitals out of the county because they are refused help in our county memorial hospital. Another point I would like to bring up is that IT had a case last month where a woman had applied for welfare assistance in the earlier part of November, and just about a week ago, she finally got an answer, a denial, which took about 414 months to get her case processed, which should not have taken any more than 30 days, according to the law. This is not just one case. These are cases that I come into every day. Another women, in particular, was denied entrance into the hospital to deliver her baby. I had 2 months before the time of delivery talked to all the agencies in town, including the health agency and the doctor. I could not make arrangements for this woman to be taken care of. She had no income whatsoever. She was not eligible for welfare as- sistance, because she had no children. So when the time came for this woman’s baby to be delivered, we had to take her out of the county to have it delivered, which was about a 214 hour drive. These cases are very, very common. 2013 Senator Kexnepy. Thank you very much. That is very helpful. Senator Ranporpu. Before you leave, are most of the patients that come to the county hospital in Wesbster persons who have worked in the lumbering and/or mining industries of that county? Would you say more lumbering or more mining i Mrs. Coon. Lumbering, probably, because the mining in Webster County has gone down considerably. Of course, you know, the lumber business in the wintertime, there are 3 or 4 months there that it is al- most completely halted. . i Senator Ranporpu. The economy of Webster County is hard hit, isn’t it? Mrs. Coor. Yes, it is. Senator Raxporpn. It is one of the most difficult of the counties of our State now to really have a population that is strong and able to take care of itself now. Thank you for coming. Senator Kexnepy. Mr. Vernon Watkins. STATEMENT OF VERNON WATKINS, PRESIDENT, NEWBERG COMMUNITY ORGANIZATION, NEWBERG, W. VA. Mr. Watkins. I represent the town of Newberg, with a population of about 494 people. About one-third of them are retired persons, which 1 am very interested in, because I am going to be one of those retired persons in a few years. Our medical facilities—we used to have a doctor there about 20 years ago but we have not had any. We are about 14 miles from Grafton Hospital, about 14 miles from Kingwood. Our old people are the most important people we have today. They are stepped on in about every way. They don’t have the income as we have heard it told here today. Most of them have income of around $80 to $100 and to try to keep a house on it and electric and telephone, and to try to get somebody to take them to a doctor is hard. Our public transportation in Preston County is worse today than it was 40 years ago. We used to get Kingwood public transportation 30 or 40 years ago and today you can’t. In Newberg, or most any place in the county. We have one bus line that runs from Oakland to Morgan- town and that is about it. Everybody, if he doesn’t have a car, just about walks today. We are one of the largest counties in the State, strung out over these hills and hollows, you might say. We have an ambulance service in this county which is inadequate today. We have two ambulances serving the whole county. I am in the coal mines. I am director of safety for a coal mine. I had to set up a plan to get men to the hospital as quick as possible. This service just started the 1st of March. T am not taking anything away from the people that run the ambulance. But it takes 30 minutes to get to Newberg, which is 14 miles. I checked with an accident we had down there last week, and also about 2 to 3 weeks ago, we had a man who had a stroke and the ambulance was called at 15 after 3. He came to the home at around 4 or 4:15. By the time they got him to the Grafton Hospital, it was 5 o’clock and the doctor had already left. They called the doctor and he stayed a while and left because he thought the man had died on the road or something, and the doctor had to be called back out again. 2014 Our dentist is another thing we have a shortage of in Preston County. I have two grandchildren living with me and both of them needed repair for their teeth. My wife called two dentists hera in Kingwood. One said the appointment would be three months away. She thought she would get something a little closer than that. She called another and he said he didn’t work on children under 12 years old. She then called Grafton, one place in Grafton, a dentist we had, and they give her a date, this was late January, the 12th and 14th of May. Those were the appointments he had available. It is just hard for o A people to get out and get to this. I am very much in favor of social security taking over our health and welfare because I believe it is a good thing. I believe it would be cheaper in the long run for everybody. It would serve more people. Senator Ken~epy. Thank you very much. That is a very good state- ment. It expresses the problems and limitations of dental services, which S. 3 covers. Thank you very much. Mrs. Shirley Dalton ? . The House of Representatives has a l-minute or 2-minute rule which we don’t have in the Senate of the United States. But we are going to ask you to try to summarize in a couple of minutes. STATEMENT OF MRS. SHIRLEY DALTON Mrs. Davron. The most important thing that I want to bring out about medical care here is this: To me, a mother of seven, right now I am in a mess. So I have been taking barbital. T have been on it for 9 years. I ran out of my pills last month. I went to the university hospital. I sent up a girl to pick up my pills. The doctor told me I would have to have an examination before I could get any more medicine. So they sent me a letter to come to the hospital to go through an examination so I could get my pills. I left home at nine o’clock in the morning. I paid $4.50 to get to the hospital. I set over there until 2 o’clock. When the doctor called me in, he told me he didn’t even know what I was there for. I called back and I talked to the social worker at the hospital. She told me that she had collected my chart, nobody had sent me a notice to come to the hospital and she didn’t even find in my chart where I had been on phenobarb. Now I can’t get no medicine and nobody can find a chart where I have been taking this medicine. So I have been wondering if I have been taking these pills all of this time for nothing or do I really need them ? What are you supposed to do? How are you going to find out ? Senator Kexnepy. It’s the question of quality. How do you even know you get prescription drugs that you are getting the right one? I suppose a lot of people worry about that. Mrs. Danton. But they told me I had to take them the rest of my life. I have my epilepsy at night, never in the daytime. But I have never been without pills. But now I can’t go get my pills because they can’t find my chart. Nobody knows who gave them to me. What is a person supposed to do? Some of the hospitals and doctors I would like to get an answer from on that. 2015 One other thing: I have got a daughter that is 15 years old. She has to take gym in school like everybody else does. So she had the tissues pulled out of her knee. So the schoolteacher called me about 11 o’clock. I had no way to get down there to take her to the hospital. So at 12 o'clock that afternoon, my brother-in-law come up and I got him to take me down to the school. When I got down there her leg swelled up that big. So we took her over to the hospital. One of the doctors came out and looked at her and he said he felt something was pulled out of her knee. So he said try to straighten her leg out. My God, anybody knows with your leg swelled up like that, you can’t straighten it out, so he just jerked the leg and pulled it. She screamed. He said take her home, if she is going to be a baby, I am not going to work on her. I took her to another hospital and they did find out something was pulled out of the leg and she had to wear one of those tight things around her leg for over 2 weeks and on crutches. Me, on welfare, I have got a medical card, so this to me, this is what it is to me. You die, OK. If you live, it is OK, because they don’t matter. Senator KennNepy. How is your daughter now? Mrs. Darron. She is OK. But still she has trouble. She wasn’t sup- posed to be taking gym, not doing anything that would pull her leg. If she don’t take it, she gets zero on her report card, so what are you going to do? You have got to listen to the teachers. So I hope you get something to work. I hope you get it out. Senator Kenx~epy. Thank you very much. Professor Linsky ? STATEMENT OF BENJAMIN LINSKY, PROFESSOR ON AIR POLLU- TION CONTROL, AND SAFETY ENGINEERING, UNIVERSITY OF WEST VIRGINIA Mr. Linsky. Senator Kennedy, I am Benjamin Linsky, professor on air pollution control, and safety engineering at West Virginia University. I would like to add these very few words to your deliberations by pointing out that in the United States we have Federal aid to educa- tion services, including medical education; we have Federal aid to housing, financing services; we have Federal aid to highway services, we have Federal environmental protection services, we have Federal aid to food services, and it looks like it is about time that we got full Federal aid to full health services even in the rural areas, including transportation, whether by stationwagon, ambulance or vertical airplane. Senator Ken~epy. Thank you. Mrs. Eloise Milne, social worker, West Virginia Department of Welfare. STATEMENTS OF MRS. ELOISE MILNE, SOCIAL WORKER, WEST VIRGINIA DEPARTMENT OF WELFARE, AND MRS. HILL Murs. Mine. Thank you very much. I was unaware until last eve- ning that I might have an opportunity to speak. I will try to make this brief. 2016 Most of the problems I am connected with have already been dealt with by Mrs. Steelman with the Welfare Department, by Mrs. Hess with the Legal Aid Society. I did want permission for Mrs. Hill to speak briefly regarding the ambulance transportation. I will present this very briefly, as IT said. } The problem we are experiencing with ambulance transportation in this county is due primarily to the fact that the ambulance company has decided—they have the contract—the funeral home is no longer providing an ambulance service. So they cannot do this. Our local ambulance owner has decided not to accept medicare. Then we have the elder people that are not covered by medicare pay- ments. They must have the cash. Then with the department of welfare, we cannot bill or the am- bulance company cannot bill for the department of welfare for the transportation unless medicare is billed previously. So we have worked very closely together in this problem. But they say the paper work is prohibitive. This is very often the case with physicians and other people. They don’t need the medical cards some- times because it is prohibitive, the paper work is tremendous. You have the burden of additional secretarial help, bookkeeping help and so forth. When you deal with medicare and welfare forms, you need the help. I did get permission to explain the plight of one lady who is cur- rently in the hospital. I was asked to bring a recipient of nursing home services, because as a social worker with the department of wel- fare, this is what I am primarily concerned with. My caseload consists of 400 of the elderly, disabled, and chronically ill. The lady that is currently in the hospital is not a welfare recipient. She isn’t eligible, because her social security benefits are $74 a month. But according to our current policy, her assets must be below $1,000. Right at the moment, her medicare days have been used up. Her assets of over $1,000 will be terminated in 1 month. So she will become a wel- fare recipient. But the plight she is in now is the same as these other 400 people. There are no nursing homes for her to go to. We have not a single nursing home in Preston County. We are fortunate enough to have Hopemount State Hospital for the chronically ill, but for the past several months no one has been able to be admitted there due to the lack of funds. They could open up 150 beds. Senator Raxporrm. Just explain the situation. I think, Mr. Chairman, we ought to know within a few miles here that there is a facility, a hospital, once operated for the tuberculosis patients. Tell us again what you are saying. Mrs. Mirxe. There is not enough funding at the moment to admit any more people into Hopemount State Hospital. Senator Raxvorri. How many are there now ? Mrs. MiLNE. T couldn’ answer that. Maybe Mrs. Hill could. Mrs. Hin. I was over there about 2 weeks ago and talked to Mr. Lovett. He is head of the hospital. He told me he had 400 beds that could be in use, and at the time there is about 135 because it has no funds. He said if they couldn’t get some transferred from some other source that he was going to have to cut down on the food for the patients. He put it like this: not starving to death, but cut down. 2017 We also have two other hospitals in West Virginia that are low on funds and are putting their patients out into these private little con- cerns. That is why we can’t get no patients, because they have to have it in the State hospitals. Mrs. MiLNE. I would also add that one morning last week I called 18 nursing homes in this State and in adjoining States trying to get—at that time, I had six placements to make. I couldn’t get one, because the State of West Virginia pays $300 to AAA nursing homes. For in- stance, the one I called in Virginia, they paid $490 for welfare clients. So, therefore, they were keeping their empty beds for their own, and rightfully so. But Mrs. Hill was fortunate this morning in that she got her mother into a nursing home within a 40-mile radius of her. But when you con- sider the expense it is to the taxpayers for even long-distance phone calls attempting to place people, when we have such a lack of facilities, like I say, we have no nursing homes here. We have custodial homes for ambulatory patients in this rural area, but no nursing homes. Thank you. Senator Ken~Nepy. Thank you very much. Mrs. Hivn. I also want to tell you that over at Hopemount in our State Hospital, Eloise told me to go over there and see about whether we could get my mother-in-law in or not. While I was talking to him, he told me he couldn’t take any patients until after July. If he was funded then, he could take them. So I started checking around then to see how far she would be down on the list. And within a mile where I live, there is a man signed up to go to Hopemount and it has been over a year ago. He is 135 on the list. Over 8 months ago there was another woman that is within a quarter of a mile where I live, she signed up and got ready to go, but she is 50 on the list. So there would be no chance whatever that the beds would be filled up now, if even they signed them up to get them in over there. Who makes the decisions whether our tax money goes to take care of our senior citizens or our older people or whether it goes to get a bushel of rocks? I have never been asked to go to anything like this. Do the Sena- tors just take it on themselves to make these laws without asking the people? Senator Kennepy. The Congressmen and Senators are supposed to be voting your interests. Sometimes they do and sometimes they don’t. Mrs. Hin. This is the first time T have ever seen anybody come out to talk to the public like this. I am a little over 27. So it has been a long time. I think if they are going to make the rules and laws to go by, if the DPA goes by it, I think they ought to come out and get the public need of what we need in our communities. I want to thank you both. Senator Kex~Nepy. I couldn’t agree more. We spend $5,300 to kill a Vietcong and we spend $1,000 for an American living on welfare. What is important ? I think it is probably more important, personally, that we start looking out after the people here. Mrs. Hivr. I went in homes after homes when I know old people are laying there in pain and suffering. They have a humane society 2018 to take care of animals, but our old people, we just don’t care about them. Mrs. Mirnk. I think Dr. Davis’ statement a while ago, regarding the group between age 50 and 65 that have no coverage whatsoever, this is the group we have to reach. It is very, very sad. Senator Kennepy. Thank you very much. STATEMENT OF SAMUEL F. BORDY Mr. Boroy. There is a certain hospital in Morgantown. I am not mentioning any names. I had two heart attacks, and I went after the second one I had to the emergency room. They wouldn’t even leave me in the emergency room because I was on welfare. It took me an hour and a half before I could get hold of a nurse. Then she treated me like IT was a dog or something, take you out in the hallway and strip down and give you a shot in the hallway, and turn you loose like you was a wild animal or something. So I don’t think that is right. Senator Kexnepy. I don’t think it is right, either. IT appreciate your making your statement. Thank you very much. It is just the kind of statement we are interested in. It shows people who have emergency situations and how the health system responds tc them. STATEMENT OF PRESTON BROWNING Mr. BrownNine. I would like to question your financing of the pro- gram. I don’t think anyone will deny the need for the program. My question is: The 1 percent of the employees, plus 3.5 percent on the payroll, are we going to still pay this on top of our regular Internal Revenue? Senator KENNEDY. You are going to pay it on top of income taxes, that is right, and it is going to amount to anywhere from $15 to $20 billion a year nationally. But you also are going to have reductions in taxes for medicaid and other programs, and you are going to have no insurance premiums. Mr. Browning. Will this do away with medicare and medicaid ? Senator Kenneny. Effectively, yes. Mr. Browning. What about private consumer costs to the doctor? Senator Kennepy. In what respect ? Mr. Browning. On a regular call for a physical or for medical exam- ination ? Senator Kennepy. The plan would pay these costs. These costs should be lower too. We hope to develop different delivery systems. We are going to have incentives within this bill that will encourage group practices. Let me stress also that it will maintain private hos- pitals and private practice in many instances. There will be the possibility of private services. But the emphasis is going to be on group practice. We will also try to develop health maintenance organizations and neighborhood health centers, and we will set strict Federal standards in terms of quality control. We hope various groups will compete to see who is going to provide comprehensive services For a particular community. One group will 2019 say, “I will do it for 2.” Another will say, “I will do it for dollars minus $1,000.” Based upon competition which is going to drive health costs down, we will provide more efficiencies in the health systems. | We are going to change the system dramatically with national health insurance. There shouldn’t be any question about it. ; The question always comes up, “Can we afford this?” I will ask you: “Can we afford not to do it?” I think we have each used more than our minute. I am sure you have some more to say. I will be glad to respond to any of the questions you have. I am always glad to do it. Mr. Brownina. I was looking at the pamphlets passed out concern- ing the bill you introduced. You said we will take one percent and up to $15,000 a year. Senator Kexnepy. That is right. Mr. Browning. This covers all personnel employed in the United States ? Senator Kenxxepy. That is right. There are certain parts of nursing home care which we don’t cover. There are certain kinds of psychi- atric care we don’t cover. We should include it in the legislation. I am flexible in terms of coverage. We have taken the best of the recommen- dations of the medical economists. I am for covering drugs also. If I think I could get the support in the Senate, I will put these things through. I think we have a basic program designed to carry out fundamental reforms. It is one we can defend in terms of costs. But I personally would support expansion of it. Mr. BrowNina. The provision for taxes, concerning Internal Reve- nue Service, what kind of loopholes are there in that that people can use, such as taking Health Security Act tax as a deduction on their Internal Revenue Service? Can this be done ? Senator KennNepy. I don’t believe it can be. Mr. Brownine. Eighty-five percent of the taxes are paid between salaries of $8,000 and so on. Senator Kennepy. If there is a loophole there, we will close it. I don’t have any problem in terms of the loopholes. I was a sponsor of the minimum income tax, which I think was the most significant and important tax reform measure before the Senate in the last Congress. Unfortunately, we were only able to get 22 votes in the Senate. I am realistic about tax loopholes and I am all for closing that up. The real point is that we are already paying for health care now. You are paying for it now. And you are paying for all kinds of ineffi- ciencies. We think if we eliminate the inefficiencies, we can supply more care to more people at the same cost. The administration said our program would cost $77 billion. They took inflated figures. I am not willing to accept their figures. But this country is spending $70 billion on health care this year. Our program isn’t to go into effect for another year. In effect, even using their figures, it would only cost $7 billion more next year than this year, and we’d provide more services. People say our plan is socialized medicine—it’s Federal control—it’s all kinds of bad things. But it’s none of these. It’s most like social se- 2020 curity or medicare. It extends social security and medicare type pro- grams to everyone instead of just to those over 65. We have got a lot of problems with the program. It is not perfect. We are he open to recommendations. We would welcome them. We are going to have a tough time getting it through Congress. Senator RaxpoLpu. Mr. Chairman, as we conclude this formal hear- ing, there is one phase that we have not discussed which I think should be included in our record, which is the problem of the closing, which is imminent, of beds in the veterans hospitals in the State of West Virginia. Thirty-six beds are to be eliminated at the veterans hospital in Clarksburg, which is approximately an hour and 15 min- utes from Kingwood. Those beds would be unavailable to veterans. Throughout the State it is a very real problem. I want personally—I am sure the chairman would express it offi- cially—to thank the people who have come here this afternoon. I watched you as you sat there very quietly, earnestly a part of this hearing, not speaking, but thinking with us, and Mr. Chairman, I hope that the record can be kept open and if the people sitting in this audience have thoughts, that these can be addressed to the Subcom- mittee on Health for consideration in connection with this hearing. Senator Kenxepy. We will keep the record open for 10 days. Any comments you would like to make, write to us and we will make them a part of the record. Send it to Edward Kennedy, Senate Health Subcommittee, U.S. Senate, Washington, D.C. We are going to be there another 5 years, anyway. [Laughter.] Senator RanporpH. Senator, I want to express appreciation for the subcommittee coming into West Virginia today. I think the hearings, some 3 hours of testimony and comment, have been most helpful. IT know that our conference later today with the university officials, including the doctors and students there, will be of value. Our visits here in Kingwood and in Fairmont have all contributed to a good record. Thank you very much for coming. Senator Kexnepy. Thank you very much. At this point I order printed all statements of those who could not attend and other pertinent information submitted for the record. (The material referred to follows:) 2021 AT rriee BF Vi SENATOR ¥ £WARD M.LEWAEDY oe i FEIDIE von Les 3% i Ty wy 4 4 sf Schoolof Medicine April 28 » 2971 The Honorable Edward M. Kennedy Chairman, Subcommittee on Health Committee on Labor and Public Welfare U. S. Senate Washington, D. C. 20510 Dear Mr. Chairman: We are writing in follow up to the hearings held in Kingwood, West Virginia, on April 19, 1971. The enclosed material is submitted for the record in response to the interest expressed by your staff in data we have been developing about some isolated rural West Virginia counties. Attached are nine tables concerning a six-county area which we have labelled "The Gilmer Circle" (Braxton, Calhoun, Doddridge, Gilmer, Lewis, and Ritchie Counties). These counties are located in central West Virginia and consist of a land area of 2,300 square miles and a population of 61,875. The most populous county is Lewis with 17,847 persons and the least populated is Doddridge (6,389). However, in size, Braxton and Ritchie are the largest. None of the counties has an urbanized area and the only county with an urban center is Lewis, which has 41 percent of its population living in and around the city of Weston (7,323). The other five counties are totally rural. The six counties have 15 towns, six of them between 1,031 and 2,183 population, and the other nine of them quite small (two below 160; five others 220, 252, 267, 397, and 412; and the final two, 591 and 795.) The latter town is the only one in Calhoun County. Eleven of the 16 towns have lost population during the last decade and Glenville, the town with the greatest gain, has increased its population through a rising college enrollment. There is a population loss of 10 percent in the "large" towns, small towns, and the country area, and a 15 percent loss in the cities (based on one city only--Weston). Declining Population During the last 20 years the six-county region has lost 23.3 percent of its population. (See Table 1.) During the decade of the 1950's the loss was 15 percent and during the 1960's it was 10 percent. With a declining population there is now an average of 27 persons per square mile in the six-county area, down from 35 persons per square mile twenty years ago. Doddridge has the lowest density (20 persons per square mile.) 2022 Page 2 Table 2 shows the changes in age groups for the state and the indi- vidual counties. For each county the population loss is greatest for young children. In some counties the decrease in the under 5 years of age group is over 50 percent. For example, in Calhoun county the under 5 group represented one person out of every eight in 1950; today it is one person out of every 14. In some of the towns one rarely sees a small child. Older children are also fewer proportionately. In all but Gilmer the 20-4k year group is reduced and the 45-64 year group has also decreased in the entire region. The only population gain is in the elderly (65 and over) in three counties, but in three others, even this group has been reduced. Between 1960-1970, this was a change for Doddridge, Lewis, and Ritchie, which had posted gains in the aged popu- lation during the 1950's. The decrease in the number of elderly in 1960- 1970 in these counties is contrary to state trends. Statewise the 45-64 year group has increased, but this is not true for the region under study. The atypical population distribution has resulted in a substantially lower birth rate and a higher crude death rate in this area as compared to the United States as a whole. In two counties the crude death rate exceeds the birth rate resulting in a decline in the natural population. Combined with out-migration, one can understand why the population has declined so drastically. Although not documented, there are indications that some persons over 55 are returning to these rural areas (when they are laid off from their Jobs in the cities or are disabled). This means that the out-migration of younger workers and able-bodied, middle-aged workers is even greater than the statistics show. The people that are left are largely the poor, the sick, the disabled, and the aged. Yet, the public services (welfare, health, mental health) are very weak and cannot handle this needy population. Hospital beds, physicians, and other medical resources are virtually non- existent in many areas. Economic Activity Per capita income (1965) ranged from $951 to $1,449 in the six Circle counties and was even lower in some of the neighboring counties (e.g., Clay, $712; Wirt $715). (See Table 3.) Unemployment in June 1970 was below five percent in Gilmer, but rose to nine percent in three counties and was 15 percent in Calhoun, despite the fact that many workers have left this region. The most workers were employed by the government (schools, city and county work, post offices), as manufacturing was light in the six-county area. Only a small proportion of the work force is engaged in agriculture. Although the region contains enormous recoverable coal reserves, there is actually very little mining. The accident rate in the region is extremely high (Table 4) compared to the state as a whole and considering the small amount of mining. Typical of these counties is the following description of economic activity in one county. The major sources of wages and salaries in Braxton County in 1965 were the government (15 percent of the total), transportation, 2023 Page 3 communication, and public utilities (seven percent), and wholesale and retail trade (eight percent). Manufacturing contributed just four percent of the wages, and farming, less than two percent. The leading industries and chief agricultural products are lumbering, natural gas, coal, dairy, livestock, poultry, and hay and grain. Such basic farming products as eggs and milk both declined in volume between 1954 and 1964. (Egg produc- tion dropped 77 percent and milk production dropped 46 percent.) Coal production was just 3,000 tons in 1968. There were two underground coal mining operations in 1968 and these employed only six production employees who worked an average of T6 days each throughout the year. Braxton lost almost one-third of its population during the last 20 years. Unemployment was 9.3 percent in June 1970 and employment has declined. Per capita income in 1965 was $1,036. Transfer payments in 1965 totaled $3,655,000, one-fifth of the total personal income. These include old age, welfare, veteran, pension, and similar government and business payments. Seventy-two percent of the transfer payments were paid by the Federal government, 25 percent were paid by state and local governments, and three percent, by businesses. The Poor There are an overwhelming proportion of poor families in the Gilmer region (5,458 of the region's 16,84k families were classified as poor in 1966). Ritchie has 27 percent of its families rated poor by Social Security standards of income and family size, but Braxton, Calhoun, and Gilmer had 37-39 percent of their families rated below the poverty level. Only 10-12 percent of all counties in the United States have a higher proportion of poor families than are found in Braxton, Calhoun, and Gilmer Counties. (See Table 5.) These counties all have a higher proportion of poverty families than the state as a whole. Welfare payments are quite low, and there appear to be wide differences among payments to recipients within the six-county region (e.g., Table 6 shows average payments for Braxton lower than those in the other five counties), Average monthly payments for Aid to Families with Dependent Children is about $90. As can be noted, only a small proportion of the poverty families are on welfare. The reason for this is that most of the poor families belong to the working poor=-wage earners at minimal salaries. Health Resources Throughout the region there is a shortage of health practitioners, and the few practicing physicians and dentists are overworked, consequently. The following is a description of health resources in Gilmer County. Glenville, the county seat, is the home of two osteopaths, two general practitioners, and one dentist. However, the two general practitioners are both over 80 years of age and in poor health; the two osteopaths, both nearly 60 years and aged beyond their years, have exceedingly busy practices. One of them fills in as the physician for Glenville State College since the College has been unable to recruit its own doctor. The dentist resident in Glenville is young and conscientious; he handles virtually all the dentistry for Gilmer, as well as caring for residents from neighboring counties. He is too busy to serve the schools. 59-661 -O -71-pt. 9-4 2024 Page U The local health department consists of the health officer who is over 80 years of age and has been paralyzed for several years; a public health nurse, near retirement; and a clerk. The county has not been able to recruit a sanitarian. The entire county health budget was $19,229 for fiscal 1970 (and it is doubtful that even this much was spent). Only $591 was from federal sources; local appropriations covered Tl percent of the budget. There is no hospital in Gilmer County; the closest hospitals are up to an hour away (a 25-bed hospital in Grantsville, Calhoun County, and a new hospital which is being built in Weston, Lewis County, to replace the present hospital facility). Presently the residents of Gilmer County must travel to one of the neighboring counties when in need of hospitalization or specialization. One former resident recalled traveling 60-100 miles for medical care, and this, over roads and terrain that are rugged. It is the hope that the Interstate Highway T9 will be completed within a few years, reducing travel time to urban medical centers. Glenville will be about 15 miles from the Interstate. Gilmer County desperately needs transportation to out-of-county hospitals, as well as emergency care and local practitioners. In a county where about half of the families earn less than $3,000 annually and welfare costs are far higher than the state norm, travel is too expensive for the majority. It should be pointed out that Gilmer County and these other rural counties support their health budgets with local and state funds and receive very little federal assistance. (See Table 7.) Tables 8 and 9 show the distribution of physicians, dentists, and hospital beds in the six-county area. Some counties do not have hospitals. Residents of these counties must travel long distances for hospital and emergency care over narrow, winding roads. In the wintertime, travel over these roads is extremely slow and hazardous. Clay and Doddridge Counties do not have any physicians or dentists. Population ratios run up to one active dentist to 14,111 persons in Roane County. Many of the physicians and dentists are between 55 and TO years. Considering that in 1963 Gilmer County had five physicians; Braxton, 17; Doddridge, 10; Clay, five; and Ritchie, 15, it is clear that when physicians have retired or died, they have not been replaced. Nurses, sanitarians, and other health practitioners are in exceedingly short supply in these rural areas. We are currently studying the problems of rural health delivery and are seeking ways of attracting physicians to rural areas. The recently passed Emergency Health Personnel Act of 1970 could be helpful to West Virginia. Using new types of manpower such as nurse practitioners, physician's assistants, and health aides will help, but not alleviate the situation. Needed for areas such as these are massive federal support to assist in 2025 The Honorable April 28, 1971 Edward M. Kennedy Page 5 organizing and financing the immediate delivery of primary cere and, then, the long-range programs to train family physicians and new types of manpower. We support the idea of comprehensive national health insurance as one way of alleviating the financial burden of paying for care. However, payment mechanisms alone cannot solve the problem of health care for rural populations. We appreciate the privilege of offering our comments, and thank you, Mr. Chairman and members of the Subcommittee, for your consideration of our views. S. erely yours, —£CA Pre . erome L. Schwartz, DriPliH7zc Visiting Professor of Public Health and Preventive Medicine AQ Robert L. Nolan, M.D., J.D. Professor and Chairman Division of Public Health and Preventive Medicine and JLS :nmt Encls. Table 1 POPULATION DATA, 1950 TO 1970 State, Gilmer Circle, and Neighboring Counties of West Virginia Percent Percent Live Crude Net Natural Birth Death Census Population Percent Net Change Migration Population Gain Rate Rate 1950 1960 1970 1940-50 1950-60 1960-70 1950-60 1950-60 1969* 1969% West Virginia 2,005,552 1,860,421 1,744,237 + 5.4 v.7.2 - 6.2 16.8 10.8 Gilmer Circle Counties Braxton 18,082 15,152 12,666 -16.5 -16.2 -16.4 -28.4 12.2 12.7 14.4 Calhoun 10,259 7,948 7,046 -17.6 -22.5 -11.4 -32.2 9.7 16.2 12.9 Doddridge 9,026 6,970 6,389 -17.4 -22.8 - 8.3 -27.4 4.6 12.8 "16.6 Gilmer 9,746 8,050 7,782 -19.1 =17.4 - 3.3 -24.3 6.9 13.7 12.9 Lewis 21,074 19,711 17,847 + 5.4 - 6.5 - 9.5 -12.8 6.3 15.8 ..13.0 Ritchie 12,535 10,877 10,145 -18.5 -13.2 - 6.7 -17.8 4.6 16.9 14.9 Neighboring Counties Barbour 19,745 15,474 14,030 + 0.6 -21.6 -9.3 -29.7 8.1 13.6 "13.8 Clay 14,961 11,942 9,330 - 1.6 -20.2 -21.9 =41.2 21.0 17.7 "11.0 Monongalia 60,797 55,617 63,714 +18.6 - 8.5 +14.6 -19.7 n.2 15.9 9.1 Nicholas 27,696 25,414 22,552 +15.1 - 8.2 -11.3 -25.9 17.7 16.6 11.2 Preston 31,399 27,233 25,455 + 3.2 -13.3 - 6.5 -26.4 13.2 17.0 10.9 Roane 18,408 15,720 14,111 -11.4 -14.6 -10.2 -22.7 8.1 4.1 12.2 Taylor 18,422 15,010 13,878 +75 -18.5 - 7.5 -25.2 6.7 15.4 "13.7 Webster 17,888 13,719 9,809 +.1.1 -23.3 -28.5 -38.3 15.0 20.5 16.7 Wirt 5,119 4,391 4,154 -20.9 -14.2 - 5.4 -19.6 5.4 14.5 - 13.5 *The live birth and total death rates for the U.S. were 17.7 and 9.5, respectively, per 1000 population in 1969. Sources: Bureau of the Census, U.S. Department of Commerce: Bureau of the Census, U.S. Department of Commerce: U.S.G.P.0., 1961. Final Population Counts. January 11, 1971. U.S. Census of Population: 1960 Final Report PC (1)-50A. Information Center, Office of Economic Opportunity: 'Community Profile Project." Computer Printout, OEO, Charleston, W. Va., received December 1970. Division of Vital Statistics, West Virginia Department of Health: Virginia, 1969. Public Health Statistics of West West Virginia State Department of Health, Charleston, W. Va. jls 020471 920C 2027 Table 2 POPULATION BY AGE GROUPS, 1950, 1960 AND 1970 State and Gilmer Circle Counties of West Virginia Percent Increase Population Percent of Total or Decrease 1950 1960 1970 1950 1960 1970 T950-60 1960-70 West Virginia 2,005,552 1,860,421 1,744,237 100.0 100.0 100.0 —7+2 = 552 Under 5 240,107 196,295 139,021 12.0 10.6 8.0 -18.2 -29.2 5-19 562,809 558,637 508,309 28.1 30.0 29.1 - 0.7 -9.0 20-44 720,383 560,666 511,954 35.9 30.1 29.4 -22.2 - 8.7 45-64 343,727 372,307 390,833 17.1 20.0 22.4 + 8.3 + 5.0 65 & over 138,526 172,516 194,120 6.9 9.3 . 11.1 +24.5 +12.5 Braxton 18,082 15,152 12,666 100.0 100.0 100.0 -16.2 -16.4 Under 5 2,110 1,548 962 11.7 10.2 7.6 -26.6 -37.8 5-19 5,740 4,865 3,639 31.7 32.} 28.7 -15.2 -25.2 20-44 5,281 3,798 3,173 29.2: 25.1 25.1 -28.1 -16.5 45-64 3,181 3,079 2,993 17.6 20.3 "23.6 - 3.2 - 2.8 65 & over 1,770 1,862 1,899 9.8 12.3’ 15.0 +.5.2 + 2.0 Calhoun 10,259 7,948 7,046 100.0 100.0 100.0 -22.5 =11.3 Under 5 1,251 766 534 12.2 9.6 7.6 -38.8 -30.3 5-19 3,447 2,545 2,058 33.6. 32.0 29.2 -26.2 -19.1 20-44 2,984 2,018 1,814 29.1 25.4 25.7 -32.4 -10.1 45-64 1,683 1,681 1,640 16.8 21.2 23.3 - 0.1 - 2.4 65 & over 894 938 1,000 8.7 11.8 14.2 + 5.0 + 6.6 Doddridge 9,026 6,970 6,389 100.0 100.0 100.0 -22.8 - 8.3 Under 5 1,007 653 471 11.2 9.4 7.4 -35.2 -27.9 5-19 2,609 2,009 1,827 28.9 28.8 28.6 -23.0 - 9.1 20-44 2,684 1,674 1,514 29.7 24.0 23.7 -37.6 - 9.6 45-64 1,733 1,564 1,524 19.2 22.4 23.8 - 9.8 - 2.6 65 & over 993 1,070 1,053 11.0" 25.4 16.5 + 7.8 - 1.6 Gilmer 9,746 8,050 7,782 100.0 100.0 100.0 =-17.4 - 3.3 Under 5 1,061 768 540 10.9 9.5 6.9 -27.6 -29.7 5-19 2,992 2,337 2,534 30.7 3.5 32.6 -15.2 - 0.1 20-44 3,088 2,195 2,224 31.7. 27.3 28.6 -28.9 + 1.3 45-64 1,700 1,624 1,460 17.4 20.2 18.8 - 4.5 -10.1 65 & over 905 926 1,024 9.3" 11.5 "13.1 + 12.3 +10.6 Lewis 21,074 19,711 17,847 100.0 100.0 100.0 - 6.5 - 9.5 Under 5 1,961 1,533 1,274 9.3 7.8 7.2 -21.8 -16.9 5-19 4,889 4,638 4,344 23.2 23.5. 24.3 - 5.1 - 6.3 20-44 6,876 5,481 4,859 32.6. 27.8." 27.2 -20.3 -11.3 45-64 4,656 4,937 4,420 22.1 25.1" 24.8 + 6.0 -10.5 65 & over 2,692 3,122 2,950 12.8 15.8 16.5 +16.0 - 5.5 Ritchie 12,535 10,877 10,145 100.0 100.0 100.0 -13.2 - 6.7 Under 5 1,295 1,036 779 10.3 9.5 7.7 -20.0 -24.8 5-19 3,312 2,927 2,771 26.4 -26.9 27.3 -11.6 - 5.3 20-44 3,659 2,716 2,570 29.2 25.0 25.3 -25.8 - 5.4 45-64 2,591 2,387 2,283 20.7 . 22.0. 22.5 -7.9 = 4.4 65 & over . 1,678 1,811 1,742 13.4 16.6 17.2 + 7.9 - 3.8 Source: Date from U. S. Census. Calculations by West Virginia State Department of Health and 0iv. PH&PM Rural Health Services Research Program. Js 0L1571 Table 3 ESTIMATED PERSONAL INCOME BY SOURCE, 1965 State and Gilmer Circle Counties of West Virginia West Virginia Braxton Calhoun Doddridge Gilmer Lewis Ritchie Per capita personal income (in absolute dollars) $ 2,065 $1,036 $1,086 $ 951 $1,205 $1,bk9 $ 1,252 Total personal income® (in thousands of dollars) 3,749,730 |. 15,317 8,430 6,741 10,192 28,844 13,265 Total wages and salaries 2,526,042 7,530 4,610 3,855 6,116 18,385 8,102 Farms 8,000 56 3k 36 b 105 68 Mining 320,800 309 672 523 2,817 1,65k4 1,473 Contract construction 133,100 376 65 350 528 268 148 Manufacturing 829,500 652 937 281 147 4,533 2,534 Transportation, communication, - and public utilities 256,001 1,057 8k2 958 599 3,088 789 Wholesale and retail trade 331,200 1,337 283 281 316 2,509 Th3 Services 207,300 1,185 253 223 27 1,8uk 649 Government 370,0L1 2,l01 1,687 1,103 1,408 4,067 1,572 Proprietors income 288,163 757 587 489 378 1,53 521 Property income 456,814 3,163 1,239 89 1,488 3,843 1,828 Transfer payments 415,682 1,655 1,858 1,481 1,767 4,673 2,624 *Totals do not add because certain miscellaneous sources of income have been committed. Source: Leyden, Dennis R. and Rader, Robert D.: County Personal Income, West Virginia, 1962-1965. West Virginia University Economic Development Services, Number 11, Bureau of Business Research, December 1968. jis ok1571 8¢0C 2029 Table U4 ACCIDENTS FOR INSURED EMPLOYEES UNDER WORKMEN'S COMPENSATION, YEAR ENDING JUNE 30, 1970 State, Gilmer Circle, and Neighboring Counties of West Virginia Accidents/ Total Fatal Non-fatal Number of $1 million Area accidents accidents accidents employees wages West Virginia 55,317 197 55,120 470,713 19 Gilmer Circle Counties Gilmer 76 2 74 920 20 Lewis 359 0 359 2,599 30 Doddridge 98 1 97 775 35 Ritchie 178 0 178 1,525 28 Calhoun 75 0 75 1,702 7 Braxton 214 2 212 1,572 41 Neighboring Counties Wirt 38 0 38 218 46 Roane 173 0 173 2,180 21 Clay 51 0 51 606 23 Nicholas 1,204 6 1,198 3,890 54 Webster 87 2 85 904 16 Source: State Workmen's Compensation Commissioner: Unpublished data, undated. ils 020571 Table 5 POOR FAMILIES, 1960 AND 1966 State, Gilmer Circle, and Neighboring Counties of West Virginia Percent U.S. Percent Counties Having Percent Poor Families Poor Families? Lower Percent of County Families in County Number of Families Number Percent Poor Families? of State Total of State Total 1960 1966 1960 1966 1960 1966 1960 1966 1966 1966 West Virginia 462,100 482,900 139,400 105,900 30.1 21.9 2 100.0 100.0 Gilmer Circle Counties Braxton 3,681 3,278 1,923 1,265. 52.2 38.6 89 90 0.8 1.2 Calhoun 1,993 1,817 1,009 670 50.6 36.9 87 87 0.4 0.6 Doddridge 1,756 1,974 733 602 41.7 30.5 77 74 0.4 0.6 | Gilmer 1,911 2,034 955 763 50.0 37.5 87 88 0.4 0.7 | Lewis 4,562 4,950 1,698 1,398 37.2 28.2 68 70 3.1 1.3 | Ritchie 2,865 2,791 1,094 760 38.2 27.2 72 65 0.6 0.7 Neighboring Counties Barbour 3,838 3,396 1,868 1,229 48.7 36.2 85 86 0.8 1.2 Clay 2,625 Z,251 1,530 1,051 58.3. 46.7 95 98b 0.6 1.0 Monongalia 13,777 15,457 3,558 3,012 25.8 19.5 54 37 3.0 2.8 Nicholas 6,013 5,467 2,570 1,829 42.7 33.5 78 81 1.3 1.7 Preston 6,549 6,079 2,894 2,140 44.2 35.2 80 84 1.4 2.0 Roane 3,767 3,590 1,597 1,150 42.4 32.0 77 78 0.8 1.1 Taylor 3,878 3,829 1,485 1,090 38.3 28.5 72 69 0.8 1.0 Webster 3,149 2,673 1,798 1,185 57.1 44.3 94 96 0.7 1.1 wirt 1,143 1,082 469 - 311 “42.0 ° 28.7 76 70 0.2 0.3 2In the typical county in the United States in 1966 there were 1,221 families ranked as poor. This represented 15.1% of total families in that "typical" county. bNinety-eight percent means that only two percent of all U. S. counties had a greater proportion of poor families than Clay County, Source: Information Center, Office of Economic Opportunity. , "Community Profile Project." Computer Printout, OEO, Charleston, W. Va., received December 1970. 1 ils nant 0€02 Table 6 WELFARE PAYMENTS BY CATEGORY, JULY 1968 - JUNE 1969 Fifteen Selected Counties of West Virginia 01d Age Assistance Aid to the Blind Aid to the Disabled Aid to Fam w/Depen Chil Annual Avg. Avg. Mo. Annual Avg. Avg. Mo. Annual Avg. Avg. Mo. Annual Avg. Avg. Mo. County Payments Cases Payments Payments Cases Payments Payments Cases Payments Payments Cases Payments Gilmer Circle counties Area totals $ 951,257 1,039 $ 23.172 33 $232,677 376 $1,269,855 703 Braxton 96,142 187 $ 42.84 2,981 6 § 41.33 48,621 109 $ 37.17 360,252 193 $ 89.50 Calhoun 67,982 108 52.45 1,102 2 46.00 37,625 62 50.56 272,902. 130, 95.98 Doddridge 65,981 62 88.68 777 1 65.00 13,739 20 57.25 55,596 22-- 89.91 Gilmer 62,604 102 51.15 3,172 5: 352.80 31,782 51 51.94 176,356.:-92 99.90 Lewis 502,786 449. 93.31 9,288 13 59.54 68,506 97 58.86 269,111 193 90.92 Ritchie 155,762 131 99.08 5,852 6 81.17 32,404 37: 72.97 135,637 73 96.62 Neighboring counties Barbour 73,969 115 53.60 7,519 12.52.25 46,296 81 47.63 279,929 129 86.15 Clay 51,041 104 40.89 1,736 3 48.33 39,206 81 40.33 445,395 210 92.24 Monongalia 199,530 171. 97.24 8,584 10 : ‘71.50 62,869 74 70.80 256,379 139 113.04 Nicholas 87,110 142 51.12 4,306 7 51.29 50,516 99 42.53 319,215 167 "- 96.28 Preston 75,917 128 49.42 4,239 9. 39.22 43,662 85 42.81 264,685 138 93.51 Roane 276,862 284 81.24 1,625 4 (33.75 49,939 84 49.55 330,421 163 102.62 Taylor 78,985 92 71.54 2,210 1 189.00 22,997 37 51.73 146,733 62° 95.89 Webster 85,176 166 42.76 4,511 7:53:72 46,256 80 48.19 492,809 264 93.52 Wirt 25,051 45 46.40 1,410 2... 59.00 11,043 21 43.81 35,317 24 95.21 Source: West Virginia Department of Welfare: Annual Report, July 1, 1968 to June 30, 1969. Charleston, W. Va. jls 012671 1€0¢ Table 7 WEST VIRGINIA LOCAL HEALTH BUDGETS, FISCAL YEAR 1970 State and Fifteen Selected Counties of West Virginia Budget and Sources Local Appropriations Federal State Local County Munici- Board Home Per County ° Total Amount % Amount z Amount % Court pality of Ed. Health Other Capita State 4,095,707 728,198 17.8 599,497 14.6 2,768,012 67.6 1,358,494 511,034 328,525 245,551 324,408 2.35 Barbour 27,030 6,701 24.8 5,579 20.6 14,750 54.6 6,200 1,900 6,000 - 650 1.93 Braxton 19,354 595 3.1 10,072 52.0 8,687 44.9 3,540 -— 4,500 - 647 3.53 Calhoun 23,049 434 1.9 4,763 20.7 17,852 77.5 5,039 - 5,150 -— 7,663 3.27 Clay 31,211 9,771 31.2 9,542 30.5 11,958 38.2 4,368 -- 4,368 - 3,222 3.35 Doddridge 18,560 365 2.0 4,390 23.7 13,805 74.4 7,413 -— 600 -— 5,792 2.91 Gilmer 19,229 591. 3.1 4,988 25.9 13,650 71.0 5,59 -— 3,911 - 4,145 2.47 Lewis 26,439 2,410 9.1 7,557 28.6 16,472 62.3 13,140 1,179 1,764 -— 389 1.48 Monongalia 702,167 447,154 63.7 23,518 3.3 231,495 33.0 94,850 8,934 16,500 112,211 -— 11.02 Nicholas 34,970 2,352 6.7 11,526 33.0 21,092 60.3 8,286 — 7,000 - 5,806 1.55 Preston 33,580 1,600 4.8 13,241 39.4 18,739 55.8 12,739 — 6,000 - a= 1.32 Ritchie 15,500 428 2.8 4,484 28.9 10,588 68.3 3,89 - 3,89% - 2,800 1.53 Roane 21,809 582 2.7 7,016 32.2 14,211 65.2 5,905 300 - 8,006 -— -— 1.55 Taylor 42,355 1,396. 3.3 9,657 22.8 31,302 73.9 4,000 2,000 3,500 21,302 500 3.05 Webster 21,941 570 2.6 8,568 39.1 12,803 58.4 2,500 - 4,477 —-— 5,826 2.24 Wirt 12,789 5,138 40.2 1,651 12.9 6,000 46.9 3,000 500 2,500 — - 3.08 Source: West Virginia State Department of Health: "Local Health Budgets - 1970 Fiscal Year." Unpublished data, Charleston, W.Va., June 30,1970. ils 012671 ce0g 2033 Table 8 ACTIVE* PHYSICIANS AND DENTISTS AND PRACTITIONER RATIOS PER POPULATION, 1971 Gilmer Circle, Neighboring, and Nearby Counties of West Vireinia Physicians Dentists No. Ratio No. Ratio Gilmer Circle Counties Braxton 3 ‘1/k,222 2" 176.333 Calhoun 2 1/3,523 0 oe Doddridge 0 -— 0 -— Gilmer 2 1/3,891 1. 177.782 Lewis 6 ° 1/2,915 2 1/8,92k Ritchie kL 1/2,536 1 1/10,1k4s Neighboring Counties Clay 0 -— 0 - Nicholas 10° © 1/2,255 5 1/%,510 Roane 6 1/2,352 x 3/ak.an Webster Ly 1/2,452 1 1/9,809 Wirt % 1/8,308 1... 1/h,154 Nearby Counties Barbour 18 1/779 3 1/L4,677 Preston 6 1/4,243 7 1/3,636 Taylor 5. 1/2,716 3 1/4,636 ¥Not included are aged physicians who have limited practices, spend part of the year in Florida, or are disabled. Source: Telephone calls to each county. Table 9 HOSPITAL DESCRIPTION AND STATISTICS Gilmer Circle and Secondary Counties* Lewis! Calhoun Braxton Roane Nicholas Webster Name Jackson Weston Calhoun Gassaway Gordon Spencer Sacred Webster Memorial State General Memorial State Heart Town Weston Weston Grantsville Gassaway Spencer Spencer Richwood Webster Springs Control Non-profit State County Corp. Corp. ° State Church County Service Med/Surg Psych Med/Surg Med/Surg Med/Surg Psych Med/Surg Med/Surg Stay (term) Short Long Short Short Short Long Short Short Beds 47 2,075 25 22 36 1,037 65 74 Admissions’ nr 1,722 nr 990 nr 1,455 2,782 2,107 Census nr 1,789 nr 20 nr 952 52 48 Occupancy (%) nr 91.2 nr 91.5 nr 91.8 79.4 64.7 Bassinets nr 0 nr 5 nr 0 12 6 Births nr 0 nr 207 nr 0 264 97 Total expense nr $5,141,000 nr $229,000 nr $2,249,000 $603,000 $424,000 Payroll nr $3,366,000 nr $149,000 nr $1,526,000 $367,000 $246,000 Personnel nr 730 nr 30 nr 322 107 22 Approvals B/M M B/M B/M B/M M J/B/M J/C/B/M *No hospitals in Doddridge, Gilmer, Ritchie, Wirt, or Clay Counties. nr--non-reporting B--Blue Cross; M--Medicare; J--Joint Commission on Accreditation of Hospitals; C--Cancer, American College of Surgery Source: Hospitals - Guide Issue. Journal of the American Hospital Association, August 1, 1970. lGeneral Osteopathic Hospital, Weston, now closed. jls 012471 $€02 2035 Health Planning ASSOCIATION OF NORTH CENTRAL WEST VIRGINIA art A NON-PROFIT CORPORATION POST OFFICE BOX 1329 CLARKSBURG, WEST VIRGINIA 26301 EXECUTIVE COMMITTEE COUNTIES OFFICERS (1969-1970) OBSERVATIONS ON HEALTH CARE PROBLEMS IN 1. DODDRIDGE OBED POLING NORTH CENTRAL WEST VIRGINIA 2. GILMER PASE Peto on P. 0. Box 1329 : 3. HARRISON Clarksburg, W. Va. 26301 Senator, as the President of the Health 4. LEWIS REV. RICHARD BOWY] i 0 5. MARION Figcmacs cens 1970-74 Planning Association of North Central West Vir- 6 MONONGALIA Fairmont, W. Va. 26554 7. PRESTON BANTZ W. CRADDOCK ginia it is both a personal privilege and an honor s. TAYLOR ECRETARY Court House West Union, W. Va. 26456 to our agency to have this opportunity to participate MINTER B. RALSTON, Il g PO. Box 852 in these hearings. Weston, W. Va. 26452 RONAN Our Region includes eight (8) counties only three MEMBER AT LARGE Miss Grace Marie Bartlett (3) of which have sizeable "urban" populations. Of the Grafton, W.Va. Dr. Ray A. Harron Clarksburg, W.Va. Vice-President three Morgantown has the benefit of the West Virginia University Medical Center and 0 other hospitals. Clarksburg has the Veteran's Administration Hospital and two recently merged general hospitals. Fairmont has the Fairmont General Hospital and the Fairmont Emergency Hospital which is owned and operated by the State of West Virginia for persons in various state institutions, but which also serves a sizeable number of both indigent and working people of Marion County with care far below acceptable standards. Of the other five (5) counties, only three (3) have hospitals in the county. Much of the region is rural and small town. There is a diversification of businesses and small industry in addition to mining. The unemployment rate in the region is high in the more rural counties, but is offset somewhat statistically by better conditions in the three major cities. Our problems are great in terms of health care. There is a critical man- power crisis. Statistics would be misleading if careful attention were not AREAWIDE COMPREHENSIVE HEALTH PLANNING AGENCY i 2036 given to the fact that much of the medical personnel in Monongalia County, the home of the Medical Center, is not involved at all in primary care. Further, if it were not for the existence of a major group practice in Fairmont, the shortage of manpower would be critical in that county. The Fairmont Clinic also operates a branch in Harrison County which helps further to alleviate the burdens there. The Board of the clinic also operates the State's largest home health service which reaches into several counties with significant care across a wide spectrum of medical services. Monongalia County also has a well-staffed Health Department which extends some of its services, especially maternal and infant clinics, into Preston and Taylor Counties. I Beatin these factors as being highly significant for those who have the benefit of their services. But also to underscore the fact that were it not for the United Mine Workers Welfare Fund's establishment of a group practice clinic with two satellites which has some 70% of its patient load from among mining families, and the location of the State's only medical school in the region, our situation would be tragic. The situation is virtually that serious in some parts of the region. Doddridge County has had a delegation appear for these hearings to tell of the crisis there. Others have testified to the problems in rural Preston County. But the situation is also grave in Gilmer County and in other counties which it borders which are outside the boundaries of our association. A group of consumers in Gilmer County has organized the Gilmer County Medical Center, Inc. and has initiated efforts to secure federal funds from various sources, but most notably, Hill Burton monies, to build a medical complex. But it should be noted that this is principally an effort to attract doctors and ancillary personnel. Although Glenville State College is located in the county seat, the county is otherwise considered totally rural. Some 54% of the population are low income. Roads in and out of the county are poor. The nearest hospital 2037 is more than 25 miles away. For most medical specialties it is necessary to travel upwards of 40 miles. Much of the population is aged. Glenville has two aged physicians who have practically ceased to practice and two doctors of osteopathy, both of whom are approaching retirement age. There is one young dentist which the Medical Center, Inc. has attracted and one physician came as a result of these efforts, but left after a short time. Given the experience of Doddridge County, we cannot place too much confidence in the possibility that a new, modern, well-equipped facility will attract doctors or other personnel. It may be imperative to look elsewhere for solutions to the artate. Alternatives are complicated, however, by the poor nature of roads and the difficulty of travel over our State's beautiful terrain. It is further aggravated by the general shortage of medical facilities and personnel. Solo practice doctors in every location are already carrying very heavy patient loads. Some of our hospitals are placing patients in the hallways. That, of course, is not necessarily an indication of the shortage of space so much as it may indicate unnecessary hospitalization and poor organization and delivery of services. It is encouraged by much of the existing insurance programs. It eats away needlessly at precious Welfare dollars. Statistics will show that the largest amount and percentage of money for health services spent by the West Virginia Department of Welfare goes for hospitalization, the highest cost to service ratio Ve¢rtually none goes for prevention. In further describing the problems of our area's health care it should be noted that many of our doctors are older and with- out the benefits of more recent training. The same is true of other health providers. Not only do they lack up to date training, Board certification is often not attained by doctors practicing specialties. While modern medicine is available to many at West Virginia University or in some other hospitals or Fairmont Clinic, it is often effectively denied to many of our region's - residents. The tragedy of the poor and the aged is clearly dpscernible. 2038 But the very nature of the problem means that many who could generally afford care cannot get it, or cannot get to it. I am convinced that several factors must be brought to bear upon our current medical crisis. Of high priority is planning. This must be inclusive, regional and genuine. A business wracked with inefficiency and outlandish costs must come to terms with its waste. Moré attention must be given to preventive care. Plans and programs must be devised which will reduce the need to travel about to see several doctors or to make long trips to labs or other ancillary services. Drug costs must be reduced by moving toward such plans as generic buying and prescribing. Hospitals must include EKG departments and others which otherwise encourage privateering by private practice physicians. There must be incentives for planning and for participation in planning or conversely, penalties or lack of benefits for those who do not. In my own county, Marion, the Fairmont Clinic and a very few solo doctors will join in planning efforts. Other medical facilities and most of the doctors will not. This makes it nearly impossible to plan seriously and effectively. Consumer participation is mandatory. Public facilities and programs should be required to include on their boards and in their decision making significant percentages of consumers who reflect and represent the population of the service area. Finally, I would underscore the need for a patient oriented or service directed system. Probably the major weakness of medical centers associated with medical schools is their impersonality. Much of this is understandable since their primary function is education and training. But service must be made more humane. If it cannot be done in the medical school setting, then doctors need to be trained out in the areas where patients live, work, suffer and die. The profit motive is basic in our society. But humanity is even more basic. The health industry must put service to patients ahead of profit. Any other approach is evidence of a truly sick society. 2039 When I look over our region, assess my own immediate community, and ° analyze my own family's health needs and the available services and the costs, I see the need to encourage group practice wherever feasible and above all to provide a system of prepayment which enables all to have equal access to equal service. I do not believe this can or will ever be achieved without active consumer participation in the planning and the policing of the health industry. Thank you for your openness to our situation and for the opportunity to present these facts and factors to you and your committee. Reverend Richard Bowyer 59-661 -O -71-pt,. 9-5 2 7 73 Mmm wij } \ \ J Grant Town fA J in Mpaningien T*** NY FN 7 7 26 25 MFI wf 57 @\-, 7 Terra ~ the most highly urbanized, and the most industrialized--Harrison, Marion, 2048 “Om and Monongalia--have the highest levels of income. Conversely, those rural counties having heavy concentrations of employment in either agriculture or mining, and high levels of unemployment--Doddridge, Gilmer, and Preston--are observed to have the lowest income levels. It should be noted, however, that in no instance do median income figures for the counties approach the median levels found in the nation as a whole. These figures are presented in the following table (fig. I.4). fig. I.4 Median Income Figures Population Number of Median Families Families (1960) Families Family Under Over (1960) Income $3,000 $10,000 (1960) (%) %) United States $5,660 21.4 15.1 West Virgtats 4,572 32.6 8.4 Doddridge 6,970 1,756 3,041 49.5 2.1 Gilmer 8,050 1,911 2,719 54,7 3.0 Harrison 77,856 20,706 4,969 26.6 8.0 Lewis 19,711 4,562 3,503 43.2 5.2 Marion 63,717 17,278 5,153 25.3. 10.2 Monongalia 55,617 13,777 4,515 29.6 8.7 Preston 27,233 6,549 3,214 46.4 3.6 Taylor 15,010 - 3,874 3,425 44.7 2.8 Source: County and City Data Book, 1967, A Statistical Abstract Supploment, U. S. Department of Commerce, Bureau of the Census. The above table makes it readily apparent that in terms of income, we are dealing with one of the poorer sections of one of the nation's poorest 2049 - 10 = states. In five of the eight counties, the number of families having an income of less than $3,000 is more than double the figure for the natfon as a whole, and the remaining three counties are substantially above the nation also, in terms of the number of low-income families. Gilmer County, the poorest in income, has a median family income equal to 487 of the national sedten, C. Death Rates The tables found in this section deal with the available Anformation on death rates by age, race, and sex, including infant and maternal mortality rates. fig. I.5 peaths, Infant and Neonatal Deaths, Number and Rate by County in 1967% Deaths Infant Deaths Neonatal Deaths Number Rate Number Rate Number Rate West Virginia 19,257 10.6 750 25.6 560 19.1 Doddridge 93 13.8 1 12.2 - - Gilmer 93:.11.3 - - - - Harrison 958 12.9 27 23.5 26 22.7 Lewis 260 13.1 7 2.6 6 21.0 Marion 748 :¢12,3 22 22.9 18 18.7 ‘ Monongalia 559 10.1 27 27.7 20 20.5 Preston 250 10.9 8 16.5 7 14.4 Taylor - 169 11.6 WET ir. 5 19.3 ‘ ‘ aa * *As reported in Vital Statistics, 1967, Division of Vital Statistics, West Virginia Department of Health. 2050 - 11 = The Division of Vital Statistics also reported four maternal deaths for the state as a whole, a statewide maternal death rate of .2 for the year 1967. D. Description of Health Resources in the Area The following is a listing of the county health departments and the personnel they employ, This information was obtained from questionnaires completed at the request of Frederick Zeller, Director of the Office of Research and Development, West Virginia University, in 1968. fig. 1.6 County Public Health Services County Professional Personnel Full Time Part-Time Doddridge County Health Officer : - - . Public Health Nurses 1 - Gilmer County Health Officer - 1 Public Health Nurses 1 1 ‘Harrison County Health Officer 1 - 3 Public Health Nurses 8 - Sanitarians 4 - Laboratory Technician 1 - Lewis County Health Officer - 1 Public Health Nurses - - -Marion County Health Officer - 3 Public Health Nurses 7 - Monongalia County Health Officer 1 - x Public Health Nurses 15 - * Sanitarians 4 - Preston County Hualth Officer - 2 Public Health Nurses 1 - Sanitarians 1 - Taylor County Health Officer - 1 Public Health Nurses 5 - Sanitarians 1 - Speech Therapist 1 - 2051 - 12 = aw 3 It should be noted that only two of the eight counties report having a full time health officer. Doddridge County not only did not have the service of a County Health officer, but reported further that there was not a physician in the entire county, the only one having left the state. This fact is not shown in the following table which was prepared from information contained in the Report of the Health Advisory Committee of the Appalachian Regional Comite ion (1965). The _ reported data is for 1963. fis, 1.7 Number of Health Personnel (1963) County Doctors Dentists Active RN's QD _& DO) ; Doddridge 1 gi 4 J gr : : Gilmer 3° 1 _ Harrison 72 39 271 Lewis 13 ; 5 39 Marion 64 3: - 179 NITE The =be Monongalia 129 46 245 ACTOR OF # Meoiean : jehnadl Preston 12 7 31 Taylor 8 5 : 32 For the same year, 1963, the West Virginia Department of Mental Health issued the information listed in the following table: 2052 -13 = fig. 1.8 Health Personnel/Population Ratio (1963) Physician Dentist Public Health Sanitarian Ratio Ratio Nurse Ratio Ratio AMA STANDARD 1/700 1/2,000 1/5,000 1/15,000 West Virginia 1/1,153 1/2,494 1/12,700 1/19,755 Doddridge 1/7,473 1/3,736 1/7,473 1/7,473 Gilmer 1/2,204 1/2,939 -1/8,817 : Harrison 1/1,608 1/1,080 1/10,338* 1/14,473 Lewis 1/2,562 1/4,100 1/20,898 1/20,49 Marion 1/1,005 1/9,892 1/9,892 1/29,677 Monongalia 1/518 or 1/8,713 © 1/26,139 Preston 1/1,643 1/3,756 ’ 1/26,293 1/26,293 Taylor 1/1,578 1/3,551 1/7,101 1/14,202 It should be pointed out that the data for Monongalia County in the preceding table includes the West Virginia University Medical Center, making it the only county within the region to meet the AMA ratio of i . a 1 physicians to population, and one of two to better the state ratio. However Many OF These Physicians NEVEIL E+QAQe iw PRIMALY parienr (Re L More detailed information on the physicians within the region is provided in the following table (fig. I.9). More detailed information on the physicians within the region is provided in the following table, (fig. 1.9) fig. 1.9 ‘Major Professional Activity--December 31, 1966 Patient Care Solo, Partnership, Group, and Other Practice total medical surgical other hosp. other inactive County non-fed | total | G.P. specialeies specialties |specialties| based Pest, W.va. 1,732. 1,575 533 222 398 150 272 83 74 Doddridge 1 1 1 Gilmer A 3 2 1 Harrison 63 55 20 6 18 8 3 8 Lewis 12 9 3 3 1 2 1 2 Marion 57 52 - 19 12 13 3 3 2 Monongalia 194 116 13 7 15 5 76 73 5 Preston 12 11 7 1 J 2 Y 8 8 6 1 1 Taylor - Hl = £602 2054 - 15 = Again, it should be remembered in considering the preceding table that Monongalia County's data includes the personnel of the West Virginia University Mcdical Center. Also, the scle physician listed for Doddridge County has since departed. " Turning to facilities, we begin with the following list of general hospitals within the area (fig. 1.10), inventoried from 1/1/67 to 12/31/67. fig. 1.10 facility : county control licensed total capacity capacity Saint Mary's Hospital Harrison Rqueprotit 193 178 Union Protestant Hospital Harrison non-profit 150 131 Stonewall Jackson Mem. Hosp.® Lewis non-profit ; 47 70 Fairmont General Hospital#* Marion city } 207 242 Monongalia General Hospital Monongalia county 104 105 St. Vincent Pallotti Hosp. Monongalia non-profit 90 66 Preston Memorial Hospital Preston county 72 £72 Grafton City Hospital¥*¥¥ Taylor city 52 94 TOTALS 915 958 * The Stonewall Jackson Memorial Hospital is a new hospital being constructed under the E.D.A. Program. Bids opened 6/18/68. This facility replaces the General Osteopathic Hospital in Lewis County. *% At the time of the survey, the Fairmont General Hospital's 242 bed total capacity was under construction. One hundred sixty-one beds were replacements, while 81 beds represented an addition. wk At the time of the survey, the Grafton City Hospital's 94 bed total capacity was under construction. Forty-four beds were being remodeled and the remaining 50 beds represented an addition. 2055 w XBiw Fairmont Emergency Hospital Patients: 68 Fairmont Eme.gency Hospital was established in 1899 for the purpose of treating persons injured in their usual occupations. The hospital accepts surgical and maternity pay cases and is the surgical clinic for the Industrial School for Boys at Pruntytown, the Industrial School for Girls at Salem, the West Virginia Training School at Saint Mary's, the Children's ‘Home at Elkins, the Medium Security Prison at Huttonsville, the Spencer State Hospital at Spencer, the Weston State Hospital at Weston, the Barboursville State Hospital at Barboursville, the Forestry Camp at Davis, Lakin State Hospital at Lakin and from the West Virginia Penitentiary at Moundsville. No charge whatsoever is made for these cases. The work of the current year at regular nospital prices represents more than the total ‘cost of the operation of the institution. The purpose of the institution at present is rapid service surgical rehabilitation. ‘Hopemont State Hospital Patients: 322 . Hopemont State Hospital on a 600-acre tract of land, formerly known as Hopemont Sanitarium, is located at Hopemont, near Terra Alta, in Preston County and was founded in 1913 as a tuberculosis hospital. In 1965 legislation was enacted to change the name of the hospital and convert it to an institution for both chronically ill and aged and infirm, The institution consists of four fireproof hospital units under one roof. Also, Conley Hospital, a separate unit, is used to hospitalize tuberculous prisoners under maximum security regulations. Other units of the hospital consist of residences, nurses' home, main dining hall, post office and laundry. } : A registered Holstein herd is maintained to provide pasteurized and homogenized milk for the institution, and a piggery provides pork. Weston State Hospital Patients: 1,950 The Weston State Hospital is located in the City of Weston. It is the oldest state institution in West Virginia, authorized on March 22,- 1858, by an act of the Virginia Assembly. Thera was considerable delay in the construction of the hospital due to the Civil War, and the first patients were received on October 22, 1864. The hospital has grown frum an initial capacity of 35 patients to 1,600. The hospital is maintained and equipped to provide adequate treatment for all types of mental and nervous illness, both voluntary and court committed. 59-661 -O-71-pt, 9-6 2056 17 «18 The hospital plant includes specially constructed buildings to take care of all criminally insane in the State, mentally ill tubercular patients, and two geriatric buildings for men and women. A section of the male wards is designated as the West Virginia Soldiers' Home and is administered by the hospital medical staff. All war veterans are admitted here for treatment. The hospital is equipped to provide various types of treatment, including psychotherapy, occupational and recreational - therapies and electro-shock therapy. The facilities consist of a laboratory, x-ray, social services, pathology department, psychology department and an In-service Training Program for the psychiatric aides. There is a Vocational Rehabilitation Center on the grounds and a Half- Way- House for the training and rehabilitation of the mentally ill. .The hospital has 615 employees including 11 physicians, a dentist, 13 registered nurses, a registered dietician, a chiropodist, beautician, and barber. A consulting staff of local physicians help provide additional services to the patients. A registered herd of Holstein cows is maintained, thus providing the hospital with an adequate supply of high grade milk, processed in a modern, pasteurized plant fully approved by the State Board of Health. A coal mine at the Western end of the farm operated by the Hospital furnishes coal for the four boilers in the power plant which supplies the heating, hot water and steam requirements for the Institution. The building and outlying farms occupy some 600 acres of land in Lewis County. The hospital grounds are large and spacious with many shade trees and provide excellent facilities for the patients. West Virginia University Hospital Morgantown, West Virginia Bed Capacity: 434 Established 1960; service area entire State, This is primarily a teaching hospital for West Virginia University. There is a waiting list for patients who are to be admitted to the hospital but this tends to be seasonal. Special services: Psychiatric, Pediatric, Obstetrics, Intensive Care, Out Patient Clinic, Special Treatment Units. VA Hospital 1 Clarkst rg, West Virginia ¥ Bed Capacity: 200 Established March 12, 1951. Service area North Central West Virginia, Eastern Ohio, Southern Pennsylvania, Garrett County, Maryland. This is a Federal hospital and only veterans can apply for services here. They have no waiting list, The services are short-term and those offered are: surgical, medical, psychiatric and out patient, 2057 HEALTH CARE IN WEST VIRGINIA The survey of a topic of such inclusiveness as "health care" is bound by certain limitations. In the first place it is not possible to touch more than superficially on any one facet of the topic, let alone offer much depth analysis of the whole scope of health concerns. Further there are the combined limitations and benefits of a consumer's point of view. There has been no direct input into the analysis by providers of health care. Perhaps senetine should be said about the advantages and disadvantages of a consumer perspective. It lacks the precise data and comprehension of technical aspects of the problem. It may very well fail to assess adequately the role of the provider in both problem and solution and fail to see modifying or contributing factors of professional inter-relationships on the one hand or physical-mental-environmental factors on the other. The consumer role is the largest part played in the wile drama of health care. Thus it is valuable to see the problem from that perspective. The provider viewpoint is often made known through meetings and the media and it is often the only view heard or expressed. There are avaltibes to all in presenting another point of view. Accepting the importance in our society of enlightened self-interest, one must never lose sight of the fact that even when enlightened, self-interest is a basic factor in all social, economic and political issues. It seems, however, that the self-interest of the consumer is more likely to be in common with more persons across a much broader section of society than is that of the provider. Federal and State Government has recognized this in providing in programs of Comprehensive Health Planning for boards to be at 2058 least 51% consumer in their composure. Public Law 89~749 provides for comprehensive health planning. I.. WHAT IS THE ISSUE? Given these factors and the overwhelming complexity of the field of health care, it seems wiser to focus primarily on the problems associated with the delivery of services. One could develop separate papers on specific problems in environmental health such as air and stream pollution, or on mental health, or on problems related to hunger and malnutrition, family planning, maternal and child care or many other important health care issues. But at the core of all of this there must be services and there must be ways of making these services available to those for whom they are intended. The central issue in health care, to those who prepared this paper at least, is the delivery of services. II. WHAT ARE THE RELEVANT FACTS? There has been considerable focus in recent years on the problem of the poor. For example, an Heal th, Education and Welfare document published in December 1967 (Human Investment Programs "Delivery of Health Services for the Poor") reveals that among persons with family incomes of less than $2,000, about 29 percent have chronic conditions with limitation of activity, as contrasted with less than 7.5 percent among persons with family incomes of $7,000 or Persons with family income of less than $2,000 have more than double the days of restricted activity per year than persons with an income of $7,000 or more. For males in the working age group 45-64, the lower income group has three and one half times as many disability days -- 49.5 in the under $2,000 income group compared to 14.3 in the over $7,000 income group. 2059 In one year, a larger proportion of persons who live in low income families have multiple hospital episodes than those in higher income groups. The length of hospital stay is longer for the poor......, and they are more often hospitalized for non-surgical conditions. This exists in spite of the fact that the poor are much less likely to have hospital insurance to cover the bill. Increasingly students of the health system in America are underscoring the fact that "Middle America" suffers from the same dificiencies of the system as do the poor. We would stress the fact that problems of the delivery of health services affect most of the people of the State of West Virginia and that the poor, white and non-white, experience the problem to a considerably greater degree than the non-poor. Because of the number of low and moderate income persons in West Virginia, the following from the same HEW document quoted above seems appropo to the State as a whole: The following are a few salient reasons for the poor health status of the low income population: 1) The current "system" in which the poor receive health services perpet- uates fragmented emergency-oriented medical care which is often relatively inaccessible in terms of time and location. 2) Despite recent legislation, inability to pay for services remains an important barrier to the poor's quest for health care. 3) Medical facilities and health manpower are particularly scarce in areas with a high concentration of poor. The problem is one of availability and accessibility of services. Medical facilities and physicians are condertrated in larger population centers. For example, a random survey of 21 low income communities was conducted in April and May of 1970 in Marion County covering 177 families representing 709 persons. Problems of getting medical services were reported as follows: 2060 43.2% listed distance to a health facility as being a problem 27.8% lack of public transportation 23.4% lack transportation 3.6% lack private transportation The 169 families responding (to this question) must travel an average distance of 9.4 miles to a doctor. The least number of miles to travel is 1 and the greatest number of miles is 30. The distance to a hospital for 124 families responding is an average of 19,23 miles. (Conducted by Marion County Community Action Association) There are many places in West Virginia where these problems are much more acute. A closely related problem is the near total lack of planning for and co- ordination of services. Various facilities such as hospitals exist in many communities with no effort to combine and exchange services. Thus the cost of care is increased while efficiency of service from which the consumer benefits directly is decreased. Solo practice and a general attitude ranging from resistance to outright hostility toward group practice perpetuates inefficiency and reduces the general quality of care. There is abundant evidence that for quality care a high degree of co-operation and sharing of resources by providers is basic. Without being in any way critical of solo practice physicians, this is a major reason why Congressional leaders, Public Health Service personnel, Health, Education and Welfare staff, insurance leaders, labor unions, and our last four Presidents say without hesitation that pre-paid group practice is foremost in the solution of our American health crisis. A U.S. Department of Commerce publication, "U.S. Industrial Outlook 1970" states that: Prepaid group practice has demonstrated that health costs are reduced by removing financial barriers to preventive medicine, early treatment and choice of needed medical services. 2061 5-6 The crisis in health care compounds itself by the lack of preventive medicine. This is the biggest factor for the poor. They can't possibly afford anything but crisis care, never seeing a doctor until it is an absolute necessity often of life or death. This keeps the death rate of newborns and infants high. (HEW figures for 1967 show that West Virginia*had a 25.6 per thousand infant death rate as compared to 22.4 for the nation. The neonatal death rate for West Virginia was 19.1 compared to 16.5 for the nation.) It keeps cost high also, for when the patient, poor or middle class, finally comes there is so much background data to work up and side problems to be dealt with that could easily have been prevented in early stages even by periodic check-ups. Such things also affect quality, for the physician, already over worked, simply cannot do all that needs to be done for all the people who come. And he is now so overwhelmed with patients (many refuse to take anyone new except in a genuinely dire emergency) that he cannot possibly do any general preventive care. There are others who insist that the problem is one of money. Few in West Virginia seem to see it as essentially a matter of organizing health care for more efficient and effective service. This includes scrutinizing existing medical services of all kinds in terms of future federal and/or state financial aid, and planning with much more care for the future. This paper was prepared by Richard Bowyer in consultation with Claude Arnett. Mr. Arnett is currently employed in the On the Job Training Program of the West Virginia Federation of Labor. He has had experience as an organizer of the HEAT organization in Marion County and in work with the Community Action Association. He has been active in the development of comprehensive health planning in Region V of the State and is a member of the Board of the Marion County Hezlth Planning Association. : Mr. Bowyer is president of the board of the Health Planning Association of North Central West Virginia, a member of the West Virginia Public Health Association, and a member of the Ad Hoc Committee on Continuing Education of the State Office of Comprehensive Health Planning. 2062 HEALTH RELATED DATA, MARION, MONONGALIA & PRESTON COUNTIES, West Va. Table of Contents Hospitals 2 Local Health Department Budgets 3 General Information 4 Economic internation 5 Public Assistance & Food Stamp Programs 6 Preston County: Population Distribution & Change 8 Preston County: Poor Families, 1960 and 1966 9 Health Characteristics of Preston County 10 Other Socio-Economic Characteristics of Preston Cty Hl Population Change in West Virginia, 1960-70 2 Compiled by Division of Public Health & Preventive Medicine West Virginia Univ. Medical Center Morgantown, West Va. 26506 Marion, Morongalia and Preston County Hospitals Marion tonongalia Preston Feirmont Fairmont Monongalia St. Vincent Hopemont Preston Emergency General General Pallotti State rierorial . Name & Lccation Hospital Hocpital Hospital Hospital: W.V.U. Fospital Hospital Hospital Administrator J. C. Morgan 0. B. Ayers |[W.B. Rhodes Sr. 11. Pia E.L. Staples H.C. Rocha | I. Allsopp Control 12 14. 13 23 12 12 13 Service 10 10 10 10 0 48 10 Stay s S "8S S S L S Beds 58 207 116 90 434 300 56 Admissions 993 8,468 3,780 3,043 11,71 195 1,564" Cerave 30 18% 76 67 349 196 3c Z Occupancy 51.2 89.8 72.6 75.0 81.1 65.2 sia Newborn Data Bassinets 10 30 18 12 20 — 17 Births 63 1,078 415 186 820 -— 204 Expense Total 335 2,780 1,693 1,028 7,140 - 1,380 492 ‘Payroll wi 1,756 621 740 ~ 1,004 309 Personnel 61 384 175 161 949 328 82 Source: Hospital| Guide Issue, August, 1970 £902 2064 LOCAL HLALTH DEPARTMENT BUDGETS 1970 FISCAL YLAR¥ ifarion Monongalia Preston Total Budget 125,036 702,167 5 33.580 State & Federal Funds 27,333 470,672 14,841 Percent Statekrederal 28% 67% Lug LOCAL APPROPRIATIONS County Court 33,212 94,850 12,739 Municipality 11,703 8,934 Board of Education 22,000 16 500 6.000 Home Health : 25,959 231.211 Other 4 829 TOTAL Local Funds 97.703 231,495 18.739 Percent Local 72% 33% 56% Population, 1970 Census 61,356 €3,714 25 455 Per capita expense 2.04 11.00 3.32 ¥West Virginia Department of Health Annual Budget, Fiscal Year 1970. . X LICENSED PHYSICIANS BY COUNTY OF PRACTICE x LOSS OR GAIN 1959-69 County Sie Loss or Gain between 1959-1969 Marion -18 Monongalia : +91 bo. Preston f dl From The Medical Licensing Board of West. Virginia Figures do not include osteopaths. **(Note: Many physicians are licensed in more than one state; licensure does not indicate active practice, e.g. the +91 for Monongalia County includes resident physicians and those in research and teaching at the University, also retired physicians invariably retain their licenses though inactgve.) 2065 GUNERAL INFORMATION hea Copmbler 3.3n West Vircinda Nay Eo iat pm ERE Va, To Mapion GL Hewtnpa¥is Treston:’ 2,005,552 11.541 €0,797 | 31,399 1,860,h21 035717 59,617 | 27,233 1,745,237 61,356. 63,714 25,455 -7.2 -10.9 -8.5 | =)3.3 -6.7 wd 37 +1176 { - 6.5 . 1 83% fSh. wing)? 24,282 31h 369 | 654 Lala deat Fairmont Horgantown | Kingood : ! Con, % nt 1on(1970)" 21,405 20,074 Von non I% 3 b 16.8 16.3 ifs . al .0 CTRL 1969° «| 31.6 12.5 9.2 fang . “gt nate, 19697 | 23.3 18.3 13.1 | 8.8% ‘ | Ni ei ER iinnnt Ati > 2 4oveporied. ECONOMIC INFORMAT iow Three Comties in West virethsa West Va. Marion Monongalia Preston Lncoue / WT rex canlta personal irnco: e(1965)0 203 25082 197h 3273 Mealen Yamily Income, 1960 572 315 £515 3234 Percent Families < 3000, 960 7 32.6 29.6 ue. Percent laullies > 10,000, i 3.4 8.7 3.6 Socio economic Ranking p ; Un Oeeupntion\@dueatlon and 15 8 } hy Incom2 Caron 55 Yast Va. Count, oy re a 90 : . (Whousands of dollar 8) (WapestSalarles) Mind ng 320,800 5532 15427 6275 Goverurent cc 370,041 10024 15448 1113 Mannich urdng 829,500 35867. 13297 3609 Pranrpori, Cowmunicatlon, ; and Public Uuilittes 256,001 10085 37h2 “3146 Who] ale ani otall trade 331,200 11527 9356 2373 ys X 1970? Tovul 24750 27060 7360. Uhenple; 870 1300 510 Lute 3.5 h.8 6.9 County Court Bude, 58.5010 14300 7850 5400 2066 ¥en vee PUBLIC ASSTHTANCE AWARD EXPENDITURES BY ZAYTGORY FISCAL YEAR ENDED JUME 30, 1969 * Cutepory of Assistance Marion '" i: _ _. Nenonpalle® . . “Preston. . Ola Age Assistance Toba) 202,168 © 199,530 a Average Nuiber of Cascs . 247 ! / we IT¥ : hyd) Average donthly Awards 75.05 97. 24 49.42 Ma to the Blind Total 3.942 8.58% 5 4,239 Average llunber of Cases : 10 9 Average Monthly Awards 47.00 71.50" / 39.22... Ald to the Disabled Total 19,558 © 62,869 43,662 Average Humber of Cases 114 7h | 85 Average lMonthly Awards + 58.23 70.80 42.81 2. DN \ FOOD STAMP PROGRAM SUMIARY OFF PARTICIPATION BY COUNTY FISCAL YEAR ENDING JUNE 30, 1969l¢ | { _farion Monongalia | Preston. Average No. of Housecholus > a Participating Monthly ; 558 384 430 Total Cash l'ald for Stamps : : : Duvlpg Year 245,810.25 158,550.00 200,037.00 Fonus Coupons (Inercused 157,229.75 131,161.75 142,553.00 Purchasing Pouer) t ' Total Value {food Stains Issued 403,040.00 269,712.06. 342,450.00 2067 REFERENCES 1. YuS. Doccanind ¢ ’ 2. JFinel Iouwwloiion Co fi, 1970, Bureau of the Census (December, 1970). 3. West Viridula Blu: Book, 1908. 4, Reports, pe(pl)-50, 1970 Census of Population, West Virginia Top vincent off Commerce. 5. Vital Stablotics, West Vireginla Department of Health, 1959, 6. County Papa J , West Virpminia, 1962-65, Leyden, D.R. and Rader, R.D. bi TBusints lesdarch, College of Commerce , .est Virginia Untvors ity Economic Development Series No 11, December, 1968. 7. Bureau ol the Census, U:3. Department of Commerce: U.S. Census of Populatien, 1960, pe (1)-50A. 8. Thompson, J.M.,Golidamitn, H.F. and Stockwell, F.G. Socioeconomic Ranking of Counties in Lae Northeastern United States from V Virginia to Maine, 1960. Mental lzalch Study Center, National Institute of Mental “Health. Lab Paper No. 13, November, 1965. 9. Department of Ekmployment Security, Charleston, West Virginia. 10. Municipal and Ccunty Budgets in West Virginia, 1958-60. Bureau for Government Research, West Virginia University, Publ. No. 27. 11. Rankings of the Counties, 1970. Research Report. West Virginia Education Association, Charleston, Vest Virginia. 12. West Virginia Department of Welfare, Annual Report, 7-1-68 to 6-30- -69, . Charleston, West Virginia. .. Age Group Under 5 5-19 20-41 45-64 PRESTON COUNTY, West Virginia Land area in square miles 64s Urban places in square miles 1.6 1950 1960 1970 Io.0 2.0 39.5 Urban Rural/farm Rural /nonfarm *Percent population 10.1 1.1L 75.5 / 7 Persons per square mile Table I Population Distribution and Percent Change 1950 - 1970%* Preston - - County State of West Virginia : i Ho. % No. 1950 1970 Change Change 1950 1970 Change Change: 3,929 2,206 -1,723 -b43.9 240,107 139,021 -101,086. -k2.1 9,284 7,585 -1,699 ~-18.3 562,809 508,309 - 54,500 - 9.7 10,33 6,917 -3,)19 .-33.1 720,383 511,954 -208,k29 -28.9 ; 5,232 5,552 + 320 +L.) 343,727 390,833 + 47,106 413.7 65 and over _2,618 _3,195 +_ST7 +22.0 138,526 194,120 + 55,504 +40.1 Totals 31,399 25,455 -5,944 -18.9 2,005,552 1,Tu4k,237 -261,315 -13.0 ’ . 2 ¥Source: OEO Communi ty Profile Project. Computer Printout, OEO, Charleston, W.Va. ¥%Source: U.S. Census. 8902 Preston County, West Va. Table II Poor Families, 1960 and 1966 Percent U. Si . ” betcent Counties Having Percent Poor Families Poor Families? Lower Percent of County Families in County Number of Families Number Percent Poor Families? of State Total of Stete Total 1960 1966 1960 1066 1960 1966 1960 1966 1966 1966 3 es State of West Virginia 462,100 482,900 139,400 105,900 30.1 21.9 100.0 100.0 friend County, W. Va. 6,549 6,079 2,804 2,1k0 L4.2 31.2 80 gud 1.k . 2.0 N 8In the typical county in the United States in 1966 there were 1,221 families ranked as poor. This represented 15.1% of total families in such a "typical " county. ; . . bEighty- four percent means that only sixteen percent of all U. S. counties had a cratilbosdenion of POE families then Preston Taubty. Source: 00 Community Profile Project. Computer Printout, OEQ, Charleston, W. Va. 6902 2070 Health Characteristics (Preston County) Five year average infant mortality rate 1961-19651 27.9 Physician to population ratio 1/4,242 Dentist to population ratio 1/8,485 Health officer part-time contributes approximately } day per week to public health duties Public health nurse to population ratio 1/25,455 Public health sanitarian to population ratio 1/25,455 General hospitals 1 . Beds 54 County Health department budget - 19702 ' Total Federal % State % Local Z Per Capita Exp. Preston County ° - 33,580 4.8 39.4 55.8 1.32 Monongalia County? - 702,167 63.7 3.3 33.0 11.02 Approximate per capita governmental expenditures for health contrasting rural ih West Virginia with urban Washington, D.C. West Virginia - Combined expenditures of W.Va. Departments of Health, Welfare, and Mental Health. 1970 Fiscal Year 7,823,000 State Department of Health 15,500,000 State Department of Welfare (Medicaid) 17,400,409 State Department of Mental Health 40,723,409 TOTAL 41,000,000 wu $24,12 per Capita 1,700,000 District of Columbia - Total expenditures of the D.C. Department of Public Health. 1969-1970° 89,000,000 = $111.25 per Capita 800,000 Sources: lWest Virginia Department of Health, The Past Twenty Years of Maternal and Infant Health in West Virginia. Compared with the U.S. 1946-65, June 1968. yest Virginia State Health Department. Footnotes: 8Comparison with Monongalia County, where the resources of West Virginia University are located, shows relative inability of rural counties in lacking sophistication in grantsmanship and health manpower to compete for and capture Federal funds for health. District of Columbia figures include equivalent appropriation categories for_ mental health and welfare cited as separate items in West Virginia. 2071 Other Socio-Economic Characteristics (Preston County) Inconel Total Personal Income (1965) ; $33,773,000 Total wages and salaries - « 2%,917,000 Total transfer payments 5,277,000 Per capita personal income (1965) ‘ 1,271 % : Median family income (1960) 3,214 “ % families < $3,000 (1960) 46.4% Z families >» $10,000 (1960) 3.6% Public Assistance ! Average Monthly Public Assistance Cases July 1968 - June 19692 Total 6 ! OAA 128 . AB 9 AD 85 AFDC 138 Education3 Median school years completed Z completed < 5 years % completed high school or more Housing” All occupied housing units 7,681 All hodsing units with plumbing facilities 5,869 All housing units lacking plumbing facilities 2,656 = Sources: lLeyden, Dennis R. and Rader, Robert D., County Personal Income West Virginia, 1962 - 1965, Bureau of Business Research, W.V.U., December, 1968. 2Y. Va. Department of Welfare: Annual Report, July, 1968 to June, 1969, Charleston, West Virginia. : 31960 Census 41970 Census 59-661 -O -71-pt, 9-7 2072 information series 12 population change in WEST VIRGINIA 1960-70 a preliminary study | ! A ——— SAA A AA TY —— AY [A FEY Ye mg A OFFICE OF RESEARCH AND DEVELOPMENT Appalachian Center/West Virginia University 3 J A ep A Ritson ci on BRA SA ale. 4 tm em nt rt i. SAA mt tA 0 ks 0 rn 1 7 fot 2073 A PRELIMINARY STUDY OF POPULATION CHANGE IN WEST VIRGINIA, 1960-1970 The 1970 data are final Population Counts (PC[V1]50, December, 1970) of the 1970 Census of Population and Housing. The Births and Deaths for January 1 to March 31, 1970 are not available so that the total number April 1, “1960 to December 31, 1969 is adjusted by % of the 1969 Births and Deaths as the best estimates of the adjustment needed. The table displays 1970 Census figures, the 1960 Census Counts, the net change 1960-1970, the rate of change 1960-1970 based on the 1960 Census base, the Births and Deaths April 1, 1960 to December 31, 1969, plus % of the 1969 Births and Deaths, net migration numbers, and the rate of net migration with the 1960 Census figure serving as the base. The two Censuses and the Births and Deaths are basic data, the other items are calculations. Net change is 1970 Census figures minus 1960 Census divided by 1960 Census and multiplied by 100. Net migration is 1970 Census minus the sum of the 1960 Census plus the natural increase. The rate of migration is net migration divided by 1960 Census multiplied by 100. According to the final figures in the table, the state lost 116,184 of its 1960 base population and has had a net out migration of 263,454. These figures compare with 145,000 net loss for 1950-1960 and a net out migration of 447,000 for the 1950-1960 period. The greatest source of net out migration, percentagewise, was from the southern coal counties which sustained the heaviest losses in the 1950-1960 decade, with substantial losses occur- ring among rural counties of central West Virginia. Kanawha County had the greatest absolute loss and greatest out migration, though percentagewise McDowell County was the highest in each instance. It is not possible, at this time, to indicate the sequence of the loss on an annual basis. While thére is evidence that the direction of population change may be reversed in some areas of the state, in others, where high levels of unemployment remain, the key to a reverse of direction — job opportu- nities in the local labor markets — is lacking. The Census figures in the table are final, but some revision will be attempted in July 1971 when 1970 Births and Deaths data will be available. In the light of the substantial population change, it was believed to be valuable and of considerable interest to have these data available at this time. LEONARD SIZER ! Associate Professor of Sociology West Virginia University ACKNOWLEDGEMENTS The author wishes to acknowledge the assistance of the ‘ Computer Center of West Virginia University in program- t ming and in performance of the calculations, the Division { of the Agricultural E * Station jn preparing certain of the data, and Donald R. Deluca, graduate assistant, in the Division of Social and Economic Development of the Appalachian Center. of M R 7 County Barbour Berkeley Boone Braxton Brooke Cabell Calhoun Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Jefferson Kanawha Lewis Lincoln Logan McDowell Marion Marshall Mason Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas Ohio Pendleton Pleasants Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood Wyoming STATE 2074 THE FINAL COUNTS OF 1970 CENSUS AND SOME PRELIMINARY INFORMATION ON THE COMPONENTS OF CHANGE, 1960-1970 1970 Census 14030 36356 25118 12666 29685 106918 7046 9330 6389 49332 7782 8607 32090 11710 39749 8855 73028 20903 21280 229515 17847 18912 46269 50666 61356 37598 24306 63206 23109 32780 63714 11272 8547 22652 64197 7031 7274 8870 25455 27625 70080 24596 10145 14111 13213 13878 7447 9929 19092 37581 9809 20314 4154 86818 30095 1744237 1960 Census 15474 33791 28764 15152 28940 108202 7948 11942 6970 61731 8050 8304 34446 11705 39615 9308 77856 18541 18665 252925 1971 20267 61570 71359 63717 38041 24459 68206 22354 39742 55617 11584 8376 25414 68437 8093 7124 10136 27233 23561 77826 26349 10877 15720 16640 15010 7750 10026 18292 38977 13719 19347 4391 78331 34836 1860421 oo Net Change -1444 2565 -3646 -2486 745 -1284 -902 -2612 581 12399 -268 303 -2356 5 134 453 -4828 2362 2615 -23410 -1864 -1355 -15301 -20693 -2361 443 -153 -5000 755 6962 8097 312 1m | -2862 -4240 * -1062 150 -1266 -1778 4064 7746 1763 -732 -1609 -2427 -1132 -303 97 800 -1396 3910 - 967 237 8487 4741 116184 Rate Births Deaths Change ~ 9.3 2603 1900 76 . 6854 3996 -12.7 4840 2379 -16.4 2596 1733 26 5163 2675 “1.2 20037 11539 -11.3 1518 877 21.9 2263 101 8.3 1032 945 -20.1 9607 6689 -3.3 1484 930 3.6 1808 899 -6.8 6247 3646 0.0 2175 1391 0.3 7683 3568 4.9 1611 998 -6.2 13363 9128 123 4064 1761 14.0 4253 2208 9.3 46209 21943 -9.5 3197 2406 6.7 4173 1938 24.9 10997 5003 -29.0 12817 6340 3.7 10595 7548 -1.2 6548 3988 0.6 4346 2245 7.3 11761 7604 34 4763 2497 -17.5 8365 3649 14.6 10228 5419 2.7 1748 1359 20 1596 979 -11.3 4805 2302 -6.2 11829 8831 / +131 1198 861 21 1268 749 -125 1866 1243 -6.5 5104 2766 172 4276 1997 -10.0 12672 7695 -6.7 5264 2981 -6.7 1753 1517 -10.2 2452 1662 -16.5 2351 1944 1.5 2273 1978 -3.9 1376 1020 -1.0 1726 1303 4.4 3346 2137 -3.6 6948 3274 -28.5 2561 1374 5.0 4186 2224 -5.4 746 577 10.8 16850 8318 -13.6 6262 2409 6.2 337646 190353 XN, Net Migr- tion Change -2147 -293 -6107 -3349 -1743 -9782 -1543 -3853 -667 -16317 -822 -605 -4956 -779 -3980 -1066 -9063 59 570 -47675 -2655 -3590 -21294 -27169 -5407 -3002 -2254 -9157 -1510 -11678 3287 -701 -445 -56365 -7237 -1398 -369 -1889 -4115 1785 -12722 -4035 -967 -2398 -2833 -1427 -658 -620 -409 -5069 -5096 -995 -406 -44 -8594 -263454 Rate Change -13.9 -0.9 21.2 22.1 -6.0 9.0 19.4 -32.3 -9.6 24.8 -10.2 7.3 14.4 -6.7 410.0 11.5 “11,6 0.3 3.1 -18.8 135 7.7 34.6 -38.1 8.5 7.9 9.2 -13.4 -6.8 204 5.9 -6.1 -6.3 211 -10.6 -17.3 -5.2 -18.6 -16.1 76 -16.3 -16.3 8.9 -16.3 -18.1 -9.5 -8.5 -6.2 -2.2 -13.0 37.1 -5.1 - -9.2 0.1 -24.7 -14.2 ~ 2075 FAMILY SERVICE ASSOCIATION 364 HIGH STREET TELEPHONE 2902-9463 MORGANTOWN, WEST VIRGINIA April 23, 1971 The Honorable Senator Edward Kennedy Chairman of Senate Sub-Committee on Health Senate Building \ Washington, D. Cs Dear Sir: Family Service Association of Morgantown, West Virginia, serves hun-— eds of rural families. As executive director I wish the following comments entered as testimony for the hearing conducted in Kingwood, West Virginia. The poverty in which so many rural families must live so jeopardizes the health of children, adults, and the aged, that any national program deal- ing with health services is bound to be excessively expensive and completely inadequate unless the legislation for adequate incomes accompanies legislation for health services. The problems of income adequate to provide for decent food, clothing, and shelter, cannot be separated from the problems of health maintenance and prevention of illness. Babies, small children, and adults have more health problems because they live in houses without windows, their resistance is lowered by malnutrition and they lack shoes and warm clothing. In Morgantown, West Virginia, incongruous as this seems, there is not one business which delivers coal to people who still heat their houses (shacks) with coal-burning stoves. There are only a few doctors willing to diagnose or treat "malnutrition" as a medical problem; worm infestations in children and adults are generally ig- nored. In West Virginia, the Crippled Childrens Program (Department of Public Hettare) provides medical services for children of any parent (not only welfare parents). This program specifically excludes children with "terminal" illness. In the past two years three children in this area have had leukemia and their working parents became completely dependent upon charity for the medical treat- ment of their children. No program covers children who were dying. The problems of prejudice must be recognized and dealt with if a national health insurance program is ever to really be of benefit to the rural poor. Based on my day to day experiences as a social worker, I see too much evidence of preju- dice and discrimination toward poor people by health providers to believe that a A MEMBER AGENCY UN ND OF THE UNITED FUND 2076 Page 2 national health insurance program would not primarily benefit the middle income group. Most doctors seem to have punitive attitudes toward poor people. There will need to be special incentives for providing medical services to the poor for doctors generally to want to reach out to the poor. These consumers need to have more power in the medical services market place. I also believe that the proposed legislation needs to (if this is possible) reward doctors for prevention rather than treatment. A major problem with our health services delivery system is that health jobs are dependent upon people continuing to get sick, not on helping people stay healthy. Sincerely, PD Bey Patricia M. oy or > Executive Director PMK/sd 2077 UNITED STATES DEPARTMENT OF AGRICULTURE FARMERS HOME ADMINISTRATION SURVEY—WATER AND WASTE DISPOSAL SYSTEMS RURAL AREAS-—WEST VIRGINIA A. Total Population (West Virginia) : 1,860,421 B. Urban Population (FHA definition): 27 Municipalities (population of over 5,500) 571,174 10% Additional (fringe area) 57,117 628,291 C. Rural Population (FHA definition—A, B) ; 1,232,130 D. Number of Households (Rural areas) (3.51) 322, 544 Water: A total of 787 communities (245 towns and villages——542 other communities) either need a community water system or enlargement or improvement in their present system. There are 120,28, households involved with an estimated cost of $150,804,000. Sewer: A total of 682 communities (235 towns and villages—A447 other communities) either need a community waste disposal system or enlarge- ment or improvement in their present system. There are 156,250 households involved, with a total estimated cost of $306,865,000. SUMMARY OF SURVEY : No. of Communities People Where Improvements Households Involved Estimated Needed Involved (3.5) Cost Water : 787 120,284 411,080 $150,804,000 Waste Disposal 682 156,250 546,875 306,865,000 TOTAL 1,469 276,534 957,965 $457,669,000 orien Aptreedi wietels, 4 £c0,6¢ 0 (SH L. Sud eC ) mn. » -.7 7 / " +7 ol re / - Sel sc Meiclars { : ’ 2078 UNITED STATES DEPARTMENT OF AGRICULTURE FARMERS HOME ADMINISTRATION Morgantown, West Virginia March 12, 1970 Dependable water facilities and safe sanitary sewer systems rank high among needs in rural West Virginia. By an expenditure of about $457,670,000 rural West Virginia families could have modern water and waste disposal facilities. The annual invest- ment in these basic facilities is thought to be in the range of $40 to $50 million dollars. : The magnitude of the problem was brought into sharp focus yesterday in a report issued by J. Kenton Lambert, state director of the Farmers Home Administration. An investigation conducted by the FHA revedled that out of the state rural population, figured to be 1,232,130, over 411,000 people are forced to rely on unsuitable drinking water and approximately 546,800 people have inadequate sewer service. The total cost of supplying these basic facilities in proper quality and quantity is estimated at $457,670,000. "The facts are documented and laid on the table,” said Lambert. "Nearly 1 out of 2 rural people have moderate to severe water and sewer problems. This unhealthful situation cannot be continued. It is not only dangerous to lives but a major roadblock to the success of rural areas." "Answers are available. They call for a sizeable outlay of cash, citizens sincere and concerned ot future conditions, and a government responsive to the attitudes of the people." 2079 The state-wide investigation into the water and sewer service needs of individual families was initiated by the FHA, according to Lambert, to help the agency develop immediate and long-range planning for financ- ing water and waste disposal systems. With the actual compilation of the facts and figures, now, it can be readily seen that water and sewer development must be in the forefront of any comprehensive program to devise a satisfying human environment in the Mountain State. "Although considerable progress has already been noted in the installation of community facilities," commented Lambert, "the need is still acute and veiains a prerequisite to the survival and growth of a large part of the State. Families are no longer willing to settle for outmoded water Svan and sewer systems that pollute the soil and air and degrade living conditions. However, the desired development won't happen overnight, nor did the ravaging pollution and water shortages occur Just yesterday." Efforts to place fresh, pure water within reach of every family and corresponding modern treatment of waste are in for intensification. Public interest has been aroused. Once more families are turning to the countryside and towns in search of living space. local leaders and government have an unusual opportunity at this Cie to plan and work in partnership for the orderly development of rural-based communities. It is vettor to plan subdivisions and town enlargement than to follow the growth with remedial programs. 2080 In arriving at the State's rural population of 1,232,130, for the : study, the 27 municipalities exceeding 5,500 people were classified . urban. These municipalities exbrone 571,174 people and added to that number was an additional 10 percent to cover the fringe areas of the cities. Rural West Virginia, under this definition, houses 66 percent of the State's population. Some 787 communities--245 towns and viXlegds and 542 unincorporated areas—were found to need 3 ‘Gentral water system or enlargement or improvement in their present system. There are 120,284 households involved and the cost of meeting water needs was calculated at $150, 804,000. Turning to the sewer problem, 682 communities split between 235 towns and villages and 447 unincorporated communities’ either need new waste disposal systems or a major improvement to present facilities. To supply asteptatle service to the 156,250 households would cost an estimated $306,865,000. Farmers Home Administration county supervisors carried out the water and sewer needs investigation under the coordination of William A. Jones, chief of the agency's community services program. In addition to county supervisors' own knowledge of the areas, helpful information and assistance were obtained from: studies made by universities, utility companies, health department, and state agencies; local planning groups; comprehensive countywide water and sewer plans which have been prepared in most counties under FHA financing; and in consultation with local sanitarians and governing officials. 2081 At this time nearly 100 towns, public service district, or nonprofit organizations have applications filed with the Farmers Home Administration for financial aid and technical supervision in securing water and sewer plants. "It is incumbent upon the Farmers Home Administration, an instrument of the tax-paying public, to operate as fairly and efficiently as possible in processing all loan and grant applications," declared Lambert. '"We will strive to meet the challenge, but ask for the patience and cooperation of everyone." GENERAL Three Counties 2082 INFORMATION in West Virginia West Va. Marion _Monongalia Preston Population 19507 2,005,552 71,521 60,797 31,399 19 960% 1,860,421 63,717 55,617 27,233 1970 1,744,237 61,356 63,714 25,455 Percent Change 50-60 -T.2 -10.9 -8.5 -13.3 60-70 -6.7 - 3.7 +14.6 - 6.5 Size (Sq. miles)3 24,282 314 369 654 County Seat Fairmont Morgantown | Kingwood County Seat Population(1970)% 24,405 29,074 2,494 Birth Rate, 1969° 16.8 16.3 15.9 17.0 Crude Death Rate, 1969° 11.6 12.5 S.1 10.9 Infant Mortality Rate, 19697 23.3 18.3 13.% 4.8% ¥% 2 infant deaths reported. ECONOMIC INFORMATION Three Counties in West Virginia 5 ee Mest Va. Marion _ Monongalia _ Preston __ Incone 6 Per capita personal irconef1365) 2033 2502 1974 1271 Mealan Family Income, 1960 4572 5153 4515 3214 Percent Families< 3000, 9607 7 32.6 25.3 29.6 46.4 Percent Families 210,000, 1960 8.4 10.2 8.7 3.6 Socioeconomic Ranking On Occupation, Education and 15 8 uy Income (jmong 55 West Va. Counties, Economie Activities Top activities 1965 6 ('housands of dollars)(Wagesé&Salaries) Mining 320,800 5532 15427 6275 Government 370,041 10024 15448 4113 Manufacturing 829,500 35867 13297 3588 Transport, Communication, and Public Utilities 256,001 10085 3742 3146 Wholesale and Ratail Trade 331,200 11527 9356 2373 County Labor Force, 1970’ otal Work Force 21752 27060 7360 Unemployment 870 1300 510 Rate 3.5 4.8 6.9 County Court Budget, 58-5910 14300 7850 5400 Superintendent of Schoo.nd Number of Schools? Elementary 68-69 Secondary 68-69 School Enrollment? Elementary 68-69 Secondary 68-69 Estimated Revenue Receipts from State and Local Sources/Enrolled Pupil 1969~70 Estimated Current u Expenditures per Enrolled Pupil 1969-70 Catepory of Assistance 2083 SCHOOLS 3 Counties in West Virginia Ola Age Assistance Total Average Huber of Cases Average ionthly Awards Ala to the Blind Total Average Number of Cases Average lionthly Awards Ala to the Disabled Total Average Hunber of Cases W. Va. ~~ Marion Monongalia Preston T.L. Pearse L.G. Derthick L. Losh 1,19 43 40 21 352 13 12 10 235,627 v,689 5,939 3,628 184,720 5,724 5,278 2,890 530 540 591 519 527 544 584 531 PUBLIC ASSISTANCE AWARD EXPENDITURES BY CATEGORY FISCAL YEAR EHDED JUNE 30, 196912 __ Marion _________ Mouongalla , _ Preston 222,466 199,530 75,917 247 27) 128 75.05 97.2M 49.42 3.942 8,584 4,239 1 10 9 47.00 71:50 39.22 79,658 62,869 43,662 114 74 85 58.23 70.80 42.81 Average Monthly Awards 2084 FOOD STAMP PROGRAM SUMMARY OF PARTICIPATION BY COUNTY FISCAL YEAR ENDING JUNE 30, 196912 Marion a Monongalia _ Preston Average No. of Households Participating Monthly 558 384 430 Total Cash Paid for Stamps During Year 245,810.25 156,550.00 200,037.00 Bonus Coupons (Increased 157,229.75 111,161.75 142,553.00 Purchasing Power) Total Value Food Stamps Issued 403,040.00 269,712.00 342,590.00 REFERENCES 9. 10. U.S. Decennial Census Final Population Counts, 1970, Bureau of the Census (December, 1970). West Virginia Blue Book, 1969. Preliminary Reports, pc(pl)-50, 1970 Census of Population, West Virginia U.S. Department of Commerce. Vital Statistics, West Virginia Department of Health, 1969. County Personal Income, West Virginia, 1962-65, Leyden, D.R. and Rader, R.D. ureau of Business Research), ollege o ommerce , est Virginia University Economic Development Series No 11, December, 1968. Bureau of the Census, U.S. Department of Commerce: U.S. Census of Population, 1960, pc (1)-50A. Thompson, J.M.,Goldsmith, H.F. and Stockwell, F.G. Socioeconomic Ranking of Counties in the Northeastern United States from Virginia to Maine 1960. Mental Health Study Center, National Institute of Mental Health. ab Paper No. 13, November, 1965. Department of Employment Security, Charleston, West Virginia. Municipal and County Budgets in West Virginia, 1958-60. Bureau for Government Research, West Virginia Univers ty; ubl. No. 27. 11. Rankings of the Counties, 1970. Research Report. West Virginia Education 12. Association, Charleston, West Virginia. West Virginia Department of Welfare, Annual Report, 7-1-68 to 6-30-69, Charleston, West Virginia. Marion, Mouongalia and Preston County Hospitals Marion Monorgalia | Preston Fairmont Fairmont Monongalia St. Vincent Hopemont Preston Emergency General General Palletti State Memorial Name & Lccaticn Hospital Hocpital Hospital Hospital“ W.V.U. Hospital Hospital Hoepital Administrator J. C. Morgan 0. B. Ayers |W.B, Rhodes Sr. if. Pia E.L. Staples H.C. Rocha | I. Allsopp Control 12 14. 13 23 12 12 13 Service 10 10 10 10 10 48 10 Stay S Ss "8 S Ss L Ss Beds 58 207 116 20 434 300 56 Admissions 993 8,468 3,780 3,043 31,721 195 1,564 Census 30 185 76 67 349 196 30 % Occupancy 51.2 89.8 72.6 75.0 81.1 65.2 siz Newborn Data Bassinets 10 30 18 12 20 -— 17 Births 63 1,078 415 186 820 - 204 Expense Total 335 2,780 1,093 1,028 7,140 1,380 492 Payroll — 1,756 621 740 -- 1,004 309 Personnel 61 384 11s 161 949 329 82 Source: HospitaljGuide Issue, August, 1970 ¢80¢c 2086 LOCAL HLALTH DEPARTMENT BUDGETS 1970 FISCAL YLAR¥ Marion ___ Monongalia Preston Total Budget 125,036 702,167 33,580 State & Feceral Funds 27.333 470,672 14, 841 Percent State&rfederal 28% 67% Lug LOCAL APPROPRIATIONS County Court 33,212 94,850 12,739 Municipality 11,793 8,934 Board of Education 22,000 16 500 6.000 Home Health 25,959 111.21) Other 4 829 TOTAL Local Funds 97,703 231,495 A Percent Local 72% 33% 56% Population. 1970 Census 61,355 63.734 25.455 Per capita expense 2.04 11.02 1.32 ¥West Virginia Department of Health Annual Budget, Fiscal Year 1970. LICENSED PHYSICIANS BY COUNTY OF PRACTICE LOSS OR GAIN 1959-69 County Loss or Gain between 1959-1969 Marion -18 Monongalia +91 Preston | From The Medical Licensing Board of West Virginia Figures do not include osteopaths. 8-6 "d-1L-0- 199-69 LICENSED PHYSICIANS LIVING IN MARION, MONONGALIA AND PRESTON COUNTIES BY AGE GROUP County 25-29 30-24 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Total Harion : 4 3 i dl 9 8 2 3 2 1 1 2 49 Monongalia 19 24 24 20 19 10 16 6 6 2 1 147 Preston 2 : I 2 3 2 3 13 From The Medical Licensing Board of West Virginia, February 4, 1570 L802 2088 NUMBER OF REGISTERED NURSES LIVING IN MARION, MONONGALIA, AND PRESTON COUNTIES Active - Total 1960 1965 1969 Marion 188 252 224 293 Monongalia isl 387 432 498 Preston 36 37 35 44 Data presented in this table are based upon information supplied by the Board of Examiners for Registered Nurses, larjorie E. Dumez, RN, Executive Secretary (1967) and Margaret Wyatt (1970). Nurses reported from cities occupying area in more than one county were credited to the county in which the major portion of that city's population was located. REGISTERED NURSES LIVING IN MARION, MONONGALIA AND PRESTON CCUNTIES BY AGE GROUP Area 5--Jan. 1 - Dec. 31, 1959 20-29 30-39 40-49 50-329 60+ Unknown Total Marion 87 69 82 38 14 3 293 Monongalia 276 80 78 43 17 4 498 Preston 6. 9 12 e 8 1 37 From: Board of Examiners for Registered ilurses, Charleston, Margaret A. Wyatt, RN, Executive Secretary 2089 STATEMENT BY LORIN E. KERR, M.D., M.P.H. ON THE HEALTH CRIS1S IN AMERICA TO THE SUBCOMMITTEE ON HEALTH " SENATE COMMITTEE ON LABOR AND PUBLIC WELFARE My name is Lorin E. Kerr, M.D. I am Director, Department of Occupational Health, United Mine Workers of America and Visiting Professor of Public Health, Howard University College of Medicine. Previous testimony which I have presented before both the Scnate and the House of Representatives has been concerned with the occupational dust diseases, afflicting the nation's coal miners. While the problem became one of my major concerns and focus of interest after joining the United Mine Workers of America Welfare and Retirement Fund in 1948, it has, since August 1, 1969, become my prime responsibility. This is due in part to the enactment on December 30, 1969 of the historic Federal Coal Mine Health and Safety Act of 1969. More important was the unanimous decision of the International Executive Board of the union, six months earlier, to establish the UMWA Department of Occupational Health. This action, unprecedented in the annals of organized labor in the United States, was primarily designed to hasten the eradication of 2090 ~23 all occupational diseases occurring among coal miners. At the same time it was acknowledged that such action would at best be Galery unless combined with a comprchensive endeavor to resolve all the health problems confronting the miners. Limitation of the new Department to the traditional concern for job-related illness usually exemplified by Slcunationti health programs was immediately recognized as restrictive and counter-pro- ductive. This union mandate to improve the health status of its members and dependents provides me with a unique opportunity to share with you the knowledge of medical care administration which I have acquired during my 35-year professional career in the hope it will prove helpful in the formulation of legislation intended to assist in resolving the health crisis confronting the nation today. My initial exposure to medical care administration antedates the initiation of this specialty as a discipline. As Director of the Bureau of Medical Relief in a midwestern city health department, I was confronted with the urgent need to improve the quality of medical ser- vices being provided more than 100,000 welfare recipients in a city with a population of 300,000. Although this health department function was initiated about 1905, the problems in 1937 were much the same as we confront nationwide today -- lack of readily accessible high quality comprehensive health services at a reasonable cost and shortages of facilities, as well as persommel. The stresses created by the depression and the enormity of the task evoked cooperation by most hospitals and doctors. The former were trying to dig out of mountains of red ink and physicians in some instances survived only as direct and indirect recipients of relief payments. There were no insurance programs and no one scorned government payments. Subsequent training and experience in public health provided convincing evidence that the major health problem confronting the worker was his inability to pay doctor and hospital bills. The major clpital divs possessed by the American worker was and still is his ability to work, so it was little wonder that he was worried about getting in and out of the hospital and back on the job as quickly as possible when he was sick. However, the financial barrier to the doc- tor and hospital not uncommonly proved insurmountable and the worker joined the host of other sick and disabled workers eking out a miser- able existence on relief. Closely associated was the financial barrier to medical care encountered daily by the public health nurse. She was constantly frustrated in her efforts ta resolve family concerns about nutrition, child care and school health because of her inability to resolve the more demanding and pervasive daily medical needs confronting families. Cuts, bruises, fractures, colds, burns and diarrhea can be very frightening, particularly when there is no medical care available. These problems took a high priority over the health department's usual stock in trade which, by edict of organized medicine, excluded diagnos- tic and therapeutic services for the worker and his family. This pro- scription, in many instances, also excluded health department 2092 A immunization of children. It was disheartening to observe a mother who, when finally convinced of the value of such services, found that this could only be done by a private practitioner whose fee was ten dollars for each of four children. Her husband was only earning twenty-five dollars per week. Little wonder that in today's parlance many families turned off on the health department and in far too many instances there has been little change in programs and attitudes. wartine production demands forced the Federal government to provide medical care programs for both the domestic migratory and imported agricultural workers. Although the U.S. Public Health Ser- vice had been providing such services for merchant seaman since 1798, this was the first time the USPHS expanded its program to include other workers. Throughout the nation there were more than one million farm workers, the vast majority of whom were imported under inter- national agreements from the British West Indies and Mexico. These workers were scattered in numerous isolated areas. The U.S. Public Health Service successfully built upon earlier programs initially developed within the framework of the Farm Security Administration program for low-income family farmers and migratory workers. These endeavors were historic in their content and achievement. There was active consumer participation, prepayment, medical and dental service, delegation of responsibility to nurses, drugs, hospitalization and monitoring of services. All of this was done for a mobile population with little loss of continuity of services. The providers of ser- vice were paid directly by the government with a minimum of paper 2093 5 work and only a trace of red tape. Following the termination of hostilities national concern about the health of people, particu- larly those in low-income and minority groups, became almost non- existant and the program was financially axed into oblivion. In 1944 organized labor, in lieu of prohibited wage. in- creases, was able to initiate the inclusion of medical care pro- visions in jointly negotiated wage agreements for which management would be granted a tax deduction up to 5% of gross payroll. This was a manifestation of the worker's long existant concern, mentioned earlier, about his inability to pay doctor and hospital bills. More importantly, it was a recognition that for the forseecable future this was going to be a responsibility of organized labor. The Federal .gov- ernment was in 1944 again abdicating to the pressures of organized medicine which it had been doing since 1920. Prior to that time the widsom of medical statesmen prevailed and even though organized medicine supported national health insurance in 1915 the morticians dug the grave for the bill that year. Since then the entrepencur leadership of medicine, characterized as the last of the cottage industries, has spent millions of dollars in a prolonged delaying action to stem the ilcreasing tempo of the demand for a national health insurance program. While the worker's demands for a portion of wartime profits gave the major impetus to the concept of fringe benefits it was the long history of fear and frustation engendered by discase and disability 2094 ~6~ and the lack of financial security when retirement was inevitable which dictated the course to pursue. Unfortunately the limited earlier experiences in providing medical services on an organized basis had not been well publicized. The same was true of studies, reports and Congressional hearings which combined presented a veritable mountain of evidence clearly indicating the need and the directions for a rational organization of the system of delivering health services. The inordinate pressures to provide benefits immediately did not allow time to seek guidance from past experi- ences. Health insurance, a blatant misnomer with its limitation to hospitalized illness, rapidly materialized. Hospital began to thrive, insurance companies expanded into a new field and organized medicine began to realize this bill paying mechanism was no economic threat. They soon joined Blue Shield with Blue Cross and the volun- tary health program, with a few notable exceptions, became the wave of the future. The exceptions were those anion-sponsored health centers such as the Labor llealth Institute in St. Louis; the Sidney Hillman Health Centers in New York, Philadelphia and Chicago; the Union Health Center in Chicago and the I.L.G.W.U. Health Center in New York which began operation in 1914. Although some of these provided nearly comprehen- sive services, most primarily provided only diagnostic care. 2095 on I have taken the time to relate these historical, and in a sense philosophical, developments which are well known to you, because once again we are confronted with legislative proposals which are singularly restricted to a primary concern about pay- ing doctor and hospital bills. In fact, the President's .recent health statement basically calls for a Federal partnership with insurance companies. Organized labor, after more than a quarter of a century of experience with a multitude of voluntary health programs is skeptical of this method of paying doctor and hospital bills. It has become abundantly clear that health insurance has done nothing to disturb the patterns of the past. In fact, it has reinforced the status quo and thereby obstructed resolution of the problems concerned with quality controls, use of manpower and the organization and distribution of medical care services. : The overwhelming desire of organized labor - the largest single organized body of consumers - is- the ready accessibility of comprehensive health services - preventive, diagnostic, therapeutic, and rehabilitative at a cost the economy can afford to pay. This is the only solution to the many problems encountered by union health programs which today are contained in nearly every jointly negotiated wage agreement. This is also the answer to 2 question posed in 1939 by the dean emeritus of medical care administration, Dr. Nathan Sinai. He opined that if the national health insurance bill introduced that year by Senator Wagner did not pass Congress, each labor union might develop it's own medical care program. Were that to happen, 2096 Be Dr. Sinai asked the seminar to consider the impact of such action on the eventual passage of a national law. While some students ventured that the unions would develop such a vested interest in their own programs that they would be unalterably opposed to national legislation, others stated categorically the opposite . point of view. Thirty-two years later the answer is in. Experience has shown that no labor union can provide its membership with the full ange of health services. This is the reason for the unanimity of support by organized labor for national health security. I would now like to share with you from a personally biased point of view the major experiences and contributions of the United Mine Workers of America Welfare and Retirement Fund which, when founded in 1946, was one of a handful of negotiated medical-care programs. Today, 25 years later, the Fund still remains the only uniform industry-wide self-insured program. My reason for focusing on the Fund is my belief that the Fund program is a mini-national program which has encountered and resolved most of the problems con- fronting a comprehensive nationwide program. In microcosm it con- tains many of the answers to problems now confronting this subcommittee. Nearly 25 years ago the Fund vividly demonstrated what has recently been repeated on a national scale by Medicare. The Fund medical care program at the start paid all bills submitted by hospitals, physicians, dentists, pharmacists, optometrists, podiatrists and nurses. 2097 ~ All equipment, supplies and appliances, including glasses, dentures and drugs were also provided. Nine months of experience, however, was sufficient to clearly document that in the absence of quality and cost controls there would never be sufficient money to underwrite the practices encountered. Painfully, the Fund proved that more than money was needed to formulate a sound program. This experience is equally applicable to a national program. It is my belief it will undoubtedly be repeated on a national basis should the Administration proposal become law. (Quality and cost safeguards must be included to assure the non-repetition of this wasteful experience. When any medical care program is limited to the provision of money for doctor, hospital, dental and drug bills, costs inevitably escalate and there will never be enough money to meet the rapidly mounting charges. The major health problem confronting the nation is the distri- bution of medical services. This is the reason the UMWA is pleased to see every conceivable effort being made to resolve this problem, while at the same time developing the fiscal aspects of the program. It is my belief that a better organization and utilization of services is the key to containing or moderating the rising costs of medical care. I seriously doubt it is possible to lower these costs without impairing quality. The miners' Fund, from its inception, has endeavored to provide a program of comprehensive medical care, including preventive, diag- nostic, therapeutic and rehabilitative services for all eligible 2098 =10- beneficiaries. Their number has decreased from the initial 1,750,000 to about 500,000 where it has remained for the 1ast decade. The Fund has spent well over one billion dollars for all the medical services received by nearly five million beneficiaries. These services included about 25 million days of hospitalization and nearly 23 million visits by physicians caring for those hospitalized. In addition, there were more than 26 million consultative, diagnostic and therapeutic services provided by group practice clinics and specialists in private offices, outpatient and emergency facilities. The annual expenditure for medi- cal care has risen in the last two years from the almost constant average of 50 million dollars to 65 million. Payments are made each year to about 1200 hospitals and 8000 physicians located in all 50 states and the District of Columbia. In providing this care the Fund has the responsibility and freedom to seek out and use the best talent and fa- cilities available without limitations or restrictions. The Fund is not an indemnity, program. Hospitals and physicians, including specialists, are paid directly by the Fund, not indirectly by reimbursement of the beneficiaries. Unlike Blue Cross-Blue Shield the Fund pays the total cost of all medically indicated services and maintains quality and cost controls. Beneficiaries make no payment to the Fund or vendors of services. It is totally supported by a tonnage rity of 40 cents, paid by the operators in accordance with the National Bituminous Coal Wage Agreement, for each ton of bituminous coal mined for sale or use. The administra- tive costs have consistently been maintained at slightly more than 3% of total expenditures. 2099 ~Y 1 The first medical task confronting the Fund was to find and then arrange for the rehabilitation of the long-neglected, severly injured miners. In less than 5 months more than 500 men paralyzed by broken backs, some bedfast for nearly 12 years, were finally located, usually in the last house or windowless shack at the end of a hollow in the hills. In one instance 12 miners took turns carrying their friend nearly 3 miles to the closest spot an ambulance could be driven. Nearly half of these men were transported by rail, 12 at.a time to a California rehabilitation center. Early successes there encouraged three Eastern centers to also provide services. All the physicians directing these centers were experienced physiatrists familiar with the destructive force of disability even when produced by wartime gun fire. None, however, were prepared for the appearance of these miners. Ulcers and sores the size of dinner plates and larger had eaten away the buttock tissues leaving all of the bones of the hip completely ex- posed. Smaller ulcers on the heel also extended down to the bone. Bladder and bowel control had often been lost with the injury and the men were unable to care for their simplest needs. Many of the miners also had massive stones in their kidneys and bladders. Not one specialist but a team of specialists was necessary to reclaim bodies deteriorated to a degree few physicians in this country had ever scen before. Determinations of individual aptitudes and capabilities as well as appropriate job training were coordinated with physical restoration. All of this took two to four years with most of the men able to return home completely rehabilitated in slightly more 2100 -12- than two years. The knowledge and experience gained from this program was immediately woven into the total program for all other disabled beneficiaries. By 1958 it was widely acknowledged that the Fund, in: ten years had advanced rehabilitation further and faster than had occurred in the previous 25 years. Today, paraplegic miners rarely require more than 9 months for complete rehabilitation which begins in less than 36 hours following injury. The savings in money and human suffering are incalcuable. The Fund, in the Appalachian Mountain coal mining areas of West Virginia, Kentucky, and Virginia--where modern medical facilities and adequate numbers of highly competent medical and hospital personnel were almost non-existant - took the initiative and created new facili- ties primarily for its own beneficiaries. Ten hospitals with a total capacity of slightly more than 1,000 beds were built and operated as a coordinated regional network by the Miners' Memorial Hospital Asso- ciation, a non-profit corporation separate from, though closely related to the Fund. The hospitals were dedicated in 1955 and open to every- one, but most of the patients were Fund beneficiaries because most of the poeple who lived in the arca were coal miners and their dependents. The Fund paid the MMHA a per diem rate based on cost for each beneficiary hospitalized in any of the ten hospitals. These hospitals provided the areca with a quality of medical care never before seen in those communi- ties. The more than 2,000 individuals employed provided a ratio’ of 2.1 per bed which was higher than the 1956 national average of 1.6. 2101 15 Residency training programs were approved by the AMA in the three largest hospitals at Harlan and Williamson, famudy and Beckley, West Virginia. These three hospitals were also quickly approved for the training of graduate nurses, licensed practical nurses and laboratory and x-ray technicians. Decreasing coal production and increasing unemployment forced the Fund to sell five of the hospi- tals in 1963 and the remaining five the next year to a non-profit organization, the Appalachian Regional llospitals, Inc., to continue the operation of the hospitals. All ten hospitals are extremely viable today, and the Fund continues to purchase services provided Fund beneficiaries. A significantly large number of physicians and other MMHA employees still remain with the hospitals which have ex- panded both the facilities and programs. Based on the carly rehabilitation program and supplemented by the hospital experience the Fund has developed three major techniques for providing medical care of high quality at a reasonable cost. The first was the control of quality which was an important element in controlling costs. An early study of rapidly increasing hospital admission rates revealed that surgery was the major cause and that much of this was of a somewhat questionable nature. Quality criteria developed by organized medicine itself were utilized by the Fund and since 1955 payment has been made for surgery only when performed by an appropriately Board certified physician, as far as this is possible. Surgical rates dropped precipitously within 90 days of the implementation 2102 od, of this provision. The rates have since remained at a much lower level than previously prevailed. Moreover, in many instances the Fund has required consultation by a Board certified physician before hospital admission of patients who do not require an operation. Closely associated with these provisions was the need to pay for specialists' office care to assure that benefi- ciaries were not being hospitalized for services that could be provided on an ambulatory basis. These procedures, although based on quality, have enabled the Fund to maintain a hospital admission rate over the years considerably lower than previously and thereby effect a major cost control. Fund experiences provide your subcommittee, Mr. Chairman, with ample documentation to support the inclusion of Board requirements for payments for surgery and non-surgical hospital admissions in any national health security legislation. Control of quality is also the reason the Fund has never estab- lished a fee schedule. Fee schedules rarely allow for differences in physicians' training and ability. Neither do they recognize differences among patients and the conditions for which they are seeking care. More- over, no recorded experience clearly indicates that fee schedules control charges. Parenthetically, the rather marked similarity of fee schedules and capitation has led the Fund to shun the latter for essentially the same reasons it avoids the former. Medical ethics not only should be ‘a code of professional ethics among doctors but also should serve as a code of fundamental morality and justice between medicine and the people. 2103 -15- The Fund's 23-year principle has been to pay reasonable fees with determinations of reasonableness made by physicians and expert medical care administrators. The Fund has been guided by fees paid by others in the same geographic area, and it has never hesitated to seek disci- plinary restraint to the extent it is available in the ranks of organized ‘medicine. Action has not always been helpful, even when services of questionable quality have been provided by an unqualified physician. In the Fund's considerable experience it is naive to expect more. It is equally naive to expect a hospital utilization committee always to disci- pline an erring colleague effectively - particularly if he has a large referral practice. Finally, the Fund has observed that respect of human rights and personal dignity usually is a key element in the provision of high- quality medical services. The manner of providing medical services cannot be deleted from evaluations of the quality of the services. Adequate provision fcr this type of evaluation should be an integral part of national legislation. The second technique in total patient care involves a single physician, the managing physician, who must be responsible for all medi- cal care a patient receives. The managing physician usually is an internest or a capable general practitioner who, by training and experi- ence, is thoroughly familiar with the value of providing comprehensive medical care on an ambulatory basis. He also has no vested interest in surgery and is thus able to assess the nced for hospitalization more objectively. Hospitals are not "...the answer to all our medical needs." 59-661 O - 71 - pt. 9 - 9 2104 16 This was the considered opinion of the late Dr. Warren F. Draper one of the nation's outstanding health officials and for 22 years the Executive Medical officers of the Miners' Fund. Use of the managing physician has been one of the most effective techniques in assuring hospitalization only when it is medically indicated. A study of 2,845 hospitalized Fund beneficiaries revealed that 18 had been admitted an average of 28 times in one 4-year period - one patient had been admitted 83 times. There had been little communication between the 17 physicians responsible for admitting these patients and generally the physicians were unable to devote the time necessary for the beneficiary to fully understand the diagnosis and therapeutic regi- men. Immediate arrangements were made for a managing physician, who with ready access to all the necessary specialty personnel and resources, could provide a continuity of ambulatory medical care. Thus have hos- pital admissions and length of stay been controlled. In contrast to the limited medical care previously provided, the managing physician is concerned with the prevention and early detection of disease and disa- bility, as well as the diagnosis and treatment of illness and injury and rehabilitation of the beneficiary. A large element of the success the Fund has encountered in devel- oping the managing physician technique is due to recognition of the dif- ference in time and manpower required to provide the full spectrum of medical services. It takes far more time to guide a patient success- fully through the maze of medical technology and develop an understanding of all that is involved than it does to treat cpisodic illness. 2105 =17- Billing on a fee-for-service basis then becomes difficult if not intellectually and fiscally dishonest. The Fund has developed a fee-for-time or a retainer method of payment which is used for paying about 70 percent of the participa- ting physicians. The method is based on the amount of physicians’ time devoted to beneficiaries and includes an equivalent percentage payment of the physicians' overhead costs. A surgeon paid on this basis is fully cognizant of the fact that his income is no longer geared to the outmoded '"piecework' fee-for-service method of reim- bursement. He knows that the Fund is equally concerned about his clinical judgment and his technical skill and willing to pay him for both. Likewise, an internist is freed from the usual economic con- straints of fee-for-service and is paid for his knowledge and ability. This method of pavaci has appreciably improved the quality of medical care provided beneficiaries, increased the number of qualified aE cians availablé in mining communities, and reduced the amount of paperwork because the physician is paid a mutually agreed upon sum, either monthly or semimonthly. Mr. Chairman, the Fund's high level of success with the managing physician and in particular the fee-for-time method of payments leads me to urge you and the other members of the subcommittee to give more opportunity for the use of these quality and cost control techniques. A third Fund technique stems from recognition of the concept that a physician can no longer operatc as effectively or as efficiently 2106 ~18+ on a solo basis. lle needs ready access to all the allied health services. The managing physician is more effective and efficient when he is part of a multidiscipline group practice unit. Before continuing, I would like to state three personal caveats which may be of help to the subcommittee in evaluating the testimony you will hear about prepaid group practice and Health Maintenance Organizations. First, group practice, regardless of the method of paying for the services, will not lower significantly the costs of medical care. It does have the potential, however, for containing or moderating the costs, particularly when it is a multi-specialty group combined with prepayment. The development of this potential is largely dependent on the adequate utilization of health manpower and medical technology, and the provision of an improved quality of medical care. Second, the designation of an aggregation of physicians as group practice does not necessarily assure that they are providing a good quality of medical care. Such an assumption is as fallacious as stat- ing Stbegerieriiy that all fee-for-service solo practitioners provide a poor quality of medical care. The real reason for concern about solo practice is that today a physician is no longer able to operate as effectively or as efficiently on a solo basis. The vast store of accumulated knowledge, the increasing tempo of specialization and the rapid advent of technical developments are forcing us to improve the methods of organizing and distributing hcalth services. Third, joining together with other physicians in a group practice setting is unpala- table to some physicians albeit this number is decreasing. The competition 2107 -19- of the solo practitioner with group practice is not too tough at this time but the life expectancy of solo practice fee-for service medicine is not too bright. The miner's Fund has been instrumental in stimulating the develop- ment and expansion of 37 group practice clinics in coal-mining commun- ities. The central clinics with from 10 to 30 physicians have been developed on a regional basis with one to three small outlying offices staffed with from two to four physicians. Physicians in the clinics are board certified in the more frequently used specialties such as pediat- rics, internal medicine, obstetrics and gynecology, surgery, radiology and pathology. Other specialists are readily available from nearby teaching facilities. In each facility there are also general practition- ers who are an integral part of the group. In some clinics psychiatric teams consisting of psychiatrists, psychologists, and psychiatric social workers are available on a regu- larly scheduled basis. The health team also includes nurses, techni- cians, and family and rehabilitation counselors. Cooperative argafiger ments with other community agencies assure the availability of such additional health personnel and resources as may be necessary. The Fund does not own or operate group practice clinics but purchases services from them as from other physicians or groups. The clinics are owned and operated by community nonprofit organizations, the membership of whikel, in many instances, consists largely of miners. The Fund pays the organization monthly for that percentage of the total costs necessary to provide beneficiaries with services. 2108 ~20- The physicians, in turn, also have formed their own nonprofit organiza- tions and the Fund pays them a single monthly retainer for that percent- age of their time in the clinic or hospital devoted to the provision of medical care for beneficiaries. Although payment is made for services after they are provided, this procedure is in fact prepaid group practice in that the two monthly Fund payments are the equivalent of the total monthly membership payment which the beneficiaries would have to make to the organization owning and operating the clinics. About one-third of the clinics are hospital based. Although none of the rest are so situated, the physicians do have privileges in nearby hospitals. Prepaid group practice with strong consumer participation has proved to be the most effective and efficient manner of providing bene- ficiaries with high-quality, comprehensive ambulatory medical care. Only in this manner has the Fund been able to control adequately hospital admissions which in some locations are at least 25 percent lower than previously a Group practice has also enabled the Fund to benefit from the economies effected by centrally located and jointly used equipment and supplies - an economy which does not usually prevail among solo practitioners. The beneficiaries who have had long experience with company physicians deeply appreciate the savings of their time and energy resulting from group practice. Beneficiaries also accept and approve the Fund's efforts to maintain them in a healthy ambulatory state. Although there is a physician shortage, recruiting physicians 2109 -21- for group practice is easier now that it was a few years ago. Appar- ently the providers of service also are convinced of the values of group practice. Just as the patient has much to gain from prepaid group practice, so do the doctors. Experience indicates that prepay- ment avoids the competitive financial tensions which have frequently proved disruptive of fee-for-service groups. Surplus earnings in prepayment are used to expand patient and staff benefits which effec- ively avoid the problems involved in limiting the distribution of these earnings among doctors. Prepayment usually eliminates the economic incentive for each physician to be a money producer. Fee schedules are unnecessary with prepayment which enables these groups to avoid economic barriers and paperwork. Also avoided is the fee-for-service incentive to promote the unnecessary use of services. Of greatest importance to both the patient and doctor, as well as to the entire nation is the undisputed advantage which prepaid group practice enjoys over all other plans in lowering hospital utilization rates. This is an amply demonstrated characteristic of prepaid group practice wherever it is located. To date, insurance companies and the Blues have been unable to implement the comprehensive ambulatory medical care necessary to achieve this saving but recent developments are forcing them in this direction. Frankly, 1 fail to perceive the incentive essential for this cost control in the fee-for-service group or solo practice. Comprehensive ambulatory care, with its concomitant quality controls and inherent cost control, exists only when the costs are prepaid cither by or for the patient. 2110 -22- Today the cost of medical care is of vital concern to. everyone but it is with prepaid group practice that the consumer has taken the leadership role in developing and maintaining programs designed to pro- vide high quality medical care at a reasonable cost. Most prepaid group practice is sponsored either by consumer-community or union- employer groups. A group that is organized on the basis of meeting both the finan- cial and medical needs of the patient is committed to serving the best interests of the sponsors, be they cooperatives, the community, or organized labor. With this commitment a synthesis of care is provided by the personal or managing physician who, covering the whole field of medical care, draws on other medical personnel as needed. When organized according to doctor's nceds, a medical care system is primarily a scheme for a division of labor. It is the producers rather than the consumers who seem to benefit more from fee-for-service group practice. A consumer- owned-and-operated facility is more patient-oriented than a facility operating on a fee-for-service basis. The United Mine Workers of America endorses the provisions imple- menting prepaid group practice. Our experience clearly indicates that this is the most effective technique yet devised for providing the continuing ambulatory services essential for maintaining people in a vertical rather than a horizontal position. When combined with the full spectrum of services, preventive, diagnostic, therapeutic and rchabili- tative, hospitalization which is the most costly medical care item is then only necessary when all clse has failed. The wide acceptance and 2111 95% implementation of this concept is truly essential for the solution of the nation's health crisis. A major step in this direction is the earmarking of funds for a three-year 'tooling up' period in the national health security legislation. For the first time this will make available on a national basis the capital money necessary for the development x. JOR, practice facilities. Heretofore, in the absence of such money, we have witnessed a painfully slow growth of these facilities. When the Fund implemented each of the three major procedures which I have presented it encountered opposition - sometimes violent - from every level of organized medicine. Adroit endeavors seeking cooperative relationships were declared '"null and void, terminated and ended." Violations of the time worn shibboleths of "free choice of physician" and "fee-for-service" were hurled at the Fund in a continu- ing effort to discredit the program. Fund physicians as well as those participating in the program were ostracized, ridiculed and on occasion threatened. It was covertly admitted that most of these activities stemmed from those physicians who viewed quality controls as an economic threat. This opposition made inoperable all attempts to establish peer review within the structure of organized medicine. While few attitudes have changed the overt manifestations markedly diminished with a decrcase in the number of eligible Fund beneficiaries during the latter years of the 1950 decade. Mr. Chairman, essentially the same experience can be anticipated before and after the passage of national health security legislation and I might add for the same reasons. 2112 a24- Proposed national health security legislation wisely makes funds available for the training of all health personnel, all of whom are today in distressingly short supply. Regardless of the discipline or specialty there is a dangerous shortage of health manpower throughout the entire nation. Undoubtedly, there will be some who will maintain that the education and training of personnel should precede the passage of the bill. This is nonsense! At the rate a resolution to this particular problem has been sought in the past, we might well never achieve national health security were the subcommittee to heed further Cassandra cries for delay. The provision of preventive services should be specified as an underlying theme pervading national health security legislation. It will be the most important feature of this legislation if properly implemented. In the absence of this concept the legislation would be just a bill-paying mechanism. The implementation of this concept is more than the provision of specified preventive services. It is impossible to achieve without those sections devoted to improving quality mentioned earlier. Unless prevention becomes meaningful we will never reduce morbidity and disabil- ity rates and our health standing will continue to compare unfavorably with other countries. This will be particularly true of those countries where prevention has become a way of life. I am deeply concerned about the fragmentation of the worker's health needs which occurs with the usual attempt to separate occupational illness and injury from those not job- related. These are inseparable because of the impact of one upon the other. I would hope that as your hearings continue the need to amalgamate these 2113 SIH services would become clear and that the prevention as well as diagnosis, treatment and rehabilitation of job-related illness and injury would be a recognized service provided by group practice facilities. This would be a major step in resolving the problem of providing these services in the vast majority of work places throughout the country where they are presently non-existent. The United Mine Workers of America disagrees with the method of financing proposed in the national health security legislation. We are in favor of health services being totally financed out of the general tax revenue. It is our opinion that a method of financing can be devel=~ oped which will avoid the pitfalls of annual appropriations and yet will tax all the people on their declared ability to pay rather than further decreasing their sorely burdened resources needed to meet the daily costs of living. Today regressive taxation should be an anathema among those who have labored so long to develop the otherwise forward- looking features of the national health security bill. Mr. Chairman, to summarize, we can no longer ignore the health crisis confronting us today. All of its ugly and brutalizing manifesta- tions have been documented many times over during the last several decades. However, each tine Congress has looked anew at the nation's worsening health status the inordinate pressures of organized medicine and other vested interests have successfully staved off the passage of essential legislation. Congress dare not countcnance further delay. Rhetoric is no longer a substitute for an adequate therapeutic regime. 2114 -26- Past experiences with a multitude of health care programs - past and present, foreign and domestic - provide ample information on which to base a comprehensive nationwide program. The enormity of the task prohibits isolated fragmented desultory cfforts. Services must be readily accessible in the ghetto and rural areas as well as affluent suburbia and the place of work. All barriers to service - economic, geographic and racial - must be climinated! During the last quarter of a century the United Mine Workers of America Welfare and Retirement Fund developed a medical care program widely acclaimed for its pioneering contributions. It has clearly demonstrated those major quality and cost controls essential for the provision of a nationwide program. Thank you for this opportunity to express the views of the United Mine Workers of America on national health care legislation and to reiterate our long-standing support of national health services as voiced by our membership in numerous resolutions in the past. 2115 Senator Kennepy. The subcommittee stands in recess. (Whereupon, at 5 p.m. the subcommittee recessed, to reconvene sub- ject to the call of the Chair.) HEALTH CARE CRISIS IN AMERICA, 1971 TUESDAY, APRIL 20, 1971 U.S. SENATE, SUBCOMMITTEE ON HEALTH OF THE CoMMITTEE ON LABOR AND PUBLIC WELFARE, Nashville, Tenn. The subcommittee met at 2 p.m. at the Vanderbilt University School of Law Building, 21st Avenue South, Nashville, Tenn., Hon. Edward M. Kennedy (chairman of the subcommittee) presiding. Present : Senator Edward M. Kennedy. Committee staff members present: LeRoy G. Goldman, profes- sional staff member; and Jay B. Cutler, minority counsel. Senator Ken~epy. The subcommittee will come to order. This afternoon the Senate Health Subcommittee resumes its field hearings into America’s health care crisis. ; For the past 2 months the subcommittee has held hearings in Wash- ington. And that hearing record documents the existence of a massive health crisis. Health care is America’s fastest growing, failing business. It is a $70 billion cottage industry. In the last two decades Americans have been forced to increase their expenditures for health care almost six- fold—from $12 billion a year to $70 billion. And much of that huge in- crease buys nothing. It 1s nothing more than inflation. For example, last year health-care costs increased twice as fast as the consumer price index. If we are to have national policies to control construction costs, why can’t we have a program to control skyrocketing health costs. Our hearings have also demonstrated that the method by which we finance health care is totally inadequate. For more than 30 years the American consumer has had to look to the private insurance industry. By and large the insurance industry has failed. After three decades of experience (and profit) private insurance only covers about one- third of health costs. It is biased in favor of sickness, not health. Most private insurance policies do not cover preventive health or health maintenance programs. Moreover, the insurance industry is essentially unregulated. Even the administration, which now looks to the insur- ance industry for solutions to the health crisis, has recommended that there be tight regulation of the industry. We also know we have a serious health manpower problem. We do not have enough health manpower. And the manpower we do have is inequitably distributed. Why is it that the wealthiest nation on earth is an importer of health manpower ? Why is it that America wins Nobel prizes for research and yet is unable to translate the benefits of that (2117) 2118 research into decent health care for its citizens? Why is it that Amer- ica ranks so low in terms of infant mortality? Why is it that there is virtually no quality control or peer review for the solo practitioner? Why is it that Blue Cross has become the agent of hospital and Blue Shield the agent of the doctor rather than both of them being the agent of those whom they purport to serve—the consumer? Why is it that most hospital emergency rooms have in fact become inefficient outpa- tient departments? Why is it that America has twice as many sur- geons as Great Britain and does twice as much surgery ? Why is it that doctors and hospital administrators privately admit the need for basic system reform and yet are reluctant to testify to that need ? Why is it that consumers are afraid to testify about their difficulties in attempts to get health care? . To fully develop the answers to these questions the subcommittee has begun a series of field hearings. Last week the subcommittee visited New York City and its suburbs. Yesterday the subcommittee spent the entire day in rural West Virginia investigating the tremendous problems that rural people have in trying to receive health care. For them, the health system too frequently has nothing to offer. Today, we are in Nashville, and we have come to let the people speak. Over the next month the subcommittee plans to visit at least seven more cities in all parts of the country. And in each of these field hear- ings I want you to know that we are biased. We are biased in favor of the consumer. The time has long since passed that his voice should be heard. The time has come to open up the health care system and let the people in. Now is the time for reform, not rhetoric or retrenchment. First of all I want to express my appreciation to Chancellor Heard and Dean Wade and the members of the faculty of Vanderbilt for their kindness and hospitality and the reception they have given to us and the staff of the subcommittee in our hearing today. During the period of the last 8 weeks the Senate Subcommittee on Health has been having extensive hearings on the health crisis. Some 7 weeks has been spent listening to the representatives of the health industry in Washington, D.C., and last week we began our initial hearings in the field. The Senate Health Subcommittee visited New York City, which in many respects reflects in microcosm the health problems we have in many of our urban areas; after a day and a half there we traveled to the more affluent suburban areas in Nassau and Westchester Counties and talked about the problems in suburbia, in the middle and upper income groups. Saturday we traveled to West Virginia. We spent a complete day trying to get a better understanding and feeling for rural health problems. It is my belief that in spite of the extraordinary problems we have in terms of urban health crisis, that rural health is equally, if not a more difficult problem that were facing in this Nation of ours. In the course of the field hearings, we're trying to spend as much time as we possibly can listening to consumers. We try in the course of the hear- ings to try and see the best and poorest facilities providing health delivery services, but we are primarily interested in listening to the consumers, those who have had some contact with the health system, or perhaps have had some contact and little else with the health system. / 2119 For the next two and a half hours we hope to listen to the consumers and then we'll open it up to any comments from the floor. If any of you would like to make any comments, give us your name up at the desk and we’ll call on as many people as possible depending on the amount of time we have. For any of those who want to make a com- ment, we'll try and give you that opportunity. If time does not permit, you may send us your statements and they will be included as part of the record which will be printed and hopefully will be reviewed by the members of the subcommittee. That is the procedure we’ll follow here this afternoon. Now we'll begin with our witnesses. We know there are a number of people on the outside. I don’t know the fire laws around here, but as far as I’m con- cerned they can come in and fill up whatever space is available. There are some seats in the middle of the third row, aren’t there ? Our first witness this afternoon is Mary Lynn Fletcher from Knox- ville, a student of the University of Tennessee. She’s on a committee at the university to study the problems of the handicapped. Mary Lynn, we welcome you before the subcommittee. STATEMENT OF MISS MARY LYNN FLETCHER, KNOXVILLE, TENN,, A STUDENT OF THE UNIVERSITY OF TENNESSEE Miss Frercier. Senator Kennedy, approximately 2 weeks ago the AMA testified before your subcommittee, I believe it was a Dr. Roth and a Dr. Parrott. They testified that the health crisis was not across the board. I'm here to refute that because they stated it was restricted to the slums and the rural poor. From my own personal experience and my family’s personal experience, I want to come before this com- mittee and say that it is across the board. My own family, four members out of five had catastrophic illness, two of them chronic and two cancer which were fatal. In my own case, I was struck with polio in 1950, and it has required 20 years and 25 operations to come from a total paraplegic to a partial paraplegic. My oldest brother had Hodgkins disease which required 4 years going from Knoxville to Atlanta on bimonthly or weekly trips. In 1965 my father was diagnosed as having bronchial carcinoma and died 3 months later. My younger brother, Charles, 11 months younger than I, 1 month after my father collapsed, was involved in a head-on colli- sion, August 3, 1965, which crushed bones all over his body. The effect of all of this financially is what I’d like to talk about. My parents were just starting in business when I was five, and they felt like it couldn’ happen to them. Anything as catastrophic as polio couldn’t happen to them. It was a question of either eating or paying insurance premiums, so they didn’t have any insurance. My mother estimated approximately 2 weeks ago that from the time I was 5 years old until T was 19 they paid as an outlay of approximately $65,000 for my illness alone. She received no help with the exception of the Polio Foundation two times. My parents’ business was doing extremely well until about 1958 when there was a general business slump. Then Jack was diagnosed as having Hodgkins Disease. We had insurance on Jack but it paid only one-third of the total cost. They had Blue Cross and Blue Shield, 59-661 O - 71 - pt. 9 - 10 2120 but the trips from Lenoir City to Atlanta and back to Lenoir City and the medicine needed was extremely expensive, and we had two people ill at this time, myself and my brother. ? Another example occurred in the summer of 1958 when Jack and I both were in Atlanta, Ga., in Georgia Baptist Hospital. He was on the sixth floor and I on the third for an entire summer. My parents paid out of their pocket $4,400. This is only a sample of what they had to pay. So othue’s business suffered reverses, and a lot of things happened in 1965. Finally they put it in the hands of a receiver in July. The Sunday after that Friday he collapsed and on Monday they said he had cancer. The following October he died. When he closed that plant it automatically canceled the health insurance for all employees and all members of the family, so he had no insurance. The doctors said he needed a private room but the hospital told my mother she could not afford a private room and made her pay an additional $300 as a deposit so we wouldn’t run off and not pay. 3 Charles, the younger brother was under the same insurance plan, and when he was in the head-on collision he had no health insurance. He had car insurance, and finally when the automobile insurance com- panies settled with him, it took a year, his medical expenses were paid. Now the American Medical Association and the Nixon administra- tion say if we go under private health insurance everything is going to be all right. I know from bitter experience this is not the case, because in my later life when I was on my own, it has become me, Mary Lynn Fletcher versus the insurance companies. I cannot get insurance, I can only come under group insurance plans, and I am being forced to enroll in the mass enrollment firms that advertise in the papers and they are frauds of the worst kind, because I cannot get the insurance. For instance, this summer I was going to school and I fell, necessi- tating surgery, back surgery, a spinal fusion. and the University of Tennessee medical insurance, Zurich Insurance, refused to pay on the basis it was a preexisting condition, because preexisting conditions are not covered. It took a friend of mine who was a lawyer and 9 months to force them to pay this. At present I am going to the University of Tennessee on an OEO grant, which in an academic year cost $1,200. Senator Kennepy. Why did the insurance company say that was a preexisting condition if it was after you fell ? How did they know this? Miss FrercHER. Because I had had back trouble before. The surgeon’s report definitely stated after he operated that it was because of a recent fall and two discs had been cracked and had not been calcified. Senator KenNEpY. But the insurance company said it was pre- existing ¢ Miss FLETCHER. Yes. Senator Kennepy. They required you to go to an attorney at least to try and realize what you felt were your own rights, and ultimately shown to be your rights, and they assumed that particular burden. Miss Frercuer. On most major claims I have had to have an attor- ney to force most insurance companies. Senator Kennepy. Who pays for those attorneys? Miss Frercaer. Well, I am very lucky in having some very nice friends who are attorneys or else I could not afford it. 2121 Senator Kennepy. Some of your best friends were attorneys. [Laughter. ] Miss FLercuer. Even if I have group insurance, as I say, the problem of making them pay is tantamount to impossibility. I had an ulcer attack, and I have yet to see what polio has to do with an ulcer, and they have used this as an excuse. I have riders, I have two insurance olicies and both of them have riders on them. It says anything relat- ing to the lower extremities is not covered. Sootior Kennepy. Who do you think the insurance companies rep- resent if they don’t represent the consumer ? Miss Frercuer. They represent themselves. There are more ramifications to insurance than just health insur- ance. I have been denied three specific jobs because they will not cover me. They say to the company, “You keep down your risks, and we’ll keep down your rates.” They can go in and say your rates go up be- cause last month you had five accidents, so the companies won't take that chance. Senator Kenxnepy. That would be true if the companies were to employ you, they’d always be threatened with the insurance company saying if you take this party there’s a possibility that your rates will go up correspondingly. Has that happened to you, do you think? Miss Frercuer. You mean do my rates go up ? Senator Kennepy. No, the company’s rates would go up if they hired you. Do you feel the fact that you have obviously had a tragic experience with polio and other health ailments, that when you go in to gain any employment, it has been manifested to you than an em- ployer is a lot less willing to hire you because you are going to affect his insurance rates? Miss Freromer. It is not that obvious. The reason I know specifically is because of these three job instances. People I became friendly with later have told me that they could not hire me because they had to keep down people with chronic illnesses. A vocational rehabilitation worker told a friend of mine if I were a handicapped person and it was not visible, he would not put it on an employment record because right there they’d throw it in the trash can. My family has had more illnesses than usual. I realize this, but it is not that we are the great exception because we are not. I have worked in hospitals where you have to have insurance to get in and I've worked with handicapped children since T was 15 or 16. I've worked with veterans, I have seen diseases and expensive diseases going from black to white to polka dot, from rich, middle, and poor, and TI just frankly dare anyone to say that mine is an exception. On my street alone there are three chronically ill people, and I’ve seen families destroyed when one person of that family is ill. I’ve seen them miss opportunities, go into bankruptcy, innumerable things. The Nixon administration says we're supposed to use the same vehicle that has brought us to this crisis to take us out of it. To me this is totally irrational. ; Senator Ken~NEpy. Let me ask you, Mary Lynn, what do you esti- mate were the total medical bills just for yourself ? Miss FrercHER. $65,000. Senator Ken~epy. $65,000. And in addition your brother was in the auto accident and your other brother had Hodgkins disease and 2122 lung cancer when your father’s business went on the rocks. I imagine it was partially due to the health expenses. * Miss Frercuer. Partially, yes. Senator Kexnepy. Have you ever throught about what these total medical bills were ? Miss Frercaer. We tried to put them together in some type of as- semblage and it would be somewhere between $80,000 and $100,000. Senator Kennepy. As I understood, you mentioned that one summer when you and your brother were both 1n the hospital, your family had about $4,000 that your father paid. What do you estimate that your family paid for the entire, the total amount of illnesses. i Miss FrercaER. That was the $80,000 to $100,000. Senator Kenney. That your family paid ? Miss Frercuer. That the family paid. Mother estimated $65,000 for me and the rest for the rest of the family. Senator Kennepy. Are they still paying any of that? Miss Frercuer. I am, and I will be for many, many years to come. Senator KENNEDY. You are still paying medical bills? Miss FLETCHER. Yes. Senator KenNepy. Since when? Miss FLETCHER. 1967. ; Senator KenNepy. And you're required to pay them. I suppose you feel morally obligated to pay those bills? Miss Frercuer. Of course, but when you do the best that you can and they still write these nasty little notes and ask you to accelerate your payments, you get to the point you say you're doing the best you can and that’s all T can do. I’ve just about reached that point. Senator Kennepy. Under the administration’s program they cover i to $50,000 for a family, so actually they’d be woefully inadequate. They pay a percentage of the first $5,000 and then up to $50,000 and that’s the cut off. Miss Frercuer. I have no idea what my medical expenses will be. They will be continuous until the day I die. Fifty thousand dollars can be spent in a period of 2 or 3 years at the rate it is now, so I don’t see how that can cover catastrophic illness. Senator Kennepy. I suppose the point which must trouble you, as well as us is the fact that you've had one of the most extraordinary types of tragedies in your families, and besides the personal tragedies you've had the financial tragedies as well. IT suppose we have to ask ourselves as Americans if this is a part of the health system. We say your case is extraordinary, but is it really? We had testimony just last week up in Nassau County in New York, a young boy playing in the 150 pound football field last fall tackled another boy and separated his spinal column. Now the father, one of the most successful salesmen for a major insurance company has had medical expenses going up to $50,000. It appears that they will have to care for this boy as long they live and have continuing medical expenses of probably $50,000 to $60,000 a year. He is at the Rusk Center in New York City. I think you made the point of the attitude of the insurance com- panies to the payment of various medical expenses to date and their attitude toward you which is a continuing attitude in terms of discour- aging job employment for yourself. A part of the administration’s 2123 program is this cost consciousness. I don’t know whether you are aware of that feature. That’s the deductible, every time you go down to the hospital you have to pay out the first $100, or the first 2 days you spend in the hospital, and the first $100 of medical expense. That’s supposed to make people cost conscious, so they don’t use the facility. I would think you are about as cost conscious as anyone, and tragic- ally so. ie FLETCHER. Senator, something has to be done now for people like “middle” Americans. It’s so tragic and it is so urgent, that I am just afraid if we don’t have something pretty soon many of us are going to be in dire bankruptcy for the rest of our lives. Senator KexnNepy. I think the other point your situation demon- strates is that the health crisis isn’t just for the rural poor of this country. It affects middle America, and it affects them in the most extraordinary ways. It can affect them in the kind of ways illustrated in your case, in the extraordinary financial obligations as well as in the health care they are receiving. There doesn’t appear to me to be any reason why we can’t have the concept of insurance in its total sense, where healthy people are paying through a progressive tax measure as we try to do in the National Health Insurance, which would help those people who have this kind of sickness or this kind of pragdy, where the burden is presented in the most progressive means possible on the whole society rather than on a particular individual or par- ticular family. That is the essence of our National Health Insurance program. Miss FrLercuEir. Senator, there are times I would never have gone to the hospital because I was unable to afford continual care. Until it became a tragedy or an emergency, I would not go to the hospital, but I could not afford that weekly in-and-out hospital and medical care, and we didn’t have it in a small town. Senator KenNEepy. I want to thank you very much, Mary Lynn. We appreciate your testimony. It is about as strong an indictment of the present system as we have heard, and we appreciate very much your willingness to come and share this experience, which I know is not a pleasant one, with us. Our next witnesses are Mr. Herbert Anderson and Mrs. Frances Lutz. Unfortunately, Mr. Anderson was taken ill and Mr. Don Vogen, a representative of the Steelworkers will tell his story. STATEMENT OF DON VOGEN REPRESENTING HERBERT ANDERSON, STEELWORKERS REPRESENTATIVE Mr. Vogen. First of all, Mr. Anderson was supposed to be here today, he is a member of the Steelworkers and has had pretty serious illnesses. At the last minute today he notified me he couldn’t be here so I thought I'd relate what I could. He had a serious heart condi- tion several years ago, high blood pressure, and diabetes. As a result he has become disabled. He is drawing some VA pension and social security, a little over $200. He ended up with a considerable out-of- pocket expense over and above what his insurance would pay. As a result of that the hospitals demand a pretty high payment out of him for his hospital and doctor bills. They demand at least $50 a month. 2124 He is unable to pay this. He has been paying about $5 or $10 a month for some time now. He felt like if he had been working or able to work anyway at all, the doctors and hospitals would have had his wage garnisheed and put an additional burden on him. He was ad- mitted to the VA hospital. Senator Kex~epy. What is this where hospitals garnishee a work- er’s wages ? Mr. Voge. I haven’t had any personal experience with hospitals, but I have had with doctors. Senator Kennepy. We had one yesterday. It often appears that the hospitals are better at chasing patients than they are at treating them. [Applause.] Mr. Vogen. May I add that most of these employers will not stand for but about two or three garnishments and then they’ll terminate. Senator Kenney. Tell us about that. If they have had people who do have these extraordinary kinds of Sospitel expenses and they’re turned over to one of these collection agencies, which I understand is one of the fastest growing businesses in the country, they go out and get a judgment against the wages. We had an instance yesterday in West Virginia where they actually fired this employee because he was paying $15 instead of $25, and he went on unemployment. Does this happen ? Mr. Vogen. It certainly does. I got involved a few weeks ago in a similar case. One of our ladies was in a car wreck. She was out of work for a very long time, 6 or 8 months, and her husband is dis- abled and can’t get a job. She had a doctor bill of $300 or $400 that she couldn’t pay. Some Se bythe collection agency got control of the bill, sent a notice, got a garnishment in court, sent it to the employer. The employer called me because they sympathized with her, and I immediately began trying to make arrangements for her to pay some kind of money to the collection agency. The attorney, which evidently was another friendly attorney, repre- sented her and went to the collection agency and offered a sizable amount, I don’t know what. ; Senator Kex~epy. I understand these collection agencies are known in Nashville as Professional Adjustment Companies. [Laughter.] Mr. Vogen. I’ve heard that; yes. They would not let her pay a par- tial payment and withdraw the garnishment. They insisted on full ayment. She wound up with a ‘garnishment and two more she may ose her job. Mr. Anderson related yesterday this is one of the things he’d be faced with. He went to a VA hospital and felt he was getting fine treatment there. They were running several tests for the heart con- dition and the diabetic condition and high blood pressure, and for some reason they would not treat him any more. They released him and sent him to General Hospital in Nashville, which I understand is a Metro hospital. He goes there early in the morning, stays all day, about once a week and all they do is give him a bag of pills and check his blood pressure. Senator Kexxepy. Why does it take all day ? Mr. Voeen. He doesn’t know. He just sits there and waits until they call him. He went out last week at 11 o’clock in the morning and stayed until 5 before they got to him. Senator KennEepy. Is that because of crowded conditions? 2125 Mr. Vogex. I don’t know, but he feels he is not getting proper care. Of course like most of us he’s not in a position to determine whether he’s getting proper care or not, but it’s going out there knowing he has conditions other than high blood pressure and they don’t seem to be concerned with his heart condition or with his diabetic condition, they just take his blood pressure. Senator KenxnNepy. He felt he was getting better care at the VA hospital, did he? Mr. Voaen. Absolutely. Senator Kex~epy. That’s the Government hospital. Mr. Vogex. Yes. Senator Kenney. Miss Lutz, you are Mrs. Frances Lutz. STATEMENT OF MRS. FRANCIS LUTZ, NASHVILLE RESIDENT Mis. Liorz. Yes. I have had three heart surgeries within a year and a half and the last one was a month ago, open heart surgery, and I am drawing social security right now of $209 a month for my son and I. When he graduates from school his part will be dropped. Senator Ken~epy. What will you receive then, Mrs. Lutz? Mrs. Lutz. Well, I'm receiving $70 for him, right now, unless he goes to college. Senator Kun~Nepy. It would be $130 then. Mrs. Lutz. Yes, and my first operation I still owe $1,200 for the hospital. This includes the doctor in the hospital, above that which my insurance paid. Spur Ken~epy. This is $1,000 in excess of what your insurance paid? Mrs. Lutz. Yes, for the first operation. Senator Kexnepy. How long ago was that ? Mrs. Lutz. That was in 1970, yes, January of 1970. Senator Kex~Nepy. January of 1970. Mrs. Lutz. My second operation was in December of 1970, open heart surgery, and then I had the last one this March; the 10th. Senator Kexnepy. Do you get blood tests every day now? Mrs. Lutz. Yes; I have to every other day since T was out of the hospital. That’s to my own private physician and, of course, this isn’t covered by insurance, the insurance I have at work. It covers some but it doesn’t cover all, it doesn’t cover my private doctor. Senator KexNEpy. So how much medical bill do you owe now ? Mrs. Lutz. Well, I would say over $1,000. Senator KexNEpy. That's part of the hospital bill ? Mrs. Lutz. That was the first operation. Senator KenNepy. Do you owe some of that to the heart surgeon ? Mrs. Lutz. Yes, and the hospital. Senator Kex~epy. Do you owe some to a cardiologist, radiologist, some for drugs? Mrs. Lurz. Yes. Senator KENNEDY. Anesthesia. Mrs. Luz. Yes. Senator KexNEpY. So that’s somewhere over a thousand dollars not covered by any kind of insurance program you had, and you're trying to pay that off at what, $10 a month ? 2126 Mrs. Lutz. Well, sometimes if I don’t have it, I just pay as I can because of the three operations. _ Senator Kennepy. You're still trying to pay that even after your income is reduced, after your son finishes school? Mrs. Lutz. Yes, and medicine. Senator Ken~epy. I suppose you're running up bills now ¢ Mrs. Lorz. Yes. Senator KENNEDY. So that’s going to mean you're going to have even more medical bills? Mrs. LuTz. Yes. : Senator Kexnepy. Can you tell us a little more about yourself? You live here in this community ? Mrs. Lorz. Yes, I've lived here about 20 years. I worked up until I had this heart condition which left me disabled, totally disabled. Senator Kennepy. You worked before the time you were disabled ? Mrs. Lutz. Yes. Senator KexNepy. How many years did you work? Mrs. Liurz. Thirteen years. Senator KenNepy. Then you were disabled by this heart condition? Mrs. Lutz. Yes. Senator KenNeEpy. And because of that it would certainly appear that you have a very serious indebtedness and will have for a long time to come. Mrs. Lutz. Yes, I'm totally disabled and will be probably the rest of my life. Senator Kexnepy. We have to recognize that heart disease is the biggest killer in this country, yet even though we know that and understand that, all the statistics show it, and the Heart Association points this out to Americans all the time, yet we're still unable to develop a health care system that will cope with it, or deal with it effectively in terms of someone like yourself who has been a working persons and is tremendously disadvantaged because of it. Thank you very much. Mr. Vocen. I'd like to add if we had had a little more time, there wouldn’t have been any room here for the spectators, there’d be so many witnesses. This is just a small example of what is happening throughout the area here. Representing the Union, if we don’t have a crisis now, I’d hate to see one. There’s got to be a better system than what there is now. STATEMENT OF MRS. MARY YOUNG, EMPLOYEE OF GENERAL HOSPITAL, NASHVILLE, TENN. Senator Ken~epy. Our next witness is Mrs. Mary Young. Mrs. Young, your name is Mrs. Mary Young? Mrs. Younc. That’s right. Senator Kexnepy. And you work at General Hospital ? Mrs. Youne. Yes. in 1967 1 became a victim of cancer, carcinoma of the cervix for which I had insurance and they paid over 80 percent. of the bill. Of course, the total amount of the hospital bill was $1,234.04. That was just for the hysterectomy that I had in 1967, that’s when they found out I had cancer. Then I became a patient at Vanderbilt and I had a radium implant and then cobalt therapy which amounted to $908.64. Out of that the insurance company paid a quarter of it. The 2127 rest I paid out of my pocket and at the present time the balance of my whole hospital bill 1s $345.66, Of course, I’m paying on that now. Senator Kexnepy. How much do you pay on that bill of $345.66? Mrs. Youna. $25 a month. Senator KENNEDY. $25 a month; that will take you 4 years to pay that off, is that right? Mrs. Youne. Well, it’s according to my salary. Senator KexNepy. You feel Tike you're going to pay that, you're going to make every effort to do that? Mrs. Youne. Yes. Senator KeNNEpy. What is your take-home pay a month ? Mrs. Youne. My weekly take-home pay, without the insurance taken out is $92 a week. With the insurance taken out it’s $86. Senator KENNEDY. So you're going to pay at least 5 or 6 dollars, about 6 dollars a week out of that, even out of the $86 ? Mrs. Youn. Right. Senator KennNepy. Which is almost 10 percent which you will be paying for the next 4 years. Mrs. Youne. That's right. Senator KenNepy. This in spite of the fact that we know that in this country of 200 million people that 50 million people will con- tract cancer; of the people living now, one out of four will contract cancer and two out of three of those will die of cancer. Thirty-five million people alive today will die of cancer. In spite of the fact we know this is going to happen, it brings about the kind of extraordinary medical expenses you have had and a great deal more in some cases. We are still not providing this country assistance with those extra- ordinary kinds of expenditures. Mrs. Youne. You still have to go through the clinic as a followup and of course that costs too. Senator KENNEDY. So you are probably going to have future medi- cal expenses ? Mrs. Youne. Sure, I'll have them until they dismiss me, which I don’t know when that will be. Senator Kennepy. If you have the drug treatment, won’t that be expensive too? Mrs. Youne. Which drug? Senator Kennepy. The cobalt. Mrs. Youne. I don’t take that any more. The doctor just follows me up now. I come in about once every 3 or 4 months. Senator KenNepy. Don’t you think there’s a better way of trying to finance this kind of medical expense than the way you have at the present time ? Mrs. Youna. Well, I wish there would be. Senator Kennepy. I would imagine so. You have a health insurance plan now with a private insurance company ? Mrs. Youna. Yes; we are compelled at Metro General to have New York Life. Senator Kennepy. What does that cover? Does that have a deduct- ible? Does that mean every time you go into the hospital you have to pay out something before you go in? Mrs. Youna. Noj all you need is your insurance card. Senator KenNEDY. I see. OK, thank you very much. We appreciate it. 2128 STATEMENT OF MRS. PATRICIA LONG, TELEPHONE OPERATOR Our next witnesses are Mrs. Patricia Long and Mr. James Parsons. Mrs. Long, Mrs. Patricia Long, is that right ? Mrs. Long. Yes, sir. Senator KENNEDY. And you are a telephone operator? Mrs. Long. Yes, sir. Senator Kenxepy. Will you tell us a little about yourself? Mrs. Lone. T have been employed with the telephone company for about 19 years. Over the period of years until I came to Nashville about 4 years ago I didn’t have much trouble. It first started in 1967 when I went to see a company doctor, and he took me off work for a week. After I got back to work he sent me a bill for $30 and then sent me a nasty note because I thought it had been taken care of by the insurance. Then on top of that my company inserted in the record an entry over this illness the next time I was out sick I'd be fired. Then in 1968 I was involved in an automobile accident with a trac- tor-trailer, which it was not my fault, it was the tractor-trailer’s fault and at the time of the accident I was taken to a motel in Grifton, Ga., about 5 miles away from the hospital. The insurance adjustor dropped me there with no place to eat or anything. He didn’t come back and check to see if T needed medical help. The investigators of the accident came back the next day and took me to the hospital because they felt I did need medical help and at the time the doctor happened to be there? But all he did was look at me and tell me to come back the next day and we’ll X-ray you and see what’s wrong. So I did, I went back the next day and stayed an hour. After my hour he asked me then to come to his office. By that time the X-rays were ready and it showed I had a sprained neck. He didn’t tell me at the time that my back was cracked. I found this out about a month later. Senator Kennepy. You had a sprained neck ? Mrs. Lone. And a cracked back. So I came back to Nashville where I have been treated now by my physician, and he has told me now that probably I will have to have surgery on my back. He has given me an estimate of what it’s going to run. So far my bills which aren’t paid yet have run in the neighborhood of $600 out of my pocket if T were to pay them, but he has consented to wait and see what the insurance company is going to do after he has released me. Then whatever they pay he’ll send me a bill. Finkel Kennepy. Do you feel you're getting adequate health care? Mrs. Lone. Not for the amount of money I'm paying. Senator Kennepy. For any amount of money you're paying, the way you told us you were treated after your accident. Mrs. Long. Even now when I go to the doctor’s office I go and sit about an hour and a half, then I go into the patient’s room and sit 15 or 20 minutes and he sees me about 5 minutes and charges $15. Senator Kennepy. Is that typical in your experience ? Talking with your friends, other telephone operators, is there this kind of feeling too that you have to wait a good deal of time in doctor’s offices ? Mrs. Long. Yes; that we're actually not getting what we should get. Senator KENNEDY. Are some reluctant, say that you work with, are 2129 they reluctant to go to doctors because of the long waits in line or be- cause of the expense? Mrs. Lona. Well, because of the long waits in line, because of the expense, because of the pressure the company puts on them, if they have to go to the doctor and if they have to be out for any amount of time they are either threatened oi being suspended or being fired. Senator KenNepy. They really wait until they are really sick before going to a doctor? Mrs. Lona. That’s right, and then they might stand a chance of being fired even if they are sick. STATEMENT OF JAMES PARSONS, EMPLOYEE OF NASHVILLE BRIDGE CO. Senator Kennepy. Mr. Parsons, you're Mr. James Parsons and you work for the Bridge Co.? Mr. Parsons. Nashville Bridge Co. Senator Kennepy. Could you tell us a little bit about some of your problems? : Mr. Parsons. Well, it started in 1964 when my wife went to the hos- pital for childbirth. The hospital bill was about $600 and the doctor bill $250. Three months later she went back to the hospital for an operation for tubal pregnancy. She came out of the hospital 3 days before she was supposed to because we didn’t have money to pay the hospital bills, because we didn’t have insurance. The doctor told her he’d have to take her out of the hospital. Senator Kennepy. What happened to your insurance ? Mr. Parsons. I was working at Wedgewood Corp. at the time and they went out of business. I had insurance with Wedgewood Corp. and they went out of business and they told us our policy was good for 90 days after the company went out of business, so I was out of work a month and a half and that’s when my wife went to the hospital and then we found out we didn’t have any insurance. Senator Kexnepy. How long did you work for that company ? Mr. Parsons. Three years. Senator KennNepy. Then they went out of business and your wife had this additional difficulty or complication, and do I understand that she went to the hospital and the doctor or someone in the hospital said she’d have to leave ? Mr. Parsons. Yes, the doctor, Crafton and Stroad. Senator Kenx~epy. He’s going to have a nice surprise on the 6 o’clock news. [Laughter.] This is after your wife had been admitted, she had some complica- tions and the doctor told you you’d have to take her out of the hospital. What did you do? Mr. Parsons. Well, they checked her out of the hospital. Senator KENNEDY. You mean you took her out of the hospital ? _ Mr. Parsons. Yes, sir, because we didn’t have any money to keep her in any longer so we took her home and then she had a setback. Senator KENNEY. What do you mean a setback ? Mr. Parsons. She started hemorrhaging, and the doctor wouldn’t put her back in the hospital, he treated her at home. 2130 Senator Kennepy. Why wouldn’t he put her back in the hospital ? Mr. Parsons. Because we couldn’t pay the hospital bill. Senator Kexnepy. All right, go ahead. Mr. Parsons. And then 7 months later she went back to the hospital for another operation for a tubal pregnancy and she couldn’t stay in the full length of time. They had to send her home again because we didn’t have insurance. Senator Kex~epy. Now did she go back to the hospital again? Mr. Parsons. Yes, sir, the Baptist Hospital, that is where Dr. Craf- ton and Stroad Senator Kexnepy. Tell us what happened them. Mr. Parsons. For the second operation ? Senator KenNEDY. Yes. Mr. Parsons. Well, the doctors put her in the hospital. They didn’t know what was wrong with her the second time. She had been to his office that Friday morning and she went back home and started being faint, so she called me at work and told me about it. Senator KENNEDY. You are working now ? Mr. Parsons. Yes, sir; so I told her to get the girl across the hall to stay with her until T could come home. In the meantime she got so bad the girl across the hall called the doctor and he said for her to elevate her feet and then the girl called the ambulance so she could go to the hospital, and she went to the hospital and stayed in there, it was 4 days, and then they dismissed her because we didn’t have the money. Senator Kennepy. Did they find out what was wrong? Mr. Parsons. A little intern found out what was wrong with her. [Laughter.] Senator KenNepy. And we talk about the need for quality control. What did he find? Mr. Parsons. He examined her before the doctor got there and found out what the trouble was, tubal pregnancy, and she had very little blood left in her system because she was bleeding inside, it had already ruptured. Rte Kennepy. Was this the first time they found it was a tubal pregnancy ? Mr. Parsons. No, that was the second time. Senator Kennepy. Were they able to discover this the first time? Did they understand this the first time? Mr. Parsons. Yes, sir. Senator Kenxepy. But they didn’t find it out the second time. So then what happened after that. You had some rather extraordinary medical bills? Mr. Parsons. Yes, sir; I had about $3,200 worth of medical bills. Senator Ken~NEDY. Not covered by insurance? Mr. Parsons. Not covered by insurance. That was hospital bills and doctor bills and drugs, and they pressured me so bad. Senator Kennepy. Who is they ? Mr. Parsons. The doctors and hospitals and collection agencies pres- sured me so bad. Senator KenNepy. What do you mean by pressure? Mr. Parsons. Well, I was paying $20 a month and I was making $70 a week. 2131 Senator KenNepY. You were making $70 a week? ; Mr. Parsons. Yes, sir; and I dropped down. I was not paying any- thing because I couldn’t afford it, and then they turned it over to the collectors, and they garnisheed my wages. They threatened us on the telephone, sent us letters. sire KennNepy. What sort of things would they say when they called up and threatened ? Mr. Parsons. That the bill was past due, and they wanted payment in full. Senator KENNEDY. You were trying to pay at least something when- ever you could, is that right ? Mr. Parsons. Yes; whenever I could. At the time they were calling on the telephone I couldn’t pay anything at all and that’s when they started pressuring. Senator KENNEDY. So what finally happened ? Mr. Parsons. I had to take bankruptcy in order to get out from under the pressure of the doctors and the collectors. Senator KeNnNepY. You had to go into bankruptcy ? Mr. Parsons. Yes, sir. Senator KenNepy. So where are you now, Mr. Parsons, what kind of shape are you in now ? Mr. Parsons. I'm in fairly good shape now. That was in 1967 when I had taken bankruptcy. Senator KennNepy. How many years have you been a working man ? Mr. Parsons. I have been working since I was 15 years old. Senator KENNEDY. And you worked all the time you could? Mr. Parsons. Yes, sir. Senator KenNepy. What sort of employment do you do? Mr. Parsons. I'm a spray painter at Nashville Bridge. Senator KeNNEpY. And you left school to work ? Mr. Parsons. Yes, sir; I left school when I was at home to go to work, and I worked in a veneer mill for a year and a half and I worked two shifts. Senator KENNEDY. You worked two shifts? Mr. Parsons. Yes, sir; because I didn’t have a father, so I was forced to make a living. Senator KENNEDY. How many members in your family ? Mr. Parsons. Three. Senator Kennepy. Well, when you were growing up, did you have some brothers and sisters yourself? Mr. Parsons. Yes; two brothers. Senator Kennepy. Older or younger ? Mr. Parsons. T have a twin brother and a younger brother. Senator KExnNepY. And they had to work too? Mr. Parsons. Yes. Senator KENNEDY. Do you have children now ? Mr. Parsons. A little girl 6, and she goes to the doctor now, prob- ably once a month and they won’t let her in to see the doctor unless we have money to pay them mn advance. Senator KENNEDY. Who won’t let them in to see the doctor ? Mr. Parsons. Miller’s Clinic. It costs $11 for her to get in to see the doctor and you have to sit out there about 3 hours and he’s with her about 5 minutes. 2132 Senator KExnepy. That’s about a hundred dollars an hour. That’s no matter how sick the child is? Mr. Parsons. No matter how sick. Senator Kexnepy. You have to get up the $117 Mr. Parsons. Yes, sir. 8 Senator Kexnepy. There couldn’t be a question in anybody’s mind whether this is how the richest society in the world ought to be caring for the health of the people. Some people say the fact that you have to pay the $11 for your child to go down and see a doctor is cost consciousness. They say that’s going to make you a lot more cost conscious. This cost conscious concept is written into the administra- tion’s program as it is in the AMA as well. They think someone like yourself who has been working all your life ought to be able to have to pay because they think you'll overutilize the facility otherwise. They think you want to give up your hours of work and get your wife sitting in a doctor’s office because it’s fun. I don’t understand that particular argument of the administration, but they feel as strong as the AMA does about it. Mr. Parsons. It’s rather embarrasing. She goes out there and sits out there almost an hour and then they’ll call her up to the desk and remind here that she has to have the money before she can get in. Yesterday I got a bill from Miller’s Clinic and I called them because I knew I didn’t owe them anything. Back in November I fell at work and cut my leg. I had to have it sewed up and that was under Work- men’s Compensation, but they didn’t charge it to Workmen’s Compen- sation, they charged it to me. So I asked her to check about it and she checked and said were sorry about this mistake, the balance of your bill is $4. The rest we'll charge to Workmen’s Compensation. Senator Kenneby. Well, I want to thank both of you very much. You really performed a very important public service here today. You really have. There’s no doubt it’s one of the most tragic comments that I have heard about our whole system. We appreciate very much your appearance here. Mr. Parsons, are you working now ? Mr. Parsons. Yes, sir. Senator Kexnepy. Where are you working ¢ Mr. Parsons. Nashville Bridge. Senator Kex~NEpy. Did they give you some time off today ? Mr. Parsons. Yes, sir. 1 Senator Kennepy. I want to thank your supervisor for letting you come down. It has been very helpful. STATEMENTS OF MRS. MARY SMITH, PUBLIC HEALTH NURSE, AND MRS. BERNA LOU KAISER, COUNTY RESIDENT Our next witnesses are Mrs. Mary Smith and Mrs. Berna Lou Kaiser. Mrs. Smith is a public health nurse in Houston County, and Mrs. Kaiser is a resident in the county. Mrs. Kaiser, we're very appreciative of your being here. Could you give us your full name ? Mrs. Kaser. Berna Kaiser, Erin, Tenn. 2133 Senator Kex~epy. Could you tell us a little about yourself? Mrs. Kaiser. I'll start with my parents. My father is not yet retired from the railroad, but he became 111 working on the railroad. During this time it took him some years to get his social security and in trying to get this the Health Department helped my mother get welfare for the kids. I come from a family of 13. Senator Kenxnepy. There’s nothing wrong with large families. [ Laughter. ] Mrs. Kaiser. In 1966 my mother got welfare and it helped them up until about 2 or three years ago. My father was able to get a little money from social security. When I was going to school there were a lot of things we couldn’t get, like medical help and then I lost a brother about 4 months ago. He was in the service. Mother was on medicare, they had medicare cards. IT have a brother who has to have allergy shots every 2 weeks. My mother was getting these shots for him off her medicare card. They took that away after my other brother got killed, so this caused a problem even though she got a small sum of money with the medical bills and hospital bills. After they took her off welfare we felt the medicare card would be a big help because if one of them got ill there was no other way for them to pay the bills. After T got married in 1968 I have had four children. In 1969 I had a child that had to have a blood transfusion. IT was in Crossville Hos- pital. My child had to be sent from Crossville to Vanderbilt and IT had no insurance and no money. They took the child in thinking my insurance would cover it but at the time I hadn’t been in it long enough for the insurance to cover it. I had to pay off $554 for this. I also have a little boy who has been back and forth to Junior League Hospital for his feet, and another little boy 10 months old is back and forth to the Junior League Hospital to Vanderbilt Hospital for convulsions. He has had these convulsions for some time but with- out the money we could not afford to take him to the doctor every 2 weeks, so they couldn’t help him because we didn’t have the money. During this time my mother contacted the health nurse and talked to her about the condition I was in and I've got him coming up here now. The problem now is my mother doesn’t have any help whatsoever with medicare and, my brother has to have these shots and he doesn’t have any way of getting them. I wanted to know why did they take my mother off medicare since my brother got killed? And this is the thing, my baby brother would have to have these shots and she can’t afford the medical bills. ~ Mrs. Sura. The son that died was in the service and the mother is getting a Government pension, and this is the reason she was taken off welfare and medicare. Senator KeNNepy. Was he lost or killed ? Mrs. Smita. He had a civilian accident. Mrs. Karser, The type of insurance I have, I have hospitalization through my job. We have to take Blue Cross, Blue Shield. The com- pany pays half. For medical bills it does not help. You know, if you have to go to the hospital, yes, you can get in on your card, but if you have to go to your family doctor, it is no good, you have to have the money. It’s just the thing where if you don’t have the money to pay for your medicine there’s no use to go to a doctor, because he can’t help you if you can’t get your prescription filled. 2134 Senator Ken~epy. You're saying hospitalization in some instances is covered, but any kind of outpatient business is not covered and the doctors prescribe medicine and the people have to have the money to pay for those prescriptions. So why bother going to the doctor? Mrs. Kaiser. I don’t worry about myself, but when I take the kids to the doctor I'd like to have money to pay for the prescriptions. Senator Kenneny. Why does it appear to you that money has to come first before health? Does that bother you? Mrs. Kaiser. It may be the way the businesses are run. Senator Kex~NEpy. It doesn’t appear to me to be the right way. Does it to you? ; Mrs. Kaiser. No; it’s not the right way, but it’s the way it’s done. Senator Kennepy. Do you think we ought to be able to find a better way ? Mrs. Kaiser. There ought to be a way. Senator Kennepy. We ought to put health first and let people get quality health care and then work out the fairest and best way of trying to finance it. Does that appear better for you and your family ? Mrs. KA1sER. Yes. Senator Kennepy. Now Mrs. Smith. Mrs. Smrra. Senator, I represent a low-income rural community, a very small community. enator KeNNepy. You're a public health nurse in Houston County and a resident of the county ? Mrs. Smith. Yes, sir; our county is one of the smallest counties in the State. We have approximately in round figures 6,000 people. Senator Kexnepy. Do you have a doctor there ? Mrs. Smrra. We have had four. We have two leaving now, so we will only have two. We have a new hospital that we worked very hard to get. Senator Kennepy. I imagine with a good deal of local contributions. Mrs. Smith. No, sir; this was I'm sorry to say Senator Kenxnepy. That’s not known as a leading question. [Laughter.] Mrs. Smrra. I think it has taken a lot of sweat and blood but not money out of the citizens to get this hoppital there because Small Business Administration didn’t think it was feasible. We kept work- ing and pulling until we found somebody who did think it feasible, and it is working pretty satisfactorily now, but this doesn’t present the real problem we have in the county. Mrs. Kaiser gave you her story and she and her family are a typical example of the ntl we have. We have a major transportation roblem because the specialists are all centered in Nashville and we’re (0 miles away from there. It takes a taxi $20 to bring one patient from Houston County up here to the medical facilities. Mrs. Kaiser. $21. I come twice a month. Mrs. Smita. $21. Senator KenNepy. Who pays for that ? Mrs. Smita. The family themselves. The service provides the doctor bill and medication if the child is accepted into the service, but here again this is a small matter compared to transportation costs. Senator Kexnepy. Isn’t that one of the key problems in getting good rural health care, transportation ? 2135 Mrs. Smita. That's right. We have grown from a very small public health department up into a pretty big one, not in personnel size, but we still have more work than we can do down there in trying to help with the preventive side. . Senator Kennepy. Why do you think preventive care is important ? Mrs. Smrra. Well, I think it’s important to keep people well so they don’t have to go in for all these medical bills, if we can do it. There’s a lot more to preventive medicine than keeping people well. In our older people we have to keep them from getting worse. A lot of times we can’t get them better, but we can keep them from getting worse. Senator KENNEDY. I'm interested in that. Some people think we have a policy and act only for sick people, only take care of people who are sick, and I think it’s your testimony we ought to have.a health policy too so if they have health they can maintain it. : Mrs. Surra. Let me go through the types of things we do in a week. One day we call our visitation day, Monday we spend consulting and visiting patients, going to see doctors and getting prescribed medicine for patients and visiting chronic illness cases. Tuesday, is our diabetes and cancer detection clinic. Wednesday we have our baby clinic. We see sick babies, give them iron supplements to bring their iron up, observe the child for any defects and give them immunization shots. It used to be that people thought prevention was shots alone. This is just the smallest part of the day’s activity. Thursday we have the tuberculosis clinic and Friday we try to round up chronic illness. Last Monday we were on a time study and for the first time we were allowed to tell how much time we spent doing our job. I found out I spent 31 hours overtime which I wasn’t getting paid for and I didn’t really get the month’s work done. There is a need for more personnel, we need more private doctors, we need bigger buildings. We have out- grown our public health department twice, and now we are outgrowing it again. I'm a provider of services, but I'm a pretty good consumer too. In this past year my drug bill was $547. That’s just to maintain me so I could work as a public health nurse. Senator KexNepy. Who pays for that ? Mrs. Smarr. I do. In addition to my health insurance I paid $250 to doctors. The health nurses get better pay than when I started out, but we’re still not the best paid profession in the world. Senator KenNepy. Do you agree with me that solo practice in these rural areas is virtually unable to do the job? The individual practi- tioner, the individual doctor working alone is as really devoted and as hard working as he might be. Mrs. Smita. Not unless we want to kill them off. We have one doctor in our community who is 90 years old, who has been a devoted servant of the people in Houston County. He is still at the present time of 90 years of age making house calls, and this is a rare thing. Senator Kexxepy. That’s right. As 1 gather from your study of health needs in a rural community, it could be much more favorably and effectively done if done in a group effort. If you're going to pro- vide the greatest degree of health service to a community, you're going to need supplementary health personnel and we have to find ways of attracting them into those areas and provide a medical atmosphere in which they can practice good medicine. » 59-661 O - 71 - pt. 9 - 11 2136 Mrs. Sarr. One other need I see now that we have a facility giving quality care in our community. We still have to send them 70 miles with-an untold cost to the family when we could get the identical serv- ice in our community. We don’t have the money to break down the service into smaller areas. They have to prove their worth, and this hospital is only 2 years old and it hasn’t been able to prove its worth yet, so this is what I would like to see. Senator Kexnepy. I want to thank you, Mrs. Kaiser, and Mrs. Smith. T understand that Reverend Nelson brought you down here today. Is he here? Mrs. Syrra. He's right in the front row. Senator Kexnepy. I don’t know if there’s anything you’d like to add from the floor. We have had good comments and enormously valu- able ones. Reverend Newson. I can only think of one thing, Senator. There needs to be some type of incentive for the doctors that are graduating to go out into the rural areas. It may be that a health insurance that could cover all the people might be that incentive. Senator Kex~epy. Well, I agree with you. We have to try to pro- vide something so doctors who practice in rural areas aren’t isolated medically, that they are given support with personnel and facilities to practice quality medicine, and that they're given help to meet the problems which exist in the rural areas. That’s really what we have to be able to do to attract people out there. There are other features needed to upgrading schools and a wide variety of other things. We try in our national health program to do just that. That’s what we're trying to do. Mrs. Smita. I want to say one more thing, Senator Kennedy, about retired assistance. We have these retired people living on small pen- sions. These are the ones I have in my chronic illness program. I go out and see these patients. When they go to the hospital they have medicare to take care of their bills. This is fine, because the doctor’s bill, and in the clinic the outpatient care is taken care of. But the bills for the drugs for these patients take up almost 50 percent of their re- tirement check and they have to have these drugs in order to live. There's a lot of people throwing slander at the doctors. I'd like to hit the drug people. Senator Kexnepy. Thank you Mary Smith and Mrs. Kaiser. We appreciate your efforts in being here and your comments have been very helpful. We have two more witnesses before we go into the other part of our program. Mrs. Mary Jones. Where do you live, Mary ? STATEMENT OF MRS. MARY JONES, EMPLOYEE OF CENTRAL STATE HOSPITAL, NASHVILLE, TENN. Mrs. Jones. I live in Nashville on Gernecker Road, 1 work at Cen- tral State Hospital. Senator Kex~epy. I understand that’s a large mental hospital. Mrs. Jones. Yes. When I first moved here about 314 years ago 1 was working at one hospital and I was sent to the hospital with asthma, at which time I was in for quite awhile with asthma attacks. I had 2137 to be readmitted several times after this. Due to the fact of me being sick I lost my job, so I went to another hospital and was bothered with asthma quite a while, and I lost my job there too because I was sick. At this time they found out I had ulcers. My blood count kept dropping and the insurance I had was Blue Cross and Blue Shield which paid only part of the bill. ; When the doctor found out I had ulcers, he suggested 1 go into psychiatric treatment. So I was out of work for 6 months this time, and I lived on $14 a month from the welfare department. The doctors and the hospital still wanted me to pay part of their bill from the welfare check, at which time I couldn’t. I was making no payments at either place. So I had been working there for about a week when I got sick. At this time I was terminated because of being sick. This is when I went to work at Central State. Senator Kexxepy. What do you mean you were terminated because you were sick? : Mrs. Jones. Well, they just let me go because of being sick and I hadn’t been working there very long. Senator Ken~epy. Your employer let you go? Mrs. Jones. Yes, so in May of 1969 : Senator Kexnepy. And as I understand from Mr. Parsons when his company closed down he lost his insurance, and was your insurance threatened after you were terminated ? Mrs. Jones. Yes. Senator Kex~Nepy. You're so sick you're terminated, and after you are terminated your insurances goes. Mrs. Jones. Yes, sir. So in May of 1969 I was put into the hospital with asthma. I had part of my stomach removed, my gall bladder, hiatal repair and an appendix removal. which caused me to be out of work. I also had phlebitis. I went into the hosptial the 10th of May to the 20th of June, and I was off work until the middle of September. At this time I was living on $75 a month from welfare because I couldn’t work. The doctor still wanted me to pay for the treatment I received, and the doctor that did the surgery had said that I couldn’t iy back to him until I had paid at least some of the money on the ills. Segator Kexnepy. You mean the one under whose treatment you were ? Mrs. Jones. Yes, sir. Senator Kex~Nepy. Did he call you? Mrs. Jones. No; I had to go for a checkup. Senator Ken~epy. And when you went back for a checkup, what happened ? Mrs. Jones. The manager of the clinic said this. Senator Kexnepy. This is what the manager of the clinic said, youd better not come back until you pay your bill, something like that Mrs. Jones. Yes, and there was no way possible. Then T went back to work in the middle of September. Senator Kex~Nepy. How much was the bill now ? Mrs. Jones. $3,900, and my insurance paid $2,800. This was the hos- pital bill, not the doctor bills or anything. 2138 Senator Kennepy. Who is supposed to pay the other thousand ? Mrs. Jones. Well, I went through bankruptcy because of the other. Senator Kexnepy. What would happen if you went back to see the doctor now after you filed bankruptcy ? Mrs. Jones. I don’t know. So now when I do go to a doctor with asthma—T have it quite a bit—and when I do go to a doctor they either want the money right then or they won’t see me. Senator Kennepy. Have you had a circumstance where the doctor wouldn’t see you until you got up the money ? Mrs. JonEs. Yes. Or if they find out you filed bankruptcy they check your credit. Senator Kennepy. Who checks your credit ? Mrs. Jones. The doctor’s office. They have signs that say credit ap- plications checked through the credit bureau. Senator Kennepy. What does that mean ? Mrs. Jones. I guess it means they check your credit. I’m sure that’s what it means. Senator Kexnnepy. They find out your credit and if you have been through bankruptcy, and what happens then ? Mrs. Jones. Then they won’t see you. Senator Ken~epy. Has that happened to you ? Mrs. Jones. Yes. Senator Kennepy. So it’s difficult for you to win in any way. If you go through bankruptcy to get out from under these extraordinary kinds of medical bills, then they won’t treat you or let you into these clinics. Is that pretty widespread, the idea of having this credit evaluation ? Mrs. Jones. Oh, yes; you can even go into a dentists office and see the signs, credit applications checked with the credit bureau. Senator Kennepy. Thank you very much. We appreciate very much your coming here and telling us your story. Our final witness representing the people, Mrs. Jean T. May. So far we have heard directly from people. Mrs. May is here to tell us about the experience of two of her friends whose situations are so symbolic of the health crisis. She has coauthored a study of the health needs in lower income areas in Nashville. I’d like to make this study a part of the hearing record. We'll make it a part of the file. Mrs. May, we're very glad you're here. STATEMENT OF MRS. JEAN T. MAY, RESIDENT, NASHVILLE, TENN. Mrs. May. Thank you very much. During the course of about 314 years that we worked on a health survey in the lower income areas of Nashvile, we heard many, many stories of hardship and deprivation as far as health care was concerned. When I heard these hearings were going to be held here, I tried to find some examples at each end of the socioeconomic spectrum that would give you an idea to corroborate what one of the earlier witnesses said about the fact that catastrophic illness can have catastrophic effects on anyone in our society. I selected two examples, both of which were struck by catastrophic illness and wiped out financially, and both have many similarities and many differences. The first case is a woman who was working 5 days a week as a domestic worker. Her husband was a taxi driver. They had 2139 three children who were not their own that they raised. The oldest at that time was about 16, and they had been taking care of these chil- dren. They had very minimal insurance which covered only him, through his employer, and they had savings of about $200. She went into the hospital for minor surgery. Before she was ad- mitted, however, she was required to go and take out the savings ac- count of $200 which wiped out their entire reserve and deposit it at the hospital to prove she’d be able to pay her bills, but she was not HT an indigent. After she entered the hospital, during a routine checkup, they found a shadow on the lung which resulted in a final diagnosis of tuberculosis. This is a case of what I call instant in- digence. At the time they entered the hospital they were not indigent, they both had jobs and a little reserve, but after 4 weeks in the hospital the reserve was wiped out. The department of public health went to the family and found all five members had tuberculosis. The husband was no longer able to work, he was hospitalized for a year and a half. However, on the hospital records, the family still had the status of being able to pay. So here, too, we have a story of bills being turned over to a collection agency to the tune of $1,100. While the husband was in the hospital, for the first 3 months of that time, she lived on welfare payments of $28 a month, which had to support herself and the children. At the some time she was being dunned by the bill collectors. Senator KenNEpy. She was being chased by the bill collectors besides ? Mrs. May. Yes. At that point she was so desperate we began to use many resources in the community to try to help this particular family. The reason I'm citing this case 1s because it was such a complex case of having to work our way through a whole complex of legal services, welfare services and health services in order to be able to untangle all the different parts of it so she could some how come out and get rid of this bill and be able to get some payment for the children, who were then declared foster children and wards of the state so she could have help for them. We helped her find a home that would be in the service area of the Mathew Walker Health Service which most people in the community are familiar with, but for any person who has this type of problem and does not live in the designated area, even though they might be eligible due to financial circumstances, would not be eligible because of geographical area. Now the family recovered from the tuberculosis, and she has had additional catastrophic illness of cancer, but at this point she seems to be able to handle this complexity simply because she has a place like Mathew Walker Health Center with legal aid service that can work out those problems and a social worker, all in one place, so she doesn’t have to go all through the community to find these services. The second instance I selected is the wife of a university professor who was a consultant on our study. During the course of the time we were consulting him, he became ill with what eventually was diagnosed as cancer of the brain. The man died at the age of 46 leaving his widow with staggering bills. Her estimate was that the total bills amounted to about $20,000. He was a Ph. D., she has a master’s degree, they were 2140 people who had status in the community, who had every reason to feel very secure because they were covered by what they thought was an adequate insurance plan until such time as catastrophic illness hit them. There is an additional irony in this story. About 6 months before he died the professor was offered a position in Israel, which was their original home, and the widow feels most strongly about this. Had they lived in the country of their origin, which has a completely different system of medical care, this entire tragic event would have had no financial consequences for her whatsoever, because under the system of medical care in Israel all medical bills would have been paid. And this was the reason I chose these two instances, of a colleague of ours who had a catastrophic illness as well as one of the people who served as a case history in the poverty area we were serving. Senator Kexxeny. These cases, are they typical; do they happen every day in every other city in this country, based on your experience ? Mrs. May. Well, certainly we surveyed an area that covered 65,000 people. We had a large field staff. There wasn’t a day I wasn’t hearing instances similar to the first one. The thing that struck us so amazingly is it happened to one of our colleagues. We people sit around and study health care problems. We think we’re immune and one of our colleagues suffered the same kind of problem, and his wife feels as though she has mortgaged her future because she’s going to have to pay for years and years in order to pay these bills. Senator Kennepy. It’s really playing roulette with the whole health care system in this country. It can happen to anybody, rich or poor, black or white, north or south, urban or rural. It can drop in any kind of slot and effectively wipe out their security. Mrs. May. Yes; that’s right. Senator Kennepy. Thank you very much for coming here and testi- fying. We have three additional witnesses, then we'll try to get into open session until about 5 o’clock. Dr. Tom Nesbitt, immediate past president of the Tennessee Medi- cal Association and president elect of the American Association of Clinical Urologists and Delegate to House of Delegates of American Medical Association. STATEMENT OF TOM NESBITT, M.D., PRESIDENT-ELECT, AMERICAN MEDICAL ASSOCIATION AND PAST PRESIDENT, TENNESSEE MEDI- CAL ASSOCIATION Dr. Nesprrr. Senator, I welcome this opportunity as immediate past president of the Tennessee Medical Association to appear before you this afternoon. We have some 3,500 doctors in the State of Tennessee. I happen to be the immediate past president as of 3 days ago, having just completed our annual meeting. I appreciated receiving your telegram this morning inviting me to appear and testify before your committee, and you and the other mem- bers of your committee. I assume there are other members of your committee present today to transmit this information to our friends in Congress. I also had the opportunity of hearing from our Fifth District Con- gressman this morning, the Honorable Richard Fulton, who is a rank- 2141 ing member of the House Ways and Means Committee, and as such has the responsibility of hearing and making decisions on any and all health care plans presented to the Congress which the committee of which you are chairman I believe has no authority and is not conduct- ing hearings today, sir. Senator Kenxepy. Well, Dr. Nesbitt, you'd better stick to your medical testimony and I hope you know more about that than you do about the jurisdiction of the Health Subcommittee. Dr. Neserrr. Thank you, Senator, I shall proceed to do that. I call this to your attention, sir, only because the Honorable Congressman from the Fifth District of Tennessee who is a sponsor of uniform health insurance reminded me of that this morning. You asked me to express my views in 7 or 8 minutes, on the nature and magnitude of the health care crisis in this country today, and what resolutions to these problems I might be able to offer you in some manner that could be considered as you consider the health care needs. I was also asked if I thought there was a crisis. This morning at breakfast, I happen to have four teenagers. My 17-year-old daughter asked me what I was to do today and I mentioned I was invited to appear before you. She said what are you going to talk on. I said the health care crisis. She said, is that what they call a crisis? I said I don’t know, what do you call a crisis. She said, “I think the Cuban missile was a crisis. This concerns most of the people in this country.” So I had an opportunity to read a definition of crisis and I’m not certain it precisely applies to what were discussing today. I do feel strongly, as do most physicians in this country today, we are faced with a magnitude of problems as relates to health care in this country and they are related to four primary areas. They are related to prob- lems of manpower, problems of distribution of this manpower, to the spiraling cost of medical care, and to socioeconomic educational factors that inevitably intertwine. In the manpower problem, we have a shortage of physicians and nurses, technicians, medical assistants, which we all acknowledge. However, in that area there are some solutions developing in this area and I'm sure, Senator, you are well aware of these. In 1967 there were some 89 medical schools in this country with 9,000 freshmen each year. In 1971 we have 103 medical schools with a potential output of 12,000. They are taking in 12,000 students this year. By 1976 we will have 11 new schools with an anticipated output of 15,000 each year. This is doubling the physicians in this decade and T would submit that is some progress. As to the distribution of the individuals in this country who are rendering medical care to the people not receiving optimum medical care, I am the first to acknowledge we do have a significant number of people not receiving optimum medical care. We have had the areas of rural America, the core city areas who do not receive medical care properly because of maldistribution of physicians, technicians, and medical facilities. There are steps being taken in this regard. The administration has recently authorized the development of some 1.500 health maintenance organizations that will be aimed toward providing medical care in these areas. Medical foundations are being developed. You today toured one of the finest institutions that has 2142 been developed in our area to help resolve some of the problems, the Mathew Walker Health Center, which has been doing a magnifi- cent job. It has been through some trying times. They handle from 500 to 600 patients daily and I am told that the patients feel they are receiving adequate medical care in this area. ) This is the type of program we hope will be expanded to help re- solve some of the problems of maldistribution of medical care in this country. However, these problems do not become resolved in a day, and you and I both know this, Senator. The third problem is spiraling costs of medical care. We are well aware this is the main topic of discussion. This is what disturbs all of us. We don’t like to see medical care costs rising. A good bit of the blame is directed at the physicians. I believe Senator Kennedy him- self expressed the belief that he did not feel physicians’ incomes were larger than could be expected according to the amount of time they spent in training and education and the amount of time spent in pur- suit of their practice. One of the contributing factors to the spiraling costs is the increased demand for medical care on the part of American people. Part of this has been engenered by the development of Federal health programs, medicare and medicaid programs. Everyone knows these have far increased the demand for services. We have had inflation in this coun- try. Labor has contributed to this, increased cost of materials, in- creased cost of doing business, and some of the other factors even more important are those of socioeconomic and educational in their origin. ‘We do have poor housing in many areas. We have poverty and mal- nutrition, and the thing, the number one cause of death in this country, automobile accidents and heart disease, can scarcely be solved by a pro- gram of uniform health insurance without educating people that our social behavior in allowing ourselves to over indulge in excessive eat- ing, drinking, smoking of cigarettes, lack of exercise, driving cars too fast, all contribute to this immense cost of medical care which we are encountering in this country today. These are not medical care problems. They are educational in their nature and they become socioeconomic in their contruction. Building a hospital every 50 miles down a highway is not going to resolve the problems of the 55,000 people that die on the highways every year. How do we resolve these problems? I have alluded to two steps being taken by the profession of medicine, the increase in manpower, the increase in output of physicians, the increase in programs of nurs- ing and technicians I have alluded to programs that has already be- gun and are under way to help solve the problems of maldistribution of medical care and these need to be given a trial opportunity. Where they have had such an opportunity they have been successful, and noteworthy in this success. ny The position of the American Medical Association is one that we believe is a form of universal health insurance for this country on a voluntary basis. Medicine’s position has always been that the inability to pay should not be a deterrent to medical care, and that it is the right of the American people to expect to have adequate health care available to them. As I alluded to previously, most of the health care problems in this country today are generated by the habits and socio- 2143 economics of our people, and for these we need programs other than complete total socialization of the medical care of this country. A bill providing for a voluntary universal health program which has been presented by Congressman Fulton from the Fifth District of Tennessee, in conjunction with a provision that will cover catastrophic illness has been presented in Congress. It has 131 cosponsors. It seems to most of us this will provide a reasonable solu- tion to the situation that exists today. It will cost by estimate roughly $12 to $15 billion and some other programs are estimated to cost some $45 to $70 billion. S. 3 alluded to today, for which we are given information on the blackboard, would cost the American people for every $100 of taxes they now pay an additional $35 to $37 per $100 of taxes. Senator KennNepy. What is your authority on that ? Dr. Nessrrr. I'm quoting Senator Bill Brock, sir. Congressman Fulton alluded today in our discussion to the fact that the Nixon administration has estimated a budget deficit in the range of $11 billion for 1971. Many say this will go far beyond that estimate. He questioned whether the country could well afford another program estimated to cost between $45 and $70 billion at this time on top of the taxload now being carried by the Federal Government, and the Fed- eral Government is not the taxpayer. It is we who are the citizens of this country and we are being asked to share an additional tax burden. I appreciate this opportunity. I feel I may have gone beyond my 7 minutes. Thank you very much for the opportunity of appearing. Senator Kennepy. Thank you, Dr. Nesbitt. If the figures that have been worked out in terms of national health do reach the approxi- mately $45 billion figure, we believe quite frankly that that’s old money that’s already in the system that 1s being used for inadequacies and inefficiencies already in existence. Do you think we can afford not to provide quality health care in this country ? Dr. Neserrr. 1 didn’t say that. I believe it can be done for a figure less than that that has been planned for a program that would not provide total Federal Government control of the health care indus- tries. We have seen, for example, that the Federal Government has had total Federal control for the postal industry for a number of years and we have found that has failed to be successful and have found another manner in which to handle that. Senator Ken~Nepy. The Federal Government has total Federal con- trol of the social security system too, has it not ? Dr. NesBrrr. And today the obligation of the social security system I am told is in the vehgiborhiod of some $3 trillion to the citizens of this country for which there is very little to back it up in the coffers. Senator KENNEDY. Are your questioning the financial soundness of the social security funds? Dr. Nesprrr. I didn’t say that. Senator Kexnepy. What are you trying to say? We have capital assets. Do you feel social security is a good thing ? Maybe we had better start with that. Dr. Nesprrr. I'll be happy to start with that. I have no question that social security as initially conceived Senator Kennepy. What about medicare; was that a mistake ? 2144 Dr. Nesrrr. May I elaborate? Medicare was a program of health care to older citizens. The American Medical Association had such a program and believe it should be instituted. I would like to point out medicare as it was conceived and passed by the Congress of the United States was the first and only program of its nature in the history of this country that has ever provided funds to a group of people whether they wanted it, whether they needed it, or whether they could afford to pay for it themselves. enator KENNEDY. Are you for repealing it? Dr. Nessrrr. I feel the program ve e modified ; I really do. Senator Kexxepy. Do you think it should be cut back? Dr. Nesprrr. I didn’t say that. Senator Kenney. What part would you cut back? Modified could mean expanded. Which way do you want to go? Dr. Nessrrr. I think it should be related to the ability of the indi- vidual to pay. For those people without the ability to pay for their medical care, I think it should be provided. I think the millionaires in this country and the many, many people who are perfectly capable of paying for their own medical care should not have the privilege of receiving benefits of tax-supported funds from the citizens of this country. Senator Kennepy. Let me ask a question which is asked me often. With the concept of fee-for-service built into our present system, which in effect makes the doctors richer the sicker people get, how do you really think we can get a handle in terms of cost control ? Dr. Nespirr. I'd be happy to discuss this on cost control. This has to do a great deal with the quality of medical care and has to do with review of what physicians are doing and how physicians conduct themselves in the practice of medicine. I would like to point out to the Senator and the audience I know of no other profession that com- pletely screens who it chooses to serve the people than does the medical profession. People interested in becoming physicians are screened from the day they leave high school. They eliminate a large number before they get to medical school based on their integrity, moral character, and so on. Further large numbers are eliminated in medical school. They are examined when they go through internship and residency. They pass examinations for basic sciences and Ls are further screened by a board of professionals in their specialization. There are existing utilization and grievance committees operating in every major medical society in this country and they operate effi- ciently and with success, and situations arise annually where steps are taken by physicians, who are the only ones qualified to review the work other physicians perform. I might also add there's a great deal of talk these days about reviewing physicians’ office work. I would like to point out, sir, a man’s hospital work is nothing more than a reflection of his office work, and this is how physicians’ practices and offices are reviewed. These are the manners in which cost control are contained within the profession. It has been shown on studies of existing group pre- payment plans, and I might add we have never been able to get a handle on what these figures amount to from any of the existing foun- dations that have been in existence for over 20 years. These plans have 2145 been available for 25 years and today less than, I think, 6 percent of the population belong to these. We have never been able to get reliable statistics to tell us what the cost control of these is. They do provide incentive in terms of available funds to provide the service in the event they don’t put people in the hospital and don’t take care of harpias and gall bladders. This is cost control. I'm sure it’s not quality control. Senator Kex~Nepy. Let’s get back to fee-for-service again. That’s what I asked. Dr. Nesprrr. This relates to fee-for-service as opposed to prepay- ment plans. Senator Kennepy. Don’t you think the present system with all the kinds of protection that have been built into it, and all the various re- views and so on, when it still results in this kind of extraordinary increase in doctors’ fees, hospital costs, additional charges, don’t you think there’s something wrong with it. Isn't it reflected in the kind of medical bills that these consumers have talked about here today. You can talk about all the statistics and we can shuffle those statistics around all afternoon, but nonetheless you see the kind of extraordinary in- creases we're having. People ask why this is so. And they ask why this country has twice as many surgeons as Great Britain and does twice as much surgery. And why, for example, in California they do four times as many tonsillectomies. Dr. NesprrT. Is that really germane? Perhaps the people in Cali- fornia have four times as many polio injections. Senator Kennepy. Well, take California, why do you think there are four times as many tonsillectomies ? Dr. NesprTT. I don’t know that they do. Senator Kennepy. Don’t you think the Medical Association ought to know that ? Dr. Nessrrr. I think we could explain if these were valid statistics. Can you show me the source ? Senator Kennepy. They are in the President of the United States’ message to Congress. [ Applause. ] Dr. Nesprrr. I don’t Foire you take everything the President says as being valid. I don’t believe you agreed with him in regard to the statements he made with regard to Vietnam, and welfare reform. Senator Ken~epY. Don’t you think if it’s in the President’s message it’s up to the medical societies and associations to try and find out why this 1s taking place or if there is too much surgery? Doesn’t the American Medical Association have a responsibility in that ? Dr. NesBrrr. The medical society does have a responsibility in that and exercises it constantly through its system of utilization of review. Senator Kenxepy. Well, do you want to leave it with that ? Dr. Nessrrr. Who would you like to leave it with, Senator ? Senator Ken~Epy. It’s interesting to hear about how the society en- dorses neighborhood health centers. That idea never came out of AMA. I can remember as the sponsor of that amendment when they opposed it. [Applause.] I think what has to concern these consumers as it concerns the American people is why the medical societies are always Fesponding at the last moment. The President talked 18 months ago about a healt 2146 crisis and then we put in a hard hitting bill and then you hear them respond. You're talking today about all the things being done in terms of holding down costs and so on, it just makes some of us wonder who’s looking out for who. Dr. Nesprrr. I feel you have a perfect right to wonder. We also realize that you are intimately concerned with matters other than health care. You deal with this in short periods of your day and we deal with it constantly. Senator Kennepy. There's been a mistaken belief that the only people who know about war are generals and the only people who know about medicine are doctors. That’s what has been wrong. We've been leaving it in the medical profession too long. I think that’s precisely what has happened. Dr. Nessrrr. I'm glad we got to hear your opinion. I'd like to hear from some of the other members of your committee. Senator Kennepy. You've been listening to Senator Brock. Dr. Neserrr. Is he a member of your committee? Senator Ken~epy. No, he’s not. [ Laughter. | You've been kind and generous with your time and made yourself available to us here. We have heard a series of consumers this after- noon and they haven’t been people who have been involved in ex- cessive eating or excessive drinking or all the other kinds of indul- gences. You heard the problems of Mr. Parson’s wife in terms of childbirth, you heard the problems of Mary Fletcher and all the problems her family had. When we just scratch at bedrock on this and leaving out all the other vestures, mini credit and all the other things, what are you prepared to tell them this afternoon? They are living in this community here, they're working people. All they want is a crack at some decent health. They are prepared to pay their bills, but they have some of the most extraordinary expenses. These aren’t untypical. What are we supposed to say. We're interested, I’m sure you are interested in trying to do something about this. What do you say we ought to do? Dr. Nesprrr. Thank you. I would say this Senator Kex~epy. What would you say to their problems? Dr. Nesprrr. I'm waiting for the opportunity. Senator Kenney. Let's hear you speak. Dr. Nesprrr. I've been waiting for this opportunity. I admit I have listened to this testimony with great concern this afternoon. I realize fully that conditions like this exist in every community. I view them with the utmost compassion and sympathy, and I wish there was a solution that the medical profession or the U.S. Government could find for the catastrophic situations that arise in daily living. These are not easy solutions, or they would have been found by our profession and the Government of the United States long before now. There are situations that arise in daily life that are a result of cata- strophic situations for which there has never been a solution in the history of mankind. I would like to find such a solution, sir. We feel a beginning is embodied in the Universal Health Insurance Act that has been promoted by Senator Fulton, embodied in the AMA’s bill which is up before Congress at this time. The President feels like 2147 we should include some mechanism to begin to take care of the prob- lems of catastrophic illness. Medicine never has been able, nor has anyone, to resolve these situations that we encounter almost daily. A day does not go by that I don’t see one or two situations that defy solution under our present system of free enterprise as we know it today. But the solutions are underway. They are in Congress. It is up to Congress to decide which of these can best be handled within the economic feasibility that this Nation can afford to handle such problems. Senator Kennepy. It is the catastrophic problems that are created that are obviously the greatest problems, but we’re also talking about the wife of someone who had childbirth, who had an $800 bill. That’s catastrophic in their lives. We're talking about two or three hundred dollars of savings taken away and bills that are going to take away 8, 10, 15 percent of these people’s take-home pay for several years. Dr. Nesprrr. Yes, I'm fully aware of this. I do not have the solu- tion nor has anyone presented a solution that has been found to be totally acceptable by the American people or by Congress. I think there are solutions available. We hope this will be forthcoming from the 92d Congress. There are opportunities available for us to resolve some of the problems and No. 1 is the inclusion of some form of cata- strophic health insurance. Senator Kennepy. Thank you very much. Dr. Nesprrr. Thank you very much. We appreciate the opportunity of being here. Senator KenNEpY. Our next witness is Dr. Lloyd Elam, president of the Meharry Medical College. Dr. Elam is a member of the Na- tional Medical Association, American Medical Association, American Psychiatric Association, and we're extremely glad to have you here. STATEMENT OF LLOYD ELAM, M.D., PRESIDENT OF MEHARRY MEDICAL COLLEGE Dr. Eran. Senator, as you said, I am president of Meharry Medical College and what I am saying today really grows out of my work at Meharry Medical College despite the fact that T am a member of some of these other organizations you mentioned. Meharry has been concerned with health care for the poor and with educating doctors to practice in urban ghettos and rural areas. Almost half of the practicing black doctors graduated from Meharry, al- though this 1s a fully integrated institution with 20 percent of our students being white. As we have moved into the community, we find three areas of serious deficit in health care. The first is the large number of persons who are employed full time but with incomes that are too low to meet the cost of health care. In our hospital 21 percent of the patients are in this category. Residents in the community are fortunate because there are ambulatory comprehensive health programs which can care for the poor and the near-poor, if hospitalization is not necessary. In preparation for the institution of a neighborhood health center in this area a study was made by the center of community studies of the health of the community of 64,500 persons. I would like to cite 2148 some of the findings. The median income was $4,000, or about half that needed to live in Nashville at a moderate level. Sixty-one percent of the 2,057 persons contacted reported current mental, dental, and physical health problems. Fifty-eight percent of the poorest households reported one or more problems which lasted for 3 months or more. i WMIAL Twenty-three percent of the population reported a major disability during the year—an illness which required hospitalization or a 7-day loss from work. ; One-third of the population had never received such preventative services as chest X-ray, tetanus shot, polio vaccine, and 25 percent of the children had no baby shots. . The most frequently reported specific disorders were hypertension, arthritis, heart disease, anxiety, and headache. Persons in the 25 to 44 age group reported most frequently that nothing had been done about their current health problems. } These are only a few of the findings but they indicate that even in a community where there is no doctor shortage, the health of the poor and the near-poor is far from acceptable. A second major deficit involves the limited scope of personal health care. In the past, acute illness care has been of concern while chronic illness, malnutrition, the need for eyeglasses, hearing aids, or dental and mental care have been available only to those with money. In a study by our Health Service Research Center, 65 percent of the black residents and 26 percent of the white residents spent less than 85 cents per person on food each day. From this population 44 percent of the pregnant women went into labor with significantly less hemoglobin in their blood than normal, which reflects malnutrition. In the same population 14 percent of the citizens had physical impairments for which they were receiving no service. There are many other statistics which show that while care for the acutely ill is less than adequate, care for the chronically ill is often completely lacking for people in all but the top economic levels. A third major deficit relates to the separation of medical education from health service. While it is necessary to assign costs to the ap- propriate area, the provision of health service is so dependent upon the availability of adequate manpower, the two must go hand in hand. Recent financing programs for health seem to discriminate against medical education by encouraging the exclusion of trainees from the health care arena. This has not affected Meharry greatly as an insti- tution, but if the potential exists in the new legislation, it must be changed in order to insure an increased flow of doctors and other health personnel. Another crucial factor regarding manpower relates to the need to have new manpower resources precede new demands on that manpower. Despite the calculations by some that allied health professionals can provide the additional care or that redistribution of existing doctors would solve the health crisis, the fact is that these measures will re- quire time as well as the education of additional doctors. Only if man- power training support is coordinated with health service support, it be possible to provide expanded health services without serious inflation. 2149 The fourth deficit is the lack of incentives to provide the kind of health system which best serves all the people. The right to adequate health care can be protected by governmental activity as other rights are guaranteed. It 1s not possible to guarantee a right on a voluntary basis—the Government must have a major role in it. The continued support of comprehensive health programs is a step in this direction. These programs, such as the Neighborhood Health Center, are extremely important in areas of greatest need. However, these centers will not cover all populations and in addition to these, legislation is needed to provide a system which will insure that every- one in the population has access to health care and that providers have an incentive to cover all persons in the population. Although Meharry has provided health care for the black and the poor in Nashville, Mount Bayou, Miss., Tuskegee, and other com- munities, we do not believe that there should be a different kind of care for different segments of the population. Despite these models which give excellent care, in general, history shows that if there are different levels of health care, the poor, the black and the disenfran- chised will receive the worst kind of care. When faced with a crisis, there are many areas which need atten- tion. I have limited myself to four major deficits. These are: (1) There is a large number of persons who are employed full time but with incomes too low to meet the cost of health care through their purchase of services or through third party support available to them. (2) There is a need to greatly expand the scope of health care to include not only acute and chronic disease care, but also systematic preventive services, including adequate nutrition, housing and sanitation. (3) The education of physicians, dentists, and allied health work- ers must be supported in coordination with the provision of health services. (4) There must be legislative incentives to provide the kind of health system which serves all the people, or stated differently, the Government must guarantee this right. [Applause.] Senator Kenxepy. Do you think the health crisis is just a crisis for the poor or do you think it’s a health crisis for middle-income people as well ? Dr. Eran. The health crisis is a crisis for everyone. We are noticing it more among the poor, it is certainly much worse among the poor, partly because as the level of living decreases the health care needs increase. But more and more we are finding that the working people do not have access to adequate health care, and more and more we are finding people who a few years ago, just in the 1930’, a family at a certain income level would have access to health care they no longer have access to it. We think it is a crisis for everyone and probably to some degree to people who don’t consider themselves middle income. Senator Kex~epy. What about the quality question? Do you think there is a real question about the adequacy of quality, not only for the poor people but also for the middle-income people ? _ Dr. Evam. Quality must be looked at in many ways. One of the ways in which you look at quality involves the kind of service a person gets when he gets service, and by and large for the middle-income group if 2150 he gets service, it is service of the highest quality in the world, and if you get into one of our better hospitals, you can’t beat that kind of service. But other kinds of things that must be involved in quality include the availability, whether or not the care is available, the con- tinuity of care and so on. If you look at all of these elements of quality, the quality is not as good as it should be even for middle class people. Senator Kennepy. How are you really going to know? Is it just a matter of paying the bills, or the ability to pay ? You find a lot of people paying their bills without any assurance that they are getting quality care. Dr. Evam. There are two ways of assessing quality. One is a kind of process evaluation. This can best be done by doctors. Process evalua- tion, looking at the process that the doctor went through to provide the care. I think maybe peer review is all right for that. Senator KenNepy. Is that being done systematically in this country Dr. Eram. Not outside of the hospitals. One of the great contribu- tions of Medicare to this country is that many hospitals do a better job of peer review than they were doing before medicare. But the other kind of assessment of quality is just as important I think, and that’s assessment of the results of the process, and of course you don’t have to be a doctor to assess that. Senator KennNepy. What is your feeling about the independence of Blue Cross from the hospitals. Are they really independent ? Dr. Evam. I don’t think I can answer that. Senator Kennepy. Do you think they ought to be more independent ? We heard last week in Nassau that half the board in Blue Cross were representatives of the hospital personnel and they didn’t describe what the other half were. Do you think that in fixing hospital rates or per- haps even reimbursement rates, there ought to be a stronger consumer voice on the board ? Dr. Evam. I don’t really think that would get at it. I think the cost of health care cannot be controlled by Blue Cross, and of course the people who get involved in Blue Cross are more than likely people who for one reason or another are very concerned with health care. So you're likely to have people involved in health delivery or who are with unions or some way have a stake in it. Even if it were completely separate, if you had the same kind of situation that you have where I can only have many procedures done if the person goes into the ospital, you're not going to be able to cut down or control the rising cost. So I don’t think you can get at what you're trying to get at by anything you can do to Blue Cross. Senator Kexnepy. Let me ask this. They purchased 15 open heart surgery units in New York City. I don’t know if they need that many, yet Blue Cross is prepared to fund that program. I think that’s because they are to a great extent captured by the Hospital Association as Blue Shield is captured by the Medical Association. I would suppose if you had consumer interest they’d make these studies and find out what is needed in terms of heart surgery. Dr. Eram. That’s a very interesting idea. One of the things we have to ask ourselves is why does the hospital purchase this piece of equip- ment if it does not need it for community care. Senator KENNEDY. Does prestige have anything to do with it? Dr. Evan. It is absolutely the reason. It is necessary to have a certain amount of prestige, hospitals feel, in order to attract the 2151 doctors and the patients they want. If it is necessary to buy an addi- tional piece of equipment that costs $50,000 in order to staff your hospital, youre likely to buy that piece of equipment. I think you can only get at that by having a system which makes available an adequate amount of health manpower in which case the hospital doesn’t have to do all these special things like staffing up for something they really don’t need to do in order to attract personnel, but that’s what goes on here. It isn’t the hospital is just doing this to make additional money or anything like that. Senator Kennepy. Thank you very much, Doctor. You were ex- tremely kind to be with us today. When we visited the Meharry College and we had a good conference with your students over there, sort of a give and take session. We met with the students and asked cach other questions, and they were extremely helpful in their com- ments. I want to thank you very much for your courtesy in coming here. Our next witness is Dr. Joseph M. Bistowish, the director of health for Metropolitan Nashville and Davidson County. He assumed this position in November 1964, after serving for 15 years as health officer of Leon County Health Department, Tallahassee, Fla. STATEMENT OF DR. JOSEPH M. BISTOWISH, DIRECTOR OF HEALTH FOR METROPOLITAN NASHVILLE AND DAVIDSON COUNTY Dr. Bisrowisi. Senator Kennedy, members of the subcommittee, ladies and gentlemen, I was asked to comment regarding emergency medical care for Metropolitan Nashville and Davidson County. I am not a clinical physician and I do not practice clinical medicine, neither am I an expert in the field of emergency medical services. However, 1 an familiar with the emergency medical services in Metropolitan Nashville and Davidson County. In my opinion, emergency medical services for this county are completely madequate. In fact, I am convinced that this inadequacy results in several deaths each year. I am told this by knowledgeable physicians in this community, and from my own observation I am in agreement, with them, that we do not have in this county a real first- rate emergency medical service room in any of our hospitals. At least three of our hospitals are planning in the near future to improve their facilities and services. This will be a great help to the community. All of our ambulance service is furnished by funeral directors. At- tendants on these ambulances have, for the most part, little or no train- ing for their work. Equipment carried on the ambulances is inade- quate. There is no provision for exchange of equipment between ambulances and emergency rooms so that belts will not be unduly delayed at hospitals. There are no standing orders as to where certain types of injuries will be taken for emergency room service. In fact, ambulances sometimes pass a hospital perfectly capable of taking care of a particular injury to go to another hospital farther away of their own choosing. Senator KeNNEpy. What do you think is the reason ? 1 Bistowisn. I have heard some rumors on this, but I’m not able really—— Senator KexnNEDY. What do you think the reason is? 59-661 O - 71 - pt. 9 - 12 2152 Dr. Bistowisa. Obviously they must have some reason for having a choice of one hospital over another. What the reason is or what the connection is I do not know. Senator KenNepy. Do you think economics is the reason ? Dr. BistowisH. It ol possibly be, but then I cannot conceive of any of our hospitals in town making any arrangement like that. It is inconceivable knowing the men in charge of these hospitals. Senator KeNnepy. What do you think the reason is if that’s in- conceivable ? Dr. Bistowisu. Well, as I indicated I could not comment. Senator Ken~epy. All right. Dr. Bistrowisa. Ambulances travel at high rates of speed on busy streets and jeopardize the lives of everyone in their paths as well as the patients within the ambulance. Most medical authorities are in agreement that high speeds by ambulances are, in most cases, unneces- sary. There is no system of radio communication between ambulances and emergency rooms so there could be advance warning given to the emergency room to get certain equipment ready. There is no dispatch service available to avoid two or three ambulances showing up at the same time. Senator KENNEDY. Suppose you had radio equipment, would it make a difference in terms of saving lives? Dr. BistowisH. Yes, it would. It would even make it possible for a physician on duty in the hospital to give information to the attendant on the scene for a particular type of injury. Senator KenNEDY. I suppose it’s resources that prohibits the kind of equipment the ambulances carry. Dr. Bisrowiss. I think it’s more than that. A public hearing was held at our metropolitan council a few years ago when we had an ambulance service before the ordinance was repealed, and at that time indications from the funeral directors was that they did not want the type of equipment we were requiring on the ambulances. They did not want their people using it. They were afraid apparently of the Liaplity involved. The more you do, the more you are likely to be sued. There was a newspaper account some time ago in which two ambu- lances arrived at the scene of an accident and the drivers argued over which one would take the corpse while leaving the injured person un- attended on the ground. Approximately 2 years ago a group of teen- agers had an automobile accident almost in the front yard of a local physician. Because of the type of injury to one of the teenagers, this physician recommended to the ambulance driver that the patient be taken to a particular hospital. The driver let the physician know in no uncertain terms that he made the decision as to where the patient would be taken. Approximately four and a half years ago, our local funeral directors announced publicly and to the metropolitan council that effective a certain date they were getting out of the ambulance business, and they informed the metropolitan council that other arrangements must be made for ambulances service. Members of the metropolitan council, along with the director of health, visited other cities to study their ambulance service. The council considered at length whether to operate an ambulance service as a part of one of the existing departments or let 2153 private enterprise furnish this service with regulations and a subsidy from the metropolitan government in the form of payment for service to indigent patients. The decision was made to let private enterprise furnish the service. Actually an ordinance was passed which gave the metropolitan health department responsibility for formulating regula- tions and supervising ambulance service. Adequate regulations were formulated which provided for the train- ing of attendants and the carrying of essential lifesaving equipment. A privately operated ambulance service, as well as a few funeral direc- tors, applied for ambulance permits. Temporary permits were issued in order to give these companies time to comply with the regulations. At the expiration of the temporary permits no ambulance company had complied with the provisions of the ordinance, and the city was faced with the decision to either close the ambulance companies and lose all ambulance service or organize an ambulance service within the metropolitan government. About that time, several funeral directors appeared before the metro- politan council and stated that they wanted to again furnish ambulance service for the county. In support of their reentering the field of am- bulance service, they stated that they had given very adequate service for many years at no expense to the government and were willing to continue this service. One funeral director stated that his company had always had high praise for its service. It was stated that a physician at the hospital had told his driver that if the patient had arrived at the hospital 4 minutes later he would have been dead. Although I am not familiar with the details of the case, it is possible that what the physician should have said was that if the patient had been given adequate care before being put into the ambulance, the driver could have taken his time traveling to the hospital without risking the lives of other motorists and pedestrians, and the patient would have arrived in the hospital in better condition. The outcome of the funeral directors’ appeal to the metropolitan council was that the ordinance and regulations were repealed, and Nashvillians still have the same inadequate emergency medical service that they had 15 years ago. This community badly needs improved emergency medical service. Improved services have been urged by the metropolitan board of health, the Nashville Academy of Medicine, the Mid-Cumberland Comprehensive Health Planning Council and many other groups. The Nashville Urban Observatory and the Mid-Cumberland Comprehen- sive Health Planning Council are presently working on a plan for a first-rate regional emergency medical service. We certainly hope that their plans can be put into effect in the very near future. Senator Kexnepy. Has the medical association taken a position ? Dr. BistrowrsH. Yes, the Academy of Medicine has. Senator Kexxepy. Is that your local organization ? Dr. Bistowtsn. That’s correct. Our local academy of medicine, Nash- ville Urban Observatory and the Mid-Cumberland Comprehensive Health Planning Council are now planning a good regional service and we do hope the plan will be acted upon favorably by all the groups. Senator Kex~epy. When will that be up before the acting body ? Dr. Bisrowisn. I believe my last contact with the group indicates it would be within the next 2 or 3 months the plan should be pretty well 2154 completed. The problem then will be to get the cooperation of 13 counties. Senator Kexxepy. How long has the problem you have identified been going on ? Dr. Bisrowisn. I suppose for many, many years. This problem is not unique to Nashville. Senator Kexnepy. Many communities have it, don’t they ¢ We were hearing about it in West Virginia yesterday. Dr. Bistrowisa. We had the same kind of problem in Florida. Senator Kex~epy. Thank you very much. We have about 10 minutes here if there are individuals who would like to make comments, if they'd be kind enough to state their names and we'll try to limit it to a minute or two. STATEMENT OF MISS GALE LEWIS, WITNESS FROM FLOOR Miss Lewis. There is an organization in east Tennessee called Proj- ect Concern which is a private organization which has been trying to fill the gap in areas where there is no medical care, in the pie Mountains. These people secured funds in March. The average income of the people in this area is somewhere between $1,200 to $2,000 a year. In some parts there are no doctors at all, and the people in Project Concern travel around 200 miles a day to small communities and set up and provide medical care for these people and provide medi- cation. The people are not able to pay anything and they do not. How- ever, the doctors and dentists working with Project Concern provide his health care. This is an example of where the public is trying to elp. Senator Kexnepy. Thank you. STATEMENT OF JAMES R. SMITH, WITNESS FROM FLOOR Mr. Suir. At a time when nurses are clamoring for higher wages, 600 to 800 doctors in this area whose duties are increasing constantly, how do you think this situation as well as providing Federal funds for education of nurses would be affected by your bill, with reference to article 6 in the bill S. 3? Senator Kennepy. There is separate manpower legislation in terms of nurses training which will expire in June of this year. We have been very much distressed by the reduction in total funding made available for nurses training over the last 3 or 4 years. There has been a $3 milion cut over the period of the last 3 years which distresses me. I think this is some indication i pn of the kind of prior- ity placed upon the whole question of the supply of nurses and nurse training. In terms of the more sophisticated utilization of nurses we would hope that through the resource development fund, which would be a fund established under S. 3, there would be a mechanism by which more innovative, creative, imaginative ways of utilizing a nurse, prac- tical nurse, paramedical personnel trained as nurses could be used. We want to make it clear we're going to get into the whole question of licenses regarding these professional personnel because for too long we have seen the licensing mechanism used to exclude competent, qualified, committed, concerned individuals who do have talents and have been excluded from nursing and other technical areas. We are going to try and deal with it in this way. 2155 STATEMENT OF MISS DIXIE TAYLOR, WITNESS FROM FLOOR Miss Tayror. As I understand it a portion of your bill would affect impacts on nursing, would limit 120 days for a spell of illness for free standing facilities, whereas a hospital bed facility would give it un- limited days. What is the reason for this? Senator KENNEDY. You are right, the distinction in our legislation is between nursing homes that have affiliation with hospitals and those that are independent. The reason for that is once again to get at cost control, where you can move from acute into ambulatory care with a great deal more efficiency and have a much greater handle in terms of control. This kind of association would be assured of continuing kinds of payments where if they were solely independent, there would be this 120 limitation. This would encourage quite obviously the development and utilization of the nursing homes within the general kind of total health complex, and we believe this is important and useful and from various observations we have seen up at Massachusetts General Hos- pital and some of the other complexes that have worked in this area, we think it will be useful. This would encourage nursing homes to develop their relationship with the hospitals and you'd get a much more efficient utilization of the system and personnel within the system. STATEMENT OF MRS. JEAN MAY, WITNESS FROM FLOOR Mrs. May. What kind of timetable do you project for the passage of your bill? Senator Ken~epy. I hope that the bill will be at the President’s desk by fall of 1972. T think that’s an ambitious program. We have 25- cosponsors in the Senate made up of Republicans and Democrats, and I think there is a strong sentiment for it and we hope we’ll get some action on it. We’ll get votes on this concept, I can guarantee that this yom and next year, but to be able to implement it, it might take a while. STATEMENT OF MR. ROB CARLEY, WITNESS FROM FLOOR Mr. Carrey. If your bill does pass, how long do you think it will be before you can get relief to these people like the people giving testimony ? Is it going to be caught up in a lot of redtape or are these people going to get the relief they want ? Senator Kex~Nepy. It goes into effect 2 years after it passes. You're talking about escalating provisions of the legislation. We start off lim- iting dental care to 14 years of age and move on up. We have certain limitations in psychiartic and pharmaceutical aspects. These features will probably have to be expanded and enlarged, but we’ll get at the kind of problem that has been outlined here this afternoon, and we’ll get to that immediately. In terms of resource development funds, we're trying to provide awards for innovative programs being developed in the whole health delivery system. That will take time and imagination. It took a long time before we got to neighborhood health centers. What we're trying 2156 to do in S. 3 is build competition between the health delivery systems rather than just adding on to the cost as we do now, with all due respect to Dr. Nesbitt. : What we're trying to do, by encouragement of health maintenance organizations, neighborhood health services, various different kinds of delivery groups is to get them to compete for the right to provide comprehensive health services. There will be strict national standards on this. Let’s make that very clear. They are going to have to meet these national standards. When one gets a contract they are going to have to live within a prefixed budget, which makes more sense In terms of the economics. They are going to be rewarded for keeping people healthy rather than making money when they get sicker. The reward will go for keeping people healthy rather than keeping them sicker. Dr. Eau. As a cosponsor of this national health insurance program, are you in a position at this time to submit a resolution to the Congress to call for a national referendum and see what the people of the United States have to say along about 1972? Senator Kexnepy. Hopefully that’s part of the purpose of these hearings: To engender a national political discussion and debate. This is going to be a controversial subject in the election. The candidates are going to have to take a position on this; the first year in the Senate medicare lost by four. The next year it carried by two and lost in the House. It is going to take sometime and much education. I’m hopeful we can really focus on that. Let me just say the purpose of coming here today was to listen to the comments and the statements that were made. We will continue to try to listen to the consumers who have had some relationship with the health system or have had no relationship because of the way it treated them, and I think today we heard eloquent testimony. I firmly believe there is a health crisis, it exists in my own city of Boston and I believe it exists in Nashville. Dr. Nesbitt and I disagree on this. We can’t get around the fact that AMA has a program that has been submitted to Congress; it has congressional support, but I think it can’t do the job that has to be done. What they are trying to do or doing in terms of their publications, and what we’re attempting to do by public hearings is to try and venti- late this whole question about finding out the best means to meet this health crisis. We have more attention on this issue than we have ever had in the history of this country. The way we’ll get the best system whether it is the AMA program or our program or industry’s pro- gram is when we really get the people interested. You have been ex- tremely kind and generous in your interest here today, and your atten- tion in this program, and I want to express my appreciation for your demonstrated concern by spending 3 hours here. I also want to express my sincere appreciation to Dr. Nesbitt and the witnesses who testified. It has been an extremely valuable and informative meeting for me and I'm sure for the other members of the subcommittee who will have a chance to review the record. The subcommittee stands in recess. (Whereupon, at 5:10 p.m., the subcommittee hearing in Nashville, Tenn., was adjourned.) HEALTH CARE CRISIS IN AMERICA, 1971 TUESDAY, MAY 4, 1971 U.S. SENATE, SuscoMMmITTEE ON HEALTH oF THE CoMMITTEE ON LABOR AND PuBLic WELFARE, Cleveland, Ohio. The subcommittee met, pursuant to call, at 1:15 p.m. in room B-1, Federal Office Building, Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present : Senators Kennedy (presiding), and Packwood. Committee staff members present : LeRoy G. Goldman, professional staff member to the subcommittee; Jay B. Cutler, minority counsel to the subcommittee. Senator Kexnxepy. This is really as informal a meeting as we can have in terms of the Senate. We have an order of witnesses which we will go through, then we will open it up to anyone who wishes to speak. Pe Mr. James Rieger here by any chance? Mr. Rieger, would you be kind enough to fight your way up to the front. I know you have got an interesting but rather sad story. We would be very much interested in it. We realize at the onset that 1t’s difficult for people to come up and tell their ills and problems. Nobody enjoys doing it; I think to a great extent, this is part of the reason we haven't developed the kind of health system in this country that we are capable of. People feel if they are sick or their wife is sick or their child, it is something per- sonal. They want to keep it to themselves. But if we are going to pro- vide a meaningful program, we have to learn about these everyday experiences. That is why we are so appreciative that you can be here telling us about your family and your tragedy. If you could go ahead now? STATEMENT OF JAMES RIEGER, CLEVELAND RESIDENT Mr. Riecer. Well, I have a wife who was about to have a baby—— Senator Kennepy. We will need quiet now, so we can hear Mr. Rieger. Mr. Rieger. I had hospitalization insurance through my employer. Senator Kennepy. Let me ask you, do you work; were you working, and where? Mr. Rieeer. Oh, yes, I work for Joseph Feiss & Co., a clothing manufacturer. Senator KENNEDY. You are married ? (2157) 2158 Mr. Riecer. I am married, and have one baby now ; one just passed away. a like I said, I had insurance through my employer, which was negotiated by my union. A, Senator KenNEpy. Your union had, through collective bargaining, set up a program for hospitalization ? Mr. Rircer. Right. Senator KennEepy. Fine, please continue. . Mr. Riecer. All right. While giving birth, my wife had a cardiac arrest, her heart stopped and they had to perform a tracheotomy to assist her breathing and several electrical shock treatments to restart her heart. Then she caught pneumonia and her lungs collapsed. She was in intensive care at the Cleveland Metropolitan Hospital for approximately 2 months and the child, who was 2 months premature, was in the infant intensive care unit for 2 months. And the total bill came out to about $20,000. Senator Kexnepy. This is for the care that was being provided for your wife when she had these complications involved in childbirth and for your child in the children’s intensive care ward ? Mr. Rircer. Right. They had to put tubes in her chest, and quite a few other things. They put a leader into her heart to register the pres- sure caused by all the fluids they were giving her, because they had her on I'V’s for a long time. And all my insurance paid was $350 of it. And there was no way I could pay the rest. We have only been married for a couple of years now, and this was our second child. And at the time, I had been laid off. There had been a trucking strike going on. There was nothing else I could do but go into bankruptcy. Senator Kennepy. Is your wife covered by an insurance program too? Mr. Rieger. No. See, my wife had been working at the same place I was, Joseph Feiss & Co., but when she became pregnant, she had to take a leave of absence. Senator KENNEDY. So she wasn’t covered ? Mr. Rieger. No. Senator KENNEDY. So you just had your program ? Mr. Reiger. Right, right. Senator KennepY. And that allowed for $350 ? Mr. Rieeer. Right. And that doesn’t pay off $20,000. Senator Kennepy. And your child was in the intensive care for how long ? Mr. Riecer. Well, she was 6 months old, she passed away a month ago. Out of the 6 months, she spent 5 months in intensive care. Shaner KenNEDpY. You have this debt of some $20,000 to the hos- pital? Mr. Rieger. Right. Senator KENNEDY. Now, did the hospital try and collect this money ¢ Mr. Riker. Yes, they called me up three times before I finally got to my lawyer, and wanted to know how I was going to pay it. I asked them if they wanted cash, check, or money order. Senator Kennepy. Did they ever get in touch with your employer, that you know of ? 2159 Mr. Rieger. Not that I know of, no. Senator Kennepy. They just talked with you? y Mr. Riecer. Right. I believe the credit department called and said, “Mr. Rieger, you owe us some money. When are you going to come up with it 2” Senator Kennepy. What did you indicate to them ? Mr. Riecer. I told them I couldn’t get $20,000. And the lady on the phone said, “Why don’t you go to a finance company and borrow $20,000 2” You know, right. Senator Kenxepy. What did you say when she said that? Mr. Riecer. I asked her which loan company would give me that much money. I doubt if any would. Senator KENNEDY. You indicated that you tried at least to pay some of it oft? Mr. Rigcer. I told them if they would come down to a reasonable amount that I could possibly handle, I would be more than glad to handle it. Because like I said, they saved my wife’s life and my baby’s life. Senator Kexnepy. And you felt an obligation to pay at least some, if you could ? Mr. Rieger. Definitely. Senator KenNepY. What do you make a week ? Mr. Rieger. Take-home pay ? Senator Kennepy. What is your take-home pay ? Mr. Rircer. My take-home pay is about $120. Senator Ken~epy. And you have your wife and child you have to care for with that? Mr. Rieger. Right. At the time this child here was born that meant four, I had two little girls then and my wife and myself. She sub- sequently expired from pneumonia. Senator KENNEDY. She caught pneumonia and passed away ? Mr. Riecer. Right. Senator KeNNEDY. I understand you are going into bankruptcy now ? Mr. Rieger. My bankruptcy petition is already filed. I lost every- thing, you know. Senator Ken~epy. What do you mean, you lost everything ? Mr. Rieger. Well, I had a car which was—well, it was stolen while she was in the hospital. And I lost the stove, refrigerator, television set, everything was taken from us since I filed bankruptcy. Senator KENNEDY. Stove, refrigerator, and television ? Mr. Rizcer. Right. And my car, as soon as I filed bankruptcy, the things I had on credit at the time. Senator KENNEDY. As soon as you went into bankruptcy, all the things you had on credit, and most people today, as I understand, are on credit ? Mr. RieGeR. Are on credit. Senator KENNEDY. Once you go in, all these things were what, taken out of your home ? Mr. Rieger. Yes. They came right away and took them. I tried calling Continental Bank, that is where I had the stove and refrigera- tor and TV through; I explained to them I would like to revive it, but they wouldn’t talk to me. What can Ido? 2160 And the damage this has caused is something I will be feeling prob- ably fer quite a few years. Senator Ken~NepY. What do you mean by that, now ? Mr. Rieger. Well, as it is, the only way I can buy anything I want x need, no matter how bad a necessity it might be, is by paying cash or 1t. Senator KenNepy. That will be hanging over your head probably the rest of your life. Mr. Rieger. Oh, yes, definitely. They look up your record through some firm, and they say, “He went bankrupt.” And then nothing. Senator Kennepy. Has this had any impact on your employment? Mr. Rieger. I am extremely, extremely lucky that I worked for who I do work for. Because they knew of the trouble I was getting into, and they stood by me all the way, so I was very lucky. Senator Kennepy. What is the name of the company ? Mr. Riecer. Joseph Feiss & Co. Senator Kexnepy. So people know. It’s good to hear the good side of the human concern, as well as the difficult. Mr. Riecer. They say in times of difficulty, true friends show their true colors, and boy I tell you, they came through with flying colors. They really did. Senator Kexneoy. Mr. Rieger, this could happen to anyone—this kind of a problem. The complications of childbirth that were involved produced this extraordinary medical bill, $20,000 in 4 or 5 months. This could happen to anyone in this country. And of course, the ques- tions I think we as Americans have to ask ourselves is why do we have to have a system which adds such a financial burden to the pain and trauma and sense of loss that you felt in terms of your infant, and the extraordinary kind of hardships that your wife has been confronted with, In fact, this system forced you into bankruptcy, which will be with you for many years. What is it all about? What has happened to you could happen to anyone else. I think you should be asking us, “Why in this Nation of ours do we have a health system that is not more compassionate, more concerned, and more attentive to these kinds of needs.” That question is long, long overdue. [ Applause. ] Senator Packwoop. Mr. Rieger, apart from the obvious financial burden, and this is certainly one of the things we are trying to allevi- ate, did your wife and your baby receive good medical service? Mr. Riecer. I have no complaints, really. As far as T am concerned, they were fantastic. Because when she had the cardiac arrest, her heart had stopped for a little over 3 minutes. They kept right on working without giving up, and pulled her through. All the compli- cations arose, they didn’t hesitate to do what had to be done, and they didn’t keep me in the dark of what was going on. They came to me and explained to me in terms that I would understand what had occurred, what was going to happen, and all the things coming up. Senator Kennepy. Which hospital is that ? Mr. Rieger. Cleveland Metropolitan. She was in the intensive care unit there. I don’t know about the rest of the hospital, but as far as the intensive care unit is concerned, those people are really, really fabulous. 2161 Senator Packwoop. Let me ask this, Mr. Rieger: Is it correct to say that what you really needed, and didn’t have, was a catastrophic in- surance plan to pay everything over $1,500 or $2,000 ¢ Mr. Riecer. Right, right. Senator Packwoop. Would it make any difference to you how that insurance might be financed, that is whether it is financed by the Federal Government or paid by the employer so long as it’s available. Mr. Riecer. As long as it’s there, that is the main point. Senator Packwoop. Thank you. Senator KennNEpy. In terms of the catastrophic problems, I imagine even if you had a $2,000 medical bill with a take-home pay of $120 it would be catastrophic. If a senior citizen living on social security, for example, had a $800 or $900 health bill it would be catastrophic. Mr. Riecer. It would be a lot better than what I got, that is for sure. Senator KENNEDY. A lot better than what you have, but it would still be pretty catastrophic. Thank you very much, Mr. Rieger. We appreciate your kindness in coming here.We hope that your wife is well. Mr. Riecer. She 1s doing all right now. Senator Packwoop. Thank you very much. Mr. Rieger. Thank you. Senator Kexnepy. Our next witness will be Mr. John Dowden, and he has some associates with him. If he would be kind enough to come up here. We have Miss Souliotis in the red dress here. Those who want to make a brief comment should give their names to her. She is right under the lights here. As I say, we will do our best to hear everyone in the time we have available to us. We want to welcome you here, Mr. Dowden. I understand you are a member of the Mount Pleasant Community Council ? Mr. Dowpen. Yes, I am. Senator KenNepY. Also a member of the Christian Social Relations Association of the Diocese of Ohio, and a member of the Eastern Ohio Council of Churches? STATEMENT OF JOHN DOWDEN, MEMBER OF MOUNT PLEASANT COMMUNITY COUNCIL; ACCOMPANIED BY A PANEL COMPOSED OF CITIZENS OF CLEVELAND, OHIO Mr. DowpeN. Yes; I am appearing here this afternoon, not in any official capacity, but simply as a citizen interested in health care. And I am going to have as my first witness or speaker, Mrs. Betty Haw- thorne, who will tell you of a personal experience in a hospital in the city of Cleveland. Senator KenNepy. Mrs. Hawthorne, where do you live? Mrs. HawriorNE. My address is 3931 East 135th. This is something that happened several years ago. My mother became ill, and I rushed her to a hospital as an emergency patient. She wasn’t taken care of. They didn’t bother to look at her at all, but they said that she did have a heavy cold and to take her home. And I did this. And I used home remedies on her for about 13 days, and she progressively became worse. 2162 I took her back to the same hospital, and they told me to call her worker. I had tried to explain to them that she wasn’t on public as- sistance, but they wouldn’t take care of her. And they asked me to take her home, which I refused to do. I called a friend who was on the board of trustees at another hospital, who came out immediately with an ambulance and took her to the hospital where he was on the board. They told me there that if T had taken her back home, that I could have called the undertaker the next day. She had pneumonia for the third time, and had massive bleeding, she was hemorrhaging from the brain, but she was saved, thank goodness. Senator Kennepy. Now evidently she had gone to an emergency room the first time, and she didn’t get any kind of treatment. They recommended that she go home with you, is that right? Mrs. HawrHorNE. Right. ] Senator KEnnEeDpY. Then she got sicker while she was at home. Did you get in touch with the emergency room? Or did you not want to go back because they wouldn’t look after her ? Mrs. Hawrnorne. Well, because they told me this was a heavy cold, I was using home remedies, which wasn’t very helpful. Senator Kennepy. They told you at the emergency room it was a heavy cold, and still you could see her condition deteriorate? Mrs. HAWTHORNE. Yes. Senator Kexnepy. Finally she was just so sick that you took the other steps of going to ask a friend, that was a trustee of another hospital, to get her into another hospital ? Mrs. Hawrnorne. Right. Senator Kennepy. Why don’t you think your mother was treated in the emergency room of that hospital? Why don’t you think that she was able to get better care? Do you have any feelings on that; was it crowded, did she have to wait a long time? Were they able to give her sufficient examination, do you remember ? Mrs. HawraorNe. No; it wasn’t crowded, but we did wait a long time. Senator Kennepy. Was one of the reasons you didn’t go back when you saw her getting sicker that you felt that they wouldn’t care for her, or that you knew that it would be costly, or that you thought they might say the same thing, that she’s got a bad cold ? What went on in your mind; did you feel the hospital was sort of a friend in need, or did you feel that it was something frightening? Mrs. HawrHORNE. Well, to me it was rather frightening. Senator KenNEpy. Thank you very much. Mr. Dowpen. May I next introduce Mr. James Price, who has a personal experience. Mr. Price. My name is James Price, I live at 13708 Melzer Avenue. My mother was a diabetic. She had a diabetic arrest, and was taken to the hospital and through the outpatient clinic they let her sit there for a while. And finally after an hour and a half, someone finally saw her and she was treated and returned home. _ Subsequently, she was hospitalized because her condition didn’t improve. This, by the way, was in November of 1962. In February of 1963, at about 7 o’clock in the morning, she suffered a cardiac seizure. She called my home and my wife was there and took 2163 her to the hospital immediately. When she arrived, she told them the condition, the circumstances; and instead of doing anything for her, she sat for an hour and a half, and this time she expired. Now, I am saying this because I had another experience about a month ago while I was working, one of the men on my route had a cardiac seizure and his wife asked me to drive him to the hospital. When I saw that the man was in such bad condition that he would never make it, so I took him to the Shaker Fire Station where they had a resuscitator. And subsequently we went to the hospital, I had to go with him because I was the one who brought him in. We took him to the hospital, and the hospital had been notified by radio that the man was going to come in. When we arrived, the hospital brought their resuscitator out to relieve the emergency vehicle’s resuscitator. The man was hospitalized about 10 days ago, he is now home recuperating and doing fine. It’s just a matter of attention, when and where and how. Also, I was once scalded and the place where I was working sent me to that same hospital, and they told them that a certain doctor would take care of me. Well, I drove myself down there. When I walked into the emergency room, I said, “I am James Price.” They said, “Oh, you are Dr. So-and-So’s patient,” and I got the red carpet rolled out or me. And about 4 years later, I had a severe cold and indigestion, which I thought was a heart condition. And my friend was at the house visiting me. I walked in the same hospital, told them what the situa- tion was. I laid down on an emergency table and it was about an hour and a half before I got any attention whatsoever. I had hospital- ization, so it wasn’t a matter of money. Senator KENNEDY. You get a different kind of treatment, in terms of fu ability to pay. Would you say this has something to do with it ? Mr. Price. No, not exactly. Now in the one case, in regards to my mother, she was on social security and the social security was takin care of her hospitalization. And they had some Blue Cross whic was covering the better portion of her medical care through the out- patient department. And plus the fact that her sons had been con- tacted to subscribe to any deficit amount of money that might be due to the hospital. Senator Kexnepy. Why do you think you were treated one time, and had to wait another time? Mr. Price. Well, I hate to say it, but I think it was blatant preju- dice in this particular hospital. Senator KenNepy. Do you think as well that some of these hos- pitals are operating on a tight budget so they can only take so many people who they assume might be poor. They know they can only recover so much in terms of medicaid, medicare, and therefore if they see someone that comes in there that looks like he’s got the re- sources to pay, they might say they are a safe financial risk and treat him, but they have to screen the poorer patients, and they are not able to take as many of those. They would like to, but they haven’t got the resources to do it. This may be part of the actual explanation, too. Mr. Price. Is a man’s life worth more than a dollar, or a dollar worth more than a man’s life ? 2164 Senator Kennepy. I agree with that, that is part of the problem, the nature of the crisis. Your situation is a good example of what health crisis means to you and to certain members of your family. Senator Packwoon. Mr. Price, is it correct to say that your problem was not money ? Mr. Price. No, sir. Senator Packwoop. You had insurance coverage, so the hospital wasn’t worried about the possibility that you might not be able to pay? Mr. Price. Right. Senator Packwoop. So money wasn’t the reason the hospital re- fused you service or made you wait for a long period of time? Mr. Price. On one occasion, the place where I was scolded at, this particular doctor, who happens to be a famous heart surgeon repre- sents this organization. They said I was his patient when I walked in and told his name, right away, it’s taken care of. A year later T went in on an emergency, gave them my hospitaliza- tion card and everything, and still had to wait an hour and a half before I was taken care of. This pain was really giving me the heebie jeebies, I didn’t know if I was having a heart attack or what. Senator Packwoop. Thank you. Senator Kennepy. I suppose it does show good organization when you are able to call down there and get immediate service. That is a good organization. But when you have to go down there and wait an hour, or an hour and a half when you are in agony, that is poor organi- zation. I suppose to some extent it reflects on the compassion of the system. We are interested in a system which is compassionate. Our system does permit the compassion of doctors and nurses and other health per- sonnel to actually get through to the patient. You have given us exam- ples of some of the difficulties. I want to thank you very much. Mr. Price. Thank you, sir. Mr. CaapmaN. My name is Tom Chapman. I live at 109 Avon Ave- nue. I pastor the Avon Baptist Church, a small church. It was in 1968 in August, about 10:30, 11 p.m., my wife, Marie, fell in our home. We helped her to the bed and discovered that the pain was so intense at that time that she would need medical attention. So we called the emergency crew, and they came out and they did take her to St. Luke’s Hospital. We arrived there, I guess about 11:30 p.m. About 12 or 12:30, she got to see a doctor there who immediately sent her to get some X-rays in the area of her back where she said she was hurting. They returned about, oh, 20 minutes later and the doctor told me she was okay, that I could take her home. I went in to assist her, but she insisted that she couldn’t move. And at this, I went back to the doctor and I related to him that Marie says that she can’t move, the pain was that intense. So he went back into the room, and of course I stepped out, and when I went back again after he had left the room again where he was waiting on her, she was crying, of course, and she says “Chapman, the doctor wants me to go back home, but I can’t hardly move, the pain is too much.” So I go back again and talk to the doctor and he says, “Well, listen, your wife has had a fall, she’s got a pinched nerve in her back and she 2165 is in pain and that is to be expected. Now I am the doctor and she is okay to take her home.” And I said, “Well, I know my wife. We have been married 15 years now, and I know she is not a pretender, she can take pain, she has been ill before.” So I refused to take her home. I went out to the waiting room. He and a nurse went back and it was about 15 minutes later that they were back there with her and they brought her out in a wheel- chair, and what they had done was to dress her and basically lift her from the place she was lying, dressed her, sat her in a wheelchair, and brought her out to me, and said, “Now take her home.” Well, at this point, I don’t believe that is the thing to do. So I told the doctor I am not going to take her home, because I believe she ought to be kept here and further attention or examination ought to be given. He says, “It’s your wife, you do what you want to do, I am through.” So he goes back to the office, and I sat there and my wife sat there in a wheelchair. It was about, oh, 2 o’clock in the morning, now, and, of course, by this time all the other emergency traffic had been cleared away, and we were the only ones there. The doctor goes back into another little room, and I guess that is where he sleeps, and about 3:30 he came out again and he saw that we were still there. He went back into the little room. And he came back in about another hour and we were still there. So it was about 4:30, 5 o’clock that my wife wanted to go to the bath- room. And, of course, she couldn’t get any help here because they had discharged her and TI couldn’t take her into the ladies’ restroom nor the Jens restroom. So she sat there until around 7 o'clock, 6 o’clock maybe. called the Academy of Medicine, it being Saturday morning and they were closed and I didn’t get any answer. Of course, I did reach their answering service which is all a taped system. Well, at this time I encouraged my wife just to release herself there. Her bladder was full, and TI said, “Well, just go right where you are. Well, she couldn’t do that. Of course, by this time, I had no al- ternative but to try to get her to the bathroom at least to the door. And as she did get to the door and finally into the bathroom and back to the chair again, I concluded that since she had been that mobile on her own account, that possibly I could take her home and do as the doctor had prescribed, which was to take sitz baths twice a day. So finally I literally picked her up and carried her to the car. We drove home and TI literally carried her into the house, put her in bed, and began her first sitz bath operation. And that kept on for the next few days and the pain did not subside. So eventually we concluded that there had to be something wrong which X-rays maybe did not reveal. So we carried her then to the Lakeside Hospital, where she in fact was given extensive X-rays. And they did discover that there were several vertebrae broken in her back. And for weeks she had been laboring, going through those processes of sitz baths and up and down. And of course at this point I just felt that there was something that ought to be done. And I sought legal ad- 2166 vice as to what we should do to find satisfaction for the kind of damage that I felt as a result of this terrible situation. 3 Senator Kexnepy. You mean that all the time they were prescrib- ing remedies for a pinched nerve, she had these fractured or dislo- cated or broken vertebrae ? Mr. Cuapman. Broken vertebrae. Senator Ken~epy. Their examination had failed to reveal that? Mr. Cuapman. There was only one X-ray as I understand that was given, which was not quite as extensive as I think should have been at this time. I think there was neglect on the part of the hospital to really perform the kind of research or examination to discover this. Senator Kennepy. How does that make you feel about the kind of care that you received? I suppose other people are going to that same doctor today. How does it make you feel about the quality of care you received ? Mr. Cuapman. Well, in that particular case, I wouldnt want to say it here before these people about what kind of care, what I think about the care that was received, or the kind of an apathetic attitude that was displayed that night. I think only the course of law and people who are concerned about changing these kinds of practices can do the things that are necessary to change the practice. Senator Packwoop. May I ask you, Mr. Chapman, because Mrs. Hawthorne and Mr. Price raised this same question. Money, or financ- ing, is not the sourée of the problems which have been related to us. Let me ask you what advice you would give to us to make the hospital or the system more compassionate ? Whether it’s a public or private hospital doesn’t seem to matter. Is there any guarantee that the Federal Government would operate hos- pitals they would be better. What is the answer ? Mr. Cuapman. In a racist society where people become geared or colored by these kinds of attitudes that say they don’t give a damn about people or really don’t care, it doesn’t matter if a person has money or doesn’t have money because these kinds of patterns have set in, and they become as a part of that person’s makeup. And this was the kind of thing, I think was happening that night. Because we had Blue Cross and I had presented a Blue Cross card. But I saw the kind of apathy go on there that night with other Diople that I thought just ought to be brought to the attention of the public. Senator Packwoop. You're pointing to a problem much bigger than medical care or medical costs. It’s basically a problem of race rela- tions, and all the money in the world isn’t going to change it unless we change our hearts. Mr. Carman. I am saying that because this kind of situation grows out of another situation where people have not had the money, and people have not had the time because people didn’t have the money to give the people the time and the care that they needed at the time that they needed it, that this kind of attitude becomes ingrained in the system, in a society, in an individual so that he reacts to other situa- tions that might not be even colored by that sare kind of situation 2167 that initially had his roles of development around. Yet, he exerts that kind of an attitude. Senator Packwoob. Let me ask you again, what would you suggest to us to change it? We are talking about medical problems, medical care, medical coverage. What should we do to change 1t ? ; Mr. Caapman. If everybody could get well and stay well, it would do one thing. But I suppose just to say publicly that we think society or the system ought to change is not enough. But I do believe that people like yourself and people who are in authority are going to have to sit down, well, like you are doing now, and talk with the people who are being constantly confronted with these kinds of things and those people who are responsible for bring- ing about these kinds of conditions and presenting these kinds of attitudes and problems for other people as a result of their own care- lessness and coarseness, that there will be a change in them. Senator Packwoop. What should we do about these problems? What would you suggest to us when we go back to Congress to write new legislation ? Mr. CaapmaN. Sir, I suppose I would be in your seat, maybe, I don’t know at this moment if I could come up with the kind of answer. But we could think about it, right. [ Applause. ] Senator KenNepy. Wouldnt at least a part of the answer be giving the community a greater voice on hospital policies? T mean if you have the voice of the consumer in your neighborhood, or your community, influencing the policies within the hospital, don’t you think it would reflect more accurately the concerns of the community? Isn't that, at least, one of the additional features that is needed, opening up the system so representatives of the community are making these policies and listening to these kinds of complaints that we hear? Don’t you think this would be useful and helpful in terms of adjusting and changing attitudes? Mr. CaapmaN. I certainly do. Senator KENNEDY. Give a stronger voice to the consumer in terms of development of things of this kind. It’s an enormously complex problem, Put obviously this could be enormously useful in giving an idea of what the needs are in a community. Mr. CaapmAN. I think so. Senator Kennepy. Thank you very much. Mr. DowbeN. I would like to say something before I leave the table because of the fact that I have here a file of cases similar to the ones that have been presented. These are all documented, and I would just want to take but 2 minutes to bring them to your attention in this matter. No. 1 is an automobile accident where four people are involved. No. 2, and I am only going to give you 10 of them, No. 2 is a rape case where the person was taken to the hospital and refused exami- nation as requested by the police. No. 3 is a new person in the city that had no doctor at that time, and went to the hospital. No. 4 is a child with a broken foot in two places, given no treatment and sent home. No. 5 is a social worker who had burns on both legs, and advised to take two aspirins and see a doctor tomorrow. 59-661 O - 71 - pt, 9 - 13 2168 No. 6 is a child put to sleep with some drugs because the child had stomach pains. No. 7 is a pneumonia case where the man was sent to the hospital by his employer, the factory where he works. This factory has a contract with this hospital, and he had to be taken to another hospital instead. No. 8 is a comment where the man said he was told, “Well, you have got to be cut or shot.” Now it’s important to recognize that I am not a professional wel- fare worker, nor am I an agitator. I receive no Federal or State funds, and I am in the business of churchmanship rather than politics. And I therefore have different thoughts from the areas who appear be- fore you on the issues of the National Health Plan. T am not going to cover all T had to say because you were asking Mr. Chapman, and I say I wish this committee would take into consideration the need for guidelines setting forth conditions for financial support to the providers of health and medical services that would eliminate some of the present areas of discriminatory practice engaged in by some hos i and health centers who must develop by an independent health package. It is my conviction that most of the citizens of America, and indeed the Members of Congress and the Senate, consider themselves to be active participating members of the religious community who sincerely want to enact just and equitable laws, and there are some in our society who are poor and unable to meet these high costs of being sick. And therefore, I would support the health plan, or Senator Ken- nedy’s bill, your bill, and I certainly say to you that I am not doing it on the basis of race, I am doing it on the basis of the fact that the people of Ohio need it. And I will be going to the Ohio Council of Churches as well as to the Department of Christian Social Relations where we have 17 denominations represented, five Roman Catholic dioceses represented; and I will be saying to them, as I am saying to you, that we should support this type of bill and this sort of thing, ecause as you have seen today, the people need it. Thank you. Senator KENNEDY. Thank you very much. That is a splendid state- ment. Ralph Tresky ? Mr. Tresky. My name is Ralph Tresky, and I live in Garfield Heights. IT am here because in effect my wife came down with kidney trouble, kidney failure in 1969. As far as the doctor in the hospital, everything was fine, it’s just that the cost was so great that my insur- ance didn’t cover it all. _ Being dialyzed in a hospital is very expensive and much of the cost 1s not covered by insurance. My insurance was what is called a Basic Blue Cross plan, and I had a $450 surgical benefit. Well, my wife had three operations, so the other two, I had to pay for those myself. But right now, I still have an outstanding bill at the hospital for $5,200. Now with kidney patients that go home, you have to have a home dialysis machine. Well, the machine itself costs $3,685, an arti- ficial kidney is another $800, you have a blood pump which costs $645, a Hepburn pump, $245. The cost is tremendous. 2169 Now, the cost for the patient to be dialyzed at home would run you on the average of $200 a month for supplies, blood tubing, concentrate, and so forth, If it wasn’t for the man that I work for and the company that I work for, the men in the local had gone out to different locals and collected money, and sold raffle tickets, and they collected over $7,000 to help me purchase the machine so that I could take my wife home. And I have had my wife home for about a year and a half, and I can say unfortunately my wife passed away on April 3 of a heart attack. We are in the process right now of setting up a community dialysis center in the city of Cleveland. And my machine will be donated to this community kidney dialysis center. Now the reason we are trying to get this set up is for people who cannot afford to go to the hospitals to be dialyzed. To be dialyzed in the hospital it costs roughly $10,000 to $15,000 a year. Some insur- ance plans will cover you for 3 years in the hospital, but after that, what are you going to do, go home and die? They don’t cover you any further, people cannot afford to go to the hospital to be dialyzed. That is the reason we are trying to get this center set up for people who cannot afford to go to the hospital and be dialyzed. Senator KexNepy. Where do you work ? Mr. Tresky. Van Dorn Co. Senator Kennepy. And did you have a health program in’ your company ? _ Mr. Tresky. Well, we have the insurance, yes; hospitalization insurance. Senator KenNepy. And how much did that cover? - Mr. Tresky. It did not cover the doctor’s fees. It covered the rooms and covers for meals and everything. But like I say, it did not cover for dialyzing. Senator Kennepy. You have a bill of $5,200? Mr. Tresky. Right. Senator Kenx~epy. There is no way in the world that you could have prevented your wife from having this difficulty ? Mr. TreskY. No, sir; no way in the world. Senator Kexnepy. Nothing that you could have possibly done in the world that you know about that could have possibly prevented that difficulty ? Mr. Tresky. No. Senator Ken~epy. It just hit your wife, really right out of the blue, didn’t it ? Mr. Tresky. Right. She had strep throat, and that is where the trouble settled. Senator Kenxepy. How old was she when she had the strep throat ? Mr. Tresky. Roughly 32 years old. Senator KexNepy. But there wasn’t anything before that that led you to believe that she had any difficulty with this type of thing? Mr. TreskyY. No, sir; not at all. Senator KENNEDY. You are a workingman ¢ Mr. Tresky. Yes, sir. Senator Kennepy. What is your take-home pay ? Mr. Tresky. Roughly $140 a week. 2170 Senator KENNEDY. Do you have other members in your family? Do you have children ? Mr. Tresky. I have two children. Senator Kennepy. You are trying to provide for their care and their housing and their education and clothing and food and shelter, me Js trying to meet these other health needs of your wife, is that right? Mr. Tresky. Yes, sir. Senator KeNnNepy. And you got to the point where you were de- pendent for your wife’s existence on the goodwill of the people where you worked ? Mr. Tresky. Right. Senator Kennepy. I suppose your colleagues, your friends, have families, don’t they ? Mr. TrResKY. Yes, sir. Senator Kennepy. And for every few dollars that they give out of that take-home pay a week, that means less in terms of their own children or giving up some other kinds of satisfaction that they and their families might like to have. And you were really dependent on them for your own wife’s existence ? Mr. TreskY. Yes, sir. Senator Kennepy. And with all of this, on top of the heartache, the suffering, you have a bill now of $5,200 ? Mr. TreskY. Yes, sir. Senator Kexnepy. And how do you think you are going to be able to pay that off ? Mr. Tresky. Well, right now again, the union has come through, and they are out making a campaign to help. Senator KennNepy. Which union is this? Mr. Tresky. The United Auto Workers. Senator Kexnepy. They are one of the stronger supporters of Na- tional Health Insurance. Mr. Tresky. Yes, sir; definitely. Senator Kexnepy. I hope you will take an interest in this as well, because I think you have shown the reasons why we have to do some- thing about this. Senator Packwoop. Mr. Tresky, let me ask you, had you had a healih plan similar to Kaiser, that would have taken care of your needs ? Mr. Tresky. Yes, but it still wouldn’t have purchased the machine. Senator Packwoon. You are talking about the burden of doctor’s fees and hospital costs. Your problem seems not unlike Mr. Rieger's ip that you have been hit with catastrophic costs with no way to pay or it. Would it be correct to say that what you need is catastrophic insur- ance that you know would take care of the costs? Mr. TresKY. Yes, sir. Senator Packwoop. Could it be provided just as well by your em- ployer as by the Federal Government ? Mr. Tresky. Yes. But it still gets down to the point that your in- surance companies, I say some of them, will not go over 3 years on dialysis inside the hospital. Senator Packwoop. Some insurance companies will go pretty far if 2171 they are faced with some minimum standards at the Federal level. Senator KenNepy. I will be amazed. [ Laughter. ] Senator Packwoop. This happened with the automobile manufac- turers and air pollution emissions. We found we could make them produce a clean car, and I think we can make insurance companies come up with good policies. The key is how it will be funded. The important thing is having the coverage; how it’s financed is secondary. Mr. Tresky. Yes, sir. Senator KeNNepy. Thank you very much, Mr. Tresky. Estella Rayford. Mrs. Rayroro. I am Estella Rayford, and I went to the hospital in 1960, T had heart failure. My hospital bill was about $3,500, which my husband paid. On last December, IT went back to the hospital, I didn’t have hospitalization ; Senator KenNepy. Can I go back just a little bit, Estella, with you, and get a little information before we get into the health questions. As I understand, you and your husband worked regularly for some time, did you not ? Mrs. Rayrorp. Yes. Senator KENNEDY. You each were employed and you worked regularly ? Mrs. Rayrorp. Yes. Senator KENNEDY. Then at some time or other, you came into a little money, is that right, or you Mrs. Rayrorp. No, we had a place of business, a little delicatessen. Senator KENNEDY. You started your own business. As I understand, you were working fulltime, you and your husband, then you decided to start your own small business, is that right ? Mrs. Rayrorp. Yes. Senator KENNEDY. And this was what, a delicatessen ? Mrs. Rayrorp. Yes. Senator KeNNEDY. So you quit your old jobs, and both of you tried to make a go of it. in the delicatessen, is that right ? Mrs. Rayrorp. Yes. Senator KenNEDpY. You were well, your husband was well, is that right? Mrs. Rayrorp. Surely. Senator KENNEDY. You had the delicatessen, you were working for yourselves at the delicatessen. Now, tell us what happened. Mrs. Rayrorp. Well, we both got ill in December. Senator KenNEDpY. December when ? Mrs. Rayrorp. Of last year. We both had to go to the hospital for an operation, and I had six operations on my legs. Senator KeNNepy. The amputation ? Mrs. Rayrorp. No; the circulation in my legs, first. And they sent me back home to see if that would work. It didn’t work, then I went back and I had five operations there. My hospital bill is $11,000, the prosthesis will cost $1,500, the chair is $250 and my husband is still ill. We, have no way of paying the hospital bill. 2172 Senator KenNEDpy. So you have $11,000 in hospital bills, and $1,500 for prosthesis, is that right ? . Mrs. Rayrorp. Yes; it will cost $1,500 to get my prosthesis, and a wheelchair would cost around $250. Senator KENNEDY. Do you have money for that ? Mrs. Rayrorp. No. Senator Kennepy. If you had the money, would you be able to get them ? : Mrs. Rayrorp. Surely. Senator KENNEDY. You would like to get them ? Mrs. Rayrorp. Yes. Senator KENNEDY. And just because you haven’t got the resources at the moment, you are unable to get them and you are stuck in the wheelchair ? Mrs. RayForp. Yes. Senator Kennepy. Now tell me, before you were working on your own, in your previous job, were you covered by Blue Cross? Mrs. Rayrorp. Yes; my husband had worked for the city, and still worked for the city 3 months after he got the business, to help pay off the bills. Senator KENNEDY. But you got sick after you went into your new business, is that right ? Mrs. Rayrorp. Yes. Senator KENNEDY. Tell us, were you covered then by Blue Cross? Mrs. Rayrorp. No. Senator Kennepy. As I understand, you were covered when you worked earlier, and if you had thought about it when you were work- ing in the delicatessen, you would have wanted to be covered, but you overlooked it. Mrs. Rayrorp. That’s right. Senator KenNepy. And through that oversight, you find that Blue Cross didn’t pay for any of your hospital bills, 1s that right ? Mrs. Rayrorp. No. Because we didn’t have it. Senator KENNEDY. You didn’t have it even though you had it before, you paid on it before, it was a program you believed in, but you over- looked it when you got your own business going, trying to make a go of it on your own. Now you have all these medical bills. Mrs. Rayrorp. Yes. Senator Ken~epy. Your husband is now very sick, as IT understand 1t. Mrs. Rayrorp. Yes. Senator Kexnnepy. What is he sick from ? Mrs. Rayrorn. Well, we don’t exactly know. The doctors, they have given some injections in the vein, it’s something wrong with the pan- creas. Senator Kennepy. How long has he been hospitalized ? Mrs. Rayrorp. Oh, he is at home now. Senator KeN~NEepy. Does he have hospital bills? Mrs. Rayrorn. No, he goes to his doctor every 2 weeks. Today is the day for him to go to the doctor for the injection. And they won’t know whether the injections worked until they go back and operate on him again. 2173 Senator KennNepy. Who is paying for his hospital bills? Mrs. Rayroro. No one is paying for them, they haven’t been 704, Senator KennNepy. He has some bills, he might not have paid them, but he has some bills, hasn’t he, if he hasn’t paid them ? Mrs. Rayrorp. Yes. Senator KENNEDY. So he has some hospital bills as well, doesn’t he? Mrs. Rayrorp. Yes. } Senator KennNEpY. And you have about $11,000 in hospital bills? Mrs. Rayrorp. Yes. Senator Kennepy. How do you think he will ever be able to start paying those bills oft ? Mrs. Rayrorp. Well, I haven’t the faintest idea. Senator Kexnnepy. You would like to pay them though, wouldn’t you? Mrs. Rayrorp. We have a triple A credit rating. Senator KENNEDY. You are proud of that fact, that you have a triple A credit rating ? Mrs. Rayrorp. Very much so. Senator KennNepy. You would like to maintain that credit rating and meet your responsibilities and obligations. You have maintained it all your life, have you not ? Mrs. Rayrorp. That’s right. Senator Kennepy. Except now you have this $11,000 medical bill that you are faced with. I suppose it’s difficult to get a job unless you have prosthetic devices. Mrs. Rayrorp. Surely. Senator Kennepy. And still they expect you to pay for these devices? Mrs. Rayrorp. Sure. Senator KenxepY. Had you been reasonably healthy before? Mrs. Rayrorp. Yes. As a matter of fact the week before I went into the hospital, I had gone out to the store and worked. My hus- band’s brother passed away, and I had to keep the place open, and I worked until the week before I went in the hospital. Senator KennNepy. Did you think about trying to get Blue Cross or Blue Shield after you were sick ? E Mrs. Rayrorp. The doctor my husband is going to told him to call Blue Cross. I called, and they said they only have a certain time of year that they take in customers, and I would have to wait until the time. Senator Ken~epy. What do you mean there is only a certain time of year that they take people ? Mrs. Rayrorp. It’s not open year around, they have a certain time of year that they take in. Senator KenNepy. Have you tried to enlist at all? Mrs. Rayrorn. That is what I called for, and they said it wasn’t the time. And I called again, and it still wasn’t the time. Senator KenNepy. When is the time ? Mrs. Rayrorp. They gave me no date. Senator KENNEDY. Where is our friend from Blue Cross who has been following this committee around the country ? When is the time ? Mr. MoonEy. I don’t know. Mrs. Rayrorp. But they did tell me that. 2174 _ Senator Kexnepy. Do you think Estella is going to be able to get into Blue Cross? What do you think? Mr. Mooney. What is her age ? Senator Kexnepy. That makes a difference. Mrs. Rayrorp. 55. Mr. MooxEy. She will be able to. Senator Kexnepy. Will you make sure she’s taken care of and give her a hand ? That would be wonderful. I want to thank you very much. Again, it’s the problem that people face through no fault of their own, and leads to extraordinary kinds of personal tragedy and disaster. Certainly we ought to be able to devise a system to beat that. We can’t solve all the health diseases and difficulties, but certainly we can go along way toward relieving the kind of financial pressures which so many people have to bear. I want to thank you very much for coming down. Mrs. Rayrorp. Thank you. Senator KennNepy. Mrs. Mansick, is Mrs. Mansick here ? Well, she is not here right now, we will have Mrs. Jasilionis. You are Mrs. Carolyn Jasilionis? Mrs. Jasiuionis. Right. Senator Ken~epy. Where do you live ? Mrs. Jasivionts. 3807 Whitman. Senator Kennepy. Very fine. You have five children, as I under- stand it ? Mrs. Jasiuionis. Yes, I do. Senator Kexnepy. Would you tell us a little bit about some of your problems? Mrs. Jastuionts. Well, I was married at a very young age, I had a girl and four boys. Each one of my boys was born with a hernia prob- lem and had to r operated on. We didn’t have insurance which cov- ered the doctor’s fees, and the doctors would charge $250 for each one of them. And within a year and a half’s time, one was in the hospital eight times, and the one time was for a period of 8 weeks. He had to have special medicine that Blue Cross did not cover that cost $15 a day, plus $10 a day for the doctor. Just with doctor bills and medicine bills for the one boy it was over $3,000 that my hus- band and I had to pay. And it got to a point where we couldn’t pay and keep up the bills either, so we were forced to file bankruptcy, which was real bad, you know. Like we lost everything over it, and it like put my husband down, made him feel like a nobody, which caused friction in the fam- ily. And when there is friction in the family, there is constant fight- ing, which caused a separation and which put me on welfare. And, like, that is about it. Senator Kennepy. The doctor said no more money, no more treat- ments for your children ? Mrs. Jasons. Right, right. We are really in debt up to our ears, and we had no choice but to file bankruptcy. They wouldn’t handle the case any more. Senator KENNEDY. You couldn’t get the kind of treatment that your children required without coming up with financial resources? Mrs. Jasmuionts. Right. Senator KEnnNepY. You had to buy some special drugs for your son ? 2175 Mrs. Jasons. Yes. My son had asthma and he had pneumonia eight times from the asthma, and he became immune to regular drugs. And there was a new type of drug, it was coming out, Blue Cross hadn’t covered it yet; therefore, we had to pay for the medicine. Senator Kexnepy. What did you pay for that per day ? Mrs. Jasiuionis. $15 per day. Senator Kennepy. For how long, over what period of time? Mrs. Jasmuionis. Five weeks. Senator Kexnepy. This reflects as much of a catastrophic problem as large bills would to someone with greater resources. How are you going to pay $15 a day for 5 weeks for your children while your total bill is amounting to several thousand dollars? : It’s as much of a catastrophic debt to you as the $20,000 is to someone else. Mrs. Jasimionis. Actually, it was $25 a day, because the doctor charged $10 a day to come in, rub the boy’s stomach, and take his tem- perature. Senator KenNepy. You wanted to get the best for your children, didn’t you? Mrs. Jasiuionis. Yes. Senator KenNepy. You would pay your last dollar to make sure they had it? Mrs. Jasmionis. We did, we did. Senator KENNEDY. And you paid your last dollar, because of your concern for your children, and that wiped you out financially ? Mrs. Jasiuionts. Right. Senator Ken~NEDpY. And put a mortgage over your whole future, and caused enormous tensions in your family. How are your children now? Mrs. Jasmionts. Well, now I am on welfare, what more can I say? Senator KENNEDY. Are they healthy ? Mrs. Jasiuionis. They are healthy in the sense that they are not walking around passing out for food. But what are you going to do? County welfare doesn’t give you enough to live on. We eat, but it’s not the proper food. Senator KexnNepy. Do you use food stamps? Do you have a food stamp program? Mrs. Jasiuionts. Yes, I get food stamps. Senator KeNNepy. Are they helpful to you? Mrs. Jasiuionts. They are helpful in a sense, yes. But IT would like to get more of them. Senator KENNEDY. You are just interested in providing some decent food to your children ? Mrs. Jasmionts. Decent food, right. Because kids go to school; in order to function right in school, they have got to have proper foods. If they don’t have proper foods, they can’t function right. Therefore, they fail, they are dropouts. Senator Kenxepy. Do they have a hot lunch program in school? Mrs, Jasmuionis. No. Our school was something like about 4 per- cent under the standards, therefore, it doesn’t qualify. Senator KexNepy. Thanks very much. I appreciate your coming in. Again, we see the problem that people are confronted with in terms of finances. The system has driven you to bankruptcy and driven you to the welfare rolls. 2176 We have here a family trying to be good citizens, trying to meet their responsibilities, in terms of their community, in terms of their family, and the system has just driven them back against the wall. That 1s what we are interested in changing. I appreciate your coming here and telling us about it. Now, we have two professional witnesses. After they have testified, we will start on the open part of the hearing. Dr. Milton Lambright is a past president of the Cleveland Academy of Medicine, Dr. Joseph I. Bilton is vice president of the Cleveland Academy of Medicine and past president of the Cleveland Academy. Gentlemen, we appreciate your appearance here. Earlier in the day, we had a chance to meet with Dr. Bilton at another session on pre- paid group practice programs. We had 15 or 18 people who were in prepaid programs, members of advisory councils, spokesmen for in- dustry, and others. We talked about a variety of subjects for about an hour and a half. We are pleased to have you here with us this afternoon. You have heard some of the concerns expressed here this afternoon. We have heard these concerns not only here, but in rural West Vir- ginia, in the urban areas of other great metropolitan centers. We will be interested in whatever comments you would like to make on these concerns. STATEMENT OF JOSEPH L. BILTON, M.D., VICE PRESIDENT, CLEVE- LAND ACADEMY OF MEDICINE; ACCOMPANIED BY MILTON LAMBRIGHT, M.D., PAST PRESIDENT, CLEVELAND ACADEMY OF MEDICINE Dr. Biuron. First, thank you, very much, Mr. Chairman, for having us here and listening to our viewpoint. Certainly we are distressed to hear the cases that were related here this afternoon. And to the extent we are responsible, I feel badly. I would like to read a statement setting out the position of the Cuyahoga Medical Society, because perhaps our position isn’t clear, if I may, and the statement goes as follows: The Cleveland Academy of Medicine and the Cuyahoga County Medical Society has no quarrel with anyone who is attempting to improve the quality and distribution of medical care and seeking methods of meeting its costs. We, therefore, are happy to participate in this hearing in a constructive manner with the hope that some bene- fit will accrue to all concerned. We also are aware that the rapid growth of medical science re- quiring sophisticated and expensive equipment, along with the infla- tionary spiral and the adjustment of hospital wages, have raised the cost of medical care to the extent that many people are finding it difficult to meet. It goes without saying that to deny anyone the right to adequate medical care is like denying motherhood; and, we there- fore, feel that every effort should be made to bring the maximum care to the largest number of people at the most reasonable possible cost. Unfortunately, little can be done to reduce the costs of medical care, in spite of many allegations to the contrary. The above-mentioned 2177 items that contribute to our present costs are those which most of us would loathe to change. It is possible that some savings in costs could be effected by methods of health care delivery, such as various types of group practices; however, this will do little to stem the overwhelming cost of top quality sophisticated treatment that is being made available and im- proved month by month and year by year. The Academy of Medicine is now engaged in an indepth study of review in the establishing of norms for medical practices. They are also studying the possibility of a foundation for the purpose of administrating various group approaches to the delivery of health care. Thus, we look forward with hope that something will emerge from these and other hearings that will guide us in our future attempts to meet the tremendous responsibilities of medical care to our commuity. Senator KeNNepy. Dr. Lambright ? Dr. LamsricuT. Yes, I would like to take a little different tact here. I am a surgeon, I have practiced in this community many years, and I am not a wealthy doctor because about one-third of my patients are patients who are unable to pay for proper medical care. I have had a great deal of experience in knowing some of the problems that you have heard of people who have testified here fodsp: Most of these concern catastrophic illness, and they exhibit in some instances racism. Sometimes it is lack of compassion, sometimes it’s purely lack of personnel and lack of time. Now, I know that anywhere that you go in this country, you are going to find the same kind of problems, you will find the same kind of testimony that will be given. My concern is that we seem to be try- ing to find the answer to the problem through the wrong door. am not only concerned about catastrophic illness and acute illness, I am concerned about the illnesses that we still don’t know anything about. How many people in this room are ill and don’t know it ? Well, we have used the survey for Senator Kennepy. Don’t look at me quite that way. [Laughter.] Dr. LamsricaT. We have used the survey for chest X-rays, and we have found a great deal of illness which has occurred in people and been present in people who have no knowledge of it. We read daily, at least in the medical profession, about many of our patients who have just left for a complete checkup, had electrocardio- grams, and everything done; the next day, the fellow dies of a heart attack. We spend billions of dollars on space vehicles and things of that sort, but I have wondered how much money we are really prepared to spend on finding the answer to our health problem. Now I would like to put this in a perspective that I think everybody might understand, so if we try to imagine this whole problem as being a circle, it depends on where we start to find the answer to it. Now if we start somewhere along the circle and we are concerned with the problems of illness that we already know about, we will go around that circle, we will try to finance, and we will try to solve the prob- lems, but we will come upon the first part of the circle that we didn’t 2178 touch. And these type of people who are ill now and have no knowl- edge of it. } ow there must be some way for us to reach a solution to this. Senator Kexnepy. I'd like to refer you to Dr. Weed, who is a pro- fessor of medicine at the University of Vermont. j Dr. Lamericar. And he has a real good knowledge, and has this much experience about this kind of diagnostic computerized medicine that we have. I am surprised to find that in none of the plans, your plans, President Nixon’s plans, and the American Medical Associa- tion’s plan, the American Hospital Association plan, Senator Javits’ plan, nobody is talking about this. And T think that if we were able to include in this one of these plans, we would possibly find part of the solution. Of course it’s not the total solution, but as a member of the board of trustees of Cleveland State University, I would like to give another idea about this. Now we have here, as part of our team to explore these possibilities, Dr. John Knowles, and also Dr. Bob Eber, along with a large group of medical specialists throughout the country. And they certainly felt that our approach should be a little bit different. Now the question is will we ever be able to develop enough physi- cians to handle the problems and avoid the difficulties that we have been listening to here today. And it seems that possibly we can’t do that, at least not in the coming decade. But there is a possibility to develop a much greater health care approach by developing para- medical personnel. I also think it would be of great interest for somebody in the Federal Government to try to bring back some semblance of the plan that was used during World War II in which we had the Cadet Corps for nursing. At that time we used to have nursing classes which were three to four times the size they are now. And I think some of these things could be explored as a positive input to try to solve these problems. Senator Kennepy. Thank you very much, sir. You have made some very interesting and worthwhile comments. We are flexible on the whole question of computerization and using computers to assure quality care. That is why we had Dr. Weed down to testify, before the subcommittee. There is nothing inconsistent with that program and S. 3. We are able to translate it into legislative form. We welcome it in terms of providing some meaningful quality standards. But you mentioned something earlier, which is a cause of concern to me. You mentioned how many people are in this room that are sick and don’t know it. How many people are sick in this room and know it and can’t pay for it? [Applause.] I am also interested in the questions of preventive medicine. That is an important feature of S. 3 and the various kinds of prepared group practice plans that it encourages. Nevertheless, the fundamental problem is often one of manpower. We recognize that we have an enormous shortage of manpower now in suburban America. We have enough doctors on Route 128 in Boston, Lexington, Weston, and Camden, but we don’t have any in 130 counties in rural America and in the inner-city areas where in many respects the health problems are most severe. 2179. I would ask you as the representatives of the medical profession, how are we going to get you and the professional doctors into those areas of greatest need? We know that you are enormously committed. Obviously, Dr. Lambright is here in the city, he is providing services, he comes here with the finest qualifications. Dr. Bilton also has ob- viously shown a special concern, but how are we going to get more doctors down here into the city ? Dr. LamericaTt. My implication is that there are not enough doctors to go into all these areas if they were willing to do so. You couldn’t find enough to solve that problem, so we have to—we used the para- medical personnel to begin to find out where the problems are. Once we solve the problems, then we take it in a step-by-step approach, and then we may bring in more and more qualified people to handle these problems. : Senator Kennepy. I am hopeful we can get the medical society to take strong positions favoring the use of paramedical personnel. Far too often in the past they have not. Dr. LamBricar. Well, we need your help, we need the help of all of the people in the State of Ohio to help change some of these medical practice laws in the State as well as other States. Senator Kennepy. We are glad we have you in the forefront as spokesmen for the medical society. I am hopeful that others have your foresightedness. Dr. Bruton. The Academy of Medicine has already made a statement concerning this. Senator Kexnepy. Well, statements are statements, but we need more than that. Dr. Biron. Sir, I say we make more than statements, we are very anxious to pursue this. However, we are hampered by the State laws at the moment, and we are working in this area so that people who are graduates of two programs in town would be qualified to do something without the risk of legal implications. Senator Kennepy. Full utilization of paramedical personnel, greater development of neighborhood health centers, HMO’s, maybe medical foundations, these are going to take enormous efforts on all our parts, don’t you agree? Dr. Biuron. No question. Senator Ken~epy. Thank you very much. Our next witness is Kenneth BE. DeShetler, the Insurance Commis- sioner of the State of Ohio. We want to welcome you, Mr. DeShetler. You come with some special credentials. Mr. DeShetler was a judge in the highest court in Toledo, Ohio, and was willing to give up that re- sponsibility with all the security and honor that is suggested by it, in order to come into one of the most difficult and challenging jobs in pub- i life today. He is the insurance commissioner for a great industrial tate. We are very honored that you would come here. We know that you have been greatly concerned about health. Mr. DeSnETLER. Thank you, Mr. Chairman. That is a very gracious way of explaining the fact that I have only been in office 2 or 3 months, and I appreciate it. Senator KENNEDY. Some of us haven’t been in a great deal longer. 2180 STATEMENT OF KENNETH E. DeSHETLER, INSURANCE COMMISSIONER OF THE STATE OF OHIO Mr. DeSuErLER. Mr. Chairman, Ohio’s health care system like that of almost all other States, continues to be severely strained by power- ful forces. Three factors especially—shortages of physicians and other medical manpower, poorly distributed manpower and facilities, and improper utilization of health care facilities—make adequate health care inaccessible to many and expensive for all. Many proposals have been made by legislators, medical leaders, and others which were designed to alleviate the difficult health care situa- tion. A broad-gaged approach, aimed at correcting problems in the orga- nization, delivery, and financing of personal health services for the entire population is absolutely essential. Most hospital administrators questioned in a UPI survey could see no leveling off of spiraling cost and charges for at least 5 years, if then. The overall increase in Blue Cross rates in Cuyahoga County alone from 1953 to date was 451 percent for the single subscriber and 512 per- cent for family subscriber. Many factors account for this increase but certainly one of the most important is a total change in the attitude of the public about hospi- talization. Whereas hospitalization was once anXiously avoided, it is now taken for granted even in cases of minor illnesses. Once the patient has paid his health insurance, he is frequently in- clined to take advantage of that prepayment whether or not he really needs a doctor’s care or hospitalization. In addition to subscriber over utilization of his hospital insurance, the problem is further complicated by the fact that Blue Cross is un- able to control costs in the health care system. Resignation to that in- ability to control costs is reflected in a letter from a Blue Cross officer to a subscriber in which he said, “Nothing that we do will ever reduce hospital costs.” A prevalent philosophy with Blue Cross seems to be that all hos- pitals must be saved from insolvency. Such a philosophy of insuring even the most inefficient operations has created a very soft cushion for the hospitals and amounts to an almost unlimited subsidy of ineffi- ciency. The treasurer of a local contracting hospital told me that there isno drive or incentive in the hospitals to keep cost down. The composition of the board of Blue Cross in no sense is represent- ative of its subscribers and yet both Mr. Ells, chairman of Blue Cross and Mr. Burt, president of Blue Cross contend that their basic loyalty is to the subscriber. This creates substantial problems when you con- sider that the Blue Cross boards are dominated by at least a majority of hospital-oriented people who have the seemingly impossible task of serving both the hospitals with which they are affiliated and the sub- scribers to whom they are accordingly pledged. Subscribers and Blue Cross, however, are not alone at fault for con- temporary health care problems. Government at every level must share in the blame for the acute problems that face us in health care delivery and cost. Government has failed to recognize the needs of its people and when vested with au- thority to control has failed to control. 2181 Doctors share the blame for not sufficiently policing their ranks for the unscrupulous doctor who over utilizes hospital facilities and over treats patients and the unscrupulous surgeon who performs a greater number of operations than medically necessary. } Hospitals share the blame for failing to effect economies within the hospital in buying supplies, laundry, et cetera. ) : Hospitals have failed to utilize industrial engineering skills to effect efficiencies in hospital operations. Some doctors have acquiesced to the hospital’s preference for full beds by admitting patients on Friday or Saturday for operations scheduled during the next week. Blue Cross has allowed its rates to be distorted by paying for indigent care as an allowable part of cost. This clearly is the responsibility of the Government and should not be assessed to individual subscribers. We have seen an amazing proliferation of exotic medical facilities. Many cities have open-heart surgery facilities far in excess of their capacity for reasonable utilization. Many cities have Cobalt treatment facilities far in excess for those needed for the community. This is directly traceable, I believe, to the prevalent practice of closed staffing in most hospitals. Closed staffing prevents doctors from taking their patients to any community hospital they desire. This then militates against the effective distribution and utilization of high- priced medical faciliies. I have inquired about the closed staff practice and after pressing for an answer I'm told it relates to the doctor’s competence. If in fact that is the purpose of closed staffing, it really amounts to a concealment of and subsidy of medical incompetence. The effect of such practice, it would seem, only guarantees a reshuf- fling of incompetent doctors but does nothing to get them out of prac: tice. The net effect, I take it, is to collect all of the incompetents in one or two hospitals. It would seem that a doctor is either competent to practice medi- cine or he is not. Supporting closed staffing and its attendant prob- lems it seems to me, is like saying that a doctor is competent to prac- tice but not on this side of town. Doctors ought to be allowed to practice in any hospital because they are competent or barred from all hospitals because they are not. It is unseemly for doctors to argue for closed staffing on one hand and complain about the increasing cost of malpractice insurance on the other. The problems which surround closed staffing are myriad. In some instances private groups of doctors operate emergency rooms as a strictly individual proprietary function. It would seem that if doctors can make money from the emergency rooms the hos- pitals could also, and thereby reduce costs ascribable to other patients. A spokesman for Ohio Nurses Association said in a rather frank admission, “The consumer of health care services already suffers from inflationary prices, health personnel shortages, and a dehumanized health delivery system.” } At this time, Mr. Chairman, with your permission, I would like to read excepts from several letters from our files. This is directed to Director of Insurance : DEAR Sik: We do not wish to appear before your board relating to the March 25 hearing, but would like our complaint noted. After 25 years we must drop our Blue Cross because of the high cost. I have sent in the other portion of our bill explaining we cannot afford this price, and could barely afford the $45.40 2182 we paid before. This price of $95.62 is fantastic. Something is drastically wrong when people have to make a choice like this. With the prices of everything like they are today, this is the straw that broke our back with this long strike now we are even lucky my husband is working. All working people would be happy if something could be done about this situation. Another letter from a man says, relating to he and his wife: My social security check, husband and wife, amounts to $145.30 a month, a total of $1,800 a year. Blue Cross and Blue Shield amount to $712 a year of my income. Nearly 40 percent went to Blue Cross and Blue Shield. Another letter saying: We will be unable to attend the meeting scheduled * * *, And at the end of the letter he says, to sum it all up: We are captive Blue Cross subscribers. The contract is very expensive, has in- adequate benefits, and is unfairly subject to rate increases which discriminate people who solely depend upon themselves to finance it. Something must be done to provide everyone with a right to the advances in medicine and to maintain good health without having to completely bankrupt themselves to get it. It should be available to all for a fairly determined and equally share cost. And another letter: I receive survivor's benefits from social security because I am a widow with a dependent child. I borrowed enough 2 months ago to pay the outrageous sum of $95.40 for Blue Cross, not Medical Mutual. I have now received billing for the next two months. In order to maintain some semblance of independence and not become another name on the welfare to overburden the already overtaxed citizens of the State, I will have to drop this insurance. My husband is 51 years old, I am 46 years old. Our payments were raised to $90.00 every two months. We have been unemployed for the last two months, we have to drop our Blue Cross because we won't be able to keep up with the huge payments. I have been a subscriber since 1943, and on the family plan for 20 years. Senator Ken~epy. What happens when they have been subscribers since 1943 and paid the benefits, and then get sick only 30 or 45 days after they lose their job? Mr. DESuETLER. If they are out of the plan, they are out. Senator Ken~epy. Even though they have paid in since 19437 Mr. DeSHETLER. Well, the amount that they would have paid would have been protection for the past exposure, which does not contemplate future exposure. Another excerpt : It was most welcome news to hear about the hearing on Blue Cross-Blue Shield rate increase. I no longer believe this organization is acting in good faith. Another letter: We pay $705 a year for Blue Cross coverage. This is 15 per cent of our total gross income. Where do we make cuts in our living to cover such high premiums? The only place they can be cut is the quantity and quality of food on the table, and that certainly does not make for good health. And I have here another letter from a doctor, just reading a portion : You no doubt know that Blue Cross came into being solely at the instigation of the hospitals themselves, and has been handmaiden of them ever since. The hospitals have had little incentive to keep down costs. Every increase in price is immediately and without hesitation met by Blue Cross and it at once is passed on as higher rates to the membership. 2183 The cost of getting hospitalization is so high that people can no longer afford not to belong to Blue Cross or some other organization. In my experience, their first loyalty is the hospital. At any rate, it is note- worthy that someone in a responsible position apparently is aiming to put some restrictions upon the free-wheeling practices of the past. We do not suggest, sir, that the people who are operating the hos- pitals are evil people conspiring against the common good. We are, however, suggesting that human nature is such that it reacts most efficiently to a stimulus. Like everyone else in the world, doctors and hospitals will only be as efficient as the forces that work upon them compel them to be. : Nowhere in the Blue Cross program is there an effective mechanism to restrain costs of building or operating hospitals. Many professional people in the health care system characterize the Blue Cross payment plan as a cost plus system and contend that Blue Cross pays every claim put before it. There appear to be certain immutable laws at work in the health care system. Among these are the following : 1. That Blue Cross functions most smoothly by paying all claims put before it. 2. That a hospital to be efficient for its own purposes must maintain a high rate of bed occupancy. 3. That a hospital with a high rate of bed occupancy must acquire new beds and additional space. 4. That hospitals with new beds must fill those beds for the reason set forth in No. 2 above. Mr. Chairman, I am sure you have heard many of these same com- ments in other cities, but I would be rather surprised if Ohio’s prob- lems varied remarkably from those of other States. During the course of our hearings March 25 and 26 held in this city, I made the following recommendations at that time: 1. Utilization studies. 2. Increased public accountability for the cost and quality of health care. 3. Institution of cost control systems. 4. Screening out of certain elements of cost, i.e., teaching cost, bad debts, depreciation methods, and so forth. 5. Consider method of recapturing intern costs. 6. Improve doctor utilization of hospital facilities. 7. Centralization of expensive medical facilities. 8. Centralization of testing and laboratory facilities. 9. Greater subscriber representation on boards of Blue Cross. The Health Insurance Association of America suggests the follow- ing recommendations for renovation of our health care system : 1. Placing emphasis in coverage on ambulatory care, including pre- paid group practice, community ambulatory care centers, organized home care services, allied health services, and care in other facilities which are less costly than are hospitals. 2. Relating coverages to preventive services. 3. Providing incentives for prompt treatment, including rehabilitation. 4. Restructuring coinsurance and deductibles. 59-661 O - 71 - pt. 9 - 14 2184 5. Stronger suport for communitywide planning for health care facilities and services. They also recommended increasing health manpower through a series of consolidated and expanded Federal training and scholarship programs and grants and measures to improve cost and quality con- trols of care provided by hospitals and doctors. Some of the recommendations involve a substantial departure from traditional practices. In the past, the major emphasis in health insur- ance coverage has been primarily on care rendered in a hospital or other facility after the person became ill. The new stress is on preven- tive services and ambulatory care and it is designed to reduce the incidence of costly hospitalization and length of stay. _ Another recommendation by the association urged insurers to help induce hospitals to adopt such cost-saving techniques as diagnostic workups performed before the patient is admitted, to save the day or two a patient must spend in a high-cost facility while waiting for the results of the laboratory tests; to use hospital facilities on a seven-day- a-week basis; to share equipment; and to adopt central mass purchasing. _ Asan example of the saving possible in one area of the health system, it has been estimated that some $1.7 billion could be saved each year if the average length of hospital stay could be reduced by 1 day for the Nation as a whole, as a result of out-patient diagnostic testing and other approaches. Other recommendations of the association were that insurers as- sume a more active role in improving the distribution and availabilit, of health services, particularly in inner-city and rural areas, throug financial contribtutions and manpower; and that companies give n- creasing attention to capital funding investments in such facilities as nursing homes, ambulatory care centers and rehabilitation centers. The recommendations were made following consultations with prominent medical economists, hospital administrators, physicians, and public health representatives. In the recommendations of the association, it was noted that there was a consensus among the medical experts consulted that the Nation’s health care systems must and will change in the 1970’s. The report said: One reason for the pressure for change is that the present systems do not deliver to all segments of the public the highest level of care that medical science cur- rently knows how to deliver, and the care that is delivered is not delivered as eco- nomically as present day technology would permit. Health care delivery systems should be responsive and relevant to the continu- ing health needs of people, rather than only to their episodic medical needs. Systems should be oriented to the whole person and his needs for disease prevention and health maintenance, rather than primarily to medical treatment and management of disabling conditions. Such systems should also integrate and interact with other social and environ- mental systems that serve in the public interest, and they should be structured so as to provide access to quality health care to all, regardless of location, resources, or cultural or social variables. Senator KenNepy. Let me just ask you one question. Based upon vour experience and study, do you think the insurance companies are ready to assume major new responsibility and resources to meet the health crises? 2185 Mr. DeSuETLER. I don’t know that the insurance companies are ready. I would say in my frank opinion, they may be as well prepared as anyone else at this point to handle that matter. I see the problem ory lies beyond the people but with the hospital and Blue Cross, in the hospitals and the practices there for the rather high cost of medical care. Blue Cross, for instance, runs on a rather nominal per- centage of total intake for administration, something like 4 percent for FR costs. But they are totally, in my judgment, un- able to control the costs in the hospitals, and that single element of high medical costs, which is the hospitalization. enator Packwoop. This morning we had a group discussion among proponents of the Kaiser and Blue Cross programs, debating compre- hensive prepaid coverage as compared with fee for service. Interestingly, Kaiser indicated that even in their hospitals costs are only 5 to 10 percent less than normal hospital costs. In lieu of this fact, where Kaiser has a direct interest in keeping costs down, what would you suggest that Blue Cross could do to dramatically bring hospital costs down? Mr. DeSuEeTLER. First of all, you might take it in two points. He said his costs were 5 to 10 percent lower for their hospitalization. Senator Packwoop. One reason why their overall hospitalization costs are less is the emphasis on preventive medicine. But when hos- pitalization does occur, costs of running the hospital are at best only 10 percent lower. Mr. DeSuEeTLER. That would be a substantial savings, and you com- bine it with the fact that many of the prepaid group practices hos- pitalize only half as many people, you can see why they come up with the essentially lower rates. Senator Packwoop. I am referring to the cost of running Kaiser hospitals. They are run as efficiently as possible, and yet their costs are only 10 paz lower than other hospitals. Mr. DeSHETLER. Even 10 percent, any reduction in hospital costs would certainly be welcome to the public. Senator Packwoop. Certainly 1f we could reduce costs 10 percent through increased effiffciency, that is good. Then we have 10 or 20 percent cost increases which do not reflect inefficiency, but reflect spiraling operational expenses. Mr. DeSHETLER. I am not ready to concede we have to have spiral- ing hospital costs, and apparently everyone else is. Senator Packwoop. As Insurance Commissioner, do you have the power to approve or disapprove insurance rates? Mr. DeSHuETLER. Blue Cross rates, yes, sir. Senator Packwoop. Why don’t you disapprove them until reforms are effected ? Mr. DeSuETLER. IT havn’t approved any. Senator Packwoop. And under that system is Blue Cross going to stop writing insurance ? Mr. DESHETLER. No, sir; but what I am going to ask of Blue Cross the next time they ask for a rate increase, I am going to ask that they demonstrate precisely what they have done in conjunction with the hos- pitals to lower the cost. Senator Packwoop. Until that is done, you are not going to ap- prove any of their rate increases ? 2186 Mr. DeSHETLER. I may well not. Senator Kennepy. Thank you very much. That is a splendid state- ment. You have outlined some very significant areas into which we ought to be looking in terms of cost control. I want to thank you very much, sir. I hope you will let us know informally what is happening out here in Ohio, what kind of steps are being taken. Now, we will open the hearing to anyone who wishes to speak. We are going to ask each person to come up in the order that they signed up. We are going to limit it to one person per minute. For those who don’t get a chance to speak, we will offer you an opportunity to file with the subcommittee whatever comments you would like to make, and we will make it a part of the record. Mrs. Arthur Woods. Mrs. Woops. I am sorry, Senator, I can’t follow your 1 minute rule, I am going to have to take three or four because I came here prepared to talk, and I want to talk. I would also like to recognize my Congressman, the Honorable Louis Stokes, Administrative As- sistant, Mr. Clarence Finch. Honorable Congressman of the 21st Dis- trict has recognized the needs, the health needs particularly in our inner-city and I wanted to recognize Mr. Finch. You tell Mr. Stokes I did this because he is my favorite Congress- man. My concern for public health service is extended in appearance as vice chairman of the Metropolitan Health Planning Corp. Unfortu- nately, three things seemingly matter in a presentation, gentlemen : who said this, how it is said, and what is said. And of the three, the latter usually matters least. I sincerely hope such will not be the case in this instance, as I speak with great sincerity of purpose, positive conviction and a hope’ for meaningful change in a different area of health service. I feel through painful experience and harrowing experiences that all emergency health services should be completely removed from the jurisdiction of the Cleveland Police Department. Emergency service, such as calls to the scenes of heart attacks, drownings, automobile accidents, shootings, sudden severe illnesses or any other traumatic experience. Because of current sociological changes in our urban structure, particularly in the central city, the police department cannot be depended upon to respond immediately, to present a proper attitude toward the patient’s family, circumstances, and because of evident lack of proper training, the police cannot be further depended upon to administer needed first aid, or respond efficiently to any specific area of concern. I would like to cite one case out of four that I was definitely in- volved in, one case is July 20, 1969, when my husband died. The police were called at 10 minutes to 12 and after three calls, repeated calls, the police finally arrived at 12:15. At the time I thought my husband had suffered a heart attack. An autopsy, though, revealed that he had died from a massive cere- bral hemorrhage, but neither I nor the police knew that at the time. I live at 1937 KE. 89th Street, which is only a few blocks away from the Fifth District Police Department. The police, in not arriving until 12:15, did not come directly to the house. They parked across the street from the house, evidently afraid of the area and what might happen, 2187 since we had had a Glenville incident, and they were very particular about any calls of this sort in the inner city. When they did finally come into the home, the police had been told, mind you, that my husband had suffered a heart attack because the telephone operator did call the police department. They did not come up with a cot to take him out, they did not come up with blankets, they came in the house, stepped over my husband and asked me was I mar- ried to this man. And they didn’t have a resuscitator either. Well, I was, at the time, giving him artificial respiration and he was still breathing. The police, I said, “Please go down and get the resuscitator, he is still living.” And the police said, “Well, I think it’s too late now.” y I said, “You are not a doctor.” And they became very hostile toward me. One finally went down for the resuscitator and came back and told the other one, asked the other one did he know how to use it, because he didn’t. So he didn’t get the resuscitator. And TI still have, for the information of the fifth district, I still have their blanket at my home where they did not cover him up to take him out to the hospital. They complained about my steps, how narrow they vere, and how heavy my husband was. But I, together with my sister, had lifted him up and put him on the floor. He did weigh 185 pounds, but when you are confronted with an emergency, you have additional strength. I also will not cite the instance of the death of my son who was shot, and it took them 25 minutes to get there. He died July 4, 1966. My mother on May 3, 1965, suffered a heart attack. The police were called and did not come for approximately 35 minutes. She is dead. And a young man was shot in front of our house. My husband and I let him in the house, and this was in 1963. He collapsed on the floor and the police came 45 minutes later. He was finally taken to Uni- versity Hospital, after the police had manifested their adverse attitudes. My suggestions are these: I am hopeful that the government would train some paraprofessionals that could travel from the hospitals. Now I know in New York City, they have ambulances coming out from the hospitals, but we do not have that here in Cleveland. And interns travel with the ambulances so that you have professional people administering health services. Also, we do have in Cleveland, I must pay a special tribute to our magnificent fire department. And they do respond in instances where there are traumatic things happening. And the fire department, of course, cannot bear the brunt of all the things that happen in the city of Cleveland. But I still feel as though that when a police department has proven itself so inefficient and having no empathy at all to the needs of the people in the central city, particularly in the areas where black people live, and I feel as though these services should be removed from the police department and the government should do something in the area of traumatic illnesses. Thank you. Senator Ken~Nepy. Thank you very much. That is a very good com- ment. One of the real problems in the whole delivery system is trans- portation. It varies dramatically in the major cities. In rural areas, 2188 it’s virtually nonexistent. We were in Nashville a week ago where ambulances are run by the funeral homes on a special contract. The first contact that a sick person has in emergency care ought to be with individuals who are trained and equipped to provide very critical help and assistance. : This is essential, and any health system should provide it. You shouldn’t have delays in getting help to come. And when the ambulance comes, it should provide topflight professional help on the way to the hospital. This point hasn’t been made before this afternoon, and I think it’s entirely appropriate she took the additional time to make it. Maryanne Ganofsky. STATEMENT OF MISS MARYANNE GANOFSKY, SOCIAL WORKER IN THE DIVISION OF CHILD PSYCHIATRY AND DIVISION OF PEDI- ATRICS AT UNIVERSITY HOSPITALS IN CLEVELAND, OHIO Miss Ganorsky. I would like to address myself to something that hasn’t been talked about this afternoon at all, and that is another side of medical care, primarily psychiatric care. My particular interest is children, as I am a social worker in the Division of Child Psychiatry and also in the Division of Pediatrics at University Hospitals here in Cleveland. I am not speaking for the hospital in any way, I am speaking primarily as a concerned profes- sional who has come in contact with some very serious problems about psychiatric care. I think of prime concern is what happens to families who do not have insurance when a psychiatric illness befalls them. This is not unusual, because psychiatric care is extremely expensive. It’s much more long term than medical illnesses, so that insurance companies are not as eager to write them into their policies. It’s not unlikely that a family has, on full medical coverage, only 50 to 80 percent psychiatric coverage, which is less than useless in some place like Cleveland where medical costs are so high. It’s also very prevalent with families who have no insurance at all, such as those on welfare. They can receive medical care for their children because the county will pay for it when the child has a prob- lem. They cannot receive private care, the only thing available to them are the very few State hospitals in Ohio. There are three State chil- dren’s hospitals for psychiatric care in Ohio. One is 1n Cleveland, halfway between Cleveland and Akron that has 90 beds; there is one in Columbus that has 30 beds, and that is a daycare center because the building is so dilapidated that they can’t stay there at night. Then there is one in Dayton that has 90 beds, so that is the total of 210 beds for the State of Ohio for psychiatric patients. What happens very frequently with these families is they come to us as a private hospital seeking psychiatric care; they don’t have insur- ance, the State of Ohio has decreed to the county welfare department that they are not allowed to buy private psychiatric care for patients, because the reason is again that there are State facilities. And of course, 210 beds in the whole State for how many children there are, just isn’t, you know, reasonable. 2189 Very often, the families then go to the State facilities and find that they can’t get their child in becauuse they are overcrowded. Then a child who has some serious behavioral problem that needs the type of control that a psychiatric hospital offers, cannot receive it. They are left on the streets in a very untenable situation where they are not able to get outpatient care because that is not sufficient, and there is no bed available for them. This is not so unusual in the State of Ohio, that children are not provided for. I think one thing we haven’t talked about today is children. Not only are there no facilities for children who have psy- chiatric problems, there are no facilities for children with a whole string of medical problems. : If a youngster has a degenerative illness that is progressively getting worse and requiring custodial care, there is no facility for them. The child is either left at home or in some hospital. I am sure part of the reason for the high cost of care comes from a child who is stuck in our hospital at $145 a day, receiving nursing care because they cannot go on to a nursing facility, because the State either doesn’t provide the money, or the facility isn’t there, or the agency for the family isn’t able to mobilize itself. I think it’s just unbelievable the way we take care of children in the State, and it seems any youngster who is stuck with a progressive illness where there is very little hope of rehabilitation, and I think sometimes psychiatric problems fall into this category, there is nothing available for them. One of the things I would like to suggest, Senator Packwood asked earlier about suggestions. I dont know quite how it would be done, but I think it should be considered and if there is some way if the Federal Government begins to move into the whole area of health, that they can provide some incentives to the States, and I suppose ours is not the only one who cares so little about children, that they can provide some incentive to the States to begin to build the necessary facilities, not only for psychiatric care, but for long-term medical kind of prob- lems. I suppose there has to be, financially, some way to help pay the cost of the child care in the hospital, because these are certainly going to be long-term problems to finding some way to help our State legisla- ture see that this is necessary, and to begin to provide the facilities which currently just don’t exist. I don’t—I think that if I had the time, I could cite you loads of cases where families have been left out in the cold simply because things they need simply aren’t available. And my task has been one of trying to find the facilities for them, making telephone calls all over the State and I get the answer, “No, I am sorry. He is too old for our program; he is too young for our program; he is too sick for our pro- gram, too well for our prgram,” then having to go back to the families and explain what happened. And T think our children deserve better than what we are giving them. Senator Packwoop. Again, I want to hearken back to this morning’s testimony from Kaiser. Kaiser has a resident psychiatrist. What is your experience with the quality of the psychiatric care for children under the Kaiser plan ? 2190 Miss Ganorsky. I may be slightly prejudiced in this, working in a A facility, but I think the care is good if the family has the nancial wherewithal to pay for it. If they don’t have the nk wherewithal, then it isn’t even a mat- ter of poor care. Senator Packwoon. I am referring here not to families with the wherewithal, but to the families who belong to the Kaiser Foundation, in this case members of the Meatcutters Union. Miss Gaxorsky. I happen to know one or two of the people who are the psychiatric consultants to Kaiser, and I happen to think they are i people. So I would assure the care they are receiving is very good. Senator Packwoon. At some point we will have to make some deci- sions on financial health insurance. In this case we see private indus- try paying for the insurance and providing the care and there seems to be a good response from the people covered by Kaiser. Miss Ganorsky. It certainly has been my experience from talking to people who are covered by it, they are pleased with their coverage. We have not had a child referred from the Kaiser Hospital to our hospital, but knowing the people who are on their staff and talking to a few people informally, 1t’s been my impression that it’s certainly good care. Senator Packwoop. Thank you. Senator Kennepy. Very good comment. T hope you will make some suggestions to us on what do you think we might be able to do to improve child care. Perhaps you could visit with some of your friends and send your suggestions to us. Next, we have Rev. Floyd Perry. Reverend Perry. My name is Rev. Floyd Perry, my address is 12905 Signet Avenue, Cleveland, Ohio. This is a personal experience that I would like for you to hear and bring out my personal experience. I would like to suggest, concerning the persons that spoke concern- ing going to emergency rooms at the hospital and failed to get the proper kind of help, someone asked what would they suggest should be done along that line. I would suggest that when things happen on that sort, that there should be an action taken in regards to penalties or reprimanding or dismissal of the person that would neglect someone actually that is seeking the help. On the Tth of December 1969, I was admitted to the hospital. First may I say that I am a senior citizen on social security. I was admitted on the 7th of December and stayed there until the 26th of December 1969. IT was dismissed on the 26th and went home, stayed there until the 8th of January. I was admitted back to the hospital for 3 days, they thought that a blood clot had formed and I stayed there 3 days. I was released, cameback home and on the 18th day of January, I had an illness and my doctor had to get me in the hospital right away. From the 18th of January to the 7th of February, I was in the hos- pital, and this cost me $6,550. Medicare paid all except $1,200. After getting out, my wife had to go to the hospital, she stayed in the hospital for 5 weeks and it cost her $6,000 and some. And the insurance paid $995 out of the $6,000. That left the wife’s bill $5,100 and some, and so my bill was $800 and some paid. 2191 Well, T wasn’t able to pay the amount left, so what I did, I went to the manager of the cashier’s department and related to him my con- dition. And after hearing what I said to him, he said to me, he said, “Reverend, I will see what I can do, I will talk to the board and see just what can be done.” And he did talk to the board, and one Sunday I went to church, came back home, and there was a letter in my mailbox. I don’t gener- ally go to the mailbox on Sunday, but that day I was impressed to go there and there was the letter from the hospital stating that that $5,000 was paid by the foundation. And I realized that it was just a warmth that touched the heart to do that, because I wasn’t able to pay. Now in regards to a bill that I read that Senator Kennedy and others have written up, I really think it’s a fine bill and anything that I can do to help foster that bill or get it passed, I will be very glad to do that. I realize with the hand of the Lord, that He would touch the hearts, and I give God the credit for even touching their hearts that the bill be paid. Everybody is not that fortunate. I really will do all in my power to help push the bill that you have. There are so many senior citizens, that the amount of money we get is so small and until we can actually hardly exist. And I was disabled for quite a while, so when I became 65 I got a letter from the Govern- ment stating that this would be cut. So I wrote my Senators and also (Congressmen, and explained that the small amount that IT was getting and knowing that they had had an increase, they had just gotten from $30,000 to $42,000 and can hardly make it, T expect for a man making $1,995 a year, how are you expecting us to make it? So, therefore, I said, “Damn the evil war.” That many of us wasn’t able to go to war to help win the war, now we get old and can’t work, and the Government only gives this small amount to us to exist. And I think it’s really unfair, and I am advocating that if there is any way that the Government can add on to social security of the senior citi- zens, it will be a blessing. Senator KexNepy. Thank you very much, Rev. Perry. This is a very interesting and heart warming conclusion to your story, getting relief from these hospital bills. As you point out, you are very unique, very fortunate to have gotten this relief. You reminded us also of inade- quacy of social security. I don’t think there is any group in our society that is hurt as much by the devaluation of the purchasing power of the dollar as are those living under social security. The Congress has failed to face up to the extraordinary inflation and yet we put a ceiling on what retired people on social security can earn. This is a tragic situation. Ladies and gentlemen due to a prior commitment, Senator Pack- wood and I have to leave. We have a transcriber here who is going to continue. I have asked my assistant, Miss Souliotis, to stay for another 40 minutes. For those who want to tell their stories, she will take the testimony, and it will be in the transcript. Senator Packwood and I will get a chance to review it later. 2192 For those that by 4:15 are unable to tell their story, Dr. Max Davis will be good enough to help you transcribe your comments. I want to express my very sincere appreciation to you. We have been here for some 2 hours and 40 minutes, you have been very attentive, and have reflected the deep concern that all of us as Americans ought to have with these problems. This isn’t just a problem for those of us in the Congress or for the doctors or even for the consumers, it’s an American problem. We have to come up with some solution to this, and we will make every effort. : I want to express my very sincere appreciation for the comments that have been made here. I think they have helped us understand the problems. I want to thank all of you for your courtesy, kindness, and attendance at this hearing this afternoon. (Senator Kennedy left the hearing room.) STATEMENT OF DR. DAVID L. KELLER, CLEVELAND, OHIO Dr. Kevrer. This is in connection with section 65. We are talking about the best health care for the community, and it has been shown in articles cited in the March edition of the New England Journal of Medicine and by the Joint Commission of Hospital Accreditation that podiatrists are now to be considered physicians and surgeons of the feet. Therefore, under your section 65, we seem to be listed under subfunds. If we are such an integral part, as has been proven over the years, of the medical community, why are you trying to eliminate us as an organization, as a profession ? I, myself, am in the 10th year of my medical training and I feel after 10 years of medical training to be an integral part of the health team. STATEMENT OF LILLIAN CRAIG, CLEVELAND, OHIO Miss Crate. My name is Lillian Craig, I live at 3111 Church, near west side. I work for the West Side Opportunity Center, and I am also on ADC. And I am one of the more fortunate people, because I am covered by medicaid. We are concerned about the marginal income families who aren’t covered by anything in my neighborhood. Women are waiting until Te are 8 months pregnant to go see a doctor because they can’t afford to pay a doctor. The hospital, the Lutheran Hospital, is in our neighborhood. You have to sign a blank note, blank. They are turning people away from this hospital. The medicines that people have to take are so fantastically high priced that if I was not covered by welfare, I couldn’t work, I would be dead. Because I pay close to $60 a month for my medicine, or wel- fare pays it. The city doctors are run by the health department here, they are worse than veterinarians. They do not treat people for the illness, they treat people in general terms. They carry no antibiotics, and that is it. 2193 The teeth and eyes of these little kids, they are growing up, there is no chance for them to have any good medical care. STATEMENT OF MARY DANIELS, CLEVELAND, OHIO Mrs. Daniens. My name is Mary Daniels, I live at 1020 East 86th Street. Nothing was mentioned about people on disability. I go to the doctor two, three times a month, that 1s $10 each time. I have to have medication. And I am supposed to go to a specialist, a kidney specialist, and I need glasses, I need teeth. What is a person going to do in a case like that, ask God to take you? That’s all. STATEMENT OF WALTER RATCLIFFE, CLEVELAND, OHIO Mr. Rarcuirre. Senator Kennedy, my name is Walter Ratcliffe with the Office of Economic Opportunity, supervisor of the Outreach De- partment, Economic Department, Kinsman Opportunity Center. I am a kidney patient. I lost both my kidneys, September 1970. As we have had one speaker for the kidney foundation—I mean for the kidney patient, I do feel that he adequately covered it. Our prices vary somewhat, the fact I find that my machine is more expen- sive than his, the machine I have at home cost $10,000 a year. My medical expense last year came to $12,000 a year not including the cost of the machine. I am now on home dialysis, which makes it possi- ble for me to be able to work, because 2 days a week prior to that, I had to go to the hospital to be dialyzed, until T was able to get the machine at home. . At the present time, I am involved in trying to help the people throughout the community be cognizant of the tremendous cost that is involved with kidney illness, and hoping that other kidney patients who have met this plight. Three weeks ago I flew to Indianapolis, Ind., to help a lady there that had just lost both of her kidneys and had 10 children. And the black paper there, the Indianapolis Recorder was starting a fund to try to raise money for her machine at the cost of $10,000. I spoke at several churches and worked with the paper and we found cn the last report they have raised $9,000 on the lady’s machine, which is really merely the initial cost, because the upkeep of the machine runs you another $10,000 a year. I do feel indeed fortunate that since I was inflicted with this horrible kidney disease which is so extensive, that I was in Cleveland, Ohio where they have the finest medical center facilities in the world to combat it. Mount Sinai Hospital, where I was a patient and Cleveland Clinic are probably two of the finest kidney units in the whole world because many places, they don’t have even these facilities. My grievance is that now that medical science has made this tremen- dous innovation of finding how to keep you alive once your kidneys are gone, that the costs are so tremendous that it’s beyond the reach of the average poor working man. I would like to see the Government in some manner be able to sup- plement this cost, even though I was assured by Kaiser Foundation and they have been very wonderful to me and helped me like I said, my 2194 bill was better than $12,000 last year, which leaves me a balance of bet- ter than $2,000 that T will have to try to pay. The hospital and founda- tion have been very considerate, and again I say I have been blessed by living in Cleveland, Ohio. So that is about it. STATEMENT OF DR. TILMAN BAUKNIGHT, CLEVELAND, OHIO; ACCOMPANIED BY VALLRIE BRADLEY Dr. Baur~Nigur. My name is Dr. Tilman Bauknight and I represent the Forest City Dental Inc., which is a group of 15 black dentists here in Cleveland. And our purpose is to bring to the attention some of the things that we feel that are being neglected in the formation of the National Health Insurance bill. 4 The first issue that I would like to bring up is the fact that the Job Corps Center for Women recently ran out of medical funds, and one of the first programs that had to be cut out was the medical and dental program. And I submit to the Senator and to the committee members that this program, the Job Corps program for women should be sup- ported in terms of refunding and increasing the funds for the tremen- dous job that they are doing. Their supportive services would be to provide the dental care and treatment of their students. Their students come from all over this country and from the poor and deprived areas, many of which have never received dental services before in their life. And we have with us today a girl who is from Detroit, Mich. Her name is Vallrie Bradley, and she happened to be one of my patients there at the Job Corps. And she can tell you her story, and what dentistry did for her there. And then TI can go into the dentistry on the national scene later. Miss BrapLey. My name is Vallrie Bradley, I am a student at the Cleveland Job Corps Center for Women, I come from Detroit, Mich. I am the first of 11 children, and my mother has been on ADC or welfare since. I had never seen a dentist until T arrived at the Cleve- land Job Corps Center where I was given oral surgery twice and had a partial plate put in, and a whole top plate, which my mother could not afford under ADC or welfare. And if there is any possible way for Senator Kennedy to put dentistry in the bill, it would be a great help and a great appreciation to the Cleveland Job Corps for Women. Dr. Bavk~icaT. Now, we just asked Dr. Davis here who is a dentist, a very prominent dentist and he is representing the official dentistry capacity, and I just asked him a question did he know whether or not fluoride treatment was paid for under the Ohio fee scale for welfare patients. In other words, could a welfare patient receive treatment, fluoride treatment, and the dentist be paid. He said he did not know, and the fact of the matter is that the welfare fee schedule does not make any allowances for fluoride treat- ment. Yet we know that topical application of fluoride is the single most effective agent in reducing the incidence of decay. So I am saying that I do feel that the people who are connected with the formation of these policies are not addressing themselves to the 2195 needs of the masses of poor people, and especially black people, be- cause they can’t relate to them. } You see, I picked this up and I am only a dentist for 5 years, but when you look through the fee schedule, I can’t do a topical fluoride treatment on a poor kid. I also notice that for one to clean teeth, according to the welfare fee schedule, they will pay the dentist $4, which is a ridiculous fee. There is no provisions for orthodontic treatment, there are no pro- visions for crown and bridge treatment, and I want to make that clear, because here according to the ADA official bulletin, when you read this, you would pat yourself on the back, because you are proud to be a dentist, because it says, “More preventive care, less tooth repair.” But when you really get down and read through here, you find the types of services that they are proud to claim credit for. For instance, fixing bridge, a single crown plate, these are the serv- ices completed, first you have services completed in 1950, then I will read the same services completed in‘ 1969. . For a single crown placed in 1950, there were 2,600,000; in 1969, there were 11,400,000. For orthodontic treatment in 1950, there were 7,800,000 orthodontic treatments; in 1969 there were 20 million ortho- dontic treatments. In 1950 there were 2,600,000 fluoride treatments; again in 1969, there were 12,200,000 fluoride treatments given. So here I am saying that what the ADA is proud of is that preven- tive dentistry is paying off for those patients who can really afford it. It’s a luxury item for those patients who can’t afford it, as indicated by the high fees charged with crown and bridge treatment or ortho- dontic treatment, indeed, they are retaining and saving their teeth. We are also aware of the fact that the age groups showing the greatest number of office visits would be from the ages of 5 to 15. This would include all the preschool dental examinations and all the exami- nations given by visiting health nurses, and this type of thing. But the gae brackets outside of the age of 15, it goes steadily down. So my recommendation is that we would include in a national health system, age groups, especially from 30 to 50, so that we can take steps to preserve the natural beneficiary rather than see the facts borne out that by the age of 50 years, one of every two Americans have full dentures, or one out of three patients at the age of 35 require full dentures. Finally, IT would like to add to the record a note that I wrote to the Director of Welfare Services here in relationship to a dental case of Mr. Robert Carter. Robert Carter comes from a family of six children. His mother is an ADC patient, but Bob won a scholarship to Dart- mouth and he had several teeth missing, and I wanted to get au- thorization to construct a prosthesis for him. The letter I wrote went as follows: I would like to have special permission to construct a partial for this patient due to what I believe is a most unusual situation. That his mother has six children, including an older brother who is in college. Robert is attending Dart- mouth and is on the Dean’s List, he is a B plus student. His mother is work- ing at present, and thus off the ADC rolls. But in my opinion, the Welfare De- partment would be in fact be aiding the entire society by helping a person better themselves in breaking the chain of welfare dependency. I began dental treatment on this student 3 years ago, and I think he should be allowed to obtain a partial. 2196 The letter I got back in response went as follows : DEAR Dr. BAUKNIGHT: I have read with very careful interest your letter of September 29, 1969, regarding authorization to construct a partial for Robert Carter. Your letter was reviewed with the Chief of the Bureau of Medical Assist- ance. While we share with you your concern for Robert, your opinion in breaking the chain of welfare dependence, and your altruistic attitude, the current policies and regulations of the Cuyahoga County Welfare Department will not permit us to authorize this. I certainly hope that you will not consider Mr. Barbin’s nor my attitude callous in this matter. However, we must abide by the policies and regulations of the agency. Please note that we are totally sympathetic with this very increasing problem. All of these things are really brought out in the fact that the ADA according to the ADA News of March 29, 1971, on a feature page says, “Board Favors Nixon Health Plans if Dental Care Will be Included.” So I am saying that the ADA has made a statement, or has come out in favor of the Nixon health plan although it does not include any form of dentistry. So if the ADA cannot see the need—well, I think it’s pretty obvious that the ADA is not concerned about poor people or black people and their needs for dental care. And again, my recommendation would be that in consideration, or in the formation of these health insurance policies, that black representation, both lay and professional be in- cluded. Thank you. STATEMENT OF DR. N. M. CAMARDESE, NORWALK, OHIO Dr. Camarpese. My name is Dr. N. M. Camardese, 48 Linwood Avenue, Norwalk, Ohio. Senator Kennedy, first of all IT want to congratulate you and offer your high commendation for the immense efforts that you are putting forth to take the story to the local community and attempt at getting their answers. Secondly, I wish to express my gratitude for being given the oppor- tunity and privilege to enter a few remarks. Your Honor, I happen to be a naturalized American citizen. I was born in Italy, I think America is the greatest country God gave the world ever, and it seems at times such as our modern, somewhat confusing state, that we seem to forget that indeed America is the best country in the world and that it is only America that has approximately 110 plus countries on its relief rolls, quote unquote, that it is helping. I would think that first and foremost, the most important value things that we must keep uppermost, is to preserve freedoms and a free America. Health care, medical care, personal problems, com- munist problems, all of these must be looked at in a vein of preserva- tion of freedoms. I firmly believe and have the strongest faith in the American indi- vidual, and it is only as individuals, who had faith in God and them- selves and a very strong faith as this, that this country was built. This we must maintain at all costs. I also should like to express that the larger an organization, a com- munity, a country, the larger a problem gets, the more necessities that the answers come from local communities. The resources of the Ameri- can citizen are tremendous if he is permitted to involve himself and 2197 given the motivation. I should like to give you the benefit of a survey that T conducted in my own private practice. It is extremely interest- ing, because whereas we are continually hearing of doctors’ fees spiral- ing upward, upward, upward, when I questioned my patients in a written survey, which took approximately 114 to 2 hours of the patient’s time to reply, it is interesting to note that when it came to doctors’ fees, it ranked No. 10 of 13 items which my patients were given to list in priority of their needs from their private physicians. Item No. 1, incidentally, was medical knowledge. Furthermore, when the question to the patient would favor total medicare from in- fancy to old age, there was 95.42 percent against this type of medical health services. When my patients were questioned on favoring Amer- ican medicine and how 1t stood in the world, 72.22 percent thought it was the best in the world. Zero percent thought it was poor, zero per- cent thought it was the poorest or the worst in the world; 83.33 per- cent of those replying stated it was as good as anywhere in the world. When questioned on the present medicare law, 71.7 percent of those that answered were against the present medicare law as it is; only 28.3 percent were for it. With reference to the type of family doctor and/or practitioner most desirable, the answers were as follows: Solo practitioner was wanted by 73.6 percent; joint practice with a partner was desired by 25.5 percent. And when polled on combining practices, several doctors in a group, only 1.7 percent were in favor of this. When given the opportunity to express their comments as they wished, and make suggestions with reference to how I might better serve my patients, the overwhelming majority were comments of gratitude, and there were several worthwhile suggestions as to how I might improve my care for them. Both of these were highly appreciated, and in those instances where it was beneficial to the patient, these submitted suggestions were implied. Again, thank you very kindly, and T respectfully submit this. STATEMENT OF MRS. MILDRED BARRY, REPRESENTING THE HEALTH PLANNING DEVELOPMENT COMMISSION OF THE WEL- FARE FEDERATION Mrs. Barry. I am Mrs. Mildred Barry, representing the Health Planning and Development Commission of the Welfare Federation, which is the voluntary health and welfare planning council in this area. I have two persons with me who are prepared to testify, whom I will introduce in a moment. First, let me say that our health commission is a citizen’s group of over 80 persons, lay and professional from a wide variety of back- grounds and experiences who arc interested in promoting improved health programs. Several years ago we conducted a health goals study, partially supported by the U.S. Public Health Service. We have com- piled a reference book on “Health and the Poor” drawing on testimony and surveys of local consumers as well as Federal, State, and local data. We have worked with neighborhood groups as well as health agencies. We have recently completed a dental study under contract 2198 with the areawide comprehensive health planning agency. From these and other experiences we believe that we are qualified to speak out on health problems. Currently we have a task force studying the several national health plans but we are not yet ready to testify about specific legislation. Health problems of the poor are recognized by us all, but the prob- lem is not limited to the poor. In many respects the most neglected group is that above the poverty level who have little if any recourse when medical crises occur. Mrs. Caroline Hatten will describe one such situation, and has been authorized and requested by the family to do so. STATEMENT OF MRS. CAROLYN HATTEN, HSC, CLEVELAND, OHIO Mrs. Haren. This is a summary of how a hard-working, childless couple’s dream of self-sufficiency—earning their own way, owning their home, paying their bills—was destroyed by excessive medical costs. The plight of this middle-aged couple came to our attention on August 5, 1970, at the Vocational Guidance and Rehabilitation Serv- ices (VGRS) outreach health care station then located in the VGRS’ building. I was the neighborhood health worker to whom this desperate couple was referred at the stage when the rising costs of lifesaving medical treatment had finally exceeded their efforts to pay for these services. By this time, having exhausted both savings and medical in- surance policies, this hapless couple had already suffered over 4 months without any kind of medical care from either private physicians or hospital outpatient services. Fortunately, physicians from Case West- ern Reserve University Medical School, serving as volunteer project staff, were able to help them reenter the health care delivery system. However, we were not able to prevent the death of the cancer stricken wife 5 months later nor to forestall the financial bankruptcy of the husband. I now wish to place in the record my knowledge of this case as an illustration of the hardship of financing medical care in the United States. First of all, this industrious, frugal black couple took the normal measures to insure themselves against the possible financial setbacks of illnesses. Mr. and Mrs. Shed Johnson were both employed and had hospitalization policies through their places of employment. In February 1969, Mrs. Johnson began to experience pain in her left hip ; she also felt a “lump” in the same area. Faulty self-diagnosis delayed her seeking medical care for 6 months. On August 13, 1969 she saw a private physician who hospitalized her immediately. She was discharged 1 month later with the diagnosis of Riticulune Cell Carcinoma of the hip bone (cancer). The recommendation from this hospital at the time of discharge was that she be treated at a private hospital on an outpatient basis with X-ray therapy. However, addi- tional examinations at this second hospital revealed that she had a pathological fracture of the left thigh bone with many cancerous growths of the soft tissue. She was then transferred to a third hospital for 6 months for long term rehabilitative care. She was discharged for followup care through her private physician and at this point, was confined to a wheelchair and homebound. 2199 Now, her problem of financing medical care became acute. She had exhausted her hospital insurance and no longer could pay her private physician for home care. Without a private physician’s certification, the Visiting Nurse Association could not continue to provide home nursing service. Knowing no other avenue of obtaining needed medi- cal treatment, she suffered at home untreated for over 4 months. By chance, she was referred to the VGRS health care project by a con- cerned community worker. Upon visiting the home, our medical team found Mrs. Johnson without hope of medical care and Mr. Johnson overwhelmed with mounting medical bills. Upon recommendation of VGRS’ physician, we began the tedious process of helping Mrs. Johnson back into the health care delivery system. We provided 32 trips with escort and orderly service to outpatient clinics and for periods of hospitalization. Professional staff served as Mrs. Johnson's advocate in getting her the needed services. Mrs. Johnson was admitted to a general hospital on September 25, 1970, discharged October 5, 1970; readmitted November 1, 1970, and discharged November 16, 1970. During the interim she was seen in the outpatient clinics. The costs continued to be added to their medical bills. On December 11, 1970, she was admitted to a chronic disease hospital as a medical indigent and died there January 23, 1971. Mrs. Johnson was not able to work from the onset of her illness in August 1969, which meant that Mr. Johnson’s weekly income of $165 prior to deductions did not enable him to keep up with the medical bills. When he was under great pressure to pay them, he would borrow from a loan company and compounded his financial situation by hav- ing to make not only the payments but also to pay high interest rates. The insurance policies paid about one-third of the costs and Mr. Johnson was responsible for the balance. He presently owes $19,796.76 for hospital and medical expenses. At one hospital alone his bill is $13,732.03. This does not include expensive medications and supplies which he was able to pay for out of his limited earnings. A lien has been placed on his home by one of the hospitals and foreclosure is imminent. With the help of VGRS’ lawyer, Mr. Johnson is filing bankruptcy as there is no other feasible way for him to solve his financial situation. This means he will lose his house which is mortgaged, his car, any saleable household effects and, at the age of 56, he will have to start from scratch. Mrs. Barry. Our next witness is Mrs. William Brooks, a resident of a public housing project and president of Seniors of Ohio. Many . assume that health care of the elderly is taken care of by Social Secur- ity, medicare and medicaid but such is often not the case as Mrs. Brooks will point out. STATEMENT OF MRS. WILLIAM BROOKS, RESIDENT OF A PUBLIC HOUSING PROJECT AND PRESIDENT OF THE SENIORS OF OHIO Mrs. Brooks. Mr. Chairman, I learned of an older woman who has a medical bill of $50 per month. She has a savings of $1,000 which she is saving for her funeral and burial and will not go into it. For this 59-661 O - 71 - pt. 9 - 15 2200 - reason she is ineligible for A.F.A. However, how long would this last at $50 per month ? Husband needs dental care. He cannot get out of the house and no doctor will call. He could get this badly needed dental care through the Home Service of Highland View Hospital that brings the unit into the home. This requires a doctor’s clearance, but no doctor to recommend it, hence no dental work. Patient needed a brace, but brace shop would not take the medical assignment on medicare. Wanted patient to pay $75 to the brace shop if some one would loan same and repay with refund from medicare. Thus no braces. Many patients have been sent home from the hospital unable to care for themselves as medicare would not pay the extended care facility. There is a need for someone to interpret the news in the vicinity of the home dental unit, visiting nurse, and why no doctor is available to make a home visit when the need is present. Q. This patient had been robbed by a confidence man, who was very much in need of glasses. Were obtained through a local agency and paid by the welfare fed. Marea) patient operated on for colostomy. Needs homemaker, no results. Blind man wishes full time housekeeper, no results. Blind man found suffering. Automobile had fallen on him badly injuring his leg. With hospital care he is improving. The hope is he will be well enough to move in metropolitan housing. These are a very small number of senior citizens because they are poor and uninformed as to their rights and services avavilable to them, not the least of which is relief from the rat infested dwellings they are forced to live in causing poor health conditions to occur. Gentlemen these statements are all authentic. This information was obtained through a built-in clinic in M.P.H. and from senior workers in Seniors of Ohio Inc. Mrs. Barry. Now I should like to take a couple of minutes to identify several other problems. 1. Prostheses and appliances. Our community information service gets many calls from people who cannot afford to purchase or rent prostheses and appliances, from dentures to wheel chairs, or cannot afford to keep them in repair. This is a neglected subject in plans to finance health services. 2. Dental care is minimumly covered by the Blues, private insurance and Government support programs. I believe the Kennedy bill is the only national proposal that makes any attempt to include dental care. Yet a dental maintenance program started at an early age could signifi- cantly reduce the widespread incidence of dental disease, the financial burden of costly dental procedures, and the attendant effects of dental disease and loss of teeth on a person’s general health and nutrition. According to estimates made in our dental study, 80 percent of the population in this county do not have the financial resources to pur- chase extensive or complete dental care. 3. Barriers to the receipt of health care, repeatedly expressed to us by consumers are: high costs, transportation and other arrangement 2201 difficulties of getting to health facilities, long waits, communication difficulties, and derogatory attitudes shown by some health personnel. 4. Financing mechanisms have focused on high cost services, par- ticularly inhospital care. Too little financial support has been provided for prevention, ambulatory care, home health services, nursing home care, psychiatric care, and certain types of rehabilitative and aftercare services. Our health commission is deeply concerned about problems such as these and believes that we must look to government for the financial undergirding necessary for a balanced and inclusive range of health services if we believe—as we do—that health is a right. STATEMENT OF KARL C. JOHNSON, VICE PRESIDENT, GARDEN VALLEY NEIGHBORHOOD HOUSE BOARD OF TRUSTEES, CLEVE- LAND, OHIO Mr. Jounson. Thank you for the opportunity to be heard. The health professional and the eleemosynary institution have failed to remedy the structural weaknesses in our health care delivery system. It isnow time for the Government to step in. President Nixon's national health strategy does not cover domestic workers. At this time they are supposed to be covered by social security, but the average suburban housewife does not make the appropriate deductions or contribute her share as employer. This means that thou- sands of domestic workers in the Greater Cleveland area are not accumulating the required numbers of quarters of experience to qualify for social security benefits. Now we are told that they mustn’t get sick either. Your plan, Senator, calls for regional and local boards to determine local priorities. I am afraid that in Cleveland, that would be a little bit like leaving local voting in the south up to southerners, rather than insisting upon adherence to the law. In spite of an HUD requirement that tenants and community people be involved, our local metropolitan housing authority has consistently ignored the problems of residents of public housing. Improper main- tenance, vermin, and assorted indignities have become a way of life. An advisory committee exists, but is rarely convened. One family received an eviction notice. When the father inquired as to the reasoning, the answer, “immoral behavior” was given, for a woman was seen entering and leaving the premises during the day. In truth, the lady was a homemaker, trained at our community college, and paid by the county to assist this family that had lost its mother. But typical of the indignities visited upon the poor, no one checked. Senator, unless you include a specific requirement that minority and community people be included on any local or regional policymaking body, the leaders of Cleveland who normally sit on such bodies will be insensitive to the true needs of those who would be served by the Kennedy Health Security Act. ; Cleveland has compiled additional evidence of its lack of caring. There are between 50,000 and 60,000 substandard housing units in this area. This means that more than 200,000 people are currently housed inadequately. 2202 In Cleveland, the United Appeal is responsible for raising volunteer donations which are then budgeted, planned, and dispersed by the Welfare Federation. In recent years, in the light of increasing individ- ual contributions, but declining corporate ones, it has become custom- ary to set a goal that they think can be achieved, instead of setting one based upon the need of the agencies served. When the private sector fails, government, theoretically, steps in. When government fails, voluntary agencies are formed to fill the breach. What are the poor to do when everything fails? Minority groups statistically carry more than their share of poor health. It is an advantage to be white, not black, or Indian, or Puerto Rican. Health impairment and income are directly related in dis- order after disorder. Even life expectancy depends upon skin color. In the schools, we have discovered that there is a direct correlation between the level of poverty, the mobilty of a child, and his reading score. The poorer he 1s, the more he is forced to move from school to school, the lower his reading ability tends to be. If Johnny can’t read, how can he get a job? If he has no regular source of income, where can he go for adequate health care where he will be treated with dig- nity and respect Where can he go that he will be treated ? It is a well-known fact in the inner city that it takes the overworked police ambulances more than an hour to respond to an emergency call. It is also known that those police ambulances will pass by hospitals on their way to those emergency wards that accept indigent patients. When the ambulance arrives, there is another wait, because there are others to be cared for. The out-patient clinic is widely heralded by most hospitals as their contribution to the community. What it is, in fact, is a quick method of training medical personnel. The institutionalized health care avail- able through the average clinic destroys the dignity and self-esteem of the poverty patients who must resort to it. When the police ambulance arrives, more often than not the patent must deliver detailed infor- mation concerning the status of his poverty before he receives treatment. One clinic patient had seen so many different doctors on her trips to the hospital that she thought the name of her physician was Dr. Staff. No, she didn’t know what he looked like. Have health care institutions been created to treat illness, or to pro- vide jobs and job training. If your health security act seeks to make the total population eligible for health care, that will not be possible using existing institutions administered in traditional fashion. There is a saying in the black community that drug addition did not become a major issue until suburban white youngsters began popping pills and mainlining. If you check the chronology of both events, you will find the statement difficult to disprove. All across the Nation there is a 20 percent increase in welfare fam- ilies ever year. In Cleveland, the rate is 33 percent per year. That adds up to an increase of 100 percent since 1968. But every museum in town has successfully mounted a sizeable building program. The Cleveland Museum of Art is one of the wealthi- est in the Nation. Not only could it submit a bid of over $1 million for 2203 a Rembrandt, it has added a multi-million-dollar addition. Less than a mile away, there is grinding poverty. The Health Museum is the first of its kind in the United States. It is located in the midst of the inner city, but all of the bricklayers who were working on its new wing were white, until a call from a concerned neighbor asked why. Two bricklayers, readily identifiable as black, were on the job the following day. The Natural History Museum has added many cubic feet to its dis- play capabilities. If we can buy paintings, build museums, talk about health, and stuff animals, why can’t we build houses; heal the sick, and generally improve the lot of the poor? It would appear that the people with the ability to help are preoccupied with other concerns. That is regrettable. Tuberculosis is on the run. We now have the knowledge, experience, equipment, and medicines to eradicate it. But doctors who specialize in diseases of the chest can tell you that many indigent patients must be hospitalized, not because of the seriousness of their condition, but to guarantee that they get the necessary medication. How can they be concerned about some little white pills, when nearly every walkin, moment is a battle against starvation, vermin, brutality, and violence ? In England, an indigent family that is being treated, may find that their doctor has prescribed nourishing food as a part of the treatment. I hope, Senator, that your Health Security Act will contain provisions that will permit doctors to prescribe an adequate diet, and then make the food available to those for whom it will be a matter of life and death, and not just good taste. Agian, in tuberculosis control, it has been discovered that some pa- tients do not have the carfare to make periodic trips for medication. The local (Cleveland) branch of the Tuberculosis and Respiratory Disease Association has included this need in its budget for the coming year. Residents of the Garden Valley area must take two buses, trans- ferring in the heart of town, to get health care at unusual hours. In the middle of a winter night, how likely is a poverty parent to risk taking a sick child out to ride the bus? What 1f that child’s care de- pended upon promptness for a cure? And if the parent did choose to take the child on the bus, what would happen to the other children? ‘Who would care for them ? Finally, if 50 percent of the 525,000 hospital bed patients in the United States are confined for psychogenic disorders, what, Senator Kennedy, does your Health Security Act do for them? My wealthy friends are eccentric and visit their private analysts periodically. My poorer friends are crazy, and are confined. . You have made yourself vulnerable to this tirade, sir, by being in- terested enough to come to Cleveland and listen. I have subjected you to it because I want your efforts to do more than solve the financial plight of Cleveland’s hospitals, or cause large numbers of people to feel better about all of the good things we are doing for the poor. We must admit that they have been the victims of malignant neglect, and resolve to remedy that. Thank you for listening. : (The following was subsequently supplied for the record:) 2204 April 16, 1971 Senator Allen Ellender Old Senate Office Building Washington, D. C., 20510 The strict confidentiality of patient's charts has always been a foundation of American medicine, recognized as necessary and the patient's entitled right. The steering committee of the Mid-Ohio Council of Medical Staffs which represents over 400 private physicians joins with the Council of Medical Staffs of New Orleans in rejecting the compliance with third party carrier requests for copies of such charts. Blue Cross requested of the Harding Hospital in Columbus a copy of a psychiatric patient's complete chart. We urge you to stop this invasion of privacy. James S. McCaughan, Jr., M.D. cc: Dr. Jose L. Garcia Oller Congressman Chalmers P. Wylie Senator Wm. B. Saxbe Senator Robert A, Taft Congressman Samuel L. Devine Dr. Donald H. Burk ou 2205 JOHN C. STENNIS, MIS5., CHAIRMAN STUART SYMINGTON, MO. NRY M. JACKSON, WASH. BAM J. ERVIN, JR, N.C. HOWARD W. CANNON, NEV. THOMAS J. MC INTYRE, NH. MARRY F. BYRD, JR., VA. MOLD E. HUGHES, IOWA LLOYD BENTSEN, TEX, T. KOWARD BRASWELL, JR., CHIEF COUNSKL AND STAFF DIRECTOR MARGARET CHASE SMITH, MAINE GTHOM THURMOND, 5.C. meme. Wlniled Dlafes Denate COMMITTEE ON ARMED SERVICES WASHINGTON, D.C. 20510 April 23, 1971 James S. McCaughan, Jr., M.D. L497 East Town Street Columbus, Ohio Dear Dr. McCaughan : This will acknowledge and thank you for your recent telegram relative to your opposition to the Social Security Law for Medicare that a copy of a patient's chart must be furnished to the insurance carrier before reimbursement can he effected. In an effort to be of all possible assistance, I have brought your views to the attention of the Commissioner of the Social Security Administration for his consideration. Please be assured that as soon as I receive a reply to my inquiry, I will be in touch with you again. With best wishes, Very truly yours, RB Sep n= 7 Saxbe United States 2 WBS :bh SAMUEL L. DEVINE 12m DisvRiCT, Onio DISTRICT OFFICE 408 FEoCRAL BUILDING COLUMBUS, OHIO 43218 221-3833 2206 Congress of the United States House of Representatives Washington, DE. 20515 April 19, 1971 James S. McCaughan, Jr., M.D. 497 East Town Street Columbus, Ohio 43215 Dear Doctor McCaughan: SLD:jl cc: COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE SUBCOMMITTEES TRANSPORTATION AND AERONAUTICS COMMITTEE ON HOUSE ADMINISTRATION JOINT COMMITTEE ON PRINTING Thank you for the telegram to Senator Allen Ellenders concerning the confidentiality of patient's medical files. I share your views and have brought this matter to the attention of the House Ways and Means Committee, which is presently consider- ing amendments to the Medicare program. Sincerely, . WRT Samuel L. Devine, M. C. Wilbur D. Mills ROBERT TAFT, JR. OHIO 2207 AVnifed Diates Denate WASHINGTON, D.C. 20810 April 21, 1971 Mr. James McCaughan, Jr. 497 East Town Street Columbus, Ohio Dear Mr. McCaughan: This will acknowledge your wire of the sixteenth. I believe you meant to send your message to Senator Russell Long as he is Chairman of the Senate Finance Committee and the matter to which you refer would come before that Committee. I will en= deavor to discuss this with Senator Long at an early date. Sincerely, Robert Taft, Jr. 2208 CHALMERS P. WYLIE 1514 DisTRICT, OHIO 1331 LonawonTi Hous Tecmo. 25208 Congress of the United States orsTmcr orrice: House of Representatives FroraaL BuiLDING 85 Manco! BLVD. Cotumous, Onio 43218 Washington, N.C. 20515 TELEPHONE: 469-5614 JACK M.FOULK ACMINSTINTIVE ASSIST, April 19, 1971 Dr. James S. McCaughan, Jr. 497 East Town Street Columbus, Ohio Dear Dr. McCaughan: coMmMITTEES! BANKING AND CURRENCY SUBCOMMITTEES: SMALL BusINESS. BANK SUPENVISION AND INSURANCE CONSUMER AFFAIRS VETERANS' AFFAIRS SUBCOMMITTEES: EOUCATION HosmiTaLs INSURANCE This is to acknowledge and thank you for a copy of your telegram to Senator Allen Ellender. I am sure you will hear from him in the near future. I agree with you that patient's charts should remain confidential, If I may be of any further service, plea CPW:cwf write again. 2209 Io lo Io I< Department of Justice, State of Louisiana Office of Jack Gremillion Attorney General February 25, 1971 Mr. Haller Alexius, Administrator St. Tammany Parish Hospital Covington, Louisiana Dear Mr. Alexius: Your letter of February 5, 1971, addressed to Attorney General Jack Gremillion, has been assigned to this writer for attention and reply. Your letter inquires as to the extent your hospital must release patient medical information to health insurance com- panies when furnished with a proper authorization by the patient. There appears to be no statute which : deals with the release of hospital records in response to written authorization by the patient. However, R.S. 44-7 which deals with the release of records under certain circumstances empowers the governing authority of the hospital to make rules and regula- tions regarding the inspection and copying of these. As you know, the governing authority of the St. Tammany Parish Hospital Service District is the Board of Commissioners, and such commissions are empowered to make and promulgate rules and regulations by virtue of R.S . 46-1055. I trust that the above is responsive to your inquiry. Should you require further clarification, please feel free to re-communicate with this office. Very truly yours, (signed) Louis A. Gerdes Special Counsel 2210 LOUISIANA STATE MEDICAL SOCIETY RESOLUTION MAY, 1971 Concerning Release of Medical Information to Insurance Com- panies, Service Contract Corporations, Government "Carriers," and Government Agencies, from Medical Records Departments of Hospitals. Introduced by: Jose L. Garcia Oller, M.D., Charles W, Miller, M.D., Christopher Bellone, M.D., Michael Smith, M.D., Kenneth Ritter, M.D., Robert Meade, M.D., Wesley Segre, M.D., and Edward Hyman, M.D. 3 1. All inquiries for medical information will be accompanied by a properly executed and current authorization for release of information signed by the patient or his proper representative. Upon receipt of an inquiry, the Medical Record Department will sub- mit information in the face sheet of the chart, which includes identification data, the admitting and final diagnosis, and the name of the operations performed, including the verified pathological diagnosis, if any. If an insurance company requires additional information, the insurance representative will be referred to the attending physician. Requests for the "entire medical record" or "photostatic copies of the history, physical, and progress notes" are considered unethical and unacceptable. 2. It is recognized that an insuror may request under the "contestability clause" specified by the law in most states, specific antecedent information during the period of contestability. This request to the physician shall identify the specific infor- mation requested from the history of the present illness. On re- quests for past history, a list of such antecedent information as may be related and pertinent to the insurance policy in question will be provided by the insuror. The physician may then review the medical record(s) and provide the pertinent information. Operative report and pathology tissue report copies should not be necessary since the surgery is clearly listed in the front sheet and is self- explanatory as to the procedure involved and the verified pathol- ogical diagnosis, if any. Reports of x-rays, EKG or other labor- atory aids used by the physician in establishing the clinical diagnosis should not be necessary. 3. for the purposes of financial audits and government pro- vider audit programs,"the provider need only show the auditor that part of the records relating to the physician's authorization for services and not the notes made by nurses and physicians or diag- nostic data which are confidential information." 4, The physician may honor requests for unusual information of a technical nature which the patient himself may not be able to provide and not covered in 2 above. 5. Certifications and recertifications are to be filed separately from the body of the medical record and shall be made available to the carrier or state agency. These should not be . entered on the progress notes. " Implementation of this Resolution shall be the responsi- bility of the Medical Records Committee of the medical staff. 2211 MINUTES -NEW ORLEANS DISTRICT-LOUISIANA HOSPITAL ASSOCIATION-MEETING 3/12/70 pg. 3 RELEASE OF INFORMATION FROM HOSPITAL RECORDS (continued) Mr. Maher stated he has been instructed by Mr, Vallon to make the following statements: (1) that Mr, Vallon has had several meetings with the Legal, Executive and Medical Committees of the Board of Managers of our Blue Cross Plan; (2) that he has discussed this subject at the last meeting of the Beard. (3) Blue Cross will write to each hospital administrator in our area a policy type letter whereby we shall endeavor to explain the guidlines of our Association with regard to ask=- ing for necessary information in terms of patient and subscriber identity, which means subscriber's name, patient's name, his group and contract numbers, and his age, We don't think the Council of Medical Staffs would object to this, (4) We would also ask, where necessary, and it is done in some cases, for a brief case history. You may abstract, if you will, a very brief statement as to the reason why the patient is admitted. (5) We would not ask for progress notes or any additional information from the hospital, (6) If this - information is necessary to process the case, we will write the physician, ~ Ir. Maher stated he has been instructed by Mr. Vallon to nakl the following stetements: (1) that Mr. Vallon has had seve meetings with the Legal, Executive and Medical Committees 8 . the Poar? of Managers of our Blue Cross Plan; (2) that he discussed this subject at the last mceting of the Board. (3) Blue Cross will write to each hospital administrator ia our area a policy type letter whereby we shall endeavor to explain the guidelines of our Association with regard to ask- ing for necessary information in terms of patient and subscriber identity, which means subscriber's name, patient's name, his group and contract numbers, and his age. We don't i think the Council of Medical Staffs would object to this. (4) We would also ask, where necessary, and it is done in some cases, for a brief case history. You may abstract, Na you will, a very brief statement sas to the reason vhy thes. 4 patient is admitted. (5) Wé would not ask for progress odd or any additional information from the hospital. 6) x information is. necessary to process the cae, we a) Ia. the physician. 2212 TEE HOSPITAL MEDICAL RECORD A Guideline for the Release of Medical Record Information Published by the Health Insurance Council in cooperation with the American Association of Medical Record Librarians THE SECURITY AND RELEASE OF MEDICAL INFORMATION As a general rule, certain information is not available from the hospital medical record for release to third parties. This includes such data as OCTAIET psychiaiiic examination information, porsonal_bistory. of patient or family, information controlled by State law, etc. re pertinent, a brief Teme may be issued regarding this type of information. Any information that would be considered an “act of defaming” the patient cannot be re- leased. Likewise, information received from other hospitals and physicians regarding past history or treatment is for informational purposes and is not considered the property of the hospital receiving it. Correspondence or social service information which may be filed with the medical record is not considered a part of the medical record. In preparing the following information, excerpts were taken from Guide to the Organization of a Hospital Medical Record Department, a publica- tion of the American Hospital Association. The information acquired in a_ doctor-patient relationship is generally considered to 5 confidential or_privileged communication. The code of ics_adopte: the American SDL t and the American & p y Hospital Association ollege of Hospital Administrators in 1957 recognizes the principle of the conhdential nature of medical information: Er hospital organization an its individual employees jointly share the responsibility for the best possible care of the patient. To fulfill this obligation, the hospital and employees are both charged with certain reciprocal ethical obligations . . . Employees are obligated . . . to safeguard confidential information tegarding patients pnd the hospital; to avoid gossip and public criticism of the hospital; to develop a spirit of mutual friendliness with fellow workers, and to be courteous to the public.” The hospital, therefore, is responsible for pro- viding adequate safeguards to prevent access to a patient's medical record sy unauthorized persons from the time the record is initiated throughout the patient’s hospitalization, and after his discharge. There can be only one person responsible in the hospital for the medical record—the attending pnysician. He alone knows all the facts and is i consequently the only one competent to arrive at conclusions. Intern and junior resident notes may reflect unimportant as well as important infor- mation, or important data written in considerable detail. It is the attending physician who must judge the accuracy of their notes as they pertain to the individual patient. When there is a question regarding: the content of the medical inf ion to be released, the di hysician is consulted for its aceuragy or interpretation. spfiand Information; Data in the medical records is of two types: - Informational data relating to the identification of the patient and the facts of hospitalization, usually found in the identification sec- tion. This data is considered non-confidential and may be released without the consent of the patient. However, even this information should be released with care and only in response to proper in- Quiries. Certain data that would be non-confidential in a general hospital might be considered confidential in a specialty hospital or in a special service of a general hospital, such as a Psychiatric Unit. : 2? 2. Clinical data obtained professionally and usually found in_the medical section of the record, is considered confidential. gE P 2213 STANDARDS FOR ACCREDITATION OF HOSPITALS JOINT COMMISSION ON ACCREDITATION OF HOSPITALS OCTOBER 1969 645 NORTH MICHIGAN AVE., CHICAGO, ILLINOIS 60611 Principles and Standards Approved, interpretations only accepted for fickd testing MEDICAL RECORD SERVICES 73 Standard III Medical records shall be confidential, current and accurate. Interpretation The medical record is the property of the hospital and is maintained for the benefit of the patient, the medical staff and the hospital. It is the responsi- bility of the hospital to safeguard the information in the record against loss, defacement, tampering, or use by unauthorized persons. Written consent of the patient is required for relcase of medical information to persons not otherwise authorized to receive this information. Records may be removed from the hospital's jurisdiction only in response to a court order. It is recog- nized that in some instances, such as in the treatment of mental disorders, certain portions of the medical record are so confidential that extraordi- nary mcans may be taken to preserve their privacy. In such cases, these portions may be stored separately and data concerning identification, medi- cations, treatments and so forth, including a resume, may be maintained in the general medical record files. For review purposes, however, the com- plete record must be available. 2214 Disclosure of Contents of Audit Program + For a general discussion of the prohibition against disclosure of informa. tio, see 113,850. Hib or wR I Tor : : Disclosure of Contents of Audit Program and Results of Audit The eT Tose audit programs adopted to date—i.e., those for hospitals - (HIM-16), home health, agencies (HIM-17), and extended care facilities (HIM-18)—provide that the auditor is not to discuss or disclose the contents of the audit program, or otherwise provide information with respect to specific audit approaches, to anyone except authorized representa- tives of ‘the intermediary and the Social Security Administration. ¢ scope of the audit and pverall audit objectives and approaches should be discussed, "however, with appropriate officials of the provider during the initial conference at-the start of the audit, and the results of the audit are to be discussed with officials of the provider and the intermediary during the audit and at the exit conference, as appropriate under the circumstances. (Note that the guidelines to be followed by the intermediary in determining the frequency, necessity, and scope of audit may not be disclosed ; see { 7627.) .01 Sources. — Soc. Scc. Act §1106, 116,375. Reg. §401.1, 118,051. Audit Pro- gram for Extended Care Facilities . . . (HIM-18); Audit Program for Home Health Agencies . . . (HIM-17); Audit Program for Hospitals . . . (HIM-16); Part A In- termediary Manual, HIM-13, § 3765. ¢ 13 Accessibility of non-Medicare pa- tients’ medical records.—Provider Relations Bulletin No. 74 [see eC IRN dS € Seusd 1 Was a joint product of Pom . Of the Amencan Hospital ASSQ- cia € Cross AS ign and our posi ial a Medicare audit must encompass review of both Medicare [™ .87 Review by auditor of provider medi- cal records and minutes.—The fol- lowing statement is_a joint ec staffs of the America t{o5p1 5 n 5 ssociation, ¢ believe a ! ner Oster a better understanding between the provider and auditor in meeting their mutual respon- sibilities: 4 for services rendered corresponds with the physician’s orders. The auditor must trace the order for services to the department rendering the service in order to verify that | the service was actually rendered, and then, he must trace the charge to the patient's ledger. : 2. The, use of RCCAC makes it essential that the auditor verify that all services Statement on Auditors’ Review of Medical Records and Provider's Board Minutes Under the Medicare Program An auditor representing an intermediary under the Medicare Program frequently has a need to review certain aspects of the medical records and board minutes of a provider, The following has been developed as a guideline for providers and auditors with respect to the extent that these hos- pital documents should be made accessible. Auditors’ Review of Medical Records The following is a listing of reasons why an auditor should have access to certain patients in the hospital. . 1. The audit is designed to review the system of internal control over the process- ing of transactions within a hospital. The financial transaction starts with a physi- cian's order in the medical record. It is the only source of authorization for services ordered by the physician and therefore it is Deecssary or the auditor to review the orders of the physician to ascertain that the charge portions of the medical records for all . rendergd are recorded to avoid a distortion in, the application of RCCAC method of reimbursement. r. : 3. The patient signs a statement on the Inpatient Hospital Admission and Billing Form. (SSA-1453) which authorizes the provider to release information necessary to support payment of the claim. 4. The - rovider contract provides for access , to information pertinent to reim- bursement. The auditor is interested in seeing the data for only a small sample of patients. Fhe provider need only show the audi tha x 2215 CONDITIONS OF PARTICIPATION REGULATIONS mo wen SUBPART F—Agreements with and Functions of Providers, Intermedi- aries, Carriers, and State Agencies. HOSPITALS § 405.612 Compliance with procedural and other requirements; individual's refusal to execute request for payment. (a) For purposes of § 405.607 (a) (2), com- pliance with procedural and other requirements means that the provider of services: (1) Has secured, from the individual or a proper person acting on his behalf, a written request for payment to be made to the provider, and the provider has properly filed such re- quest; and (2) Has in its files the required certification and recertification by a physician relating to e services furnished to the individual (see §§ 405.1625-405.1634) ; and (3) Has furnished to the Secretary such information as the Secretary has found neces- sary in order to determine the amount due the provider on behalf of the individual for the period with respect to which payment is to be made or any prior period; and (4) Has complied with the provisions requir- ing timely utilization review of long stay cases so that a limitation on days of service has not been imposed under section 1866 (d) of the Act (see § 405.617). SUBPART J Conditions of Participation; Hospitals 405.1026(a) 405.1026 Condition of Participation—Med- cal Record Department.—The hospital has a medical record department with administrative re- sponsibility for medical records. A medical record is maintained, in accordance with accepted profes- sional principles, for every patient admitted for care in the hospital. (a) Standard; Records Maintained. — A medical record is maintained for every patient admitted for care in the hospital. the h |. Such records are kept con fidential. The factors explaining the standard are as Tollows: (1) Only authorized personnel have access to the record. (2) Written consent of the patient is presented as authority for release of medical information, (3) Medical records generally are not removed from the hospital environment except _upon_sub- poena. See SUBPART J Conditions of Participation ; Hospital 405.1023 (n) Standard; Medical Records Committee, — The medical records committee (or its equivalent) supervises the maintenance of medical records at the required standard of completeness. On the basis of documented evidence, the committee also re. views and evaluates the quality of medical care given the patient. The factors explaining the standard are as follows: (1) The committee meets at least once a month - exclusive of the summer months, and submits a =e Written report to the executive committee. (2) The committee’s members represent a cross section of the clinical services. In large hospitals, each major clinical department may have its own committee. (3) Membership is staggered so that experienced committee physicians are always included. Senior residents may serve on this committee, (4) Review of the record for completeness can be performed for the most part by the medical record librarian. In addition, on-the-spot scanning of current inpatient records for completeness is done on the floors. (5) The quality of patient care is evaluated from the documentation on the chart. In some hos. pitals, this function may be given to an “audit” or “evaluation” committee. (6) The committee: (i) Makes recommendations to the medical staff for the approval of, use of, and any changes in form or format of the medical record 5 (ii) Advises and recommends policies for medical record maintenance and supervises the medical records to insure that details are recorded in the proper manner and that sufficient data are ~ present to evaluate the care of the patient; g (iii) Insures that there is proper filing, index- ing, storage, and availability of all patient records; an (iv) With the aid of legal counsel,_advises and develops policies to guide the medical record Ti rarian, medical staff, and adminis ration so far as matters of privileged communication and legal re- [ease of information are concerned, 2216 UNIFORM POLICY FOR RELEASE OF MEDICAL INFORMATION All inquiries for medical and other information shall be accompanied by a properly executed and current authorization pertinent to the period of hospitalization for which the request is being made and signed by the patient or his proper representative during or after this hospitalization. Upon receipt of an inquiry, the hospital may submit only the following information: identification data, date of admission and discharge, diagnosis or diagnoses and the date at which the diagnosis of the current illness was made; statement as to the reason for the present hospitalization and the name of the operations performed upon the patient. If additional information is required, the hospital shall refer the inquirer to the attending physician for further information who shall respond without delay. Under the provisions of Title XVIII and XIX of the Social Security Act, the medical records of such hospitals as choose to utilize the Utilization Review Committee of the official fiscal intermediary shall become available for the purpose of such utilization review to the intermediary. For the purposes of financial audits, the confidential aspects of the record shall be removed from the sampling of records requested, prior to such audits, specifically the history and physical examination record and progress notes; except the progress notes shall not be removed when used to certify the need for hospitalization under Title XVIII of the Social Security Act. - Requests for release of medical information from attorneys claiming to represent the patient will be handled on an individual basis by the administrator. Note: The above is recommended for adoption by the hospitals comprising District VI of the LHA by the ad hoc committee appointed for that purpose by the President, Sister Mary James. Phyllis D. Eagan, Chairman Sr. Mary James » David Smith . Paul Bjork September 11, 1970 2217 [From The Citizen Journal, Columbus, Ohio—April 9, 1971] Doctor REBUTS NEW HEALTH PLAN To The Editor: As a private physician as well as the Chief of Surgery at the State School for the Mentally Retarded, I want to commend Governor Gilligan for distributing and showing the motion pictures taken of conditions prevalent at the State Hos- pital. Conditions at the State School exist which would not be tolerated for one day in private medicine, and the State School of Columbus is held as the model school for the rest of the state. This is a vivid, close to home example of government intervention in medicine. Presently the public is being told by opportunistic politicians that there is a medical crisis, and they are going to cure it by a socialized medical program. The public is being told that they will receive the same or better medical care they now receive from private physicians and they won’t have to pay for it. THIS IS A ridiculous assumption. In the first place they will have to pay for it every year through taxes whether ill or not. Robert Myers, who was the chief actuary for the Social Security Administration for 23 years, estimates the cost will be between $660 to $1000 per worker if the Kennedy-Saxbe Health Security bill is passed. The Social Security Administration itself estimates the cost for fiscal 1974 will be $77 billion, Don’t forget that the SSA has consistently underestimated the cost of Medicare and Medicaid. Politicians credibly state that the public will only have to pay a small percentage of this and the rest will be made up from general taxes. Those general taxes come from the public. Most important, the private physician/patient relationship will be destroyed and the quality of medical care will certainly deteriorate. One need only examine presently existing government facilities such as the State Hospital to predict the future. Public Health Service hospitals have been permitted to become so outmoded that the government decided in December, 1970, to discontinue them. In 1969 the average stay in short-term government general hospitals was 19.9 days while 8.3 days in similar non-government hospitals. IN THE READER’s Digest of March, 1971, was a report of an intensified investigation of the VA system which showed that it was beset with critical malfunctions, problems of management, financial support and utilization of re- sources that mean misspent funds and mis-directed treatment, It was recom- mended that new managerial blood is urgently needed and they must be given authority to make decisions free of needlessly stringent bureaucratic regula- tions. Reports of the VA’s own chiefs of services were: “tight budget policies have imposed serious fiscal constraints on our abilities to employ adequate per- sonnel and provide necessary facilities”; ““. . . insufficient equipment, insufficient personnel and grossly inadequate support in the crucial areas of pathology, ra- diology and clinical laboratory and physical medicine”; *. . . radiology equip- ment is obsolete in the worst sense of the word, broken down in the very true sense of the word.” The V.A. Hospital system is a $1.9 billion a year operation with 166 hospitals. The funding for the following year is based substantially on the utilization of the hospital from the previous year, therefore there is a great tendency to keep patients in the hospital longer than in private hospitals, as is shown statistically. Military hospitals use “walk-in clinics” for the ambulatory ill. This usually subjects the patient to a different doctor at each visit and not infrequently the clinic will be manned by a physician trained in a specialty other than what the patient’s illness requires. A SPECIAL committee on Municipal Hospital Services appointed by Mayor James Tate to study the future of Philadelphia General Hospital (a city-owned service which received $30,961,946 for fiscal 1970) reported on April 20, 1970 : “The present PGH is obsolete and beyond economic renovation. This manner of allocat- ing money deals with health problems too late, costs the most, and does little to prevent illness. Administrative and management inefficiencies were found in present operations of city personnel health programs.” It should be noted that changes in the Philadelphia General Hospital on June 17, 1970, were: per diem for inpatients $68, clinic visit $25, receiving ward visit $20. The average private physician office charge is less than $10. Similar reports can be made for Massachusettes General, Cook County General and other city and county-owned hospitals. 4 2218 Not many private patients are beating down the doors of government hospitals to obtain care. Government is not infallible as we can see daily in the newspapers. In RESOLUTION-62 at the annual convention in 1969, The American Medical Association reaffirmed its belief that, “It is the basie right of every citizen to have available to him adequate health care.” However, it also states, “It is the basic right of every citizen to have a free choice of physician and institution in the obtaining of medical care.” If the Kennedy-Saxbe comprehensive health insurance or the American Hos- pital Association’s Ameriplan is put into effect, the practice of medicine will be completely altered in that the private practitioner will disappear from the scene. The patient will no longer have a choice in who treats or operates on him or his loved ones. Thus while imperfect, the greatest medical system ever devised is going to be destroyed, unless the private patients let their congressmen and their newspapers know that they still want to have some say in who treats them. Write a note to Congressmen Chalmers Wylie or Samuel Devine, or Senators Robert Taft or William Saxbe in Washington, D.C. and let them know your feelings—JAMES S. McCAUGHAN, JR., M.D., Central Ohio Medical Clinic, 497 E. Town-st. 2219 MARVIN I. KOHN, M. D. TIBOR V. KOVACS, M. D, OBSTETRICS AND GYNECOLOGY 7918 MUNSON ROAD oS MENTOR, OHIO 44060 TELEPHONE 287-7227 May 4, 1971 Senators Kennedy, Packwood and Taft: I am a private practitioner of obstetrics and gyme- cology in Mentor, Ohio, near Cleveland. I represent no organization and hold no office in my county medical society. I took a few hours out of my practice to attend the hearings and see for myself what the Senate is trying to do. I wish to present some of my personal thoughts on these hearings and on health care. 1. The parade of witnesses before the subcommittee's hearing in Cleveland clearly showed that the problem in med- ical care is neither service nor availability, but money. And money was clearly a problem because of catastrophic ill- ness. An insurance program including catastrophic coverage that would include all cithzens, possibly appended to F.I.C.A., and with guarantees of insurance for the indigent and/or un- employed would certainly seem to be a rational approach to the problem of health care expense. It is also an uncompli- cgted approach. The witnesses who complained about inadequate treatment in emergency rooms, or about police rescue squad ineptness, or about misdiagnosis, or about "racism" in med- ical care obviously had an axe to grind. If these witnesses feel their civil rights were violated a Senate subcommittee hearing on health care is a poor place to register their complaints and only serves to introduce emotionalism to the question under consideration. 2. The problem of the "doctor shortage" is more shadow than substance. A maldistribution of physicians exhsts, not a numerical shortage. I would suggest that the committee consider a plan, analagous to the Berry Plan, to wholly or partly finance medical eduacation and training wherein the student so financed would have a contractual obligation to practice in a doctor short area for an agreed time. There are plenty of doctors in Cleveland, but Vinton County in Ohio's Appalachia, has not a single ph sician for its 10,000 people. This patterniis repeated al crogs the country. I recall an incident 18 years ago, when I checked into a motel in Lordsburg, N.M., the innkeeper tried to get me to stay in their town because they needed a doctor! 2220 MARVIN I. KOHN, M. D. TIBOR V. KOVACS, M. D. OBSTETRICS AND GYNECOLOGY 7918 MUNSON ROAD MENTOR, OHIO 44060 " Qo TELEPHONE 257-7227 Sens, Kennedy, Packwood and Taft De 3. If medical care in America truly needs reorgan- ization and restructuring as Senator Kennedy states in his speech of Jan. 25, 1971, I submit that the place to start is with government itself. Let government at all levels recognize ats total responsibility in health care in the areas it already denotes as community health problems but fails to fund solutions for those problems. An example of government failure in community health is family planning. The United States is the only major nation in the world with no government directed family planning program. True, Federal funds are available to supplement monies provided privately or by other levels of government. But a comprehensive program itself is non- existent. As long as private agencies continue to tilt at the family planning windmill, government seems determined to ignore its total responsibility in this recognized com- munity health problem. Drug abuse is another community health problem neglected by government. In my county, Lake, there is a Free Clinic for Drug Abuse; it is privately organized and funded, with government making some fiscal contribution. But a health problem is either a community concern or it's nots If it is then public resources ought logically to be used to meet the problem. It is hardly equitable for pri- vate monies to be applied to public problems, Tax dollars have already been contributed for such purposes and it is certainly the government's duty to allocate those tax dol- lars wisely to meet problems that government itself recog- nizes as public. : . Private funds are donated for all manner of health problems that in other nations are met by government alone. We Americans seem to be uhique in our generosity to support every medical problem from M.S. to V.D. Perhaps it's time to stop private support of public health problems; maybe it's time for government to "reorganize and restructure" its dele ivery of public health care. ' _ Ptfer INE 2221 rn MAKE HEALTH CARI} A RIGHT, NOT A PRIVILEGE ! Most people needing health care in Amcrica, and most people working in health-related jobs are in trouble: Millions have no family doctor to rely ons many urban neighborhoods and rural homes have no health care at all; working people pay more and more for their health care in doctor bills, drugs, insurance payments, and taxesjy if you don't like a doctor, a hospital, a nursing home you have no way to change it; and if you work in a hospital, you have no way to get training for a better job! | We believe Senator Kennedy's Health proposal has some merit, and feel that it is the best plan currently before congress, Its GOOD points: It greatly rcduces out-of-pocket expenses for health care It tries to eliminate insurance companies It wants to control wasteful costs But Kennedy's Plan is NOT the ahswer! His plan: Fails to place family oriented doctors in every neighborhood and town. Pays for health care by extracting billions in taxes and social security payments from working Americans, not the rich, Allows drug companies and other health industries to make HUGE PROFITS from people's sickness, Like Nixon's plan, creatos Health Maintenance Organizations (HNO's) designed to increase their profits by keeping the patient out of the doctor's office and out of the hospital (even though the patient may need or want the care). Also encourages a two-class system of care: Understaffed HMO's for poor and working people; private practice for the rich, Leaves the health carc system in the hands of those already proven incapable of running it-—doctors, administrators and corvorationsj refuses to allow eonsumers and health workers a meaningful voice, We feel that a National Community Health Service should guarantee health care as follows: FRUE health care of equal quality B6rEV:RYBODY ! This includes physical, dental, mental, environmental und social health care, EQUAL DISTRIBUTION throughout the country of a massively increased number of doctors and other health workers. TRATNING for all health workers so that orderlies, technicians and nurses can, if they so desire, receive advancement throush on-the=job training, and even become doctors in this way. END OF RACE, SIX AND SOCIO-ICONOMIC DISCRIMINATION by training tens of thousands of minority group health professionals and workers, FINANCED PUBLICALLY AND NATIONALLY by a tax which makes the rich pay their share. Working Americans should not pay more taxes. PROFITS ELIMTNATUD ¥R6M the henlth care system, No individual or organization should profit from people's sickness, This means abolishment of fce-for-servicepayments to doctors, climinatos insurance companies, and places drug companies under public ownership, NEIGHBORHOOD BASED, COTUIITY=TORKER COHNTRQLLED health conters in every aroa of the hi HEALTH AND S'T.MY OF HORKERS GUARANTEED Bmployment should be meade healthy fo: for all workers in all . jobs. Power and llon1th to the neonle! Modical Committco for Human Rights EEE National He:lth Insurance Committeo 2222 (Whereupon, at 4:10 p.m., the Senate Subcommittee on Health of the Committee on Labor and Public Welfare was adjourned.) Oo HEALTH CARE CRISIS IN AMERICA, 1971 HEARINGS BEFORE THRE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE UNITED STATES SENATE NINETY-SECOND CONGRESS FIRST SESSION ON EXAMINATION OF THE HEALTH CARE CRISIS IN AMERICA MAY 5, 1971 CHICAGO, ILL. MAY 13, 1971 DES MOINES, IOWA MAY 14, 1971 DENVER, COLO. PART 10 Printed for the use of the Committee on Labor and Public Welfare & HEALTH CARE CRISIS IN AMERICA, 1971 HEARINGS BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE UNITED STATES SENATE NINETY-SECOND CONGRESS FIRST SESSION ON EXAMINATION OF THE HEALTH CARE CRISIS IN AMERICA MAY 5, 1971 CHICAGO, ILL. MAY 13, 1971 DES MOINES, IOWA MAY 14, 1971 DENVER, COLO. PART 10 Printed for the use of the Committee on Labor and Public Welfare 2 U.S. GOVERNMENT PRINTING OFFICE 59-661 O WASHINGTON : 1971 COMMITTEE ON LABOR AND PUBLIC WELFARE HARRISON A. WILLIAMS, JRr., New Jersey, Chairman JENNINGS RANDOLPH, West Virginia JACOB K. JAVITS, New York CLAIBORNE PELL, Rhode Island WINSTON PROUTY, Vermont EDWARD M. KENNEDY, Massachusetts PETER H. DOMINICK, Colorado GAYLORD NELSON, Wisconsin RICHARD S. SCHWEIKER, Pennsylvania WALTER F. MONDALE, Minnesota BOB PACKWOOD, Oregon, THOMAS F. EAGLETON, Missouri ROBERT TAFT, Jr., Ohio ALAN CRANSTON, California J. GLENN BEALL, Jr., Maryland HAROLD E. HUGHES, Iowa ADLAI E. STEVENSON, III, Illinois STEWART E. MCCLURE, Staff Director ROBERT E. NAGLE, General Counsel Roy H. MILLENSON, Minority Staff Director EUGENE MITTELMAN, Minority Counsel SUBCOMMITTEE ON HEALTH EDWARD M. KENNEDY, Massachusetts, Chairman HARRISON A. WILLIAMS, JRr., New Jersey PETER H. DOMINICK, Colorado GAYLORD NELSON, Wisconsin JACOB K. JAVITS, New York THOMAS F. EAGLETON, Missouri WINSTON PROUTY, Vermont ALAN CRANSTON, California RICHARD S. SCHWEIKER, Pennsylvania HAROLD E. HUGHES, Iowa BOB PACKWOOD, Oregon CLAIBORNE PELL, Rhode Island J. GLENN BEALL, Jr., Maryland WALTER F. MONDALE, Minnesota LEROY G. GOLDMAN, Professional Staff Director JAY B. CUTLER, Minority Counsel (IT) CONTENTS CHRONOLOGICAL LIST OF WITNESSES WEDNESDAY, MAY 5, 1971 CHICAGO, ILL. Daley, Hon. Richard J., mayor of Chicago, TIL... ii aun diel Ln Mattox, Lyle, health services consumer, Chicago, Il ___________________ Johnson, Paul, health services consumer... __ o_o Lewis, Mr. and Mrs. Louis, health service consumers... ______ Villa, Mrs. Olga and Miss Ninfa Ruiz, health service consumers__________ Brislen, Andrew, president-elect, Chicago Medical Society ___.____________ Campbell, James, president, Rush-Presbyterian-St. Luke's Medical Center__ Grigna, Carol, health service consumer, American Indian_______________ Towne, William, Residents Association of Cook County Hospital, and Nick Rango, Interns Association of Cook County Hospital __________________ Ricks, Phil, practicing physician, Chicago, Ill... co fl ool ul Love, Mrs. Marie, past national secretary for the National Consumers and chairman of our Model Cities health task force ______________________ THURSDAY, MAY 13, 1971 Des MoINES, TowA Dimery, Porter, Des Moines, Towa _.. ._Zo Jl los. 0 alo SB ull Hentges, Mrs. Judith," Dubuque, Towa... CL Cd Jeol uni uid Sonu, Williams, Mrs. Joanne, public health nurse, and Ray Tillery, Des Moines, TOWER oem di a He a i i EN BL SUL teh dumbed Roby, Miss Angie, nurse at Des Moines General Hospital, Des Moines, TOW: atc in naib cc emma Tm A Ls Le Banks, Mrs. Charles, nurse, Des Moines, Iowa... __________________ Richards, Mrs. Shirley, Des Moines, Iowa... o_o __ Lister, Kenneth E.; M.D., president-elect, Iowa Medical Society, Ottumwa, JOWR oc Sr onto tn ins 0 lt sim sal om i i Be to Seebohm, Dr. Paul M., associate dean, College of Medicine, Iowa City, Jown trade. at a LLL a EN AR Nino Leimbach, 8. Pi, MLD, Belond, JOWA.. cow messmo ms smi aries un Grahek, Bernard M., president, Towa Hospital Association. ______________ Dunn, Donald W., executive vice president, Iowa Hospital Association_.___ Melller, Robert, Ios MOINES, TOW... o.com od it om sme don suomi so gi be pe is ime unio Oberbillig, Robert C., director of the Legal Aid Society_______________.__ Machio/'Pat, Des Moines, Towa. Lou. ib dS i wd bm eb i pd min FripAay, MAY 14, 1971 DENVER, COLO. Breeze, Mr. and Mrs. Gary, residents, Denver, Colo____________________ Smythe, Mrs. Patrick, employee of Coors Porcelain, Denver, Colo_________ Anderson, Mrs. Catherine, retired, disabled government employee, Denver, CIOL. ct moto ss spe sigh ap im maitre sg pp ors ser pal Hi se gp sg eg ment pelts mls on pg Quick, James, National Jewish Hospital, Denver, Colo _________________ DeWitt, Mrs. Dean, Southwest Denver, Colo. ; accompanied by Dr. Joseph Butterfield, acting medical director, Children’s Hospital, Denver, Page 2227 2232 2234 2236 2241 2246 2248 2251 2258 2258 2274 2278 2281 2285 2293 2296 2302 2304 2310 2314 2315 2316 2318 2338 2341 2345 2349 2351 Iv Villareal, Jose, migrant worker; accompanied by Mrs. Maria Bealls, mi- Srant’ nurse, Denver, COl0. mm ean EL emer perm mend Wirth, Wally, Safeway checker, Denver, Colo ________________________ Johnson, Mrs. Marvin E. M.D., president, Colorado Medical Society, IA OL, ONO co mrs cm mm meg eto i lr Br Prepared SLALCMENL. « co Ee ie loins spose ok rm oso ms et mrs ere i Platt, Kenneth A., M.D., president-elect, Colorado Medical Society, Denver, Espinosa, Mrs., witness from the floor of the hearing__________________ Hagen, Paul, transmitting by television to the floor of the hearing from BOUL OL OVO. oc oni sion me ms i i 5m et pe ss mi ADET, BaD, MER CA SOC ec i tam Teo i ie nt i ie sip ge Peterson, Peter, M.D., chief resident, Denver Medical Center, Denver, Fritts, C. A., M.D., chairman, Legislative Committee of Comprehensive Planning Health Commission, Denver, Colo ____________________ STATEMENTS Anderson, Mrs. Catherine, retired, disabled government employee, Denver, CINE roids eae oslo sso wm on gh oe I A roa £58 Fo wh ree te RE Apter; Bob, 1eGICR) SOMEONE ce oe Se el eee ci cm tr sci i oe i mm Banks, Mrs. Charles, nurse, Des Moines, IOWA. oo como coca ll Breeze, Mr. and Mrs, Gary, residents, Denver, Colo ___________________ Brislen, Andrew, president-elect, Chicago Medical Society_______________ Campbell, James, president, Rush-Presbyterian-St. Lukes Medical Center__ Daley, Hon. Richard J., mayor, city of Chicago, Il_____-______________ DeWitt, Mrs. Dean, Southwest Denver, Colo. ; accompanied by Dr. Joseph Butterfield, acting medical director, Children’s Hospital, Denver, Colo__ DINELY, POLL, 1008 MONIES, TOW oo co iio wom ion polos me i oe rnp eet Dunn, Donald W., executive vice president, Iowa Hospital Association____ Espinosa, Mrs., witness from the floor of the hearing____________________ Fritts, C. A., M.D., chairman, Legislative Committee of Comprehensive Planning Health Commission, Denver, Colo ________________________ Glenn, Ralph, Dubuque, Iowa, prepared statement______________________ Grahek, Bernard M., president, Iowa Hospital Association______________ Grigna, Carol, health service consumer, American Indian________________ Gross, Sidney, president, National Farmers Union, an Iowa farm organi- ZALION, PLrEPATEA SURTOINBIL.. .. «ci es in imino sion sm i i i i i i Gunnar, Rolf M., M.D., Director, Division of Medicine, Cook County Hospital, Prepared SEALOINONT . .... wwii mm ois miei mos opm se oe serio Hagen, Paul, transmitting by television to the floor of the hearing from BO IACT CON 0. cin cc ce isms sin so Eo ri Hentges, Mrs. Judith, DuDUGUE, TOW... come mmo om orm ot rt em sm ie sm om ee ms om Johnson, Mrs. Marvin E., M.D., president, Colorado Medical Society, Den- OT COND. ct coc ctsg imi i mem pipe mi re Aa BE a ae a Be RB err Prenared Bla teIONE ee mi ——————— Johnson, Paul, health services consumer_______________________________ Leinbach, 8; P,, M.D., Belong, JOWA....cmewi iim mic mm misma Lewis, Mr. and Mrs. Louis, health service consumers____________________ Taster, Kenneth E., M.D., president-elect, Towa Medical Society, Ottumwa, DVR, hon et scm me me i Se ee omg di mi SA ra rr SR lle Brepared. Statement. J coc dS ii Ee rte Love, Mrs. Marie, past national secretary for the National Consumers and chairman of our Model Cities health task force_____________________ Machio; Par, Deg Moines, JoWh qc. ween em sim Lee eo pbs mee Mattox, Lyle, health services consumer, Chicago, T11___________________ Mettler, Robert, Des Moines, ToOWA. ooo cee an Oberbillig, Robert C., director of the Legal Aid Society_________________ Poipsson, Peter, M.D., chief resident, Denver Medical Center, Denver, SOLO cot rinses somes iss Fo SR il sr met tn pe eer epee A ir EE Platt, Kenneth A., M.D., president-elect, Colorado Medical Society, Denver, ClO RT TR RR Te Te Page, 2354 2357 2360 2364 2370 2376 2378 2379 2379 2380 Richards, Mrs, Shirley, 1De8 MOMMIES, TOW... cw mmm wm mim ——— Ricks, Phil; practicing physician, Chicago, ll... mmm mmmmmm mmm eto Roby, Miss Angie, nurse at Des Moines General Hospital, Des Moines, IOWA “comes — i RR in Seebohm, Dr. Paul M., associate dean, College of 2302 Medicine, Iowa CHES. TOW oii irises ioe aeiie ved ae res da penile ee Smythe, Mrs. Patrick, employee of Coors Porcelain, Denver, Colo________ Towne, William, Residents Association of Cook County Hospital, and Nick Rango, Interns Association of Cook County Hospital ________________ Villa, Mrs. Olga, and Miss Ninfa Ruiz, health service consumers___________ Villareal, Jose, migrant worker; acompanied by Mrs. Maria Bealls, mi- grant nurse, DENVeEr; Col. cuss onmrmpmsmnmmme mii mm mmm Williams, Mrs. Joanne, public health nurse, and Ray Tillery, Des Moines, TOWEL cio vc ey 00355 te 5 os Em mr Wirth, Wally, Safeway checker, Denver, COlOw eo ooo oo ADDITIONAL INFORMATION Articles, publications, ete. : “Chicago's Health Care Crisis,” by Rolf M. Gunnar, M.D., director, Division of Medicine, Cook County Hospital .___________________ “Health Care for All Through the Increased Utilization of Allied Health Professionals,” by Henry K. Silver, M.D. professor of pedi- atrics, University of Colorado School of Medicine, Denver, Colo____ “School Nurse—Child Advocate,” by Mrs. Ann Short, Mrs. Susan Amosson, Mrs. Lorrine Glazebrock, Des Moines, and Mrs. Ruby WWREALIY, ANKENY, TOW commision i osm ic min oe i me we on sham ime Communications to: Haughton, James G., M.D., Health and Hospitals Governing Commis- sion, from Rolf M. Gunnar, director, Division of Medicine, Cook County HOSDIMAL, MAY 1, LOT 1... cm mmisn mimes messes eos mmm so esse sn impress Kennedy, Hon. Edward M., a U.S. Senator from the State of Massa- chusetts, from Herrick S. Roth, president, Colorado Labor Council, AFL-C1O,- Denver, Col0., MAY 14, 107 cucu memes mi ie 2261 2384 2329 2268 HEALTH CARE CRISIS IN AMERICA, 1971 WEDNESDAY, MAY 5, 1971 U.S. SENATE, SuBcommITTEE ON HEALTH or THE CoMMITTEE ON LABOR AND PuBLic WELFARE, Chicago, III. The subcommittee met, pursuant to call, at 1:30 p.m. in the audi- torium of the Passavant yin Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present : Senators Kennedy (presiding), and Packwood. Committee staff members present: LeRoy GG. Goldman, professional staff member; Jay B. Cutler, minority counsel to the subcommittee. Senator Kennepy. The subcommittee will come to order. I first of all want to express the appreciation of the members of the Senate Health Subcommittee for the kindness of this hospital and its staff for making this facility available to the Senate Health Subcom- mittee. They have been extremely kind and generous in their time and making it possible for us to have this public hearing here this afternoon. I also want to express my very warm sense of appreciation to the Greater Chicago health and medical community including specifically the three hospitals that we visited last night and the numerous other health facilities that we visited here today. During the period of the last 9 weeks the Senate Health Subcom- mittee has been holding extensive hearings on the problems of the health crisis in this Nation. In Washington we have listened to the experts, the representatives of the different groups who have important interests in the adminis- tration of hospitals, the insurance industry, the American Medical Association, Blue Cross-Blue Shield, and various other groups. Over the period of the last 2 weeks the Senate Health Subcommittee has begun to hear from the people. We feel there is much that can be learned in the hearing rooms of the Congress, but we think that there is an important dimension that can be added by bringing the sub- committee to the people. Thus far the subcommittee has been in New York, West Virginia, Tennessee, Ohio, and now Illinois. We realize that there are problems affecting the health of millions of people in this Nation. We think they are expressed in a variety of different ways. They are expressed by the mother who wants to get a doctor in the middle of the night or even in the day and can’t find one. It is represented in the long waiting lines in emergency rooms and outpatient clinics. It is represented in the extraordinary kinds of medi- (2223) 2224 cal bills that individuals are forced to pay even though they are covered by a health insurance plan, which turns out to be terribly inadequate. It is reflected in the faces of young residents and interns who are trying to provide high quality health care and yet do not have suffi- cient supporting health personnel, facilities, or equipment, to provide that kind of health care that they have been trained to provide. The health crisis affects every American. Tt is truly a national tragedy. And so today we are here to listen to the consumers and to listen to their problems and their comments. Before we hear from them, I would like to ask Senator Packwood, the Senator from Oregon, who has been extremely interested in the problems of health as a member of the Health Subcommittee, and has been one of its most active members and concerned members, if he would like to make a comment. Senator Packwoop. Most Americans, if they are working, if they are making $7,000 or $8,000 a year, if they have an employer paid or in- dividual health plan, and if they don’t get too sick too often, they receive very good medical care. The medically indigent at best receive-haphazard care, sometimes fond but limited. But what is also clearly apparent is that catastrophic 1llness is just that—catastrophic—no matter how much money you make or how thorough your care. Therefore the two things that I am most interested in are: 1. How is the problem of the catastrophic illness solved # How should it be financed ? 2. For the medically indigent what is the best way to provide good medical services? What is the best approach—a major county hospital or a small sub- urban neighborhood health center, another alternative, or some combination ? Senator Kennepy. We would like to express our warm welcome to the distinguished mayor of this great city. Some weeks ago I took the opportunity of calling the mayor and indicated that we would like to come to the city of Chicago to have a view of the both best type of health services delivery and some of the more troublesome features of health delivery. What we found here has been really a microcosm of our Nation in many respects. There have been so many comments about Cook County Hospital and the comments that are made about that hospital are just as readily made about D.C. General in Washington, about Massachusetts Gen- eral in my own State of Massachusetts, and about many others. However, the things that impressed me, of course, in the visits were, once again, views of those that are trying to provide the services. Commissioner Brown and Mr. King of the health department traveled with us today. We visited some of the maternal child clinics in the city and we are delighted to have you, Mr. Mayor, to lead our witnesses off this afternoon. Would you be kind enough to proceed. [Applause.] I am reminded that it is Boston City Hospital, not Mass. General. I don’t want to get in trouble with John Knowles up there. [ Laughter. ] 2225 STATEMENT OF HON. RICHARD J. DALEY, MAYOR, CITY OF CHICAGO, ILL. Mr. Dairy. Senator Kennedy, Senator Robert Packwood, I am happy to welcome you and the members of the Senate Subcommittee on Health to Chicago. Your mission is a most important one and I hope the people of Chicago can help you achieve your goals to assure the best and most comprehensive medical care for all of the citizens of our country. The fundamental problem that must be addressed by the Congress of the United States is that health care systems as we know them in this country are failing to do the job. It is not only failing the residents of the inner city and the rural areas, but also failing to meet the needs of health care of all areas in the Nation. It is far too expensive, too disjointed, and the care it delivers is too unevenly distributed. : It produces too few doctors and technical personnel and too often its priorities seem to ignore the cost. Under Illinois law, the city of Chicago has no responsibility for providing direct medical care serv- ices and yet because the need is so great and the city is a governmen- tal agency which is closest to the people, we have had to become in- directly involved in health care. Our efforts to date have been largely directed towards high impact specialized programs. For example, we have developed a model program in the Nation for detecting and treating children with lead poisoning. We are the first city in the Nation to promote and provide quality prenatal and infant care for families who cannot afford the high cost of private care. We are now providing prenatal care for about 25 percent of the mothers delivering in the city. We lead the major cities in our country in immunization of. our children against all major childhood diseases. Last year alone the city provided more than one million shots against all communicable dis- eases and we successfully stopped a diphtheria epidemic. Veneral disease is rampaging in other cities, but our program with respect to syphilis has brought it to the lowest point since 1959. We are now embarked on a major construction program for a net- work of comprehensive neighborhood health centers which will serve as a cornerstone of the new health care system. Seven are in the neigh- borhoods already and I think you visited some of them in Uptown, Woodlawn, and North Kenwood. Provident will open on June 1, 1971. If the private health care system were functioning effectively and equitably, most of these federally funded local programs dealing with direct medical care would not be necessary, but until such time as the system can be made to work, these programs will require in- creasing Federal support. Our citizens are paying for the failure of the system. Even with union and employer health benefits, unheard of a few years ago, the working man and his family are too often required to make extreme sacrifices to meet the cost of medical care and hospitalization. The poor, on the other hand, find the health care available for them often too hard to reach and too snarled in redtape and long waiting periods. 2226 Chicago has many fine hospitals and medical institutions. It is the center for the Midwest and much of the Nation for research and ad- vanced medical training, and yet within our Chicago metropolitan area we find that hospital beds and medical manpower are poorly distributed. Some neighborhoods have virtually no doctors or hospitals and other neighborhoods have hospitals which are on the verge of financial collapse because of soaring costs. Extended care facilities, including nursing homes, should be an integral part of the health care system, but as we have seen, they are not. Our senior citizens deserve the best that our society can provide, so that they might enjoy their golden years with a minimum of discom- forts and the highest quality of medical attention to assure adequate medical care and supervision. Extended care facilities should function as extensions of private hospitals. We are urging hospitals to assume this new responsibility as one minor step in the development of a better care system, but the hos- pitals cannot be expected to take on such major new duties without first being provided with commensurate administrative authority, money, and manpower. In other sectors we are also receiving evidence that our health in- stitutions have a sincere desire to help improve the system. Our medical schools are now exploring ways in which we can pro- vide licensed practitioners to serve under contract in city-sponsored neighborhood health centers. One local medical school is developing a program to attract and train students for innercity neighborhoods as physicians. The hospitals of the city have recently organized a system for im- proving emergency room services, according to a regionalized plan to cover the entire city. They have also devised a similar plan to more adequately serve their immediate neighborhoods. I have not come before you today to place blame on anyone or to suggest that all that is needed is more money for existing programs and services, but rather T have come to support the need for a total comprehensive approach to remaking the health care system that will provide high quality service with dignity to all of the people. I have confidence that the people of this Nation want such a system and that legislation will bring about an equitable system of health care which is essential to the welfare of all of our people. Once again, I welcome you to our city and I look forward to your findings and recommendations. [ Applause. ] Senator Kex~epy. Thank vou very much, Mr. Mayor. As you mentioned, both in the maternal clinic we visited earlier today and also the neighborhood health center, we had a chance again to visit with your people, who are very cooperative. TI think in terms of the comprehensive reform which you mentioned here, that is certainly my conviction. We have had strong statements by other mayors of major cities who have seen or perhaps know firsthand where the health crisis is most severe in many of the urban areas. 2227 In many respects they are more aware of this health crisis than the rest of us, and having support for a comprehensive approach on this is absolutely basic and fundamental. I want to express our apprecia- tion for your interest, sufficient interest in this problem to be with us here this afternoon in order to deliver your comments. . Senator Packwoop. Thank you, Mr. Mayor. Senator Kex~epy. Thank you very much, Mr. Mayor. The first witness we will hear will be Mr. Lyle Mattox. Now, while Mr. Mattox is on the way up, the way we are going to conduct this hearing will be as follows: We have some five consumer witnesses and two professional wit- nesses, and then we are hopeful of being able to, as we have at other times, to open up this hearing for other kinds of comments. So if there are people that would like to make a comment, in the limited amount of time we have after our scheduled witnesses we ask you to put your name on the piece of paper at the table on my right. We have to leave at 3:15 so that we have got until then, approximately an hour and a half. We hope to have 20 or 25 minutes at the end for anyone who is in here and wants to make a comment. We will ask you to limit your testimony at that time to, perhaps, a minute of comment unless we have more time available, and then for any of those who are unable to make a comment we will ask them to write down their observations and we will include them as part of the record. ' I can assure you that I will get a chance to review these expressions, and I am sure Senator Packwood and the other members of the sub- committee will, and it will be made part of the record. We will do the best we can. We would like to keep this as informal as possible, and try to get as many consumers as possible. I want to express appreciation to the witnesses for their willingness to come here before the subcommittee. We find it is very difficult for people to tell about their particular health problems, health needs, and the tragedies which have affected them and their families and also the financial plight that they are in. So I want to say that they provide a very special service. I think this has really been one of the real problems in developing a health program. Americans, for one reason or another, feel that if they are sick or in need, they don’t want to bother other people to share this experience. As a result, I think this has contributed to the sort of topsy-turvy way that the whole health system has developed. If we are really going to come to grips with it, we have to be able to have the facts and I think the most important fact that probably has been excluded from the health system is the active voice and role of the consumer. We hope to hear from them this afternoon. Mr. Mattox, we are glad to have you here. STATEMENT OF LYLE MATTOX, HEALTH SERVICES CONSUMER, CHICAGO, ILL. Mr. Matrox. Can I be heard all right ? ] Senator Kennepy. Yes, if you would just pull the microphone a little closer. 2228 Mr. Matrox. My name is Lyle Mattox. T am age 52 years and I am self-employed as a skilled craftsman. I am a Chicago resident. On November 27, 1970, I suffered a coro- nary occlusion. Now, previous to that I had had a history of high blood pressure and, on November 24, after a month of increasing illness I saw a local doctor who instantly diagnosed my condition. On the night of November 27 I went into St. Elizabeth’s Hospital where, on the emergency room table, I suffered the actual coronary occlusion. I was there for 15 days and then released for convalescence at home. On the day of my release we received the updated bill to that date for $1,500 for the hospital expenses plus $150 for the doctor bill. My wife withdrew all of our savings out of the First National Bank and paid those two bills. A few days later we received a $300 bill from the hospital and by that time an agency called MANG, Medical Aid-No Grant, came to our aid. They paid the $300. They have paid for all subsequent medications. They have paid for doctors’ calls and hospital visits. At the time of my illness I had no private insurance because they would not insure me. Senator Kennepy. Why not ? Mr. Matrox. In 1963 the Prudential Insurance Co. approached us about buying hospitalization and they sold it to my family. But they found out, on examination, that I suffered from high blood pressure and that was the first time that I knew it. Then from then on I could not get hospitalization insurance. Senator Kennepy. You had health insurance, though, from 1949 to 1963, is that right ? You were covered by a group plan ¢ Mr. Matrox. I was covered through—well, most of the war and up until 1962. I was covered by a group health insurance. Senator KEnNEDY. You have been covered from at least 1949, prior erhaps in terms of the war, but at least 1949 to 1962 you were covered y a health insurance policy of your employer, which was the Music Department Store ? Mr. Matrox. Yes. Senator Kennepy. When you left that job, you lost your insurance, became a part-time worker at a music department and you worked 2 hours a week short of qualifying for their group health policy? Is that right ? Mr. Matrox. That is correct. That was at Roosevelt University, the Chicago Music College. Senator Kennepy. And then because of high blood pressure you were refused individual health insurance by several firms, is that right ? Mr. Matrox. By the before-mentioned company and also T was approached in the middle to late sixties by Bankers Life Insurance Co. and they accepted my initial application knowing my blood pres- sure condition, and the home office refused to ratify it, and I did not receive it. Senator Kennxepy. Why don’t the insurance companies want to insure you when you have got high blood pressure? Mr. Matrox. They don’t want to insure anybody unless it is a pretty sure bet. [ Laughter. | 2229 Senator Kenxepy. Unless what ? Mr. Matrox. I don’t say that facetiously either. I mean it very sincerely. ] Senator KexNEpy. I am sure you mean it very sincerely. Mr. Matrox. Also, they think if you are going to live a thousand or hundred years, fine, but otherwise, they don’t want to insure you. Senator Kex~epy. I'm sorry. : Mr. Marrox. I say unless you are going to live a hundred years, they don’t want to insure you. Also, my blood pressure was immediately brought under control after I discovered 1t in 1963 and I was under doctor’s care, and the pressure, under medication, became normal. . Senator Kexxepy. Why do you think the insurance companies don’t want to insure you? Mr. Matrox. Why? Senator KENNEDY. Yes. ‘ Mr. Matrox. Well, the only thing I can answer would be by saying 1 guess they want pretty much of a closed sure gamble on their part. Senator Kexnepy. What do you mean by “a closed sure gamble on their part”? Mr. Marrox. Because if somebody looks as though they are not going to live long enough to give them very much money, I imagine they don’t want to have anything to do with them. Senator Kexnepy. Do you think that that applies to sickness as well ? Mr. Marrox. Yes. Senator Kennepy. Do you think the reason for this, in your case, was because of this high blood pressure? Mr. Matrox. It is the only reason I was refused; yes. Now, I have been approached recently by a company who says, “We will underwrite your hospitalization and medical costs despite the fact that you have had a coronary,” but they will only underwrite three- fourths of the cost of any conditions relating to the coronary or to cardiovascular conditions and the premiums will cost about $30 a month. I have not yet heard from them as to whether my application was accepted. Senator KenNeDpy. But anyway, you had this sickness and you have been able to save, as I understand it, some $2,000 ¢ Mr. Matrox. Yes. Senator KENNEDY. Over a period of years? Mr. Matrox. Yes. I actually saved $4,000. Senator Kennepy. And how long did it take you to save that $4,000 Mr. Matrox. It had taken us 12 to 15 years. I had raised two children. They are now grown and on their own, and we had spent part of the money the previous summer to move and to buy household appliances. Then when this illness came, the entire bank account was wiped out. Senator Kexxepy. And how long a time—in how long a time was your bank account wiped out ? Mr. Marrox. Well, I haven’t been able to add to it. I am just barely getting back to work now. Senator KexNeDY. And are you covered by any kind of insurance now ¢ 2230 Mr. Matrox. No, sir. Senator Kexnepy. So, if you get sick now what would happen? Mr. Matrox. I think probably that the medical aid-no grant under—I think that is an Illinois branch of the public aid, they have been paying my expenses and I imagine they would continue to. Senator Kenxepy. In other words, you had been working, you had been, as I understand it, a hard-working individual all of your life and you had been able to set some resources aside in savings. And then with just a few days in the hospital with a coronary, which you had absolutely no control over, your whole savings were wiped out? Mr. Marrox. That is correct. Senator Kennepy. And in effect, if you were to get sick now you would be forced to go on medicaid ? Mr. MaTrox. Yes. Senator Kexnepy. Or to go on welfare to receive it? Mr. Mattox. Yes. Senator Kex~epy. That is what the system has done to you? Mr. Matrox. That is what I am on. They now pay for my visits to the hospital and to the doctor and for my medicaticn. Senator Ken~Nepy. And you want to work as I understand it? Mr. Marrox. Do I want to work ? Senator KENNEDY. Yes. Mr. MaTTox. Yes. I had a fine business built up and I intend to revive it as rapidly as I can. Senator KennNepy. What do you think of a medical system that provides not only the kind of personal hardships which are associated with coronary sickness which you have virtually no control over or virtually very little control over and then wipes you out financially, by taking your savings away. Do you think there is something wrong with that kind of a health system ? Mr. Marrox. Well, there are so many things wrong in the world that that is one of them, yes. [ Laughter. | I agree with that. Senator Kennepy. That doesn’t mean that we shouldn’t try to change it, does it ? Mr. Matrox. That is absolutely right. Up to this point I don’t know that the U.S. Government is involved in a sickness situation like mine. Now, social security gives no relief at all unless I were to be totally incapacitated for a year and yet I have been paying as a self-employed person $400 a year into social security. Senator Kexnepy. Yes, I believe under social security you have to be totally disabled. Mr. Matrox. Yes. Senator Kennepy. For a year. Mr. MaTTox. Yes, you do. Senator Kennepy. That is right and that is before you get any kind of help or assistance ? Mr. Marrox. That is right. 2231 Senator Kennepy. Now, we hear in the Congress and the Senate about catastrophic kinds of illnesses and we have heard, and perhaps this afternoon we will hear about individuals that run into extraordi- nary kinds of medical bills. In Nassau County we had a father who was paying the medical bills of his son who had been playing football last fall because the son severed his spinal column and he will be paralyzed for the rest of his life. Within a short period the father had $40,000 in medical bills in 6 months. This gentleman, the father, was the number one salesman for a major insurance company and he had the best health insurance program that company provided. Still his back, so to speak, was against the wall because his insurance wouldn’t cover the costs. Now, there is a focus in this Nation and we will probably see the (Congress move toward catastrophic illness and try to meet these needs but it appears to me that $2,000 to you is just as castastrophic as $50,000 is to a businessman. Mr. Matrox. Yes, when it becomes a matter of any figure down to zero, that is catastrophic. [Laughter and applause. ] Senator Kexnepy. Do you have any questions, Senator ? Senator Packwoop. Mr. Mattox, would you tell me more about the medical aid-no grant program which you mentioned ? Mr. Matrox. At first I thought it was a part of the medical program of the Federal Government but now I am not sure because it seems to be connected as far as the paperwork goes, with the Illinois Public Aid Department. Senator Packwoop. Are the bills sent to you or directly to the hospital ? Mr. MaTrox. I never see the bills. All T do is take the public aid green card to the hospital doctor or to the drugstore where it is processed. Senator Packwoop. You show the green card and all of your medi- cal expenses are then taken care of ? Mr. Matrox. That is correct. Senator Packwoop. This is very similar to the type of medical coverage that the Kaiser health plans provide. Mr. Matrox. But this is exactly the same kind of card that any- body on public assistance carries. Senator Packwoon. I appreciate that. We may have some other witness who will explain how it is funded and, if so, IT would appreci- ate that information. Thank you very much. Senator KexNepy. One thing that seems apparent to me as a lot of things do, is when you lost your job you lost your insurance practically. Mr. Marrox. Yes, I did. Senator Kexxepy. And we find, now I don’t know if it is as high in this State, but we have got about 7.2 percent unemployment in my own State of Massachusetts. I know so many of them want to work but are unable to work and they have lost their insurance. The effect of this is that even though you paid in for all of those years from 1949, anyway, through 1962, some 13 years, it didn’t do you any good. 2232 Mr. Matrox. May I say that I feel that T have been very fortunate in a comparative basis because I did have help when I needed it from the medical aid-no grant. I did have a good doctor and I had a good hospital that would accept me without knowing that I had a dime in the bank. The night they took me in they didn’t know whether I had a dime or not. Senator Kexnepy. You had to go on welfare to get it, though, didn’t you? Mr. Matrox. That is right. By the way, may I comment that your figure for 1970 for Chicago on daily hospital costs is obsolete, that $99.89, because I pair $1,800 hospital charges for 15 days. Senator Kex~epy. That is the average, but I see what you mean. Mr. Matrox. And that did not involve any surgery or anything like that. Senator Kex~epy. Okay, thank you very much Mr. Mattox. "I'he next witness will be Mr. Paul Johnson. STATEMENT OF PAUL JOHNSON, HEALTH SERVICES CONSUMER Senator Kex~xepy. Mr. Johnson, we want to welcome you. Mr. Jonson. Thank you. Senator Kexnepy. Would you tell us your story? I understand you had a 10-year-old son. Mr. Jounson. Yes, I had a 10-year-old son. Senator Kex~xepy. Tell us about what happened to your son. Mr. Jonson. On December 15, 1969 he had a seizure at home and he passed out. I picked him up, rushed him to the nearest hospital which, by the way, T went by the police station and was led to a hos- pital by the name of St. George’s here in the neighborhood. T asked the police to carry me out to County, and he said he couldn’t go out of his district so I carried him there for emergency service. The doctor didn’t even look at him or put his hand on him at St. George’s but in the meantime they interviewed me to find out my his- tory of my financial arrangements, my insurance and this and that, T had Traveler’s insurance at the time. Now, that was very good insurance. It paid for everything toward medical, hospitalization and what not. However, this was through a company and I couldn’t afford it privately. So we left this hospital and drove all the way from 79th over here to County Hospital where my son died in a matter of an hour or so afterward, but they didn’t even give him any kind of care or anything pertaining to medication or examine him or let me know that he was as serious as he was. If they had let me know we would have made some other arrange- ments about getting oxygen or what not for him but they didn’t do anything. Senator Kex~Nepy. You mean you went the first time to St. George’s Hospital ? Mr. Jornson. Yes. Senator Kexxepy. And you went to the emergency room of St. George’s Hospital and you asked for service 2233 Mr. Jornson. Yes. Senator Kexnepy. That is, you asked for someone to take a look at your boy, is that right ? Mr. Jornson. Yes, but in the meantime they interviewed me before. Senator Kex~epy. When you did this, in effect, your son was ac- tually in the process of dying and they were asking you questions about where you lived ? Mr. Jornnson. Yes. Senator Kexxepy. And about the kind of insurance you had? Mr. Jornson. Yes, sir. “Do you own your own home?” and this and that, and “who do you work for?” and “how long?” Senator KexNepy. And then after that when you pleaded with them to get some kind of help Mr. Jonunson. Yes, I asked them if they needed further information and what not they could call out to County Hospital, that he had been a patient there and he was due to go in for a checkup which was that Friday, the 19th, and he didn’t make it. They would have given them the information if they needed it but he didn’t even try to do anything. They would voluntarily—they had voluntarily told me also that if anything happens to Carl, even to have a tooth extracted or a tooth filled or anything, to call them and they would give the doctors the in- formation that is necessary so it wouldn’t be fatal to him. Senator Kex~epy. Then you took your son over to the other hos- pital, to County Hospital, is that right ? Mr. Jornson. Yes. Senator Kex~epy. Going by all of these other hospitals? Mr. Jonnson. Yes, because I was afraid to stop. I think the same thing would have happened if I had stopped at one of the other hos- pitals which were St. Bernard’s and there was another hospital up there, and they were associated and they are run by the same staff, and I would say it would be a waste of my time. I might as well try to make it to the county. I drove down the expressway with my oldest son, while my other son was in pain. Senator Ken~epy. Was your other son with you at the time ? Mr. Jonnson. Yes. I had my oldest son with me, and my son was in pain and he was going into a coma, and he was hysterical and every- thing, and we were holding him. : Senator KENNEDY. You were ? Mr. Jounson. I laid him down in the car. Senator KEnNEpY. As he was hysterical, the doctor said, “If you don’t like the service here, take him elsewhere.” Mr. Jornson. Yes. He told me that “he couldn’t be sick with a heart condition if he is able to scream and holler like that”, that is what he said. Senator KenNepY. So then you went to Cook County Hospital? Mr. Jonnson. Cook County Hospital and they decided right away to put a pacemaker in and what not, but he went into a coma and passed before they got a chance to insert it. : Senator Ken~epy. Now, did you every hear from St. George’s again ? Mr. Jounson. Yes, I heard from them. I paid the emergency room bill. 59-661 O—T71—pt. 10——2 2234 Senator KenNepy. You what? [ Laughter. ] You what? Mr. Jornson. I paid the bill for the emergency room. Senator Kennepy. From St. George’s Hospital ¢ Mr. Jounson. Yes. Senator Kexnepy. They sent you a bill after this? Mr. Joanson. Yes, two bills. Senator Kennepy. They sent you two bills ? Mr. Jounson. Yes, one was a doctor’s bill and one was the emer- gency room bill. Senator Kennepy. One was the doctor’s bill and the other was the emergency room bill? Mr. Jounson. Yes. Senator Kennepy. How much were they ? : Mr. Jounson. $12.50 for the emergency room and $7 for the doctor’s ee, Senator Ken~epy. That is evidently the value of your son’s life to that hospital ? Mr. Jornson. No, it is not. Senator KenNepy. I say to that hospital ? Mr. Jounson. No, it is not—oh, maybe to the hospital, but not to me. Senator Kexnepy. And what happened afterward ? Did you lose your job afterwards? Mr. Jounson. Yes, I lost my job through a cutback, lack of business. I had been working for a short period of 15 months and I got laid off and I had to go to unemployment. Senator Ken~epy. Do you think a hospital ought to be able to pick and choose its patients? Mr. Jonson. No, I don’t. T think a hospital is in the neighborhood and I think it is supposed to serve the people that are living in the neighborhood, who are supporting it. Senator Kexnepy. Because there is something wrong with a health system that sees money first and treatment second ? Mr. Jounson. Would you repeat that question ? Senator Kexxepy. Do you think there is something wrong with a health system in our country or at St. George’s or anywhere that says, “You have got to pay before you are going to get treated?” Mr. Jornson. Yes, I think so because if T didn’t have the money and I am sick, and I think T need the medical care give me a chance to pay it later if I am unable to provide it now. Senator Ken~epy. Senator Packwood ? Senator Packwoob. No questions. Senator Kennepy. Thanks very much. Mr. Brown. Thank you, Senator. Mr. and Mrs. Louis Lewis will be our next witnesses. STATEMENT OF MR. AND MRS. LOUIS LEWIS, HEALTH SERVICE CONSUMERS Mr. Lewis. My name is Louis J. Lewis and I am retired—I will be retired, I’m not retired as yet. Senator Kexnepy. Will you pull the microphone, the center one out to the front of your table so that we can hear you. 2235 Mr. Lewis. Am I talking loud enough ? Senator KexNEpY. Yes; just pull that one right in front of you. Mr. Lewss. I had a sister who recently died from cancer. She was operated on the first time in June of—rather July of 1967. She was in the hospital for about 3 weeks. She stayed at my home for 2 weeks because she couldn’t take care of herself. She stayed home another 2 weeks from her job. } Mrs. Lewis. Two months. Mr. Lewrs. Two months and then she went back to work and she worked off and on and when she got too sick she stayed home. In 1968 she took the complete cobalt treatments on the advice of her doctor, and in the meantime she had to see her doctor every week. She went and got examinations and a shot of some sort. In 1969 she had treatment by special therapy and IT don’t know what they call it, for cancer, but it took—she took a series of those treat- ments and in February of this year she got pretty darned sick. She kept going back to her doctor for a long time until finally in June or July the doctor put her in the hospital to find out what was wrong. Well, they immediately performed a colostomy operation. They had to relieve the pressure of the cancer, or whatever you call it. She stayed in the hospital 5 weeks, about 514 weeks. T knew she couldn’t take care of herself so I put her in a nursing home. She stayed in the nursing home for 51/4 months and she passed away. During the time she was in the nursing home she was under a doctor’s care. She also had to go to the hospital for an examination for another tumor. The tumor was inoperable and that is all there was to it. In the meantime I was getting bills from the nursing home which T paid and everything else was fairly well paid, but if she hadn’t had a very good health policy I would have been money out. Senator Ken~epy. But she had a good health policy, is that right ? Mr. Lewis. She had a very good health policy. Senator KenNepy. And how much were the doctor’s bills or hospital bills, approximately ? Mr. Lewis. Oh, T would say the first one was around $1,200 or so. Senator Kex~epy. What were the total expenses for the illness over the whole time, do you remember that ? Mr. Lewis. Oh, I would say around, well, T can’t say exactly, but I will say it was, the last 5 months, they were over $10,000 and previous to that they must have been about $10,000 also. Senator Kexxepy. So it was about $20,000? Mr. Lewis. That is right, sir. Senator Kexxepy. And the Insurance company, the insurance paid about how much of the $20,000, do you remember ? Mr. Lewrs. They didn’t pay any of the nursing home except the drugs, 80 percent of the drugs, and the hospitalization paid about 80 ercent. b Senator Kenxepy. So they paid what, $7,000 or $8,000 of that first $10,000 because they didn’t pay any of the last $10,000 which was as- sociated with the nursing home? Mr. Lewis. They paid some of the last. ! Senator Kennepy. The hospital—well, of the $20,000, what do you figure was paid approximately? Do you remember what it was? 2236 Was it about half, was it about a quarter, or what, Mr. Lewis? Mr. Lewis. I think it was about Senator Kexnepy. Did you have to use up any of your savings, do you remember ? Mrs. Lewis. Yes. Senator Kexxepy. Why don’t we start off from that side. How much of your savings did you use up Mr. Lewrs. About $3, 700. Senator KexnNepy. About $3,700, so that they didn’t pay. They didn’t pay the $3,700 and you had to pay that out of your savings, is that right ? Mrs. Lewis. That is right. Senator Kennepy. And then you had a brother or a relation that had some savings too, is that right Mrs. Lewis. No. Mr. Lewis. No. Mrs. Lewis. No. Her insurance, her health insurance was running out in fact. Senator KENNEDY. Yes. Mrs. Lewis. And had that illness been prolonged it would have gone on and we would have used up our pension money that we have saved. Senator Kennepy. Are those the only savings then that you used, was the $3,700? Mrs. Lewis. Yes. Senator Ken~Nepy. I see. Was that all of your savings? Mrs. Lewis. No, but had her illness been prolonged it would have been a pretty good chunk out of our savings. Senator Kexxepy. But the insurance policy that you had didn’t cover the $3,700 in any event ? Mrs. Lewis. No. Mr. Lewis. No. Senator Packwoob. I have no questions. Senator Ken~epy. Thank you very much. Mrs. Olga Villa and Miss Ninfa Ruiz. STATEMENTS OF MES. OLGA VILLA AND MISS NINFA RUIZ, HEALTH SERVICE CONSUMERS Senator Kenxepy. How do you do. Mrs. Vivra. Just fine. Senator KennEepy. It is nice to see you. Mrs. Vivra. Shall I start. Senator KenNepY. Yes. Mrs. Vicea. I am Olga Villa and this is what happened to me. This was about a year and a half ago that I went to pick up my nephew. He was 4 years old at the time. He had been in the hospital for from 10 to 15 days. He had been very sick and they thought that there was a possibility that he was a diabetic and he had to go through a lot of tests. At that time I went to pick him up and usually when you go and pick up a child you have to dress him and make sure that he is not r unning a temperature before you leave the hospital. This time he was already dressed and ready to go. 2237 So I just took him home. Well, when I got home and started, you know, to change his clothes and put him to bed I noticed that he had bruises all over his body. Senator Kennepy. He had what all over his body ? Mrs. ViLra. All over his body. Senator Kex~epy. What did he have ? Mrs. Viora. Bruises and scratches, you know, like he had been scratched. Then when I touched him he was pretty hot so I took his temperature and he had a temperature of about 105. Well, right away 1 called the doctor. He lives close by. Senator Ken~epy. This is as soon as you got home ? Murs. Virwa. Yes, it was about a half hour later because the hospital is not too far away from my place. So I called the doctor and explained that the baby had a temperature of 105 and he seemed like he was very sick and I noticed that he had bruises on his body and then he said, “Well, bring him over.” So it was a block away and I took him right away and he said, “Well, he must have fallen off the bed.” Something like that happened to him in the hospital and I didn’t think that was possible because he was very sick and wasn’t able, you know, to move. So the doctor sent us back to the hospital, and when we went there to the hospital the Mother Superior did not admit us. They would not. admit him back to the hospital. Senator Kex~epy. They wouldn't take him back in? Mrs. Vira. No. Senator Kex~epy. They discharged him with a temperature but they wouldn’t take him back? Mrs. Viera. Right. Senator KexNepy. Was this the same day ? Mrs. ViLLa. About an hour later. It took me a half hour to get him home. Senator Kex~Nepy. And they hadn't taken the boy’s temperature ? Mrs. Vira. Not in front of us. He was all dressed and I took it for granted, because they had OK’ed him to go home; but I took him back and I told the Mother Superior that the doctor sent us back because he was sick and then I wanted to find out about those bruises. I thought maybe it had something to do with his sickness when I noticed the scratches and then I thought—well, the Mother Superior, she said, “I guess you did that at home.” And you could tell that the bruises had been there for days because they were not new. They were about 2 or 3 days old, or something like that, so I explained that we had just taken him out of the hospital and now we cannot get him back and he is sick. Well, at that time some policemen were there and I talked to the policemen and I explained what had happened. The hospital didn’t want to take him back and then we called this doctor that was seeing him and then when the Mother Superior saw that we had talked to the policeman and had signed a complaint and everything right there, why, right away she took him back. Rain Kexxepy. After you signed the complaint they took him rack ? 2238 Mrs. Vina. When we talked to the policemen and explained every- thing, they called some doctors in to examine him and the doctors said that the bruises were not from a fall. Senator Ken~epy. The doctor said this? Mrs. Vinra. The doctor said that, yes. Senator Kex~Nepy. Who examined him? Mrs. Vira. Yes, and we were on the other side of the door but we heard that and there was three persons besides myself, and, of course, they were my relatives who were very concerned. The doctor said his bruises were not caused by a fall. Then when we told the police they advised us to go and see a lawyer, so we did that. We went to the Legal Aid and as far as we know, we are still waiting for them to call us. Nothing was ever done. © My nephew had the measles at the time we took him back besides what he had had before. Senator Kexnepy. How long ago was this? Mrs. Viva. A year and a half ago. Senator KennNepy. You are active, as I understand it with the Benito Juarez Health Center ? Mrs. ViLva. Yes, sir. Senator Kex~epy. What do you do? Mrs. Vivea. T help in about everything like when we register the people and help out in the lab or with translations and things like that, because we have that language problem when we speak to our people. Senator KENNEDY. So you have been involved in a health center ? Mrs. ViLra. Yes; for a year. Senator Kex~NepY. And you have been trying to work and help ? Mrs. Vina. This is one of the reasons why I am very interested. Senator Kenxepy. So you have got other than just the maternal interest in the caring about your nephew. You also had this kind of an interest in health in any event? Mrs. Virra. Yes; we have a lot of problems in our community where things happened to me with our own people. Senator Kex~xeny. What do you think happens? Mrs. Viera. Well, one of the policemen that talked to us said that we had to do something about it because the way he saw it somebody in the hospital was sick in the head to do something like what hap- pened to my nephew. Senator Ken~NeDY. “Somebody was sick in the head”? Mrs. Virea. Yes; somebody, because those were scratches and bruises and the doctor had said that it was not from a fall. Well, I talked to the doctor, you know, because I consider him my friend. I told him if he would back us up in what had happened and he said that he couldnt say anything different because he had not been there and to him it was their fault. Senator Kenxepy. Why do you think they discharged the boy with the temperature, then? Mrs. Vinra. I don’t know. I mean, as far as that is concerned, I know this never happened before because I know about that. They never let you go home if you have a fever, so I just don't know what the reason is. 2239 Senator Kennepy. Do you think they would have discharged him if they knew what his fever or temperature was? } Mrs. Vina. I really can’t say about that, but as I said, he was dressed and ready to go home. Senator Kex~epy. Senator Packwood. Senator Packwoop. Mrs. Villa, let me pursue this a bit further because you are raising a question that I too have asked but cannot answer. The question is not moneys, is it ? . Mrs. Vira. No. Senator Packwoon. How can we change this type of situation? What can the Federal Government do? What kind of a law could we pass or what kind of financing could we provide to prevent the kind of treatment you received? Mrs. Vira. Well, my goodness, I really wouldn't know what to say. There are so many things. Well, to start with, we have this problem, you know, with the lan- guage and sometimes we are not understood, you know. Senator Packwoon. We had some witnesses yesterday who were black and they had run into the same discriminatory treatment, and again, it wasn’t a money problem. Mrs. Vina. 1 have noticed, when I see people that to me I think can afford to really pay, they are treated very different, and this is not only my opinion, it is the opinion of many people that go to our center. Senator Packwoop. From what we have heard, that is very true. Mrs. Viva. I felt bad because I have two sons in the seminary and being a Catholic hospital, I was not expecting something like this, and I was very hurt. Senator Packwoon. Thank you very much. Miss Rutz. I think that perhaps maybe a provision could be made to employ some Spanish-speaking people in the hospital or, English or American, Anglos, to understand the language because so many times, our people are turned away because they do not understand them. These people are poor. These people are sick. Senator Packwoop. Unless Mrs. Villa’s English has changed in the last year-and-a-half, she speaks very well now. Miss Rutz. That is one instance, but Mrs. Villa happens to be only one instance. We have so many people in our community who do not understand the language and who cannot even begin to verbalize it, much less try to communicate with somebody in the hospital who has a certain attitude. Senator Packwoon. I understand that and am intrigued here be- cause communication wasn’t a problem at that particular hospital. They understood her and she understood them. What is the problem ? Can you put your finger on it? Miss Rutz. There are so many problems. Senator Packwoon. Why does this happen ? Miss Ruz. Well, T would say it is the staff or the people that are there. Thev iust don’t have a genuine interest. They don’t care just because thev work in the medical profession an the medical profession is glorified so that once they come into this 2240 profession, they think that they have all power and therefore they can say who is to come and who is to leave. , Senator Packwoop. One of the misgivings I have in dealing with the Federal bureaucracy is that they are not always civil. Miss Ruiz. Right. Senator Packwoop. I’m not sure that I want to turn medical care over to Federal bureaucracy. Miss Ruiz. I can see that also, but I would think that is one of the reasons why they are indifferent. I think they just get immune to sickness and to sick people and to attending to their needs because they are there day in and day out. If you do something, for a long period of time, you just get tired of it and you become immune to the people. Senator Packwoon. If you are poor, you are not supposed to hurt so much ? Miss Ruiz. Right; and they are no longer sensitive to the problems. Senator Packwoon. Thank you. Senator Kex~epy. All right. I think what Mrs. Villa has pointed out is what happened to her when she was sophisticated enough to use the system. I think I should point it out that thousands of people who have a language problem, who are experiencing either abuse or maltreatment, are further disadvantaged because they don’t know how to wend their way through the system because of the language difficulties. And they are hesitant to go to a hospital because they don’t think they will find somebody at the door who they can speak to. Miss Rutz. Yes. Senator Ken~epy. And for me, I don’t think that we have to endure the system that treats people the way Mr. Johnson was treated. I think it reaches the whole question of quality and if we have got people that have perpetrated these kinds of instances on your nephew and those who treated Mr. Johnson so harshly, T think we have to do something about it. T think we can get standards and I think we can enforce them. I don’t think we just have to tolerate this kind of abuse that people have received. I think a lot can be done and T think that we ought to be able to bring the community into a more active role. If that requires legislation, we ought to be able to legislate and if it requires community assistance, if the communities are going to get the Federal funds, we will insist on it and perhaps then we can reach and correct these abuses. I agree with Senator Packwood that it is awful awfully difficult to come up and say, “Give me an amendment” to correct what happened to your nephew and Mr. Johnson’s son. But I think this problem reaches one of the essential elements of the whole crisis with respect to the health care system and it is a question of quality and what we have to endure; and I, for one, don’t think that we should endure these abuses. Senator Packwoon. Before we think about imposing a federal medi- cal bureaucracy on our people. we in the Federal Government should examine what we do for our veterans in our veterans hospitals. T have some miseivines about usine this standard of care for evervbody. Senator Kex~epy. Well, T think no one is talking solely about the veterans hospital. 2241 I mean, we can all talk about that, but I am the first one to be criti- cal of the kind of education we buy for the Indians in this country. There are a lot of meaningful reforms, like neighborhood health centers, that resulted from legislation that was passed in the Congress and which is bringing local people into the health care picture. We visited one this afternoon and that one was trying to provide dental care, and we saw a lot of children in this black community getting this dental care this afternoon who wouldn’t have unless it was legislated way back in Washington, D.C. As I say, we have a lot of problems, but I think that we can solve them. Well, in any event, Senator Packwood and I will be wrestling around and trying to see what we can do later on, but we appreciate your interest and kindness in coming to tell us your stories. Miss Ruiz. Thank you. Senator Kennepy. Mr. Ralph Lipowski and Mr. Joseph Dorich. (No response.) Mr. Lipowski and Mr. Dorich, are they here? (No response.) We will then go to Dr. Andrew Brislen. Ie is the president elect of the Chicago Medical Society. STATEMENT OF ANDREW BRISLEN, PRESIDENT ELECT, CHICAGO MEDICAL SOCIETY Senator Ken~epy. We have Dr. Brislen with us and is that the right pronunciation, Dr. Brislen ? Dr. BrisLexn. Brislen, yes. It used to be O’Brislen, but it is Brislen now. Senator Kexxepy. And we have Dr. Campbell and then we will open it up to the floor. I appreciate your coming here, Dr, Brislen. Dr. BrisLen. Thank you for letting me come. When Mr. Lee Goldman asked me to testify before you, he told me that the subject was to be, “Crisis in Health Care. Does it exist or not.” He suggested that I might give my views or those of the Chicago Medical Society on the subject. I am pleased to give mine. I am not privileged to speak for the society yet. I am the president-elect and in 2 months, when I become president I will be more able to speak for the society. I am delighted that the subject of your hearing is, “The Crisis in Health Care,” because it contains the obvious admission that the crisis is not solely attributable to a deficit in medical care nor solely the responsibility of medicine. Health care includes medical care, but it also includes all the other factors influencing health. Not the least among these is medical care, but medical involvement is only a fraction of the total and certainly does not exceed that of any of the others. The responsibility of medicine for the existence of a health care crisis is no greater and in many instances is less great than that of the other modalities which contribute to the total health crisis. Senator Kexnepy. What would you say the elements of the crisis are or are you coming to that? I don’t have a copy of your statement. Dr. BrisLen. Well, I didn’t give you one. [ Laughter. ] 2242 In many instances it is magnified by deficiencies in other modalities. Housing, education, nutrition, availability of hospital care, avail- ability of preventive medical care and immunization, social environ- ment, ambition as influenced by opportunity, employment, the various ecological factors, each of these are involved in the delivery of health care. Certainly as long as there is a gap between the ideal health care and current health care there will be a health care crisis. Tt is my personal opinion that the crisis in health care is not at all new. There can be no question that the factors enumerated above have always been deficient. However, the number, not the percentage, the relative number suffering because of the inadequacy of health care was so small that it was considered to be an irreducible minimum until currently when population growth has geometrically progressed to a point where no one can fail to recognize the deficiencies nor isolate himself by turning away nor believe that the solution to the basic problem is the bestowal of largesse. Medicine, and T as a physician must be involved in the development of systems designed to improve the ability of the physician to deliver, as well as to improve the actual delivery of quality medical care in greater quantity to more people for a predictable and reasonable cost while at the same time avoiding the calamitous results of offering more than it is possible to deliver. The search for the solution to this problem makes these times most interesting and most stimulating. Each of you has heard again and again the aphorism that says that, “The Chinese character for crisis includes both that for danger and that for opportunity.” We must be wary of seizing at opportunity without full appreciation of the dangers to our national structure of unbridled enthusiasm, I will answer any questions you may have now. Senator Ken~epy. Thank you very much, Doctor. Earlier in the afternoon—well, let’s start this off in a different way. You mentioned that the medical profession is no more responsible for the kind of health crisis that we have than the other modalities, and then you mentioned the questions of “housing, education, socio- economic, and ambition as influenced by opportunity.” Now, that is what I wrote down here as you were speaking. Now we listened this afternoon to Mr. Lyle Mattox about how he was a part of an insurance program; got high blood pressure, was dropped by his insurance company and then had to spend all of his savings to pay his bills. We listened to Mr. Paul Johnson who brought his son to a hospital, and how he was turned aside and later his son died. Certainly nothing about housing or education or ambition or socio- economic conditions were mentioned in that. We also listened to Mr. and Mrs. Lewis about the problems that his sister had with cancer and how that cut in heavily into their savings that they had been accumulating for a lifetime. And then Mrs. Olga Villa whose good will is sufficient to involve her heavily even today at the Benito Jaurez Health Center, trying to help her people. T don’t know what the questions of housing are, but certainly we listened to those consumer 2243 people who have had some contact with the system, and I don’t think that they are untypical. Where the criteria which you have mentioned here this afternoon really fails to fit in, is with respect to their particular difficulties. Still they are treated harshly by the system. I repeat—they are treated harshly by the system and they ask, what I think many of us in the Congress ask why the medical societies and the AMA are not leading the spirit of reform rather than being dragged into it? What kind of reaction do you have to that? [ Laughter. ] Dr. BrisLen. You have raised [Applause. ] You have raised several points and I made a quick note of at least three, any of which would take a fair length of time to discuss. On the other hand, the things that some of these people who were here testifying mentioned are heinous. Senator Kennepy. Are what ? Dr. BrisLe~. Heinous, there is no question about this. On the other hand, for me to give an opinion on them without know- ing all of the facts would be like treating you after making a snap diagnosis without trying to confirm it. If the facts are such, they are bad and I have no excuse for them. I presume that there are bad actors in all professions. Certainly some of this sounds as though there might be some here. Secondly, you brought up the point of catastrophic illness. Catastrophic illness, in fact, uninsured illness is dangerous for anyone to have. Almost anyone is incapable of handling its costs. I think the services rendered for the costs justify the costs. The method of paying for them may be a problem. You mentioned another thing just in passing; hospital costs, which of course influence the cost of medical care. You suggested that the patient who was taken—the black man’s son Senator Kennepy. Mr. Johnson’s son ? Dr. Bristen. Yes, who had been a patient at the county hospital receiving specialized care. This is an inference which I am making, not because I am familiar with the case, but because I did read some- thing in the newspaper and because of some statements Mr. Johnson made. The patient had been receiving specialized care in a unit provided to give that specialized care at the county hospital. : L The fault in this particular case seems to have been in the delivery of the patient to care. Instead of taking him where be belonged, they took him to a hospital where they were incapable of providing that care. Senator Kexn~epy. Do you think al Dr. Brisrex. Now, had the hospital been capable of providing that care, it would have had to have had in existence and in operation, a unit to provide esoteric care, expensive esoteric care which might be called upon only one or two or three times a year. Now, it seems appropriate to ask “Shall all hospitals be required to have all types of care available or shall certain types of care be located at certain centers with patients being taken where the care can be delivered ?” 2244 I think to require all hospitals to have infrequently used expensive equipment will cause daily hospital charges to rise a great deal more. T am sorry I interrupted on a question of yours, Senator. Senator Ken~epy. That is all right. } Well, what do you think of Mr. Johnson’s situation when they asked him what he was doing for a living or even when they were try- ing to solicit social information, and no one was examining the child? Then when he complained about this, Mr. Johnson, and the doctor allegedly said, “If you don’t like the service here, take him elsewhere.” He did the appropriate thing: He tcok the child to the hospital where he should have been taken initially—to the county hospital where the appropriate equipment, knowledge, and records of his con- dition were available. Dr. BrisLen. If Senator Kexnepy. Do you think that is the kind of treatment he deserved ? Dr. Bristen. If, before the child was even looked at, this is im- proper; yes. The duty of the hospital and the duty of the physician is to treat the atient. 8 The fact that the hospital administration may coincidentally and concurrently inquire into financial responsibility is not necessarily reprehensible. Senator Kexnepy. You see, these witnesses that we heard here this afternoon were consumers and we heard yesterday the same stories in Cleveland. We heard the same stories in rural West Virginia; we heard the same stories down in Nashville, Tenn.; we heard the same stories in New York. We are hearing the same stories in every part of our country. These aren’t just poor people that had some kind of a brush with the hospital system in the city of Chicago. We are getting the same story all over the country. Dr. BrisLex. Sir, I recognize this. Senator Kexxepy. And I think the question that comes to my mind, whether you would agree with me that there is really a crisis in health- care delivery today. Would you agree with that ? Dr. Bristex. Yes, I think there is. I think there is because there are so many people who need care. Senator Kexxepy. Well, why wouldn’t the AMA then really pro- vide some leadership? Perhaps they will understand you out here, but why wouldn't they really take a leadership role to meet this crisis? If you recognize the crisis, then you have to recognize the kind of dramatic steps needed to meet the crisis, and that is what crisis means. Dr. BrisLex. What would you have the AMA do? Senator Ken~epy. Well, we could start with having them support S-3. [Applause. ] No, but I'say the response should be—— Dr. BrisLen. Well Senator Ken~Nepy. Let me just finish, please. AMA’s position on medicredit didn’t materialize until long after the President said that there was a crisis, and then introduced his own 2245 program. That preceded by some time the formulation and develop- ment of the AMA’s program. Theirs deals with financing. There isn’t a part of the medicredit that deals with resource devel- opment, manpower development. There isn’t any provision for cost control. T am just hopeful that the leadership of the AMA will propose some cost controls. We would like their cooperation in getting the kind of resource development we need, to take the lead to get States to relax the laws so that paramedical personnel can actually practice, not just paying lip service to this and saying, “We need paramedical personnel,” and then having them do cleaning work in hospitals. Now, it just seems to me that this is the kind of leadership, and I would think that if you sat down with the AMA, you could think of so many better ways to reform the system then Senator Packwood and I and the other members of the Senate could. I sincerely hope that we could have that kind of leadership from you and from the association. Dr. Bristex. Well, I think that you will find that we are more than willing to cooperate with you. Maybe we won't buy everything that you have to sell. [ Laughter. | Miss Rippon. Senator Kennedy, I would like to know how many people in this room feel that Dr. Brislen has spoken representatively for them. Senator Kexnepy. Well, we will try afterward. [Laughter and applause. | We will let Dr. Brislen conclude. He has been kind enough to come here and I will let you be first up after we hear from some of the other witnesses, and then you can say what you want but we haven’t permitted other interruptions of witnesses. Senator Packwoon. Let me get back to the problem that still con- cerns me. Our problems do not seem to be money or financing prob- lems, except in the case of catastrophic illness. What we see is a lack of communications between the minority groups in this country and the hospitals. I am not quite sure how to rectify it but do you have any suggestions along that line? Dr. Bristen. I can only speak for the sphere in which I practice. I practice in the Woodlawn Hospital. The Woodlawn Hospital is in the Woodlawn area. My hospital has a census of approximately 70 percent black. I treat black and white patients in my office and TI hope TI treat them well. I treat them better than most of the patients who have been testify- ing here have been handled. Now, how should care be delivered? There has to be a total change in the delivery of care. There must be. 1 was on a program recently in which someone was kind enough to suggest that maybe IT had a Brislen plan. Well, I have a Brislen concept. 1 see care being delivered—that is primary health care being de- livered in community health centers. I think community health centers are decidedly advantageous as a way of delivering care. In the first place because community health 2246 centers are established by the community where the community wants them to deliver the services that the community wants, to the com- munity. I think that they should be the source of primary health care and that each health center—each community health center—should be a satellite to a nearby hospital. One hospital should have two, three—I don’t know how many, com- munity health centers. Each hospital backing up and providing the necessary secondary medical care and that each of the hospitals should in turn be satellite backed up by a tertiary care unit and since this is Chicago; and I practice in Chicago, I conceive of this tertiary unit as being one of the medical schools in Chicago, five currently, soon six, and even seven soon. This system would permit a whole gamut of care starting in a com- munity health center and extending through all echelons as necessary. It would also permit locating specialized equipment throughout the city, that is in the appropriate satellite hospitals so that the patient could be taken to the proper source of treatment. There are loads of bugs in this. There are loads of problems in this, not, the least of which will be to convince some doctors that multiple staff appointments may be desirable and that changes in the ways they do some things may be an improvement. However, it is a suggestion and although mine it is not the mecca, not a paragon. It is a concept and one you must have to have a concept to begin with. I think this is a good one. Senator Packwoop. Thank you. Senator Ken~epy. Thank you very much, Doctor. T appreciate your mentioning that you feel that the problem is of crisis proportions be- cause the A.M.A. in Washington wouldn't be nearly as descriptive of this and I think what you have indicated is a good start. Dr. Brisven. I defined it in a little different term. Senator Kenneoy. Well, we will go with the record on your state- ment and thank you very much. [ Applause. ] Our next witness is Dr. James Campbell. He is the president of the Rush-Presbyterian-St. Luke's Medical Center. STATEMENT OF JAMES CAMPBELL, PRESIDENT, RUSH-PRESBY- TERIAN-ST. LUKE'S MEDICAL CENTER Dr. CamrererL. I have no prepared statement. Senator KenNepy. We are beginning to get a rundown in terms of time but we want to hear from you, Doctor, so we will let you proceed in your own way. Dr. CaxrrerL. I have no prepared speech Senator Kennepy. Fine. Dr. CampBeLL (continuing). Which will save you some time. Senator Kennepy. All right. Dr. CameeerL. I have made some notes. Senator KexNepy. Fine, OK. Dr. Cameeern. When I had the good fortune of sitting next to Mr. Mattox, he turned to me and asked: “Are you a victim or an expert ?”’ [ Laughter. ] 2247 I have the feeling that I am a bit of both. I think that if we don’t have compassion for the stories that you have heard today we are unfeeling and insensitive. If we were not to try to do something about them, as you, Senator Packwood, and Senator Kennedy are doing, we would be guilty of malfeasance. It seems to me that there are three issues that stand clear to me. The first of all is cost. It is easy for all of us to understand that dollars are a readily translatable term. The first issue under cost perhaps is: Does cost, does payment for care block the opportunity to get care? It seems to me that that is clear. I believe this is a crisis. I think all of us, whether we are consumers have had problems—and to para- phrase Pogo: “We have met the consumers and they are us.” I think if costs stands between us and getting care, we have to do something about it. As purveyors we are victims, Mr. Mattox, as well as experts because our people depend upon us for their bread and butter. So we are anxious to see that they have a standard of living which is above the poverty level, which until very recently many hospital employees did not enjoy. So cost has to be scrutinized. First it is a barricade to care and, sec- ond, do we get our money’s worth ? And this will vary as the technology advances. It will vary as effi- ciency and system analysis can be brought into play and a help as we become more cost conscious. I think cost analysis in the health industry is absolutely essential. I think it can be done and must be done and when I say “health in- dustry” I also include not only the purveying of care but also the education portions of the health industry as well. A second major item which seemed to be discussed was quality con- trol. I think quality control is essential in this industry as in any in- dustry, and I think it is more important when we deal with the ill- measured variables of the spirit and the psyche that are so important in sickness and in health. Then, finally, it seemed to me, we were hearing the issue of avail- ability discussed. I think many of the things that we heard about, going to an emergency room for care for a sick boy, bothers me be- cause emergency rooms in hospitals don’t deliver care any more than Wrigley Field plays ball. It is the Cubs who play ball and it is the people who deliver care. The setting is what we talk about in many instances. Now, I don’t mean to get bogged down in that too much in detail but what we need is manpower. Now, the statistics which you have are behind you, I would like to emphasize, have particular local meaning with respect to manpower. The State of Illinois, as you know, it is about fourth in population. It is about third in per capita income, and yet it is 18th among the States in physicians per 100.000 people. As proud as we are of Chicago, although it is second or third in population in comparison to Los Angeles, New York City, Cleveland, Detroit, and San Francisco and is third in per capita income, it is the 2248 next to the last, and this is the general Chicago area, in the number of physicians per 100,000 people. Yes; there is a crisis in health care and we share with you the dream of trying to meet that crisis. I do hope that you will focus on meeting the costs, and I hope that the rest of the Congressmen will focus on meeting the costs in the most appropriate way to keep the consumer in control so that he gets a guaranteed purchase, so to speak, from the purveyors whether the be physicians or osteopaths or hospital service or any other healt personnel. i he that that will be studied very carefully so the costs won’t be a hurdle. I hope the quality control and the cost control will obviously be our own responsibility for developing the modalities and the method- ologies for measurement. But availability, if you do all of those things, even giving a credit card to a store, it is like giving a credt card to a store that has no wares or at least has the shelves only half full. This is where the real crisis is. Manpower is short. Now, we must meet that and I hope that S. 3 will be given careful scrutiny to see that even more adequate manpower coverage is included and that we keep the timelag in mind. The way to get people to come back to the ghetto is to start from the ghetto and the way to get people to come to the rural areas is to start from the rural areas and keep the spectrum in mind. I didn’t mean to make a speech when I said I had none prepared. Senator Ken~Nepy. Very good. Dr. Camperr. It is only that T had something to say. Senator Kex~epy. Well, that is very well said and very precise and, of course, you were kind enough to spend about an hour or so with us earlier today in bringing us through your facility and meet- ing with some of the other deans of the medical schools and we are very appreciative of your appearance here. I want to thank you very much for that statement. Senator Packwoon. I have no questions. Senator Kexxeny. We want to thank you very much, Dr. Campbell. Now, we have Mrs. Carol Grigna. Is Carol Grigna here ? Mrs. GrigNa. Yes. STATEMENT OF MRS. CAROL GRIGNA, HEALTH SERVICE CONSUMER, AMERICAN INDIAN Senator Kexxepy. How are you ? Mrs. Griana. Fine. Senator Kexxeoy. T want to welcome you, Mrs. Grigna. I know you have got something to say and we are going to try to hear you through. We have got about 20 minutes left so we will do the best we can and we want you to be able to feel comfortable and use as much time as necessary to give us your message but we also do have others who want to make some comments. Mrs. Grioya. I am Mrs. Grigna, an American Indian. 2249 Senator Kex~epy. Just pull that microphone, the one with the black end on it, that is the correct one, just pull that a little closer to you so that we can all hear you. Mrs. Grieya. I am an American Indian. I am speaking for about 10.000 or 15,000 American Indians in Chicago. The American Hospital on Irving Park and Broadway should be investigated. It refuses service to the American Indian. Senator Kexxepy. Go nice and slow. You are doing very well and everyone should be relaxed and we are very interested in this prob- lem with respect to the American Indians so just take your time now and don’t be nervous. Mrs. Griexa. They take our Indian women’s babies away, because they said that she was drunk. The nurses signed against the mother and there are hospitals in the city that won’ *t even accept Indians as welfare cases. They are treated like dirt and they have to wait for hours before they are cared for. Always they are given the worst doctors and T had my son who as beat up by six Puerto Ricans and they gave him an old doctor Te could hardly see. T don’t recall his name but my son was treated at the American Hospital at that time and the nurses at the Ameri- can Hespiiod treat people just like animals. Now, I am on ADC and I have talked to a lot of Indian people and they told me a lot of their problems. I have heard of the poor four Indian children having lead poison- ing from old paint in the housing conditions they have to live in and how many more we don’t know about. I have talked to a lot of people and it is terrible the way they get treated by some hospitals; they think we are just a bunch of drunken Indians and our living conditions and welfare are just ignored in the city of Chicago, and not only here but in other urban areas and also on the reservations. It is about time society realized that the Indians should have first priority. Our territory was taken away from us Indians and we are just treated like animals, and that is something that society can’t do. is take away the Indians’ pride. They have taken away everything else, on and off the reservation. Society doesn’t know how to handle Indian people because Indians only know about Indians and no one else does. Other counties benefit from the Indians which are near the reserva- tions and the Indians don’t have anything on the reservations. There should be an Indian hospital here in Chicago specifically for Indians and with all fields of medical care included, including gen- eral care. Let the society not tell the Indians how to take care of Indians be- ‘ause no one else does or ever will. We have the Society for American Indian Development and Edu- cation. This is our organization and before you leave Chicago you Toon talk to them and you might learn some of the needs and wants of the American Indians. Thank you. Senator Kexxepy. I want to thank you very much, Carol, for com- ing here and sharing these thoughts with us. 59-661 O—71—pt. 10——3 2250 I don’t think there is any question that the native Americans have been the most forgotten of all our groups in society and this is true in terms of health and it is certainly true in terms of education Mrs. Grieza. IT have taken my children out of school. I do not be- lieve in the public school system. Senator Kex~epy. I think the comment which you make with such feeling is a forceful reminder to all of us and I think that T know what you have said and you have said it so well and I won’t even begin to try and repeat it but it is important in terms of education and it is important in terms of health and it is really under local control. But there is no reason in terms of education that we shouldn’t have elected Indian school boards. There are 225 Indian school boards in this country and there are four elected in spite of the fact that President Nixon said 18 or 19 months ago that we ought to encourage election of local school boards. They are not active in terms of the determination of education of their young and they are not active in terms of the determination of the kind of quality of health and certainly we ought to recognize this and be much more responsive to it. Mrs. Grieya. Mr. Kennedy, could I say something? Senator Ken~epy. Certainly. Mrs. Grigya. I forced the Foti of education to take me to court. My children were behind in school and they were pushing them through school and they didn’t have any special programs or classes so they could get caught up in their work. This is what happens to most Indian children and that is why there are so many dropouts. The board of education knows of 1,300 Indian children and there are about 15,000 Indians in Chicago with 45 percent of them being of school age. Where are the other 3,500 Indian children? I asked the judge that and he said, “I don’t care about 3,500 Indian children. I care about these six.” Well, T go to court on June 2 and I wonder if they will throw me in jail. Senator Kennepy. Sixty percent of all of the Indians live in urban areas, off-reservation areas, and if we are talking about really meeting the kind of needs and realizing our special responsibilities and obliga- tions, we are just going to have to find ways to help and assist them. Mrs. Grigya. My children and I were evicted from our apartment last year and there hasn’t been anything done at all for the American Indians in Chicago. I don’t think that because we lived in a living hell for 4 months that this should be something that should go on but rather that there should be something done by now. Senator KeN~NEDY. Do you have any questions? Senator Packwoon. No questions. Senator Kuxxepy. Thank you very much. I appreciate very much your coming here. You have provided a real service to us, really. Dr. William Towne and Dr. Nick Rango, they are from Cook County Hospital. We are glad to have you here, gentlemen. 2251 STATEMENTS OF WILLIAM TOWNE, RESIDENTS ASSOCIATION OF COOK COUNTY HOSPITAL, AND NICK RANGO, INTERNS ASSOCIA- TION OF COOK COUNTY HOSPITAL Dr. Towne. I am William Towne and IT am a 4-year resident in internal medicine in Cook County Hospital. We have a document here which represents the feeling of our group which we have presented to you. I would like to read part of this document. Senator Kex~xepy. We want to welcome you, Dr. Towne ; Dr. Rango and Dr. Towne were kind enough to bring us through the county hospital last night about 10:30 and it was very helpful having their insight and thank you for coming here. Dr. Towne. Sure. Cook County Hospital Senator Kexxepy. We can include this in the record. I notice that you have a statement some eight pages long and 1 will be glad to include it if you want. If you want to speak off-the-cuff and just highlight the particular concerns you have, we will be glad to listen to them but actually we are really running out of time. We will include this in its entirety in the record and T will take time to read this on the way back this afternoon to the cast coast. But, I would appreciate it if you could really highlight what your particular concerns are. Dr. Towx~e. Cook County Hospital, is a 2,000-bed charity hospital that, at present, constitutes the only available source of health care for the poor of the Chicago metropolitan area. The population it serves is well over 1 million in number. The Residents and Interns Association of (look County Hospital is an organization to which over 95 percent of the house staff of the hospital belong, 400 members. As such, the association is the largest house staff organization in the country. The house staff consists of those physicians engaged in internship and specialty training at the hospital. These doctors provide the primary care for all patients at the hos- pital and are in most cases the only physicians a patient will see dur- ing his hospitalization. Any patient at Cook County Hospital who is asked the name of his doctor will respond with the name of a resident or intern. Residents and interns at county hospital are not required or ex- pected to participate in medical research. Their interests are in pro- viding quality patient care and in furthering their postgraduate traming, The purpose of this document is to provide the committee with what the residents and interns association’s position regarding the existent problems and inadequacies of the health care delivery system. . How this document is to be acted upon is beyond our area of exper- tise. However, our strong recommendation is that this document be carefully studied and considered by every committee member. The fact that the health care of the Chicago area poor is inferior has been well documented. 2252 We believe that this is not a reflection of the physicians at Cook County Hospital who are involved in patient care. For medical conditions requiring the type of intensive care that requires the presence of a physician, severe traumatic injuries, exten- sive burns, patients from all economic strata are frequently trans- ferred to Cook County Hospital from other institutions, often over great distances. Almost any physician who has had experience at Cook County Hospital would ask to be brought there were he to suddenly develop a life threatening condition because he could be assured of prompt treatment by a physician who would handle the problem in person and not over the phone. What, then, are the problems in health care of the population Cook County Hospital serves? (1) The hospital is inadequate in size for the population it serves. Other Chicago area hospitals refuse to care for the poor of their area. Patients are frequently transferred to Cook County Hospital in such serious condition that their lives are seriously jeopardized en route—documentation attesting to these unsafe transfers has been ac- cumulated by the residents and interns association. This practice would be reprehensible enough were it done because the patient had no means to pay. However, since the advent of third-party payments, we have to our dismay found that having medicare or health insurance does not pro- tect a person living in a ghetto area from receiving such criminal treatment. The only logical explanation for this phenomenon would seem to be racial or class discrimination. (2) The distance to Cook County Hospital for many of the popula- tion it serves is such an inconvenience that they choose to make the trip only when desperately ill. Neighborhood health centers have never been provided by local authorities, such as the board of health. Recently some community organizations have started several of these centers. Their efforts have not only not been aided, but have, in many cases, been actively fought by local government. The Chicago Board of Health is currently involved in a bitter strug- gle to close down several community-controlled neighborhood health centers because these centers function independently of the political control of city hall. (3) Even if the area served bv Cook County Hospital were to be limited to a reasonable size, the inefficiency with which the hospital is administered would, in our opinion, still render the health care of the population inadequate. The remainder of this document will attempt to explain the grounds for that statement. Maladministration at Cook County Hospital has resulted in the fol- lowing problems: 1. Tmpending disaccreditation by the Joint Commission on Accredi- tation of Hospitals. The hospital. is currently only temporarily accredited by the Commission. 2253 At the time of its next review, the Commission must either fully accredit or discredit the hospital. The lack of meaningful improve- ments in conditions since their last visit would make an unfavorable judgment seem likely. 2. Increasing difficulty in recruiting attending and house staff phy- sicians. Cook County Hospital matched less than 25 percent of the desired interns for the period of July 1971 to July 1972. 3. Continuation of 19th century “sick-house” conditions of patient care in many areas of Cook County Hospital. Enclosed is a copy of a current Look magazine article, May 18, 1971, issue, which speaks to many of these conditions publicly. The fact that patients on most of the other hospital wards have no access to privacy whatsoever does not appear to excite much sympathy with the hospital administration. The above problems existed before the governing commission was formed. They existed because their solutions would have been politi- cally inexpedient for certain individuals and groups. The Residents and Interns Association actively supported the for- mation of a fiscally autonomous governing commission because we felt that improvements in patient care at Cook County would result. Thus far we have not seen those improvements. More importantly, we have detected a sense of priorities that is especially disturbing. The offices of the governing commission will be air-conditioned be- fore the operating rooms, carpets installed before ward bathrooms are built. We hoped that we could effect a change in the governing commission by suggesting a person for membership whose goals would be more in keeping with improvement in health care of the population we serve. The man we chose to endorse was also backed by numerous com- munity groups and to the best of our knowledge, his appointment to the commission was opposed by no one connected with the practice of medicine at Cook County Hospital nor any consumer representative. Nonetheless, this individual was turned down for membership on the commission. Mr. Stuart Ball, an individual who last year publicly accused a group of concerned doctors, nurses, and paramedical personnel, of a conspiracy, on behalf of the selection committee denied the commu- nity’s nominee membership. He stated that Lopez was not eligible by virtue of lacking U.S. citizenship, We consider this statement specious. In the extreme, enclosed is the legal opinion of the community board’s counsel on this point. We are also forced to conclude on the basis of his past actions as well as his attitude on this question that Mr. Ball is interested in pre- serving the status quo at County Hospital. We felt that the acquisition of a governing commission would also lead to reforms in the division of laboratories as well as in the rela- tionship of Hektoen Institute to C.C.H. Both the division of labs and the Hektoen Institute are headed by Dr. Samuel Hoffman. Dr. Hoffman has been fired by the previous hospital director from the hospital position but he remains on as a result of a civil service technicality. 2254 He has been asked by all of the house staff physicians, by petition, to leave both positions, but has refused to do so. The laboratories he administers have been under repeated criticism for lack of quality. The institute he administers doesn’t provide laboratory space for the cardiovascular surgery service at Cook County Hospital but does pro- vide space for the same service at the University of Illinois Hospital. It has somehow come to pass that the laboratory where autopsies are performed in the institute facilities has tables and lighting superior to those in the hospital operating rooms, as well as being air conditioned. Dr. Hoffman has attacked the Residents and Interns Association as well as the previous hospital director publicly on numerous occasions. He opposed the appointment of the governing commission. We conclude that Dr. Hoffman is determined to preserve the status quo at Cook County Hospital. Dr. James Haughton has been selected by the governing commis- sion to be the chief administrator of Cook County Hospital. He is the highest paid public official in the State of Illinois, with a higher salary than the Governor and U.S. Senator. He has acquired a staff to match. He has promised sweeping reforms. We are awaiting results with increasing skepticism. Since his arrival 6 months ago, no substantial improvement in patient care have resulted. As stated above, we are appalled at the sense of priorities evidenced by Dr. Haughton and the governing commission. In conclusion, the Residents and Interns Association believes that the health care of the population served by Cook County Hospital is inferior and that as a first step toward improving that care, there must be betterment of facilities and operation and increased efficiency at the hospital itself. We feel that there is a group of individuals who, while never saying so publicly, opposed that view for their own political reasons. We reject the idea that Cook County Hospital or any other similar institution should function as an inferior health care system for the poor. We pledge to continue to work as hard as we can and with all means available to bring medical care that is second to none to our patients. Dr. Towne. Cook County Hospital, as T say, is a 2,000-bed charity hospital in Chicago, which is the only available source of health care for the large part of the poor community, a community which numbers well over a million. We feel that the care for this segment of the population has many inadequacies and some of these inadequacies are the fault of the hospital. We do not feel that these inadequacies are the fault of the doctors at the hospital nor have they ever been. We feel that Cook County Hospital always has been and remains today one of the best hospitals for certain types of problems anywhere in the world. We feel that if one is to become a victim of a severe gunshot wound 2255 in the abdomen or chest, or if one has a heart attack, one could not find better life-saving treatment than at Cook County Hospital, but we feel as far as many things are concerned, that they are also im- portant to the community such as routine tests or workup of illness. The conditions at Cook County Hospital leave a lot to be desired. We feel that part of the problem of Cook County Hospital is its size and the size of the area it serves. We feel that even if the size of the area that it served were diminished to an extent where care were possible, we feel that the care would still not be adequate because of the problems in administration of the hospital. With this in mind, many groups at the hospital urged the formation of a governing commission at the hospital and in place of the county board, which had previously administered the hospital. We later on campaigned for fiscal autonomy for this governing commission which was obtained. The governing commission has now been in operation almost 2 years and we have not been happy with what we have seen there. This statement documents with facts and figures that situation and we attempted here to say what we think is wrong with respect to the adminisration of Cook County Hospital. Dr. Rano. I am Nick Rango, and I am chairman of the intern body at the Cook County Hospital. I would like to begin by thanking you for coming and it is high time that we begin to talk about, humanistically, the crisis in health care, but what we really mean is the collapse of health care systems. I think that the emphasis that the hearings have placed on the in- credible facts with respect to profiteering which go into the health care system, particularly the insurance companies; Blue Cross, Blue Shield and the way that they handle their patients is a good one. It is not unusual for those of us at county hospital to have patients dumped on us from private hospitals with a little note saying that “His in- surance benefits have run out, but he is a good patient, and please do the best you can.” These kind of things happen every day. I think I have some things Senator Ken~epy. What do you mean, “every day”? Do you mean that it is actually the situation ? Dr. Raxco. Yes, it is. When we are on the wards, and you know we receive our admissions oftentimes as transfers from private hos- pitals and that is if they don’t have the money. Senator Kexnepy. Why do they transfer them over to Cook County ? Dr. Rano. Because they don’t have money or their insurance has run out. They are transferred from the medical schools if their pa- thology is uninteresting and they are brought to places like Cook County Hospital. Senator Kexxepy. You mean just because they can only afford to take so many into their hospitals, given their kind of budgets and therefore, after they reach sort of a ceiling, they turn them over to Cook County Hospital ? Dr. Raxco. I think that is involved, but I think it is something much more important than that and that is the fact that our patients at Cook County, 60 percent of them do have third-party payments and most of these patients are nonwhite. 2256 There is quite a bit of racism that goes into the rejection of the pa- tients at the private hospitals and the responsibility of the medical pro- fession for this racism has never been acknowledged. I think that one of the signs of solution is possibly the recognition, such as depicted by the house staff of the young sector of the medical profession with respect to the admission of this racism and class bias which provides an opening for working with progressive political people such as yourselves. The thing that I want to just comment briefly on is that I think that we have witnessed here today a very important political phe- nomenon. You had three speakers representing different sectors of the health care system who have testified. One of them represents the political sector, the board of health, Mayor Daley who has told you some of the positive facts about the program, but has not mentioned the fact that in the negative sense these board of health clinics provide second-rate care, and the neigh- borhood health centers that they are building now are only in response to the community’s own efforts in developing neighborhood health centers. In the last 2 years we have heard from the spokesmen of the tra- ditional medicine, the Chicago Medical Society, which, less than 1 month ago, Senator Kennedy, denounced these neighborhood health centers because they did not have professional people “who they thought were qualified to work there. Well, T have worked at these centers with the women from the Bonito Juarez who represent one of the centers, and I can assure you that they are community-initiated efforts and they were blocked by the medical society. The last speaker was from the Presbyterian-St. Luke’s and he repre- sents the new mode, the new medical mode and they are the liberal corporate kind of approach to medicine that is trying to establish the medical school’s interest in these situations. However, Presbyterian-St. Luke's is still a segregated system who refused to enter into an agreement with the Bonito Juarez Health Center when they came to them last year to provide backup care for the people. These people were turned away and Cook County has been providing that service. Senator Packwoop. Let me ask you something because we toured St. Luke’s and then we toured Mile Square. Dr. Campbell indicated that admissions from Mile Square to St. Luke’s take place all the time and none are turned down. Dr. Ranco. Well, 3 months ago they organized Mile Square—Iet me restate that—3 months ago, we had one of the formal organizers of Mile Square on a general ward at Cook County Hospital. Senator Packwoon. Would you repeat that ? Dr. Raxco. Three months ago, we had one of the community orga- nizers of Mile Square as a patient of Cook County Hospital. Senator Packwoon. IT am sure there may-be people from Mile Sauare in a number of hospitals, but Dr. Campbell, did indicate to us that if anybody is recommended for admission to St. Luke's from Mile Square, they are admitted. 2257 Dr. Ranco. That is true from Mile Square. The community that was approaching them last year was the Chicano community in the immediate vicinity of Presbyterian-St. Luke's, and what I am referring to is the institutional lack of responsi- bility of the medical schools, of the professional medical representa- tives, the AMA, the Chicago Medical Society, and please, don’t turn to these people because they are not the experts. The solutions will not come from any of those bodies, and only after you have made a radical reappraisement of the structures of medicine and how doctors are paid will you reach a solution. Senator Kexnepy. Is S-3 radical enough for you ? Dr. Raxco. I think your plan is probably the most progressive o* all of them. Senator Packwoop. But not radical enought ? Dr. Raxco. It only begins to solve it. Senator Packwoop. How does it solve the problem when these pa- tients are being discriminated against although they have third-party insurance coverage and the problem isn’t money ? Dr. Raxco. I don’t think your solution is going to eradicate that. I think that the solution is going to rest with more proper fundamental social changes that will come when you Senators and the politicians start addressing themselves to questions of finance. Why are the health insurance people allowed to get away with what oes on with respect to Blue Cross and Blue Shield? Why are doctors allowed to make the kind of money that they do? Until you make a restudy of the structures of health delivery, you can talk all you want about financing, but you won’t do any good or it won't do any good. Senator Packwoop. How much should a doctor be allowed to make ? Dr. Raxco. IT think that is going to have to be determined in the same way that you determine what other workers are allowed to make. Senator Packwoon. Well, give me a fair idea, say, for a doctor who has practiced 10 years, not what he does make, but what he should make ? Dr. Raxco. T think it depends upon the community, and TI think it is reasonably easy for anyone in this country to support Senator Pack woop. Give me your idea. Dr. Ranco. $10,000 to $20,000 a year. Senator Packwoon. $10,000 to $20,000 a year? Dr. Rango. Sure. Senator Kenxepy. I want to thank you very much for your appear- ance here. We have just a few more minutes, and T am delighted that we cot a chance to hear from vou. It is good that you came. We have taken the opportunity to meet with the residents and interns in Bellevue in New York City when we were up there. We had about a 214- or 3-hour rap session up there. which was very informative. We talked about the draft, the effect of this. the voune people wanting to work. and the impact of the emer- eency health manpower bill. and the importance of a lot of different featnres which we really haven’t touched on here. So T know there are so many of these kinds of questions which they are interested in which vou can provide information on. : 2258 Dr. Raxco. We applaud your efforts, and we are anxious to help in any way we can. No, enator Kennepy. All right. Now we have Dr. Phil Ricks. STATEMENT OF PHIL RICKS, PRACTICING PHYSICIAN, CHICAGO, ILL. Dr. Ricks. T happen to be a physician, obstetrician. Senator Kennepy. You can come up here if you care to. Dr. Ricks, I wish we could give you a lot of time, but at 3:16 we are going to have to walk or leave, I am afraid, but whatever you have to say we would be glad to hear. Dr. Ricks. I am an obstetrician-gynecologist and a practitioner in the black community. I think that many of the statements the last gentleman made were quite true. I want you to know that many of the problems in Chicago, partic- ularly as to why Cook County Hospital is overburdened, is that the majority of the black patients are brought or transferred from the ghetco to a facility such as Cook County and that oftentimes the black physician is not privileged with respect to the facilities of many of the centers, in even the black community or the ghetto. If you take most hospital staffs, you will find that you have an in- ordinate number or small proportion of black physicians. The South Side and the West Side areas where the majority of black patients and physicians reside, if you take them, you will find, as T say, a gross disparity between the number of physicians that have the opportunity of using adequate facilities in many of the larger hospitals. Many black patients, particularly women in labor, they bypass at least five hospitals on their way to County Hospital. However, if you take the number of these hospital staffs, you find an inordinate number, I mean, as I say, a small percentage of black physicians, particularly in the surgical specialties and in obstetrics and gynecology. Now, this gets back to racism, and the story about the patients being rejected is a daily phenomenon in many of these hospitals. Senator Ken~epy. Thank you very much. Dr. Ricks. Thank you. Senator Kexxepy. As I say, thank you very much. We have Marie Love, Martin Luther King Neighborhood Health Center. Is she here? Mrs. Love. Yes. Senator Ken~Nepy. We have just a couple of minutes. STATEMENT OF MRS. MARIE LOVE, PAST NATIONAL SECRETARY FOR THE NATIONAL CONSUMERS AND CHAIRMAN OF OUR MODEL CITIES HEALTH TASK FORCE Mrs. Love. I wanted to answer some questions of Senator Packwood. We have a problem with the welfare patient. They have a green card and most of your physicians in the Chicago area do not accept 2259 the green card. They do not accept the people on welfare and the reason 1t 1s important to me and to the people whom I represent to have national health Insurance program that will include all people SO Jou will not be discriminated against because you have a green card. You will not be discriminated against because you happen not to belong to the particular religion that developed the hospital in the first place. “Many of the problems come because the hospitals were started either by fraternal organizations or religious institutions and many of those hospitals still remain in neighborhoods where other people now reside in those neighborhoods. And there seems to be a resistance on the boards of many of those hospitals to accepting the new people who now live in the neighborhood. As you know, when they created or funded the comprehensive neighborhood health centers, they were given a lifespan of 5 years by OEO. Well, many of those health centers are now reaching that 5-year period. After the 5 years, the health centers were supposed to be self-sustaining. Many of the neighborhoods where these health centers are located. will not be able to pay the fees that are required unless there is some method of third-party payment. This is why it is important that some form of insurance that does not have discriminatory clauses built within them, be available to those people. Then when you go to a medical institution asking for health care, then if your card is green, you will not be given second-rate care be- cause there is some kind of a gentlemen’s agreement to where you cannot even get the same medicine. The doctors will not write you a prescription for certain medicine if you show this green card. You want to know what your committee could do ? Senator Kex~Nepy. Yes. Mrs. Love. We know most of the medical institutions do receive Federal funds. I would like to see that built into the legislation because they re- ceive Federal funds. That means that those institutions belong to all of the people, no matter if they belong to that particular fraternal organization or religion or whoever created the institution in the be- ginning and that being a human being, needing the care, should be important, and that receiving health care should not be based on whether you can afford it. I would also like to see some kind of different type of program of education indicating that the young men and women who come from the minority groups, who come from the poor communities, that they will be able to go to medical schools. The cost of medical care is phenomenal and many of the youngsters are discouraged before they leave high school to go into college, to take premed because they know they cannot afford the course for the professional schools and I think some legislation is needed in order to provide this kind of vehicle for those people, coming from the poor communities. Thank you. 2260 Senator Kex~epy. That is an excellent statement and really clarifies some of the points. : I couldn’t agree with you more regarding financing neighborhood health centers in terms of the comments you made about the green cards and also the needs. I want to thank you again. We are going to have to leave. We have a 4 o'clock plane that we are going to try to make. What we are going to do, though, is to ask Dr. Caper, who is a member of the staff of the Health Subcommittee, to stay here until those that have got some comments can give them to him. He will be right up here at this desk and he will be around until the last person has had a chance to comment, and you can come in this afternoon with them or you can mail them in and they will be made a part of the record. I want to thank you all again for your attentiveness, for your inter- est, and for your concern that you have shown. This has been very useful and a very helpful meeting, and it has been for me, and I know the record will reflect that in terms of the other members of the subcommittee. (Senators Kennedy and Packwood left.) Miss Rippon. My name is Martina Rippon. I am a freshman medical student and I was the one that made that comment, about Dr. Brislen because I didn’t feel that he spoke for many of us here in this room. Dr. Campbell—oh, excuse me—well, all right, Dr. Campbell pointed out some of the difficulties involved both in the areas of financing and the areas of availability. He did not state concerning matters of accessibility, that even if all of these things were paid for, that they would still not be acces- sible to the people, that they are not accessible now, and that is the poor who still lose out. But mostly I wanted to speak about the prob- lem that Mrs. Villa voiced, that Miss Carol voiced, and the last speaker. These were the matters dealing with people being treated with dignity so that they have a right to health care with dignity and that they are not getting it and that the reason that they are not getting it is that the health care system is not responsive to their needs. What is needed is a system that is under community control be- cause only under those circumstances will people be able to make their needs known and respected and that is the only guarantee that people will ever get the care with dignity that they deserve. Dr. Caper. At this point 1 order printed, at the direction of the chairman of the subcommittee, all statements of those who could not attend and other pertinent material submitted for the record. (The material referred to follows :) 2261 STATEMENT REGARDING CHICAGO'S HEALTH CARE CRISIS Rolf M. Gunnar, M.D. Director, Division of Medicine Cook County Hospital To qualify myself, I have been at Cook County Hospital for 23 years as house officer, voluntary physician during the nine years I was in the private practice of Medicine, Director of the University of Illinois Section of Medicine at Cook County Hospital, Director of the Department of Adult Cardiology, and for the past year, Director of the Division of Medicine. I have been on the faculty of the University of Illinois since 1954 and have been Professor of Medicine since 1967. I make this statement to supplement the statement made by the Residents and Internes Association of Cook County Hospital since, in most respects, I agree with their statement. I wish to detail some experiences at Cook County Hospital because they seem to exemplify the types of problems that are ptaVenuing our health care system from being effective for those patients who need it the most. I feel that, at the moment, we are facing a dangerous crisis of health care in the Black, Spanish speaking and poor areas of the City of Chicago. There are not enough private hospitals to care for the patient population. The university hospitals are inadequate for this task and there has been a flight of physicians from the inner city so that ambulatory care is almost non-existant. The great hope of a year ago when Cook County Hospital was removed from the control of the Board of Commissioners of Cook County and placed under a non-political Health and Hospitals Governing Commission is now rapidly fading. This new body, instead of facing the real problems of health care delivery, hides behind housekeeping chores to excuse its inaction in'major decisions that could improve the quality of health care delivery. 2262 We must start with the principle that we dedicate ourselves to delivering the finest of health care to the patient population the hospital serves. The quality should be no less than care which would be available in a university hospital or a large private hospital. A prime requisite to excellence in health care is having highly qualified physicians. The patient at Cook County Hospital with skin disease should be able to see a Dermatologist just like the patient from a middle-class community would be able to see a Dermatologist. The same applies to the expertise in many fields including Rheumatology, Allergy, etc., as well as having a general physician qualified to bring all the information together and see the patient as a whole person. This requives a full-time staff at the hospital of academic orientation interested in the delivery of health care. Such a full-time faculty would attract qualified house staff who would render the patient care under the guidance and direction of the senior physician. Cook County Hospital cannot run without qualified house staff, and one must remember that the house staff can change entirely on July lst of any year. Some of our present difficulties are due to taking on some poorly qualified house staff one year ago at a time of crisis when qualified physicians were impossible to recruit because the full-time faculty was departing. Nine of these house officers have not had their contracts renewed because of poor performance. By rebuilding the faculty, we have recruited an excellent group of house officers in Medicine for July 1, 1971 - but, by July 1, 1972, they could all be gone if they do not see continued growth in the faculty and if present frustrations continue. The immediate crisis one year ago, when the hospital almost did close, was due to the fact that much of the full-time staff had left, and the chances of keeping the house staff without the senior staff were remote. With the advent of the Governing Commission and the hope that closer ties would be 2263 -3- developed with the surrounding medical schools, full-time staff returned to the hospital and we were able to rebuild the Department of Medicine to cover some of the major disciplines. We developed a Department of Infectious Diseases, which had been non-existent; rebuilt the Department of Hematology, from which all the physicians had left, rebuilt the Department of Adult Cardiology, in which there was only one physician remaining; and increased the staffing in the Department of Renal Diseases. We now face a similar crisis to the one we faced a year ago. I realize that the historical roles of the universities at Cook County Hospital have been less than satisfactory. In the last few years, this philosophy has finally changed and the local schools have shown that they will accept responsibility for patient care if given the authority to make change. In addition, the creation of a governing board for the hospital gives a mechanism for community participation so that the needs of the consumer can be protected. The Governing Commission and the new Executive Director have not seen fit to develop ties with the surrounding academic community and have decided that the hospital can function independent of support from the medical schools. As I understand it, because of these attitudes, the University of Illinois is proceeding to develop its own University Hospital across the street from Cook County Hospital. They have tried since the Spring of 1970 to obtain an agree- ment with Cook County Hospital where they could share resources and responsi- bilities. The University of Illinois needs a community hospital in the inner city; Cook County Hospital needs the academic resources of the University of Illinois or any of the other universities in the City. A planning report developed by the University of Illinois called for a 1,500 bed combined University of Illinois/Cook County Hospital, which could have gone a long way to.solve the health care needs of the surrounding community. The University 2264 = was willing to build in guarantees for other schools that needed the resources of Cook County Hospital, and the Deans of the area medical schools apparently agreed that with such guarantees this would be a feasible plan. The reason I place these discussions first is that I can foresee the possiblity of a sudden collapse of Cook County Hospital should the full-time staff decide that without the academic opportunities promised a year ago they could not continue to devote their careers to Cook County Hospital. Such an exodus of the qualified physicians would leave our patients without any possibility of quality care. Unsupervised, poorly trained physicians would then be the health care providers for the 2,000 poor; patients that come to Cook County Hospital each day. Another requirement for attracting faculty is the ability to provide laboratory space to allow the physicians of various disciplines to develop sophisticated diagnostic tests needed for patient care as well as pursue some of their own clinical research. For instance, we have had with us for one year a physician trained in some of the sophisticated endocrinological examinations needed for the proper evaluation of patients with high blood pressure. High blood pressure is a common and very serious malady in the Black population of Chicago. This physician, who could have been identifying remediable causes of high blood pressure in our patients, has not been af forded laboratory space or equipment to develop these tests. Our cardio- thoracic surgeon must go to Loyola University, some ten miles away, to do his research because the space and facilities are not available to him at Cook County Hospital. At the same time, we have a modern laboratory building with research laboratory space empty or assigned to physicians working in other institutions. This strange situation comes about due to the fact that there ua private corporation known as the Hektoen Institute which has been able, over the years, to collect the overhead from federal grants for research to be 2265 [5 done at Cook County Hospital, and accumulate the overhead, since the actual overhead costs are paid by Cook County Hospital. In this manner, that Institute has been able to accumulate about $3,000,000 in cash and securities while the young investigator is unable to obtain support to initiate research or purchase equipment. The Director of that Institute is also the Director of Laboratories at Cook County Hospital and, despite the fact that he was charged with a conflict of interest in holding these two positions by the Executive Staff of the Hospital, he has remained in both positions. It may be that having three members of the Board of Commissioners of the County of Cook on tlie Bonds of Directors of the Institute has facilitated the development and perpetuation of this strange arrangement. To have accumulated over the years this amount of money while the equipment in the laboratories of Cook County Hospital became archaic has created a good deal of dissatisfaction among the full-time staff at the hospital as well as the house staff. Thus, even though we thought we had escaped from the devastating influence of machine politics, it has remained a severe impediment to appropriate growth of the hospital. During all this turmoil, the patient population we serve has been unable to have a voice in the direction of the hospital. A community group which attempted to relate to the hospital found that they could only do this through the Division of Medicine. They became a source of great support and inform— ation for that Division and had expressed great willingness to relate to the entire hospital. However, the Executive Director of the hospital saw fit to order the disbanding of this group despite the fact that they were made up of highly qualified professionals from the community. Mr. James Wagner, from the Mid-South Health Planning Organization, was the convener. Mr. Obed Lopez w from Citizens Health Organization, and Mr. Steven Berry from West Side Health 59-661 O - 71 - pt. 10 - 4 2266 Planning, were members, as were members from the Uptown Community group, the Benito Juarez Health Center, and Fifth City Health Center. We, as a staff, "in the Division of Medicine were very anxious to work with these people since they represented the community we serve. They desparately needed the support of the health centers they were trying to develop. Their small but functioning clinics trying to provide health outposts in the community surrounding Cook County Hospital had been caught in a squeeze between the Health Department of the City of Chicago, which talked a good deal about developing health centers but delivered nothing, and the Model Cities program which, except for the support we were able to give it at Cook County Hospital and an embryonic effort in Uptown, never developed a program. A year ago, I asked the Commission to develop a method to relate the hospital to these community health centers but, to this date, I have not received a reply. The patient in the inner city has a strange and rather disenfranchised lot when it comes to his own health care. Let us compare him to the patient in a suburban community. In the suburban hospitals, the Board of Directors of the hospital comes from the community. The patients, therefore, in the community have input into the governing board of the hospital. At Cook County Hospital, only one member of the Commission has contact with the Community the hospital serves and, had it not been for the demands of the house staff organization of Cook County Hospital, even this person would not have been on the Commission. The patient in the suburban community, through his private physician, can influence hospital policy through the executive staff of the hospital, which is a powerful force in influencing hospital policy. At Cook County Hospital, the patient's physician is frequently tile intern or resident and, although they have some representation on the Executive Staff at Cook County Hospital, the Executive Staff of the hospital has very little influence on policy of the hospital. The Joint Conference Committee meets infrequently 2267 -T- and usually without a member of the Governing Commission present. The Executive Director's office has effectively isolated the Executive Staff from influencing policy. In essence, the patient can neither influence policy from above, as he should through the Board of Directors, nor from below, as he should through his physician. With the turning aside of a highly respectable community group that could have been the voice of the community at the hospital, the Commission has isolated itself from the population it serves. Thus, the consumer has no influence on the priorities the commission chooses for expending its resources. When the Commission chooses to afford another public relations executive and cannot afford a Rheumatologist, how does the consumer raise an objection? I think it is urgent now that we decide whether Cook County Hospital should or should not exist. If the decision is that it should exist, then it should be supported fully by linking it with the neighboring medical schools and building a highly qualified full-time staff orientated to patient care as well as to have laboratory space and support of their own. With such a full-time staff we can attract a house staff to an exciting atmosphere for health care delivery and training. The method of delivering emergency care and outpatient care at the hospital must be entirely restructured to give the patients a feeling of continuity of care and personal concern. We must then link the hospital with a geographic area that it should and does serve and develop health centers in these areas. The health centers that have been initiated by the community groups are the start upon which we could build. We must stop looking at experimental models such as the 0.E.0. Mile Square Project as solutions, but instead use their data ad our own long experience to be innovative as we expand our services. « If Cook County Hospital is not to continue, then we must be prepared to take the consequences of suddenly closing this institution since a hospital of this type does not phase out but merely collapses. However, there is nothing to indicate that the health care system in Chicago would then provide quality care for the disadvantaged and we would, in my opinion, witness a further disintegration of the present apartheid health delivery system. 2268 Hiediln anu nusbiats QUVLITHING LOHTIIILLIVIE U1 LOU Luu Vor * A a! ‘yy 1 Cook County Hospital NE 1825 West Harrison St., Chicago, lilinols 60612 (312) 633-6000 Yay 7, 1970 EE i | | , James G. Haughton, M.D. . | i . aan Executive Director : 3 ! fh ues = } 1k ; | Health and Hospitals $ } ’ : Governing Commission ' Dear Dr. Haughton: ; As the Director of one of the major Divisions of the hospital, I think it important that I write you and express my concern over some of the recent administrative decisions you have made. Your repeated remarks against an academic orientation for Cook County Hospital, and the decisions to reduce the support for the full-time staff of the Division of Medicine, are stopping the ‘healthy growth of this Division and you must be cognizant of this. : We had the opportunity to create the finest Department of Medicine in the ' City of Chicago, and had begun a program of staff development toward this end. You have, however, changed the philosophy which could have nurtured such growth and set the goals at a much lower level. I had understood my charge as Director of the Division of Medicine was to provide the best of patient care. We should provide our patients no less than they could receive either at a large private hospital or a university hospital. I do not agree that there should be a second class of medical care for poor people and will not stand by voiceless if we do not commit ourselves to excel- lence in patient care. If a person of means deserves a specialist for care of his special problems, then a poor person deserves no less. As a matter of fact, because of the years of neglect shown our patients, the level of expertise nceded for their care is probably greater than that needed by the general population. It is inconceivable to me that this hospital should not have a Dermatology Department with full-time staff members, when we provide the most patient service of any Dermatology group in the city. We provide 17,360 Dermatology outpatient visits per year while the next largest department provides 8,430 outpatient visits per year and has six full-time staff physicians. Does this mean that poor people with skin diseases do not deserve to see a dermatologist? We have no pulmonary physiologist to evaluate patients with lung problems, no rheumatologist or clinical immunologist to care for the patients with arthritis or asthma. We see innumerable asthmatics in the emergency room of this hospital, but cannot provide the expert workup needed to give them any more than temporary relief. i i ’ ‘ i i | COMMISSIONERS: Julian B. Wilkins, Chairman; Edwin L. Brashears, Jr., Secretary; James E, Bowman, M.D.; Mrs, W, Milas Burns: Charles A, Davis; Jacob RB. Subar, MD.: 2269 Under the premise that our patients deserve the best, I have rebuilt the departments of Cardiology, Hematology, and Infectious Diseases, and strengthened the Department of Renal Diseases. I have put attending physicians in the out= patient department, established the Model Cities Clinic, and supported, as best I could, a voluntary relationship with the community clinics. I have restaffed the Endocrinology Department and, if we can get modern laboratory support, we will have a modern Endocrinology service for our patients. 1 should have thought you would have been pleased because, simultaneous with providing consultation services, I have provided full-time attending coverage for almost all the general medical services. We are in sight of your goal of excellence in medical care, and awaiting the supporting services and changes in the physical plant. We wish to attack the outpatient problem and the problem of the community clinics by supporting them, but your change in philosophy may make these goals unobtainable. Excellent physicians will work at Cook County Hospital because they feel the care they deliver is no less than the best and, in addition, they have a satis- factory intellectual life. This requires laboratories for those whose disciplines . require laboratories to diagnose difficult patient problems and pursue patient oriented research. The best clinicians, when recruited for employment, will ask! about patient care facilities and availability of laboratory space and support before asking about salary. The prime requisite for delivery of the finest patient care is a full-time * | staff of high competence who will then attract junior staff and house staff, and organize and supervise their delivery of care to our patients. Internists of academic orientation can do this and can create the atmosphere of excitement that will attract the best house staff. You have stated that you are not interested in academicians and have followed this by withdrawing laboratory support from the Division. With the present environment, I am certain we will no longer be able to attract physicians of high excellence. We are in the middle of the City with a fierce physician shortage, and must recognize and act on this or fall into the trap of offering the poor patient worse than mediocre care because we have not tried. In a recent conversation with Dr. David Earl, Head of the Department of Medicine of Northwestern University, I was hopeful for the return of Northwestern students to our wards. After consideration, he informed me that he could not support such an effort because of the present anti-medical school environment at Cook County Hosptial. This was also the message received by those who heard you speak at the University of Illinois. Without medical students our ability to attract house staff will be tenuous. Without good house staff it will be impossible to deliver patient care of excellence. You have the ability to reverse this trend. Support the intellectual activities of the full-time staff. Recruit academicians of clinical excellence. Develop close ties with the local medical schools. Measure ourselves not against | what we have been, but against what we should be. We can be the best patient care facility in the Midwest, but must have the best of staff to do this. With such a! staff, the house staff it would generate, and the input from the community that -the Community Board can give, we can be innovative and energetic and be able to ! make a lasting positive impact on health care delivery to our patients. With a weak Division of Medicine we will only react from weakness and deliver inferior © care, even if we have clean floors and a slightly improved physical plant. Sincerely yours, Rolf }}. Gunnar, M.D. RMG/mt Director, Division of Medicine cc: Dr. Clyde W. Phillips 2270 Dr. Caper. The hearing is adjourned. HEALTH CARE CRISIS IN AMERICA, 1971 THURSDAY, MAY 13, 1971 U.S. SENATE, SuBcommrITTEE ON HEALTH oF THE CoMMITTEE ON LABOR AND Punic WELFARE, Des Moines, owa. The subcommittee met in the Towa Methodist Hospital Nursing School Auditorium, Des Moines, Towa, Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present : Senators Kennedy, Hughes, and Dominick. Committee staff members present: LeRoy G. Goldman, professional staff member to the subcommittee; Jay B. Cutler, minority counsel to the subcommittee. Senator Ken~epy. The subcommittee meeting will come to order. I first of all want to express the committee’s appreciation to Tom Evans and to the staff of the hospital for being kind enough to pro- vide this marvelous setting for our hearing here this morning. They have been cooperative and generous in their time and hospitality and we are in their debt. I also want to thank Senator Hughes for joining with us in our visit here to Towa. He has a great insight into health needs and problems as well as into the various health programs in the State of Towa, having had a very close contact with the whole health issue, as Governor of Towa, and being a member of committees in the Senate that are con- cerned with health legislation. : Senator Dominick and I also appreciate the various courtesies which have been extended to us over the last several hours when we were visiting many of the hospitals here in Des Moines, trying to get a better feel for some of the new things going on here in the health area and also some of the problems that the health system faces here in Des Moines. We come to Towa in the setting of some 9 weeks of hearings held in Washington. We have listened to the experts, the representatives of the medical associations, the hospital associations, the medical schools, even many of the student organizations. They have spoken as experts on the health crisis. During the period of the last 3 weeks we have traveled to New York City, a major urban area to Westchester and Nassau Counties, some of the more affluent communities in America, to West Virginia, the second-most rural State in our Nation, to Nashville, Tenn., one of the great medical complexes in the South. (2271) 2272 Last week we traveled to several midwestern industrial comunities, Cleveland and Chicago. When we leave Towa we go on to Colorado. Finally, the field hearings will conclude in California in the early part of next week. We take the experiences that we have in our brief visits to hospitals, as part of a total experience of some 4 to 5 months of comprehensive hearings into the health crisis. We try to then draw from this experi- ence recommendations for changes in existing legislation and for new legislation to meet the health needs of our country. I feel strongly that you can gain a great deal of information in Washington, but until you get out into the field, you really don’t see the full picture. There are a number of our colleagues that remain in the Nation’s Capitol. But I think the most effective kind of under- standing of these problems is to develop a sound basis for understand- ing the problem in Washington hearings, and then travel around the country and talk to the people who are on the receiving end of the health system. That’s really what we want to do this morning. We have listened to those that have been delivering and financing health care. We are in- terested this morning in listening to the problems and comments of those that have been receiving these services. We think this is very important, because if there is one lesson that we have learned. it is that the consumer has been left out of the health care system. I firmly be- lieve that in any future legislation at the national level, we have to give the consumer an important role. We hope later to open the meeting to any of you here this morning that would like to make a comment or observation on the health crisis in the country. We will hear as many as we can within the time available, and for those that do not have an opportunity to testify, we will hope that you will write down whatever comments you have and submit them to us in the U.S. Senate. We will make those comments a part of the com- plete record. We look forward to hearing from you, and reading what ideas and comments you might make. Before hearing from the consumers, we will hear from our host this morning, Senator Hughes, then T will ask Senator Dominick if he would like to make a comment. Senator Huares. Well, Mr. Chairman, I really don’t want to utilize much of the time that we have allotted here to hear the people who have attended the hearing. I simply wish to offer an official greeting on behalf of the people of Towa and all of us who are consumers of health services in Towa, to the entire committee, particularly you as chairman of the committee. and to Senator Dominick of Colorado who has been traveling and making great contributions in the entire field of public health in America. We are pleased that you selected Towa and Des Moines to hold this particular series of hearings. Senator Kex~xepy. Senator Dominick. Senator Dominick. Mr. Chairman, T just want to acknowledge my thanks to both you and Senator Hughes for the leadership and hard work that we have put into the health field. 2273 I do have just a few things which T think might be of interest to the group, as to the Health Subcommittee jurisdiction and what we have been trying to do. In the last Congress under the chairmanship of Senator Yar- borough, this subcommittee acted on a wide range of health legisla- tion and much of it was enacted into law. We recommended and Congress enacted legislation which provides grants to schools of public health, assistance to modern agricultural workers’ health programs, Federal aid to community mental health centers, Federal assistance to medical libraries, Federal dollars for vaccination programs and extension of the regional medical program which funds projects across the country in health education and de- livery, control of heart disease, cancer, strokes, and now kidney diseases. We also acted on legislation during the last Congress to extend comprehensive health planning, provide additional aid to fight men- tal retardation and help children with development disability, to ex- tend and improve training programs for allied health professions, to establish a landmark program for the prevention and treatment of alcoholism, to authorize the use of public health service personnel in areas where there are shortages of physicians. Additionally, we acted on legislation to provide help to persons desir- ing family planning information. We passed occupational health and safety legislation, the Clean Air Act, the Child Protection and Toy Safety Act, the Federal Coal Mine Health and Safety Act, Lead Base Paint Poison Prevention Act and the Air Pollution Control Stand- ards Act. In this Congress some 30 bills and resolutions covering a broad range of health matters have already been referred to us. Some of the most important of these deal with problems relating to the shortage and maldistribution of health manpower. For example, the Health Profession’s Educational Assistance Act which provides Federal as- sistance to schools and students of medicine, dentistry, osteopathy, podiatry, pharmacy, optometry and veterinary medicine, will expire July 1 of this year, and bills which would extend and modify that are now pending action before the subcommittee. It has been said in the analysis of the health care crisis there is an acute and worsening shortage of all kinds of health personnel, espe- cially doctors, but the truth is that we have one of the highest ratios of doctor per capita in the world. The number of physicians is growing at a rate faster than our population. In 1950 the population of the physician ratio was 711 to 1. Now it is 630 to 1. The number of medical schools and medical students is showing unparalleled growth. In the school year of 1966 to 1967 there were 89 medical schools and just over 33,000 medical students. It is anticipated that by next year, 5 years later, there will be 114 schools and over 43,000 medical students, an increase of 25 schools and 10,000 students. Now, this is not to say that we don’t need more medical schools and more doctors. We do. But as Senator Kennedy has said, the basic problems, or many of them, are maldistribution, too few doctors in the innercity and rural America and maybe a tendency to specialize. 2274 Steps are being taken to correct this and I hope that we will be able to go get some help on it. What I'm really trying to point out is that the health problems of the country are very complex and it is unrealistic to place too much faith in just simple solutions. We have made progress. More prog- ress must be made. But there really isn’t any simplistic answer, no one scheme or pro- gram can do it all. Lincoln once said that for every human problem there is an answer that is simple, neat, and wrong, and I think it is worthwhile keeping that in mind as we go through the various prob- lems that are in the health field. Let me tell you how delighted T am to be here to listen and to learn. Senator Kennepy. Thank you very much, Senator Dominick. TI hope everyone can see these charts, which give a visual represen- tation of the rising costs of health care, both in terms of doctors’ fees and hospital fees. We have here also a chart that shows the in- crease between 1960 and 1970 of an average hospital day in Des Moines. In this other chart, you see the number of patients per doctor in Towa, which shows a steady increase in the number of patients per doctor. This highlights your increasingly serious doctor shortage. The AMA suggests one doctor for 750 patients is good, but in rural Towa it is one doctor to 3,000 people. In 1950 it was one for 1,912. Today it is one to 3,000. So we can see the problem getting worse. Shortage of health manpower, of course, is a very important fea- ture of the health crisis everywhere in rural America. We have seen some very interesting programs here in Des Moines attempting to get doctors out into the countryside. Those who wish to testify should come to this desk. Miss Souliotis, in the green dress, will take your names and we will just call on you in the order in which names are filed. Mr. Dimery, Porter Dimery. Mr. Dimery, we are glad to have you. I would just say, sharing one’s family sicknesses or hardships 1s always difficult, and to do it publicly is even more difficult. We are enormously appreciative that many individuals this morning are willing to tell us about their family problems. American people just don’t like to bother other people about it when they are sick. They don’t like to bother people about family difficulties. I think that is one of the reasons that we haven’t moved more dramatically in the health area, people don’t like to speak out. It is most important if we are to gather some idea of the dimen- sions of the problems people face, to have this kind of information, so we are very appreciative to all of the witnesses this morning. STATEMENT OF PORTER DIMERY, DES MOINES, IOWA Myr. Dimery. Senators Dominick, Kennedy, and Hughes. Yes, IT am going to talk about my personal problem, but I want to go back about ) years. I think this is about the time the OEO program came into the city of Des Moines. I was one of the persons that received benefit: from this program, and we want to talk about the health problem in the city of Des Moines and the State of Towa. 2275 Through this program there were people like myself who became involved and brought the awareness of the health problem to the entire State. I don’t have any statistics to tell you what has been done In this period of time, but I know there still are people, who like myself, are trying to bring forth these kinds of things to the proper people who are administrators of the health program. . I think we have come a long way in the State of Towa and the city of Des Moines in terms of health, but there is still a long ways to go. I suppose that you are all aware of that, or you would not be here this morning if there wasn’t a problem. s ’ I want to say that I personally, on behalf of my wife and my family, we appreciate this opportunity to bring our information to you because there was a time when we were pretty well up against a wall as far as health problems were concerned. . Unfortunately, there were no particular foundations of any kind that were set aside for the particular problem we had. We went through a series of humiliating experiences before we obtained the kind of help that we needed. : I want to take this time to say to the city of Des Moines and the State of Towa, I think if we continue to take interest as we have in the last 6 years progress will be made. I say I have been involved in the OEO program, and you will help as a committee, which I think is doing a marvelous job. I think we are going to go a long way in getting some of the problems solved. We don’t get the entire health problem solved, but we are going to get most of it done. I want to say again I appreciate this opportunity. Senator Kenxepy. Now, you had some problems with your son. Could you share those with us? Mr. Divery. Well, after a period of time there were Senator KexNepy. You were working a number of years and then were caught in the transfer of some jobs. Then your son got sick. Could you tell us a little bit about that? Mr. Dimery. Right. This was a very unusual situation. I worked at the Iowa Packing Plant for 20 years and it closed down, and through all the period of time I was deciding what 1 was going to do, and with the help of Senator Hughes and some other people, why, there was a training course established for meat cutting and retail. I was just about halfway through this when this happened to my boy, and the diagnosis was that he had tranverse myelitis, which is a very rare kind of disease, I suppose. There was no foundation, as I said. There were no foundations established for this particular thing. Senator Kex~epy. This happened when you were between jobs, is that right? Mr. Dimery. Right. Senator KexNEpy. And your boy got sick so he went to the hospital ? Mr. Divery. Right. The first initial contact was Broadlawns, which I think you people visited. He was there for a period of time and it was determined that they had done what they could for him, and as a result he was transferred to Towa City for some work down there, at the end of the crisis period. For purposes of rehabilitation. This is 2276 when the problem. as far as the family responsibility is concerned, when it was time for him to come home. Senator Kex~xepy. How long had he been in the hospital? Mr. Divery. A year and a half. Senator Kex~epy. And you had gotten another job? Mr. DimEry. Yes. Senator Kexxepy. But when he first went into the hospital you weren’t working, is that right ? Mr. Diarery. Right. T was in school at that time. Senator Kex~yepy. You had been working and then you were in be- tween jobs and found out your son was sick and he went to the hos- pital and then you got a job. How long was it in between jobs? What was that period of time? Mr. Dimery. About 9 months. Senator Kexxepy. About 9 months. Did you get some bills during this period of time in between jobs? Mr. DiMERY. Yes. Senator Kex~xeny. Hospital bills? Mr. Dimery. Right. Senator Kex~epy. Were you covered by insurance ? Mr. Dimery. I had a very small insurance, which is just a kind of thing which just gets you in the door. Senator Kex~xepy. Kind of insurance just to get you in the door? Mr. Divery. Yes. Hospitalization, you know. I think it provided about a 30-percent coverage. Senator Kex~epy. You need some insurance just to get inside the door? Mr. Dimery. Yes, as IT went further I found this to be the case. 1 mean the determination one has to have to overcome these kinds of things, but I think this is one of the problems in the entire health situation. Senator Krxxepy. What were your total medical bills for your son ¢ Mr. Dimery. I would say roughly about $8,000. I know in this par- ticular hospital it was $6,000. Senator Kexxepy. And how much of that bill did your insurance cover or pay ? Mr. Dimery. It didn’t cover any. Senator Kex~epy. Didn’t cover any ? Mr. Dimery. No. Senator Kexxepy. Would it have covered part of that bill if you had been working during that period of time ? Mr. Dimery. Right. Well, I was just in a probation period with the second job I went into. Senator KenNepy. You were in the probation period. But you were in between jobs when you found your son got sick, as I understand it? Mr. Dimery. Right. Senator KenNEpy. And then you were later employed but on the probation period, so the insurance still didn’t cover you ¢ Mr. Dimery. Right. Senator KenNepy. And this is a rare disease which you have abso- lutely no control over, do you ? Mr. DimEery. No. 2277 Senator Kennepy. There was no way you could have taken care of your child or prevented him from having that, as I understand it ¢ Mr. Dimery. This is very true. Senator KennNepy. Then you got this bill in excess of $6,000. Now, what are you doing about that? What can you do about it ? Mr. Dimery. Well, fortunately enough of the bill was paid by some very nice people, the entire State of Iowa, including Illinois and some others. They paid for it. Senator Kennepy. You had to depend upon the good will of some of your friends, neighbors and other people who were kind enough to make some contribution to pay that bill off ? Mr. DimEery. Right. A Senator KexNeDY. And so now you don’t have any medical bills, or o you! Mr. Dimery. Yes, I've had medical bills. I think the first 3 months of this year I've spent about $700. Senator Kennepy. How much ? Mr. Dimery. $700. Senator Kennepy. Is this for your son ? Mr. DimEery. No, not for the son. This is for the entire family. Senator Kenxepy. How much of those bills are covered by insurance ? Mr. Dimery. Well, the hospital part. Senator Kennepy. About how much would that cover, do you remem- ber, offhand? You are covered now by some hospitalization program ? Mr. DimEery. Yes. Senator Ken~NEpY. And your son, he’ll be coming home to enter high school, is that right ? Mr. Dimery. Right. Senator Kennepy. And will there have to be some expenditures for care for him in the future? Mr. Dimery. Right. Senator Ken~nepy. And were you able to get a new insurance pro- gram that would cover those expenses ? Mr. Dimery. No. This insurance covers—I mean, the insurance is hospitalization only. It does not cover the same kind of sickness. Senator Kexnepy. How do you expect to be able to pay for those bills ? Mr. Dimery. Well, this is up in the air, I suppose, and depends on what I can do. IT have no doubt that he is going to be taken care of. Senator Ken~epy. Well, you'd spend your last dollar, wouldn’t you, to take care of him ? Mr. DimEery. Yes, sir. Senator Kennepy. And you have probably spent almost your last dollar for him today, haven't you? Mr. Dimery. Very true. Senator Ken~epy. And still you can only look forward to continu- ing medical bills for your son for how long in the future ? Mr. Dimery. Well, until he’s able to make himself independent of me, that is, by vocational training and obtaining a job. Senator Kennepy. OK. Thank you very much. Mr. DimEery. Thank you. 2278 Senator Huanes. Mr. Dimery, I'd like to ask you just a few ques- tions. I'd rather say Porter than Mr. Dimery. We have been friends for many years. I'd just like the record to show that Porter Dimery has been a hard- working man all the days of his life that I have had an acquaintance- ship with him. He worked in the packinghouse down here for 20 years, as he indicated. He rose to the position of supervisor. He is well re- spected in his community. He worked together with me on many of the common problems of this community, the black and white racial problems that existed here, and on job opportunities and public service boards; I had the privilege of appointing him to them when IT was Governor of this State. ; He is a man who, as he indicated—and I guess I am really stating this as a character witness more than anything else—has worked hard for his family. I have visited in their home and met their children, and they have experienced what is a rather common tragedy in America. An acute and serious illness struck one of the children, and it literally will take every dime that they have managed to work and save for. He was in an intermediary training program for meat cutters and butchers at the time his son was stricken, and if it had been possible for this man in any way to cover medical expenses, he would have. That's the only thing I wanted to make sure that the record shows very clearly. Again I express my appreciation and offer my own en- couragement for what you have been doing. Mr. Dimery. Thank you, Senator Kennedy and Senator Hughes. Senator Kenx~epy. Thank you, Mr. Dimery. We appreciate very much your appearing here. Mrs. Allen Hentges. STATEMENT OF MRS. JUDITH HENTGES, DUBUQUE, IOWA Mrs. Hexters. My name is Judith Hentges, and 1 live at 1137 High Bluff in Dubuque, Iowa. I am employed by National Tea Clo. and have been for the last 8 years. I am a member of the Retail Clerks Union. and IT underlined this at the very beginning. Just after the birth of our first baby 11 years ago, my husband came down with cancer. Three operations followed at this time, and a first tumor was treated with 6 weeks of radioactive cobalt. A second tumor was halted with X-ray treatment about a year later. Last No- vember, he went back to work for the first time in 10 years. Three days later he fell, and they found cancer in his hip, and they had to amputate over 25 percent of his body. During this same 13-year period, the first of our four children, Brad, had undergone six major operations plus measles, meningitis. scarlet fever, and a host of other ailments. We have a long list of other problems suffered by our family, but I simply won't take time to count these. My husband had group insurance coverage originally, but it ran out when he was permanently disabled. When I became a member of the Retail Clerks Union 7 years ago, our family was literally saved from 2279 financial disaster. The union has negotiated an excellent program, and I understand clearly that this is a union gain. We have given up wage increases in order to build a better health care program. In this union, benefits paid for a major portion of our health care bill, but the private insurance system doesn’t work. Even when our family had two private insurance programs, it didn’t work. We were covered by two different private insurance plans when Brad was ill, and we simply exhausted all private insurance benefits and had to pay everything out of our pocket. Last summer since July, my husband, Allen, has undergone surgery six different times. Even with the very best union coverage, we face these bills yet: $270 to the doctor, $755 for medicine, $135 for anes- theties, and $210 for the hospital, which totals $1,370, but we got a break as the hospital called and said that our bill was paid in full. Our family has been at Xavier Hospital so often that the Xavier Gift Shop Circle paid the entire $210 of the bill for hospitalization. Now, I make good money at my job, but I don’t make enough to pay $1,160 at any one time. Things have been so tough at our house that my mom and dad have chipped in over $1,600 just to have food, and they have mortgaged their future. I am 30 years sold, and my disabled husband is 34. We are both proud and so are our four children, but we face a bleak future. He didn’t want to be ill, and I myself am now waiting surgery on a growth resulting from an ulcer brought on by these stresses. I think we should figure out a system of help here that keeps us healthy. I think we have a right to this good health care, and I think we should pass a law to make it available to all the people throughout the country. I am proud, and I don’t want benefits staged for myself or my family. I don’t like friends passing the hat, and I don’t want bowling leagues sending gifts. I am very grateful, but it still hurts. It hurts my husband, and it hurts my children. As Americans, I think we have a right to good health care; and IT want my Government to pass a law that would make this right a reality for all people because there are people that have many, many more problems than we do. [ Applause. ] Senator Dominick. Mrs. Hentges, we have run into similar situa- tions in other hearings in which there have been circumstances just as difficult as in your case. Would you tell me what problems you en- countered with your so-called private insurance? Did your private insurance company just run out of the amount of money that was involved? He~Ters. Yes. When Brad was stricken with the meningitis he ras totally deaf for over 6 weeks and he had to have several operations as a result of this, and on meningitis and ear operations they have a maximum and he ran out of the maximum the last two operations that he had. They were well over $3,000. But, I mean, here again we were very lucky. As I said, T know there are many people who weren't near as lucky because we have been very, very lucky. We have a marvelous doctor and when he found out the insurance companies had paid the maximum, he allowed us $365 off of our total of his bill which was almost half of what we still owed him 2280 and he didn’t charge us anywhere near as much as he could have, be- cause he had to rebuild bones. He had a plastic eardrum put in, and several other things. Senator Dominick. What happened in the retail union care program which you now have? Does that program cover a good portion of your bills? Mrs. Hexters. Very, very much of it. With Allen’s last operation he had to go to Towa (lity because it was something that they had never done at the Xavier Hospital. When he was first stricken with cancer he had to go to Towa City on the State because we had already had over a year with Brad in and out of the hospital. He was born with abnormally large tonsils and extremely small ear canals and he was in the hospital most of the first year he was operated on. When he was 15 months old, in fact, he was operated on on a Thursday and Allen had a chest exploratory operation the following Friday at Towa City for the cancer, and it was very rare. We were down there over 3 months and Allen had 6 weeks of cobalt treatment, which at that time was very expensive. It was relatively new, and the State covered all of these costs. Senator Dominick. The State covered all of the expenses? Mrs. Hentors. All of these costs for Allen’s care down there and they are paying the balance now of his care because he had to have his left leg, entire hip and the entire half of his pelvis removed, plus two other operations along with this, as he had a bone cancer that was running through the bones. He will be going back again in June and we will have to go regularly for 2 or 3 years. Senator Dominick. Is there a maximum amount of coverage in your retail union care program ? Mrs. Henrtees. Well, they pay just so long. T mean I don’t know exactly what it is, but I mean they have paid very well because he was in the hospital last summer, the first operations he had. He burst both major arteries in his stomach and he had to have emergency surgery on that. He had several transfusions and was in intensive care in the hospital. The union insurance paid very, very well on that. We were left with somewhere around $600 or $700, and the medical bills were really, you know, what was high, because he was on medi- cation and has been on medication since, and he will be yet for some time to come. Senator Ken~epy. Your family has suffered enormous pain during the period of these recent years. I suppose the question you are asking 1s why in our society individuals who have so little control over the kinds of problems you have, should endure not only the enormous pain and suffering and inconvenience and personal hardship but also the financial tragedy as well ? Mrs. HENTGES. Yes. Senator Kexnepy. I mean it is a thing you have absolutely no con- trol over. As Senator Hughes pointed out about Porter and yourself, you are hardworking people trying to raise a family, making some kind of meaningful contribution to the community, and yet your total savings have been wiped out. This affects the education of your chil- dren. It affects your parents’ retirement as well. They have been able 2281 to accumulate some savings over a lifetime of service to the commu- nity. Why should you and they be confronted with this kind of a bankruptcy ? Mrs. Hextees. Yes. I feel very strongly that my parents and his parents—his dad is dead now, but he has contributed well over $2,000 for clothing and food and things like this. IT mean they are all necessities. Senator Kexxepy. When we talk about these catastrophic kinds of expenses, I suppose that $1,370 looks as catastrophic to you, as $5,000 or $10,000 would look to a wealthy man. I mean catastrophic expenses are really relative. For somebody who is hard working, such as your- selves, $1,370 is a lot of money, and I for one am not satisfied that even if we provide for catastrophic expenses in terms of some dollar figure, say $15,000 or $20,000, that that would be useful and helpful. Thank you very much. Mrs. Hextees. Thank you. Senator Kex~epy. Mrs. Williams and Ray Tillery. Mrs. Williams is a public health nurse. We want to welcome you here. We have seen the public health nurses performing important serv- ices in many different parts of our country. I was most impressed see- ing them in some of the most remote, difficult parts of the country in Alaska, and making a terribly important contribution. We are great believers in the public health nursing system, and I want to welcome you here. STATEMENT OF MRS. JOANNE WILLIAMS, PUBLIC HEALTH NURSE, AND RAY TILLERY, DES MOINES, IOWA Mrs. Wirriams. Thank you. I was asked to come with Mr. Tillery to be able to speak for him, and I will try to do just that, letting him answer questions in writing that you might have, and I will read those to you. I do that since Mr. Tillery had a total laryngectomy last month, and that is the reason that he was referred to the Des Moines Polk County Public Health Nursing Association, and we have been seeing him since that time. Mr. Tillery was operated on in Towa City on the 10th of April this year. As opposed to the two people who have been speaking, their prob- lems with medical care have been going on for a very long time. Mr. Tillery’s of much less time than that, but probably he is a good exam- ple of how these kinds of problems begin, and we would hope that something could be done before the problems that he is now experi- encing snowball and become much larger than they are already. Mr. Tillery, after having the laryngectomy, returned home to Des Moines on the 26th of April and this is where problems begin, particu- larly in the area of funds. To have the kind of care that is needed to care for this surgery that he has had requires some special equipment. These things, the main items, would be a humidifier that is crucial for him to have in his home at all times, and a tracheal suction. He does not know vet how much of his hospital bill is going to be covered. Tt is a $2,000 bill. He suspects that he will have a portion of that to pay. 59-661 0—71—pt. 10——5 2282 He got himself into an emergency situation that we feel that he was not responsible for, soon after returning home, and part of this, we felt, was one of the gaps that have occurred in his care. He was asked to go to a local agency to obtain the humidifier and the suction that he needed. He followed through with this and did bring home a humidifier, but he did not bring home the suction. He was told that this would have to be rented, and no help was offered in getting that for him. When we saw him following this, we found that Mr. Tillery had to go to the hospital as an emergency patient. He was taken there by the fire department because he couldn’t breathe, and the reason that he couldn’t breathe was because—well, two reasons. He hadn’t had a suc- tion to do the kind of suctioning that he had been instructed to do and he had a humidifier that he had obtained, but this humidifier worked so poorly he might as well not have had one. Since that time we have gotten a humidifier for him and we were able to get that without cost to him, but the suction is rented and this is costing him $20 a month until we can find some other means of pro- viding this. He has not, at this time, been able to have any kind of funds coming in. He, of course, is unable to work yet. He will not be able to return to his old job because of the laryngectomy. He will not be able to speak and his job involved using a telephone. Social security and other possibilities of funds, these things take time. That means that there is no immediate help for him. That means that there are no funds coming in. Yet, he has costs immediately and bills are coming already. Bills for the suction already. The fact that he got into this unfortunate emergency situation that just should not have happened means that he had to go to the doctor every other day as a result of that, to be seen, and his insurance doesn’t cover doctor bills. He is still, at this time, having to see the doctor on a weekly basis and this would not have happened had he had the equipment that he needed or had some plan for covering these costs right away, and he doesn’t know yet how soon he will have any help with covering these costs and they keep coming. This is going to be not just for a few weeks but for an indefinite period of time. That’s basically the situation. Maybe you have questions that IT could ask him specifically. Senator Kexnepy. As T understand it, he’s worked all his life? Mrs. Winnianms. Yes; he worked as a rate clerk for a truckline. Senator Kex~Nepy. About how many years? Mrs. WirLiams. Thirty-one years. And the nature of that job means using the telephone. Senator Ken~epy. Thirty-one years and he’s had this kind of dif- ficulty. As I understand it, after he left the hospital he went home; is that correct? Mrs. Winriams. Yes. Senator Ken~Nepy. And he lives by himself? Mrs. Wirriams. Yes; his wife is dead. 2283 Senator Kex~Nepy. Lives by himself and he’s at home and he is told when he leaves that he has to get a humidifier and also a suction ? Mrs. WiLLiams. Yes. Senator Kexxepy. Now, how in the world does somebody know where to go to get a humidifier and suction? Do they know where to go? Mrs. Wirpiams. He had some names of places. Senator Kennepy. Do they give you a list of places and put you on your own ? Mrs. Winriams. Yes, and he was trying to follow through with this and, of course, when you go to where you are instructed to go and you don’t get what you need, then you are blocked, and that’s what happened to him. And the fact that he is alone, it was very fortunate that when this happened to him, this emergency arose, it was very early in the morning, about 6 or 7 in the morning, and he was able to arouse someone else in the building. The gentleman who he did get awake said at first he just didn’t want to go to the door, this early in the morning and somebody knocking, and he said, “Who’s there”, and nobody answered. Of course, Mr. Tillery couldn't answer, and nobody answered and he just almost didn’t go to the door. Of course, if he had not, Mr. Tillery undoubtedly would have died. Senator Kex~epy. Now, what’s the cost of renting this kind of equipment ? Mrs. Wirniams. $20 a month. That doesn’t sound like a lot, but when you don’t have any money coming in, you have got that plus bills for doctor’s office visits. Senator Kex~Nepy. He doesn’t have these resources even in terms of social security disability? You have to be disabled for a year before that starts? Mrs. Wirniams. It would be some time. Senator Kenxepy. And then even the money that you do get is completely inadequate. rs Mrs. WirLiams. He’s made application for it, but it doesn’t help now. Senator Kex~NEDpY. So he’s got $20 a month and because he is un- able to get that $20 a month cold cash, he is unable to get that piece of equipment. Mrs. WirLiams. And Mr. Tillery, being a very conscientious man about his bills, this bothers him, you know. He showed me he’s got one bill already, and they will, of course, be continuing, and this is a concern. Senator Ken~epy. What did his insurance program in the union cover? It must have covered some of this. Mrs. Wirriams. Probably will cover—again I’m not sure, but hope- fully will cover a good portion of the hospital bill. Senator Ken~epy. His hospital bill ? Mrs. WiLLiams. Yes; about two-thirds. Senator Kennepy. About two-thirds. But he still will have bills. Will they cover the payment for this other equipment ? Mrs. WirLiams. No; and not for the doctors. 2284 Senator Kex~epy. That has to be paid for by him ? Mrs. WiLriams. By him. Not for the doctor’s office visits. Senator Krx~epy. Has he had some savings over the period of 31 years? Mrs. Winriams. Some savings. A little. Senator Krx~epy. How long does he think the savings can last ? Mrs. Wirniams. Maybe 2 or 3 months. Senator Kex~epy. Two or 3 months? Mrs. WirLiams. Without any income coming in. And he, of course, will later begin some training for his speech, but this you cannot begin right away. Senator Kennepy. How did you become involved in this case? Mrs. Wirriams. This was through referral from Towa City and we were pleased that he was referred to us since we are trying to provide some help. Senator Ken~epy. How much time had elapsed from the time he had been dismissed from the hospital to the time of your referral ? Mrs. Winriams. Just 2 days, but all this happened so quickly. Senator Kenney. All this happened in 2 days. Mrs. WiLLiams. Yes. Senator Kennepy. Did he know that you'd be coming ? Mrs. WirLiams. Yes. Senator Kennepy. They had told him that there would be somebody ? Mrs. WinLiams. Yes. He didn’t have really any way of knowing just who we were or anything, but he did know a nurse would come. Senator Kennepy. But you don’t have anything in your budget that would help ? Mrs. WiLLiams. No. Senator Kennepy. You can recognize the need and see that it is really only a modest sum. You can see $20 a month is significant to somebody who hasn’t an income and only a modest savings and has medical bills besides, but you don’t have any resources and there is nothing available to you to provide this? Mrs. WiLuiams. No. We have no funds through our agency that would cover this. There is, through agency funds, through United Way and so forth, who may be the ones that will be picking up costs for our visits. Of course, our visits, you know, do involve a fee and we would not expect Mr. Tillery to have to pay "those. We are not sure just who is going to pay those yet, but it will be picked up some way so that he would not have to pay those. Senator Ken~epy. I suppose the chances of an emergency would be much less for Mr. Tillery if he had the suction machine and the humid- ifier, would they not ? Mrs. Winniams. Yes. Because he did receive some instruction before he left the hospital. Senator Ken~Nepy. IT mean if he had those two devices, the chances for complications are vastly diminished ? Mrs. Wirniams. Yes. Senator KexNEpY. Nonetheless, even as he walks out of this hearing today it is simply financial support that he lacks. He will be going back to his place where he lives, by himself, having that question al- ways in his mind whether that fellow is going to answer the door the next time he knocks. 2285 Mrs. Wirriams. Yes, and he will be for a long time going through still a recovery period. Something could happen. Senator Donner. Mrs. Williams, T gather that Mr. Tillery has worked 31 years for the trucking company. Do they have a retire- ment program for him ? Mrs. WitLiams. Yes. We have talked about that a little bit and there is a possibility that he will go ahead and retire. Senator Kex~epy. How old is he ? Mrs. Wirniams. Is it 62, Mr. Tillery, or 63? 56. That’s still, you know, a young man, but he could retire. That would be probably, he’s told me, about 4 months before that would begin. ¥ Senator Dominick. Now, does the union also have disability payments ? ¥ Mrs. WiLLiams. No. Senator Dominick. How long in your opinion would it take after he applies for social security, to start receiving benefits. _ Mrs. Witniams. They will not give us a date. From our exper- lence we would say that it is several months. Probably a minimum of 3 or 4. Possibly considerably longer. Senator Dominick. Is there any way of speeding up that process in this kind of situation ? Mrs. WinLiams. Don’t know of any. Our agency has contacted—— Senator Dominick. The application has been submitted ? Mrs. WiLLiams. Yes. Senator Kex~epy. We will follow up. Here's just one example. I'm sure there are thousands of examples like this. We can follow up on this. We will. But I don’t know why you should have to have Members of Congress following up on these matters and not having it as a matter of right. Thank you very much. Angie Roby, a nurse from Des Moines General Hospital. STATEMENT OF MISS ANGIE ROBY, NURSE AT DES MOINES GENERAL HOSPITAL, DES MOINES, IOWA Miss Rosy. I am speaking on behalf of my parents who really didn’t feel they could go through this themselves. They had a 6-year old child who—it will be 3 years this April— had been a fairly normal child. He had a mild cerebral palsy which only really affected him from his elbow down, and he was classified as an epileptic but yet he was a very intelligent child which showed even when he was in kindergarten, so we felt very happy even though he had this limited cerebral palsy. We thought, well, it could be worse. Well, on a Tuesday in April it struck. He had a seizure which we thought was a regular seizure. We took him to the hospital, but he never came out of the coma One week later on a Sunday Dr. Spevak was called in and he decided the child needed a blood exchange. This didn’t help. He did a craniotomy and tracheotomy. He was still living, but still it didn’t help. : My parents, after 2 or 3 months, took him to Rochester in hopes that the tumor they found during the craniotomy could be removed. They spent a week to a week and a half up in Rochester to no avail. They 2286 said that they couldn’t prove that there was a tumor by the tests they performed, but yet if he had a tumor they couldn't remove it here they wouldn't be able to remove it there, so they brought him back and he had to travel by airplane both ways because they didn’t feel he could travel by ambulance or car. During this same summer of June, July, and August, both my par- ents and one of my brothers were admitted to Lutheran. They just couldn't take it any longer because they had all been so close to little Allen, so we had bills pile up from psychiatric care for my mother and my brother. Then he was readmitted to Mercy up until September. We got a letter from the utilization committee saying they could no longer take care of this child, he didn’t need hospital services. He was just taking up a bed. Senator Kennepy. What's the utilization committee ? Miss Rosy. As far as I know, they eliminate unnecessary patients to keep the flow of beds open. Senator Ken~epy. What do you mean by that ? Miss Rosy. Well, I talked Senator Kenxnepy. What sort of unnecessary patients do they eliminate ? Miss Rosy. Well, they feel, from what I got from one of the doctors, was if they didn’t use X-rays and need the facilities that are right there in the hospital, like if they needed custodial care, then they really didn’t need a hospital, even though we had insurance "that would have covered the child for 2 years. Yet we couldn't bring this child home, we felt, because of the situation with my mother and brother. Senator Ken~epy. So the utilization committee said the boy had to leave? Miss Rosy. He had to leave, right. Senator KexnNepy. In spite of the conditions in your home? Miss Rosy. Right, and, you know, they weren't going to be out of any money either. Senator Kenxepy. Well, money doesn’t make a difference, does it, to the utilization committee ? Miss Rosy. No. We thought maybe it would, you know, so we ex- plained to them our insurance would pay on this. Senator Kexxepy. Why did you think it might? Miss Rory. Well, as a nurse, I know when insurance runs out a lot of times then they want to transfer them, which would have been fine if our insurance would have run out, to be transferred to Broadlawns. Senator Kexxepy. They wouldn't want to transfer someone just be- -ause his insurance ran out, would they ? Miss Rory. They will, right, and they will transfer them to Broad- lawns. They get very good care and a lot of times the very same doctors. Senator Kex~eny. Transfer to where? Miss Rosy. Broadlawns. Senator Kexxepy. Out of the private into the county hospital? Miss Rosy. Yes. Senator Kexxepy. Just because the insurance is running out? Miss Rosy. Run out; and this a lot of times is to the advantage of the family so they don’t have mounting hospital costs. 2287 In November we did bring him home because we had no alternative. My parents had to take out a $5,000 loan to help with the cost to bring him home. We were told that we had to have a bedroom downstairs because they didn’t feel this child should be carried upstairs and carried back or left upstairs by himself. So we had to build a bedroom and we had a good $150 or $200 in just supplies that we had to have because he was being tube fed. He had to have a suction for a while, and all these things added to the cost. Besides, we had to have special diapers made and gowns to fit him. We had him home until the middle of February. He was readmitted to Methodist Hospital for reevaluation and he had pneumonia and from here he was taken to the convalescent home. He was there for a month and we were told that he would have to leave because they could only keep him on a rest period basis because they did not take care of total care patients on a long term, but yet there were children there who had been there 2 or 3 years, some of them. So we contacted Tom Whitney on the Polk County Board of Supervisors. Senator Kennepy. They also wanted to move your brother out? Miss Rosy. Right, and also when he was in Methodist, he was there 20 days for reevaluation and they gave a utilization committee letter saying he no longer needed hospital services. He needed custodial care. So when they took him to a convalescent home, after about a month or a month and a half my mother got a call saying they would have to remove him, come and get him that day. He was dismissed. It was rainy, it was cold. My mother assumed that the doctor had ordered it, because he had given the order for the child to go to the convalescent home. We got him home and 2 or 3 days later he was running a tempera- ture. He was developing pneumonia again. She called the doctor. He was very surprised. He didn’t even know the child had been dismissed. Senator Kex~Eepy. The doctor didn’t know ? Miss Rory. No, he didn’t. So then we had him home and he was re- admitted. Only after going to welfare, and this was the only way, could we get him readmitted to the convalescent home until we could find a foster home because it was a tremendous burden on my parents. They couldn’t afford the cost. It was mounting. They were spending $75 to $100 just on doctor bills, medicine, and supplies that were needed for him, and yet welfare will not pay or help you in your home. My father had a job at Firestone where he made good money, but yet he still had the $5,000 loan and hospital expenses that were partially left over, and doctor bills. Senator Kexxepy. And eight other children ? Miss Rosy. Right. So eventually we got him back in the convalescent home temporarily until a foster home could be found and welfare told us if we could find one and they approved it, he could go. _ Well, we found one. The woman was too old, they were going to re- tire her. We found another. They had one total care child already and they would not allow them to take another one. 2288 Our sources were beginning to be exhausted and then we got a call, on the birthday of my little brother, that he would be dismissed in a couple of days by the administrator again. } Senator Kex~xepy. Didn’t they know you were searching, trying to find one? Miss Rory. They knew this. Senator Kex~xEpy. Were you a nurse at this time? Miss Rosy. Yes, I was. Senator Kex~Nepy. So you know your way around the health system about as well as anyone ? Miss Rosy. And it does just about as much good as a lay person really. Our insurance was paying half of what they paid in the hos- pital bill. Tt was $17.50 to the convalescent home, so it was in October that they told my mother that she would have to remove the child in a couple days. We called Dr. Spevak and he said do not remove the child until he discharged him. We talked to Tom Whitney—that’s when the Polk County Board of Supervisors became involved. We had a hearing. Senator Kenxepy. You had to go to the Polk County Board of Supervisors ? Miss Rosy. And Tom Whitney told us that we wouldn’t have to worry. He told my mother that that child would not be removed until there was a place to take him, and they told us that he was to be out of the hospital by December 23, out of the convalescent home. Well, on December 23 at 4 a.m. we were called to come and get the child and take him to the hospital. December 24 he died. ~ We still have medical bills left over. Even though they are not mounting like they were during that period, but still you have to alleviate them. Besides, my mother had polio when she was 3 and we have bills still for her treatment, through the years, for surgery. Senator Kenxepy. How much are your medical bills, do you think? Miss Rory. Well, I know my parents still owe Dr. Spevak $269. They still owe $4,000 on the $5,000. They owe their own family doctor for the care of my mother, close to $300. Senator KenNepy. They have that $5,000 loan still to be paid? iy Rory. They have paid most of the interest on it. Now they owe $4,000. Senator KennNepy. They still owe the $4,000? Miss Rory. Right. Senator Kexxepy. Plus what, approximately $2,000? Miss Rory. Right. Then my mother’s shoes, which she needs—should be renewed every 6 months, but she can only buy a pair every year be- cause they are $130. ) Senator KeNNEepy. Is this because of the polio? Miss Ropy. Yes. And she’s trying to work now at a full-time job to help make ends meet. Senator Kexyepy. And you are going to try to pay this off ? Miss Rory. Yes. Senator KeNNepy. And your insurance didn’t cover the Miss Rony. They covered pretty well; most of the hospital bills. Senator Kex~epy. They paid part of it, but you still have, in spite of that coverage 2289 Miss Roey. Right, because they didn’t cover anything after the child was placed in the home, and later came back to the home. Senator Kennepy. They don’t cover that ? Miss Rory. No, they don’t. Senator KENNEDY. So you and your family, you are going to try and pay that off ? Miss Rosy. Right. My sister works and I work and Senator KenNepy. How old are the other members of the family? Miss Rosy. Let’s see. There's Bob, he was in the service but he’s going to school now with the service, but he’s 19. Senator Kenxepy. Where is your home ? Are you from Des Moines? Miss Roy. Right. On the west side. Senator KENNEDY. Just as a matter of information, did he volunteer or was he drafted ? Miss Rosy. Ie volunteered, but he didn’t spend the whole time be- cause during the time that the baby got real sick he asked for an emergency leave. He came home. The baby was still sick. He asked for an extension. It was granted by the sergeant. The lieutenant called and told him he could only have 5 days. He was to report back De- cember 19. He reported back. He got there and as soon as he got to the base the lieutenant told him he could take the extra time—if he had the money to go back home, if he wanted to, for Christmas vaca- tion. But my parents could not afford to send him the money to come back home, which if he had been granted the 12 days like he was sup- posed to have, he wouldn’t have had to pay the extra, and then he had to turn around and come back when the baby did die. Senator Dominick. The children’s convalescent home then, is de- signed to take care of those people who they consider to be curable be- cause of that home’s specific type of treatment. Is that correct ? Miss Roey. Well, this is what they claim, but they are also licensed to be a custodial and pediatric nursing home. Senator Dominick. They are licensed for both ? Miss Rosy. They are. Senator Dominick. So they are licensed for a custodial home as well ? Miss Rogy. Right. Senator Dominick. Is it more expensive at one of these children’s convalescent homes than it would be in a rest home or some other home? Miss Rosy. In the laws of Towa you cannot put a child in a nursing home for elderly people. They feel that this isn’t right, and I know my parents wouldn't have, you know, been able to accept this either. They had taken the child to Woodward for an evaluation that was requested by welfare. They went through the total care area and they couldn’t bring themselves to place him there because there are so many in just rows of beds that they didn’t feel he'd get the attention he needed, and the care, and also he was so susceptible to infections that he wouldn’t have lasted. Senator Dominick. Are the rest of the children in your family younger than you are? Miss Rony. Yes. Senator Doyintck. And they are all in school ? 2290 Miss Rony. There's three of us out of school now and the others are still in school. Senator Dominick. Now, you said that the insurance coverage would pay the home expenses up to a period of 3 years and yet you say that there were bills left unpaid. Miss Rony. They would have paid the hospital for 2 years and full coverage, except for doctors. They wouldn't have paid for the doctors. The convalescent home, they would have paid up to 120 days and we could have gotten an extension and they would have paid $17.50 a day. I think the fee then was $20, and my parents felt that considering the cost that it would have been at home, to bring him home, and the trauma and this, the extra $2.50, they’d manage it somehow. Senator Dominick. Thank you very much. Senator Kex~epy. Next is Mrs. Charles Banks. Mrs. Banks also is a nurse. STATEMENT OF MRS. CHARLES BANKS, NURSE, DES MOINES, IOWA Mrs. Banks. My husband is the individual I am talking about. He had a very sudden illness and he was taken ill on March 3, 1970. We had absolutely no warning. This is called an intracranial aneurysm. It is something like a stroke, but there’s much less chance of any type of guess as to the nature and extent of recovery. He could have died immediately and practically did, or any number of other things. He was taken to Lutheran Hospital that evening, within a period of about 10 minutes after we knew he was ill, and he stayed there for a little over 2 months. Then he was transferred—not quite. Excuse me. He was transferred on the last of April to Methodist Hospital, to the Younkers rehabilitation part, Younkers Rehabilita- tion Center, and he was there continuously until August 20, 1970. We had, in the middle of the summer or thereabouts, some letters from our msurance and they did pay the bill at Lutheran Hospital, but in November of 1970 I got a bill-—not a bill, excuse me. I got a letter from our insurance company saying they would only pay for half of his time at the Younkers center, and the reason they gave was that this was rehabilitation care that wasn't covered under our insur- ance. Now, we have the maximum coverage that you can have under this insurance. It is Blue Cross-Blue Shield, comprehensive 365 major medical. I work full time. I was in quite a state. God, I didn’t have any idea how I was going to pay a $6,000 bill, and in the meantime anyway I was paying about half of all the doctors’ bills and anesthesiology and all these things because my insurance covered roughly half. Oc- asionally a little more than that. We had, oh, anywhere from six or more doctors, so we had quite a few doctors to pay. This is where my doctor here at Younkers really stepped in for me and if he hadnt we just—well, I don’t know. I'd still have all unpaid bills. This is a little bit different. T had a little bid of insight as to where to go, so the first thing I did was to come to the Social Service De- partment here, and with which I had been in close contact anyway. 2291 All the way along I kept asking if there would be any chance my in- surance wouldn’t cover care at the rehabilitation center, otherwise I would have transferred my husband to Veterans’ hospital in the city. We knew this was going to be a long siege of hospitalization. The kind of care he needed related to his having some paralysis on one side. He had total memory loss at the time, and no ability to fune- tion on his own. They would restrain him in the room or in the wheel chair. He had a lot of bladder problems. Some of these things were directly associated with the acute illness, with bleeding in the head, which is what it was, and then these other problems arose as a result of the surgery. This involvement from the surgery is what gave us some of the other problems. Primarily the memory and the judgment. The man was what we call mentally incompetent and still is at this point. He is totally disabled and unable to work for that reason. I had been given no idea that my insurance wouldn’t cover the re- habilitation center when I got the letter, and then went back down to social service, and numerous phone calls to my insurance company, to try to find out who I was to talk to. Finally then I found out that if T had my doctor write a letter explaining exactly why the care that he had received essentially the last 214 to 3 months here at the Younkers Hospital was necessary above and beyond rehabilitation, apparently then they would take this under consideration again. My doctor did this and the letter pointed out that ever since this part of the hospital had been started, rehabilitation had been a covered service if it was directly in association with an acute illness, which his had been, and then at this point then it was paid. So we were finally reimbursed for it. By letter we knew it would be covered in February. Senator Kexxepy. Do I understand that you first went to the Younkers Hospital during April through June, and at that time Blue Cross paid this bill. Then at some point you went down to social serv- ices to try to get this Mrs. Banks. No, it paid the first hospital and then he was trans- ferred directly from one hospital to another. He was dismissed in August and in November I got the letter saying they would only pay half of his hospitalization. Senator Kexxepy. But had you checked before with the Social Serv- ice to get their guidance as to whether Mrs. Banks. Right. Several times. Senator Kex~xepy. I mean you had foresight ? Mrs. Banks. Yes. Senator Kex~epy. And you believed they would, and then rather than just leave that to chance, you went down to social service and asked them what guidance they might give you because you knew that there was at least the possible alternative of considering the VA Hos- pital. Then as I understand. they indicated to you that their interpre- tation was that it would be covered. Then when the time came for the bill, you found out they were only going to pay for half, and then you had to go through all the burdensome procedures to get full compen- sation for the hospitalization; is that correct ? Mrs. Baxxks. Yes; that’s right. 2292 Senator Kex~xepy. Now, why should Blue Cross be able to make that interpretation themselves? Mrs. Banks. I still don’t know, Senator Kennedy. I still have a bill I got 2 days ago, that my husband now has been back in the hospital for some minor ur inary problems again in January, and just 2 days ago I got another bill, saying a Blue Cross adjustment, and there is $320 they hadn’t covered again, so I have to go through this all over again. “Senator KexNepy. So you have to go through it all over again ? Mrs. Banks. Right. Senator Kux~epy. This is arbitrary. They make their judgment and then require you to go through this procedure to get it straightened out? Mrs. Banks. The responsibility, as far as their interpretation of it, rests with the consumer. The consumer must go to them and find out if there is some arrangement that can be made, if there is some reason why it should have been a covered charge; and my husband is still in need of 24-hour care. My husband still needs 24-hour care. I have someone with him at all times. T choose to do this so I can work. We had no idea it wouldn’t be covered. Senator Kexxepy. Are you taking steps to get some judgment on this? 1 would think that most people would have assumed that it would be covered in the first place, but you took an exploratory step to be sure, and then you were still put under the burden of having to get the doctors to sign and write these letters. What are you going to have to do now? Mrs. Banks. Well, T have to go through the process of calling and trying to find the right person again, and 1 suppose pulling out the rec- ords that they have and what part of the hospitalization Senator Kenxepy. We have Mr. Martin from the Blue Cross with us. He’s been kind enough to follow every time we have a hearing. He’s been traveling around the country with us. We have a good case for you here. If you can help out Mrs. Banks on this, we’d certainly appre- ciate that. You get Mr. Martin, Mrs. Banks, and see what he can do. Senator Dominick. Mrs. Banks, how is your husband now? Is he at home? Mrs. Banks. My husband physically would seem fine. Mentally, he is classified as an incompetent, which means he can’t be left alone in the house and can’t work, and we have no idea whether this is totally permanent or whether some time he might return to some kind of work. Senator Dominick. Do you have any children ? Mrs. Baxks. I don’t have any children. My husband had two chil- dren, and we had the child-support involvement there. We got social security—he was ill on March 3 and we finally got social security com- ing through in November. Up until that time, I assumed all the bills. Senator Dominick. This has been part of the problem in the social security disability area. It takes about 6 months to process a disability claim in Baltimore. I am happy to say we have a fellow from Colo- rado here, who I hope will speed up the system. Mrs. Banks. I have a question on that. When I originally went down, I was told there was no such thing as back payment for the 2293 months in between the time he was ill and the time it started, and IT am told now that there is and there isn’t and there is and there isn’t. So apparently this is no set thing either, and whether there would have been some money at that time that would have been available for us, I don’t know. Senator Dominick. Was the insurance that you had at that time taken out by you, or was that part of your husband’s insurance ? Mrs. Banks. It was taken out by my husband, and then when his sick leave was exhausted at his place of employment, then I trans- ferred it directly over to my group insurance. This is another concern of mine, because the type of his illness, he would never be able to get another insurance policy that would cover him. Senator Dominick. So at the moment then, you have group insur- ance under your own name ? Mrs. Banks. Yes. Senator Dominick. The original bill that you were talking about, which was close to $6,000, has been paid by Blue Cross ? Mrs. Banks. Yes; this was paid. It was $5,990. Almost $6,000, give or take a couple dollars. Senator Dominick. Well, the best of luck to you. Senator Kex~Nepy. We have better than luck. We have Blue Cross right over here. [ Laughter. | The next witness is Clifford Thomas. I understand he couldn’t be here; and his daughter, Mrs. Shirley Richards, is here in his place. We are glad to have you. STATEMENT OF MRS. SHIRLEY RICHARDS, DES MOINES, IOWA Mrs. Ricaaros. I didn’t know about this until 8 o’clock this morning. Senator Ken~epy. That's all right. Mrs. Ricuarps. But my mother has multiple sclerosis, and this was diagnosed in the year 1957. She walked up until about 2 years ago when she fell and she broke a vertebra in her back. She was taken to the hospital, and from there she went here to the Younkers Rehab Center, and she was here, oh, I think a couple of months, 2 or 3 months, and a man from a nursing home nearby said he would be more than happy to have her come over there because they had therapists, and this is what she needed because maybe she could take a few steps, and this would be better than nothing. So he took her over there, my stepfather. Well, first, he said that he didn’t have that type of money to put her into a nursing home. He said, “Well, forget about that. We will help her.” So they took her over there and she was there until October and it was something like pretty close to a $4,000 nursing home bill, and I found there were two nursing homes on the south side so I found one that I could get her in Jo my children could go see her because I figured this would help 1er too. So we took her over there, where the charge was $320 a month. I might add, that his income is something like $420. So he kept getting loans in order to do this. Her medication over there was somewhere in the neighborhood of between $50 and $70 a month. It varied. Well, they kept her just drugged. Half the time when we’d go up there she was just sort of half asleep. 2294 Senator Kexnepy. How do you know they drugged her? Mrs. Ricuarps. Well, this goes on. Because of the type of medication that she was taking. He asked a pharmacist. Well, anyway, it got to the point where—well, there was a member of the family who killed himself and this upset her quite a bit and she went into one of her little rages and started screaming and crying and they put her up- stairs in an attic room, and my 10-year-old came home—and this from a 10-year-old—he said, “Mom, there should be such things as mercy killing.” He said, “For my grandmother to be up there in that little attic room where you can’t even stand up, she’d be better off if she wasn’t here.” : So the next day I got on the phone—which I might add, we went to the social services. We tried to set some help from the State. We had an appeal. Mr. Gearing turned us down. So we started this all over again last October and we were turned down again. But anyway I got her into another nursing home which is $310 a month and it is also nearby. She is very happy. Our drug bills were cut in half, anywhere from $30 to $45 a month. They said she didn’t need these other medications that had been sent down from the other nursing home. This is why she told me, the nurse there, told me that she had been drugged. They kept her sedated so she wouldn’t cause any trouble. This is where I judge my opinion, from what the nurse told me. I called Multiple Sclerosis and asked them for help, because when we know she’d have to go to a nursing home IT was interested in some- body coming into the home and taking care of her this way and there was no way. Finances just wouldn’t permit it. We just couldn’t get any help any way, any place. So anyway he has tried and been turned down, and the social serv- ice commissioner told us that there's one way that he can get some help and that is if he does not pay his bills. However, he is a very hard working, proud man. If he wouldn’t pay his bills, get a court order—which this one nursing home had sued him for the balance of the bill. If he didn’t pay his bills, then they wouldn’t consider this income. Therefore the State would come in and help him. She just turned 54 years of age. She cannot get social security be- cause she hasn’t worked in the last 15 years, 15 or 20 years they said. She worked for Solar Aircraft. She worked for the ordnance plant. She’s worked all of her life, but yet she cannot get social security or any type of help at all. He has sold his home. He doesn’t own anything any more. So that is the story. I called Multiple Sclerosis, the center, and I asked them for a wheel chair and they said at that time there wasn’t any available and so they couldn’t help me. Senator Ken~epy. If you were able to get a wheel chair, what would that mean? Mrs. Ricuarps. Well, she could have—2 years ago she could have gotten around in this wheel chair. She could have pushed herself because she still has strength in her arms. Senator Kenxnepy. The fact you didn’t have the resources for a wheel chair meant she was bedridden ? 2295 Mrs. Ricuarps. She is bedridden. She is completely bedridden. About 6 months ago Multiple Sclerosis called me and told me they had a wheel chair available for my mother and I told them it wouldn't do any good now because she can’t sit in it. It is the type of disease which just deteriorates the muscles, so this is really sad. Senator Kex~Nepy. What do you think the total cost has been to your stepfather? Mrs. Ricaaros. Well, it’s $310 a month plus anywhere from $30 to $45 a month for drugs. This doesn’t count the nightgowns I sew. Senator KenNepy. You have been paying on this how long? Mrs. Ricuarps. Two years. Plus he has a back bill of about—I imagine it’s about $3,500. Senator Kexnepy. No insurance ? Mrs. Ricuarps. There was Blue Cross and Blue Shield and they paid about two-thirds; and when she came here, it didn’t pay it to the re- habilitation center. Senator KeN~epy. It ran out? Mrs. RicuarDs. Yes, it had run out. Senator KENNEDY. And this wiped out your savings? Mrs. Ricaarps. Yes. It wiped out his savings. He sold his home, he sold his furniture, and he does have an old automobile, but that’s it. He’s just been a hard working man all his life. Senator Ken~epy. How does he think he is going to be able to pay this in the future? Mrs. Ricaarps. I don’t know. There’s one person—He just keeps going from day to day. He gets a loan here, a note, and pays this one. This is the way he’s been going. The only people that have paid him, have helped him, was half of his nursing care which was $155, T believe, is the Disabled Veterans. He was a World War II veteran. He faced action, and they are the only ones that could do anything, and I said if they can do something for this man, why can’t somebody else? Our taxes pay for this. Senator Kexnepy. True. Senator Dominick. Did Mr. Thomas have any coverage at his job which would have taken care of his situation? Mrs. Ricraarps. This is Blue Cross. Tt is a group plan. T couldn’t tell you which one it is because IT don’t have that information available. Senator Dominick. Is that the insurance program that ran out? Mrs. Ricuarps. Yes. It ran out because she was in the hospital with this broken vertebra, which T might add the hospital didn’t keep very close care or watch on her, and she fell out of bed and was in pretty bad shape then, because when her head hit the floor: Senator Dominick. This is one of the problems that we face in many of the long-term illnesses of this kind. This particular case is really an excellent one to prove the need for some kind of long-term care. Mrs. Ricuarps. Yes. Well, our doctor is very, very reasonable. T know there are doctors, compared to my doctor, whe charge three- fourths more than what they should, and T don’t know. When you hear of things like this, you always look to socialized medicine. Would this be an answer? Senator Ken~Nepy. You don’t really have to go that far. [Laughter.] 2296 Mrs. Ricmarps. Sorry, but why should one doctor be allowed to charge so much more than the other when they usually aren’t as good? I had a case of this in my family a couple weeks ago when I went to a different doctor than our private doctor for my boy. Senator KenNepy. We are going to have the medical society testify later. Mrs. Ricaarps. Well, my doctor I know would be behind me 100 percent because we have discussed this, and this matter of drugs, this 1s something else. When people are in the nursing home, why should one drug store, one pharmacy, be allowed to charge twice as much as what the pharmacy ever here does? They all have the Federal stamp on them, so why should they be allowed to make more money on somebody who is sick and disabled ? Senator Kennepy. Thank you very much. T appreciate it. Mrs. Ricaarps. Thank you. Senator Kennepy. We now have two professional witnesses. Kenneth Lister is president-elect of the Towa Medical Society, and he has some people with him. He will introduce them. Lets see if we can keep to 12 or 13 minutes for this presentation, so we will have time later to open the hearing to others. Dr. Lister, IT appreciate very much your being here. You have a statement here that is some 12 pages long. Dr. Lister. It is our intent to highlight that statement. Senator Kex~Nepy. We will put it in the record in its entirety, follow- ing your testimony. You have heard a number of tragic situations this morning. We ’d be interested in what insight you would be able to pro- vide this subcommittee into some of these problems and what you think should be done. We are interested in trying to understand both the best and the more difficult aspects of the health system. We have heard about some of the more difficult aspects in this testimony. We have seen some of the best facilities early this morning and last evening. If you could proceed in that way and show us both sides we would appreciate it. STATEMENT OF KENNETH E. LISTER, M.D., PRESIDENT-ELECT, IOWA MEDICAL SOCIETY, OTTUMWA, IOWA Dr. Lister. On my left is Dr. S. P. Leinbach from Belmond, Towa. He is a past president of our society and a vice chairman of the Rural Health Council in the A.M. A. for many years. On my right is Dr. Paul Seebohm who is an associate dean of the College of Medicine at the University of Towa and a professor in the Department of Internal Medicine. At your suggestion, we will highlight some of the things in this statement which we feel require emphasis and let the remainder go. Senator Kenxepy. The full statement will appear in the record. Dr. Lister. Actually we want to direct our remarks to the delivery of medical care as contrasted to health care. We are not including environment, housing, nutrition, et cetera, so that our remarks will be limited to the delivery system of medical care. This actually divides itself into four segments, the preventative segment, diagnostic, therapeutic, and rehabilitation. Preventive care has been totally accepted in our State. We have a very enlightened population and a very active medical population. 2297 We report that 90 percent of our school children have received im- munizations including a statewide measles program which has prac- tically eradicated the disease in our locality. As you are well aware, the poliomyelitis is no longer a problem. We have had eight cases reported i in the last 5 years in the State of Towa, so there are some things of which we can be justly proud. As far as the manpower picture is concerned, this is a distressing graph which you have over here indicating the doctor shortage in Towa. I would draw your attention to the fact that in the last two decades, however, it’s been relatively stable. Since 1950 the popula- tion in the State has remained approximately the same and it is of interest to note that there’s been only 23 less doctors in 1970 than there were in 1950. So, to this group, of course, 2,400 physicians in the State, we have the help of approximately 400 osteopathic physicians who add greatly to the delivery of health services in our State. The cooperation between the physician and the osteopathic physician is increasing almost daily. In the health manpower picture approximately 50,000 persons are involved in the delivery system in the State, including all the ancilliary people. We are distressed by the rural to urban migration. We have been aware of it for many years. Physicians have tended to leave the smail community and congregate in the larger areas. They do this for the same reason that people move out of the rural areas. They want to associate themselves in groups so that they can have time free for study as well as time free for their own pleasures. We think that this situation is probably beyond remedy. We don’t think there is any way that they can be encouraged to stay in the smaller communities as compared to the larger ones. It is equally true that the mobility of our population has undergone the same improvements and we feel certain there is no citizen of our State who is more than 30 minutes away from either a doctor’s office or a hospital, Senator KENNEDY. You mean there is no one in the State of Towa that lives farther than a 20- to 30-minute drive away from a doctor or hospital ? Dr. Lister. That’s correct. In our efforts to remedy the situation so far as numbers are con- cerned, the State Medical Society has been very active in supporting the College of Medicine to increase enrollment. In the past 5 years the enrollment at the university, as Senator Dominick has mentioned, has increased 40 percent. In 1975 they will have an intern class of 175 students, which will be a big help. 1t is of interest that the college now is directing its curriculum into the community health cares anticipating using the larger urban hospi- tals in their community teaching and we feel that this program in itself will entice younger physicians to stay within our State. It might be of interest to you to know that the doctors in Towa have {financed a loan program, a foundation program, and we have actually loaned $400,000 to approximately 250 students on a return basis, so there is a continuing loan fund. The students have availed themselves of this money to its maximum. 59-661 O0—71—pt. 10——6 2298 I won’t go into the facilities. I'm sure somebody from the hospital industry will speak to those. There are a few rather unusual ones which are the total responsibility of the medical profession which should be brought to your attention. As T said, group practice is increasing its popularity and I think it will continue to do so. In addition to this, the State Medical Society has sponsored the development of community health programs. We have some 20 programs in the State now directed not only to the mental health state tself, but abuses of alcoholism and drug abuse. These are actually functioning groups and have been extremely well received. Most of the people in Towa, 80 percent, are covered by some form of health insurance. If you include the 16 percent that are covered by governmental programs, medicare and medicaid, 96 percent of the population has some form of health insurance. We agree that some of this is adequate and some is not adequate, but the figure is quite high in our State. The medical society has recently developed a foundation for medical care. This foundation will follow some of the tenets of the California foundations. We are not anyways near as sophisticated as they are in the application of peer review, but this is something that we have been doing for many years in our State anyway, so we hope to become more sophisticated and has a continuing on-going peer review program. This will assure quality in medicine at an equitable cost to all of the citizens of our State. One of our greatest assets is the health of our people. There is no denying that difficult challenges stand before us. No more challenging perhaps than those of the past, but nevertheless demanding our un- ceasing efforts. Indispensable in the delivery of modern health care are intelligent, motivated. and responsible people. The Towa Health Care team is one segment of the total State population known for its industrious nature, and with continuing leadership from this team the health care chal- lenges of today and tomorrow will be met. Thank you, sir. (The prepared statement of Dr. Lister follows :) PREPARED STATEMENT OF KENNETH E. LISTER, M.D., PRESIDENT-ELECT, IToWA MEDICAL SOCIETY, OTTUMWA, Towa This statement is for the purpose of providing to the U.S. Senate Subcommittee on Health basic information relative to health care and health care delivery in the State of Iowa. A completely comprehensive discussion of a subject so broad as health care could span many, many pages, even for a moderate-sized state such as Iowa. We have elected to abstract from the massive health care data which is available certain salient facts. In this way we believe it will be possible for the Subcommittee to gain some rather accurate impressions of the health care situation as it exists in Iowa. The population of the State of Towa is approximately 2.7 million ; its total area is just over 56,000 square miles. In both of these departments Iowa is very near the national mid-point with about as many states larger as smaller. At its birth in 1946 Towa was a setting of uncertainties for its scant population. The dreaded cholera took a heavy toll at that time. Life was most precarious during the early years of the State’s history. The frontier Iowan would be amazed at the progress his kin have made in safe- guarding and prolonging human life. He would be surprised to learn that nation- ally people in 1900 lived to an average age of 47.3 years. We think he would be amazed to know that by 1965 the life expectancy figure had increased by 23 years 2299 to 70. We think further he would find satisfaction in knowing Iowa's life ex- pectancy figure of 71.9 years ranks second in the nation. This means the life span of the average Iowan has about doubled in the State's 125 years. The much-maligned infant mortality statistic has shown great improvement through the years. There were 30.3 deaths per 1,000 live births in 1945: in 1969 this was reduced to 18.9, a figure below the national statistics. How important is good health to the citizen of Towa? Without it, the 220,000 agricultural workers on Iowa’s 145,000 farms would be hare pressed to continue providing the nation with 10 per cent of its food supply. Without it, the productivity of the State’s 218,000 industrial workers would be endangered. And the 10 billion dollars worth of Towa manufactured products would almost certainly dwindle. Without it, the approximately 40,000 educators in Iowa’s public and private elementary and secondary schools would be handicapped mightily in their teach- ing tasks, and the State’s claim on the highest functional literacy rate in the nation would be threatened. Simply stated, without good health, the state’s 1,176,000-member work force— and their families—would be in jeopardy. Our quest for good health should be and is never ending. Our objective is that of making life healthier, happier and more productive for everyone. What is good health care? It can be described as that effort expended by the individual Towan, the parent, the members of the health care team, the community, the state, etc., to provide these elements: Good medical care, adequate nutrition, good dental care, satisfac- tory working and living conditions, a sensible activity program ; rest, relaxation and recreation ; and good emotional adjustment. So defined health care may be divided into several major categories: Preventive or protective care, diagnostic care, therapeutic care and rehabilitative care. Preventive care receives much attention in Towa. Some 90 per cent of Iowa's youngsters are immunized against such diseases as whooping cough, smallpox and diphtheria through the combined efforts of private physicians and community clinics. We would call your attention to poliomyletis as a particularly dramatic chapter in preventive medicine in Towa. In 1952, Towa had 3,562 cases of polio; in other years cases ran between 500 and 1,500. In 1962, Salk vaccine became available and was administered from border to border ; the total number of cases dropped below 10. In the five-year period from 1963 to 1968 Towa had only eight reported cases of polio. We must, of course, not become complacent; we must maintain our immunization levels. Fluoridation of water is another important example of protective health activity. Towa ranks fifth nationally in percentage of population on public water supplies receiving the benefits of optimum fluoridation. This percentage includes all of the state’s 10,000-plus communities. A very recent example of conscientious preventive health care in Towa is repre- sented by the 1970 state-wide rubella eradication program. The massive effort involved hundreds of volunteers and 750,000 public and private dollars. In excess of 521,000 Towa youngsters (88.4 nercent of the susceptibles) received the vac- cine in this concentrated effort. The State Department of Health and the Towa Medical Society worked closely in the coordination of the program which we understand was a national pacesetter. According to the State Department of Health, over 1,200 hours of time were contributed to the total program by Towa physicians. These preventive measures are considered most important by the physicians of Towa. So, while the State's medical profession is proud of its organ transplant program and other dramatic innovations, it recognizes most assuredly the need for constant attention to those day-to-day efforts to protect the population from sickness and disease. What about the health manpower picture? There are approximately 50,000 Iowans working to protect the health of the total population. This means that one of every 22 employed persons in the State is in a health occupation. These individuals have some role in the care of 75,000 patients daily and their efforts comprise a $500,000,000 annual endeavor. There has been a 36 per cent increase in number of health care workers between the early and late 1960's. 2300 Despite this growth there nonetheless exists a real concern among many as to the State’s ability to balance the supply of personnel—professionals and suppor- tive workers—with the demand for services. The general shift in Towa’s popula- tion from farm to town and city is well known and is part of a state and national phenomenon. The urban population in Iowa increased by about 214,000 (6 per cent) residents from the decade of the ’50s to the decade of the 60s. A parallel pattern exists in the health care field. In the late 1940's about 50 per cent of Iowa's medical doctors practiced in the 16 most populous counties; in the late 1950's this increased to 61 per cent, and in the late 1960's two-thirds were in the larger communities. The actual total change in number of physicians (Iowa Medical Society members) during the period studied was only 23, from 2,381 in the late 1940 period to 2,404 in the late 1960 period. Towa health professionals have two principal reasons for choosing urban loca- tions: (1) A logical wish to be within close proximity of professional colleagues, of similar and different specialty training, for referral and consultation purposes, and (2) an obvious desire to be near the sophisticated facilities (coronary care, intensive care, rehabilitation units, etc.) which are more economically feasible in the larger clinic or hospital setting. It is true that a number of small Iowa communities no longer have a physician within their corporate boundaries. And it appears others will likely experience a similar fate when the current practitioner retires. It is equally true that the mobility of Iowans has increased significantly. It is believed that all Iowans are within a 20- to 30-minute drive of a doctor's office or hospital. And rarely does the Iowan have the snarled traffic problem that confronts his metropolitan counterpart. What specific involvement has the medical profession (Iowa Medical Society) had in the area of health manpower? Here are several examples: (1) The Iowa Medical Society has advocated a steady growth in the enroll- ment of The University of Iowa College of Medicine, and in pursuit of this objective the profession has supported an adequate state appropriation for the College. The Society has been gratified at the growth projections which the Col- lege has announced, i.e., there were 145 students in the last entering class, there will be 160 in the fall of 1972 and 175 in the fall of 1973. By 1976 there are expected to be 700 medical students at the University, an increase of 40 per cent over 1969. The Society is on record favoring an entering class of 200 if and when adequate resources are available. (2) Approximately four years ago the Iowa Medical Society created a task force on medical manpower. This body of physicians has sought to examine the future impact of the manpower situation and to recommend means for alleviating problems. This task force has presented two series of statewide seminars to brief both physicians and other community leaders on the manpower situation. (3) The Iowa Medical Society has supported recent steps which have led to the founding of the Department of Family Practice at the University of Iowa College of Medicine. It is hoped and believed this Department will win many medical students into its fold and will in time produce an increased number of family practitioners for Iowa and elsewhere. This program as well as others are and will bring Towa’s community hospitals much more directly into the medical education mesh. (4) Cooperative efforts are now going forward to establish a model rural health clinic for use by medical students and others. This program will be in addition to the long-standing preceptorship program which enables and requires medical students to spend brief time with Iowa practitioners in their offices and communities. (5) The Towa Medical Society, through its Scanlon Medical Foundation, has loaned $385,000 to over 240 deserving Iowans attending medical school. Approxi- mately half of the loan recipients remain in the State as medical practitioners. (6) The medical profession has supported sound education programs for much needed paramedical workers. Most recently, the Towa Medical Society has pro- vided constructive leadership in the 1971 passage of state legislation to formalize the training programs and job descriptions for the rapidly emerging physician's assistant. Nurses, therapists, technicians and other assisting personnel are valued by the medical profession and instructional programs for them are supported. As an indication of growth in this area the number of subbaccalaureate health occupations education programs has jumped from two in the late 1950's to 43 in the late 1960's. 2301 What about health care facilities in Iowa? More than one-half billion dollars worth of health facility construction has occurred in Towa since 1947. There has been no less than 170 construction projects during this period. There are 14,000 acute hospital beds in Iowa now, approxi- mately 6,000 more than in 1948. Hospital length-of-stay in Iowa contrasts sharply with 20 years ago. In 1947, for instance, the average length of stay for an appendectomy was 14 days. Today, the usual hospitalization for this surgery is four days. The health care facilities in Towa may be categorized in several groups. There are the private offices, clinics, pharmacies, hospitals and nursing homes. There are municipally and county controlled health care institutions. There are state operated facilities, which include the massive University Hospitals in Iowa City, the four mental health institutes, the two facilities for the mentally retarded, and, incidentally, Towa has been a leader in the development of a network of community mental health clinics. There are also Federal Veterans Administra- tion Hospitals in Des Moines, Iowa City and Knoxville. There are approximately 150 licensed hospitals in Iowa, and 90 per cent of the beds are in hospitals accredited by the Joint Commission on Accreditation of Hospitals. There are approximately 500 licensed nursing homes and more than 300 licesed custodial homes. There has also been a substantial growth in Iowa programs which provide home health care. What about costs or the economics of health care? Iowa health care costs are higher than they were five, 10 or 20 years ago, just as they are for food, clothing, housing, ete. Inflation is obviously respon- sible for part of this. But it is important to bear in mind that Iowa physicians are treating diseases which were incurable 20 to 25 years ago. This treatment requires more highly skilled personnel, more extensive equipment, etc. As previously mentioned, Iowa's population is about 2.7 million. Of that number, 2.6 million or 96 per cent have some form of health care coverage, be it with a private insurance company, Blue Cross-Blue Shield or the government. Approximately 80 per cent have health insurance with a private insurance company or a Blue Cross-Blue Shield Plan. Medicare covers approximately 350,000 Towans and Medicaid provides for about 90,000 persons. This means that about 16 per cent of the population is provided coverage by the government. Many years ago the medical profession, through the Iowa Medical Society, founded Iowa Medical Service, the Blue Shield program which now finances health care for more than one million Towans. The Medical Society and Blue Shield, while separate corporate entities, work together closely to upgrade and make more comprehensive the programs which are offered through Blue Shield. Significant progress has been made in recent years to bring to Iowans broader health coverage programs. Blue Shield has functioned as the fiscal intermediary for both Medicare and Medicaid since the inception of both programs in Iowa. While the Towa medical profession has opposed and continues to oppose the Medicare philosophy of government financed care for all at age 65, it has supported the Medicaid philosophy of medical care for those who need it but cannot afford it. This latter policy has prevailed for many years. In fact, Towa can boast of a unique and effective health care program for its indigent, a program which has existed for much of this century. Each of Iowa's 99 counties are privileged to send those low-income persons who need medical care to the University Hospitals in Iowa City. This practice continues in effect even though Medicaid recipients may now elect the point at which they receive care. While there are undeniably some few Iowans for whom access to health care may not be totally adequate, the State's overall performance is excellent. Those who do not avail themselves of needed care do not, primarily, for lack of moti- vation or lack of education. What are specific involvements of the medical profession (Iowa Medical Nociety) in the socio-economic area? (1) As has been mentioned, the Society actually established Iowa's state-wide Blue Shield program in Iowa and it also stimulated the formation of Blue Cross. (2) Through the years the Society has been actively involved in such govern- mental programs as the Veterans Hometown Care Program, the CHAMPUS Program (the Society was the fiscal intermediary for this program until this year), the Kerr-Mills or MAA Program and its vendor payment forerunners, etc. 2302 (8) The Society has sought to maintain its ethical values through the years and has disciplined those members found to be taking ethical liberties. In the past three years, as a demonstration of the foregoing, the Towa Medical Society has devised a state-wide peer review program (12 district committees) which is available to all public or private third parties. Questions regarding the manner of treatment or the level of charge rendered by any Iowa physician may be referred to the Society for review and recommendation. The Society's peer review pro- gram operates in tandem with the quality assurance program of Blue Shield and safeguards against abuses in both the public (Medicare and Medicaid) and private programs offered through Blue Shield. (4) As a further and significant indication of the medical profession’s belief that it must provide leadership in fostering high quality care in the right quantity and at a reasonable cost, the Towa Medical Society this year has formed an Iowa Foundation for Medical Care for this primary purpose. From the 11 founding principles of the Foundation four might be set forth here to identify the thrust of the new instrument: (a) To develop, promote and encourage the distribution of quality medical services to those served at an equitable cost and in appropriate quantity; (b) To promote, develop and foster the availability of high quality health care, either alone, or in conjunction with individuals, physicians, medical societies, other professional organizations representing persons engaged in health care, hospitals, nursing homes, schools, the various branches of government, the insurance industry, representatives of management and labor and other interested persons, organizations or institutions; (¢) To promote, develop, operate and or- ganize peer review activities providing objectivity in dealing with health costs and utilization of services encompassing the total health needs of patients and by this peer review mechanism to assure the public of optimum use of its health care expenditures, and (d) To promote, foster and coordinate the involvement of the health professions in experimentation and evaluation of programs aimed at relieving acute manpower shortages, in improving the availability of preven- tive services and in expanding the availability of ambulatory care as an alterna- tive to institutional services and, in connection therewith, to disseminate the results to individuals, physicians, hospitals, schools, foundations, institutions, governmental bodies, corporations and the general public. (5) Directly related to matters of health care economics are the important health planning programs which have come into being. The Towa Medical Society was the driving force behind the formation of the now-active Health Planning Council of Towa (HPCI). This Council has stimulated much activity at the local and regional levels in voluntary planning. Since the inception of HPCI the Towa Regional Medical Program and the Comprehensive Health Planning Program have come into existence. To each of these bodies the medical profession has given and is giving leadership. One of Towa’s greatest assets today is the health of its people. This statement has been prepared as testimony to this assertion. There is no denying that difficult challenges stand before us, no more challenging perhaps than those of the past, but nonetheless demanding our unceasing efforts. Indispensible in the delivery of modern health care are intelligent, motivated and responsible people. The Towa health care team is one segment of a total state population known for its industrious nature. With continued leadership from this team, the health care challenges of today and tomorrow can be met. Thank you very much, sir. Senator Kexnepy. Would the other gentlemen like to make any comments ? STATEMENT OF DR. PAUL M. SEEBOHM, ASSOCIATE DEAN, COLLEGE OF MEDICINE, IOWA CITY, IOWA Dr. Seesonm. Senator, I'd just like to point out the role that the University of Towa Hospital and College of Medicine Center may play in the health care problem and the educational problem. The university hospital center is a closely integrated educational and service institution. The hospital administration provides the 2303 service part of the operation and the faculty of the college of medicine provides the professional medical care of the patients in this program and constitutes about 20 percent of at least the hospitalized patient care provided in this State. We have 300,000 patient days and 250,000 outpatient visits. It is a referral center generally, and a program that was referred to earlier is a fundamental core of the program of health care, and that is the State of Towa provides for low-income people comprehensive care at the medical center when they are referred to that institution. They are outpatients. They are housed and fed, in addition to being taken care of for their medical needs. Inpatient care is also comprehensive with no professional charges, so to speak, the service being provided by the faculty. Senator Dominick. I don’t quite understand that point. Let me in- terrupt if I may at this time. Do I understand correctly that you are saying the medical school provides comprehensive free care coverage for those who can’t pay, both inpatient and outpatient ? Dr. SeeBoam. Yes, sir; for those who are referred to us from the counties, and this is on a county-distributed basis. Senator Dominick. And they are referred to the medical school ? Dr. SeeBorM. Yes; by other physicians. Senator Dominick. We have had a number of people here already testifying before us on this matter. How does their testimony fit in with that type of situation? Dr. SeeBorm. Well, I think several of the patients that testified were referred to the medical center for surgical care. I have forgotten the name of the person who so testified, but she stated that her hus- band’s expenses while in Iowa City were not her immediate problem because she was under this part of the program. I might say, transportation is also provided to about 30 percent of these patients through a hospital car-ambulance. An assistant goes out through the State and picks up the patient at the farmhouse door if necessary. Senator Dominick. All right. Is this type of coverage not made possible by contributions but by appropriations from the State? Dr. SeeBonm. Yes, sir. Senator Dominick. Or is it done from the local medical societies or what ? Dr. SEeponm. State appropriations. Senator Dominick. State appropriations. Dr. Seeony. Now, in addition to the center care at Towa City we have outreach programs of field clinics for children, obstetrical pro- grams out in the State, the mental health community programs, and there’s been a migrant workers’ program at Muscatine which has been sponsored by the county medical society, faculty, and students. The problem of the physician shortage in Towa we have been trying to attack in the following ways: I might say we have been exporting 50 to 60 percent of the physicians trained in this State to other States who seem to also be in need. We believe that it is going to be necessary to increase the enrollment to help solve this problem, contrary to some of the predictions of others who claim it is all distribution, or maldistribution. 2304 We believe also that we need to work on maldistribution and we have established a family practice department to bolster up the train- ing of the primary care physician. We have also established community hospital affiliations, one here in Broadlawns, and we have four other communities under negotia- tion at the present time, so there our students will be able to move out of the hospital center in Towa City after their core training into the community setting for their additional experience. Last, we are experimenting with a delivery system program par- ticularly related to a rural health center at Oakdale, which is a com- munity about 5 miles outside of Towa City. T’d be pleased to answer any questions. STATEMENT OF S. P. LEINBACH, M.D., BELMOND, IOWA Dr. Lernsacin I am a rural doctor and rather proud of it. I'm at the age where I have seen many of the problems in rural health develop. Many have been resolved, and we still have problems. I'd like to point out that here in Towa the 1,200,000 of our population live in rural areas if you include towns of 2,500 and under, so we are pretty much—about 45 percent of the people are rural oriented. It is my impression, and I spend considerable time in this particu- lar area, that the rural health care, generally speaking, is good. There are some defects and I will mention those later. 1 would like to point out that few people in Iowa are further away than a 20-minute drive to a doctor, and within 30 minutes most of them could be in a hospital. Now, there are some very fine hospitals in Towa. There are 142. Hill-Burton funds were responsible for the de- velopment of many of these hospitals, and they are well staffed; 90 percent of them are accredited by the joint commission on accredita- tion, which causes these hospitals to measure up to certain standards in health care. Since World War IT theres developed in rural areas particularly many small group practices, maybe from two to 10 or 12 doctors join together for the practice of medicine. They join their expertise, their equipment, their personnel, their ancilliary personnel, and thus can do a better job. This is a trend that’s occurred and is a rather signifi- ant trend as far as health care is concerned in the rural area. We do have a shortage of physicians. The osteopathic profession is helping very much in this particular area, but we do have a shortage of physicians. I would like to point out that in the rural area a high percentage of children are immunized against the various infectious diseases, polio, measles, rubella, and the rest of them. ‘We have had a tremendous reduction in farm accidents as a result of education and, of course, with the development of better, safer equipment. I'd Tike to state that the Institute of Agricultural Medicine, which is unique in the country located at the University of Towa City, has done tremendous research into this area. ’ When I began practice a few years ago, zoonotic diseases, diseases transmitted from animal to men, were very, very common. I saw much of the ravages produced by bovine tuberculosis, tuberculosis of the 2305 spine, tuberculosis of the adrenal gland. We have had a lot of brucel- losis, undulant fever, multifever. These have been all eradicated. Our health care, I think, is very excellent. We are proud of our schools. Ninety percent of the children that graduate from the area in which I practice go on to college or trade training, which is a good indication that these people and their parents are looking forward. They are progressive people, not only in education but in the health care. I think we have a lot to look forward to in health care in the rural areas. The medical school at the university is expanding its services, increasing its enrollment, and I'm sure that the shortage of physicians that we now have will be in part eradicated. 3 I'd like to point out though on your chart up there stating that there is one rural physician to each 3,000 people in Towa, but that really probably isn’t a true evaluation for the reason that, for instance anyone who lives within a radius of 20 miles of Des Moines, which would be rural, they would come to Des Moines for their health care, so this group of people is not being neglected, nor are they short of facilities for health care. T’d like to point out—Senator Hughes is well aware of this—there’s been a transition as far as the migration of people out of the rural areas. The small industries are coming into the small towns that relate to either the processing of agricultural products or the development and production of equipment used on the farms. This is significant. We have been concerned about the outmigration from the rural areas, but I think it’s been reversed, just as I anticipate that the outmigra- tion of physicians out of Towa will be reversed. As our schools become more numerous and increase in size and the doctor shortage is elimi- nated, I'm sure there will be better distribution of doctors. Dr. Lister. Could I speak just a minute to the utilization commit- tee? I think there might be some misunderstanding. The utilization committees are required not only by the Joint Commission on Ac- creditation for hospitals but they are required by Federal law in the handling of any Federal programs. The utilization committee is a committee of staff physicians who review not only admissions to hospitals, but progression through the hospitals from the acute phase into the extended care facilities into the skilled nursing homes and finally into the custodial home. The utilization committee’s function is actually to determine how long benefits under a contract are obliged. They actually have no authority to remove somebody from the hopsital. The only thing they can do is tell you when payment for these services is no longer obliged by a contracting agent. Senator Ken~epy. That’s about the same, though, isn’t it? Dr. Lister. It works out about the same, but actually they can’t re- move anybody from the hospital. Senator Dominick. What would you do, Dr. Lister, in the case of Miss Roby who was talking about her brother being turned out be- cause of the utilization committee ? Dr. Lister. There should be some other facilities in the community Sin could properly take care of him outside of an acute hospital ed. Senator Ken~epy. Who should try and find it? 2306 Dr. Lister. I think that takes the cooperative efforts of lots of peo- ple, physicians, the social service department, hospital facilities. Senator Ken~epy. It’s been shown this morning that the burden is falling completely on these people, these families. Dr. Laster. I think this is a matter of education. Senator Kexnepy. Educating who? Dr. Lister. The public and the profession. Senator Kex~Nepy. Do they need to be educated ? T mean they're out there working day and night trying to get their children, their sisters, their brothers into some kind of facility and we have had two people who have been nurses who probably understand the system as well as anyone else, and if they are having problems of doing 1t, I just wonder who has to be educated, whether it should be that utilization com- mittee. They should have an additional responsibility to try and find some other facility where the person can get the kind of care that’s needed. They are supposed to have the expertise. They are the ones that are studying that patient. They know the needs of that particular patient. They have the doctor’s input, the nurses’ input. They have seen the records. They know whether a person can go to such a place or not, and they know the various facilities which are available. Prob- ably they know it a good deal better than a sister or mother who just knows she has a sick child. So I'm not sure that the education shouldn’t be within the utiliza- tion committee, the medical societies, the hospital administrations. It seems to me that there is a responsibility there as well. Dr. Leinsacu. Senator, I would say that the cases this morning were very sad, but they are somewhat the exception to the rule. Now, I know physicians do look after the patients after they leave the hos- pital. They are vitally concerned. That’s their primary function. Senator Kex~epy. Doctor, we have had these stories come up every day, and we have a list of more people here that want to testify. One of the great problems, I think, is that many groups in our society think that these are the exceptions. I don’t believe they are. I don’t believe they are. We are finding them all over this country, every community, every city and town. I think you could keep this hearing going for weeks hearing about these kinds of situations. I think we do ourselves a dis- service in trying to understand the crisis by saying these are the exceptions. I don’t believe they are. T think that’s rather one of the basic and fundamental differences that some of us have with the medical societies. I think that there are a lot more like this, and I think that every in- dividual that spoke up here could give you an example of four or five different families who have had the exact same kind of situation that’s happened. Senator Domixick. I would like to ask a couple more questions. 1 don’t know what percent of the population we are talking about, but these still are all individual, tragic cases. The problem seems to be largely in the question of (#) you want to get the patients out of a hospital as soon as you can, both for the better utilization of beds and for the purposes of the utilization committee. In the hospital we have seen here in Des Moines, they have 90 to 95 2307 percent occupancy which is higher than the figure they think it ought to be for proper emergency facilities. What, if anything, has been done either through the State legislature, the medical association, or anybody else in providing more extensive care and treatment which would be absorbed at some form of public expense ? Dr. Lister. I think we could safely say that there are very adequate extended care facilities available in the State presently. Their use, however, is hindered by ability to pay for it. Senator Dominick. Yes. Dr. Lister. That’s the problem. You can’t transfer a person to an extended care facility—well, IT can’t say never, but almost never— unless they require some sort of physical therapy or some actual manipulative assistance. Skilled nursing homes, there is no provision in either Government or private contracts to pay for this kind of care. There has to be some changes made in the financing of health care. We all agree to this. It is just a matter of how best to do it. Senator Doaixick. Is it your feeling that this should be done through the regulation of the insurance programs that are being is- sued, through governmental action, or some other method ? Dr. Lister. 1 have the feeling that the insurance industry can up- grade itself quite adequately. I think that the primary problem is in catastrophic illnesses which we have heard described today. These people are entitled to some relief. There is no question about that. T think we are obligated to see that they get it. Senator Dominick. We have provisions in the proposed compre- hensive health care program, for some type of Federal regulation of the insurance companies in the event this comprehensive health care program goes through, at the President’s suggestion. The program also provides for health education centers in the various States, and a whole variety of things at this time which TI think would be help- ful. None of these provisions in my opinion hit on one of the real problems in this area, which is the long-term illness or the cata- strophic illness problem. I don’t really know what we could do about that. Do you have any thoughts you could give us on that subject? Dr. Lerxsacin I quite differ with Dr. Lister. T think the Govern- ment has to support catastrophic illnesses of a long-term nature. The private insurance industry obviously can’t afford to or can’t provide these services because they would have to upgrade their premium rates, which would make it rather expensive for all people. I do be- lieve this is one area where the Government has the responsibility, with the type of cases we heard about today; and when private in- surance can no longer take over the paying of these bills, then T think there has to be some other source of payment. These people are en- titled to good care. Senator Domrxick. Do we have any estimate of costs on this? This is one of the things we have been trying to discover, and T don’t know whether Senator Kennedy or Senator Hughes has been able to find out. I haven't been able to find any estimate of cost. Dr. Laster. Cost of extended care facilities, you mean ? Senator Dominick. Catastrophic and long-term illnesses. 2308 Senator Kexnepy. Senator Long’s bill provides $214 billion. That is what he introduced as an amendment to the social security, $214 billion a year. ; Dr. Lister. To set the record straight, Dr. Leinbach may disagree with me, but T don’t disagree with him because I thought we said the same thing. [ Laughter. ] Senator Kexxepy. T have a fundamental disagreement perhaps be- cause I am not sure that we should have a profit motive in health care. We don’t have it in education. IT don’t know why we should have it in health. But Senator Dominick and T will be debating that for days and weeks to come. Senator Hughes? Senator Huenes. Gentlemen, IT really have perhaps a statement, plus a couple of questions. I have had an opportunity, at least, to know and to work with a couple of you. I had the experience of seeing Dr. Lein- bach after a tornado swept through his town wiping out half of the town and causing a power failure in his little hospital. He took over over magnificently and provided care under almost impossible circumstances. The tragedy does hit rural communities, and the availability of these services is absolutely a necessity. Would it surprise you, however, Dr. Lister, if T were to tell you that when T was Governor of this State, I tried to call a physician for my son-in-law in this city, and that I could not get a physician to go to his home and to see him when he was suffering some severe cramps and intestinal distress. We were afraid to move him, and I called the Polk County Medical Society for help. There was no physician they would give me for help. T was told as Governor of this State to go to the house and get him and bring him to the emergency entrance of this very hospital. No one would see him. Does that surprise you? Dr. Laster. I have to admit that I'm not surprised because I have heard it, but T am surprised that it happened. Senator Huemrs. When that happens to the Governor, you know, I wonder what happens to the rest of the people. I say this even though I know how hard you men work and how dedicated you are and what our medical school is doing. T have supported what they are doing and what they are attempting to do. So much of the medical care in this State is excellent and magnifi- cent in quality, and yet we have so many that are totally left out. That’s what we are talking about. I might add, just to make the record equal, that last year as a U.S. Senator in the State of Virginia my second daughter was seized one night with severe pain in the abdomen. We called an ambulance. We rushed her to a hospital where we could get no medical help because we couldn’t find a doctor who knew us. The doctor whom we called on, and T called the Senate physician, couldn’t make a recommendation to me. Pain was almost impossible to bear, yet they would give her absolutely nothing to relieve the pain. Seven hours later I was calling physicians in Des Moines, Towa, try- ing to find out the types of pain relievers and drugs given to her dur- ing earlier illness. I finally traced down at Okoboji, the physician who had treated her in Towa after at least 15 long-distance phone calls. 1 2309 called Dr. Bedell at the University Hospitals for help. He had been my own physician for many years. When finally medical care was found and a diagnosis was made, she had suffered from an inversion of the small intestine and gangrene had set in 3 days later. I threatened a doctor in the hallway of that hospital and told him I'd break his neck if he didn’t come in and do something about my daughter. I'm pretty upset when I find conditions like this in America. I'm sorry these things happen, but in my own personal life they have happened to me and my family. As far as catastrophic illness, I'd like the record to show that we have suffered that catastrophic illness with one of our daughters. It started with cancer 17 years ago and has proceeded over that long course of 17 years through two major surgical procedures last year, none of which has been covered by insurance. Now, I am able to pay those bills and I thank God for it, but I don’t know what happens to a family who is getting 10 percent of what I am getting every year in the way of a salary. It’s obvious, I think, what’s happening to many of them from the testimony that has been presented to this subcommittee. I know you share that concern with us and I know that your life is dedicated to trying to alleviate that pain and misery under those sets of circumstances. In conclusion 1 only want to express my deep appreciation for what you are doing in Towa. I hope you will help us in any way you can to alleviate these problems in America. We all share those common goals. Forgive my impassioned plea, but it is pretty upsetting, you know, when you suffer these things yourself, and 1 know you don’t like it and I don’t like it. Thank you very much, Mr. Chairman. Senator Dominick. Could I ask one question? Dr. Lister, I listened to Senator Hughes and 1 was most interested in what he said. His experience is not unique, if I may say so. It has also happened to us in a variety of different places. What do we do about this? Is there any system that the medical societies can set up so someone can get a doctor when he needs one or is the idea of a doctor coming to a person’s home when they are sick going out of fashion now because there simply isn’t enough time for the doctor to make these visits? Dr. Laster. IT think your last statement is very appropriate. People can be taken care of better in an office setting or hospital setting than they can in their home. Senator Doainick. That’s true technically, but the thing that most people are concerned with is their feeling that they need a doctor com- ing to their home and then maybe the doctor can take them to the hos- pital, which is fine. It is my feeling that many of the new techniques overlook the concern that the patient and family are experiencing. I wonder if there are enough qualified people such as paramedicals which could be made available for a program of this kind. Dr. Luixsacir. Senator Dominick, T think many of the physicians do do something like this. Whenever a person goes out in my commu- nity to another aréa, I tell them to obtain a family physician. He may be a surgeon or he may be a pediatrician. He may be a man in general practice. 2310 But anyhow, if that family gets into difficulty then he can be the person that makes contact for them with their individual physicians that they should see. Senator Huaies. What if they can’t find them, Dr. Leinbach ? Dr. Lernacu. Well, I think most physicians would assume that re- sponsibility of being responsible for your well-being with a great amount of concern. Senator Huenes, T wish I had found that to be true, you know, but I haven't. Excuse me, Senator Dominick. Senator Dominick. I was going to reiterate somewhat the same thing. Suppose you have a gal who is just about to have a baby and you go to the obstetrician. Most of the time the obstetrician has an answer- ing service of some type, so that if he is not there someone else can respond. But you have been dealing with one person all the way through. In this very personal relationship it strikes me that not only are we deal- ing with the need of a patient to have adequate health care. but we are also dealing with the need of a patient to have a doctor of his choice available. This is what concerns me with any kind of a unilateral ap proach. T think that with the very evident concern being shown for the multilateral approach we seem to be moving away from the single ade- quate health care issue. Not that the concern over the adequate health care issue isn’t there, but the fact that some kind of concern is evident. Dr. Linsactn. I think that is somethine medicine fears, because as health care become more sophisticated and more complex, there will be a loss of that phvsician-patient relationship that has been so important in the history of our people in America. and that is a danger that the medical profession is. I'm sure. aware of. Senator Kexxrny. Thank you very much. Mr. Graneg. We have your statement and we will put it in the record. If you'd like to make any brief comment, then we could at least get to one or two of the other witnesses. STATEMENT OF BERNARD M. GRAHEK, PRESIDENT, IOWA HOSPITAL ASSOCIATION Mr. Grane. My name is Bernard M. Grahek. I serve as president of the Towa Hospital Association representing 138 hospitals and re- lated institutions and am associate administrator of Mercy Hospital in Cedar Rapids, Towa, an institution of 305 general acute beds plus 80 extended care and nursing home beds. With me is Donald W. Dunn, executive vice president of the Towa Hospital Association. My hospital, similar to those you have visited here in Des Moines, has concern for all the people in our area and our community—those who are able to pay and those who are not. In addition, we are con- stantly concerned with upgrading the quality of health services we are able to provide. Recent efforts at our hosnital have resulted in a care- fully planned. developed. and operational trauma center which brines to bear as rapidly as humanly possible the necessary equipment, phy- sicians, nurses, and other health personnel to care for people who are 2311 in need of immediate and emergency care, e.g. accident victims, coro- nary insufliciencies, burn accidents, and other emergency cases. Docu- mented results are not yet available, but our early experience makes us confident that some patients will be saved and many others will more quickly be returned to good health as a result of this important service. We in Towa are appreciative of your efforts, Senator Kennedy, in the areas of nurse manpower and other health professions educational assistance, specifically Senate File 1747 and Senate File 934. Also, we support strongly your work, Senator Hughes, in alcoholism and drug abuse. We commend your preserving efforts to assure funding to ad- minister the Alcoholism Abuse Act of 1970. The member institutions of the Towa Hospital Association share your concerns on these key issues relating to effective health care. All of the 138 member institutions of the Towa Hospital Association are either units of government—city, county, district or State; or are nonprofit corporations under the laws of the State of Towa, whose only reason for existence is to serve the community need. The persons employed in Towa hospitals are public servants and we share your concern that all people of this great country receive the benefits of comprehensive health care. The decade of the 1960’s developed the concept that health care, like education, is the right of every person. We in the hospital services enterprise agree that this country should assure access to preventive, curative, and restorative care to all. The passage of medicare, medi- aid, mental health, partnership for health, and other health legisla- tion has assisted in implementation of this goal. However, problem areas and key issues have been highlighted, made more visible, by the massive infusion of money, public interest, and public scrutiny attend- ant to the legislation of the 1960’s. T am confident that we will see in the decade of the 1970’, the fulfillment of the promise of health care for all. The health services enterprise, as represented by our community hospitals directed by trustees representing the people being served, stands ready to serve as a partner in meeting the challenge. Our effectiveness depends on finding the solution to three key issues: First—is health manpower. Of particular concern in Towa is physician manpower for our rural areas. A ratio of one physician to 1,000 people is regarded as adequate to make medical care available. But when the ratio exceeds 1 to 1,500 people, availability of medical care is less than desirable, and a ratio of one to 2,000 or more makes for inadequate availability of medical care. Although the physician ratio in Towa statewide is one to 841 per- sons which appears to be favorable, it is not so in rural areas which have lost physicians to urban communities. In 1967, Towa counties of less than 10,000 population averaged one physician to 1,529 people with several counties experiencing a ratio of one to more than 2,000. This poses a dramatic problem in sparsely populated areas with a high percentage of aged persons in need of health care. Towa holds a more favorable position regarding nurse manpower, due in large measure to the significant teaching programs in hospital schools of nursing. To assure continuation of adequate nurse man- power, support for Towa’s 18 hospital schools which educate 75 percent 2312 of the registered nurses trained in Iowa, along with support for bac- calaureate and associate degree programs—support such as that found in Senate bill 1747—is needed. ] ; The second major issue is finance. The need for financing expensive health care for the aged, the poor, and near poor is apparent. Current Federal programs were built upon a system appropriate for prior decades and a different environment. Administrative pressures have caused curtailment of those programs so that many aged and poor persons, for whom the programs were designed, are now being denied (sometimes months and years after receiving care) of governmental payment for needed health service. Such curtailment, along with ar- bitrary change in the hospital reimbursement formula, has caused severe strain on hospital capital financing. To establish new services, such as our trauma center, adequate reimbursement to hospitals is es- sential. A more rational reimbursement method as proposed by the American Hospital Association, which includes prospective rate reim- bursement, should be implemented immediately to assure the fiscal integrity and continuation of hospitals, but also to assure incentives for economy in the operation of these community institutions. The third major issue involves the very system for delivering per- sonal health services. Massive additional infusions of money without modification of the system would be similar to administration of 50 pints of blood to a patient. Veins and arteries would burst and the patient would be lost. In the folder we have provided is a copy of Ameri- plan, the report of AHA’s high level Perloff committee. This blue- print for a modified health care delievery system integrates a new method of financing with new organizational structure adequately regulated by national and State health commissions. It would foster development of health care corporations to provide comprehensive health services to defined population groups. Incentive to provide pre- ventive and ambulatory care would discourage provision of expensive inpatient care when not essential to the patient’s well being. The de- velopment of prepaid group practice in regional centers of rural Towa would alleviate severe physician shortages. A single responsible agency, the Health Care Corporation, would be held responsible for fulfilling an individual’s need for care. Decisionmaking and policy for- mation would be decentralized, assuring programs and activities re- sponsive to the area and community needs. T share the attitude of a fellow native of Minnesota, the Honorable Donald Fraser of Minneapo- lis, that all problems are not solved by totally centralized administra- tion. Ameriplan allows national standards to be set. regulation at the State level and operational decisions close to the people being served. Ameriplan addresses itself to organizational structure tied to pluralis- tic, decentralized financing merchanisms and would assure care for all—poor, near-poor, aged and affluent. We commend it to your con- sideration as solutions are sought to the vexing problems in health care delivery. Thank you for the opportunity to speak to you on the health care crisis. I represent the Towa Hospital Association as the president of the 138 hospitals, Senator, and we share some of the concerns that people in the Senate share as far as health care delivery is concerned. 2313 We feel that it is a right. We wish to cooperate with you and in every way possible to make this right a reality. We, as members of the Iowa Hospital Association, have and do encourage your continuation of support to our nursing programs, not only the hospital programs, the baccalaureate programs of all the schools in the country. More attention to the manpower situation is needed. You talked with the doctors a moment ago. They are needed in the rural area. We sense this as far as hospitals are concerned. Hospitals have at- tempted to participate with their communities in providing health care, in upgrading the health care and I feel that we will continue to create and promote partnerships such as we have been, and just for example in my prepared statement where we have in my hospital, Mercy Hospital, Cedar Rapids, Iowa, we have initiated a trauma center to provide adequate and immediate care for emergencies, and 1 think that this type of engagement with the Government to the Hill- Harris program is very valuable. Also I think there is a question of financing insofar as the hospitals are concerned in health care delivery. The need for financing for the care of the aged, the poor, and the near poor is very apparent. The current Federal programs were built on a system appropriate for prior decades in a different environment, but I think that we have to have a radical change in the health care delivery system. I feel that this is ultimately important, but I feel there has to be a partnership with the hospitals and physicians and the Government. I agree with you, Senator, that the consumer has an integral part in fis health care delivery system and we should certainly encourage this. Ameriplan addresses itself to organizational structure tied to plu- ralistic, decentralized financing mechanisms and would assure care for all—poor, near-poor, aged, and affluent. We commend this Ameriplan for your consideration, Senators, in the future. Senator Kex~epy. Thank you very much. We haven’t had that plan submitted to us. Mr. Granek. It is now in the process of being developed. Senator Kenxepy. But it hasn’t been submitted to us yet in the Senate. We will look forward to it. Mr. Granek. You have a copy of the Ameriplan in the folder I have given you, Senators, Senator Dominick. I just have two questions. I know how pressed for time we are. One is, we heard from the hospitals last night and this morning about the computerization system which you have and which is, I presume Mr. Granex. Shared computer. Senator Dominick. Is it mostly for billing purposes? Mr. Granek. For accounting purposes. Senator Dominick. Accounting purposes. What type of peer review do you have for billing costs? Such as doctors, hospital, laboratory, or drug costs? Mr. Granex. With me is Donald Dunn, executive vice president of the Iowa Hospital Association. I will let him talk to that. 59-661 O—71—pt. 10——7 2314 STATEMENT OF DONALD W. DUNN, EXECUTIVE VICE PRESIDENT, IOWA HOSPITAL ASSOCIATION Mr. Dux. Review is conducted by organized medical staffs within our hospitals of the care delivery. A review of billings and costs are conducted by a third party peer and the most active in this area has been Blue Cross and Blue Shield, both for their own plans and also for their role in medicare and medicaid. That is where the review does occur. One of the problems that we are now encountering are the cutbacks and denials that are occurring even in the Federal programs as well as in the voluntary programs that we have heard about this morning. Senator Dominick. Say you have a $5,000 hospitalization insurance program under Blue Cross and one hospital charges $100 a day and another charges $40 a day. You are then going to get under com- parable care, 214 times the length of time in the $40 hospital as you do in the $100 before the insurance runs out. Is there anybody monitoring that type of expense program ? Mr. Dux~. Yes; the third party payers are monitoring the differ- ences in charges and costs delivered by hospitals. This is a difficult and a complex review that has to take place, however, because it’s compar- ing apples and oranges when one compares the delivery of a service in an institution like Towa Methodist Hospital with its complex array of very technical services that a medical center provides, with half, perhaps as little as half, as much as a daily cost and daily charge which would occur in some other areas of the State where services are less complex and where personnel are not compensated as adequately as they are in the metropolitan center. Mr. Granexk. Senator, for example, in my hospital we have had for the past 12 years a free clinic, called a free clinic. We don’t receive any county or Federal or State funds for this clinic. It is entirely supported and stafled by our medical staff and our personnel. The costs of this are borne by those that can afford to pay. In other words, they are put into the overall cost of the hospital. We also participate in an education program. There’s two hospitals in Cedar Rapids, Towa, and we have a joint internship program which is now going into a family practice program and these costs have to be borne, but we feel that they are necessary. We talked about the doctor shortage. We feel that the larger hospi- tals in the State have to attempt to participate in this education pro- eram to support the rural areas if we can, and keep the doctors in Towa. We also just recently had begun participating in the drug abuse clinic. Our hospital has given the crisis center of Cedar Rapids, with the mental health center sponsorship, some space so these costs have to be a part of it. Mr. Donn. I would like to add just one other thing to point out our AWATCNeSS——— Senator Kex~epy. Quickly if you might. Mr. Dunn. Yes. Our awareness and our concern and our desire to make things happen at the State level. The Iowa Hospital Associa- 2315 tion is strongly supporting the Senate file 239 which would authorize the creation of nonprofit corporations to deliver comprehensive pre- paid group health services, and so we are working in those directions to change that system and assure adequate financing. Thank you. Senator Kenxepy. Thank you very much. T appreciate your willing- ness to summarize. You are kind, and perhaps we will have some additional questions we can file with you later on. We are running out of time. We will just be able to take a couple witnesses from the list of people here, but I'd like to at least take some. Mr. Robert Mettler, if he is here. He was here earlier. Come right up here and just take a couple of minutes. Then TI will ask Robert Oberbillig to make just a brief comment. I know it is difficult, but do the best you can. STATEMENT OF ROBERT METTLER, DES MOINES, IOWA Mr. MerTLEr. I live in Des Moines, Towa. We were real fortunate. We had what is called a catastrophic illness, I guess you’d call it. My wife had chronic failure of the kidneys. There was no place in the State of Towa to take care of this, and to this date yet there is none. We were real fortunate to get in at Mayo and they performed a kid- ney transplant a year ago yesterday. She 1s getting along beautiful and she is waiting for Blue Cross-Blue Shield to pick up with the addi- tional expenses, and it’s been rough, but God willing we can make it fine. Senator Kexxepy. How much of the expenses have you had to pay yourself ? Mr. MerrLER. I have no idea. We just pay them as they come. Senator Kexxeny. How much about? Are you talking about a couple hundred dollars, a thousand dollars? Mr. MerTLER. We are talking about a thousand. Start there. Senator Kenney. That you have to pay of your own money ? Mr. METTLER. Right. Senator Kex~Nepy. Do you work now ? Mr. MerTLER. Oh, you bet. Senator KexNEDY. Are you covered by any insurance ? Mr. MerTLeR. Yes, Blue Cross-Blue Shield, major medical. Senator Kexxepy. In spite of that you will have to pay a thousand ? You tell me approximately. Mr. MerrLER. Well, now, T don’t know, Senator. J Senator Kexyepy. How much do you think you have paid out so ar ¢ Mr. MerrLER. Oh, a couple, $3,000, $4,000 out of my own pocket and we don’t know what the balance is yet because they have still not com- pletely released her. She’s getting along beautifully, no problems at all, but she’s waiting for Blue Cross and Blue Shield and Mayo to get together to find out how much is left to be decided to be paid for, and I understand that we will have a percentage of that that we will have to come up with at the end. Senator KexNepy. Where do you work ? 2316 ~ Mr. MerrLEr. I am service manager at Conway Buick here in Des Moines. We were real fortunate. Senator Kexnepy. We hope your wife is well. Thanks very much. Robert Oberbillig. STATEMENT OF ROBERT C. OBERBILLIG, DIRECTOR OF THE LEGAL AID SOCIETY, DES MOINES, IOWA Mr. OsersirLic. I am Bob Oberbillig, director of the Legal Aid Society. Senator Ken~epy. Pardon my mispronunciation. If your name were O’Hara or Shaughnessy, I wouldn’t have any trouble. [ Laughter. ] Mr. OserpiLuic. Our office represented the Porter Dimery family. We are continuing to represent them. We have also represented and continue to represent the Clifford Thomas family. There are legal issues that are involved that are denying these families legal assistance in the State. But contrary to what the doctors have said today, it isn’t 96 percent of the people that have available to them medical facilities. The State of Towa as a result of the Dimery case, which incidentally on a technicality was reversed, that would have granted medical assistance to every person in need in the State. The State in their briefs and in our public statements found there were 350,000 Towans who had medical needs that did not have the money to provide for them and would be eligible, but for the limited eligibility standards which Towa follows in providing medicare relief. That’s in addition to the 75,000 who are eligible because they relate categorically. In several of the material areas of our welfare laws which help to determine the eligibility of these programs, we have in Towa some of the most restrictive eligibility standards such as in the aid to disabled. To qualify you must be helpless, but you must have the assistance of another person in your daily life, not on the basis of employability, but literal helplessness, before you can qualify and there are hundreds of people turned away each year who meet all of the tests of disability on a permanent basis but cannot get medical assistance because they don’t qualify on the helplessness theory. We can go on in the absent parent situation which is what was in existence with the Dimery family. T might say in working with this family for the last 3 years, if it wasn’t such a strong family this family would have disintegrated. Porter Dimery would have, under normal circumstances, left the family and their family would have qualified for ADC and then qualified for medical services. Nobody knows what that family, just one family, went through, to give up, so that the son could get medical services and the parents could relate to him. The fact is that all the children in that family have sacrificed so that this boy could still be a family member. The availability of Towa City may only be a couple hours drive and maybe only an ambulance away, but much of the healing process is having to support a family, and when a child has to be removed 2317 or a parent removed from the family and treated as an inpatient at Towa City, the process is slowed down and the cost is increased. . What I would like to say though is that I think it is time in the United States and in Iowa—where in Iowa last year we spent $31 mil- lion for medical services, we're only one-sixth of the people who are literally eligible. It is time we found different ways of providing this service. I happen to believe in legal services, and if this can be a similar test, in the city of New York alone legal aid has provided in the crime and civil field to the extent of three-quarters of a million dollars. The city has done some extensive survey work to determine that they have to go to an asisgned council basis. In other words, hiring a lawyer on a per case basis. They found that the probable cost to do that would probably be $29 million. We are still in Iowa providing medical serv- ices on that basis. We have not found ways of hiring doctors on a per case basis, but literally hiring them on a salary basis and providing for those that need it and need it on a 24-hour basis. We have 15 lawyers in the city in legal services on an OEO grant. We served more than 10,000 people last year both by telephone and in the offices and in our courts. We cut costs considerably to provide that type of service. We think that that would be a reasonable way to pro- vide medical services. We know that the medical students that are coming out of Iowa and other medical schools are no different than the law students. We have a steady stream of young men high in their class coming to our offices willing to work for $10,000 or $12,000 a year to provide services for the poor and the needy. I’m quite certain that AE students are no different coming out of the medical schools as doctors, that they are willing to provide these services if we would provide it. Now, the Government has found ways of requiring communities such as Des Moines and any other State that has large areas to con- tract with legal aid societies to provide legal services and to other rural areas on a per diem basis. Why not have the same type of requirement in the medical service? Senator KennNEDY. Is there a need there though? Is there really a need ? Mr. OBerBiLLiG. There is no question there's a need. They may only be 20 minutes from a hospital, but there are people within walking distance from a hospital in the city who cannot qualify for medical services. There are people who live next door to doctors who cannot get it because they don’t have the money. We can also look from another consumer standpoint. The most harassing type of collection practice is those institutions who buy up the medical bills that are unpaid and then go after the debtor who cannot pay them. In our experience in bankruptcy we find this to be an on-going cause of many bankruptcies. : 2318 No, T think medical services and medical expense in proportion to what the State already is paying is well out of proportion. I might also point out that less than 7 percent of our State budget goes for welfare programs in their entirety, and this State has not found the way or ability to meet what they already recognize as a medical need. Senator Kexxepy. Thank you very much. If you would like to give us an additional note on this area I think it would be helpful. I think we could make it a part of the record if you would like to do that. Mr. OpersiLLic. I'd be very happy to. Senator Kexxepy. We are well over our time. We will take Pat Machio and then we will conclude. STATEMENT OF PAT MACHIO, LAW STUDENT, DES MOINES, IOWA Mr. Maco. Tt is my contention that the University of Towa Medical School is not. in fact, making an effort in good faith to increase enroll- ment or to do anything to solve the problem of doctor shortage, and in fact, on the contrary, they are intentionally seeking to limit their enrollment. : Senator Kexnepy. Just a minute. They talked about an increase in enrollment of about 40 percent. Mr. Maco. Senator Kennedy, you yourself pointed out in the chart up there, and that has to be mistaken. Senator Kexnepy. But as I understand, a heavy percentage have been leaving Towa. Mr. Macro. That’s true. They are. But like I said Senator Ken~Nepy. Are you a student up there? Mr. Macmio. No; I'm a law student. The figures do not jibe with the chart. Senator Kexxepy. They could to the extent they have increased their enrollment in the last few years, that a great percentage or the majority that have graduated from the school are going to other States and therefore not going here, so it would be consistent really with the chart. Mr. MacHio. It isn’t if you calculate the difference offset by the per- centage. It doesn’t mean they are increasing their enrollment. He gave the figure of 175 students in medical school in 1975, and that certainly isn’t staggering. My basic question is this: Is there Federal medical assistance avail- able to medical schools for education of doctors, and, if so, have they applied for it at various medical schools and what type exists? Senator Kennepy. Well, there is, but we don’t do nearly enough. We've got several hundred million dollars, about $400 million, of un- funded applications which have been approved at the present time. We have inadequate funding in the budget for health. I think they are also inadequate in terms of direct scholarship grants to students. We are trying to increase the contributions to medical schools. My bill, S. 934, incorporates recommendations of the Carnegie Commis- sion. We've had some hearings, three or four hearings, on this already. 2319 Mr. MacH1o. As chairman haven’t you seen some evidence, however meager that it might be, that a lot of medical schools are laying out plans more or less pursuant to the law of supply and demand, that they don’t want to get too many doctors into society because then there would be too much of a fuss raised or: Senator Kennepy. I think it is a fair criticism to make in terms of the medical societies 20 or 30 years ago. I'm not so sure it is fair at the present time. I think there’s been a rather significant increase in enrollment, and quite frankly, the medical schools are in financial crisis. Over half of them, 120-odd medical schools, have applied for emergency grants just to keep their doors open. I think there’s a much greater recognition of the need for more doctors by the medical schools today than there was maybe 20 or 25 years ago. I think the schools are under enormous handicaps in trying to provide training. Mr. MacHio. Senator, you can throw out all these handicaps and there are at least 15 reasons why these medical schools can’t increase their enrollments, but the one other underlying reason is that they don’t want to get too many doctors on the market. Thank you, sir. Senator Kex~epy. Thanks very much. There are other witnesses, but we are going to have to recess this hearing, and we will ask any of the others if they’d like to write down their name and file either a statement up here now or send it in to us later. We will make it a part of the record. If the hospitals or others have been mentioned here or there has been representation made about them which they feel deserves clarification, we will include that as part of the record so that we have as complete a record as possible. I want to thank all of you for your attentiveness and your interest in this. This hearing has been of enormous value to us. You have been extremely kind and patient. We want to thank all of you for coming this morning. We hope it’s been of some interest to you. I want to thank you all. At this point I order printed all statements of those who could not attend and other pertinent material submitted for the record. (The material referred to follows :) PREPARED STATEMENT OF RALPH GLENN, DUBUQUE, Iowa My name is Ralph Glenn. I am from Dubuque, Iowa. I have an interesting case that I would like some advice on if posisble. This young man is 17 years old. He’s not eligible then for social security. He is not a veteran, therefore he cannot go to a Veterans Administration. His bill was $12,000 for the first three months. He is a quad-paraplegic. His right leg is off at the hip. The left leg and two arms are totally paralyzed. He is right now in—he went to Iowa State University Hospitals. He's been released from there. He is now in the Younkers Rehabilitation Center. My problem as executive director of the Tri-State Health Planning Council, a 314 (b) Grant organization, comprehensive health planning, is this: Is it possible for me or my organization to request to have this boy put into a Veterans Admin- istration Hospital? He needs it and I'd like to have some advice on that. Thank you. 2320 PREPARED STATEMENT OF SIDNEY GROSS, PRESIDENT, NATIONAL FARMERS UNION, AN |10WA FARM ORGANIZATION Senator Kennedy, Senator Hughes, and other distinguished members of the Committee - Speaking in behalf of the members of Iowa Farmers Union, an Iowa Farm organization, I am pleased to have the opportunity to bring before this Committee what we feel is a case that points up rather well discrimina- tion in the application of health and hospital insurance care in Iowa to- day. After being elected president of Iowa Farmers Union in December of 1966, I found car insurance by mail and hail insurance, both through our National organization, was the total insurance services offered by our organization. No health care service was being offered. Since Blue Cross-Blue Shield does not require licensed agents, in the winter of 1967-68 I contacted, by telephone, Blue Cross-Blue Shield officials in Des Moines as to the availability of a contract with them for health care for our members. Two men from the state Blue Cross- Blue Shield office came out and after visiting for a time asked for the membership list in several counties to take back and check to see how many were already enrolled in an existing Blue Cross-Blue Shield plan. 2321 wD I was later contacted and informed that, since quite a large number were already enrolled in onuet groups, Blue Cross-Blue Shield could not see where it would be to the advantage of either of us to proceed further. Being new and naive at this sort of thing I accepted it as a plausible reason. There the matter rested until January of 1970. Suddenly full page newspaper ads such as these (show) appeared all over the state announcing a statewide "hook up" between Blue Cross-Blue Shield and the Iowa Farm Bureau. Look at those advertisements carefully. Then I would raise the question who paid for them, who is the chief beneficiary and what do they implant in the mind of the average person? Immediately our state office was bombarded by members asking if we, too, were going to get health care for our members. Since I could not correlate the fact any more farmers in Iowa Farmers Union would already be signed in existing Blue Cross-Blue Shield con- tracts than any other cross section of farmers, I immediately called the Des Moines Blue Cross-Blue Shield office protesting the apparent discrimination in providing health care for Farm Bureau members after turning us down two years before. 2322 - Bi After several weeks delay, because of other commitments by Blue Cross- Blue Shield officials, a discussion meeting was arranged. At this meet- ing it was mutually agreed to re-open negotiations regarding a health care plan for Iowa Farmers Union members via Blue Cross-Blue Shield. In this interim period and while open enrollment was available, we had several inquiries, of which one from a lady in Carlisle, is typical. Her husband, when living, had been a member of Iowa Farmers Union, dis- agreeing quite strongly with Farm Bureau philosophy. Although she wanted to remain loyal to her husband's memories, she felt she needed health insurance coverage and should take advantage of this open enroll- ment period unless we, too, would have similar health care available soon. I assured her that we were negotiating and that we hoped to have a like health care plan to offer in the near ry but if she wanted to be on the safe side she should take advantage of the opportunity and enroll, which she did. She still laments, to this day, the fact she was forced to join an organization against her will just to get health care. In May of 1970 a Blue Cross-Blue Shield policy was offered the officials of Iowa Farmers Union for study. The plan (Plan I) was identical 2323 sh ~- with the Farm Bureau plan except for slightly better provisions regard- ing prescription drugs and an added $300.00 supplemental accident cover- age. However, the family premium rate was upped from $30.00 a month in the Farm Bureau plan, to $39.80 - a difference of almost $120.00 per year. We protested that the added coverage was not commensurate with the increased costs. Their answer was to bring us Plan II. Plan II con- tained full coverage Blue Cross-Blue Shield with added Major Medical, exactly like the Farm Bureau policy except that all accident and drug provisions were deleted. Yet the family rate was set at $35.75 per month compared to $30.00 under the Farm Bureau plan, or a difference of $69 per year, even with the lessened coverage. After due consideration the Executive Board of Iowa Farmers Union decided that this was not really offering a service and that it was stretching loyalty beyond the human breaking point ® ask a family in our organization to pay from $70.00 to $120.00 a year more for the same health insurance as their neighbor across the road just to remain loyal to the beliefs of the organization. We, therefore, termination negotiations with Blue Cross-Blue Shield. Many of our members still do not have health insurance. 2324 ='5 -b = One young family recently experienced a heavy financial drain through an illness of one of the children. They badly need health care insurance at a reasonable rate. Another result of the Farm Bureau - Blue Cross-Blue Shield hookup is that in many counties of Iowa any contact for Blue Cross-Blue Shield health care insurance must be made through the County Farm Bureau Office. The address and office for both are one and the same. Senators, this had been a most revealing experience, from the adver- tising through the rate setting, and where this built-in interlock is leading. We believe this is a vivid demonstration of one of the weak- nesses in present health care. That it points up the very real need for a National Health Care Program so that Joe Dokes who lives on one side of the road is not treated differently than John Doe on the other side. So that equality in health A Te to all regardless of organization membership or philosphical direction. We believe it is time Congress puts a stop to the discrimination and conniving taking place today, at the expense of the health care of the people. We trust this testimony will be of value in determining legislative direction and we thank you for the opportunity to appear here today. 2325 REPORT ON COST AND PROBLEMS OF HEALTH AND WELFARE I, William F. Fenton, have been Chairman of Local 254, International Association of Machinists and Aerospace Workers Health and Welfare Trustees since 1958. When we started the plan in 1958, the cost was $10.40 per month, which is approximately .06 cents per hour. This was for a basic plan, which at that time was for most of the cost of the health care. In 1960, the cost of the same plan went to $11.51 per month. In 1961, the cost was $13.57 per month. In 1964 the cost rose to $17.90 per month. In 1967, due to the rise in hospital cost, the program was not adequate and we added Major Medical, which made the cost $30.03 per month. In 1968, the Insurance Carrier asked for an increase in premium, and we put the program up for bids from Insurance Companies. A new Carrier was selected and the cost remained at $30.03 per month. In 1969 we were told that there would be an increase of $l.32 per month, unless we would agree to delete the Coordination of Benefits from the policy. This was done and then the cost remained at $30.03 for one year. We were notified then, by the Carrier, that there would be a premium increase to $39.08 for the same coverage. This now increases the cost for insurance from .06 cents per hour in 1958, to .23 cents per hour in 1971. 2326 ~2s We asked the Insurance Companies at this time, to give us a three year guaranteed premium rate which they submitted, showing a $5.23 per month increase, effective 1972, and an additional $6.46 per month increase in 1973, which then made our cost go, for an identical program, from $30.03 in 1970, to $50.76 in 1973, or a 66 2/3 % increase in insurance cost in a three year period. We were told by the Insurance Companies that the increase would be necessary because Medical Care Costs were rising at the rate of 13% per month, or 18% per year. This is not a true figure because the 18% each year is compounded on the previous premium rate, which as shown above reflects a 66 2/3% increase rather than a 54% increase. The insurance program that I have made reference to above, does not pay the full cost of medical care, which leaves the employee then to spend additional monies making his cost for health and welfare insurance in some cases, far in excess of the .23 cents per hour. Although our plan is better than most plans that I have studied, it still leaves a great loop-hole that should be covered by a Federally supple- mented policy. I will refer to one case in particular which resulted in a Kidney Transplant, and although our policy has paid over $30,000., the insured still has a bill in excess of $7,000. Also, in the same case, the Donor was going to be refused, and in most cases would be, any coverage under his Health and Welfare Program because the Insurance Companies were claiming that donating a Kidney is elective surgery and would not be covered. We have one insurance program which pays the full cost of medical care, however the cost of this program is $61.00 per month which reflects a cost of .35 cents per hour. We have found that a minimum program that people should be covered by, would at least cost .20 cents per hour and when you reflect this according to the Minimum Wage Law, which provides $1.60 per hour, this then makes an employee pay 123% of his wages for an insurance program, which most people can not afford; therefore, they do not get Health coverage. Another problem which adds to the cost of an employee's insurance is that most employers do not pay the full cost of the program and the employee's share is deducted from his pay check, which then makes him pay income tax on this money which then adds another 18% to 30% cost for his insurance. We have also found that when employees pay part of the premium, if the insurance company pays a retention to the policy holder, very seldom is any of this retention monies distributed back to the employees. We have also found one large corporation which is doing business in the State of Iowa, that told the employees there would be an increase in their insurance program cost. We then asked this Company for a copy of their D-2 Health and Welfare Disclosure Act Report Form. In checking this form we then found out a $171,000. premium that was paid and then checking the amount of claims paid, there was $33,000. that was not accounted for on the D-2. We asked the Company where this money was and have been refused an answer to this date. Therefore, I think a closer review should be made of all D-2 forms to make sure all information 2328 is submitted as required by law. I also do not believe that Insurance Companies are interested in keeping the cost of a Health and Welfare Program at a minimum, or do they care about the cost of Medical Care, because they operate on a percentage of the total premium, which I have had Insurance Companies admit to me, is from 13% to 27% of the total premium. This then, taking the situation as mentioned earlier, when we go from a $10.40 per month premium, to a $50.76 monthly premium that the Insurance Company then on the same amount of people, which would reflect approximately the same amount of book work and cases makes this Insurance Company make five times as much money for handling the same group of people. We have had to supply each hospital in the City of Des Moines with a copy of our Insurance Program. The hospitals claim they need this for billing purposes. I cannot see where the connection should be between a patient's coverage under his insurance program and the amount of his bill. Health care should be based on need rather than money. In the current outmoded organization and distribution of services, delivery and treatment are too often determined by the individual's income--or lack of it--and by the fine print in his health insurance policy. Too often, money determines, both in quality and quantity, the patient's treatment. Respectfully submitted, Wottiim FLT William F. Fenton WFF:ip 2000 Walker Street opeiu #37 afl-cio Des Moines, Iowa 50317 2329 SCHOOL NURSE == ''CHILD ADVOCATE" The well and happy family is the basis of a stable and wholesome society as well as a key to individual happiness. Education is concerned not only with familial hygiene but alse with the economic, social, cultural, and spiritual phases of family life. Youth should develop consideration for other persons, a realization of the importance of conforming to the mores and ideals of his society, and knowledge of how family life and parental obligation can be met in such a way as to bring satisfaction and achievement to both parents and children. Growth and developmental changes occur continuously. An individual is developing feelings about himself and others and as a member of a group, he must learn to understand, accept, and deal adequately with the changes which are occuring within him. A child receives his education today from many sources and at an early age. Television, radio, motion pictures, magazines, and newspapers bombard the child constantly with ideas not always based on scientific fact. The school, in part, has the responsibility to help children to cove with the world around them. It is necessary, therefore, that a strong, continuous health education program be developed to aid in the assimilation of all that it takes to have a healthy, happy, satisfying life. The program would include all school age children. The combined efforts of the home and school are required in order to provide children and youth with scientific information, sound attitudes, and desirable health practices. 59-661 O - 71 - pt, 10 - 8 2330 The profession of school nursing is a dynamic discipline which embraces a variety of functions. Because of her medical knowledge, academic preparation, and professional skill, the school nurse has the qualifications to: 1. Assess and evaluate the health and developmental status of the pupil in order to make a nursing diagnosis and establish priority for action. 2. Interpret the health and developmental status of thempil to him, his parents, and school personnel. 3. Interpret the results of medical findings concerning the pupil to him, his parents, and school personnel. 4, Counsel the pupil, his parents, and school personnel and plan action for eliminating, minimizing, or accepting the health problems that interfere with pupils' effective learning. 5. Motivate and guide the persons responsible for pupils’ health to appropriate resources. 6. Recommend to the administrator modifications in the educational program when indicated by the health or developmental status of the pupil. 7. Serve as a health consultant and resource person in the health instruction curriculum by providing current scientific information from related fields. 8. Use direct health services as a vehicle for health counseling. J. Serve as liaison among the parent, schcol, and community in health matters. 10. Be a member of the placement committee for special educational programs. The quality and quantity of learning of each student is in direct proportion to the physical, mental, emotional, and social levels of health. The primary function of the professional school nurse is to strengthen the educational process through improvement of the health status of children, youth, families, and the community. Optimum school nursing services will assure each student the opportunity to realize his maximum health potential. The emphasis, therefore, in schoel nursing and health education is on prevention of health problems. Schools reach the whole population. It is recognized that school nurses, due to their direct relationship with individual children, families, and the community, have the opportunity to impart to this blooming society the knowledge of independent health care. Formal and informal health teaching wendd be utilized to accomplish the goal of independent health care. The reason that health teaching can be successful in this area is that youth is the time of habit formation. By repetition and reinforcement of what constitutes good health care, desirable practices can be established and maintained. Educating the child involves transferring to him the responsibility 2331 (2) for health behavior and equipping him with such attitudes and knowledge as will ensure healthful living now, in later childhood, and in adult life. Children must make adaptations in the transition to the adult life, therefore, reliable, factual information based on scientific knowledge, is essential for a continuation of healthful living. Instruction in health commands the interest of the child, stimulating the enjoyment of positive health rather than concern for disease. A comprehensive program in health education should be designed to provide students with the ability to live a healthy, happy, satisfying life. Modern health education is necessary because to date it is clearly shown that present health practices are poor, our attitudes toward disease have prompted us to act as though the responsibility for our health were our physician's instead of our own, and a lack of basic health information exists among the general population. Areas for consideration in a health education program could be: A. Personal hygiene 1. Privacy 2. Cleanliness 3. Nutrition 4, Grooming 5. Exercise 6. Rest and relaxation B. Anatomy and physiology 1. Skeletal structure 2. Body systems 3. Physical growth and development C. Heredity and genetics D. Tobacco, alcohol, and drugs E. Safety F. Family unit 1. Members-needs 2. Privacy, 3. New members 4 + Death 5. Grandparents, aunts, uncles, siblings, etc. 6. Internal pressures-external pressures a. divorce b. marriage c. moving d. loss of a memberoflousehold 7. Child roles 8. Adult roles G. Community agencies 1. Social 2. BPoluntary 3. Church 4, Public 2332 (3) He. Interpersonal relationship 1. Cooperation 2. Sharing 3. Decision making 4, Respect for others 5. Responsibilities 6. Understanding handicaps I. Emotions 1. Behavior 2. Decision making J. Leisure time 1. Enjoyment of life 2. Recreation K. Environment 1. Ecological problems 2. Cultural differences L. Ethical standards M. Communicable diseases 1. Disease process 2. Controls N. Consumer education The teaching of health is adapted to the maturity and grade level of the students. His role in society as he grows and develops shculd be considered. Society cannot function properly and adequately withcut goed health. The lack of facilities fof optimum health care emphasizeé the need to utilize preventative health measures. The school nurse serves as a liaison between the children, family and available community resources, Knowledge of where to go for health care intime of need is possessed by the schocl nurse and can be imparted to children and their families with hopeful carry-ovey for independence in our future. School nurses propose a method to contain the rising cost of medical care and reduce the present over load on physicians, hospitals, and other health oriented agencies. This method being the utilization of the school nurse practitioner. Special education is now available in three centers in our nation for this purpose; The University eof Colorado, Denver, Colorado, St. Louis, Missouri, and the Bunker Hill Program in Massachusetts. More states are moving into this type of program. The emphasis is on delivery of direct services to the child and his family. The preparation of the school nurse practitiemer would allow her to perform a physical examination which would include the skills of observation, palpitation, auscultation, and percussion. She would also be able to evaluate simple laboratory prodedures, namely: a complete blood count and urinalysis. School nurses realize the critical shortage of personnel in health professions. One of the objectives of any national health care plan should be to utilize more effectively the existing supply of health manpower. Use of the school nurse practitioner's unique skills will: 1. Greatly reduce the number of children who never receive an assessment of their health status; 2. Increase the number of children who will benefit from adequate management and remediation of their health problems. 2333 (4) In summary we want to stress certain aspects of the preceding. The promotion of healthful living and prevention of disease and injury by the school nurse, educators, and the total school health program, should play a very important role in elimination of escalating medical costs and in development of ambulatory health care services. Health teaching is a privilege and an opportunity as wells a responsibility in the field of education. The schoel nurse is vital in establishment, maint@mance, and reassessment.of the health status of children, families, and the community. We can only hope as society looks to the future, that some day every human being will be well, intelligent, physically vigorous, mentally alert, emotionally stable, socially reasonable, and ethically sound. School nurses Mrs. Ann Short = KV 1923 37th Des Moines, Iowa 50310 Mrs. Susan Amosson RL: 3433 Hillcrest Dr. Des Moines, Iowa Mrs. Lorrine Glazebrock £ JV 8168 Northwest Dr. Des Moines, Iowa 50322 Mrs. Ruby Wheatly rRv;BS 301 E. Third Ankeny, Iowa 2334 Senator Ken~epy. The subcommittee will stand in recess. (At 12:20 the hearing was recessed subject to the call of the Chair.) HEALTH CARE CRISIS IN AMERICA, 1971 FRIDAY, MAY 14, 1971 U.S. SENATE, SUBCOMMITTEE ON HEALTH OF THE ComMITTEE ON LABOR AND PuBrLic WELFARE, Denver, Colo. The subcommittee met at 1:45 p.m. in lecture room No. 2, Denver Medical Center, Denver, Colo., Senator Edward M. Kennedy (chair- man of the subcommittee), presiding. Present : Senators Kennedy and Dominick. Committee staff members present : doRay G. Goldman, professional staff member to the subcommittee; Jay B. Cutler, minority counsel to the subcommittee. Senator Ken~epy. I want to express a very warm sense of appre- ciation to the Colorado Medical School and the deans and the faculty for the cooperation and the hospitality that they have extended in permitting us to have this meeting here this afternoon. They have been extremely kind and generous with their time and cooperation, and I want to acknowledge that at the outset. Our hearing today is really a continuing part of our effort to learn about the condition of health care in America. We began these hear- ings some 9 weeks ago in Washington, with a series of meetings where we heard the experts, the representatives of the various interest groups, testify before us. Then, the subcommittee began a series of field hearings. First, we went into New York City to consider the urban health crisis. After New York City, we traveled to Westchester and Nassau Counties, where a more affluent group of people live, to study the health care issue in the suburbs, especially the quality of care issue. Then we traveled to West Virginia, which is the second most rural area in the country. From there, we went to Nashville, Tenn., which has one of the great medical centers in the country. Then our sub- committee visited Cleveland and Chicago to see the health problems of urban areas in the midwestern part of the country. Yesterday we visited Des Moines, Towa, a city of 250.000 to 300,000 people. We had an interesting opportunity to visit with the heads of many of the private insurance companies, and in the later part of the afternoon we went out into rural Towa. Today. we are here in Denver, and we will continue our hearings in the early part of next week in California. We are particularly delighted to come to Colorado with Senator Dominick, who is the ranking member of the Senate Health Commit- (2335) 2336 tee and who, of course, has been greatly interested in the health issue. Although TI have had a chance to visit this great State on many dif- ferent occasions in the past, I have never had the opportunity to visit as many of its medical centers or the health delivery centers as I have had during the period of the last 18 hours. In that time, we visited a number of the major hospitals of Denver. We have seen the microeye surgery unit at Mercy Hospital and the computer EXG center at St. Luke’s. We have seen the impressive fa- cilities at Denver General Hospital, which is clearly one of the best municipal hospitals in the United States. This morning we visited the Craig Rehabilitation Center, one of the most important rehabili- tation centers for spinal injuries, which is enormously impressive. We also visited the East Side and the West Side Neighborhood Health Centers which are trying to reach out to the community to provide comprehensive health care for lower income families and poor communities. Later this afternoon, we will visit the Park Hill Health Station, which T understand is another important link in the commu- nity health network of Denver. In other portions of our visit, we have heard many of the innova- tive achievements of medical foundations in Colorado. We have also had an opportunity to talk with some of the deans and students of the medical school at lunch this noontime. Irom what we have seen here today in Denver, we can’t help but be impressed. We recognize that we do have a health crisis in this country, but it’s a good deal less apparent in Denver than it is in many other communities. The crisis is severe in some of the poorer parts of the city of Denver, and T understand that it is also serious in rural Colo- rado which, unfortunately, we won’t be able to visit at this time. But I want to say that we have seen much that is good about the health system in Denver, and that we are indeed appreciative of all of the help and assistance that we have had. In our hearings this afternoon, we will have testimony from the consumers of health care. We want to listen to their stories, hear how they have been treated by the health establishment, and hear their observations and comments. Then in the time that we have available before concluding the session, we will try to open up the meeting for comments that consumers and others in the audience would like to make. Let me request anyone who would like to make a comment to submit his name now, and we will take them in the order in which the names are presented. Now, perhaps Senator Dominick would like to make a comment. Senator Dominick. I want to welcome Senator Kennedy to Colo- rado, to start with. He has instituted a series of hearings which will be of really quite a good deal of value in our determination of what we are eventually going to come up with by way of legislation. We have, just for the record, all kinds of different pieces of health legislation in Congress. Senator Kennedy's bill, for example, which he’s very much in favor of, is not before our committee. It’s before the Finance Committee. The bill that I put in to try and help the Metro Denver Medical Foundation, to be able to provide coverage for civil servants if they 2337 want to, is not before our committee. It’s before the Post Office and Civil Service Committee. But we do have before our committee, I think, the responsibility, for building a record, which I think we have done very well, on the problems of the distribution of health care, and the problems of some of the consumers. A radical change both in at- titude and in ideas has gone on among health providers throughout this country, and I think this is really a tribute to them. An enormous number of improvements are being made, an enormous number of dif- ferent types of ideas and methods of distribution of health care are being developed, and all of these will be in the record. I think whatever bill we eventually come up with will have a good deal of very solid evidence behind it. Now, one of the things that we have been working on is to try and figure out what we do about bringing medical care to the low-income districts, both rural and intercity. What do we do about making the administration of hospitals more efficient? How do we lower costs to consumers? We have heard testimony on a whole variety of issues of this nature all over the country, and I for one am very happy that we started this series of field hearings. Hopefully, from these we are go- ing to get something of value, not only for Colorado, but for the whole country. Senator KennNepy. There has been, as I understand it, a lot of prep- aration for our visit that I didn’t know about. I have a. memoranda here prepared by the Colorado Hospital Association to advise the medical societies and other health providers in the area about the sub- committee, and I will just read one paragraph: “Representatives from the Colorado Medical Society, Denver Medical Scciety, surrounding counties’ medical societies, dental societies, and myself representing the A.H.A. and C.H.A., were present at the briefing session held on April 30, 1971, at the Colo- rado Medical Society. In addition, the AMA had three staff peo- ple, a gentleman from Chicago who has been traveling through- out the country attending the hearings and taping them, and two AMA field representatives, one from Columbus and one from Denver. The field representatives have been covering the hearings in their own regions and the ones in the region directly to the east. So there is great continuity among AMA staff people.” So, if the doctors are wondering why their AMA dues have been rising, it’s because they have a lot of staff going around the country following us. A rather interesting memorandum. We are glad to read about it. Now, we shall hear from the consumer witnesses. We are very ap- preciative of those who come to comment here. It’s not a part of our tradition in this country to draw public attention to one’s ills or diffi- culties or pain or suffering or unfortunate family experiences. Usually, people are very reluctant to talk about their problems, and we are very appreciative of the fact that so many individuals have been kind enough to share their experiences with the subcommittee. Only in this way will we really be able to respond with effective health legislation. Our first witnesses are Mr. and Mrs. Gary Breeze. 2338 STATEMENT OF MR. AND MRS. GARY BREEZE, RESIDENT, DENVER, COLO. Mrs. Gary Breeze. Senator Kennedy, Senator Dominick. Gary’s accident took place approximately 2 years ago, in July of 1969. He was driving home from work, and there was an automobile accident. He suffered a fractured vertebra, C6-CT7, a spinal cord injury, and multitudinous internal injuries. He was taken immediately to Lutheran Hospital. He was in inten- sive care 12 days there. We were told initially that he would probably be in intensive care for at least a month, but because of an infection, he was taken out, and put in a private room. He was on a special frame and these things, of course, necessitated a private room. He was in Lutheran Hospital for 3 months because of the internal injuries, and then he was at Craig Rehabilitation Center for 3 more months, He was a regular outpatient for approximately 2 months and has been an outpatient periodically since then. Our bill at Lutheran Hospital was something like $12,000. Now, Gary was in a rather unique position. He had been president of a bank prior to the accident, and he had the job of voting on a particular type of health insurance that he wanted for the bank per- sonnel. The staff was relatively young, and, of course, we looked at it from that viewpoint. So, consequently, he looked at health insurance as maternity insurance for a wife or as insurance for Johnny’s broken arm or a skiing accident or something of this sort. We had no prece- dent as far as something like Gary’s accident was concerned. We voted on what the bank could afford and what we knew. Our insurance covered a 3-month stay in a hospital and then you're out for 3 months before it will cover any more in-hospital costs as such. So it did cover the entire cost at Lutheran and about 2 weeks at Craig. The costs at C'raig Hospital, we were told the day before we entered, would be $3,000 a month. The doctor would be $350 a month; pros- theses, which would mean braces, wheelchairs, tilt boards, and things necessitating skin care, would be $5,000, so these things, of course, we have had to pay. Outpatient care is not considered as a part of the cost. We are still, of course, seeing doctors. We have therapists working with us at all times. These are, of course, you know, on our own. I think that’s Senator Kennepy. Now. do I understand that, during the time that Mr. Breeze was at Lutheran Hospital, Blue Cross covered his expenses ? Mrs. Breeze. Yes; we paid something like $875. The insurance cov- ered all but that. Senator Kexxepy. For how long a period ? Mrs. Breeze. Three months. Senator Kex~epy. And then you went to Mrs. Breeze. Craig Rehabilitation Center. Senator Ken~Nepy. And you had to make a deposit there, did you? Mrs. Breeze. Yes, $5,000. Senator Kexxepy. Before he entered Craig? Mrs. Breeze. Before he entered Craig. Senator Kenxepy. And was that money used up ? Mrs. Breeze. Yes; it was, sir. 2339 Senator KennNepy. And your husband was a bank president? Mrs. Breeze. He was. Senator Kennepy. And he was required to put up $5,000 before he could enter Craig? Mrs. Breeze. We put up a deposit of $5,000 toward the end of Sep- tember. Gary was admitted to Craig Rehabilitation Hospital on Oc- tober 3, Friday, of 1969. Senator Kenxxepy. Then, after leaving Craig, he has also endured some medical expenses ? Mrs. Breeze. As I said, his prostheses costs over—the total run would probably go about $5,000. His drug bills run about $75 a month supplies, $50 to $75 a month, and this is the major part of the cost. Senator KENNEDY. So your expenses now run about $150 a month? Mrs. Breeze. Yes. Senator Kexxepy. How long do you expect these expenses to continue ? Mrs. Breeze. There’s no end in sight, Senator. Senator Kexnnepy. And who pays for that now, the $150 a month you are now charged ? ge Mrs. Breeze. Well, we are no longer, of course, on hospitalization insurance. The only thing that the insurance would cover at this point would be if Gary went back in a hospital. So anything at this time we carry ourselves. Senator Kexxepy. And can you get any insurance now ? Mrs. Breeze. No, not now. Senator Kenxepy. Have you tried to? Mrs. Breeze. Yes. Of course, we are not insurable now. Senator Kexxepy. Why do you say “of course”? Won't the insur- ance companies provide any health insurance to someone in your situation ? Mrs. Breeze. No, no. Senator KexxNepy. So you are going to have to pay these bills yourselves ? Mrs. Breeze. Yes. I haven’t found an insurance company that would over us at this point. Senator Kex~Nepy. IT haven't either. What are your prospects now? Are you going to have to go on welfare in order to survive? Mrs. Breeze. No. We are fortunate to have parents that have helped us. We would certainly hope that one of these days Gary will be able to go back to work. Hopefully, there will be a day that he will be able to go back to work. This is what we are working toward. We have three little children. It’s what he is striving so hard for, but we don’t know. Senator Kexyepy. We have made so much progress, I think, espe- cially in terms of the Vietnam experience in helping and assisting and finding new ways of helping injured individuals. I think there’s cer- tainly a hope with you that things will work out well. Senator Dominick. Now, let me just say that Mr. and Mrs. Breeze have been friends of mine for a long time. Mrs. Breeze. Yes. Senator Dominick. I frankly hadn’t realized that this had hap- pened. Gary. Let me tell you how sorry I am. I wish I had known about it earlier. 2340 Did you find that the Craig Rehabilitation Hospital work was help- ful to you? Mr. Breeze. Very much so, sir; yes. Senator Dominick. The real question is, how do you finance these kinds of things? I don’t quite understand the financing at Craig. I understand that the Craig Rehabilitation Hospital had been built almost entirely on voluntary contributions. Mrs. Breeze. I don’t know. I can only speak from our own experi- ence. Senator Domizick. There are people at Craig which we saw this morning, who I'm sure have the same or perhaps even greater prob- lems than you have had and there still is hope that all of these people will be able to go back to work. Mrs. Breeze. Of course. Senator Dominick. Now, I wish you the best. IT think this is terrible for you, for the county, and for the State. I'm sorry it happened. Senator Kex~epy. Mr. Breeze, may I ask you this question? You must have felt—as president of the bank—that you were working out an effective insurance program for the employees of the bank, did you not ? Mr. Breeze. Hopefully ; yes, sir. Senator KexNepy. And you must have felt, I suppose, when you had your accident, that you were insured for any accidents you might have had, didn’t you? Mr. Breeze. Well, sir, I can’t really recall the accident, of course. 1 don’t recall anything from that time until recently. I can’t really say that T did feel that I was insured to take care of this kind of thing, this injury or injuries. Murs. Breeze. 1 don’t think we had ever known anyone that had such insurance. Perhaps that’s had a great deal to do with how you feel about this. As I say, it was a particularly young staff at the bank, and you just don’t think of something of this nature. Senator Kex~xepy. This really could have happened to anybody, could it not? Mrs. Breeze. Yes, of course. Senator Kenney. It was an accident and you happened to be the president of a bank. Yet, as T understand it, the accident has provided a very substantial and significant financial hardship upon your family, and it will affect your children as well. I suppose that a serious ques- tion is raised. Why should we have a health system which permits the extraordinary pain and suffering that an individual experiences from a Serjous accident like this to be coupled with the threat of financial ruin ? That’s what happens in our health system. Here you have some- thing that could havé happened to anybody. In fact, it happened to a man who is a president of a bank. You would think he would be pretty well able to handle his financial problems. Now, we see the kind of fi- nancial tragedy that this accident has caused. I want to thank you very much. Mr. Brerze. Thank you. Senator Kexxepy. Mrs. Smythe, Mrs. Patrick Smythe. Mrs. Smythe, we want to welcome you. 2341 STATEMENT OF MRS. PATRICK SMYTHE, EMPLOYEE OF COORS PORCELAIN, DENVER, COLO. Mrs. SmyraE. Thank you, and as you can tell by looking at me, I'm a specimen of health. 1t’s my husbana that is sick. Two years ago last January he had heart surgery. For 1 year pre- vious to that he had suffered numerous heart at acks. We did not live in Denver then. However, we were recommended 2 years ago to a doctor in Denver. We came here. He began the surgery. It was a special kind of surgery with a graft. I can’t explain it to you because I'm not familiar with— Senator Kennepy. Is that open-heart surgery ? Mrs. SmyrHE. Yes. They take arteries and graft them into the heart, or something. Shortly after the heart surgery, while he was still in the hospital, he had just been taken out of intensive care and he had to have ulcer sur- gery. As a matter of fact, he almost bled to death before they decided they would have to chance the operation. Soctiy before the latter part of May, he was allowed to go back to our home. He had been in Denver for all that time, most of the time in the hospital. After we had gone home and had been home about 6 weeks he once again had to come into Denver for more surgery because the incisions would not heal. He then went home again and it was then that we moved to Denver. Mr. Smythe was told he could not go back to work for 1 year after the surgery, so this means one person earning the living. Our insurance was exhausted completely. We had a $15,000 major medical policy from Prudential, which had been gone for some time. In the hometown where we lived, everybody knew the history. Every- body is afraid to give this man a job. You know, “What if he has a heart attack while he is working tor us? We don’t want this man in the place. ” We moved to Denver and we found a kind person that gave him a job. Senator Kexnepy. You think part of the difficulty in finding a job is that it might raise the premiums for health insurance for the em- ployer’s group. Mrs. Sayre. Well, this could be. I don’t even know if he would have been acceptable. I mean, I don’t know. But we did come to Den- ver. He does have a job. However, the person he works for does not offer medical insurance. I also work. I work for Coors Porcelain, and they do have a medical plan. I'm not very familiar with what it is. I have just recently gone to work there, but they will not accept him for 11 months thereafter. Each doctor’s call, each hospital call, everything that happens to us is out of our own pocket. Incidentally, our bills were over $30,000. We lost our home. The year that he had the surgery, our son was a junior in college. I did work, and through the help of my father, we did get him through school. But it has left us at this point with basically nothing. Mr. Smythe’s pay is around $220 a month. This is after taxes. After taxes I bring home around $90 a week. 2342 Of this we are paying St. Luke’s a $150 on one hospital bill each month. We are paying $30 on another hospital bill. We are paying two different doctors $50 a month, so after this you see how little we have to live on. Now, I want you to know that I am not condemning the surgeon. I think he’s one of the finest. I'm not condemning the hospital, because he got fine care, by God, he should have had fine care what they charged. I mean, truly. I shouldn’t have said that one word, but Senator KenNepy (continuing). No reason why you shouldn't. Mrs. Smyrue. It is expensive care, “2” amounts of dollars. There is no such thing as little bills. Everything is not $1 but hundreds of dollars. In this hospital, he was paying $32 for a room. Yet, this man is in intensive care, and not in a room at all. He is dying. I go and ask, “Why am I paying $32 a day #” “Well, the doctor might come in this morning and move Mr. Smythe to a room.” I said, “Well, put him in the hall for a day.” Senator Kexnnepy. You had to pay for a room ? Mrs. Smyrie. We paid for a room out in the hospital. Senator Kexxepy. Which he wasn’t in ? Mrs. SmyrHE. No, he was in intensive care. He was in intensive care for almost 5 weeks, but we also paid for a room in the hospital. Senator Kennepy. And they were also charging you for intensive care? Mrs. SmyrHE. Oh, certainly. Not only that, but each and every ounce of blood and each and every little ounce of oxygen, whether he got it or whether it escaped. Senator Kexnepy. Now, you had medical insurance which paid $15,000 of the approximately $30,000 bill—is that right ? Mrs. SmyraE. That is everything. Senator Kexnepy. After you used up your savings, did you still owe anything on the hospital bills? Mrs. SmyTHE. Yes, about $6,000. : Senator Kexnepy. And your income together is now about $600 a month—is that right ? Mrs. SmyraE. That’s right. ; Senator Kennepy. And out of which you must budget about $300 a month for payment of medical bills ? Mrs. SyyrrEe. That's right. Of course, we have our apartment. Senator Kennepy. How do you live ? Mrs. Smyrue. It’s pretty slim. As a matter of fact, I was reluctant to use the gas to come over here today. I have that gauged down as to how I can get to work with @ number of gallons, and this has to come out each month. Senator Kennepy. What about your house ? Mrs. Smyrae. We lost our house. We sold it. We took what we could out of it to pay off some other bills. Senator Kexneny. And you have been paying St. Luke’s $150 a month on their bill ? Mrs. SmyraE. Ever since he got out, yes. Senator Kenxeny. How long has that been ? Mrs. SmyTHE. Well, a year and a half. 2343 And, of course, St. Luke’s knows this man can’t go to work so I don’t know how they expect it to be paid. They have turned it over to a collection agency because they don’t have time to bother with you. Senator KeN~NEDY. A collection agency. They are one of the fastest growing health businesses in the country. [Taunghter.] Senator Kennepy. What happened when your husband tried to get back into St. Luke’s ? Mrs. SuyraHE. When he went in for the surgery on the incision, they immediately put him in a room, and they sent word for me to come right down to the office and pay them before the surgery could be done, because we had no credit. Senator Kexnepy. Even though you had been paying $150 a month ? Mrs. Saryrae. This doesn’t make any difference. Senator KennepY. And they were aware of your income ? Mrs. SyyTHE. Yes. Senator Kenxepy. And they still required that you put up a deposit before they would go ahead with surgery ? Mrs. Ssyre. That’s right, and when he went back in last Septem- ber for the heart catherization—once again, there had to be cash beforehand. Senator Kenxepy. Could you have gone to another hospital ? Mrs. SmyrrE. No. Senator Ken~epy. Why not ? Mrs. Smyrne. Because our surgeon operates only at St. Luke's. Senator Kennepy. So you had to go to that hospital? Mrs. Sayre. That’s right. My husband could have gone to the veterans hospital. He is a veteran; but here, once again, the doctor couldn’t go there to operate. Senator Kennepy. Are you happy with the doctor? Mrs. Syringe. Oh, IT think he’s the most marvelous man I ever saw, and I'm not saying that he’s expensive, because the bill was not large for what he did. Senator Kex~epy. How long do you think you will be paying off medical bills? Mrs. SsytHE. For the rest of my life. Senator KexxNepy. What do you think now of the insurance policy you had? Mrs. Sayrne. I think our insurance policy wasn’t big enough, as I think most American insurance policies aren’t big enough. But can most Americans afford a bigger policy ? If you go to a $30,000 major medical, the average person may not be able to afford it. Senator Ken~epy. We just heard from the president of a bank, and you saw the problems he has had in paying off his health bills. Mrs. Smyrie. And your insurance premiums go up. The hospitals raise their room rates another $10 a day. And take all of the doc- tors—from a psychiatrist to an internal medicine man to a surgeon to a family doctor—there’s never been a fairer group of people, and there's only been one doctor who I thought was unreasonable. For one of them it was $125 a call—not one of the surgeons, one of the others. I don’t think our problems stem from what the insurance companies pay. They probably pay what they should. I think it stems 2344 from the fact that most of us cannot afford insurance that would cover hospital bills as they are today. I don’t know whether hospitals are a moneymaking organization, but they must be. g Senator Kex~epy. Hospitals aren’t, but insurance companies are. Mrs. Syyrie. Well, I don’t know. I mean, of course, my main feel- ing right now is the hospitals, because they are the ones that have been the orneriest and most inconsiderate. Senator Dominick. Insofar as the hospitals are concerned, I think we can say without exception that there isn’t a single one that isn’t in a deficit position. I personally went out and raised some money for a new wing at St. Luke’s myself. Mrs. Smyrae. I paid for that wing. [ Applause. | Senator Dominick. This was some years ago. Mrs. SmyrHE. It was the newest wing. Senator Dominick. Mrs. Smythe, when your husband went into intensive care and the doctor had him admitted into the hospital, was it an emergency ? Mrs. Sayre. No. Mr. Smythe was in the hospital about a week before surgery. During this time, there were preparatory steps, such as the heart catherization. I think there was a psychiatrist called in to talk to you before you go into this kind of surgery and make sure you are ready for it. And on and on. He was there for approximately a week before the surgery. The surgery, I think, was performed about the third of February, and he came home about the 26th of May. Senator Doaintck. Thank you. Senator Kennepy. Now, we saw the marvelous EKG equipment at St. Luke’s last night. We saw hundreds of thousands of dollars spent for elaborate equipment, and yet they can’t afford to take your hus- band back. Mrs. Smyrne. There is another thing that truly disturbs me about the surgery. Before the surgery, we were told that there was a 90- percent chance that this man will not live. This is surgery which is very new and which has been done very seldom. So you go ahead and you take this chance, and the doctors work like mad. The hos- pio) works like mad to save the man, and then they kill him with the bill. Another thing that disturbs me is that our Heart Association wouldn’t even talk to a person like me. IT called them not once but numerous times and begged them, “Is there anything at all you can do for us?” “No,” they said. There’s nothing they can do for us, so I am waiting for them to come for a donation. Senator Dominick. For the record, I think it’s only fair to say that the electrocardiogram unit in St. Luke’s was paid for by a grant and given to the hospital for experimental purposes by the general tax- payer, and not paid for out of patient costs. Senator KenNepy. I suppose it’s a general question of priorities in health spending. Senator Dominick. But it ought to save money in the end, not in- crease spending. That’s what I understand anyway. Senator Kex~xepy. I understand, Mrs. Smythe, that the Prudential Insurance Co. is constructing a new building in Denver. You will be happy to know about it. 2345 Mrs. SmyrHE. I paid for part of that, too. Senator Kexnepy. You can watch it rise and go up here in Denver when you are riding to work. Mrs. SmyrHE. Fine. Senator KexNepy. Thanks very much. Our next witness is Mrs. Catherine Anderson. We want to welcome you. STATEMENT OF MRS. CATHERINE ANDERSON, RETIRED, DISABLED GOVERNMENT EMPLOYEE, DENVER, COLO. Mrs. Anperson. Thank you, Senator Kennedy and gentlemen of the committee. My problem is similar to the others. In 1964, I suffered a severe attack of pneumonia, damaging one of my lungs; also, I had acute thrombophlebitis. It was prior to the building of the new St. Joseph Hospital, and I required 36 tanks of oxygen to save my life. Then I was on crutches and was forced to take total disability from the Government after 17 years of service. This was quite a drop in salary, which was a shock and upset my family—myself, my husband—but I had no alternative, dropping from a $6,000 a year position to $85 per month at that time. Before that, my husband was afflicted with anxiety, but it was not very severe. With the worry and the pressure of my illness and health problems, his affliction and health problems became worse, and he became totally disabled. We panicked. We lost our home, our lovely car, and were forced to move into cheaper living quarters in a less desirable section of the city. I did not take this as a long-term thing. I felt that it had to be temporary. Each year I pushed myself and pushed myself and would try to return to work. I will say the Government will give you an opportunity to return to work if you can ever recover, and I do mean reach total recovery. I could not do this. Each year I am hospitalized for pneumonia. I’m hospitalized, put to bed, and require additional medical expense. I have Blue Cross, and I have never understood why I end up owing so much money—to the medical men, the surgeons, the anesthesiol- ogists. There is problem after problem. Our child suffered a fall, and we had to take him to Children’s Hospital. We have a 16-year-old boy. This involved surgery, and I ended up with another hospital bill. I also had to go in to have eye surgery involving special glasses, contact lenses, and we were just lost. We tried to spread our income across the board. This was impossible. It forced us into bankruptcy. We felt a deep moral obligation to the people who had trusted us, so we divided our money, split it up, and gave each of them some. We have been able to hold our furniture, but that is all. It was suggested that we talk to a representative of the welfare department, so that possibly we could get food stamps. T was delighted 59-661 O—T71—pt. 10——9 2346 at this, but also I felt a depression and letdown. We had struggled so hard. We were taught to push to get ahead, to better ourselves and our condition, and this was quite hard for us. My dignity was affected, and I'm sure my husband suffered hurts from this, We did start out on welfare, and I felt that when I was able to, I would return to work. I returned to work last May and became quite ill and was hospitalized in August. : I find that I'm playing a game I can’t win. We have been given further assistance by Welfare, an additional $27 a month, but we still have an anesthesiologist to pay, a dental bill to pay, internal medi- cal men to pay. We have a psychiatrist for my husband, and some- times at night I wonder how in the world, how can we win? I can’t figure it out but I manipulate. I juggle the expenses. One month I pay one and the next month I skip the other. I do appreciate the assistance we have received. I think we probably would have completely crashed without it. It gave us a ray of hope, but I do hope some day we will have a better insurance program. You carry it; you pay it. It will take care of everything. Thank you. Senator KENNEDY. You went into bankruptcy. Mrs. Axperson. We went into bankruptcy. Senator Kex~epy. How many years have you worked ? Mrs. ANpERSON. Seventeen with the Government, and since I have been away from the Government, I attempt to work, but I never make a full year. Senator Ken~epy. Your husband is not working ? Mrs. Axperson. No, sir. He's totally disabled. Senator Kex~epy. He had been working before ? Mrs. Axperson. He had been working. When I was forced into this disability, the worry, the fear caused him to fall and crash completely. Senator Kex~Nepy. You have medical bills now that you are paying ? Mrs. ANDERSON. Yes. sir. Senator Kexnepy. Even after the bankruptcy ? Mrs. ANDERSON. Yes. sir. Senator Kex~nepy. How much in medical bills do you have now? Mrs. Axperson. I have approximately $400. Senator Kex~epy. $400. That’s a lot of money, isn’t it? Mrs. ANDERSON. Yes, it is to a family with an income like ours. Senator Kexxepy. What has happened to your credit since you have been in bankruptcy? Can you charge anything? Mrs. ANDERSON. No, sir. We cannot charge one thing. . Senator Ken~epy. Can you get anything ? Can you keep a refriger- ator or buy some appliances? You have a child? Mrs. AxpersoN. We have one child. Senator KeNNepy. You have to pay everything on cash? Mrs. ANpErsoN. Everything has to be on a cash basis. Senator Kexnepy. How was your credit before this? Mrs. ANpERsON. It was good. Senator Kenxyepy. You were working for the Government ? Mrs. AxpErson. Yes. We had accounts at Neusteters. We could purchase the car on credit. And the TV and a home, a lovely home. Senator KENNEDY. And now you are not able to do that? Mrs. Axperson. That is right. 2347 Senator Kex~epy. Are you going to try and pay those medical bills, the $400? Mrs. Anxperson. Yes, sir; we are. We are paying each month. We send a small amount. Sometimes they become quite angry with us. If we have to, we borrow from Peter to pay Paul, but we are getting the job done. Senator Kex~epy. Now, Mrs. Anderson, there has been a great deal of talk about the proposal that’s before the Congress in terms of cata- strophie illnesses—people with large medical bills over a long period of time. They say that Congress ought to meet those needs. But TI sup- pose that $400 is pretty catastrophic to you, isn’t it ? Mrs. ANpERsoN. Yes. Senator KeNnNepy. As catastrophic as a $5,000 bill might be to somebody else ? Mrs. Axperson. To me it is. Everyone loves to hold their head high with dignity and know they have paid their bills, made a decent living, and given their child the things they really need and some pleasures. With our present income we do not have money to go out to dinner, to go bowling. It has to be something without cost. T think we are all entitled to a decent living in America. I think we are. Senator Kenney. How is Blue Cross in paying the bills? Did they cooperate with you? : Mrs. Axperson. They have cooperated, but I still do not understand why we end up owing a hospital bill after having coverage. Senator Kenx~Nepy. You mean that you think when you get Blue Cross hospitalization insurance, you assume they are going to pay the hospital bill ? Mrs. Axperson. I evidently have assumed wrong, sir. T feel that something is wrong here. We end up paying an anesthesiologist. I end up being charged for laboratory work, and IT do know that something is wrong. I do expect to pay visits to the doctor’s office. Senator Kexxepy. Yes, but you thought the expenses of the hos- pitalization were covered? Mrs. ANDERSON. Yes, sir. Senator Kenxepy. What did they say to you when you asked them about those expenses? Mrs. Axperson. They told me that Children’s Hospital operated on a different procedure, that our child was in a private room. Blue Cross could not pay all of the bill. : Senator KexNepy. You didn’t know that when the child went in? Mrs. Anperson. No, I didn’t. Senator KExNEDY. You just thought that your policy covered that? Mrs. A~NpersonN. Right. Now, when my husband entered Mount Airy Hospital, it paid full coverage. We had no balance to worry about. However, I did lose because IT was not able to work. IT had to come home and take care of my husband, and at present he has to be cared for. His medications are approximately $36 per month. Now, I am receiving some assistance from Park Hill Clinic plus some psychiatric consultation, and T am given instructions on how to administer the medication, how to care for him and myself. This has been a very big help. : 2348 Senator Dominick. Mrs. Anderson, how long did you say you worked for the Government ? Mrs. ANDERSON. Seventeen years. Senator Dominick. You were under their medical coverage ? Mrs. ANDERSON. Yes. Senator Dominick. Did that include Blue Shield as well as Blue Cross? Mrs. ANDERSON. Right. Senator Dominick. What hospital were you in ? Mrs. Axperson. The first hospitalization was at St. Joseph's. Senator Dominick. They took care of the bills there? Mrs. AnpErsoN. I had a balance there. Senator Dominick. For laboratory tests ? Mrs. ANDERSON. I'm not sure what the costs were, but I had a bal- ance. Senator Dominick. Now, did you get retirement pay from the Government because of this occurrence ? Mrs. ANpERsON. Yes. I started receiving $83 per month. It has been boosted due to the rising cost of living, and I now receive $109 per month. Senator DomINIcK. At that time was your husband working? Mrs. A~NpersoN. My husband was working and worked through 1969, and he collapsed. Senator Dominick. Did the company that he worked for provide any kind of coverage to him? Mrs. AnpErsoN. No, sir; they did not. Senator Dominick. Did he know that ? Mrs. Anxperson. I doubt if he knew this when he started working for them. Senator Dominick. Did he get any kind of recompense from that company ? Mrs. Axpersoxn. No; he did not. Senator Dominick. Did he get any kind of assistance from the company ? Mrs. Axpersoxn. No. Senator Dominick. How long had he been working for the company Mrs. Axperson. He had been working in that position for about 3 years. He would have attacks of anxiety, would become upset and would leave his position. I knew something was wrong, but I could not quite pin it down until we had professional advice from psychiatrists and medical men. He was the former purchasing agent at American Wood- men Insurance Co. ¢ Then he started becoming depressed and would take anything. He wasn’t happy with any of his smaller positions, and then he reached total disability. Senator Dominick. What is your son doing ? Murs. Axperson. Our son is attending George Washington High School, and he has a little band put together. Senator Dominick. Is he able to make money to help out? Mrs. Anperson. Occasionally he does, and he’s a very fine person about bring it to us. He takes very little of his own pay when he re- celves 1t. 2349 Senator Dominick. It’s your feeling that the medical assistance which you received is agreeable ? Mrs. AnpersoN. Yes. I don’t believe T would be here talking to you if T had not had the very best doctors, surgeons, so forth. I had no complaints. My problem was getting them paid. I have deep respect and admiration for the doctors who cared for me so very well. I know it would not be ethical to mention their names, but they certainly saved my life several times. The surgeons were also very good. I had been advised not to attempt to work anymore. Of course, I’m forced to stay home now to care for my husband. Senator Dominick. Thank you, Mrs. Anderson. Mrs. Anperson. Thank you. Senator Dominick. Thank you very much. Senator Ken~Nepy. Our next witness is Mr. James Quick. We will try and move along just a little faster. We have a few more consumer witnesses and then two professional witnesses, and then we will open it up to the audience. Mr. Quick, I thank you very much for coming. Would you like to proceed ? STATEMENT OF JAMES QUICK, PATIENT, NATIONAL JEWISH HOSPITAL, DENVER, COLO. Mr. Quick. In 1965, I was exposed to a great deal of limestone dust and came down with pneumonia. After the pneumonia, I was wheez- ing, and they said it was asthma, and from that day to this IT have not been able to work. I was in the hospital the first go-around about 6 weeks. I was out for 2 weeks, then back in. I've been back in about every 5 weeks ever since, until I came to National Jewish Hospital in Denver. Before I came to National Jewish I was transferred from one State to another, one climate to another, and everything else, and never got any relief until I came to Denver to National Jewish. Since 1965, my total hos- pital and medical bills have run somewhere in the neighborhood of $80,000. Senator Kex~epy. How much was that ? Mr. Quick. About $80,000, including what I have received from National Jewish and Colorado General free, which amounts to about $50,000. I had insurance with two companies, which paid one bill and then canceled. Senator Kexxepy. What insurance did you have ? Mr. Quick. New York Life and Travelers. They had New York Life at the company T worked with. The com- pany changed after I became ill to Travelers under which I was cov- ered for a while. But. Travelers never did pay, and they wouldn't pay National Jewish because they said it was a nonprofit organization. The first claim was filed with New York Life by National Jewish, and they wouldn't pay because they said National Jewish was a non- profit organization. Senator Kenxepy. They wouldn’t pay ? Quick. They never paid a dime, never did pay a dime on the ill. 2350 Senator Kex~epy. And do you have a bill? Mr. Quick. Well, they have a bill on me but, of course, I'm not re- quired to pay it, because if you can’t pay, they don’t require you to. Senator Kennedy. Do you have other medical bills now? Mr. Quick. Oh, yes. We paid off the 1965 bills in 1969 in Alabama, and we will be paying other bills here for doctors’ office calls while I was discharged from National Jewish. Tt will take us the next 2 or 3 years to pay them off. Senator Kex~epy. About how much are you billed ? Mr. Quick. Somewhere in the neighborhood of $4,000. Senator Kexxepy. Are you going to try to pay those off Mr. Quick. We are paying them off. My wife works 5 days in the week and then she works every other weekend 11 to 7, all to make extra to help pay these bills and send our daughter to college. Senator KexNepy. Do you work now ? Mr. Quick. I'm not able to work at anything. I'm back in National Jewish now, have been since January. I was there 22 months the first time, and I have been there since January this time. Senator Kexnepy. And you and your wife together are trying to pay the bills? Mr. Quick. We are paying them off. Senator Ken~Nepy. Have you tried to get any insurance? Mr. Quick. Yes. As soon as IT moved to Denver I had many insur- ance men contact me. I said, “Yes, I will take some hospital insurance,” but when they come down to asthma, they rip up the policy and throw it away. “Senator Kexxepy. When they come to asthma ? Mr. Quick. When they find out I have asthma. Senator KexnNepy. So they won't sell it to you. Senator Dominick. Mr. Quick, did New York Life and Travelers pay about $25,000 of your bills? Mr. Quick. That’s right, about $25,000. That was before I got to Denver. I was in Alabama, Florida, and Texas. Senator Dominick. When you mentioned the $80,000, you were talking about the bill which they keep on you at National Jewish but which they don’t require you to pay? Mr. Quick. That's right. Actually we have paid right in the neigh- borhood of $20,000 cash ourselves. All of our savings we have paid in doctors’ bills and medical bills and hospital extras. Senator Dominick. But not to National Jewish ? Mr. Quick. No, the New York Life does not cover while IT was in the hospital, and when I was going in the hospital, I always re- quired to have a private room which insurance did not cover, except semiprivate. Senator Dominick. You didn’t have any Blue Cross or Blue Shield ? Mr. Quick. No; because my insurance was through the company. Senator Dominick. Neither your New York nor your Travelers policies covered any hospital expenses ? Mr. Quick. They did before I came to National Jewish, but they don’t cover outpatient expenses when you go to the doctors’ office or drug bills, which ran very, very high. Senator Dominick. I sympathize with you. I have been active in this respiratory field for a long, long time. My father-in-law had it se- verely so I know what problems are involved. It’s tough. 2351 As far as National Jewish is concerned, they are Mr. Quick. I wouldn't have lived 30 days longer had I not gone there. It’s just unbelievable. They give you the best of everything that’s available. Senator Dominick. Thank you, sir. Senator KenNepY. You are not going to be able to get any more insurance in the future; are you? Mr. Quick. It looks like I won't be. Senator Kenxnepy. And if you didn’t have National Jewish, you would be Mr. Quick. I would just have to die, that’s all. Nobody would carry you for that amount of a bill. I didn’t realize it until last night. We ronghed out how much we had paid out in actual cash since 1965, and it’s around $20,000. Senator Kex~epy. Even though you had some coverage ? Mr. Quick. I figured I had “$95, 000 in coverage between the two policies. Senator Kexxepy. How many years had you worked? You worked in Alabama for a number of years? Mr. Quick. Twenty years for the railroad. Never missed a day of work in 20 years. Senator Ken~Nepy. You had good health during that time? Mr. Quick. That’s right. Senator Kex~epy. And then through no fault of your own this con- dition developed? Mr. Quick. It developed as a result of paving the street right beside the office where I worked. It was limestone dust in an air-conditioned office. We just ate that limestone dust. I wound up with pneumonia, and I have been sick ever since. Senator Dominick. Mr. Quick, didn’t the railroad have any pro- vision to cover you on this? Mr. Quick. They just paid disability insurance, which is $170 a month. Senator Dominick. They are paying you that now ? Mr. Quick. Yes. Senator Dominick. Thank you. Senator Kex~epy. Thank you very much, Mr. Quick. Our next witness is Mrs. Dean DeWitt, who is here with her infant child and her physician, Dr. Joseph Butterfield. Thank you for coming. Mrs. DEWrrT. You are welcome. Senator Kexnepy. We have never had a baby at one of these hear- ings. This is our youngest witness. Where do you live ? STATEMENT OF MRS. DEAN DeWITT, SOUTHWEST DENVER, COLO.; ACCOMPANIED BY DR. JOSEPH BUTTERFIELD, ACTING MEDICAL DIRECTOR, CHILDREN’S HOSPITAL, DENVER, COLO. Mrs. DEWrrT. In southwest Denver, in Brentwood. We have had insurance with our company for 7 years. now and thought we were pretty well covered. But when we found out we were having twins, which was 6 weeks before they were born, we discovered that we were not covered for the first 15 days in the hospital. Then one of our babies, unfortunately, was born with a ruptured bowel and has 2352 been in Children’s Hospital for the last month and we discovered we had no coverage. a KuxNepy. What do you mean? Your insurance didn’t apply Mrs. DEWrrT. No. We found that newborns are completely uncov- ered for the first 15 days, on our policy. Well, this was kind of bad because it was a critical time for Debbie. She has had surgery twice, and we wound up with a bill of $5,000. Our hospital insurance has been kind enough to provide something like $700 for the whole thing, so it’s been pr etty much all but useless. Senator IKexxepy. How long have you had the insurance policy ? Mrs. DEWrrt. Well, before I was married I had it for 3 years, and then we have had it 7 years as a family policy, so I have been with Prudential for 10 years now. Senator Kex~Nepy. You have had a policy with Prudential for 10 years? Mrs. DEWirT. Yes. Senator Kenx~epy. And it excludes the first 15 days of life. I guess this is a pretty common practice, is it ? Mrs. DEWrrT. Well, apparently so, because I know I thought that we were the only ones caught by it. But I have run into many “parents up there in the last month that have the same difficulty. Senator Kexnepy. Why do you think the insurance companies do that? Mrs. DeEWrrr. Well, T think it’s a pretty handy way to get the pre- miums and get out of the dangerous part of a new baby. This pretty well fixes them up, because if the baby is sick when it’s born, this is the bill that’s going to be big, and usually it’s over by 15 days and the companies wet off pretty well. Senator Kex~epy. How many children do you have? Mrs. DEWirrr. We will have seven children at home, when we get Debbie home. Senator Kexxepy. And your husband is a furniture repairman? Mrs. DEWITT. Yes, he subcontracts for May-D&F. He does touchup work. Senator Kex~epy. How are you paying the bill ? Mrs. DEWrrr. We haven't quite figured it out yet. I guess we will have to go on payments. Senator KENNEDY. What is your husband’s take-home pay? Mrs. DeWirr. It varies with the work that he does. He usually works by the piece. There have been months when we have made $300 or $400, and other months when we have made $800. Senator Kex~epy. But you are going to have to pay at least some of that. Is that right ? Mrs. DEWrrT. Yes. Senator Dominick. Mrs. DeWitt, I don’t quite understand your in- surance situation. Before you had your twins you had five children, right? Mrs. DEWirT. Yes. Senator Dominick. Now, on the assumption that nothing happens to them during the first 15 days. I gather the insurance covers the hospitalization during that period ? 2353 Mrs. DEWrrT. Yes. The maternity benefits will pay $250, which, up until this year, has been sufficient. We had not had any children for 4 years. This wasn’t really planned, but when we found out we were going to have some more, we started saving. The insurance didn’t cover anything like the full maternity bill. We still had to pay a balance of $214 just on the maternity bill. Senator Dominick. Is that because the maternity benefits didn’t cover twins? Mrs. DEWrrT. No, this was just on the $20-a-day deductible. Senator DoMmINICK. I see. Mrs. DEWrrT. And we are paying $38 a month for this policy, and we couldn’t afford to have it increased to cover the hospital costs as they went up. Senator Dominick. Mrs. DeWitt, your husband didn’t have any policy through his company ? Mrs. DEWrrT. No, because he subcontracts. He is not actually an employee, so there is no policy. All we have is our family plan. Senator Dominick. Is this a different situation that you are tell- ing me about because the child is in Children’s Hospital, as opposed Jo pein in any other hospital ? Mrs. DEWrrT. Oh, I don’t believe so. I mean, the policy wouldn’t cover any hospital. It wouldn’t cover any hospital at all. Senator Kennepy. Let me ask. Dr. Butterfield: Are you affiliated with Children’s Hospital ? Dr. Burrerrierp. Yes; I'm the acting medical director. Senator Kexnepy. Is Mrs. DeWitt’s situation unusual? How fre- quently does this kind of situation occur? Dr. Burrerrierp. I'm also the director of the newborn center into which this child came for help, and we find that the insurance policy exclusion of the newborn during the first 14 or 15 days of life is not uncommon. In fact, we did a study recently and found that about 30 percent of employers’ policies had the 14-day exclusion. So the new- born, in fact, is a forgotten American in a sense. When this does happen, when the parents are unable to meet the total responsibility as in this case, we share the responsibility, and the insurance company here will contribute a small amount. We hope that the National Foundation-March of Dimes may provide some support, and that perhaps the parents themselves will participate to the extent that they can. In this case, the financial burden will fall largely on Children’s Hospital. We anticipate that we will support this case to the extent of possibly 75 percent of the entire bill. Senator Kenneny. How often does this happen ? Dr. Burrerriernp. The bill itself is a little bit unusual, as Mrs. De- Witt said, because of the complications. This was a very unusual case of intestinal obstruction and other problems. Recognized promptly and dealt with, I think you will admit, very well. Mrs. DEWirT. Fantastic. Dr. Burrerrierp. Taking all the patients that come to the regional newborn center at Children’s, the average bill is about a thousand dollars. Bills of in excess of $2,000 represent about 5 percent. Senator Kennepy. How frequently do you find bills of a thousand dollars? These are major bills, and I am trying to find out how fre- 2354 quently it happens that you have complications with infants in the first 15 days. Dr. Burrerrrerp. In our experience, of all infants that have prob- lems that need center type of care in the special unit, approximately half would have bills in excess of $1,000. Senator Kennepy. How frequently do infants develop complica- tions which bring about medical bills such as this ? Dr. Burrerrierp. I think it’s a safe statement to say that about 5 per- cent of all children born require some form of intensive care. That’s a guess. Bont KennNepy. They wouldn't be covered by the general kind of insurance policy that Mrs. DeWitt has? Dr. Burrerrierp. Correct. Senator Kennepy. What should the insurance companies do in this area? Shouldn’t they cover this? If cases like this arise 5 percent of the time, shouldn’t they be filling that gap ? Dr. Burrerrrerp. You are asking a question out of my expertise because I'm not an economist. I know that the American Pediatrics Association and the American Medical Association and certain legisla- tors are interested in coverage from the time of birth. For instance, there’s a bill, the Brathwaite bill, introduced by Yvonne Brathwaite in California, which would make it a requirement that insurance com- panies must include the newborn from the moment of birth. This is going through that legislature. Whether that will succeed or not, I don’t know. There should be some sort of inclusion of the newborn. We ought to take care of the high-risk mother and the high-risk newborn. Senator Ken~epy. I agree. Thank you very much. Thanks so much for coming. Our next witness, Mr. Jose Villareal, who is accompanied by Mrs. Maria Bealls. Mrs. Bears. I'm a migrant health nurse and I have been working with Mr. Villareal. STATEMENT OF JOSE VILLAREAL, MIGRANT WORKER; ACCOMPA- NIED BY MRS. MARIA BEALLS, MIGRANT NURSE, DENVER, COLO. Mr. Virrarearn. Back in June I had to have a colostomy operation, so I had to go to intensive care in Greeley. I stayed there for about 3 days, and then I spent about 20 more days down in a room. Then ¥ had to come back within 2 months to have it fixed. Then when I went out, the bill was about $2,000, and we had to pay this. Great Western Insurance paid about a thousand, and we had to pay one-third of the rest of it. We only had about a hundred dollars, and they wanted $350 before we could go out, before they would let me go out. Senator Kenneoy, What do you mean “before they would let you go out”? Mr. VirLarear. Before I could get out of the hospital. Senator Kexnepy. Before you could get out of the hosnital? Mr. Vitrarearn. Yes. They wanted $350. We only had $200, so that’s ‘what we gave. : Senator Kexnepy. You only had $200. 2355 Mrs. Bears. That's right. He was in the hospital for the colostomy, so before he could come out of the hospital to wait until the second operation could be done, the family had to go to the hospital to have him released. But they wouldn't let him out of the hospital unless he could pay $200. Well, the mother only had a hundred dollars with her at the time. She tried to get in touch with me, and I was nowhere to be found. I was out in the field, and she went back home and talked to some of the family members and some of the other migrants and finally came up with the other hundred dollars so they could release him. Otherwise, he would have had to stay there and continue to pay the hospital bill, which they didn’t have the money to pay. Senator Ken~Nepy. And they wouldnt let him out? Mrs. Bears. Right, right. We have no hospitalization money for migrants. And this is a problem, because they often go into the hos- pital. They have emergency problems. They need surgery, and then they have no funds to pay for it. I am holding here all these bills that have been coming to this family, and they don’t know what to do with them. Senator Ken~epy. These are his hospital bills? Mrs. Bears. Right, just hospital bills from his surgery and the rest of the members of his family. Senator KennNEpY. Are those bills from collection agencies? Mrs. Beavis. Bills from collection agencies, hospital bills, and doc- wor bills. They don’t know what to do with them. The mother is very nervous. She says she doesn’t know what to do with these bills, and we don’t have any funds in the program to pay for them. We have funds for the doctor for the surgery, but we have no hospital funds at all. Senator Kex~epy. How much are those hospital bills? Mrs. Bears. It’s over a thousand dollars, and this was a problem not only with Jose's family, but with the rest of the migrants. If they have emergency illnesses like appendix, gall bladder, and things that require surgery immediately and the Health Department has no funds allocated for hospitalization, what can you do? You go to the hospital and you tell the hospital, “well, I will try to get money for the hospital bills somehow.” But, you just can’t find funds for it. And this is a problem, because next time you take a migrant in, they won't accept him because you can’t come up with the money. Senator Kexxepy. The money has to come before the health care comes? Mrs. Brarrs. Right. Patients have come in, and we haven’t been able to pay for them, so they are hesitant. Senator KenNepy. Fconomics before health ? Mrs. Bears. Right, and migrants don’t have insurance. They don’t have money, so what do you do? Last year we had several organizations that came over and talked to us during orientation. They said, “Well, you know, if you ever need any help for anything, just call on us.” Senator Ken~Nepy. Who said this? Mrs. Bearrs. Oh, organizations like Fund and Migrant Administra- tion and various other organizations. 2356 But, whenever you go for help, they just don’t come through on anything. : Last year I spent 14 days running around trying to find food for a diabetic who was completely out of food and didn’t have money. Finally, one of the doctors at the Health Department said it was a drug requisition, so I could get emergency food for them. Senator KExNEDY. How typical is this? Mrs. Bearis. Very typical, and these people come here without any money. A lot of times they come without relatives, and so it’s hard for them to borrow money from other people. If they had relatives or friends they could turn to, it would be different. The Federal Government is not responsible for them; the State is not responsible for them; and all the health centers here in Denver are fine for the people around here, but they just won’t accept migrants, because they are outside the county lines. Senator Dominick. What you are saying 1s very interesting, because we just finished a second-year grant out at the Fort Lupton area of over $400,000. The Weld County Public Health Organization has now got an application in for the rest of Weld County. Mrs. Bears. Right. Senator Dominick. Now, from what you are saying. this money isn’t being spent ? Mrs. Beans. Last year it wasn’t. Senator Dominick. Who is getting it ? Mrs. Bears. I don’t know, but I didn’t get any of it. My migrants didn’t get any of it. : Senator Doarnick, This is part of the problem we are talking about. Mrs. Bearis. I have started work. I have spent several days driving around, calling people, trying to get money tor the different services, trying to get migrants settled down, and I talked to the migrants. They are willing to stay, but whenever you come to the organization, there is no money. “We will see what we can do,” they say, but nothing comes out of it. Senator Doyinick. I just wanted to follow up on that because I have been active in these two particular fields in Weld County. Mrs. Bears. Well, I worked with Weld County part of the time last year. Senator Domixick. The Fund organization is working in Fort Lup- ton, or at least it’s supposed to be ? Mrs. Bears. Right. I sent a list of names. It was Mr. Janos I called, who is stationed in Fort Lupton. I went there several times. I talked to him. He said, “That’s fine ; get all those names for me,” and I left in September, and as far as I know, all of the families I sent are still around the area. Jobs were found for them through sources other than Yand, I'm not aware of what’s going on now. I have been out of the State. Senator Dominick. In the health care area, though, which is what we are talking about at the moment. you are unable to get any support either out of the Fund or out of the Public Health Service for this problem ? Mrs. Bears. What do you mean out of the “Public Health Service” ? 2357 Senator Dominick. Well, is the Public Health Service able to be of any help to you? Mrs. Beares. Noj the Public Health wouldn’t have anything to do with the migrants, because they weren’t residents. They hadn’t been here long enough to apply for welfare or medicaid or anything like that, so we were solely responsible for them. But we didn’t have the funds for it, and what could we do? And hospitalization is a real prob- lem, because most of these migrants come here and a lot of them don’t want to go to the hospital. They can’t afford the time from work to be in the hospital to recuperate from illness. Senator Kex~Nepy. What about the Medical Society ¢ Have you ever asked them for help? Mrs. Bears. Well, yes; all these organizations come out at the be- ginning of the year, and they say, “It’s great. If you need any help, come to us.’ Last year, as I said, I spent 14 days. I went to the welfare for food stamps. Senator Kennepy. How long have you worked in this area ? Mrs. Beavis. I worked here all last summer, and IT am back this year, but I think that, because I was able to communicate with a lot of them, I was able to become aware of their problems. They have been able to tell me the things that were most important to dr the things they were having problems with. enator Kennepy. Let me ask Mr. Villareal, how were you treated in the hospital ? Mr. Virrarearn. Oh, I was treated pretty good. I had a fine doctor. Mrs. Bears. Our only problem was getting him out. Senator Dominick. 1 don’t think I have anything further. We will try to keep you out. Senator KennEpy. Thank you very much. Mrs. Bears. Is there anything you can do about hospitalization ? It’s really a problem. We just can’t do anything without funds for hospitalization. Emergencies come up and people have to go to the hospital, but if you don’t have the money and nowhere to get it, what do you do? And pretty soon the hospitals stop accepting them. Senator Kennepy. That’s what we are here to find out. Mrs. Bears. Good. Senator Kexnxepy. Our next and final consumer witness is Mr. Wally Wirth. \ STATEMENT OF WALLY WIRTH, SAFEWAY CHECKER, DENVER, COLO. Mr. Wirth, we are glad to have you here. You are a checker for Safeway in Denver, i is that right ? Mr. Wirt. That’s right; yes. Senator Kennepy. Tell us your story. Mr. Wirta. My wife has an incurable disease. It’s a fungus germ in the bone marrow, and it’s called actinomycosis. The medical “doctors can probably recognize it, and she has had it over 20 years, and we have been in and out of the ‘hospitals all this time. 2358 In fact, we were able to get into the National Institutes of Health for some research there, but because they weren’t doing any research on her particular germ, they wouldn’t treat her there. They sent her back here for treatment, and she’s been in and out of the hospital quite frequently. We have to take lab tests approximately once a month, sometimes more often, and these run around $50 a treatment every time we run through this. In the laboratory, they said that certain antibiotics would kill the germ, and so they tried them on her—penicillin and all the rest of the drugs. They would kill the germ in the laboratory, but they wouldn’t kill it in her body. She’s on full sulfa now. She gets to the point where she becomes too weak and then, of course, we have to hospitalize her. : : Our medicine runs around $40 a month. I'm covered by a health insurance plan through the Retail Clerks. It’s a really good plan, but it doesn’t cover all the bills. We have spent approximately $75,000 over the last 20 years, and we have paid approximately one-third of this out of our own pocket. Some years the excess over our insurance will run around $2,000. As you know, a poor grocery clerk makes very little—$7,500 a year. My life, T might say say, has more or less béen a financial nightmare. I have lost about half my insurance. Senator Kexxepy. What do you mean you have lost your insurance ? Mr. Wirrn. Well, T borrowed on it, and it was to the point where it was useless. I borrowed so much that it was useless to pay it back, so I let it go. Senator Kex~epy. You mean you borrowed on your life insurance to pay your medical bills? Mr. Wirrs. That’s right, and to pay other necessary items. We have been to Mayo’s twice, and to Johns Hopkins. We have to fly her there, and these are heavy expenses. These things are terribly expensive, as you know. TI have been on the verge of bankruptcy several times. In fact, about 5 years ago, I had a $4,300 doctor and hospital bill, and T paid about $50 a month on it. T got disgusted, and at the end of the year I went to my attorney, and I said, “Let’s file bankruptey.” b He called the hospital, and he gave them an offer of $200 and said, “Well, you either take this or you won’t get anything,” which they wouldn’t have. And so that bill was wiped out. But, as you see, this thing just keeps on and on. They have never found a cure for her illness, and the only thing we can do is try to keep the disease under control. We have a vial of ACTH in the refrigerator at all times; and when she gets into one of these attacks, which sometimes come frequently, we give it to her. Otherwise, I have to rush her to an emergency room in the hospital and give her treatment there. its I might say that I'm 62 years old, and I will retire in a few years. T have an insurance policy now, and I'm covered fairly well. I'm grate- ful to the insurance companies and the hospitals and the research clinics—the National Institutes of Health and the Government labora- tories, especially the one down in Atlanta, Ga., that has done rve- search on the germ. This laboratory work has been expensive. 2359 The hospitals here in town have done a lot of the work. But after I retire. there will be a time that T will have no coverage for my wife at all. This is the thing that T think you onght to take into consideration. Senator Kexxepy. You won't be able to buy any insurance ? Mr. Wirrir. T won't be able to buy any, no. Senator Kexxeny. So after you retire, T guess you can look forward to being forced onto welfare. don’t you? Mr. Wirrn. Well, is this the answer, or what is the answer ? Senator Kexxeny. Well, that’s apparently what the system pro- vides now for somebody who has worked all his life and saved. And this is what you have to look forward to. after paying off $20,000 or $25.000 bills ‘yourself. That is what the system has provided for you and your family. Mr. Wirrir. That's right. Senator Kexxepy. What do you think of that? Do you think that’s pretty rotten? Mr. Wirt. I think so; I think so. Senator Kex~xepy. I do, too. Mr. Wirt. I'm an ex-serviceman also. I fought for my country, and T would die for it even today. Another thing Senator Kennedy, have you ever considered people like myself getting some extra tax relief ? This would be a big help, and it would have been a big help all the way along. Has anyone ever con- sidered that? Senator Dominick. That’s a good point. It hasn’t gotten anywhere as vet. Senator Kexyepy. You had about $25,000 worth of bills that you have paid. If you had been able to subtract your expenses from your taxes, you would have had some relief, but you still would have had to pay out a great deal of money, wouldn’t you ? Mr. Wirt. Yes; that’s right. Senator Kex~epy. As an alternative, would it have helped if you had been covered by a Health Security Act? Mr. Wirrn. Right. Yes, it would ; that’s very true. Senator Domrzicx. Does your company have a retirement program for you? Mr. Wirrn. Through the union ; yes. Senator Dominick. So you will have some income coming in? Mr. Wire. I will have some; yes. Senator Dominick. Why do you say that your insurance lapses at that point? Is that union insurance ? Mr. Wirrn. Union insurance ; yes. Senator Doainick. When you retire, the union cuts you off and says you can’t have any more insurance ? ’ Mr. Wirt. Right. Senator Dominick. That's not a very good bargain for you as a union member ? Mr. Wirt. Well, no. I have two members of the union here. Senator Domivick. I think we ought to bring it out. : Mr. Wirrn. Yes; that’s a good point, too. I have tried to buy addi- tional insurance, and they have turned us down. 2360 Senator Dominick. Well, I'm sure that you have a problem. I can’t even get any for myself, so I'm sure you have a problem in your situation. Senator Kenxepy. We are pretty well covered under the Federal program. Senator Dominick. I'm not under it. [ Laughter. ] Let me ask you something : What you are saying is that you think it might be a good idea to have, in a situation such as the one which you and other people who testified are in, where they have a catastrophic or a longtime condition of illness, where the insurance which they carry due to their own fault or not doesn’t cover them, a tax break of some kind? Now, of course, you can deduct a certain percentage of your medical expenses. Mr. Wirrn. That’s right. Senator Dominick. And you do, of course, get an additional de- duction at the age of 65. Mr. WirtH. Yes. Senator Dominick. But you are talking about something over and beyond that? Mr. Wirra. That’s right. Senator Doainick. You have some very good input and I'm glad that you have presented it. This has been discussed but it has not come up in the Finance Committee. Mr. Wirrn. I think it would help in lots of cases. Senator Dominick. Thank you very much. Mr. WirrH. You're welcome. Senator Kex~epy. Thank you very much. Now, we have two professional witnesses, Dr. Marvin Johnson and Dr. Kenneth Platt. Dr. Johnson is president of the Colorado Medical Society, and Dr. Platt is the president-elect of the medical society. Dr. Prarr. I'm Dr. Platt, and this is Dr. Johnson [indicating]. STATEMENT OF MARVIN E. JOHNSON, M.D., PRESIDENT, COLORADO MEDICAL SOCIETY, DENVER, COLO. Dr. Jonxson. Senator Kennedy, Senator Dominick, I'm glad to have you with us, and we appreciate very much the opportunity to participate in this discussion. The problems that you have pinpointed here today are those, of course, in which we have a great deal of interest too, and I would like, for a few minutes, to tell you about some of the things that the medical society has been doing. It’s always a problem when you see medical successes that end up in economic failures, and we agree that this is a real problem. I think it hasn’t been brought out today that many of the hospitals do give quite a bit of free service, and the one I'm associated with makes quite a sizable contribution to the community each year in the form of free service for patients who cannot pay, but I think you very well pin- pointed the fact that major illness contributes to big economic problems. 2361 The medical society for a long time has maintained a grievance committee and an insurance committee to ascertain the fairness of fees. I would like to point this out in the public hearing, that the patient always has the opportunity of redress if he feels that a wrong has been done. Senator Ken~epy. What is the redress that is available ? Dr. Jounson. The patient can file a complaint with the medical society stating that he feels he has been treated unfairly either in the treatment itself or in the fee. Senator Kex~Nepy. I don’t want to interrupt you, but just on this point, I think the opinion I have gathered from the witnesses here is that they have been uniform in their acclaim of the doctors and the hospitals and the treatment. This is a good deal different from what we have heard in other places. The people here have really been uniform in their statements that they think the doctors have done well and the hospitals have done well, but then they get the bill, and what are they going to do? They think the doctors are superb. A mother here this afternoon was just choked with admiration for the doctor who saved her child’s life, and for the treatment they received in the hospital. Now, what are they going to do? Against whom should they fill out a claim ? Dr. Jonson. Well, we, of course, have no binding control over the insurance companies. This is one of the virtues of a foundation ap- proach, in which standards are set for policies that are realistic. The medical society, in its function of peer review controls which claims are paid and so forth, and I would like to get into that a little bit later in regard to the medicaid program. 1 would also say, before I overlook it, that the nurse from the mi- grant health program has pinpointed an extreme need. The problem there is that all Federal grant funds specifically prohibit any money being paid for hospitalization of the migrant worker, and this is a very bad situation. Senator Dominick. Can TI interrupt there? Is that the fault of the operation or of the law ? Dr. Jounson. This is the law, Senator Senator Dominick. Is it the law or just a rule ? Dr. Jorinson. Well, T can’t say as to that. They look the same to me. Senator Dominick. The law or the rule are not always the same as a result of the agencies thinking up their own rules which have little or nothing to do with the laws which we pass. Dr. Jomnson. And the migrant worker problem extends beyond health. Tt gets into the nutrition. It gets into housing. And it’s a prob- lem that should probably be handled on a Federal basis because these people go from State to State. There should be some uniform cov- erage so they could properly be cared for, and I hope the Congress will work on this. : . The group at Greeley, the health department, the medical society, and interested citizens cooperated fully in the second request that’s in from the Greeley area, and we hope that some money can be forth- coming on that. 59-661 O0—71—pt. 10——10 2362 Senator Dominick. I'm sure there will be money forthcoming. Dr. Jornson. There are some changes necessary. We also feel that there is a need that the migrant worker get better coverage under the workmen’s compensation law, but, of course, that’s a State matter. But it possibly could be covered in the Federal legislation, too, because this is a high-risk group, and there is no question that they need a lot of help. Now, just briefly to go over a few things that we have done: In 1961 in this area the medical societies, the four county medical societies in conjunction with the State and county health departments and the voluntary health agencies, had a task force to study the problem of people getting into the health system and finding the resources which are there. Without belaboring of the point, I would like to say that an information and referral service was developed and still exists today. It has functioned for 10 years very successfully. But, again, it’s hard to get the information to the people that if they call a certain number, they will get professional information at no charge on where to seek health care. It will help them with other socioeconomic and health- related problems. This has had the full endorsement of a lot of respon- sible people. It’s still working today, and when we needed an emer- gency publicity campaign for the veneral disease crisis, this has become the center information point. The operations of this group prove that you can utilize Federal funds at the local level with very successful cooperation of every level of government and the private health pro- viders. We think that this is one of the most important things. Now, we too are deeply interested in the cost of health care. We be- lieve that, of course, prevention and early detection of serious diseases are a key point. The objective, of course, is disarmingly simple. We agree on that. It is to attain the highest quality of care at the lowest possible cost under an arrangement that preserves the most dignity, safety, well- being, and freedom of the patient and the provider. This is our orien- tation on these problems. and we are willing to work with anyone that wishes to help them out. Now, the medicaid program in this State got into sever difficulties, as it has all over the country. This happened because the law was hastily written, without adequate planning for checks and balances, and then there was the inadequate funding that resulted. In actuality, it was probably the inflationary trend, plus the fact that the Supreme Court threw you a curve with the decision throwing out residency requirements, so that the costs were increased by about 25 percent after all the budgets were made. In any event, we had a medical conference which involved our State Department of Social Services, the Colorado Osteopathic Association, the Colorado Hospital Association, and the Colorado Medical Society, and we devised a plan for utilization review of all inpatient care. This was carried out using the hospital Utilization Review Com- mittees which already existed and, to borrow a phrase that is often used to damn us a little by innuendo, the fox was indeed given the task of guarding the hen house. We are happy to report that it worked out, 2363 all right because we have reduced the average stay from 6.5 days to 4.5 days under this plan. Only 73 percent of the days assigned under the P.A.S. standards are used. Where extensions are requested because of complications or multiple illnesses, we have only a 59-percent utiliza- tion of the time granted. We have a two-appeal mechanism so that no one will be unfairly treated. There's a regicnal committee that either the hospital, the doc- tor, or the patient can appeal to, and then we have a State committee in case the regional committee can’t come to an agreement. We have saved a tremendous amount of money working closely with our State agency, and we feel we can do the same thing on the outpatient pro- gram if given the opportunity to do this. We are very interested in the manpower crisis. We supported fully the Child Health Associate program. We are supporting the Colorado Health Careers Council, which makes an effort to reach out and recruit people for health careers in all segments of society. Senator Dominick. May I interrupt? Here is the Health Services for Domestics which was passed last year. It does specifically provide for special projects to establish a continuity in health services and to improve the health conditions of domestic agricultural migratory workers and their family, including necessary hospital care. Right there in the law. If someone is saying that these provisions aren’t in the law then they are out of their mind. Dr. Jonson. I'm glad you pointed that out. We will club certain individuals with that information. Senator Dominick. Section 310. Dr. Joux~so~. It always pays to go to the top. [ Applause. ] One or two last points, if I might, Senator. We recognize that obso- lescence is the single greatest hazard to the physician, and we are mak- ing a great effort to have a successful and available continuing educa- tion program for our physicians, which is geared to our peer review results. We feel that everyone can work together, and it is a necessity. The problem far exceeds the capabilities of Government or organized medicine or anyone else. We offer our services individually and those of our Society for any cooperative effort whatsoever because we are just as interested as you are in seeing that we can prevent repetitions of these hardship cases that we have heard about today. Thank you. (The prepared statement of Dr. Johnson follows :) 2364 COMMENTS ON HEALTH CARE PROBLEMS IN COLORADO BEFORE SENATE HEALTH SUBCOMMITTEE Denver, Colorado - May 14, 1971 Marvin E. Johnson, M.D. President, Colorado Medical Society The Colorado Medical Society is pleased to have an opportunity to comment on the problems of health care before this important committee. This Society's 100 years of service to the people of this area have given our physicians considerable insight into the needs, the resources and possible solutions to health care problems in this area. Over this past century the members have recognized that the independent, even isolated, role of the physician in rendering medical care to individuals has been altered by technological and sociological changes. Our society has made a sincere effort to define it's new and broader role of contributor to the cooperative effort in providing a better coordinated health care system. I shall endeavor to state some of the problems that we have identified and the actions that have proven helpful. THE PROBLEM. OF PATIENTS and their families having difficulty either enter- ing the system or finding the proper resource to aid in health related problems was identified by a special task force in 1961. This type of situation was found not limited to the indigent nor the aged patient but occurred in all economic and age groups. The four metropolitan county medical societies worked with the State and County Health Departments and the voluntary health agencies under a Public Health Service Grant to establish an Information and Referral Service to assist and advise people without charge and to identify unmet needs. This agency has functioned well for 10 years and performed an additional service to the community by establishing coordinated social service departments in many of the 2365 private community hospitals for the first time. With a relatively small amount of additional funding the system could have been expanded over the entire state. This agency functions well today and has been designated as the prime informational source for the emergency VD program inaugurated by the State Health Department because of the alarming increase in VD locally and nationally. The experience with this agency proved unequivically the wisdom of careful joint planning ‘and jointly shared authority and responsibility in producing successful and economical programs for health care. This enlightened endeavor is generally credited with having eliminated or prevented many misunderstandings between the many people and institutions involved. Such joint utilization of Federal funds and expertise in cooperation with the regional agencies which are so knowledge- able, well accepted and adaptable can be recommended most highly to those responsible for future planning for health care. Cost of care is a great problem to everyone who shares in any aspect of the planning or provision of care. In my 28 years as a physician I have concluded that the best possible care is always the most economical ultimately. The prime examples of this premise are prevention of serious illness by simple low cost immunization and early detection of still curable serious illness. The expedience of fruitful research to increase the number of diseases that can be handled this way is espoused by ail physicians. The clinician while awaiting further significant breakthroughs in this area and hoping for improved accomplishments by governments in the nutritional, environmental, educational and sociological areas must currently contribute his expertise to cost control. The objective is disarmingly simple to state: Attain the highest possible quality of care at the lowest possible cost under an arrangement that preserves the most 2366 possible dignity, initiative, freedom and safety of both the patient and the physician or other provider of care. Again the experience in Colorado clearly indicates that cooperation, coordination, mutual planning and trust are perhaps the tmporeant but often unused tools in accomplishing this objective. A case in point is the Medicaid Program in the United States. This well intentioned effort to fulfill our national responsibility to provide good care for our needy and unfortunate citizens soon came under great criticism because in every - single state it was soon in an extreme deficit position. This happened here and was inevitable. Our analysis of the problem was that the law was hastily written without adequate planning with the providers so that proper checks and safeguards could be incorporated and adequate education on how to use the program could be given. The second error was inadvertent inadequate funding by the federal and state legislatures in the presence of continuing inflation and increasing welfare roles because of an unanticipated Supreme Court decision. The third error was our usual over optimism that the money can never run out so let each of us do what is most convenient for him whether he be provider, patient or administrator. Fortunately our State Department of Social Services, which is responsible for administrating the Medicaid Program, was well organized and informed and detected the coming crisis many months in advance. A confevente was arranged with representatives of the Welfare Department, the Colorado Hospital Association, the Colorado Osteopathic Association and the Colorado Medical Society. A plan was devised for Utilization Review of all Medicaid inpatients by the physicians which constitute the hospital Utilization Review Committee in an effort to minimize length of stay and encourage outpatient workup. The guideline designated was the average stay for patients with each specific diagnosis as published in the national PAS standards. The plan 2367 was for the local hospital Utilization Review Committee to review each case that was still in the hospital on the day prior to the expiration of those assigned days. The patient thus had to be either discharged on the following day or on extension of days granted by the Utilization Review Committee, which was acting as the designated authorized agent of the Department of Social Services. The Department agreed to accept this UR committee decision for any additional days up to the 18 day limit set by law. To borrow a phrase often used currently to malign the providers of care by inuendo, "The fox was indeed given the task of guarding the chicken- coop." There is great pleasure in reporting that the chickens, the owners of the coop and the fox have all fared beautifully. The hospitals have been saved from that unfair hazard, the decision for retroactive denial which meant no pay or only partial pay long after the patient had been given the service and discharged. The physicians have avoided either the need for prior authorization for admission, further reduction of the al- ready substandard fee or categorical denial of admission for patients with certain specified conditions. Those government departments held responsible for the health care of Medicaid patients have been given tremendous assistance in quality and cost control so that they can concen- trate on problem areas rather than routine admissions. Our State Legisla- tors who have the ultimate moral responsibility for sociological decisions and fiscal stability have been aided in their mission by the improved efficiency of all concerned. The most important result has been that no needed service to patients has had to be reduced. Educational emphasis on outpatient workup may in fact improve quality of care. The traditional mutually good relationship between patient, provider and third party has not been damaged by any devisive or destructive regulation on anyone. 2368 Objectively this coordinated. effort accomplished the following startling results. The average length of stay for Medicaid patients was reduced from 6.5 days to 4.5 days. The length of stay of 6.5 days was 1.2 days below the national average so that the Colorado program was much better than average even before this 2 day reduction in length of stay. Two other statistics that prove the providers can be entrusted with the con- trols of health programs are these. Only 73% of the days granted under the PAS average standard are used. Only 59% of the days authorized for additional stay in complicated or difficult cases are ever used. Another critical fact is that this program was conceived of, designed, agreed upon and implemented in less than six weeks time and has never faltered. The fact of decreased utilization shows conclusively that the providers can be entrusted with local control under standards mutually agreed upon with the third party payor. Experiences with Foundations for Medical Care such as the one in San Joaquin have demonstrated that these controls can be exerted over outpatient cost and quality. We feel that we shall be able to accomplish this with our Colorado Foundation for Medical Care in the future if given the opportunity to do so by the government. The efforts to increase manpower have been supported actively by the Colo- rado Medical Society. The Child Health Associate program of the University of Colorado received our unqualified endorsement. Our society initiated a recommendation that young Public Health physicians be allowed to serve their two years of government service in rural understaffed areas or ghettos. This type of program was introduced at the AMA level by our Delegates and was very much like the Federal Law that was ultimately passed. For many years the Society and it's Auxiliary have furnished facilities and given operational money to the Colorado Health Careers Council. This Council has carried out a very active educational and recruiting program in the high schools to encourage young people of every group to enter the health field. 2369 Recognizing obsolescence as the single greatest hazard for the physician or other professional, the State Society is working actively in conjunc- tion with the AMA to develop a successful and available continuing educa- tion program for it's physicians. Many other problems exist and some seem to become more difficult with each attempted solution either complicating the old problem or creating a new one. In my experience this type of difficulty can be avoided best by proper coordination of all involved parties in the planning and implementa- tion of a health program. Forthrightness rather than secrecy, cooperation rather than imposition, mutual respect rather than antagonism appear to be the key attitudes to assure progress in new désigns for health care. Many things have happened in Colorado which prove the great value in sincere cooperation between Federal Government, Local Government and medical or health organizations. The greatest possible good for the most patients can come only by increasing this coordination and communi- cation. The services of the Colorado Medical Society are available to : all, at anytime, in any effort directed toward improving quality and availability of health care while controlling cost and preserving the dignity and rights of our citizens. 2370 Dr. Prarr. Senator Kennedy, Senator Dominick. T have a prepared statement which T will set aside. You have it there for the record. Senator Kenx~xepy. It will be entered at the end of your testimony. STATEMENT OF KENNETH A. PLATT, M.D., PRESIDENT-ELECT, COLORADO MEDICAL SOCIETY, DENVER, COLO. Dr. Pratt. T would like to speak to you just for a few moments both as a concerned professional and as a compassionate human being. The tragedies you have heard here, both personal and socioeconomic, are in a sense the tragedy of all of us. The very fact that one such instance could occur 1n a country as rich and powerful as this is a concern, not only to you and me, but to other taxpaying members of this group today. I am assuming a position now as the president-elect of the medi- cal society. I have been in organized medicine for years, and I can truthfully say that I espouse causes and promote programs that 10 years ago would have been considered heresy in the medical profes- sion. We have reached that point now where our technology is eating us alive. It’s creating a demand for our services and an expense that’s far beyond the average capacity of the wage earner to afford. Now, the medical profession is fortunately becoming more con- cerned and more enlightened and more knowledgeable about the prob- lems than ever before. It is our hope that through mechanisms like the foundation program, by computerized laboratories and so forth we can cut the cost down, that we can provide the technologically superior care that these people need and demand and keep it within the bounds of their ability to afford and pay for. There are just a few points that IT would like to make, since Dr. Johnson has covered many of the specifics. We feel that the only solution to the costs, whether it’s under Government programs or un- der State programs or under private health insurance, is to orient the public out of the hospital. They have simply got to be trained, and the doctors have to be trained, to seek their care outside the hospital, be- cause it’s the cost of the hospital that’s taken the cost of medical care beyond the reach of most people. This is not to indict the hospitals, because they are caught in ex- panding costs, particularly expanding employee costs. The hospitals are not unaware of this problem, and we have here in Colorado a unique program, which I think you should be aware of, that we be- lieve will be a partial answer to hospital costs. We have a major urban center with expanding suburbs. Each year the population moves farther and farther away from our core-city hospitals. It becomes a matter of economics, traveling back and forth to seek care or to visit people who are under care in the hospitals. It makes little sense to build bigger and bigger centrally located monolithic structures. So we are now building a satellite out in the northwest sector of Denver, a full-scale facility, approximately 115 beds, caring for 80 to 90 percent of the needs of the local population. They can remain in their local areas. They can be treated generally 2371 in their local areas. They can be transported when they have major crises by helicopter or by ambulance. We were able to build that hospital at a cost of $21,000 a bed; which is about a half or a third what it costs in the metropolitan area. This is one of the ways we are trying to reach out to the public and bring them the care they need at a cost they can afford. An attempt to set up rigid standards for insurance coverage is be- ing made that will prevent some of the things you have heard today, such as inadequate coverage or exclusions the patient is not aware of. I’m not going to make a plea for any one great, simple solution to this problem. Many people have varied greatly in their solutions to the problem. It is your prerogative as an elected representative to come up with an answer that makes economic and professional sense. I hope that when you go back to Washington to debate these prob- lems, you will recognize the contribution that the physicians of Colo- rado are trying to make their solution. You should also recognize that the health professionals represented in this room and the students represented in this room are just as concerned and just as aware of the problems as you may be. That’s all T have to say. Senator Kenxepy. Let me ask you, if I could, what has been the reaction of the insurance companies to your efforts to get people out of the hospital beds, or to set up the satellite facilities in the com- munities? I can remember when I offered an amendment in the Senate to set up a program of neighborhood health centers. It was opposed by the Medical Association, opposed by the Hospital Association, op- posed by almost all of the organized health groups. Here was an idea that wasn’t developed within the existing health system. We in the Congress like to see initiatives coming from the groups that are work- ing in the field. I suppose you could say the AMA now has a health insurance bill and so do the hespitals and so does everyone else. There are about four or five different kinds of proposals that represent the different kinds of interests in the health field. I would be interested in what reaction you are getting from the insurance companies to your efforts. I agree with many of the things you have said in trying to achieve the aims you have just cutlined here. Does your group meet with the insurance companies? What kind of reactions are you getting? Do you talk with them? Dr. Pratt. Yes, in open dialog. Senator. Ken~epy. What's the result? Can you tell us about the dialog? Dr. Pratt. The dialog is often heated, Senator. The results are mixed, but like the reluctant dragon, I think we will bring them across the threshold. Senator Kex~epy. Why do they have to be dragged across? Dr. Prarr. I think that, like most of the physicians 10 years ago, they were concerned with a certain aspect of the socioeconomics of the issue. Senator KeN~EDY. Is it more economics? Dr. Pratt. I would imagine that, as in any free enterprise system and a profit organization, economics played a great role. 2372 Senator KennepY. I suppose that raises the question, whether there ought to be health for profit ? Dr. Prarr. I think it depends on what you call profit. Senator KenNepy. I will take the profits insurance companies make on health insurance. Let’s use that definition. i Dr. Prarr. I'm not an expert in this field, but I have seen statistics that say that the profit on health insurance in the country as a whole is approximately 1 percent or less. Senator Kexnepy. Why do private carriers retain almost half of the premiums that are paid in for individual policies, instead of paying them out in the form of health benefits? Why is the overhead so high ? Dr. Prarr. I think this is part of the national debate that has to go on. I would also like to point out that we do not necessarily find that at the Federal level, the economics is of the best. Senator Kennepy. That’s right. I couldn’t agree with you more on that, but often it’s been the Federal programs that have tried to meet the need. Dr. Jornson. I think the secret of making the program work is more local or regional responsibility and authority. Many times the local agency is more knowledgeable and more adaptable, because con- ditions vary from place to place. Senator Kenney. I think it is very worthwhile for you to work with the insurance companies to give them the benefit of your experience. Senator Dominick. I just want to make one closing statement. I think this hearing shows the need we have for an exchange of view- points between many people. I don’t pretend to defend the insurance companies because just among the witnesses here they have paid out virtually hundreds of thousands of dollars in premiums to fulfill their contract responsibilities, and that ought to be put into the record too. They are not all just trying to rook the public, I don’t believe. Another important area is trying to find some method for covering those situations where people either cannot afford the major type of medical insurance or in the case where during a long-term illness the insurance runs out. I have a feeling that a good deal of this work is going to have to be done with either State or Federal help. I don’t think it can be any other way. The income level or the type of conditions that may be involved which would bring this situation about can be discussed at length somewhere else. I think the input that we have received has been ex- tremely successful insofar as it demonstrated the concern felt here in Colorado which has been complimentary about the medical attention, the hospital attention, and the innovations that have been going on here. T want to congratulate you. I think you have done a great job. Senator Kennepy. I want to thank you very much for coming. Your complete statement will be included as a part of the record. (The prepared statement of Dr. Platt follows :) 2373 KENNETH A. PLATT, M.D. PRESIDENT-ELECT, COLORADO MEDICAL SOCIETY TESTIMONY BEFORE THE HEALTH SUB-COMMITTEE OF. THE SENATE LABOR AND PUBLIC WELFARE COMMITTEE DENVER, COLORADO Senator Kennedy, Senator Dominick and members of the Senate Subcommittee on Health, | wish to express my thanks for this Spportupity to contribute to the current dialogue on the health care system in the United States. 1t is both fitting and proper that the manner in which health care is delivered and financed should be a matter of National concern. Any nation as rich and as powerful as this cannot afford the '"'luxury' of neglecting the health needs of its citizenry. That there are problems existing in our present system of health care delivery is an established fact and the only basis for argument is over the methods used to overcome these problems. welisimentioted and knowledgeable men vary widely in their proferred solutions and it would be presumptuous of me to critique the various plans that are currently before the Congress. Instead, | should like to discuss briefly some of the things “currently astir in Colorado as our profession is rising to the challenges before us. Undoubtedly the most exciting advent in the past two years was the formation of our statewide foundation for medical care. It envisions a ‘network of regional foundation entities tied into geographical and population considerations all under the umbrella of a governing board at the state level. This board would be comprised of representatives from all the major providers of health care such as doctors of medicine and osteopathy; pharmacists; nurs- ing home operators; and hospitals. The foundation's major fields of endeavor 2374 would be in the areas of peer review; utilization control, and quality assurance. It is our sincere belief that through education and peer review both cost controls and quality assurances could be guaranteed. We have already established the effectiveness of such a mechanism in our current cooperative effort with the State Department of Social Services and the Medicaid program. Projected savings to the program for the first year of our joint efforts is in the range of 1.5 millions of dollars. The Foundation is currently exploring ways to expand into other public and private sectors in order to further enhance the already high quality of medical care in our state. As the committee is well aware, the most troublesome scctor in our rapidly escalating health care costs is the hospital scctor. In an attempt to bring these troublesome costs under control we have embarked on a pro- gram of hospital satellization. Two of the major private hospitals in the Geter area are constructing satellite hospitals in suburban communities. They have found that this meets the local needs but at great savings both in initial construction costs and in management savings. In the suburb of Westminster, St. Anthony's Hospital is just completing a l15-bed satellite built at a cost of only 21 thousand dollars per bed. This compares to an average cost of 35-45 thousand dollars per bed for hospital construction nationwide. In addition, by the joint purchasing, management and staffing of the two hospitals further savings are anticipated. Another area of progressive innovation in medical care in our state is the increasing use of helicopter evacuation of critical medical and surgical cases from outlying areas to our major metropolitan medical centers. Just in the past month a heliport was dedicated on the rool of 2375 St. Anthony's Hospital in Denver. Already it has been used to receive several accident victims who were evacuated directly there from the scene. It is the intention of most of the major centers in the state to tie in with private, police and military helicopter evacuation teams. Hopefully a state-wide network can be programmed to take care of rapid transit of highway victims to areas of primary care. These are but a few of the on-goina programs of advancing mediical delivery in our state. In addition we have pioneered in such areas as neighborhood health centers; migrant worker programs and mass inoculation drives. Nationally recognized as a progressive state in many fields, Colorado has been particularly active in the health care area. It is with pride that | point out to you gentlemen that these accomplishments have been largely created by the private sector of the health care team. In defense of our ''cottage industry" and contrary to certain current opinions, | have found the practicing physician both concerned and innova- tive in his attempts to improve our ''non-system''. Given governmental support and legislative help | believe that a free profession of concerned individuals can do a great deal to solic these vexing problems. It is my fervent hope that our national goals will be met by building on what we have rather than discarding all we have accomplished for a nebulous, monolithic, bureaucratic program of total federal care. 2376 Senator KENNEDY. We are running into a time problem, but we will hear from some witnesses from the floor. Dr. Sparkano has agreed to file his statement. We had a good visit with him earlier today. It was very informative, and he has agreed to yield his time so that we may hear some of the other witnesses. Mrs. Espinosa? Is she here ? Mrs. Espinosa, we want to welcome you here. STATEMENT OF MRS. ESPINOSA, WITNESS FROM THE FLOOR OF THE HEARING Mrs. Espinosa. Senator Kennedy, welcome to you here, and to Senator Dominick. I'm kind of shaky from seeing you this morning at the center. My problem here is the difficulties that T have had with my children, with myself. IT have seven children, and I have gone through a lot of tragedy in the past 2 years with a husband that passed away, a daugh- ter that committed suicide—hung herself 2 years ago on the fifth of April. Another son that had polio—he got polio at 9145 months old. He has had two operations, has braces on his legs—on each leg. The boy is disabled with polio. He has worked hard trying to get a job, and everywhere he has gone he has been rejected. He is a good artist—he’s an artist, and he has tried hard to get into these jobs with the art program, and Gilbert has gotten nowhere. Funds are not included for purposes of this type of work for Gilbert. The girl was going to beauty school, too, and there were no funds to help Rosalie finish her school, her college education; Gilbert also. There is another problem: I have had all this tragedy, the death of the husband, me raising the children alone, and I'm on A.D.C. re- ceiving three twenty-three a month. There are six of us at home now, and we can’t make ends meet with this money. One thing that’s good is that T have medicaid, which covers my hospital for my children and for myself. I have been real sick in the past, and I had a wonderful home at 2526 Kearney. It was a nice home. Duane is another one of my sons. He is a deaf mute and hard of hearing. He is 15 years old, and we had no help from any funds from anyone. We have been trying hard to put Duane through school, and this is one thing that I would really appreciate—if someone would come up with something to help these children with school. You know that a lot of children need not only money. A lot of moth- ers are left alone. A lot of children are left alone with just the mother and not a dad, and my kids were left without a dad. Duane is not eli- gible in any public school because of his hearing and speech therapy. Another problem that IT have had—I always weighed 150 pounds, Senator, and in the past 2 years I don’t know what came over me, whether it was my daughter who hung herself in the basement of my home or the other tragedies that came to me. Gilbert is a problem. Duane is a big problem. I have Debbie and Nora, who are going to Annunciation School today, and I have fees for those girls. It’s a $90 fee for Debbie and $90 for Nora. One is in the eighth 2377 grade. The other one will graduate June the 3d, and it is a problem for us to pay these fees, especially on my welfare. oe I have been sick in the past, and I have a nervous condition. I had a real nice doctor, I thought, but after I had been going to this doctor for a whole year, I found he was treating me for the wrong thing. Every time in his office, he would say, “Take all these pills and take a different kind of pills at a certain hour,” and I would take them. 1 was always on drugs, heavy drugs. I was always asleep. OK. I went to him till one time he gave me the wrong medicine and treated me with the wrong medicine. I never did anything about it. I said, “God will help me and he will help me get well.” It is in my prayers that T would get well for the sake of my children. : Well, T went and changed doctors. I went to Dr. Richard Hamilton, and he is my doctor now today. I do have a touch of thyroid. At one time I couldn’t walk. I couldn’t talk. I couldn’t help my children. 1 couldn’t see. My vision was blurry. My legs were off—I couldn’t do anything for my children. I wondered what was going on. I called the priest. He called the am- bulance, and he said, “Annie, you are going to be rushed to St. Joseph Hospital,” and I was rushed there, and I was treated there, and I have been having all these problems for 2 years, and this doctor didn’t know what was wrong. He told me I had a nervous condition and put me on tranquilizers. All the time I was always doped on them, and there was no problem of a nervous condition whatsoever. The problem with me today, which worried me so much, is that my weight was 150, and today I weigh a hundred and twenty-five. My weight has really gone down since December, and T have a problem of sickness, a nervous condition, and it’s not bad. I have thyroid. I have an active thyroid, and I am a diabetic. And another thing. I tried to get together with the Welfare Depart- ment to see if they could help me out with some kind of extra money for my diet because I'm not on insulin. I’m not on pills, but I’m on a strict diet. Sometimes when I don’t have the money—when I have to buy for the other children and I don’t have enough—I go out. I need this for myself and my children, Senator Kennedy. Senator Kex~epy. This is certainly a very tragic set of circum- stances for you. We don’t have any easy answers on this, Mrs. Espi- poss, but I want to thank you very much for sharing it with us here today. : Witness in Aupience. I think we have seen from the previous wit- nesses here what major illness can do even if you have a stable in- come. But I think it also pretty well illustrates what can happen if you are poor to begin with. The results that can happen are even more distressing, especially as they relate to the family, because the only thing the family had to lose is its relationship. And they have lost a good portion of that because they were economically down to begin with, and now they have had a major illness. It’s even more tragic than losing money. Senator Ken~Nepy. That's a good point, one that hasn’t been made. Thank you very much. 59-661 O—T71—pt. 10——11 2378 I understand that these hearings are being piped in to Boulder, where Mr. Paul Hagen is standing by. Do you have a comment, Mr. Hagen ? STATEMENT OF PAUL HAGEN, TRANSMITTING BY TELEVISION TO FLOOR OF HEARING FROM BOULDER, COLO. Mr. Hagen. Senator Kennedy, Senator Dominick. we have heard several comments concerning the high cost of drugs. These are what my comments are concerned with. Would you please consider for legislation under your health in- surance plan the idea of physicians prescribing drugs by generic name ? This would allow poor people to take advantage of the same price structure that others do. There have been several films on this ques- tion. The cost varies in the neighborhood of tenfold to twentyfold, depending on the item. Senator KExNEDY. Senator Nelson in the Senate has had a series of hearings on this issue and has pointed out the problem. I think it’s a very worth while suggestion. It’s a good comment. Mr. Hagen. If they are really interested in cooperating in all of the local areas, they could do it. Senator Ken~Nepy. The AMA could do it. Mr. Hagen. Yes, they control what the doctors do, and it could be done tomorrow. Senator Kenx~epy. I would like to ask Dr. Platt or Dr. Johnson to make a comment on that. Dr. Prarr. For those of you who don’t know it, I have led the fight in the State for the last 2 years and in the house of delegates of the State society regarding compulsory membership in the AMA, which I think should be abandoned and which we hope will be. This doesn’t mean I take necessarily any opposite stand to many of the things the AMA stands for. I merely mean it should be a professional choice. Interestingly enough, despite the fact that I oppose the AMA on this issue, I still ended up on the board, so I doubt that they control it. Senator Ken~epy. You are a good politician. How about the view of the AMA on those pharmaceuticals? Dr. Prarr. I think there has been some problem here, but I would like to say that many of the physicians in the State, and I, personally, prescribe mostly by generic name. Dr. Jonnson. The AMA, God rest their beaten soul, you know, has just sent to all members a new book published by the council on drugs which very accurately reflects those drugs which are good and their generic name in an effort to get rid of useless drugs. So, they are attempting through educational efforts to improve drug prescriptions. Senator ex ~Epy. Do you have the power to do it here in the State without waiting for a national resolution ? Dr. Jorxsox. No. Senator Kex~epy. Could the medical society here in the State pass that resolution at its next meeting ? Dr. Jonxsox. For one thing, only approximately 2,700 of the 3,200 practicing physicians belong to the Colorado AMA, and this doesn’t include the osteopaths. Senator Kex~epy. That would be a good start, wouldn't it ? 2379 STATEMENT OF BOB APTER, MEDICAL STUDENT Mr. Apter. If IT may comment, my name is Bob Apter, a medical student here. The winter clinics passed a resolution recommending generic prescription of drugs and then the Colorado Medical Society will meet on it Dr. Prarr. Which, by the way Senator, is an innovation of the State of Colorado to have a student society, and their input is particularly vocal. : Senator Kenxeoy. Now what are you going to do with their resolution ? Dr. Pratt. We are going to pass it. Senator Dominick. The Food and Drug Administration also is looking at this, as you know. Senator Kexxepy. Very good. Well, thank you very much, Mr. Hagen. We hoped to be able to get up to Boulder, but we want to thank you. Is there another question from Boulder? We would like to have one more. Can you identify yourself, sir? Mr. Hamer, Senator Kennedy and Senator Dominick, I am Ru- dolph Hampf, associate director of the university-industry rela- tions, University of Colorado. We appreciate receiving and participating in this television inter- change with your committee from the Boulder campus, University of Colorado. Thank you. Senator Kex~Nepy. Very good. Are there any other questions? STATEMENT OF PETER PETERSON, M.D., CHIEF RESIDENT, DENVER MEDICAL CENTER, DENVER, COLO. Dr. Perersox. I want to point out something on your map. My name is Peter Peterson. I'm one of the chief residents in medicine here at the Denver Medical Center. This is where we are in Denver County (indi- cating). This is Adams County (indicating). We have 1,000 doctors in this county; we have 21 in this area (indicating), which is a ratio of 50 to 1. The populations are in a ratio of 4 to 1, and Adams County has one of the highest infant mortality rates in the State. It’s twice the national average. This ratio of doctors to population is about like the Philippines. We have given quite a bit of criticism to the insurance companies and the medical society today, and the university has gotten off scot free. I would just like to say that the university, to my knowledge, has no Outreach program into this area. Many of our migrants are also in this area and their infant mortality rate is three times the national average. It’s been brought out that the only hospital where migrants can easily be taken care of is Colorado General. However, Colorado Gen- eral has no responsibility to the migrants, and T would wonder if we shouldn’t consider that if we are going to fund Colorado General, we should give them some responsibility also. [ Laughter. ] A couple of other points: It’s been mentioned that we are concerned with economy; we are concerned with peer review. The doctors from the AMA mentioned that, and ambulatory care, and yet these are not 2380 emphasized in medical school teaching to any great extent. I wonder, if we are going to fund the medical schools, shouldn’t we teach them peer review? T don’t think that there’s any program in the medical school to teach peer review. There’s also a number that has been given that we need 50,000 more doctors in this country, and T don’t know where that figure came from. Is anybody able to tabulate that? And when we train these 50,000, are we going to require that they are trained to solve the problems that we are concerned with, which are immunizations, maternal health, child health, and so on? Thank you. Senator Kexxepy., Good comment. [ Applause. ] Let me ask. since we have some of the medical students, how many of the medical students are going out to practice as general practition- ers and going out into rural America or the inner city to practice? Dr. Peterson. I asked the dean here if they had any record of how many students go out to practice in rural areas who are trained in this medical center. The information isn’t available. And we are going to add 10 students to our medical school class, but likewise, I don’t think there will be a record of how many of those people go out and solve the problems that you are concerned with. Senator Kennepy. Of the ones that are here today—how many of you intend to practice in rural America ? [ There was a showing of hands. ] Senator Kennepy. How many of you are in the rural health pro- gram? I understand you have such a program here. You have only just got started ; is that right ? Senator Dominick. I would like to ask how many of those which raised their hands are going to practice in rural Colorado? [ There was a showing of hands. ] Senator Ken~epy. Are there further comments? We have about 3 more minutes. Dr. Frrrrs. T will try to limit it to one. We appreciate Senator Kennedy and Senator Dominick coming to Colorado. Senator Kexxepy. What is your name ? STATEMENT OF C. A. FRITTS, M.D., CHAIRMAN, LEGISLATIVE COM- MITTEE OF COMPREHENSIVE PLANNING HEALTH COMMISSION, DENVER, COLO. Dr. Frrrrs. C. A. Fritts, F-r-i-t-t-s, chairman of the Legislative Committee of the Comprehensive Planning Health Commission for Colorado. Fifty percent of the membership of our group are consumers. We have the State divided into 13 areas, and we have councils in each of those. We are striving to help solve some of the crises you have out- lined. For instance, the quality crisis is certainly one of our main goals. The system crisis is probably the greatest goal. How can the 42 dif- ferent agencies that are giving health services in our State be corre- lated so there will be no duplication or less duplication of effort, even in the rural sections? 2381 We are spending a lot of time in working on that. We think we have some legislation that is working satisfactorily. We in the podiatry field are working hard, and I want to go on record that we are getting excellent cooperation from the medical societies. There is no disagree- ment of any sort, but we are doing our best to see that we keep out of the hospitals, when the hospital average cost is $80.01 a day. If we can keep them walking, keep them out of wheelchairs, we can keep the cost of hospitals down. At least, it won't run up the insurance quite so fast. Senator Kennepy. Thanks very much. We have a final student question. Dr. Prerrrer. I am Dr. Pfeiffer. I plan to teach in the medical school. I would endorse wholeheartedly points 1 through 4 of the Health Security Act. I think it’s important for the Senators to realize that there are physicians who would support an activity and wholeheartedly work toward some sort of national insurance program, but who would have very grave concerns about the precise structure of the program. Those of us who have personal concerns with the military or the VA health programs, find that the resources, by and large, are ill- used, because there is no coinsurance, howeever trivial it might be, be it 50 cents a visit or a dollar a visit. Those of us who have family members or who have worked in a variety of other hospitals would also question very gravely the gen- erally accepted premise that group practice, of which Kaiser is an illustration, is-a perfect answer to the problem. I would suggest, and I obviously can’t elaborate, that the lower costs are perhaps illusory because of a very markedly different patient population ; namely, that the care tends to economize on the single most expensive part over which the doctor has great control—his time in taking a history. This is the most important thing in medical care and it is diminishing, at least today. There are aspects of efficiency of medical care which are for the moment beyond the reach of this sort of legislation. I would give the single example in cancer detection that there must be patient and physician acceptance and nurse acceptance even in hospitals of such things as undressing, as having retal examinations or transmitting stools for tests for blood. All of these would be appropriate and neces- sary and inexpensive and nontechnical forms of cancer prevention and detection. But they are just not available to us because of public attitudes. Thank you. Senator KenNepy. Thank you very much. I want to thank all of you very much for your attention this afternoon and for your interest, particularly the witnesses who were kind enough to attend the hearing this afternoon. We want to express our appreciation, and our thanks again to this fine school for cooperating with us. I think it’s been very helpful. T know it has been for me, and I'm sure it has been for the committee. Senator Dominick. I would just second your thought. Senator Ken~Nepy. Thank you very much. At this point I order printed all statements of those who could not attend and other material submitted for the record. (The material referred to follows:) 2382 HERRICK S. ROTH A. TOFFOLI PRESIDENT SECRETARY TREASURER ER fils Ls Coil AFL-CIO 300 DENVER LABOR CENTER + 360 ACOMA STREET + DENVER, COLORADQ 80223 + PHONE 303/733-2401 May 14, 1971 EMERITUS OFFICERS EXECUTIVE VICE PRESIDENT an Hon. Edward M. Kennedy, Chairman Harry L. Stewart Hon, Peter Dominick, Member and U. S. Senator from Colorado VICE PRESIDENTS and Other Members LA Ader U. S. Senate Committee on Labor and Public Welfare, Cletus A. Baumhover Subcommittee on National Health Insurance Chester A. Burry Clarence A. Christiansen ables Senators Kennedy, Dominick and Members of the Committee: Roy Gauthier william 1. Gordon f 2 Grime We are delighted that you are looking at the matter of Wilkur © Juetsah health care at the grass roots of our Nation's communit- | ed Jeznac! i : + y So Philip Kniss ies. You will find here and in your other visits through- Goole Li lacy out America the human equations that back up the statis- Jahn A. Moraes tical treatment of "national health," "health care," and a hoes "Health insurance" that is already so abundantly clear Chitier &, Roggets to you and in the records of your Committee for the ready Mamink Sektionl evidence that makes the case for national health insurance. . A. 1; . William F Smith ! VRE bh We will not burden you, therefore, by repeating these WW. Wallace facts. AFL-CIO President George Meany's testimony on Matthew J. Weaver September 24, 1970, still reflects the current situation nationally; your own testimony, Sen. Kennedy, on behalf of S 4297, the Health Security Act, on September 23, last, is replete with much of what we in the trade union community believe. We cover a vast cross-sectional income span in organized labor today--from lower to upper middle income--but when the heavy but often absolutely necessary costs of health care fall upon any of us or our families, rest assured, none of us so situated finds it possible to meet the entire cost, even underwritten by private insurance (profit or non- ’ profit based). So, let us relate for the moment to local area events that will add to the comprehension that each Senator and Representative must have in order to act in the national interest for total health care for every one of our citizens. For instance, this Council and its affil- iate local and district labor organizations, in cooperation with the regional administrator of the United Mine Workers Health and Welfare Fund, were among the principal instigators responsible for the Kaiser Health Foundation and Kaiser Permanente Medical Group establishing in (more) 2383 the last two years a Colorado operation, based for the moment in Denver Metro and growing more rapidly than perhaps even they could comprehend when they elected to open facilities east of the Great Divide in Denver and Cleveland, Ohio. The experience of this advent in our town and its suburbs has meant (1) a new quality of delivering total health care; (2) a cost opera- tion that is pre-packaged to avoid economic catastrophe for families who otherwise would be or would have become medically indigent; (3) a liberalizing of the viewpoint of both the medical profession and related health care personnel--and we must, indeed, give these highly skilled persons a tip of the hat for the positive manner in which they have received Kaiser and also for their own realistic evaluation of how they best serve in other respects the health care needs of our area; and (4) an outgrowth recommendation to you and your Committee, that any health insurance plan made available under the auspices of Government must permit the operation of pre-packaged, private not-for- profit plans, groups and foundations which meet the requirements of total health care to the families who accept membership in these programs. Second, if no one else brings this to your attention, we wish to do so. The Craig Rehabilitation Hospital here has received national attention. Its current publication (April, 1971) points out a significant state- ment by its medical director, Dr. Robert R. Jackson, which in summary points out that the incidence of catastrophic injuries has increased fifty per cent over the past five years involving potential expendi- tures of up to $500,000 of lifetime care--a cost to society that could approximate $61,500,000 if these cases had not been brought into the Craig program of management for the severely disabled--part of the health care of our society. We hope you will seek from Craig a full report, to study its relationship to national health insurance, and to relate the findings and legislation proposed by your Committee to clinical and hospital rehabilitation programs that are in the national interest so far as both lesser cost and quality of rehabilitation services are concerned. Lastly, we must caution that you cut no corners. We have had the op- portunity to talk personally with HEW Secretary, Elliott Richardson, here in Denver several weeks ago. We especially discussed health care. We urged him not to package less than a full program within the purview of his Administration. We pointed out that health care now assumes the significance of the educational nurture of our society. We don't pro- vide free public education and make it successful by "partial payment," by "partial insurance" and "deductibles." We "insure" for total pro- gram for our youth. We must "insure!" for total health care of all Americans and hope that you will settle for nothing less. This is our Colorado trade union challenge to you and your Committee. Thank you. Respectfully submitted, 2 (A Herrick S. Roth President 2384 HEALTH CARE FOR ALL THROUGH THE INCREASED UTILIZATION OF ALLIED HEALTH PROFESSIONALS by Henry K. Silver, M.D.* *Professor of Pediatrics, University of Colorado School of Medicine, 4200 East Ninth Avenue, Denver, Colorado 80220. Informational data compiled for hearings of the U. S. Senate Subcommittee on Health, May 14, 1971, Denver, Colorado. 2385 It is generally recognized that a crisis exists in providing health care for an enlarging population of children and that the only effective, practical, and acceptable method of meeting the need for additional health manpower is through the proper utilization of various types of well trained "allied" health professionals such as pediatric nurse practitioners, child health associates, and school nurse practitioners. This presentation des- cribes the three programs that I have developed to prepare these new types of health professionals to provide improved and increased health care to children. It also reports on the significance of these programs and on the performance and the acceptance by the public of these health workers. PEDIATRIC NURSE PRACTITIONER Our pediatric nurse practitioner program was the first program in the 1960's in the United States to prepare a new category of health worker to carry out functions and activities which physicians traditionally had performed. Nurse practitioners are graduate nurses who receive four months of special training at our medical center which gives them the capability to fill a markedly expanded role in nursing in various public health facil- ities and in the offices of physicians in private practice. They are the only non-physicians now in practice prepared to provide augmented and improved direct health care for our child population. For the period of the next five to seven years, they will continue to be the only health professionals who could be trained in sufficient numbers to meet the needs for additional health manpower for children; not until 1975 to 1978 will other types of health professionals be graduating in large enough numbers to make an impact on these needs. All other health professionals, including physicians, physician's assistants such as those from the Duke Program, and MEDEX could not be trained rapidly enough (as would be the case with physicians) or do not have the capability to care for children (as is the case with physician's 2386 2. assistants and MEDEX who, presently, are only equipped to provide health care to adults). Within months, on the other hand, hundreds of pediatric nurse practitioners could be prepared for practice. A number of pediatric nurse practitioner programs have already been established, but the training of 20 nurses a year for the next three years at each of 100 additional pediatric centers -- a goal that is readily attainable -- would result in a doubling of the total quantity of new professional-level health care, including that pro- vided by physicians, that becomes available each year to children. The pediatric nurse practitioner can take complete histories; perform comprehensive physical examinations; carry out necessary immunization; evaluate hearing, speech and vision; determine developmental status; perform laboratory tests; evaluate and manage common problems of the healthy child and those with minimum illnesses; counsel parents; assist in managing emer- gencies; care for newborn infants; and handle telephone calls. These fun- ctions and activities include most of those that a pediatrician carries out in his office. We have carried out a number of evaluation surveys of graduates of our program with the following findings: 1) Pediatric nurse practitioners can, by themselves, care for approximately three-fourths of all children coming to an ambulatory office setting for health care. 2) Pediatric nurse practitioners can provide almost total care to all well children, and can evaluate and manage a majority of the problems of sick and injured children seen in the office. 3) Ninety-four percent of parents expressed satisfaction with the combined care provided jointly by a pediatrician and a ped- iatric nurse practitioner in a private office; fifty-seven percent 2387 Be found joint care to be better than that which they had received from a physician alone. 4) Ninety percent of parents consider an association of a physician and an allied health professional to be a desirable and inevitable trend in the practice of medicine. 5) There was a high degree of agreement by pediatric nurse practitioners and pediatricians in assessing the health status of children; a significant difference in assessment occurred in only 1% of cases. This is undoubtedly as good as might have been found between different physicians. 6) Pediatricians who have pediatric nurse practitioners as associates in their practices have found that such an association results in the physician seeing from one-third to one-half more patients and in having at least one-third more time than they formerly had. The concept of the pediatric nurse practitioner has been endorsed by the American Academy of Pediatrics and the American Nursing Association. A nationwide project financed by the Federal Government to train adequate numbers of pediatric nurse practitioners would represent a feasible, in- expensive, and rapid method of meeting a significant portion of the need for health care for children. The cost of such a project would be only a fraction of the cost of training physicians to give the same quantity of child health care. CHILD HEALTH ASSOCIATE The second program for allied health professionals that I developed at the University of Colorado is concerned with the training and preparation 2388 df= of an entirely new category of health worker, the child health associate, who has greater capability and growth potential to provide health care to children than any other allied health professional now serving the public. Students in this program complete a three-year curriculum at our medical center after two or more years of college preparation for a total course of study of five years after high school. This is in contrast to the eleven years that it takes to prepare a pediatrician and the nine years for a gen- eral practitioner. Child health associates have problem-solving and decision-making capabilities similar to physicians. However, they spend even more time in the areas of diagnostic pediatrics, preventive pediatrics, in well-child care and supervision, and in the care of the child with minor illness than is usually spent not only by medical students but also by members of pediatric housestaffs in most pediatric internships and residencies. Child health associates concern themselves with the broad generalized problems of child care which occupy much of the time of ped- iatricians in private practice -- respiratory ailments, minor injuries, communicable diseases of various types, minor gastrointestinal disturbances, allergy problems, mild disorders of the skin, infections of various types, as well as well-child care and family counseling in many forms. They are qualified and will be certified under a specific law in our State to give almost total diagnostic, preventive, and therapeutic care and services (including the writing of prescriptions for non-narcotic drugs) to approx- imately 80 percent of all children seen in a typical pediatric practice. The child health associate program is a new and innovative attempt to cope with our increasing manpower shortage. It is the first program of its kind anywhere in the United States, and represents a major modification 2389 5% of medical practice since it allows a non-physician to provide total primary care to a patient. The child health associate program could serve as the model for a major revision in medical education and in the system whereby health care is provided; the child health associate and similar health workers in other branches of medicine have the potential of becoming the major purveyors of primary health care. SCHOOL NURSE PRACTITIONER The third program we developed, the school nurse practitioner program, prepares the school nurse for an expanded role in providing more and better health care in the school setting. The school nurse practitioner program aims to rectify a major loss in the present health-care system: the failure to utilize fully the skills and services of the 16,000 school nurses in the United States. School nurse practitioners assume basic responsibility for identifying and managing many of the health problems of children. They perform routine health assessments; participate in providing comprehensive well-child care; evaluate and assist in managing children who report with complaints of illness; assess and coordinate the evaluation of perceptual problems and those producing learning disorders, psycho-educational problems, and behavior problems; counsel with parents; visit classrooms, and make home visits. Effective utilization of well trained school nurse practi- tioners in a school setting ensures greater continuity of care and ushers more children into the general health-care system with the result that the school becomes the place where an increased proportion of the health care of children is given. At present, school children receive most of their health care either in the offices of physicians in private practice and in various public 2390 health facilities (neighborhood health centers, hospital outpatient depart- ments, well-child conferences, etc.). Unfortunately, many school-aged children fail to be brought to either place for continuing comprehensive care or for the meaningful prevention or correction of physical, emotional, and learning problems. As a result, many children with perceptual diffi- culties, low-grade chronic health problems, or other conditions affecting their ability to learn may go undetected for long periods of time. We propose that additional health care be provided in the schools where children between the ages of five and 18 are regularly and readily accessible where meaningful evaluative and preventive services could be provided by - well-trained health professionals, where a complete picture of an individual child's problem could be ascertained, and where ongoing care could be pro- vided by well-trained health professionals, where a complete picture of an individual child's problem could be ascertained, and where ongoing care could be provided and therapeutic measures carried out. Our program is already serving as the model for similar programs else- where in the United States. SUMMARY The crisis in providing health care for an enlarging population of children can only be met by the effective utilization of ''allied'' health professionals. The three programs developed by the author to prepare pediatric nurse practitioners, child health associates, and school nurse practitioners have the potential of producing markedly increased and improved health care to children. 2391 Senator Kexnepy. The hearing stands in recess. (Whereupon at 4:15 p.m., the hearing was closed.) © Re TT OT Tr RE ET zr, wo TR ar ere Ee rR HEALTH CARE CRISIS IN AMERICA, 1971 HEARINGS BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE UNITED STATES SENATE NINETY-SECOND CONGRESS FIRST SESSION ON EXAMINATION OF THE HEALTH CARE CRISIS IN AMERICA MAY 17, 1971 SAN FRANCISCO, CALIF. MAY 18, 1971 LOS ANGELES, CALIF. PART 11 Printed for the use of the Committee on Labor and Public Welfare &3 HEALTH CARE CRISIS IN AMERICA, 1971 HEARINGS BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE UNITED STATES SENATE NINETY-SECOND CONGRESS FIRST SESSION ON EXAMINATION OF THE HEALTH CARE CRISIS IN AMERICA MAY 17, 1971 SAN FRANCISCO, CALIF. MAY 18, 1971 LOS ANGELES, CALIF. PART 11 Printed for the use of the Committee on Labor and Public Welfare & U.S. GOVERNMENT PRINTING OFFICE 59-661 O WASHINGTON : 1971 COMMITTEE ON LABOR AND PUBLIC WELFARE HARRISON A. WILLIAMS, Jr., New Jersey, Chairman JENNINGS RANDOLPH, West Virginia CLAIBORNE PELL, Rhode Island EDWARD M. KENNEDY, Massachusetts GAYLORD NELSON, Wisconsin WALTER F. MONDALE, Minnesota THOMAS F. EAGLETON, Missouri ALAN CRANSTON, California HAROLD E. HUGHES, Iowa ADLAI E. STEVENSON III, Illinois JACOB K. JAVITS, New York WINSTON PROUTY, Vermont PETER H. DOMINICK, Colorado RICHARD S. SCHWEICKER, Pennsylvania BOB PACKWOOD, Oregon ROBERT TAFT, Jr., Ohio J. GLENN BEALL, Jgr., Maryland SEWART E. McCLURB, Staff Director ROBERT E. NAGLE, General Counsel Roy H. MILLENSON, Minority Staff Director EUGENE MITTELMAN, Minority Counsel SUBCOMMITTEE ON HEALTH EDWARD M. KENNEDY, Massachusetts, Chairman HARRISON A. WILLIAMS, Jr., New Jersey PETER H. DOMINICK, Colorado GAYLORD NELSON, Wisconsin THOMAS F. EAGLETON, Missouri ALAN CRANSTON, California HAROLD E. HUGHES, Towa CLAIBORNE PELL, Rhode Island WALTER F. MONDALE, Minnesota JACOB K. JAVITS, New York WINSTON PROUTY, Vermont RICHARD 8S. SCHWEIKER, Pennsylvania BOB PACKWOOD, Oregon J. GLENN BEALL, Jr., Maryland LEROY G. GOLDMAN, Professional Staff Member Jay B. CUTLER, Minority Counsel (II) CONTENTS CHRONOLOGICAL LIST OF WITNESSES MonpAY, MAY 17, 1971 SAN FRANCISCO, CALIF. Page Sklar, Mrs. Rita, housewife, expatient, Kaiser Hospital, Oakland, Calif___ 2394 Blackwell, Richard, police officer, San Francisco, Calif_________________ 2398 Henderson, Mrs. Ruthie, cardiac patient, Oakland, Calif________________ 2400 Schermerhorn, David, social worker for Hunter's Point Bayview Com- munity Health Services __ 2402 Petrich, Mrs. Alexandra, TeSIAen. cov mcime mmm ———————————————————— 2403 Ichiyvasu, Mrs. SHIzZakl, TeSIARNL. co oc ms smn msm mem swim it om me im smn i me 2405 Espinosa. Joaquin, retired electronics technician _____________________ 2410 Fenlon, Roberta, M.D., San Francisco. _________ oo __ 2412 Gibson, Count D., Jr., M.D., chairman, Department of Preventive Medicine, SS EANLOLA, CANE ec csi om ss sm sms im ts msm i ots it sw sr os pa om eo 2435 O’Brien, Msgr. Timothy, director of Catholic Charities, Archdiocese of San FLaltIS00 cu ccnmsnmmmnssm msm me sme es Ss sim wi wma wear 2438 Lannon, Miss Cecilia, legal aide, Marin County, Calif ___________________ 2448 Steele, Percy, chairman, Board of Directors, Westside Community Center 2450 Offhouse, Miss Charlotte, nurse specialist in comprehensive care of stroke DAE TOYIS cinco osm rota se i a we a i A ER Ee 2450 TueEspAY, MAY 18, 1971 LOS ANGELES, CALIF. Los Angeles County-USC Medical Center OL OT, BI IDIUCL,, J OTTO co co imines css imei i i oi me m rs m 2557 Sternberg, Harry, resident of Los Angeles_____________________________ 2560 Moore, Mrs. Birdell, Multipurpose Health Service, Watts, Los Angeles____ 2564 Gentz, Dale, member, administrative staff of a teaching hospital in SOULHOND | CAlILOTNIN im mim simi imi mmm miss wm ais oi mm io ams rm i ie 2565 Rodarte, Mrs. Aurora, resident ________ 2569 Chavez, Fernando, resident __ ee. 2570 NANCE: MIS, BVH, LORIN. oom mi oie mii on iim oo me ie i ic ire 2572 Eekerson, Mrs. Shelene, BoslleIE co ie im mimi mimesis is im wii ios immion 2576 Mohn, Einar, Brotherhood of Teamsters... 2577 Piercy, William, of the International Longshoremen & Warehousemen’s UNION, TOS ANOLON, CIE... sims so sion im rac mmr 0 i lo 35 i 2579 Arywitz, Sigmund, executive secretary-treasurer of the Los Angeles County FRACTION OF LADOE, ATPL CT. mm orion mim mm mmr mo mes ese om 8 rm emt 2581 Schrade, Paul, United Auto Workers Union, Los Angeles, Calif__________ 2588 Gerber, Alex, M.ID., 108 ANZRIOR... cui om minions mim se io ms os ime fi me 2590 Martinez, Gerardo, of San Fernando Valley, Calif ______________________ 2593 Green, Bex, BLD, Y08 AMBION. «comm mmm iii is me iis rm 2594 W008, MIKE, LeIONIL Junie mammm mmm smi = mr ie is oes ee ee 2596 Iv UCLA Medical Center McKinney, Vermont, director of the TBA program in Venice and the Page Venice Health COMBE... commis sms mlm wm mim mn 2600 Busch, Mrs. Lynn, administrator of the Venice Health Council ___________ 2601 Harris, Jeff, fourth-year medical student from UCLA_________________ 2602 Comacho, Andy, East Los Angeles Health Center—_____________________ 2602 Fields, Miss Anastasia, Southeast Community Health Counecil_______ 2603, 2607 Ferguson, Randy, community organizer, last Los Angeles Health Task TOOL. cc cps Sm mr me er sc me a 5 i St imi 2604 Guzman, Mrs. Carmen, of the East Los Angeles Health Center__________ 2605 Tamskae, Miss Olga, dental patient and medical technologist__________ 2605 Fedousky, Stephen, fourth-year medical student, UCLA_________________ 2607 Spellman, Mitchell, M.D., dean of the Drew Postgraduate Medical School 2613 Tranquada, Robert, M.D., associate dean of the USC Medical School_____ 2613 STATEMENTS Arywitz, Sigmund, executive secretary-treasurer of the Los Angeles County Federation of Labor, AFI-CIO_____________________________ 2581 PrEDOATCA SEALOINBIIE ci crm mismo mom smi oi oi SE WR em Se 2582 Blackwell, Richard, police officer, San Francisco, Calif_________________ 2398 Busch, Mrs. Lynn, administrator of the Venice Health Council ____________ 2601 California Blue Shield, prepared statement with enclosures________ Co 2482 California Hospital Association, prepared statement____________________ 2440 California Medical Association, prepared statement____________________ 2420 Chavez, Fernando, resident ____________________________________________ 2570 Comacho, Andy, East Los Angeles Health Center________________________ 2602 Cotton, Sumner, attorney. _ ee 2557 Dudley, Mrs. Juanita C., assistant regional director, National Urban League, Inc., western office, prepared statement______________________ 2624 Eekerson, Mra: Shelene, TaSIABNL. ..q-wenmmmmm mmm es wR Em 2576 Espinosa, Joaquin, retired electronics technician_________________________ 2410 Fedousky, Stephen, fourth-year medical student________________________ 2607 Fenlon, Roberta, M.D., San Francisco. _________________________________ 2412 Ferguson, Randy, community organizer, East Los Angeles Health Task TNOROB mnie mcm hm Sent aap ge emp ri 2604 Fields, Miss Anastasia, Southeast Community Health Council ._______ 2603, 2607 Gentz, Dale, Member, administrative staff of a teaching hospital in South- CITY SC TTL OTANI ci ison ooo i imo ER ER BT SS 2565 Gerber, Alex, M.D., Los Angeles______________________________________ 2590 Gibson, Count D., Jr., M.D. chairman, Department of Preventive Medicine, Stanford, Calif___ mem 2435 Oreen, ROX, WID., L008 ANG CLES... cn ce me mses sm sess onstage Sion 2594 Guzman, Mrs. Carmen, of the East Los Angeles Health Center__________ 2605 Harris, Jeff, fourth-year medical student from UCLA____________________ 2602 Henderson, Mrs. Ruthie, cardiac patient, Oakland, Calif ..______________ 2400 Ichiyasu, Mrs. Shizuki, resident_______________________________________ 2405 Lannon, Miss Cecilia, legal aide, Marin County, Calif___________________ 2448 McCaughan, James §S., Jr., M.D., Central Ohio Medical Clinic, Columbus, OhI0, DreDATEl BUAICINCII . cm oemsimiomin mom mom simi mad So Se mi i 2628 McKinney, Vermont, director of the TBA program in Venice and the Vinice Health Council ____________________________________________ 2600 Mapes, Mrs. Eva, resident _________________________________ 2572 Martinez, Gerardo, of San Fernando Valley, Calif __.__________________ 2593 Mohn, Einar, Brotherhood of Teamsters______________________________ 2577 Moore, Mrs. Birdell, Multipurpose Health Service, Watts, Los Angeles__ 2564 O’Brien, Msgr. Timothy, director of Catholic Charities, Archdiocese of SEITE. IT TEIN CTEICD 0n50n se n i is e BE SE E 2 2438 Offhouse, Miss Charlotte, nurse specialist in comprehensive care of stroke DABTCREE oc ioe rms miming ios 5euins mi a 357 ARES kt i mob 2450 Prepared statement with enclosure _______________________________ 2452 Petrich, Mrs. Alexandra; reSident. co cocursnnmnahemspsnsess mim mee me 2403 Piercy, William, of the International Longshoremen and Warehousemen’s Union, Los Angeles, Calif___________________________________________ 2579 Rodarte, Mrs. Aurora, resident pr Schermerhorn, David, social worker for Hunter's Point Bayview Com- TOUNILY JHEAILN Sol W COS «ccc cmt mae ion oi i ri i i Schrade, Paul, United Auto Workers Union, Los Angeles, Calif________ Sklar, Mrs. Rita, housewife, expatient of Kaiser Hospital, Oakland, Spellman, Mitchell, M.D., dean of the Drew Postgraduate Medical School__ Steele, Percy, Chairman, Board of Directors, Westside Community Center Sternberg, Harry, resident of Los Angeles ___________________________ Tamskae, Miss Olga, dental patient and medical technologist _________ Tranquada, Robert, M.D., associate dean of the USC Medical School____ Wood, Mike, LeSIAonl. coc ani ns ammmmimimmt Sm on ia mish mmm mim ADDITIONAL INFORMATION Articles, publications, etc. : “Prevalent Problems Encountered in the American Free Indian Clinic,” by Lois Boylen, M.D., assistant professor of medicine, Uni- versity of California-______________________________ “The True Crisis,” by James S. McCaughan, Jr., M.D., Central Ohio Medical Clinie, Columbus, Ohio ___________________ Communications to— Caper, Philip, M.D., Subcommittee on Health, Committee on Labor and Public Welfare, U.S. Senate, Washington, D.C., from Jason I. Green, M.D., Beverly Hills, Calif.,, August 24, 1971______________ Kennedy, Hon. Edward M., a U.S. Senator from the State of Massa- chusetts, from Cecil R. Nipps, Orange, Calif.,, May 21, 1971 (with CTICTOBUITE Ye ce mm om mit ts 5 Sl i Page 2569 2402 2588 2394 2613 2450 2560 2605 2613 2596 2614 2628 HEALTH CARE CRISIS IN AMERICA, 1971 MONDAY, MAY 17, 1971 U.S. SENATE, SUBCOMMITTEE ON HEALTH OF THE CoMMITTEE ON LABOR AND PuBLic WELFARE, San Francisco, Calif. The Subcommittee on Health met at 9:15 a.m. in the University of California Medical Center, San Francisco, Calif., Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present : Senator Kennedy. Committee staff members present: LeRoy G. Goldman, professional staff member to the subcommittee ; Jay B. Cutler, minority counsel to the subcommittee. Senator Ken~Nepy. The subcommittee will come to order. I, first of all, want to express my very sincere appreciation to Mr. Phil Lee, who I have had an opportunity to know for a number of years and whom now serves with great distinction in his position, for the help and cooperation that he has provided to us in making this facility available to us. For a period of the last 3 months the Senate Subcommittee on Health has been having hearings. The first 8 weeks took place in the U.S. Senate in Washington. We listened to the experts, the spokesmen for the industry, the insurance industry. We listened to the American Medical Society. We listened to the Hospital Association. And now, during the period of the last 3 to 4 weeks the Senate Subcommittee on Health has traveled to New York City, to see the health crisis in that area. The next day we went to Nassau and West- chester Counties which are very affluent, to consider the quality of health care. We traveled to West Virginia, which is our second most rural State in the country, to see the health crisis as it is portrayed in a rural community. And later we traveled into Cleveland and Chicago; in the Midwest TIowa—again to try to get some feel for the health needs in rural owa. Today, we are here ; and tomorrow in Los Angeles. I think, of all the testimony that we have taken, none of it portrays the health crisis any better than some of the witnesses that we will hear from this morning, and other consumer witnesses that we have heard from in different parts of our country. I think they tell the story in dramatic detail, and in many instances in tragic terms to the prob- lems that we are facing here in this country. So, we will go ahead with the consumers; and after we have heard from some of the consumers we will hear from three professional per- (2393) 2394 sonnel, and then by the time that is available, we will open up this hearing for comments from the floor. We never have as much time as we like; and usually we have to keep the comments down to a couple of minutes depending on how many people we have. We will do the best we can. Anyone who does not testify who wants to make a comment, write to us and we will include your comments as part of this record. These charts, here, reflect in some ways the shortages that we have in terms of health manpower; also, in terms of health status, and, also, the various criteria which are identified in that column. This chart over here shows inflation on health costs, generally; and although S. 3, my national health insurance bill, is not before this sub- committee, it summarizes very briefly some features of the national health security crisis. This chart indicates where we are going, in terms of future costs under the present system and under the Health Security Act. And then, finally, this chart over here is of some significance because it shows how the money is being spent at the present time. Thus you see, by next year, we will be spending a hundred billion dollars for the quest of health—and what we will be spending on national de- fense—under the administration’s program, will be a hundred billion dollars. Under S. 3, the cost of the Health Security Act is $68 billion; the administration suggests it is $77 billion. I think our figures are more relevant to the cost, that is, $68 billion. We are finding we will be spending approximately the same amount of money whether we go by the present administration amount—and really the question is whether we are going to attempt to reform the system and try to provide some significant reform within it, or wheth- er we are going to build on the present system and move to the admin- istration program which relies heavily on the insurance mechanism. In any event, we will hear from our consumer witnesses and then from the professionals—and then open it up for any comments from the floor. We have until 11:30—and I hope we can have at least 15 minutes for comments from the floor. I will ask Rita Sklar to proceed. I welcome you. We are very appre- ciative for your comments, since it is a part of our tradition not to really share our tragedies or personal experiences in public, or even with a Senate Subcommittee on Health—and so it is always a great service that individuals provide. I think a part of the reason that we have the health crisis is that we have people, particularly consumers, who are reticent to ex- press themselves about the system itself. So, we are very appreciative of those who have come here to make comments on their experiences. Please proceed. STATEMENT OF MRS. RITA SKLAR, HOUSEWIFE, EXPATIENT AT KAISER HOSPITAL, OAKLAND, CALIF. Mrs. SKLAR. I am here to talk this morning about my experience at Kaiser Hospital, in Oakland. My first appointment at Kaiser was November 13, T had just had a baby. I was 7 weeks post partum; I was nursing the baby and I wanted to continue nursing the baby. 2395 When I found out I couldn’t take birth control pills because of a change in the hormones and a limit to the amount of milk that I would have, I decided that I would try to get an IUD—intrauterine device. I called Kaiser and they told me there was only one doctor who would insert an IUD, and that would be in 2 weeks’ time. I called them back, because I wanted to find out why this was so, and I wanted to speak to a doctor—which is hard to do. When you call up, you always get a receptionist. So, I got a doctor on the phone. He said that was nonsense and he would take me that afternoon, but, of course, he didn’t make appointments and he told me to call the appointment desk. So, I called the appointment desk and they wouldn't believe he wanted me to come in in the afternoon. So, it took a number of other phone calls and different processes like that to finally convince that attendant he did want me to come in that afternoon. So, in the afternoon of November 13 I went to Kaiser for the first time, and in the course of examining me, prior to putting in the IUD, the doctor put a hole through my uterus by mistake. I was immediately hospitalized and spent the night in the hospital and I was released the next morning. I was hospitalized because they were afraid I would bleed and that I would have to undergo surgery ; in fact, that didn’t happen—so I was released the next morning. But a week later, I began to have pain, and the pain began to increase; I began to have diarrhea and vomiting and I finally went to the emer- gency clinic. The first doctor 1 saw asked me a lot of questions and I told him the whole story; and he pressed my stomach, which by this time was very hard and distended and very tender—and he gave me a rectal examina- tion. And at this point, he left. He was off duty and he left with all this information. And the next doctor that came in asked me all the same questions, pressed my stomach—the routine went on and on—and then they called in a gynecologist who asked the same type questions. He gave me a pelvic examination. He called in someone from surgery, who came in and asked the same questions, and he insisted on giving me another rectal eximination which I just had a half hour before. And the only person there who had any kind of a human response to me and my husband, as people, was a young intern who happened to be on emergency that night, and who walked in just to talk to us. Of all the people I saw that night he was the only one who was in any way personable and human and was concerned about how I was feeling ang about the whole situation. I spent a week in the hospital at that ime. I want to point out the irony of the situation, because originally I wanted to get an TUD because I wanted to continue nursing my baby and here I was in the hospital, unable to nurse the baby and separated from him, and always worrying about whether the milk would stop, whether the baby would get used to the bottle. So, after I spent a week in the hospital I was put on antibiotics for a week and then as soon as I got off the antibiotics the pain came back and I had to go back to emergency and then I was seen by the chief gynecologist who did a very painful pelvic examination. And I real- ized, at that point, that he did not know what it felt like to have a pel- 2396 vic examination ; he had no idea; he would never know what that was like. And immediately after he examined me, he had an intern examine me for his own practice. Senator KExNEpY. You had been examined how many times? Mrs. SKLAR. I haven't counted them. IE After awhile—there is another whole element to this, which is that all the while that IT was in the hospital I was in the gynecology ward, but they kept saying to me, “Maybe it was appendicitis”—not wanting to accept responsibility for the fact they had caused my illness and al- ways trying to think of something else I might have that they wouldn’t be responsible for. L When I went back to emergency the second time and saw the chief gynecologist, he said to me that he realized that it was a part of the infection that was caused from the punctured uterus and he told me to go home and wait and it would go away. Time would make it go away—and that is what I did; until around the middle of January when I had an attack of pain in the night. I didn’t want to go back to Kaiser but when it wouldn't go away—I kept taking pain pills—so finally we went in and we saw a gynecologist and he said that he just didn’t believe that it had anything to do with gynecology and he told me to go to medical, which 1s across the street, and a whole different department. o the next day I went to medical and this doctor I saw said he couldn’t believe that it was such a thing, a coincidence, that I would have something else wrong, like a gall bladder or ulcer, and I should go back to gynecology. So, I walked back across the street and I went to see the head of the gynecology clinic and this man wanted to ex- amine me and I explained I had just been examined a few hours earlier by one of the doctors, who suggested I go to medical and I saw no reason to do that again. He insisted he examine me and he found nothing, and he said I should go back to medical. This was the first time that the doctors had ever gotten together and discussed my case and decided on a course of direction. I went back to medical and he told me I should go to the X-ray department and get a barium X-ray; so, I went across the street again to the X-ray department and they told me I would have to wait a month. IT put my name down, and in fact in a month I did take an X-ray which turned out to be negative—which I knew it was. At that point, I gave up on Kaiser, and I haven’t been back since— and TI just decided to get well on my own, because every time I went it was just such an upsetting experience. So I want to say, also; when I had this interview with the head of the gynecology clinic he said to me, “I can’t understand why you have so much trouble. We do this once a week. We perforate a uterus once a week” T think that borders on malpractice; and it sounds incredible. Well, IT would like to share with you some of the conclusions I have come to, from this experience. One is that I feel that health care is a right that every American has and a right that we have already paid for. Consider if 70 cents out of every tax dollar that we pay to the Government were spent on health care and related services to the people, were spent on maintain- ing life instead of destroying life, as it was—70 cents in every dollar 2397 that goes to defense in this country—and 70 cents in every dollar—the whole world would benefit from it. I think this is important. I think that this should be part of your legislation. I think, from this experience, that women are no longer going to take the fact that gynecology, which specializes in the female medi- cine, is controlled by men. Men, as I said before, cannot feel what it is like to have a pelvic examination, to have an TUD, or an abortion, or to give birth. And I also feel—if you haven't already done so—you should try to visit Berkeley Free Clinic—because there in the clinic they try to educate you about your own body, they try to tell you how it functions, they try to demystify medicine. fy time I went to Kaiser, the doctor was writing out a prescription and I said, “What are you writing?” He patted me on the head and tweaked me on the cheek—something that is good for me. This is really absurd. This is really terrible that doctors have—that medicine has an aura of mystification. I think this is something that also should go into the legislation— that any kind of medical center should have an educational facility, where people can learn about medicine and their own bodies. I also feel—and this is very important—that any kind of a health program must service the people. The problem with Kaiser is that it doesn’t service people; its pur- pose is to make money. And if you visit the Berkeley Free Clinic, which is set up to service the community, you can see there is no com- parison at all in the service that comes from it. I feel that the Government, instead of serving the interest of Kaiser and Blue Cross and the AMA—the Government must serve the peo- ple—and what else is Government for? Senator Kexxepy. Very truthful. I want to thank you very much for coming here this morning. I think you have provided some of the most eloquent testimony that I have heard in this committee about the problems with the health system—its impersonalization, its lack of continuity of care; the fact that the consumer doesn’t have any real kind of voice, and very little alternative. What are you supposed to do after you have been abused? What alternative do you really have? This is why it is so important—as you point out. Mrs. Skrar. There is no alternative at all. Senator KexNepy. And this is where you point out the consumer has to have it—and you mentioned the fact—Why should there be provided profit in the whole health industry? We don’t in terms of education, in primary and secondary schools, and even in higher education. Why should we provide it in terms of health, in this Nation, as well? I think this is important. _ I want to commend you on your statement. It says it all—and there is very little any of us can add. I want to thank you very much, for coming and sharing with us your experiences. Richard Blackwell. I appreciate your coming, Mr. Blackwell. Tell us your story. 2398 STATEMENT OF RICHARD BLACKWELL, POLICE OFFICER, SAN FRANCISCO, CALIF. Mr. BuackweLL. Well, my problem has not been with the medical staff, itself. As far as the medical staff, IT have had the best. My prob- lem has been with the hospital cost. In 1959 my second oldest son was born with a congenital heart de- fect. IT was in the service at the time. I went all over the country, try- Ing to get medical care and no doctors would touch him. No insurance company would touch him. Finally, I came to Dr. Shumway, at Stanford, who said if I could keep him alive for 2 years he would do surgery. By the time the 2 years was up I was $72,000 in debt, 80 percent of that was hospital cost; not due to the doctor’s fee. I worked for years paying off the debt and I finally had to avail myself of the Federal Bankruptcy Act, chapter 13, which is a wage earner’s assistance, to get the hospital off of my back. They were bugging me at home, writing me letters at my work; and that was finally the only way I could pay them and keep them from bugging me. And then October 10, I had another tragedy in the family. My youngest son, 9, was accidentally shot in the head and he was in the hospital from October 10 until the week before Easter. My insurance has now paid $38,000. I paid an additional $7,000. I have forty more thousand dollars to go. Senator KENNEDY. You are going to try to pay that? Mr. BrackweLL. I will have to pay that ; IT have no choice. Senator Kexxepy. How long do you think this will take you? Mr. BrackwerL. I paid for 10 years on my other child and I will probably pay 10 years on this. The hosital is only interested in the dollar. The medical care I think is the best. As far as the medical staff, I have no complaint about them. It is the ridiculous fees that the hospital charges that is bother- ing me. My son was in the pediatrics ward, after he was taken out of the intensive-care unit, after two and a half months in the pediatrics ward, in a room with four other boys—it cost $98 a day. Senator Kexxepy. Did you have insurance during this time? Mr. BrackweLL. My insurance paid $38,000 of it, and they wouldn’t pay any more. enator KexNepy. What do you mean “They wouldn't pay any more” ? Mr. BrackweLL. That is the maximum they pay you under the policy. I have New York Life. Senator Kexnepy. After it reaches some point, they cut you off and you are on your own. Mr. BLACKWELL. Yes, sir. ; Senator Krx~epy. Have you tried to get any more insurance? Mr. BrackwerLL. Yes, sir; no insurance company will take me. 1 went to welfare and they just laughed at me. They said, “You don’t rate it.” I haven’t been able to get help of any type. I have applied to the State ; the State has turned me down. Senator Kex~epY. You are working; they turned you down. 2399 . Mr. BLACKWELL. Yes, sir. And my son has three more surgeries fac- ing him. Senator Kex~epy. Does your wife work, too ? Mr. Brackwerr. She has to, to pay for the first operation of my other son. Her salary goes to the court each month, We don’t see it. We survive on my salary. Senator KenNepy. You pay part of that, too? Mr. Brackwerr. That supports my three children, my wife, my- self—and my daughter needs epileptic medications. I have been advised to file bankruptcy, but I don’t want to file bank- ruptcy. I would rather pay the people. I have been paying them. Tt is a ridiculous cost they charge. I think something should be done to put some kind of a reasonable control on a hospital, for a workingman. Senator KennNepy. You have not only experienced that kind of per- sonal hardship—with sick children, an epileptic daughter, an accident to your son; so that you have endured those considerable personal sac- rifices and hardships and unhappiness. But, beyond that, the health system worked toward putting you right up against the wall in terms of finances. Mr. BrackwerL. Yes, sir. I have had my back against the wall for 10 years and will probably be there for another 10. I see no chance of seeing daylight and enjoying a reasonably comfortable life. Senator Kenney. Wouldn’t the easy way out be to go into bank- ruptey Mr. BrackwerL. Yes, sir; this would be the easy way. Senator Kex~NEDY. You want to pay your bills. Mr. BrackwerL. I dont’ want to take the easy way. People are en- titled to some money, but I don’t believe the amount they are request- ing. T am willing to pay a reasonable amount. Under the system I have no choice but to pay their fee. Senator Kenxepy. You have always paid off your obligations and debts. Mr. BrackweLL. Yes, sir. Senator Ken~NEpy. Your credit is good, too. Mr. BrackwerrL. I don’t believe in credit. T can get credit. Senator KENNEDY. You can’t get insurance. Mr. Buackwerr. My children are not insurable. Senator Kennepy. Don’t you think they should be? Mr. BrackwerL. Yes, sir; I think they should be. My 11-year-old son, who had open heart surgery—no insurance company will touch him because he has had heart disease. : And now my son, who is 10, cannot be insured for this accident be- cause the incident is a prior condition. They will cover anything after this, to a degree, but they will not, in any way, assist with his present injury. . Senator Kenxepy. Well, you have got 200 million people. Why shouldn’t we be able to spread the risk among the population, rather than have it borne by an individual, in terms of this kind of a hard- ship? Do you think that would make more sense ? Mr. Brackwerr. I think it would—if some control was put on these hospitals, to give some kind of relief ; not full relief, but a degree to the workingman, to a person who can’t afford this type of fee. 2400 Senator Kennepy. These are collection agencies that bother you. Mr. Brack weLL. They are collection agencies. Senator Kexnepy. They are one of the fastest growing businesses in the country, I understand. Mr. BrackweLL. Yes, sir. In this State, if you can’t pay a bill, re- gardless what it is for, a doctor, a dentist, it automatically goes to the collection agency. The collection agencies—they harass you, your em- ployer, they call you at all hours. The business office at Stanford Hospital calls me—and three times they have been cited in court for contempt, because under the act they are not supposed to contact me in any case. Senator Kex~epy. What kind of work do you do? Mr. BrackweLL. I am a police officer on the Peninsula. Senator Kexxepy. For how many years have you been a police officer ? Mr. BrackweLL. I have been with the police force 10 years—and I was an investigator, Marine CID, for the Marine Corps. Senator KENNEDY. And your wife? Mr. BrackwerLL. My wife is a lab technician. She makes $480 a month, Sem and the Federal court gets every penny to pay the hospital. Senator Kexnepy. Thank you very much. I appreciate it very much. Ruthie Henderson, we want to thank you very much for coming down. STATEMENT OF RUTHIE HENDERSON, CARDIAC PATIENT, OAKLAND, CALIF. Mrs. HenpersoN. I am Ruthie Henderson, from Oakland, Calif., from one of the worse ghettos. I am here to talk about the Medi-Cal cut. I am a cardiac patient. I suffer with obesity. I have hypertension and I am a diabetic. T live on less than $200 a month. I am raising a little granddaughter on $31.50 every 2 weeks. As a result of the cutback, I have suffered. I have a situation that is called fluid and I have to have Met-hydrine (phonetic) shots at least once a week ; and they have been sending a registered nurse to my home every Friday morning for me to take these shots. The Medi-Cal cut that out. I have to have a certain type of nerve pills—they cut that off. When a doctor wrote a prescription that I had to have this medicine, they sent it to Sacramento, to headquarters. They had to wait 1 month be- fore they had a hearing, and sent it back; so I could receive it. Every 90 days I have to send this paper back to Sacramento and have it okayed in order to get the type of medicine. I am partly blind. I need glasses and cannot get the type of glasses that I need. Medi-Cal will not pay for them. I have a little granddaughter who was hurt at the school site last year, and her eye muscles are turned this way. She has to go to Mt. Zion Hospital to have some surgery on both eyes the last week in June. 2401 Medi-Cal refused to give this kid the type of glasses she needs. I had to request Oakland for something called in-aid in order to receive the glasses and proper nerve medicine this little girl needs. They finally gave her the first glasses. Now she is up for another pair until the operation. She does not do good work in school because she cannot see very well. And the teachers and doctors have sent to Medi- Cal—have just sent the card that I might be able to use to get this operation. But she will be real sick after this operation. She will not be able to stay in the hospital more than 3 days, and I have been told Senator Kennepy. Why is that? Mrs. Hexperson. Because they don’t want you to stay in the hospital but a certain amount of days. They do not want her to go to the doctor over twice a month. Senator KenNepy. Who doesn’t ¢ Mrs. Hexperson. Medi-Cal—They will not pay for it, and—— Senator KexNeEpy. Who makes that decision ? Mrs. Henperson. They have the list and they pay only for certain drugs. The main drugs that you use they will not pay for, and some- time I have to end up buying those drugs like the eyedrops that she used to dilate her eyes before she go for these eyeglasses. I had to buy them because it dilates them when she gets to the doctor and he can take her in. : Another experience I have had—my baby girl is a cardiac patient, also; and she receives $130 a month. She cannot follow a strict diet because it will not pay rent and clothe her and her baby adequate; so she wanted to go to this doctor for a weight problem. He told her if she saw another doctor he would not be able to see her under these terms—and he didn’t see her last month because she was taken sick and she had to see a doctor and he wouldn’t see her because he sees her twice and you cannot be seen more than twice a month on your Medi-Cal card. Senator Kexnepy. That is a limitation; is that right? Mrs. Henperson. That is the limit. Senator Kexnepy. Even though you might be sick or in need of some additional attention, you are not entitled to more than two visits. Who makes that decision? Is that made by the doctor? Mrs. HENDERSON. It comes from Sacramento, from headquarters— I don’t know who makes that decision. Senator Kex~epy. How do they know whether you are sick and need it ? Mrs. HenpERsoN. I don’t know. Senator Kex~Nepy. They don’t know. Mrs. Henperson. They send a requisition and all your doctor can do is requisition for you and ask for these things and you don’t always get 1t. With this “fluid” problem I have also my leg I am supposed to buy ointment, and they tell me I can’t have this ointment because it is not in the Medi-Cal book—so I have to buy this ointment which is very expensive, to get my leg well in order for me to be able to walk. Senator Ken~epy. Is Medi-Cal helping people? Or trying to save money ? [Applause.] 2402 Mrs. HexpEersox. It is not helping you. It is harming you and a lot of people are suffering because they are poor and have to be on Medi-Cal. Senator Kex~Nepy. Thanks, very much. David Schermerhorn. David, we appreciate your being here. Do you want to tell us your story? STATEMENT OF DAVID SCHERMERHORN, SOCIAL WORKER FOR HUNTER’S POINT BAYVIEW COMMUNITY HEALTH SERVICES Mr. ScHERMERHORN. My story is not as dramatic as some of the others we have heard. I think it could get like that. I am a social worker for Hunter's Point Bayview Community Health Services, which is an HEW-funded project in San Francisco. : My salary is about $10,000 a year, of which I take some of that 10me. I am here to testify because I feel that even with what I had always thought would be a good salary for a person—I am married and have two small, adopted children. I thought, with $10,000 a year you ought to be able to live well, and I found I cannot afford good, comprehen- sive, preventive health care with my salary. We found out recently that my agency’s health insurance has a maximum of $100 a day for hospital charges—and after $100 a day, the patient is stuck with the rest of the cost. One of the staff members’ husbands in the office T work in was in the hospital for 3 days and came home with a personal bill for over $500. The insurance had paid $300 and the patient was left with about $280 to pay, after 3 days in the hospital. I used to have Kaiser coverage which T liked very much. I had a different kind of experience than the lady that testified before. And T found the Kaiser coverage that we got was very compre- hensive. That was when I worked for the Federal Government; but after IT quit working for the Federal Government—it was costing me about $450 a month—mnot a month, pardon me—a year, which is about 5 percent of my salary for the coverage which did not include prescriptions, laboratory tests, or any kind of dental work and T felt it was too expensive for me to carry by myself; so I dropped it. My two babies are nwo using public facilities for “well baby” care. They go to the city “well baby” clinics. When they get older, and are no longer eligible, then it will get much more expensive. One thing that has me kind of nervous is that my wife, a couple of weeks ago, had a Pap smear that came out positive—which is a dangerous kind of sign and it is quite possible that she will be having to undergo some serious kind of surgery in the near future. IT have the feeling that will be very expensive for me and, in fact, T may not be able to afford it. With the kind of insurance I have now, T don’t think it will cover it. We will have to find it out. At this time, we don’t know. Senator Kex~xeny. What kind of insurance do you have now ? Mr. ScierMERTORN. Tt is called Blue Shield. Senator Kex~epy. Do you have Blue Cross? Mr. SciErMERHORN. It is called Blue Shield. It is very poor. It covers outpatient service after you spend $100 per person per year. 2403 Senator Kennepy. You get a deductible. That is the famous de- ductible. Mr. ScuErMERHORN. Right. And the deductible is $100 per person; after which they pay 80 percent. Senator Kennepy. That is to make you cost conscious. Mr. ScHERMERHORN. I am very cost conscious. Senator KeNx~epy. I find all consumers are—that is why I always have difficulty in sort of understanding why that is such an important feature of the administration’s health program. Mr. ScuermERHORN. One of the reasons that I feel that I really cannot get good medical care is because of the nature of health cover- age, of health care that we have in the private sector which is a frag- mentary kind of thing, where we do not have family doctors anymore. Doctors are all specialized and they don’t keep track of each other in the private sector. This is one of the reasons I like group practice, because IT feel they are interested in keeping me and my family well, and there was also some guarantee of efficiency. I think that medical care is much more expensive than it ought to be because of the kind of fragmentation that exists. I think it could be much more efficient and much better than it is. Senator Ken~Nepy. Thanks very much, David. Our next witness is Alexandra Petrich. Mrs. Petrich. STATEMENT OF MRS. ALEXANDRA PETRICH, RESIDENT Mrs. Perrica. What I want to talk about, today, is the kind of health care that people who are not poor enough to be on welfare have. I don’t have insurance, for one reason or another. Three and a half years ago, when I was pregnant, we didn’t have any kind of insurance. We weren't eligible to go to Kaiser, or any place like that, and couldn’t afford the bill for the payment to a private doctor. So, I went to the outpatient clinic at Saint Mary’s Hospital, which is a very large clinic and has a very large turnover of patients. It is staffed and run, from what I have been able to tell, by interns and it is designed to serve as a learning place for interns. The women who were coming there to have their babies—they have all kinds of service; but I was just in the place for pregnant women. The women would all be given an appointment at 9 o’clock in the morning and if you were lucky and happened to get there early you might be able to see a doctor by 10:30—or sometimes you had to wait until 11:30, or so. After this you see the doctor for 5 minutes. I never saw the same doctor twice. IT think maybe once I saw the same person twice but it was always a different person and there was never any kind of an at- tempt made to treat anybody who is there like they were a person or like they deserved any kind of attention as being a person—it was just being a pregnant being, who had to get this baby delivered. One time, toward the end of my pregnancy, one of the interns, or doctors, examining me decided there was something slightly irregular about the position of the baby: and so he went out, without saying anything to me, and called in five or six other people, who all pro- ceeded to poke and stick their fingers in me. 59-661 O - 71 - pt, 11 - 2 2404 I was only 19 years old, and it was my first pregnancy. I sort of re- Sard the fact of a roomful of strange men just coming in and doing this. Another thing was that at no time was an effort made to explain to me the process of what was happening; and I always was reluctant to ask any questions because the attitude was sort of to get you in and get you out and don’t bother us with your questions. This made it hard. When women are pregnant they get kind of in- secure and nervous and I was not experienced and T just felt very un- easy about the whole thing. When 1 finally got to the hospital and had the baby the person who delivered it was somebody that I had seen once before. He, I believe, was a resident in obstetrics. The fact of the matter was he was not going to have to come in and see me in my room, a couple of days later. He wasn’t really my doctor. He was just delivering the baby. So, as a result—when he put the stitches in—1I don’t know what he did, but it was really pretty bad. I couldn’t move from the bed for 3 days. The other women were getting up a few hours later. Some of them went home—but I could hardly move. If T complained, they just kn of said, “Oh, yes” and mumbled something and handed me some pills. Senator Ken~Nepy. Did you talk with the other women down there, too? Did they share this sort of impersonalization feeling ? Mrs. Perricn. They seemed kind of—a lot of them, you could tell, were very poor and a lot of them had so many children and they seemed afraid and kind of reluctant to impose themselves on this big, you know, impersonal kind of system that obviously knew so much more than they did. Senator Kexxepy. Why do you think people are afraid ? Mrs. Perricn. 1 just got the feeling T wasn’t being told—because T was poor, I was dumb; therefore, I shouldn’t bother anybody—and I am not dumb. But that was the kind of impression that I was given. It was obvious that the people who were there were not interested in them and they were just there to serve as experience for these interns who were going to go out into private practice some day. It wasn’t exploitation for money. It was exploitation for other rea- sons, and there didn’t seem to be any kind of empathy on the part of the doctors toward the patients. I just thought it was kind of a bad way to have a baby, but T didn’t have any other choice, and my attitude was, “You are lucky to be here. You are lucky vou don’t have to have your baby in a hospital with a big ward full of 50 people.” Senator Kexxepy. Your husband works for the Post Office. Mrs. Petrie. Yes: he was making about $2.65 an hour, which isn’t enough. IT didn’t want to get a doctor bill of a thousand dollars—which it would cost, close to that, for a private doctor. Senator Kexxeny. Wouldn't he be covered with some program? Mrs. Perrier. T can’t remember why—he wasn’t covered, for some reason. There was some kind of reason; there was some problem and he wasn’t covered—but T am really not sure why. Senator Kexxepy. But, in any event, you went to the outpatient clinic. 2405 Mrs. Perrici. 1 went to the outpatient clinic. It was considered a very good one. It was referred to me by several people—and it just turned out to be a bad experience Senator Ken~Nepy. As 1 under: stand, a lot of insurance policies re- quire you to wait 10 months before they cover you for pregnancy. Mrs. Perrici. I am not sure. If the carrier does that, they are sure all these people are going to sign up as soon as they find they are preg- nant. It’s oriented to get Senator KExNEDpY. We were talking about cost consciousness, before. It seems the insurance companies are cost conscious. They make you wait 10 months, in many instances. Mrs. Prrricin. They are in it to make money. They are not a public service. Senator Kexxepy. Do you think they ought to make money on health ? Mrs. Perricir. I don’t; but Senator Kex~epy. That is an important opinion. Mrs. PerricH. Yes, sir; I guess so. Senator Kexxepy. You fave experienced the system—and you do have a strong opinion about some of its obvious defects. Thank you, very much. Mrs. Ichiyasu, we want to welcome you. Would you like to tell us your story. STATEMENT OF MRS. SHIZUKI ICHIYASU, RESIDENT Mrs. IcHIYASU. It was about 18 months ago—about 18 months ago my husband was injured on the job; and at the time he felt it wasn’t too serious since it didn’t incapacitate him, in any way. Senator KENNEDY. Where does your husband work ? Mrs. Icuivasu. Ata hardware store. Senator Kex~epy. For how many years? Mrs. Icuaiyasu. Since 1952. Senator Kennepy. Eighteen, nineteen years. Mrs. Iciivasu. Not taking the injury very serious, he just mentioned it to his employer ; but he continued working. Gradually the discomfort became worse and worse and finally he decided he had better be examined by a doctor. He was told that since it was an industrial accident that he must go to a doctor that was designated by the insurance company, and Senator KennNepy. They had an insurance program, a medical in- surance program for the hardware store where he worked ? Mrs. Icarvasu. Yes—for this type of liability. The inference was very strong if he did not go to the doctor they designated, he may end up assuming the full financial responsibility for any expenses that might be incurred—so he went to the insurance doctor, who diagnosed it as bilateral hernia. He had surgery. The doc- tor’s report stated a slight hernia on one side, no hernia on the other. But after a period of convalescence my husband felt increased dis- comfort of the back, the left leg. The doctor tried to tell him he had gout, at that point. Senator Kennepy. Which doctor is this? 2406 Mrs. Icuryasu. This is the insurance doctor. Senator Ken~epy. They told him he had gout. Mrs. Icuryasu. A series of uric tests indicated that he had gout and, therefore, this doctor said he would recommend a certain type of medical treatment, or medication, to correct this situation. Since it was not related to the injury, my husband felt at this time, if he did have gout, he would rather be treated by his own personal physician. We consulted our doctor, and he sent my husband for a series of uric acid tests. The results were completely in contradiction to what the insurance doctor had indicated, so my husband refused to con- tinue the treatment. So this insurance doctor said, at the end of De- cember, “So far as T am concerned, you are ready to go back to work.” Senator Kennepy. Do I understand when he went to the doctor that was recommended by the insurance company he diagnosed it as gout? Mrs. Icuaryvasu. Initially it was diagnosed as a bilateral hernia; and when the pain did not go away, he diagnosed it as gout. Senator Kex~Nepy. When the insurance doctor said it was gout, your husband thought it wouldn’t be covered, so he went over to his own doctor and he diagnosed it and said it wasn’t gout. Mrs. Icnrvasu. If it was related to his injury, it was covered: but the gout, which is a total medical Senator Kex~epy. How is your husband supposed to know—if one doctor says he has gout, and the other says he doesn’t have it, what is he supposed to do? Mrs. Icarvasu. He had his personal physician perform a health ex- amination periodically and he figures his own doctor knew more about it than a new doctor coming in out of the cold, treating him for an- other condition. And the lab report was done by another pathologist, not our own internist and, therefore, this is two doctors’ opinion actually contra- dicting the gout diagnosis. The pain persisted and with much negotiations with the insurance company, we finally got them to go along with the idea of having my husband examined by a back specialist who diagnosed it as some kind of muscle injury related to the back. He had physiotherapy for about 2 months, during which time the condition worsened and the doctor, at least, was honest to report that he was no longer able to help my husband and so he was referred back to the insurance company who, in turn, contacted a neurosurgeon. Senator KeNNepy. I am sorry to interrupt. Your husband has been told he has a hernia and gout and a muscle sprain by three different doctors: is that right ? Mrs. Icnryasu. No—the hernia and gout was one doctor. He has enough doctors without adding any more. Senator Kex~Nepy. Two doctors and three opinions. Mrs. Icmivasv. He was hospitalized, after various tests—electro- myelograms, and so forth. They determined it was disc damage. May 1 he had surgery done. Immediately after, they noticed that there was some infection which they weren't able to pinpoint to any other cause and the reports indicated that it possibly was related to the back surgery, although there was no visible signs of that as far as X-rays and tests were concerned. 2407 He was put in a body cast in which he remained for about 2 months. Most of the time he spent at home. Now, if you visualize the body cast from, say from the chest down to, almost to the knees—you realize that a man is not able to sit. For his meals, he would have to stand. In order to go to the hospital to have the cast removed and have further evaluation we had to purchase a car, in which he could recline in. " He had the cast removed, had other tests done, evaluations—and he was discharged, and from the late summer to December of 1970 he re- mained at home. We had a physical therapist come to the house for a couple of weeks. The treatment was very minimal and the results were absolutely nil, so he explained to the doctor that he didn’t think it was helping him any. In December, he was hospitalized, again, for further evaluation, and discharged. And from January through March he went to a physiotherapist twice a week. And from March, the insurance company indicated they had wanted him to go every day, but the doctor—this is the insurance doctor—said this was too much and suggested trying three times. Up through April 9 he was going thrice weekly. The following Monday, he was admitted to the hospital for psycho- therapy because they felt that possibly some of this was psychologically induced ; they said there was probably nothing physically wrong with him any more than due to the depression and things of that nature. And he was not getting along well; he didn’t get along with the medi- cines, and there was a fight for about 10 days after he was abruptly dis- charged. All medication was suddenly cut off—and out of desperation I consulted my own doctor who recommended we taper off the drugs. After 10 days at home, he developed bladder and lung congestion, I feel after two much drugs. By then he had lost about 40 pounds and he wasn’t eating: [Emotionally upset. ] Senator Kexxepy. Now, you just take your time, Mrs. Ichiyasu. Mrs. Icnrvasu. I consulted my own doctor and he said it sounded like a very serious medical condition, but he said it is all related to his original condition and the fact that he was not able to get well. So, he suggested I call the insurance doctor. And in turn, this doctor was very good about it and said, “Knowing your husband, I feel that you have more confidence if your own doctor were called in.” And at his recommendation the insurance company called in our own doctor who, in turn, called in a urologist—the urologist—and things of that nature. He was admitted Friday, April 30. He was extremely violent and they thought that he would have to be institutionalized. By midmorning, Saturday, he was comatose and they found a lung infection and things of that nature. So realizing it was a critical medi- cal condition brought on by all this, our doctor started the proper treatment and after 2 weeks of hospitalization he came home with the acute medical problems corrected. 2408 The urinary problems they found wrong—and the doctor’s opinion was that because of the drugs that he had lost control of his bladder so that he was not able to eliminate and being in the bed I imagine would create a lung congestion. He is home now and he is still in bed and the doctor was out yester- day and he said that we will see what transpires. So IT asked him to see if they could follow up on the neurologist’s report and get the insurance company to not wait so long and take some definite action so that they can get my husband on the mend for a change. A year and a half for a person who has been very active is quite an ordeal. And I have three growing boys and they have been very good, but T am afraid that it has some kind of a chain reaction to the whole family. Fortunately, through the union, over a number of years, the Retail Clerks Local 1100, T have been able to negotiate and get very com- prehensive coverage for a union member and their family and cur- rently I believe it covers your basic TAH, plus your medical, it covers about 90 percent of prescription drugs, it covers about 70 per- cent of dental, it covers corrective glasses, ophthalmologist’s fees, doctor’s office visits; it’s just a percentage, but still it helps. However, because my husband was off for a maximum period of 1 year, with total coverage, and 6 months with the coverage paying the premium, after 1 year it lapsed. To backtrack a little—about 7 years ago, one of our sons had lymphosarcoma surgery. We hope it was successful. He is very well, but the insurance companies would not risk covering him, except with the exclusion. Because of these various things, my husband is very conscious for the need of ample coverage for the family—insurance, some form of security. And so when “he was not able to go back to work he decided we had better find an alternative coverage. We have found some coverage that will be of some help if anything should happen to the family. My husband actually is not insurable, but if anything should happen to my husband, medically speaking, that is not related to the accident, it wquld wipe out our assets, what little assets we have. So far we have been able to manage, but I feel that insurance should be for those who really need it. Those who have preexisting conditions get eliminated from insur- ance coverage. This 1s a terrible mental strain on families and the reason people take out insurance is to alleviate that anxiety. National health plans—I really haven't been up on the various ideas by the different Congressmen, the ones that they have pre- sented or have been thinking about ; but you hear pros : and cons about various national health plans that have been incorporated in England or Japan—because I am more familiar with that. Possibly there are many advantages and disadvantages, but 1 feel a person has a right to this, and is entitled to this. T think good health care should be made available to all who need it. And like people before me have said—those who are wealthy prob- ably don’t have that anxiety. Those who have no means of income 2409 possibly have no recourse but to go to welfare and depend on the State for whatever they need. But those of us in the middle class, who would like to still pay their own way, if it could be made a reasonable rate and good coverage made available to them, I am sure they would all be much better off. Senator Kex~epy. Thank you, very much. Let me ask—you must have undergone great personal anxiety when you had these different diagnoses made of your husband’s illness, did you not, when you had one doctor tell you one thing and another doctor tell you another? Mrs. Iciiyasu. Yes. Senator Kexxepy. And even considering a third—muscle sprain. How is any consumer to know whether you are getting the right diagnosis? Mrs. Icmivasu. Well, this is why I feel that it is so important—mno matter what insurance, whether it is industrial insurance, or whether it is your own private form of insurance—that a person should have a choice of a doctor. Usually the doctor who has treated the family over a number of years can take into consideration all factors and better evaluate what the condition is; and if a person has a history of any kind of a related condition, then he may take that into consideration. Another thing—my husband has gone to many hospitals, and there are hospitals that have a very excellent staff and give excellent care. Yet you have those who absolutely lack compassion and they don’t seem to realize they are treating people who are there because they need understanding and care. And I imagine all too often the people who take up any profession or seek employment in any of these hos- pitals—to them it is just another source of income; it is not a profes- sion or a position that they take personal pride in, personal interest. But I do have to say, in all fairness to our own doctors, our family doctor, pediatrician, gynecologist—they all take into consideration the fact that my husband is not working right now and they have been more than good to us. And I hear too much criticism about doctors and nurses lacking this, but I don’t think that I am the exception—but we do have good, com- passionate, understanding doctors as far as our own family. Senator Kexxepy. Would you have to pick up and pay some of the expenses beyond those covered by insurance ? Mrs. Icarvasu. When the union obtained for us the limited cover- age—my three sons required some sort of treatment—and currently I have two still going to an orthodontist—but with the termination of the insurance that coverage stopped and it is up to us whether we would like to continue it on our own, or whether we would like to drop it at this point. But it does boil down to dollars and cents—and we do have to con- sider how much it might cost; so that we haven’t acted upon it as yet. But aside from the normal periodic physical examination for the rest of the members of the family, we have been quite fortunate. Senator Kex~epy. Is your husband covered by insurance at the pres- ent time ? Mrs. Icarvasu. Noj only for his back injury, or any condition re- lated to it. Senator Kex~Nepy. He can’t get any insurance. 2410 Mrs. Icarvasu. Through our Japanese-American Citizens League, which has an open period beginning each year, we took out group coverage. That is a family plan; but it is not as good as the one wit the Retail Clerks. Senator Kennzepy. He could become a member of that. Mrs. Icuivasu. Yes; we have been members all along and they have some certain waiting period—but it is not that long—10 months, pos- sibly—but it isn’t that long. It is just when my son becomes ill, or gets a stomach ache you often wonder “Goodness, a return of his previous condition.” But aside from that, we have been quite fortunate. I imagine there are those that are not quite as fortunate because their company doesn’t have a union providing this type of coverage for their members. I would like to see them make certain exceptions for persons who are in the category in which my husband finds himself, that they would make allowances and give us coverage, even if the family had to pay the total premium. enator KeNNEpy. Do you think your husband could get coverage now, if he wanted to? Mrs. Icaryasu. No, he is uninsurable and even if they did insure him, they would exclude his present condition and they would ex- clude many things and there would be an automatic waiting period. I am not saying that the insurance companies are wrong, but since there are people who do have past medical problems, those are the ones that need the insurance and the system should take that into account. Senator Kennepy. They are the ones that usually can’t get it. We will have one final consumer witness, and then we will have three professional witnesses, and then we will open it up to the floor. Mr. Espinosa. STATEMENT OF JOAQUIN ESPINOSA, RETIRED ELECTRONICS TECHNICIAN Mr. Espinosa. There isn’t much that I can say after all that was said already, but when you reach the age for medicare, you find that through the years the cost for medical aid has been exorbitant. There- fore, when you are not working, you are unable to pay. I have refused to pay for medicare. I have not contributed the $5.66 per month for the reason that I paid in the organization, in my union, maybe 40 years ago. With the Kaiser plan I paid for 22 years and as the rate increased I finally dropped out, hoping that medicare would solve my problem. Senator KENNEDY. You are a retired worker. Mr. Espinosa. I am a retired free lance electronics technician. Senator KenNepy. And you have retired under social security, is that right? Mr. Espinosa. That is correct. Senator KeNnepy. You get a little over a hundred dollars a month ? Mr. Espinosa. A little over—and because IT am unemployed T must depend upon my friends so that I continue to survive. And so I re- sorted to the tactic of organizing the Liberty Hill Defenders in my 2411 district, which is in the mission and now contains 40 percent unem- ployment. And acting with the Liberty Defenders I am in the capac- ity of a political adviser. Senator Kennepy. You are married ? Mr. Espinosa. That is correct. Senator Kennedy. And your wife is not eligible for medicare be- cause she is not old enough. Mr. Espinosa. Until she reaches 62 she is not eligible. Senator KeNn~Nepy. How is she now ? Mr. Espinosa. She is seriously ill. She has been passed from hos- pital to hospital and has had nine doctors; and finally we were con- vinced, between the two of us, that we will solve the problem ourselves, and consequently she is recuperating. And that is 16 years of illness. Senator KennNepy. She has had 16 years of illness? Mr. Espinosa. That is correct. ; Sunator Kexnepy. You had medical bills during that period of time ? Mr. Espinosa. That is correct. Senator KENNEDY. Did you try to pay some of these off Mr. Espinosa. I had to pay them off. Senator Kex~NEDY. Do you expect you will have other medical bills now? Mr. Espinosa. Well, I expect so, until we have completely free medi- cal assistance. Senator KenNepY. You get just a little over a hundred dollars a month ? Mr. Espinosa. I have a little work on the side. I act as an elec- tronics instructor and adviser. Senator Kenn~epy. From that you pay, obviously, your living expenses. Mr. Espinosa. With the ownership of my home, which is rent free, and with the help of relatives who pay the taxes, I can survive on around $200 a month. Senator KennNepy. But you can’t afford the medicare payment— is that right ? Mr. Espinosa. I refuse to pay them because I know too many people who are unhappy about medicare. ] Senator Ken~epy. Have you had any coverage by any insurance program ? Mr. Espinosa. I was covered by Kaiser Plan for 22 years. Senator Kennepy. Did that serve your needs ? Mr. Espinosa. Yes. Through the birth of three children, and as a consequence of the loss of the first one we decided the medical plan was an alternative. Senator Kexnepy. But after you retire you don’t get any cover- age on that? . Mr. Espinosa. I have no coverage now. I am solely on my wits at age 66. “Senator Kr~x~epy. You have paid in premiums on various programs for how long? Mr. Espinosa. Twenty-two years with the Kaiser Plan stopped about 2 years ago. which was 2412 Senator Kex~epy. Those premiums, I would expect, would keep going up. Mr. Espinosa. They have. Senator Kexnepy. You have stopped it ? ] Mr. Espinosa. They have—in anticipation of medicare taking care of any problem. Senator Kexxepy. Do you think other people will have to drop out if those rates keep going up? Mr. Espinosa. Undoubtedly they do. Senator Kex~epy. What do you think of that kind of a health system ? Mr. Espinosa. I think it is “lousy.” Senator Kex~epy. So do I. Thank you very much. Mr. Espinosa. Thank you, sir. Senator KXex~Nepy. Dr. Fenlon. Dr. Fenlon is president of the California Medical Association—and she is a private practitioner who has specialized in internal medicine in San Francisco for the past 26 years. She is a past president of the San Francisco Medical Society and currently is a clinical professor of medicine at the University of Cali- fornia in San Francisco, and an active staff member of Childrens and Franklin Hospitals here in the city. Welcome. STATEMENT OF ROBERTA FENLON, M.D., OF SAN FRANCISCO Dr. Fenvon. Mp. Chairman, my name is Dr. Roberta Fenlon. I am in the private practice of internal medicine in San Francisco. As president of the California Medical Association, I speak for an organi- zation representing 25,000 physicians. There are approximately 27,000 practicing physicians in our State. First, let me thank you for the opportunity of speaking about some of the health-care problems in California and some of the solutions we have developed. I might add that our experience in California should provide sound information for use on a national level. In many ways our State acts as a representative cross section of the country—in the types of economic levels of our population, urban and rural dis- Juin of our people, and the diverse geographical features of our tate. We realize that the amount of time available for this hearing is limited. Therefore, considering the amount of relevant material we feel must be presented, we are submitting more lengthy written testi- mony in addition to my comments today. We are not here to claim that our present health-care system is perfect. It contains significant deficiencies. Some people who cannot afford adequate care often go without it, because it simply isn’t as avail- able to them, or because they don’t know how to obtain it, or because they lack the education to use what is available. Government health programs promise full health care, but don’t budget enough to provide it. 2413 Furthermore, catastrophic illness can hit any income level. Even those with incomes well above poverty levels can be wiped out finan- cially by a prolonged family illness. In addition, certain people living in remote rural areas or in urban ghettos have no readily available access to the health-care system. But these factors do not constitute a health-care “crisis.” Rather, they represent deficiencies that must be eliminated. The inability of any American to get proper medical or health care, for whatever reason, is a totally unacceptable situation to all of us. But the largest measure of Americans today do receive excellent medical care as soon as they require it. [ Vocal audience reaction. | Senator KexNepy. We will have order. Dr. Fenvon. Therefore, we should not destroy the present health- care system, but rather extend it to those people it has previously bypassed. In addition, we firmly believe that deficiencies in health care can be eliminated effectively only through well-reasoned and proven mechanisms. What steps are physicians in California taking to insure high-qual- ity care on realistic cost? Our “peer review” program on behalf of Medi-Cal serves as a good example. Briefly stated, it includes: county medical society review of physi- cian claims, hospital and nursing home utilization review committees, a State association appeals review committee, survey teams composed of physicians who continuously review medical staffs in hospitals and nursing homes, and the many hospital committees required by the Joint Commission on the Accreditation of Hospitals and by CMA. One might truthfully say that a physician’s colleagues are contin- uously scrutinizing the professional activities of each individual doctor [ Vocal audience reaction. | Dr. FEnrLox (continuing). Both in regard to medicaid and to Medi- (Cal practice generally. Another CMA activity that should interest this subcommittee is our recently launched program in continuing medical education. It con- sists of “certification” for physicians participating in a minimum of 200 hours of continuing medical education in a 3-year period. It pro- vides specific mechanisms for accreditation of educational programs and acts both to improve educational quality and make it more effective as a means of improving patient care. California doctors are also working to make more and better health care available to all our citizens. I will give just a few examples. CMA runs a Physician Placement Service created specifically to place physicians in locations where medical services are needed. San Francisco Medical Society is working with OEO in bringing medical care programs to the “inner city.” Kern and Sacramento Medical Societies are operating mobile clinics for the treatment of rural migratory workers. Senator Kennepy. What sort of success have you had in the place- ment of physicians? ] Dr. Fenrown. I would like to finish my testimony before answering your question. 2414 Monterey has an innovative rural health project in King City using the health-team approach. _ CMA is working to increase medical school admissions from minor- ity groups, and we sponsor preceptorship programs at California’s eight medical schools. We are working, to make Medi-Cal care available. The CMA is also moving ahead with establishing the new occupa- tion of health care assistant—sometimes referred to as a “Physicians’ Assistant.” We are developing criteria for education, working on leg- islation for certification, providing means for recruitment, and sug- gesting the best possibilities for employment. This new breed of trained and licensed health-care professional, working under the su- pervision of a physician, will be able to handle much of the routine— freeing the physician for critical diagnoses and treatment. In this way, more patients can be served and health manpower shortages reduced. In another approach, we are working to increase the efficiency of the health-care team through better communication. CMA now maintains 19 advisory panels to different medical spe- cialties in order to bridge the inevitable communication gaps. In ad- dition, we are working with such differing groups as hospital admin- istrators, dentists, nursing home administrators, ambulance drivers, nurses—to name only a few. Perhaps the best way to demonstrate CMA’s general outlook regarding health and medical care is to tell you about my organization’s proposal for American health care. The CMA “universal-voluntary” plan would offer benefits to all families and individuals on a voluntary basis, with financial assistance geared to need. Benefits would include all areas of health care. In fact, our program would be so attractive that every economic level would participate because it sets guidelines for adequate health care coverage. To avoid the usual problems of unrealistic funding, the budget for the program would be updated biannually for all areas of the country on a basis allowing for inflation. Under CMA’s proposal, all plans or programs must furnish evidence of effective peer review activities. It also would provide for demonstration and experimental approaches to the organization and delivery of health care. Certainly one of the most significant aspects of CMA’s proposal is the fact that it is a comprehensive, long-range program. Today—I don’t need to remind this subcommittee—there are more than 100 Federal health programs for specialized sections of the popu- lation—Indian affairs, crippled children, OEO, medicare, medicaid, and so forth. Our program would immediately absorb the functions of most major Government health programs. On a longer range basis, it would ultimately incorporate the medical aspects of the Veterans’ Admin- istration and other Federal programs providing or financing medical services. In other words, it would create a single, coherent, integrated approach to health care. In conclusion, may TI impress upon this subcommittee that no one has a deeper concern about health care than the medical profession. As practicing physicians, we live with our patients’ health problems and illnesses every day of the week. 2415 We will continue our efforts to improve health care, our experi- mentation, our pilot projects. We firmly believe there is no single, simple solution to the widely varied health difficulties of the American Nation. We firmly believe that a pluralistic system is essential. We plan to continue our search for improved methods in the delivery and financing of health care—and we respectfully ask the support of this subcommittee. I wish to thank the subcommittee once again for the opportunity of presenting this testimony. Senator Kexxepy. 1 would like you to answer the question I asked about placement services. Dr. Fexrox. We have had a placement service for many years, and - many physicians have been placed in areas in which there has been a crying need, or we have placed him in an area vacated by some physi- cian who has left or passed away. Unfortunately, some of the areas in our State are not conducive for family life, and shall I say, raising of children—which is one of the problems that I think, we as a socially minded Nation, have to face. These are not primarily health problems, but these are social prob- lems which I think could be solved, with great help from everyone concerned. But it is not necessarily a problem in health, but we would like to see some of these problems solved. Senator Kenxnepy. I want to express our appreciation for your comments. Earlier today we listened to some of the consumers of health and health care. And in our visits around the country we found that these are not really extraordinary circumstances—I don’t think they are. They are really what we have heard today—the police official faces longtime financial obligations; the retired union member whose wife is ineligible for medicaid, she hasn’t reached the age; the young newly married w ife, who is having her first pregnancy; ; another who had a contact with the Kaiser program and was moved from place to place; another man who was given two or three diagnoses. In terms of their own kind of a problem—you can imagine the frustration and confusion. This is usually the quality—and this is usually the financial obligation. These are people we heard this mor ning who are the real main- stream of our society; and they are describing quite a different system from what you outline in your comments. And I suppose my question would be—Which is reality ? [ Audience applause. | Order. Dr. Fenton. Senator Kennedy, thank you. I think that I listened to all of this testimony this morning and it was most impressive and I think this is why the California Medical Association has been working on the plans that they have been work- ing my No. 1, it is most important that there be a personal health ap- proach to this problem—and I think you heard repeatedly from each one of these individuals, practically without exception, that the thing 2416 that they really want—and they went back to this—what they really wanted was their own personal physician. The clinic, the big clinic— and this impersonalization was one thing they did not like. I think, secondly, their trust was in their own personal physician and this is why we are trying to say that a pluralistic approach to this problem is a most important one. I am sure there are individuals in the world who are going to clinics who are happy with these clinics. And we see these people all the time in our clinics, here in the uni- versity and throughout the city, because they have felt a rapport and they had a contact, that they enjoyed this sort of relationship. But there are others totally unhappy. I think we listen—and if we had one system of health care in the United States it would not solve everyone's problem—it might solve some, but it could not solve everything. Senator KexNEpY. Suppose we had comments from those not get- ting to see physicians. We are getting complaints about impersonal- ization and the kind of situation with Mrs. Henderson, how her little granddaughter can’t see a physician. This is one thing about impersonalization—and I am sure you and I know prepaid, group practitioners which give personalized attention. But you are also getting complaints from those that arent even seeing a physician—and how the system works to discourage people from coming in and having any kind of contact. Dr. Fexvon. Senator Kennedy, I listened closely to Mrs. Hender- son. She has a medical problem. Senator KenNepy. She has a health problem. Dr. Fexvown. This is a problem that we have in our State. Senator Kexnepy. We have it in the Nation. Dr. Fexron. Medicaid throughout the Nation is in trouble—and this is a fiscal responsibility which has not been taken over—as you may or may not know, we in the California Medical Association are suing the State of California for patients just like Mrs. Henderson. Senator Kexnepy. I noticed vou were careful not to mention the word “crisis” but one time. And I noticed that in other statements be- fore the Senate subcommittee by professional groups, that they were always careful not to mention it; although there are differences in medical societies with respect to this. For example, in Chicago, they testified that they felt there was a “crisis.” And the President has recognized there is a “crisis”—and the Sec- retary of HEW. And I think these consumers have more eloquently testified to this than any other kind of expert witness we could pos- sibly expect to hear from. I think they were describing the extent of the “crisis.” And T suppose the question which we in the Congress and the Senate have to think about is whether we ought to be relving upon some of the institutions that have brought us into this “crisis” situation—the in- surance industry, the attitude of organized medicine—to bail us out of the “crisis” we are in. Whv do vou think we should ? Dr. Fexron. Senator Kennedy, did I understand you to say that the health insurance industry and the medical profession brought us to this problem ? 2417 _ Senator Kennepy. I think it contributed heavily, yes. I think that is right, yes. [ Applause. ] I think, if I can elaborate on that—you have had the insurance in- dustry working in the health field for 37 years, and I don’t think you need any more eloquent testimony than the comments of how they failed to aid these people in greatest need. I think these companies failed us. Dr. Fexvon. Senator Kennedy, this is a matter of personal opinion. As 1 say, the physicians do not believe the insurance companies have failed the American people. We have provided programs—the insur- ance companies have provided programs. Some of these were business negotiated, and some of these were plans in which there was not adequate planning. In our planning for the California Medical Association, we have set the criteria for adequate health insurance planning, and we believe it is very important. Senator Ken~epy. We have been hearing that, with all due respect, since 1946. ‘We have heard about it from the insurance company representatives who come down and appear before the Congress. Representatives of he Ava tell us we can solve this particular problem of health care needs. And we heard the same kind of statement in the medicare fight— “We don’t need medicare. And the AMA is going to develop a new kind of comprehensive program to meet the ‘crisis’. ” What do you see? Now we come back to a new national debate, and we hear different personalities from the same organizations saying one thing, “we can do it, we can rely on our good, old friendly insurance company to pro- vide the means of a mechanism to bail us out. The system and our or- ganizations are going to develop new types of programs to meet the needs of the people.” I say, why should we rely on them? And this, I think, is part of the problem. Even the President says that the insurance industry is going to have additional, heavy regulation. Now, he is not saying that, not the President—— Dr. Fenvon. Senator Kennedy Senator Kexnepy. He is not saying that because he thinks they have been responsive in this area. . I am all for it if they want to go out and sell life insurance, in- surance on my boat. ) Why should they do it in terms of health? Why should you permit people to make a profit? Every time a person has a claim it is a threat to the profit of the industry. Why should we have to do that? We don’t do that for the education of the young. We don’t do it in educa- tion. Why should we do it in health ? Dr. Fexvon. Which one do you want me to answer first ? Senator Kex~xepy. Make your response to any of those. Dr. Fenron. Senator Kennedy, we heard this morning an indict- ment of the Medi-Cal system. Do vou believe there is a Government program where you would like to sell Senator Kennepy. It is a State program. 2418 Dr. Fenvon. It is also a Federal program—50/50 reimbursement ; right ? Senator Kexnepy. Right. Dr. Fexvonx. We have found with Government programs that the financing aspect is where we run into many problems participating in the State of California. The reason is we have many fiscal responsi- bilities in this State, and as a consequence we have great difficulty in getting these programs funded. Medi-Cal is in the problem it is today because it has a closed-end budget in this State and an open-ended welfare State—and we have that problem, Senator Kennedy. Senator Kennepy. Is the fee for surgery any part of that? Do we have four times more surgery on medicaid patients as we do for other people in this State ? Dr. Fenvon. Senator Kennedy, you read incorrect figures in the article in Medical World News. Senator Kexnepy. I am taking the President’s message. Dr. Fenvon. The President’s message took it from that, too. Senator Kennepy. Well, T have to rely on the President sometimes. Dr. Fexvon. If you will look at the Department of HEW figures, as of 1968 it was 1.7, or thereabouts—and these are HEW figures; so somewhere or another these figures got twisted. Senator Kexnepy. Do you think we have too much surgery today ? Dr. Fexvon. Well, I think everyone has been telling us we have a manpower shortage in medicine. Senator Kexnepy. The question is: Do we have too much surgery ? Dr. Fenvon. I don’t think so. Senator Ken~epy. You don’t think we have too much surgery. Dr. Fenvon. No; I think we have the necessary surgery. I would point out that there is no nation that has the health care that our United States has. Have you read the later material? Even Sweden is in trouble. We know that England is. We know that England is bankrupt, prac- tically, from their social system. And I would dislike very much to see our United States come to this point. Senator Kennepy. You were making an observation earlier with the situation out here in California. One of the questions that must come to mind is: Why are the medical societies so worried about money and not worried about health ? Dr. Fenton. We have always been worried about health and our plan we presented to you this morning was a good example. That is originally why the AMA and the CMA originated it—it was for the care of patients. Senator Kex~epy. I think the question is whether you think the people who commented here really represent what is happening to the American people—or whether you think they represent some kind of freak accident. If you feel that is representative, I think you have a “crisis” of major proportions. If you do, then you are going to reform the system. and you are not just going to approach it with a Band-Aid and patchup kind of legislation. 2419 If you don’t—and I know there are those that do not think we do have a “crisis,” then you are just going to try to patch up the existing system. Dr. Fexvon. This is not the way I stated this in my statement—and perhaps I should restate it—it 1s that we know there are problem areas and we are trying and we hope that some of these will be covered. But we do not think replacing it with an entirely new Government . program, in which the responsibility lies with the Government—and with the changes in administration, that we have in Government— that we can depend on fiscal support, necessarily. This is one of the reasons education has problems today. This is the reason the postal system has problems. We would rather see it remain in the private sector. Senator KEn~Nepy. But the mail gets delivered—and that is what we would like to do with regard to health care. Thank you, very much. (The prepared statement of the California Medical Association follows:) 59-661 O -71 - pt. 11 -:8 2420 STATEMENT OF THE CALIFORNIA MEDICAL ASSOCIATION Submitted to the Subcommittee on Health Labor and Public Welfare Committee United States Senate by Roberta Fenlon, M.D. President, California Medical Association San Francisco, California May 17, 1971 The California Medical Association, founded in 1856, represents approximately 25,000 doctors of medicine in California. There are approximately 27,000 practicing physicians in our state. In many ways, California acts as a representative cross section of the nation as a whole. Perhaps more than any other state's, California's population represents every section of the country, every social and political view, and every economic level. In addition, the fact that one tenth the population of the United States -- 20 million people -- lives within California's 158 thousand square miles is a singular health- care situation in itself. It is estimated that California's population may reach 40 million by the year 2000. The California Medical Association realizes that the size of our job and the complexity of the problems will increase as our population grows. We are deeply in- volved in planning for the future. We have had wide experience studying the health-care problems associated with such a large and diverse population and such an immense area. It is our feeling that familiarity with these problems cannot help but provide sound information for the whole country. We have arrived at many innovative solutions. Yet, in spite of the dramatic progress made in the last few years, the job of providing efficient and effective health-care to all our population is massive. Since the inception of our Association, we have actively worked for the improvement 2421 wie of health standards in our state. We can proudly point to the fact that the CMA is respon- sible for the introduction and passage of a large proportion of legislation passed to insure good health-care in California during the one hundred and fifteen years of our existence. ” Our Present Health-Care System And Its Deficiencies To state an obvious fact, the purpose of any system of medical and health-care is to bring together one patient who needs help and one physician who can see that he receives help. It can never be forgotten that medical care is given to one individual at a time. In fact this framework of individual attention is the only one which allows adequate medical care to be given. Within this framework, Americans have developed a medical and health-care system that continues to do an excellent job in many respects. But it does contain some very real inad- equacies. People who cannot afford adequate care many times go without it -- because it simply isn't available to them, or because they don't know how to obtain it, or because they lack the education to use what is available. Government health programs promise full health- care, but have not budgeted enough to provide it. Furthermore, catastrophic illness can hit any income level. Even those with incomes well above poverty levels can be wiped-out finan- cially by a prolonged family illness. In addition, certain people living in remote rural areas or in urban ghettos have had no readily available access to the health-care system. The inability of any American to get proper medical or health-care --for whatever reason -- is a totally unacceptable situation to all of us. But solutions to this problem must be developed with the awareness that a substantial percentage of Americans today do receive excellent medical care as soon as they require it. Therefore, it seems to us that the need is not to drastically restructure, or further control, or destroy the system. Instead, the need is to expand it. It must be extended so that it is put within the reach of those who do not now receive its benefits and services. At the same time, it must educate those people who do not know how to gain access to it or use it properly -- and this is the responsibility of all our society. In other words, we firmly believe that our country must 2422 bridge the gaps in the present system without discarding those aspects of it traditionally doing a good job. However, we believe just as firmly that these inadequacies can only be eliminated effectively through well-reasoned and proven mechanisms, In addition, there is an obvious necessity for instituting such mechanisms under the guidance of some overall, long range concept which considers the effect of one program upon another and upon the sys- tem as a whole. In addition, we cannot afford to ignore the impact of any program on our nation's economy. California's Medicaid Experience and the Future Our state's Medicaid program -- Medi-Cal -- provides a prime example of what can happen when attempts are made by government to solve health problems piecemeal, without consideration of the effect on the system generally, and without the essential independence from political considerations in operation and funding. It should be noted for the record that, from the beginning, CMA strongly supported and sponsored the state bill that became Medi-Cal. One reason for our support was that the bill embodied a concept we physicians feel is essential to good medical care for our patients -- the concept of ''mainstream medi- cal care. The law cites this concept as one of its objectives: ''to allow eligible persons to secure basic health-care in the same manner employed by the public generally and without discrimination or segregation based purely on their economic disability." However, in the spproxtnstely five years since the implementation of Medi-Cal the intent of this compassionate program has been compromised for political expediency, dimin- ished by fiscal demands, and eroded by administrative regulations. Today, instead of real- izing its stated intent of mainstream care for all Californians, the Medi-Cal program has deteriorated to the point that it restricts access to medical care. And as you all are aware, California is not alone in its Medicaid difficulties. Many other state are experi- encing equal or greater problems. Clearly, California's Medicaid experience demonstrates the danger of inadequate safeguards for separating politics from funding in any government health program. 2423 he One effort by physicians to make our Medicaid program operate effectively is the CMA proposal, introduced in the California Legislature last Thursday. It would remove our state's Medicaid program -- Medi-Cal -- from the political difficulties referred to earlier. Under our plan, California's Department of Health Care Services would be replaced by an appointed 15-member Medi-Cal authority, responsible for administering the health-care pro- gram for the poor. The authority would serve as a contract agency for the state and would provide no medical services itself. It would contract with a carrier to provide a scope of medical benefits. Possible carriers are insurance companies, Blue Shield, Blue Cross, county foundations for medical care, counties directly, health maintenance type organizations, and so forth. The state authority would also be responsible for obtaining operating funds from the Legislature and accumulating adequate reserves to take care of financial peaks and valleys from year to year. California's Experimental and Pilot Programs Of signigicant interest are various approaches taken in California to experiment with different methods for the delivery and financing of care. The San Joaquin Medi-Cal Pilot Program serves as one example. It was established to determine whether savings to the state could be realized by putting physicians' services on a 'prepaid' basis. A premium rate per recipient per month was established for all physicians' services within a specific geographic area. A system of medical claims and utilization review by profiles of providers and recipients was put into effect. The project is designed to determine if a greater per- centage of the eligible beneficiaries would be seen by a greater proportionate of physicians under this approach. In this way quality medical care would be assured and at the same time supplied for less cost. Again, let us emphasize that this is only one of several existing innovative projects we could cite. A further example of the medical profession's efforts in California to improve cost and availability of health-care, without sacrificing quality is the proposed Big Valley Project, recently endorsed by the CMA Council. It would encompass the Sacramento, San 2424 Joaquin, and Santa Clara valleys in California, an area including the widest possible range of environment, population types, and socio-economic levels. The proposal is composed of three parts: a proposal to the Social Security Administration to cover those patients under Medicare; a second proposal to the state of California to cover those patients on Medi-Cal; and a bridging proposal developed so as to correlate the coverage in both of these programs. This pilot project proposes to assume prepayment risk for all recipients of Title XVIII (Medicare) and XIX (Medicaid/Medi-Cal) benefits. It would employ an 'overlay' concept, giving all recipients the advantages of good claims review, quality control, progressive patient care, and an easier entry into the medical care system. A third objective of the proposal is to create a realtively simple administrative organization, enabling both federal and state governments to provide a prepaid program for a large area and a large number of recipients. A single administration would be able to make decisions based on the total medical care objective. A fourth objective is that of research. The program would be large enough to require computer involvement and yet small enough that the results could be easily analyzed. In addition, there seems to be possibilities of developing private funds for research. It is the intent of the proposal that a developmental contract would be amended effective July 1, 1971. The California Medical Association has authorized a loan to assist in meeting start-up costs of the Big Valley Project. Pilot Projects Necessary for HMO Concept It seems to the California Medical Association that the concept of Health Maintenance Organizations, as emphasized so strongly by the present administration, includes several specific dangers that could be avoided through pilot projects. The potential exploitation of health-care when individuals -- whether health oriented or not -- can form an HMO and contract with providers for comprehensive health services could be catastrophic. We have witnessed a similar situation after the passage of Medicare with the great influx of poor quality nursing homes. Among other potential dangers of HMO's is the fact that they have no provision for 2425 ts discouraging patient over-utilization. There also is no provision for freedom of choice -- a State could be an HMO or the only hospital in a community might be an HMO, Personal patient records, under the concept, must be available for government audit for any purpose the government deems advisable. There would also be unwarranted, and conceivably arbitrary, control of all providers of service -- including the para-medical groups =-- by both the owners of the HMO and the government. One can only be deeply concerned over the direct control which the federal government, acting through the Department of HEW, would have over premiums, costs, providers, and other components. This control would appear to encompass the setting of rates, standards, and regulations which will affect a segment of the public for whom the government now has no direct financial responsibility =- community enrollment. Furthermore, these HMO's -- with their government subsidies -- would be in direct competition with all other insurance plans and thus might well cause the gradual elimination of private health insurance. In short, the capacity of such a program to accomplish its purposes must be deter- mined. For example, there are questions regarding in-fact cost savings, as well as the quality of health-care which may be provided when there are economic incentives to providers to reduce utilization. Furthermore, it should be realized it is extremely unlikely that those outside the medical profession could effectively evaluate either the quality or the cost of care. It is CMA's feeling that any approach to the delivery of medical services must be pluralistic to be successful. This is true whether we are discussing services furnished by group practice, by the individual practitioner, or in some other manner. The HMO concept would be best tested and modified based on pilot projects. Physicians Tackle Medical Costs The escalating cost of medical and health-care today is perhaps the most criticized and least understood aspect of our health-care situation. For a moment, let us concentrate 2426 -7- on the physician's share of increased cost. Obviously, the medical community is no more immune from the economic forces at work today than any other segment of our society. Phy- sicians face the same problems others do: rising labor costs, rising equipment costs, rising office costs -- spiraling inflation in general. Also obviously, these increases are coupled with increased expenses resulting from continuing medical and scientific research: new drugs, new equipment, newly developed and highly complex procedures, and so forth. All of these factors are easy to comprehend. Less obvious to the public as a cause of increased medical costs is the soaring expense of professional liability premiums -- largely a product of unrealistically high awards by juries in liability cases. Not only has the situation significantly affected medical costs, but it has greatly increased the difficulty of patient care for the physician. The California Medical Association has been tackling this complex problem in several ways. One of our approaches is to make use of education. With the California Hospital Asso- ciation, California Nurses Association, Hospital Councils of Northern and Southern California, and the insurance carriers -- CMA has sponsored a unique series of malpractice prevention workshops throughout California. These workshops have sought ways to alleviate the present malpractice situation by confronting the practical problems related to the everyday provision of health-care. With the CHA and others, we have also approached the problem from the standpoint of possible arbitration. Eight southern California hospitals have embarked on a demonstration project in the use of arbitration as an alternative to court litigation of claims against hospitals and attending physicians. We feel that this mechanism may very well provide one way == in the future -- to greatly reduce liability premiums and therefore medical costs. Also, CMA has maintained a comprehensive and continuing legislative program in regard to professional liability. This program -- active since the 1968 Session of the Legislature -- has the basic objective of curtailing the trend toward unreasonable liability insurance rates -- and, again, reducing medical costs. Yes, the problem of rising costs plagues physicians, as it does everyone. Our peer 2427 28s review system checks on the charges for, as well as the quality of, care rendered. This is a voluntary system whereby physicians review their colleagues in terms of charges made, treatment given, length of hospital stay (utilization) -- the whole picture. We are greatly concerned about costs and are taking all possible steps to keep them at a minimum. The problem of medical costs is also compounded by increased hospital costs. The physician, often unfairly, is tarred with this brush, Patients seem to equate a hospital bill with the doctor's charges, although they are separate. Hospital costs have risen con- siderably but unavoidably. About 70% of a hospital's costs are labor-related. Nurses and other hospital employees have received major increases, and these increases must be reflected in the hospital bill, Hospitals have installed sophisticated medical equipment, and this life-saving equipment is expensive. In addition, the numbers of health personnel have con- stantly increased to further improve the quality of hospital care. Increased utilization by the public of the health-care system is a further factor. Obviously, for a variety of reasons, more people are making use of medical care today than ever before. Not the least important factor in this growing trend toward utilization is the advent of Medicare and Medicaid. And not only is greater utilization per capita a result, but every year the number of eligibles increases. For example, in the roughly five years Medi-Cal has operated, the total number of persons eligible for Medi-Cal increased 76.7 per- cent. During the same period, the total cost of care increased more than 104 percent . . an increase of more than 530-million dollars. California's population, of course, has grown during the past five years . . . an average of 1.5 percent a year. But the increase in the number of beneficiaries under Medi-Cal far outstrips the population increase. At the outset, during fiscal 1966-67, one Californian in 15 received Medi-Cal benefits. During the current fiscal year this ratio is estimated at one person in eight . . . nearly double the original rate. Physician Efforts to Assure Quality Care Quality and cost are two areas of health-care which bear an especially close rela- 2428 tionship. Nonetheless, what steps are physicians in California specifically taking to insure high quality care? For the purposes of illustration, and since government health programs are important to this discussion, the profession's efforts to insure high quality care -- and hold the line on costs =- for the Title XIX program might be used as examples. To even further strengthen the recommendations forthcoming from ''peer review' committees, the California Medical Association has strongly supported several legislative measures in this area which have been enacted into law. Examples deal with disclosure of possible conflicts of interests in referral of patients to facilities; carrier authority to place a provider on prior authorization; making false or fraudulant claims a felony; and making suspension of a provider from participation in Medicaid a grounds for suspension or revocation of license. The California Medical Association and its component county medical societies have in fact initiated an extensive and comprehensive system of ''peer review'' that applies to the Title XIX program (Medicaid/Medi-Cal). Briefly stated, it includes: county medical society review of physician claims; hospital and nursing home utilization review committees; a state association appeals review committee; medical staff survey teams, composed of physi- cians and sponsored by the state association, that conduct surveys of medical staffs in hospitals and nursing homes (ECF's) to insure quality care; and the many hospital committees required by JCAH and CMA. One might truthfully say that a physician's colleagues are contin- uous ly scrutinizing the professional activities of each individual doctor -- both in regard to Medi-Cal and to medical practice generally. Carel E. H. Mulder, past director of the California Department of Health Care Services, expressed his special appreciation for the arduous task of those doctors who, without com- pensation or other material gain, devote many hours to the review of suspected claims and courageously decide whether or not the services claimed to have been performed conform to established community practice. CMA has very recently developed a statewide peer review program to further coordinate and strengthen peer review activities. Under the plan, the scope of existing peer review mechanisms, which have proven highly effective, would be enlarged using a variety of local 2429 =-10- approaches to assure quality care for the public in the most economical ways. This approach embodies such factors, among others, as a State Advisory Council consisting of representatives of the public and representatives of appropriate provider organizations. To give a few examples of the plan's advantages, on the local level it is designed to provide for regional seminars and workshops on peer review; encourage continuing medical "education; and work toward the widest possible innovative and constructive exploration, by the local review units, of improvements in the various peer review mechanisms. This CMA plan illustrates both the long-range value of California peer review -- and its inherent genius. Not only has peer review traditionally served California's needs through such services as hospital review boards, but it provides an overall mechanism capable of constant improvement and change to meet changing needs. One can cite few better examples of the medical profession's active commitment in California over the years to assuring high quality medical care at the most economical price. Three other continuing CMA projects deserve the attention of this Subcommittee. They provide a fair estimate of the determination and success characterizing CMA's efforts in the area of insuring quality care to the citizens of California. Many of these activities receive very little public acknowledgement. For one example, our Medical Staff Survey Program -- assisting quality care in local hospitals through con- tinuous supervision and review -- is currently beginning its 11th year of operation. In the last 10 years it has contributed immensely in assuring high levels of hospital treatment to Californians. During this period, we have surveyed 644 hospital staffs. Secondly, we are proud to note that CMA -- after extensive preparation and in con- junction with the California Joint Council to Improve the Health Care of the Aging -- has just seen the adoption of the ''Long Term Care Review . . . a statement of principles." This doc- ument, embodying principles and standards to be used in surveying the level of care in these institutions, is equivalent to our "Guiding Principles for Physician-Hospital Relationships''-~- now a national standard for hospital surveys. With the adoption of the ''Long Term Care Review," we are embarking on a program of review to insure the quality of care in nursing 2430 w= homes. A third CMA activity that should interest this Subcommittee is our recently launched program in Continuing Medical Education. It consists of ''certification' for physicians participating in a minimum of 200 hours of continuing medical education in a three year period. An additional aspect of the program is its '"Accreditation' of the continuing medical education programs of health facilities, making the California program unique. Instead of merely counting hours, the emphasis has been placed on actually improving the quality of such education, on making it responsive to the needs of practicing physicians, and on making it effective as a means of improving patient care. The act of accreditation entails strict guidelines, requiring that the entire educa- tional environment be evaluated. Our Accreditation Program for continuing medical education is just getting under way. Accreditation applications now total approximately 1,700, and more are coming in daily from hospitals throughout the state. CMA's long term plan is to accredit all programs and activities of merit within three years. The California Medical Association also holds five annual regional postgraduate institutes, three circuit courses in rural areas, and extensive annual scientific sessions. In addition to the activities we have outlined, CMA seeks to improve the public health through an extensive program of printed health-care material and radio health-care news and public service announcements in the California media. Furthermore, we could give a long list of specific CMA programs dealing with specific health and safety problems -- maternal and child health, drug abuse, alcoholism, highway safety, aviation safety, and so forth. Making Health-Care Available To All Californians In focusing on CMA efforts in the area of promoting availability of care, we must comment that no single element of any health-care system can be understood in its proper prospective if it is completely divorced from various other elements of the system. There- fore -- and we hardly need to impress this fact on the Subcommittee -- our efforts necessarily 2431 -12- have included a wide range of activities. Stated simply, "availability of health-care' might be said to concern the fact that doctors and other health professionals are not equally available in all locations and to all sections of the population. This lack of doctors is especially acute in ghetto and rural sections. And in both these sections, the problem is further complicated for many people by language differences, by people not knowing how to seek and use health-care services, and by lack of transportation. What are California doctors doing to meet the challenge of making health-care available to all Californians? A few examples will serve to illustrate these efforts. CMA runs a Physician Placement Service created specifically to place physicians in locations where medical services are needed; San Francisco Medical Society is working with OEO in bringing medical care programs to the '"inner city"; Kern and Sacramento Medical Societies are operating mobile clinics for the treatment of rural migratory workers; Monterey has an innovative rural health project in King City using the health team approach; CMA is working to increase medical school admissions from minority groups; and we sponsor preceptorship programs at California's eight medical schools. We are working to make medical care available to all. California Medical Association made an all-out effort in behalf of Proposition One in the June, 1970 election with financial aid and service. But the voters narrowly turned down this bond measure that would have provided funds for completion of three medical schools and facilities to train dentists, nurses, public health professionals and other needed health- care experts, The CMA will continue to support such bond measures in the future. In the meantime other things are being done to meet the challenge of providing more physicians and other health professionals. We are giving college scholarships to many deserving students -- 35 so far -- who plan careers in the health field. Wherever practical, we are urging medical schools to expand their enrollments and to actively seek out and financially assist interested and potentially qualified minority students who desire educations in the health fields. The CMA is also moving ahead with establishing the new occupation of Health Care 2432 13+ Assistant -- also sometimes referred to as the ''Physicians' Assistant.' The Santa Clara County Medical Society pioneered in this field with a unique training program for recently discharged medical corpsmen. It is hoped that this new breed of trained and licensed heal th- care professional, working under the supervision of a physician, might handle much of the routine -- freeing the physician for critical diagnoses and treatment. By augmenting and increasing the efficiency of the health-care team, more patients could be served and health manpower shortages reduced. CMA is taking the lead in establishing this new health worker: developing criteria for education, working on legislation for certification, providing means for recruitment, and suggesting the best possibilities for employment. In another approach, we are working diligently to improve the efficiency of the health-care team through cooperative work and better communication. But this is not an easy task. Not the least of the problems is the vast number of professions and individuals in- volved in the health field. And the constant move of our nation and society toward special- ization in every area causes this problem to increase with every year. Because of the growing number of medical specialties, it's a full time job just insuring that good communication exists among physicians. The California Medical Associatic now maintains nineteen advisory panels to different medical specialties in order to bridge the inevitable communication gaps. The California Medical Association also is working with such differing groups as hospital administrators, dentists, physicians' assistants, nursing home administrators, ambulance drivers, nurses =- to name a few -- to solve mutual problems. We are making defi- nite progress toward effective coordination of efforts among all health professionals as a matter of course -- coordinated research and sharing of information, coordinated long range planning. CMA Develops National Health Proposal Perhaps the best way to demonstrate CMA's general outlook regarding health and medical 2433 == care is to tell you about our proposal for American health-care. The CMA ''universal-voluntary' plan would offer benefits to all families and indivi- duals on a voluntary basis, with financial assistance geared to need. When feasible, patients would share in the financing -- along with state and federal governments. Benefits would be provided through vouchers or tax credits for the purchase of insurance coverage defined as acceptable. Full use would be made of existing insurance industry experience and mechanisms. At the same time the plan would make it highly advantageous for the industry to provide realistic programs that extend coverage to far more people. The plan would be open to everyone -- regardless of income, age, or employment status. Every family and individual, of whatever income level, would have incentives to participate. IF Sets standawds fer heatth cave cevermqe Benefits would include all areas of health-care. The plan would permit each recipient to choose his own physician and choose the programs that best fit his needs. In fact, our program would be so attractive that people in every economic level would participate. The program would also provide non-political administration. It would be supervised by the United States Civil Service Commission, a non-political body with more than a decade of experience in the successful federal employee's health insurance program. To avoid problems of unrealistic funding =~ such as encountered in Medi-Cal and many other government health programs -- the budget for our program would be updated bi-annually for all areas of the country on a basis allowing for inflation. Under CMA's proposal, all plans or programs must furnish evidence of effective peer review activities. Another important feature -- our plan provides for demonstration and experimental approaches by health-care professionals. These would include programs in the organization and delivery of health-care, including the utilization of new types of manpower . . . such as the health-care assistant. Liaison with comprehensive health planning agencies in inaugu- rating these new programs would provide for community participation. Certainly one of the most significant aspects of CMA's proposal is the fact that it is a comprehensive, long-range program. Today there are more than 100 Federal health programs for specialized sections of the population . . . Indian Affairs, Crippled Children, OEO, 2434 w15m Medicare, Medicaid, and so forth. Our program would immediately absorb Medicare, Medicaid, and every other program at all feasible. On a longer range basis, it would ultimately incorporate the medical aspects of VA and other government programs providing or financing medical services. In other words, it would create a single, coherent, integrated approach to health-care. It would not be a stop-gap measure treating only the symptoms of the health problems as they confront us. On the other hand, it would not require massive federal finan- cing. Nor would it require dependence on an entirely new and untried system of health and medical care, In conclusion, may we impress upon this Subcommittee that no one has a deeper concern about health-care than members of the medical profession. As practicing physicians, we live with our patients' health problems and illnesses every day of the week. We will continue our efforts to improve health-care, our experimentation, our pilot projects. We firmly believe there is no single, simple solution to the widely varied health difficulties of the American nation. We firmly believe that a pluralistic system is essential We plan to continue our search for improved methods in the delivery and financing of health- care -- and we respectfully ask the support of this Subcommittee. | wish to thank the Subcommittee once again for the opportunity of submitting this testimony. HHH HHH 2435 Senator KeNNepy. Dr. Gibson. Dr. Count Gibson has been an old friend and adviser for many of us in the Senate, on health matters. He is presently chairman and professor of the Department of Preventive Medicine at Stanford. He previously served as a professor and chairman of the Depart- ment of Preventive Medicine at Tufts, Boston. He was of enormous help in getting Columbia Point Health Center started up in our community in Boston—and the Tufts-Delta Health Center in Mout Bayou, Miss.; and he engineered a number of others. I think he has brought an enormous interest to the whole delivery of health care. We miss you back East. STATEMENT OF COUNT D. GIBSON, JR., M.D.,, CHAIRMAN, DEPART- MENT OF PREVENTIVE MEDICINE, STANFORD, CALIF. Dr. Gisson. Senator, thank you very much for inviting me here today. I think this was a very moving set of experiences we heard this morning, for those of us interested in medical care here. They are far from the exceptional or unusual. With due respect to my colleague who just testified, I think the data on the charts, as well as many other indices, suggest to us not merely that we could do bet- ter in our own rights, but in comparison with other nations of the world we have much more progress that we can make. As a matter of fact, some of the experiences we had in Boston, and which you shared with us, back in 1966, gave us a few clues to how we can approach the problems today. I would like to suggest two ways in which I really feel problems are clearly getting worse. The first one is the dilemma of success—the technologic advances that have been made now pose a challenge to us as to how to make these available to everyone in the country. Dr. Shumway certainly represents some of the most remarkable tech- nologic skill in the country, in cardiac surgery which is carried on. We see what dilemma this poses. Twenty years ago there wouldn’t be the question of cardiac surgery. The patient would have died. That would not represent a medical care cost. With all the research money poured in, we now have the ability to lead the world, if we find the mechanism to spread it around. But I think the very point that we do research makes it all the more painful, not only to those who attempt to receive care through the old ways, but for the large numbers who cannot get to it, or don’t know about it. I would say there is another measure of the way in which we are fail- ing, today, and that is in regard to the distribution of physicians. Dr. Fenlon pointed out the experiences of a placement service in California. Most States have had placement services. And with the best efforts of the placement services, the physicians are getting more and more concentrated in suburbia and less and less in towns and rural areas and our great cities. So, we slide in numbers, year by year, fur- ther and further behind. 59-661 O - 71 - pt. 11 - 4 2436 I see this “crisis” in California, not only in our great cities but in our valleys, in small towns, that have always prided themselves on keeping physicians—who have slowly slid from 30 to 24 to 21 to no physicians in the community. In a sense I profoundly do not believe in a Federal, licensed system of health care, in which Washington figures out these problems for us all. We have many different kinds of people and we have many differ- ent parts of the country. The solution which seems to me important to foster is increasingly the development of consumer control of health care. Now, you had the opportunity to see, with us ,what at that time was a very strange notion, at Columbia Point. We were talking about a con- sumer voice, at that time, or an opinion. I think most of us physicians have had very little experience with what that means. As time has gone on, we have attempted to develop an OEO center, to develop a National Consumer Health Committee. It seemed that was something that related to minority Black people or poor people. Since I have been in California, I have had the good fortune to see this is very relevant for everyone. The town of Livingston, in the San Joaquin Valley, was faced with the loss of its one doctor and asked us, at Stanford, how they might try to solve their problem—and we had them form a nonprofit com- munity corporation. This is a community that has poor people and it has well-to-do people. It is a very multiethnic community. And so a community board was formed, representing all the economic segments in the com- munity—the farmworkers, the people in town, the people in the rural areas. With this nonprofit corporation, they have, for the past year and a half, poured all of their health care dollars in the area and redis- tributed them so that the need of everyone in the community can be met. The board consists of 30 people, and there are another 50 through- out the community, solving many of the different kinds of health care problems with their staff. This is an answer, as I see it—control by the community. We have been talking about the schools—and I think schools will solve their problems to the degree that their community controls de- veloping what the needs of the community are and that they are financed adequately. It seems that S. 3—and H.R. 22—are the only proposals before the Congress, at this time, that foster and promote a reworking and re- structuring of our health-care system—and this is why it seems to me that not only in terms of a financing mechanism, but as a restructuring, that this action is so important. I would like to give one local example. You have some really won- derful examples at the hearing—and there are several ladies from the American Indian Health Board. Now this group of native Americans approached the Department of Interior, because for the first 6 months after a native American leaves a reservation and comes to the city, the Department is responsible for his health care. 2437 So, they wanted to figure how to carry out this responsiblity. They offered to purchase insurance in Kaiser, saying this is one of the broad- est, most comprehensive programs available. They said, “Let’s meet the Kaiser folks.” And they were told this was broad, comprehensive coverage. And they said, “We have a few things of concern. Ever since you Palefaces introduced to us firewater, we have some real problems with alcoholism.” And they would like to know the coverage. “But, unfortunately that is one of the exclusions.” Otherwise, we are very comprehensive. We have another kind of condition—trachoma, which causes a great deal of blindness and we have a need for special glasses and special lenses of other sorts. Could you tell us what is covered ? “Well, that is another one of the small exclusions.” And we have a great deal of deafness—and we know if you are go- ing to make it in the city life you have to have good hearing. We assume your plan will take care of a hearing aid. They said, “That is one more exclusion.” And at that point they said, “Couldn’t you please provide us with the money and we will work out a health program that will meet our needs?” I think that is an example of a Kaiser program that meets the needs of many people very well, and fails to meet the needs of special people. And this is where we come back to the crucial voice of the community in health coverage. I would like to conclude my remarks by registering one great cause of complaint. The case has been made about retaining health care primarily in private enterprise. So far, there has been private enterprise and it has been good—but just as I think, in our times today, it can produce great good in the society, I think it is also capable of causing great harm. In the HMO proposed, the planning specifically envisions the possi- bility that HMO’s can be operated by proprietary interests that aren’t even physicians. This is what is called a consumer prescribed patient program—and I think, not only is it important that we see the devel- opment of health centers controlled by consumers, but also guard care- fully that we do not get off in the private corporate sector that pro- vides against health care. I think we have to guard against that one. I think as we need to move toward the particular advantages of per- mitting a restructuring around the community oriented health cen- ter—that is a very crucial part of what we need. Senator Kex~epy. Thank you, very much. Just a couple of ques- tions, because we want to move along. What do you think about the question of—Do we have too many operations? Dr. Gieson. Well, we have very good data on this. My colleague, Dr. John Bunker, who is a professor of anesthesiology at Stanford, has made a very careful comparison between Great Britain and the United States—and his data which have been widely attacked, analyzed, and strongly supported, suggest we are doing twice as much surgery per thousand population in this country as is done in England. And this 2438 was with a large segment of our population that doesn’t have access to surgery at all. d I think the data is quite clear—we have an excessive amount of surgery. Senator Kex~eny. Why don’t you conclude maybe they aren’t get- ting enough surgery done in England You better be able to answer that one. ] Dr. Giesox~. I would say with their health situation and an analysis of what goes on—in terms of who is walking around with a hernia that should be repaired and doesn’t get repaired—maybe they are not get- ting as much as they need. Senator Kex~epy. What is your feeling about the profit motive in terms of meeting health needs? You referred to this just briefly in your comments. Do you think that ought to be a feature in terms of our system? Would you make any comments about the fee-for-service concept ; whether this helps to keep cost down ? Dr. Gieso~. I know from the time I trained to be a physician, I saw this as an opportunity for providing service to an individual. I think this is some of what has been implied in the term “profession”. I think the incentive of a fee-for-service is the only way to get people to work hard, and not what basically is of service for people. I think the fee-for-service has kept up, around item-by-item of particular tasks to be done—and there are some very idealistic people who operate within such a fee-for-service system, but in my view not because of it. And I see the opportunity for both in health centers. There are a whole group of physicians—some of them in this room— that find satisfaction of serving, not patient by patient, but working with the community through a board and developing manuals of all things not being done health education, preventible mechanisms, anti- cipating problems before they happen. Half the problem has been taken care of with return to the community with a maximum effort for remaining there. And I think the only way we are going to be able to turn around is to return to the commitment for service, rather than a fee-for-service. Senator Ken~epy. Thank you, very much. It is a pleasure to hear you. Our next witness is Msgr. Timothy O’Brien. Monsignor O’Brien is director of Catholic Charities for the Archdiocese of San Fran- cisco. He is past president of the Catholic Hospital Association and is now the president-elect of the California Hospital Association. Monsignor O’Brien, the subcommittee is pleased to receive your testimony. STATEMENT OF MSGR. TIMOTHY O'BRIEN, DIRECTOR OF CATHOLIC CHARITIES, ARCHDIOCESE OF SAN FRANCISCO Monsignor O’Brien. Senator Kennedy, thank you for the oppor- tunity of being here. It is nice to be the last man. It means everything has been said. I had an old professor who said, “If you can’t say it in 3 minutes, the collection drops.” Being in the business I am, I will try to make it brief and to the point. 2439 Senator Kenxepy. If you have some comments, we can include it in the record. Monsignor O’Brien. Let me just try to make four points. No. 1—about the crisis—yes, there is no question that the basic problem in our present health delivery system, as far as I am con- cerned, is fragmentation. I believe our country has the best trained doctors, nurses, and other health professionals. We have the finest in health facilities. But, unfortunately, too often, we do not play as a team. As health professions we have preferred to play “king of the moun- tain.” I think we should be playing “tug of war,” which really means pulling together and being mutually accountable for our efforts. The goal of a national health system must be to mold the world’s finest health professionals and best health facilities into an effective health delivery system. I want to make it very clear that I believe we need a radical reorgani- zation of the Nation’s health resources if we are to build a team. The second point I would like to make is that today, we in the hos- pital field profess, as our basic belief, that health care is an inherent right of each individual and of all the people in the United States. We see that four corollaries flow from this basic belief : That health care must be so organized and located that they are readily accessible to all. That health services be available without regard to race, creed, color, sex, age, or to any person’s ability to pay. That the purpose of health services is to enhance the dignity of the individual served and to promote better community life for all men. And that it is the function of Government to assure that all this occurs. The third point that I would like to make is that a reorganized health system must bring under one organizational entity at the local level the various providers of health care. These providers must be able to give to their community that assurance that all reasonably needed levels of health care are available to the community served. These local organizational entities should be under the regulatory power of a State commission. This commission should issue certificates of need to avoid duplication. It should approve the rates to be charged to all purchasers of the service. It is imperative that the regulatory power of the system be separate from the purchaser of the health services. The fourth point I would like to make is that the building of a team—which is, as I see it, so important in order to carry out our be- lief—must continue to attract the most competent and most dedicated people in our society. The new health system must retain the strongest asset of the frag- mented system ; namely, an ability to attract the highest qualified peo- ple into the health professions. : h The quality of health care received is based primarily on the pro- fesional competency of the health professional. As we move from the fragmented to the nonfragmented health care, the biggest danger we face is decreasing the quality of care as we increase the availability and the accessibility. 2440 I want to make it clear I believe that a team system fostering profes- sional freedom, financial incentives, private ownership, and dedicated religious service can be created if the creator has this goal in mind. In conclusion, I would like to make two points. The first is that I do think the health system is trying to move ahead; it is trying—it is difficult. We are talking for California—the California Hospital Association is trying to put through an act, and we are having trouble doing that— it is an act that would demand disclosure of all the financial informa- tion of all hospitals. A second point I would like to make is that the new nonfragmented system can only come about by evolution and not by revolution. There was a book, “Too Much Too Soon.” Too much too soon can be destruc- tive. We all know that applies to alcohol. We know in the Catholic Church that too much too soon can be destructive to renewal of the Christian church. I think it can also apply to the creating of a health system. Thank you, very much for the privilege. Senator KexNEpY. Too much too soon might be bad—but too little too late is also bad. You have been very good, Monsignor, to be with us and we appreci- ate very much your taking the time. (The prepared statement of the California Hospital Association follows:) 2441 STATEMENT OF THE CALIFORNIA HOSPITAL ASSOCIATION BEFORE THE U. S. SENATE SUBCOMMITTEE ON HEALTH May 17, 1971, San Francisco The California Hospital Association appreciates the courtesy of the opportunity to be heard by this important committee. We will return this courtesy by being as brief and clear as possible. Although the increasing curve of costs may not show it, the hospital leadership in California has been very much concerned with controlling hospital costs for many years. Until recent years, however, efforts have been spotty, uncoordinated, and focused on short-term corrective measures. About three years ago, the California Hospital Association began a program covering two broad fronts hav- ing the aim of riding herd on costs. The two fronts can be identi- fied as internal management improvements and external pressures. It should be noted that this association has no coercive powers. Our tools have been persuasion and reason. The first frontal attack was formally initiated in 1968 under the leadership of Samuel J. Tibbitts, president of the Lutheran Hospital Society of Southern California, who was then president of the California Hospital Association. This was the management approach. 2442 The external approach was initiated in 1969 with the adoption of a CHA-sponsored Health Facilities Planning measure prohibiting licensure of facilities built or expanded without having partici- pated in voluntary area planning. A companion measure adopted that same year prohibits Medicaid payments to any health facility built or expanded without a favorable final decision by an area health planning agency. A second aspect of external control measures is before the California Legislature. It is the Hospital Disclosure Act, also sponsored by CHA, which was approved by the California Senate Health and Welfare Committee April 21. The measure would establish a State Hospital Commission empowered to obtain and fully disclose to the public hospital financial information based upon compulsory accounting and financial reporting procedures to be designed by the seven-member commission. Failure to comply with provisions of the proposed law would subject an institution to loss of its license. These two control approaches represent two legs of a public utility concept. Through planning, entry of new or expanded facili- ties into the field is based upon the needs of the community. Through disclosure, reliable and valid information regarding costs will be provided so that governmental and private agencies such as insurance firms can make valid comparisons and projections regarding costs. 2443 The third leg of the public utility concept is regulation of rates. We are moving cautiously in this area because of our strong conviction that regulation of rates without valid cost information would be at best hazardous and at worst catastrophic in terms of providing quality health care. We are pleased to note that Maryland's new law establishing a State Hospital Commission shares this concern. The Maryland Commission will function for three years as an information-gathering and disclosure body before it will be authorized to set rates. This is where we stand now on the external control front in California. Progress has also been made on the internal management front since its 1968 beginnings mentioned earlier. The management program contains one aspect we believe to be especially worthy of note. Included was a built-in means of measuring management improve- ments on a statewide basis. Following initiation of management improvement programs sponsored by the California Hospital Association, a means of measuring ''productivity'' was designed, tested and put into effect. There have been three major aspects to CHA's management improve- ment program. The first was a series of meetings statewide to familiarize top hospital management with methods and techniques available and to urge their participation in these programs. Most notable of these is the hospital adaptation of industrial engineering 2444 methods developed by the Commission for Administrative Services in Hospitals (CASH), which is headquartered in Los Angeles. This program essentially relates to the measurement of time required for the proper care of patients and establishes standards so that an institution can determine whether it is devoting too much or too little time to a wide variety of functions. The CASH program en- joys an excellent reputation in California and nationally. A second program explained to hospitals is the Hospital Admini- strative Services program (HAS) of the American Hospital Association. This service provides hospitals with statistical reports regarding a variety of '"indicators' such as figures on lengths of patient stays, costs for various hospital departments and so forth. HAS reports permit the institution to compare its figures with those of other institutions of similar size or of different size through- out the nation. With HAS, hospitals can measure performance com- pared to others. With CASH, hospitals can measure performance against their own past performances. The CASH program also pro- vides for recommendations for improvements based on accepted in- dustrial engineering methods and studies performed in the hospital by CASH experts. The initial series of ''sales' meetings held statewide resulted in significant increases in the number of hospitals participating in HAS and CASH. At these same meetings, held during 1969, the 2445 second phase of management improvement was previewed. CHA's management goals were explained and a series of seminars for hospital top management was announced. The seminars were held in the fall of 1969 and proved quite successful. As a result, the seminars concerned with ''Management by Objectives'' were expanded to hospital middle management. These were held in the spring of 1970. Following their completion, the third phase was begun, consis- ting of a management accreditation program. This program was under development and testing for a year. Initiation is scheduled for June 1 of 1971. 1It consists of an analysis of hospital records, visits to hospitals by administrative experts which will cover one and one-half days of study and consultation with administrative personnel. Recommendations for improvement will be made and certi- ficates of management accreditation will be awarded to institutions meeting management standards. This last phase, of course, has not yet had any effect. The first two phases, however, are showing positive results in California based upon productivity measurements designed and analyzed by CASH experts. The original 1968 goal was to tool up and attain a 5 per cent productivity increase by the end of 1970. 2446 The actual productivity increase as measured by CASH has been three per cent. This is not as high as we had hoped but it is by no means a failure. This is a significant increase in productivity per patient stay. This increase has saved the citizens of the State of California approximately $36 million over the two-year period that measurements have been taken. The rate now is $28 million annually. There has been a decrease in the average length of stay per hospital patient from 7.3 days in 1968 to 6.9 days in 1970. This is a 5.57% improvement, which is in large measure attributable to peer review, a responsibility of hospital medical staff physicians, and hospital administration. This adds significance to the fact that productivity per em- ployee and per patient stay has increased by the aforementioned three per cent. Normally you would expect a greater utilization of employee hours per patient day as patients stayed in the hospital for shorter periods and the patient population turned over faster. While we did not reach our full five per cent goal, we are pleased with this performance. It proves something can be done. It substantiates the value of our program to improve management of hospitals. This not only provides the savings indicated earlier, but should make our future programs that much more saleable and that much more effective. We have educated others, and we have also been educated. 2447 The California Hospital Association recognizes that hospital costs are high. When our management programs began in 1968 the average cost per patient day as measured by CASH was $74 per day (73.90). In 1970, this reached $94 per day (93.96). The national average for 1968 was $59 and for 1970 was $75. The Association also recognizes that there is no hope for any significant reduction in hospital costs given the state of our economy and the continual improvement in hospital and medical tech- nology. We can only hope to contain the cost rise at some acceptable percentage as long as this is consistent with hospital care. This does not mean that we are pessimistic about the total health care bill, however. The solution, we believe, lies in preventing hospitalization through improved means of delivering health care so that disease and injury is prevented or made treatable outside the hospital set- ting to the extent possible. In the long run, maintaining health is far less expensive and more productive than restoring it. This becomes even more obvious if costs such as time lost from work, from the family and from productive activities of all kinds are considered as part of the cost of hospitalization. It must also be recognized that as hospitals are able to perform at more advanced levels of care, costs will rise inevitably, if these costs are measured only from the standpoint of their economic cost. We must also look at the benefit to the community and to the nation which arises from having productive citizens restored to full activity. We also urge everyone concerned with the future of this nation and with health care to be wary of overstressing dollars to the detriment of human values. Human values, we submit, are in the final analysis infinitely more important than dollars. 2448 Senator Ken~Nepy. Miss Cecelia Lannon, legal aid—from Marin County. STATEMENT OF MISS CECELIA LANNON, LEGAL AID, MARIN COUNTY, CALIF. Miss Lax~on. I would like to tell you, very briefly, about a particu- lar view of the medical program here in California that is not just related to the failure of medical service, but the absolute denial of medical service to the most needy poor persons in our Nation. This has been made possible by linking medical service to welfare eligibility for the majority of poor persons. The particular persons that I want to tell you about are minors—an unpopular group politically in California in terms of receiving public service. These minors are emancipated. That means they can contract for medical service without their parents being involved, without pa- rental consent, and without financial responsibility. These minors are women. These women minors are pregnant. Their medical need is prenatal care. In some cases an abortion is absolutely essential. With these minors, what medical experience has shown— unless this particular age group gets the necessary prenatal care the chance of giving birth to a dead baby or a stillborn, goes up. Also, the chance of her suffering toxicity from that pregnancy, impairing her health, goes up unless she gets prenatal care in the first trimester. In the case of a minor who needs to work, it is just that crucial, be- cause unless the minor can get an abortion—and that means a person who is neither physically or emotionally capable of giving birth and raising the child—she is forced to have the child. The situation in California is this: If these pregnant girls were wealthy or even from middle-class families, they have recourse—they could get this medical care. This would be no problem. With a minor, poor in the sense she must go to the welfare department; and despite the fact that California law specifically excludes her parents from involvement in her medical problems, despite that fact, that policy, California does not give this minor medical care even though she qualifies, until after the welfare department has checked with the parents of the minor or has involved them in her medical care. The result of this—if the minor doesn’t get parental consent, and the in- vestigation takes a long time to do—the minor doesn’t get the care. In some cases it results in simply not being able to involve the parents in the medical care—and nv io a right not to, under Califor- nia law. The result of that is disastrous to the girl who doesn’t get the care, and has to give birth, or sometimes self-aborts. This policy has resulted in litigation. Our office is struggling to try to change that policy. There is no basis in California law for this Ley and there is no basis in Federal law, but it is the policy in the tate of California. And it is also impossible for these minors simply because in order to get that care you have to be eligible for welfare and being eligible for medical care depends on welfare; it is subject to political manipulation—and also, unfortunately, by personal abuse by some welfare workers. 2449 It is our position that these minors are absolutely in need of medical care. It is essential to their health, to their future. It is also essential to curbing the welfare cycle because these girls, if they can’t get the aid they need, they are going to have a second and third child and are going to end up on welfare. The crisis is political; it is not a financial one—it is the result of political manipulation and total lack of recognition of the problem. In order to remedy this, the only way I can see would be a separate type of medical service from welfare, have separate agencies, have no type eligible determinations they require now for welfare. That is the only way the poor are going to get adequate medical care. Senator KENNEDY. Very good comment. If we had the time, you could go through a lot of these other kinds of instances like we heard—Miss Lannon you could probably do this, working for a legal service. We had some comments at other hearings. They have an extraor- dinary access to the kind of cases we have heard this morning. This has been their experience, as well, generally where you have these consumers that are, as you identified, a very poor group in our so- ciety—but for others, as well—that are deficient in terms of. health needs and health care. Miss LanNox. Do you mean in terms of the poor? Senator KENNEDY. Yes. Miss Laxnon. I didn’t get the first part of your question. Senator KeNNepy. The kind of cases we have had this morning; and we have heard from the legal service people—you could give us a whole stack or list of people. What we are trying to find out is whether the seven people are ex- ceptions or whether you are rubbing shoulders with these kinds of people day to day in your legal service. Miss Lax~Nox. In our county we have had a lot of experience with the young people, because there are a lot of young people in this area—but the abuses this group suffers because they are denied medi- cal care the older people suffer because the delivery of medical services is denied. Middle-age people can’t get glasses. They can’t go in for surgery. Sometimes, if they have to have medical care that isn’t emergency medical care, under the medical program as it is set up now in Cali- fornia, surgery can be delayed up to 90 days—if the particular medi- cal consultant decides that he wants to delay it. They are just unlimited—the number of people that can testify as to their own personal disasters, poor persons who can do this. Senator Kex~epy. Thank you, very much. That is another reason why the CRLLA should be funded. [ Applause. ] Senator Kennepy. Percy Steele, chairman of the board of directors, Westside Community Health Center. 2450 STATEMENT OF PERCY STEELE, CHAIRMAN, BOARD OF DIRECTORS, WESTSIDE COMMUNITY CENTER Mr. Steere. Thank you, Senator. In consideration of the time factor, I will just be very brief rather than to repeat other concerns that have been expressed already this morning. Westside has had a tremendous insight into the overall problem related to comprehensive health planning, based on 3 years of experi- ence in the welfare area field of the community which is largely a ghetto area. One of the things in reading S. 3 we wanted to point out—we would like to see this health oriented rather than illness oriented because of the ramifications. And we feel that psychiatric patients should have equal freedom and access to the kind of services described in this legislative proposal. One of the secrets of an adequate health planning and health de- livery service, based on my own experience, is that there must be an opportunity for built-in participation for the residents of all levels; that is, youths, adults—not only planning for health delivery services, but carrying them out. The training aspect is one we give 100 percent support to because we do not have enough professionals and we do not have enough para- professionals in medical delivery of services—and we hope there is a strong effort to move toward this. Senator Kex~epy. Thank you, very much. Charlotte Offhouse. You have a statement here. We will put this in the record. STATEMENT OF MISS CHARLOTTE OFFHOUSE, NURSE SPECIALIST IN COMPREHENSIVE CARE OF STROKE PATIENTS Miss Orrrousk. I know it is hard to include everyone in the series, but we haven’t heard from nursing and it is a critical area. I am in the clinical nursing specialty—and from the testimony I have heard today I can verify it is true in many, many comunity agencies around the bay area. I see these things in the hospital and out of the hospital. I think in my testimony I went into detail and covered a lot of things other people said. In our present system of medicare, we have two levels of inpatient care which, again, is a very costly aspect. We have acute and subacute care; and probably the most important is the subacute aspect of care, because at the present time all of the subacute care is at a costly rate, at the acute care rate—and we really havent provided facilities to take care of the subacute. I won’t got into all of the definitions be- cause they are lengthy. But I think in our health industry we have to look at the role of the nurse. 2451 _ In the State of California—and I had trouble deciding my priori- ties because I should be up in Sacramento defending our nursing services because there are hearings on what is called skilled nursing care and that means sticking needles and tubes into people. And I would very much like to see some of the new roles for nursing man- power directly reflected in any proposed health security system such as nurse practitioners, nurses in primary care roles, clinical nurse specialists, and so forth. Certainly with the management of subacute and chronic disease coming to the fore, a recognized, responsible role for nursing should play an important and dynamic part. A current study in the Ey area indicates no shortage of nurses but demonstrates misappropriation of services in many facilities—utilization of health manpower should be scrutinized, reassessed, and clearly outlined in any new system that may emerge. A recent article in the San Francisco Chronicle told of an empty bed crisis in San Francisco’s hospitals—“a crisis so severe that many institutions here are in deep financial trouble * * * almost all major San Francisco hospitals are in the midst of an intensive building program right now or have just completed them”—perhaps a sign that we are not meeting community needs. Ironic as it may seem, that same paper told a story of a hospital in a neighboring town which is soliciting funds to build 131 acute care beds—another indication of a lack of sensitivity to community needs. For this reason alone, it is costly not to define levels of care and place limits on length of stay within the bounds of levels of need. Our present system is not defined by patient care needs. This has produced so-called abuses which are usually an attempt to provide some kind of care to patients even though it may not fall within the bounds of the system. We speak of controls and incentives, but where are they? The cost of health care will continue to increase because consumers will be rele- gated the responsibility of paying for these unnecessary and unusable facilities which are being built. Our communities—as we saw here today—are telling us loudly and clearly what their needs are, yet several groups of health professionals who have attempted to meet these needs have been denied funding or denied payment after services were rendered. 3 The present system does not permit us to meet these pressing com- munity problems—we need ess concrete and mortar and more patient services outside of the institutional setting. ] In order to best utilize existing structures it would seem appropriate to immediately engage in regional surveys of present resources and convert facilities to fit within the proposed framework of levels of care. It should be clear by now that superimposing new concepts onto old frameworks is impractical and unworkable. } If we are to embark upon a health security plan for all, let us listen to the needs of our people and meet them. Senator Kex~epy. Thank you, very much. (The prepared statement of Miss Offhouse follows:) 59-661 O - 71 - pt. 11-5 2452 TESTIMONY FOR THE HONORABLE EDWARD M. KENNEDY ON HEALTH SECURITY FOR AMERICA MONDAY, MAY 17, 1971 SAN FRANCISCO, CALIFORNIA I am Charlotte Offhouse and am presently employed as a Nurse Specialist in the Comprehensive Care of the Stroke Patient. In the past I have been a direct pro- vider of health care to patients. My present work takes me into many community agencies on a consulting basis. At the onset, I would like to commend you and your staff for your efforts to es- tablish a comprehensive national health insurance program for all our people. I read with great interest your bill to create a Health Security Program. I concur that it is critical to eliminate eligibility clauses if we believe health to be eo right for all and not a privilege for a few. After studying your proposal, I would like tc discuss with you the urgency to change our present system of health care delivery to meet community needs if we are, in fact, going to provide health care services for all. It seems reasonable that to meet community needs, we must first look at what those needs are. This can be done by defining levels of care and tten to think of alternative methods of providing services which will embrace the entire cormunity. Certainly one of the alternatives would be coordinated groups of health professionals giving primary family care. A major emphasis should be on ambulatory, out-patient care including minor surgery not requiring overnight stay in hospital. We should provide for organized out-patient programs to meet specific community reeds such as alcoholism, drug addiction, venereal disease, terminal cancer, medical diseases 2453 such as heart disease, cancer and stroke, mental health problems, family planning, maternal and child health care, environmental health problems and home care programs all geared to work with patients outside of an institutional setting when possible. There should only be enough "back-up" beds for in-patient treatment as absolutely necessary. In-patient care can be defined as follows: Acute care: crisis intervention, unstable conditions, acute exacerbations of existing conditions in need of intensive care Sub-acute cares immediate post crisis intervention, stablizing conditions in need of intensive rehabilitation Interim cares - stablized conditions in need of supportive care Long-term care: chronic conditions in need of supervision og activities of daily living If we think in terms of separating patients according to patient care needs and not by diagnosis, we could hope to have -each staff especially trained in certain activities which would pertain to that particular level of care. For example: staff in an acute unit would be prepared for admissions on a 24-hour basis. They would be equipped to start intravenous feedings, draw blood, take and interpret electrocardiograms and make critical observations. There might be 24-hour physician coverage if necessary. All staff should be involved in rehabilitative measures but the staff in a sub-acute unit would be specifically trained in teaching patients to transfer safely, offering psycho-social therapeutics and other such rehabilitative measures. I have attempted to outline the levels in a progressive order from acutely ill to well patients. A patient should be able to enter the progression at any point that is 2454 deemed necessary by his care needs. It would be a rare instance that one patient would need care from all of the units but the following sequence might occur: A woman aged 28, undergoing a prematiral examination, is diagnosed as having metastatic cancer. After being informed of her status she becomes suicidal and rejects her family and friends. Under the proposed system, her physician would enter her into the sub-acute level of in-patient care for intensive rehabilitation: psycho-social therapy, recreation therapy and diet therapy to help her overcome her fears and better understand her disease process. This therapy would also provide support for her fiance' and family. When her condition stablizes she could return home and receive drug therapy as an out-patient. When she evidences further me- tastesis and if acute care is indisated, she could be adnitted to an acute care unit for radical surgery. Such surgery could precipitate a deep depression. As soon as physically possible after surgery, she would be transferred to the sub-acute unit for continued psycho-social therapy and post-operative care. At this point her condition may become terminal. She can be successfully discharged to a home care program which has been coordinated with her in-patient care. The home care program will provide the necessary support and services throughout her final stages of life. Perhaps the most critical area in this scheme is the sub-acute level of care. In today's system of care the acute facility has been the seat of all health care de- livery. The Medicar, Law has defined two levels of in-patient care =- acute and 2455 extended care. This program philosophically encompasses existing hospitals and nursing homes but in reality new terminology was coined for traditional health care services, Extended care has been delegated to the nursing homes and convalescent hospitals which have been certified as Extended Care Facilities. By and large, these facilities are neither staffed nor equipped to properly handle sub-acute care. Thus sub-acute patients are remaining in acute beds which creates a costly program. Usually, by the time a patient is transferred to an extended care facility he is well into or already passed the sub-acute phase of illness. Then, because care needs do not fit into the system, confusion results from trying to justify the need for further in-patient care. Modern medical advances have greatly reduced acute illness in this country. If we are to embark upon a new system of delivery, I think it imperative that we identify and give credence to the management of Sbraratertiineses This can be done by analyzing patient needs. Under our present insurance systems we have the term "covered care." This has hidden meaning, is ill-defined and often leaves patients with unanticipated health bills because benefits are denied after the fact as "non-covered care." Hopefully, if we institute a system of clearly defined levels of care "covered care" could be specifically differentiated from "non-covered care.” I have seen interpretations of the Medicare laws vary from time to time and place to place. A patient in one facility is covered when a similar patient in another facility is denied as the result of undefined guidelines. Some attention must be paid to who will provide which services and at which level. Acute care takes place in present-day units such as intensive care units, coronary care units, stroke intensive care units, etc. Most sub-acute care is given on 2456 5 general medical and surgical units in acute hospitals. If an extended care facility were specially staffed and equipped, sub-acute care could be provided out of the hospital setting at a lower cost but the cost for this care should be higher than the present rate of reimbursement for nursing home extended care beds. Interim care and long term care could be provided in present-day nursing homes at lower costs than the first two levels of care. Such deliniation eliminates the false concepts that nursing homes can provide extended care or that acute hospitals should continue to offer sub-acute services while being reimbursed at acute rates. If there were more definitive separation in levels of care, both hospitals and nursing homes could specialize in their own area of expertise. I am aware that these ideas are non- traditional and will be resented or misunderstood by most people in today's health care industry. One of the most unfortunate problems I have seen evolve from the Medicare program which I would like to see reversed is the role of nursing. In no way does the definition of covered care reflect what nursing really is. The only nursing care which is recognized is called "skilled nursing care" and that basically reflects sticking needles and tubes into people. We in nursing are aware of various and often conflicting public opinions of what nursing is. Some of this confusion is generated from within the profession itself. The recently published Lysaught Sop: which is the report of the National Commission for the Study of Nursing and Nursing Education has made great strides in defining nursing roles in present-day health care. I 2 recommend this report to anyone concerned with national health and would very much like to see some of the new roles for nursing manpower directly reflected in any proposed health security system such as nurse practitioners, nurses in primary care 2 Lysaught, Jerome P., An Abstract for Action, McGraw-Hill Book Company, New York, 1970. 2457 6 roles, clinical nurse specialists, etce.. Certainly with the management of sub-acute and chronic disease coming to the fore, a recognized, responsible role for nursing , should play an important and dynamic part. A current study in the Bay Area indicates no shortage of nurses but deminstrates misappropriation of services in many facilities: utilization of health manpower should be scrutinized, reassessed, and clearly outlined in any new system that may emerge. A recent article in the San Francisco Chronicle told of an empty bed crisis in San Francisco's hospitalsv-"a crisis so severe that many institutions here are in deep financial trouble...almost all major San Francisco hospitals are in the midst of an intensive building program right now or have just completed TR perhaps a sign that we are not meeting community needs. Ironic as it may seem that same paper told a story of a hospital ina neighboring town which is soliciting funds to build 131 acute care beds =~ another indication of a lack of sensitivity to community needs. For this reason alone it is costly not to define levels of care and place limits on lengths of stay within the bounds of levels of need. Our present system is not defined by patient care needs. This has produced so called "abuses" which are usually an attempt to provide some kind of care to patients even though it may not fall within the bounds of the system. We speak of controls and incentives but where are they? The cost of health care will continue to increase because consumers will be relegated the respon- sibility of paying for these unnecessary and unusable facilities.’ Our communities - are telling us loudly and clearly what their needs are yet several groups of health professionals who have attempted to meet these needs have been denied funding or denied payment after services were rendered. The present system does not allow for accommodation to these pressing community problems: we need less concrete and mortar and more patient services outside of the institutional setting, In order to best 1 San Francisco Chronicle, londay, May 10, 1571, Page 1. 2458 utilize existing structures it would seem appropriate to immediately engage in regional surveys of present resources and convert facilities to fit within the proposed framework of levels of care. It should seem clear by now that superimposing new concepts onto old frameworks is impractical and unworkable. If we are to embark upon a Health Security plan for all let us listen to the needs of our people and meet them. Prepared by: WD CHARLOTTE D. OSFEOUSZ \ Nurse Specialist 2459 REPORT OF THE CALIFORNIA TASK FORCE ON DENTAL CARE IN NATIONAL HEALTH INSURANCE PROPOSALS February 6, 1971 2460 REPORT OF THE CALIFORNIA TASK FORCE ON DENTAL CARE IN NATIONAL HEALTH INSURANCE PROPOSALS INDEX Page I. Introduction | 2. Composition of Task Force | 3. Health Care as an Essential 2 4. Need for Dental Services 4 5. Education of Dental Health Professionals 5 6. Prevention . 2 7. Eligibility 10 « 8. Organization and Administration 10 9. Delivery System 3 10. Quality and Cost Control } } 14 Il. Peer Review: An Essential Factor of Quality and Cost Control 16 12. Cost and Program Design 18 2461 REPORT OF THE CALIFORNIA TASK FORCE ON DENTAL CARE IN NATIONAL HEALTH INSURANCE PROPOSALS INTRODUCT ION The California Task Force on Dental Care in National Health In- surance proposals was charged to develop suitable dental health planning recommendations for consideration by legislators, health professionals, and consumers concerned with current legislative activity in the field of national health insurance. Members were requested to review current health planning at state and national levels, the present systems of dental care delivery, utilization of dental manpower, education and also some of the logistic fac- tors directly related to dental health program planning. This summation of task force deliberations addresses the issue from a background of information developed to insure an under- standing of a basic practical philosophy which it is believed must be the foundation for sound national health planning. It also describes direct program elements Witt recommendations designed to reflect a sound and necessary position for dentistry in NHI plan- ing. COMPOSITION OF TASK FORCE Members of the California Task Force were selected for their in- terest and expertise in various facets of health care, from a cross section of ethnic and income groups, representing consumers, 2462 == insurance carriers, labor, industry, government and dentistry. HEALTH CARE AS AN ESSENTIAL Past history shows that whether the origin of any given health program is private or governmental, there are seldom adequate sources of funds to provide total health care for all. This has led to severe competition of priorities by those who design health programs. The designers are not always legisla~ tors or government officials. They may be recipients of care motivated by desires related to their own needs, with subsequent communication to some collective agent, representatives in government, or an insurance company. In the race to establish the priorities of health care and by virtue of limitation, it became necessary to define what was to Establishment of constitute the "basic essentials" of health, the base from which Priorities all additional health care programs would pyramid as superstruc- ture. The base has been defined under federal law (Title XIX) and is the mandate to be used by states in considering the avail- ability of federal funds in existing programs. To date, as out- lined in Medicaid (Title XIX) Guidelines, the federal government has not included dentistry as a "basic essential" service. Presently, oral health care is defined as an elective service by legislators and administrative officials. Program designers have frequently expressed the hope that sufficient funds would be available to provide some oral health care Services at the onset of proposed health programs and that at some later date, such pro- visions would be expanded to include comprehensive oral | 2463 health care services. This expectation is seldom realized; in fact, the reverse is true. In California, for instance, government sponsored dental care has repeatedly been one of the first services to be reduced or omitted when budget deficits occurred. This has been demon- strated as recently as December, 1970 with Medi-Cal cutbacks. At one time, only a legal technicality prevented total elimina- tion of all dental care under the California Medicaid program. Other "elective" services have suffered the same dilemma. A dichotomy apparent to many in the dental profession is that in medicine there are electives which are included with Messen- Oral Health as an tials"; in dentistry "essentials" are included with "electives". Essential Service An understanding of the dichotomy should make it apparent that it is impossible to virtually eliminate all oral health care as a non-essential in regard to basic health care, or to avoid its vital essentiality in consideration of total health care. Conversations in depth with governmental administrators have demonstrated their understanding and agreement with this premise. Therefore, for the benefit of the people who are demanding that their right to adequate health care be honored, it is critically : Right to Oral Health Care important that they be entitled to a proper definition of essen- tial health care. That defintion is faulty without the inclusion of oral health care. There is no more logic to arbitrarily ruling out the treatment of disease of one part of the human anatomy, i.e., the oral cavity, than there is in deciding to treat deseases of the right arm while ignoring the left. 2464 -4- The long standing principle that denfal care is an essenii. component of total health care must be strongly reinforced. Dental Components of Dental care must be on a parity with other essential health Health Programs care services in all public and private health programs. The dental components of such programs should include diagnosis and prevention, education and motivation, and treatment and maintenance. NEED FOR DENTAL SERVICES There are many reasons underlying the generally accepted fact that the dental needs of our population are not being met. These include manpower shortage and maldistribution, economic. barriers, and lack of educational acceptance and motivation. Incentives to attract dentists to areas of greatest need should be provided in order to help correct the problem of maldistri- . Maldis tribution of bution. One method would be to establish government or privately- Dental Manpower sponsored scholarship grants and incentive loans for dental students, fied to emphasis on location in designated need areas upon graduation. Designation of areas of need and numbers of dentists required should be made by the regional comprehensive health planning agencies. Substantial government loans should also be made to finance office development including remodeling, equipment and initial supplies to those who are willing to prac- tice in designated need areas. Incentive loans should be interest free until graduation from Incentive Loans dental school and should be forgiven on a graduated scale with 2465 5m increasing increments for each year spent in practice in a des- ignated need area. |f a dentist secures both an educational loan and office development loan, both loans could be considered under the forgiveness concept. Manpower needs are not limited to dentists alone, but apply to dental auxiliaries as well. The dental profession recognizes Auxiliary Manpower its obligation to initiate and direct programs under its con- Needs trol which will: : I. Increase the number of auxiliaries employed by dentists. 2. Effect better utilization of present auxiliaries under existing laws. 3. Review and revise dental practice acts where necessary to encourage involvement in expanded duties for auxiliary mem- bers of the dental health team. EDUCATION OF DENTAL HEALTH PROFESSIONALS Dental schools in the United States, while expanding enrollment in existing facilities and adding to the number of teaching in- Dental Manpower stitutions, are not keeping pace with current population growth, Shortage Future projections do not show improvement in the ratio of den- tists to population. Recent figures released by the United States Public Health Service show an estimated current shortage of 17,800 dentists by 1980. California licenses at least one third of needed dental manpower from dentists trained outside the state. This is also true of other populous states, with a resultant serious, net manpower loss to those states which are unable to retain health professionals who have been trained in their state. 2466 -6- Emphasizing educational needs, the Carnegie Commission's report on Findings C { Higher Education and the Nation's Health, released in October 1970, gs of Lormegie suggests a 20 percent increase in dental school enrollment by 1980 Commission with greatly expanded educational facilities. It also suggests the adoption of uniform tuition fees for health professions schools in the range of $1,000 per year, per student. State subsidy grants to private health professions schools in order to avoid Berrumics coupled with increased federal subsidy, is recognized as a pressing need. The Task Force is in agreement with these concepts. At present the health professions do not show proportional representa- tion of recognized minority groups. Incentive programs consisting Minority of financial assistance should be encouraged by the health professions Students to motivate minority individuals to enter the health professions. Education in the health professions has always been costly, but in recent years expenses have soared. Dental Education is now the Cost of Dental most expensive career to pursue from the standpoint of doctoral ex- Education pense, since it involves equipment and supply expenses as well as the costs of tuition and living. Unfortunately, government sponsored . scholarship funds have been decreasing in recent years rather than in- creasing and the debt profile of students in dental schools across the nation is reaching critical proportions. Recent action by the American Dental Association House of Delegates ri : : American Dental has approved guidelines for more flexible curriculum development and . Association operation in dental schools than was previously allowed. This should al- : Guidelines low action by educators to improve educational opportunities related to increase in and better utilization of all types of dental manpower. While recognizing the need for manpower, this Task Force also strongly recommends that 2467 -7= research in health professions institutions, especially related to prevention, should be strongly urged and funded at aoonrotrizte levels. It seems certain that the principle of prevention, strongly im= planted in students during the educational process and reinforced Preventive Measures by research activity of health professions scholars, is the only certain way that reduction of dental needs will be met in a way which may make it possible to meet the demand for services in the foreseeable future. Without this approach, ramified throughout the profession, remedial. rehabilitative care will continue to overburden our health manpower pool and unnecessarily drain pri= vate and governmental fiscal resources. PREVENT ION The philosophy of prevention as a priority must be incorporated at the inception of national health insurance coverage, if the objective of massive reduction of dental disease is ever to be met. Preventive measures in a national health program must be effective in preventing oral disease practical for incorporation on a large scale and combined with incentives to encourage use of preventive measures. Since water fluoridation is the most effective preventive dental measure presently available, a national health insurance program tater Fluoridation must encourage its use. Incentives should be provided for those consumers in states or areas which require fluoridation and for patients of specified ages who take a prescribed course of pre- ventive topical fluoride treatments. 59-661 O - 71 - pt. 11 - 6 2468 Br It is recoanized that comprehensive dental care should be avail- able to all persons. However, studies have shown that a given Preventive Care fon amount of money will provide care for more young patients than older patients. Money spent on the care of the young can be, oe in effect, returned to the program by eliminating the need for expensive procedures at a later age. Sound dental health plan- ning and sound fiscal planning both encourage and emphasize care for the young recipients. The dental profession believes that primary emphasis of preventive dental care should apply to pre- schoolers through age 18. Evidence points to the fact that there is a need for innovation in dental health education, both in the dental office and other settings adapted to meet the specific needs of particular target populations. Educational material presented to the patient should include in- formation as to where and under what conditions dental care is Educational Material available and how such care will be paid for. Information should be provided on specific preventive techniques such as topical fluoride applications, plaque control, carries prevention, nutri- tion and diet, oral care during pregnancy, home care for the periodontal patient, the orthodontic patient, ‘etc. Clearly, the dental office provides an ideal opportunity for the dentist tc educate and motivate the patient on a one-to-one basis. Patient Education in It is recognized that at present health education in the dental Zhe Dental Office office is sporadic and that the dentist's time may be better util- ized in providing care that only he is qualified to perform. 2469 Therefore, emphasis should be given to innovative approaches which improve the "one-to-one" educational approach in the dental officeby utilizing auxiliaries and audiovisual methods and materials to ef- fect productive patient education. Established school dental health programs are also very impor- tant. They must be continued and improved. Any dental health A Dental Health school program must be preventive oriented. Present school den- Education tal health education, like much of the dental office education, in the Schools is sporadic, with some schools providing relatively good preven- tive programs and others virtually no programs. The minimum content of a school program should include an audiovisual pre- sentation on dental health concepts and an annual dental examin- ation of the school children by a a or dental hygienist with a report to the children's parents. Effective follow-up ‘must be used to ascertain that children receive needed care. The use of community health aides to provide fol low-up and to & educate patients has proven to be quite effective, especially 3 Community Health Aides in low income areas. Use of community health aides in an OEO center has raised the recall utilization rate for dental ser- vice from 22% to 87%. Funds should be provided to train com- munity aides for use in connection with health insurance pro- grams where necessary. As noted earlier, factors directly related to detailed planning of a health program were studied in addition to consideration of essential ity of care, need for services, manpower needs and pre- ventive measures. The following recommendations relate to program 2470 -10- details of eligibility, organization and administration, delivery systems, quality and cost control, and cost and program desi... PRIORITY This Task Forcestrongly believes that there is an immediate and imperative need for clear reordering of the nation's priorities; that it is now time for this nation to adopt as national policy, the right of dignified access to total health care for all its residents, unobstructed by racial, ethnic or economic barriers. ELIGIBILITY In developing and implementing a national health program, funda- mental consideration must be given to providing dental care cover- age, including preventive and remedial dental services, for all residents of the United States. ORGANIZATION AND ADMINISTRATION A National Health Insurance Program Board should be established which will be responsible for public accountability of the total National Health NHI program. The Board should have significant dental represen- Insurance tation; furthermore, it would seem logical that the Board be re- : Program Board sponsible to the Secretary of Health, Education and Welfare Department (HEW). A National Dental Advisory Committee should also be formed, com- posed of members of the dental profession and of the public at National Dental large, in order to insure both professional and consumer orien- Advis ony tation of program development. The Dental Advisory Committee : Committee 2471 would be responsible for recommending scope of benefits, stand- ards for dentist participation, quality control and policy guide- lines regarding actual delivery of dental services. The National Health Planning Board, with the assistance of the Advisory Committee, should work to assure efficient administra- tion and effective coordination of the program by using existing private health agencies for fiscal administration. These agen- cies should compete for administrative contracts. The National Health Insurance Program Board and the Dental Ad- visory Committee should be represented also at the regional, * state and local levels. Such a system would assure a greater response to the needs of the public and the providers of care. In consideration of the organization and administration of a dental care program under a national health insurance program, the following recommendations are emphasized: I. The fee concept adopted for reimbursing the provider of services must be on a parity with all health disciplines included in the program. 2. The program should be established on a fee-for-service basis reflecting usual, customary and reasonable charges, adopting the concept of establishing individual fee pro- files. The unique advantage of the usual, customary and reasonable concept over other methods of reimbursement is that it will insure wide professional acceptance of a Regional, State and Local Representation Fee Parity Fee-fon-Service Concept 2472 -12- national health insurance program and will thus allow eligible patients to have a meaningful choice of practitioners when seeking dental care. Additionally, the program should . encourage exploration of other fee systems. 3. The administration of the plan should provide a mechanism for clearly determining the scope of benefits and the eligibility Scope of of the recipients. If a recipient is to make direct payment Bene fits for partial or selected services, predetermination of total financial responsibility should be clearly outlined. 4. Maximum care should be exercised in the overall organization and administration system so that it does not work to the disadvantage of dentists in lower income areas nor place a stigma on any recipient. It is recommended that existing fiscal intermediaries, on a competi- tive contractual basis, establish processing centers to perform all Processing administrative phases of dental forms processing. These centers J Centers should be established in locations conducive to maximum efficiency. Personnel should be professionally oriented to assure competence in administering ‘the provisions of the national health insurance program. The processing centers should I following functions: I. Provide dentists with dental treatment planning forms; re- Functions of ceive and organize dental statements from dentists who Processing Centers render covered services to eligible patients. 2473 -|3- Determine if treatment is within the scope of benefits and regulations established by the National Health Insurance Board. Select cases for review by regional dental consultants, in- cluding but not limited to the following: Regional Dental Consultants a. Those which present irregular treatment patterns b. Those involving patient complaints regarding satis- faction of services. c. Those randomly selected for post screening, in suf- ficient quantity, to assure that a high grade of service has been performed. Problems related to review which cannot be resolved by regional consultants should be referred to the appropriate counselling or review committees of the state dental association. Prepare checks for payments to dentists. Serve as distribution center for communication with dentists con- cerning program developments and changes under the health program. Aid in liaison and coordination with the dental profession at the local level. DELIVERY SYSTEM Since there are a variety of systems which may fit specific needs, no one delivery system should be penalized at the expense of another. In a national health insurance program,the recipient should have the right to Free Choice 04 Delivery Systems 2474 ym unrestricted choice of available delivery systems. At the same time, recognition should be made of the right of the dentist, for profes- sional reasons, to choose the patients he will treat. It is recognized that a national health insurance program may be implemented before full comparative studies of different methods ! P P } Comparative Studies "of delivery can be completed and evaluated. However, such studies should be undertaken as soon as possible in order to obtain valid supportive data relating to positive and negative points of various delivery systems. Studies should measure efficiency on the basis of: I. Increased productivity 2. Quality of service 3. Patient utilization 4. Acceptance of the system by the public and the dental . profession 5. Cost of operation. QUALITY AND COST CONTROL Quality and cost contrél should provide mechanisms for controls within a system of national health insurance to insure that the best possible care is being delivered under the limitations of funding and.that care being provided meets standards of reasonable cost. Cost must be considered reasonable by both the financing agency and the provider if the level of quality is to remain sound. 2475 -|5= Under any health delivery system, cost would be considered the dollar outlay expended by the funding agency to achieve a unit 3 Definition of Cost of treatment. This would include individual payment of the pro- vider and also associated administrative costs. If a unit value system is used, it would be translated into the cost per unit required to deliver the care to the patient-recipient. Although the cost of a program necessarily includes expense for organization and administration, these costs could outweigh the Control of Costs cost of the treatment provided if they are not properly controlled. For this reason, the competitive system in the administration of public or private programs is vitally ‘important. To attain optimal cost control, long range consideration must be given to the type of treatment provided. Preventive and Prevention and Early early treatment, especially for children, must be emphasized Treatment of Children as a most effective cost control measure which will avoid costly treatment in the future, resulting in — savings and maximum utilization of the funds available. For example, it has been demonstrated that the cost of onepartial denture for a recipient who has been missing teeth for many years would provide care for six chiidren in a fluc-idated area and three children in a non-fluoridated area for one year. Regular maintenance of oral health care as a concomitant effective method of cost control must also be encouraged with financial incentive to the provider where possible. In considering quality control in a program of health care, Definition of Quality attention must be given to the exact definition of what is Control 2476 -16- being considered. Quality may be defined as a class, kind or grade of treatment; the term itself does not denote excellence, i.e. quality may be excellent, good, fair, acceptable, pccr or unacceptable. To be effective, quality standards of dental care must be controlled by Evaluation the dental profession, with guidelines set by the profession itself. and Control of Evaluation of quality should be provided through peer review, using Quality random sampling techniques for selection of consumer and provider parti- cipants, in addition to review initiated through complaint. The possible problem of lack of interest in participation, especially by the satisfied consumer, would be avoided by clearly stipulating that both provider and consumer be required, as program participants, to accept random sampling evaluations if selected. PEER REVIEW: AN ESSENTIAL FACTOR OF QUALITY AND COST CONTROL A challenge was issued to dentists and physicians in the July, 1969 "White " 1 . "n House Report on Health Care Needs", which declared: We will ask and White House challenge the physicians, dentists and other practitioners of the nation Report through their national Societies and through the County Associations to establish procedures to review the utilization by their members...and to discipline those who are involved in abuses." In November of 1967, the National Committee on Health Manpower recommended ‘ Saad ret Peer Review that professional societies, health Insurance organizations and government Procedures . extend the development and effective use of a variety of peer procedures in maintaining high quality health care. The Task Force believes these pro- cedures should incorporate the following principles: 2477 =P I. Peer review should be performed at the local level with professional societies acting as sponsors and supervisors. Consumers of health care should also be represented on peer review committees. 2. Assurance must be provided that evaluation groups perform their tasks in an impartial and effective manner. 3. Emphasis must be placed on assuring high quality performance and on discovering and preventing unsatisfactory performance. A peer review committee should have responsibility for quality evaluation, determining utilization and evaluation of cost/unit Quality Evaluation patterns to assure the highest level of care possible at reason- Procedures able cost to a program. When a peer committee determines that care provided by an individual is below the acceptable level it ‘must have the authority and wisdom to properly discipline that individual. Such discipline should, if necessary, extend to ex- clusion of the provider from the program. In addition, the com- mittee should encourage better standards of care by requiring further training or post graduate study if necessary. A bipartite peer review system with consumer representation that is included in any dental insurance program is invaluable in demonstrat- ing to the public that the dental profession will not white-wash abuses and that those few men who violate their professional trust will be disciplined by their peers. : 2478 -8- The Task Force recognizes the conflict between optimum desirable services and available funds. In this regard, the Task Force recommends that the concept of patient copayment should be utilized, where necessary, as a device to (a)broaden the scope of services and (b)to control program uti- lization and cost. However, the Task Force recommends that the copayment concept should be avoided in the case of (a)emergency care for all partic- ipants and (b)with respect to preventive care for children. . Copayment should also be held to a minimum with respect to other children's services through age 18. As stated, the Task Force emphasizes the need for comprehensive care for all residents of the U.S.; it also recognizes that certain areas of dental care may remain outside the scope of the initial national health insurance program because of fund limitations. This fact may require that program designers know what specific services can be obtained according to the amount of money available. The Task Force therefore recommends six plans which delineate services relative to scope of benefits and cost. The pro- posed level of benefits Is summarized as follows: PLAN I: . COMPREHENSIVE: This Plan provides for: a) Preventive & Diagnostic b) Basic --Operative --Oral Surgery --Periodontics --Endodontics c) Prosthodontics d) Orthodontics PLAN 11: Includes the same benefits as Plan | except for (d) Or- thodontics. PLAN 111: Includes the same benefits as Plan | except for (c) Prosthodontics and (d) Orthodontics. PLAN 1V: EMERGENCY ONLY Provides for elimination of pain and acute infection. 2479 -19- PLAN V: CHILDREN'S PROGRAM TO AGE 18 - This Plan provides for: a) Preventive & Diagnostic (including space main- tainers) b) Operative (amalgam, silicate and plastic res- torations)--stainless steel crowns and crowns for fractured anteriors. c) Endodontics d) Oral Surgery . PLAN VI: Combines Plan IV for adults and Plan V for children. The estimated cost of each plan can be expressed in units with Plan | being designated as a base of 100. Plan | =. 100 Plan Il = 90 to 95 percent of Plan | Plan Ill = 64 to 69 percent of Plan | Plan IV = 5 to 7 percent of Plan | Plan V = 22 to 26 percent of Plan | Plan VI = 28 to 32 percent of Plan | 1f Plan | for optimum care cannot be funded immediately under NHI, the Task Force urges that funding be attained within five years from the initiation of a national health insurance program. With respect to those services not included in the initial national program, the Task Force recommends that existing private plans continue to provide den- tal care coverage at a level which in no way reduces the amount of coverage provided prior to the advent of the national program. Further, any savings realized by existing programs through benefits provided under NHI should be utilized to improve the overall level of care in conjunction with the national program. 2480 -20- \ The Task Force recognizes that present national health insurance proposals contain recommendations for several methods of financing, which generally include the following: 5. Employee contribution through social security taxes. Employer contribution through payroll tax. Government subsidy from general revenues. Tax credit. A combination of the above. Irrespective of the method of financing a national health insurance program, comprehensive dental care must receive the same priority as other essential health services. 2481 Senator KenNepy. We are going to have to recess the hearing—but before we do, if there are others who would like to comment we ask them to send us their comments and we will include them in the record. We will keep the record open for 10 days. And also, if you want to write to me in care of the Health Subcom- mittee of the Senate—we value that. Again, I want to thank the school administration for their kindness, and to thank all of you—you have been enormously attentive and in- terested and I think it has been a very worthwhile and valuable hear- ing—and in terms of the total record to the Senate—I am sure it is going to give all of us in Congress a much better insight into the prob- lems, in human terms, that are affecting so many people. I want to thank all of you for your attention and your kindness in being with us today. (The material referred to follows:) 2482 STATEMENT OF CALIFORNIA BLUE SHIELD SUBMITTED TO THE SENATE SUBCOMMITTEE ON HEALTH CARE OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE Thomas C. Paton, President California Blue Shield May 17, 1971 2483 TABLE OF CONTENTS 1. Statement of California Blue Shield 2. Exhibits: IL Operating Highlights for the Medi-Cal and Medicare Programs II. California Blue Shield Utilization Review Plan for Government Programs; and Re=- print from California Medicine: Utilization and Peer Review. III. Estimated Reduction in Physicians' Billed Charges - Government Programs 1970 IV. Sample Subcontract between California Blue Shield and Foundations or Medical Societies 59-661 O - 71 - pt. 11 = 7 2484 Although a previously scheduled meeting prevents my attending this hearing, California Blue Shield welcomes the opportunity to submit this statement for the committee's consideration. California Blue Shield began in 1939, the nation's first statewide nonprofit medical care plan. During the succeeding thirty two years we have matured into an organization that now serves 5,422,000 Californians (about 28% of the state population) through our regular Blue Shield programs and the three government programs where we act as intermediary or carrier -- Medicaid (called Medi-Cal in California); Medicare; and the Civilian Health and Medical Program of the Uniformed Services, popularly termed CHAMPUS. During 1970 a total of 43 million claims were paid for benefits provided to beneficiaries by physicians and allied health care professionals participating in these four programs. The total value of the benefits received was $680 million. The overwhelming majority of physicians in private practice in this state are Physician Members of California Blue Shield. As of now, such membership totals over 19,000 physicians, who have entered into agreements with Blue Shield to provide service benefits to subscribers. Throughout the state we employ 3,000 persons in the administration of these claims for medical care benefits. Attached to this statement are pages showing the operating highlights for the Medi-Cal and Medicare programs in the years 1967 through 1970. In 2485 this statement I would like to direct the Committee's attention to (I) the Utilization and Peer Review programs now operating for all our programs, including Medicare and Medi-Cal, (2) our network of local and regional operations, and (3) our concerns about utilization of services. Utilization and Peer Review California Blue Shield -- in cooperation with the California Medical Association, its component local medical societies, the Foundations for Medical Care and other associations whose members provide services within Blue Shield administered programs -- has developed a comprehensive system for utilization review. The purpose of this review system is to measure the quality of care and the frequency of use. The emphasis is corrective and educational -- not punitive. The system seeks to control cost and quality with equity for the patient, the provider, and the purchaser. From a system where medical advisors reviewed problem claims and cases individually, with the advisor exercising his best judgment to determine unnecessary services, it has evolved into a sophisticated program where primary utilization auditing is done by computer. First, area "norms" for physician performance are established through computer stored data. Against these norms the individual performance of each member of the group can be compared. Computer generated reports of providers whose pattern of practice differs from the norms are printed out for medical review. Any other related data about the physician is 2486 collected and the ''case' is forwarded for review by a Blue Shield medical advisor in the provider's specialty. This is the first level of peer review. Where the medical advisor finds unacceptable practice he may handle the matter himself, working with the provider. Failing resolution of the problems, he will refer the case to the local county peer review committee serving the provider's county. This is the second level of peer review. The review committee reviews the '"case' and makes a determination -- upholding Blue Shield's findings or not. Additionally, in cases that appear to involve fraud, the matter is referred to the proper authorities. This is the third level of peer review. As a final level of peer review, in the event either party continues to disagree with the decision, provision is made for appeal to the California Medical Association or, in the case of a non-physician provider, his allied health field association. More detailed information about this sytem is included in the exhibits. In 1970 estimated reductions in physicians' billed charges resulting from medical advisor performance totalled $12,567,000. In addition, estimated reductions resulting from committee and Utilization Audit Review staff performance amounted to $520,000. This review activity, together with the application of our Profile System and the application of program percentiles, produced estimated reductions in physicians' billed charges totalling $66 million in 1970. The detail of these 2487 estimated reductions is set forth in Exhibit III. Regional Operations Through a series of contracts and subcontracts with 17 county Foundations for Medical Care and Medical Societies claims in 31 of California's 58 counties are reviewed locally before being transmitted to the central office for payment and record maintenance. (Sample subcontracts are included as exhibits.) This localized claims review provides for on the spot resolution of incorrect or incomplete claims, it provides local examination of claims for both charge and utilization patterns, and it facilitates local peer review. Local peer review, pioneered under this system as an integral claims processing function, now is achieving national recognition as an essential ingredient in utilization and quality control. It is important that this local review is accomplished while the significant advantages of a statewide information bank and payment procedure are retained. Our most recent local claims processing operation began in April 1970 in Compton, the southeast area of Los Angeles County. Because of the high welfare population -- Los Angeles County produces about 40% of the total statewide volume of Medi-Cal claims -- the Compton office was set up to process claims for physicians' services rendered to Medi-Cal patients in the area. Medical review of the claims is performed by Medical Advisors recruited from the communities served. As an example of the smoothing out of claims processing that can be accomplished through localization, when the office was first set up, 4% of all claims required review. Now only 1% require review. During the first four months of 1971, claims processed through this office are averaging 55,000 per month. fie 2488 Regional claim processing and review has progressed steadily in California in recent years. This approach will be expanded to new geographical areas and provider groups whenever local capabilities mature to the point where significant advantages will accrue to both the programs and the people being served by these programs. Utilization Concerns For the information and record of the Committee, I have submitted several exhibits which illustrate some of the administrative and professional practices in utilization control. Included are a description of computerized Peer Group Norms and a sample subcontract between Blue Shield and Foundations for Medical Care. Our experience in administering health care programs has verified that abuse or misuse is centered in a relatively small number of providers of health care services. The medical profession in California has been most willing to discipline and educate physicians who misuse or abuse the programs. Our emphasis in utilization thus far has been almost exclusively aimed at over utilization. The reductions that are being made in billed charges -- $66 million during 1970 -- clearly demonstrate the conservation of the tax * dollars and the private dollars paid for health care. Our next proper concern in utilization is that of under utilization of services. Here we are talking about needed services not being supplied for one reason or another. We are already experiencing the squeeze on state and federal budgets that require cut-backs in 2489 Medi-Cal and greater patient participation in the cost of Medicare benefits. We can anticipate that introduction of Health Maintenance Organizations and the spread of capitation payment programs may sharpen the concern over the potential for under utilization because of the incentives to reduce services in order to stay within the capitation payments. Clearly, an effort in the direction of under utilization will not be based upon the conservation of dollars. However, as new systems are developed, there must continue to be concern for both the dollars involved and the quality of services, and for both over utilization and under utilization. MEDI- CAL HIGHLIGHTS . 2490 Exhibit I (a) 1967 - 1970 1967 1968 1969 1970 Eligibles & 1,407,739 1,541,391 1,774,336 2,174,486 Claims Received 19, 903,000 21, 551, 000 28,761, 000 34,573,000 Claims Processed 19, 975, 000 20,762,000 29, 648, 000 34, 446,000 Benefits Paid $225, 858,000 $228, 443, 000 $313,450, 000 $389, 946, 000 Average Benefit per Eligible by Provider Type: Physician $ 92,65 $ 81.99 $ 94,01 $ 93.87 Other Medical 16,17 15.42 21,08 20,87 Dental 21,41 20,13 23.26 25.69 Drug 30,18 30.70 38.34 38,95 Total Benefit per Eligible $160.41 $148.24 $176.69 $179.37 Operating Expense Average per Claim Processed $.45 $.50 $.50 $.56 Operating Expense as a Percent of Total Program 3.9% 4.4% 4.5% 4.7% Costs Average Daily Claims Processed - - -- 139, 338¢/ Monthly Average Preliminary y y 4 Source: California Department of Health Care Services Reports Based upon September-November 1970 California Blue Shield Prepared by: Corporate Planning and Research California Blue Shield May, 1971 2491 MEDICARE HIGHLIGHTS Exhibit I (b) 1967 - 1970 1967 1968 1969 1970 Eligibles 8 1, 048,500 1,110,500 1,140, 250 942,200 Claims Received 3, 669,000 4,265,000 4,800,000 4,890, 000 Claims Processed 3,410,000 4,160,000 4,877,000 4,976, 000 Benefits Paid $115, 085,000 $129, 747,000 $148,268, 000 $137, 898, 000 Average Benefit per Eligible $109,76 $116,84 $130,03 $146, 36 Operating Expense Average per Claim $2.11 $2.39 $3.32 $3.19 Processed Operating Expense as Percent of Total 5.9% 7.1% 9.8% 10.3% Program Cost Average Daily Claims Processed - -— -— 18, 1539 8 Annual Average IY Estimated g Based upon September- November 1970 Source: Social Security Administrative Reports California Blue Shield Prepared by: Corporate Planning & Research California Blue Shield May, 1971 2492 Exhipit II (a) THE CALIFORNIA BLUE SHIELD UTILIZATION REVIEW PLAN FOR GOVERNMENT PROGRAMS Propared by: Providor Roview Division California Blue Shield Rev. 1 September 1969 2493 ADDENDUM September 1, 1970 The Utilization Review and Control Program, explained in some detail in the following pages, remains essentially as reported, with the following changes and update of performance data: | 1. The early computer casefinding system referred to in the original document has been completely replaced by the new Peer Group Norm Comparison technique -- also described in detail in the original document. Peer Group Norm Comparison provides a 100% audit of all providers and each procedure performed, furnishing an exception listing of all providers exceeding any one norm. . California Blue Shield currently employs 170 Medical and Allied Health Field Advisors. 3. California Medicine and Paramedical Associations provide 117 local peer review committees consisting of more than 1,600 private practitioners who donate in excess of 100, 000 man hours per year to the review of utilization cases arising out of the three governmental programs administered by Blue Shield. Updated Performance Data 1969 Title XVIII (Medicare) Performance. 18, 642 Individual claims reviewed by Advisors. 290 Major Utilization cases closed. $488, 065 Program Savings from review activity. 2 Special Studies (including audit and review of all claims submitted by 65 providers who earned $25, 000 or more in the Medicare Program during 1968). 2494 1969 Title XIX (Medi-Cal) Performance. 326, 584 Individual claims reviewed by Advisors. 830 Major Utilization cases closed. $11,363,983 Program Savings from review activities. = California Blue Shield formalized its Utilization Review activities in February of 1967 with the creation of the Provider Review Division. Since that time, through July 1970, it has recorded the following performance. Total individual claims roviewed 1,597,692 Total cases closed 7,302 Total Divisional savings 28, 831, 131 Total suspension from Medi-Cal recommended 38 9 Total (Action by Director, DHCS) Total revocation of licenses (Action by Bd. of Medical Examiners) Total criminal investigations : 15 Total continuous "corrective reviews' by Medical Advisors(ordered by Peer Review Committees) 190 2495 AN OVERVIEW The California Blue Shield program ol utilization control has many facets --- some are integral parts of the Provider Review Division, while many others are inherent in the good business practices of the Corporation. Claims review starts in the Blue Shield mailroom and is continuous through- out the claims handling process. At California Blue Shield, formal utilization audit and review is performed by a corporate division (the Provider Review Division) headed by a Vice President, and employing 89 full-time stat. In addition to the "in-house! operation, California Blue Shield, in parinership with Calilornia medicine, has developed the most effective professional re- view mechanism in the United States: Calitornia Blue Shield employs more than 160 J. Medi moedic: advisors must be actively engaged in the private practice of medicine and have had experience in review procedures through prior service on a county medical society or hospital review committee. (See Appendix I, 1969-70, Medical Advisors). 1 Advisors I advisors to review unusual and questioned cases. All medical 2. County and District Review Committees - In addition to the advisor system employed by California Blue Shield, county and district review committees provide "peer! review ol questioned medical practice and recommend appropriate corrective action, both to the plan and to their appointing socicties, (See Appendix 1H, 1969-70, Peer Review Com = mitlees), ssional peer review is the key to effective utilization control. finding is a luncton well within he ca capability « ol most carriers the collection of facts and records demonstrating a misuse, and their rote presentation to the proper committee, is a time-consuming, manual operation but also within the capability of most carriers organized to perform such a function. The all important ingredient is the existence ol a review committee that will examine the evidence and render a valid medical opinion in the light of community practice and custom. Go Society and Foundation Review Organizations - Currently, 12 societies and foundations review elaims on hehalf of California Blue Shield. In these organizations all Medi-Cal and foundation sponsored claims are examined and processed for payment. Included in this process is a "built-in" utilization review mechanism. ‘This review procedure is being extended to include Medicare (Title 18) claims in selected counties. 2496 Provider Review Division serves as a clearmg house and Californi: control center for all the "misutilization” information generated within Blue Shicld, as well as information from outside sources (individual physicians, review committees, State agencies, uroups, subscribers, recipients, paramedical associations, cte.) Systematic review of provider-vendors is performed by the Division. Cases involving matters of medical practice necessitating medical evalu- ation and opinion are submitted to advisors and or county review com- mittees. Cases involving fraud or other criminal acts ave submitted to the proper legal authority in the form of eriminal complaint ov informa- tion. Cases involving misuse and abuse are presented to county medical societies for appropriate corrective action. Deterrent Effect In the "control™ of any human behavior, the most pro- ductive approach is to deter unaceeptable behavior. California Blue Shield employs this approach in its Utilization Control Program. Awareness on the part of providers of medical and paramedical care and recipients of Blue Shield benelits, that a comprehensive "control" program c¢xists, supported by a very sophisticated electronic surveillance system, generates a self discipline among providers and beneficiaries and promotes a conscious eftort to operate within the established rules of the program. Utilization Audit and Review, as employed by California Blue Shield, is a highly specialized activity combining the latest Electronic Data Processing equipment, direct microfilm printouts of magnetic tape information, pro- fessional scanning and evaluation of provider files, with tried and proven methods of fact-finding and investigation, The key to its success is the system of professional review committees that provide an acceptable mechanism lor case disposition. Functionally, Utilization Audit and Review can be divided into 5 distinet steps: 1) Case -finding, including computer profiles and summaries, prepayment reviews, routine field audits, and complaints and information from all sources. 2) The gathering together and summarizing of all the records "in the house! pertaining to cach case. 3) Field investigation and case preparation, including the review ol hospital and office records, patient interviews, and the col - lection of facts "out of the house, 2497 4) Case presentation and disposition. 5) The keeping of records and the preparation of reports, Each of the tive steps are essential toa successful program of utilization control. THE PEER REVIEW MECHA When Blue Shield has reason to believe that the Title NIN = Medi-Cal Program, or any other health care program administered by it, has been misused and abused by a provider, the professional review committee of jurisdiction is asked to examine claims, reports, records and the profile ol the provider to determine whether, in their collective opinion, an abuse or misuse has in [act occurred. The committee's investigation includes adequate provision for the provider to appear before the committee, to hear the charges made against him, to examine the evidence, and Lo present evidence and/or to make a statement. In the event the committee Tinds that the provider's practices constitute a misuse and abuse of Blue Shield administered health care programs, the review committee is asked to: I. Provide Blue Shield with a written statement to the effect that in their opinion the claims, records and reports reviewed by them clearly in- dicate that the provider his misused and abused the health care program administered by Blue Shield, and 2. Recommend a suitable disposition of the case. Such dispositions may take the form of the tollowing: 2s Recovery of monies improperly paid. he. Deletion of services and reduction of tees billed. Ce Establishing a prepayment review as a corrective or educational device, either by the committee or by a committee designated advisor. d. Recommend prior authorization by the county Medi-Cal consultant tor the type of service being abused. ih Recommend suspension From further parcticipation in the Title NIX Program, 2498 PHE APPELIA LE BEVIEW MECHANINY The California Medical Association, the California Phavmacceutical Association, the California Podiatry Association, and the California Optometric Association have cach established a state level committee of appeals (hat, acting on behalf of its Association. provides a profes- sional appellate review body in relation to questions, grievances or appeals from patients, physicians, county or district review committees, and Blue Shield veparvding the delivery of health cave services under the 9-97 and Medi-Cal, provisions ol S GUIDELINES FOREN IEW COMMITEE These puadelines are mtended to be applicable in any case where a review committee may adopt a recommendation to CPS Blue Shield dealing with a provider's future participation in the Medi-Cal program, the reduction or deletion of fees billed, or with the payment of e¢laims which a provider may submit in the future. | These guidelines should be regarded as applicable as soon as it appears to the committee or to the Blue Shield utilization field representative that the commillee is considering a matter which may warrant recommendations altecting the provider's continued participation or the payment of present ov lature clam: The gidelines are not intended to be applicable in rou- tne retevvals which my olve question: of reasonable fees in specific instan- ces, an distiganshed Drom an apparent pattern of misconduct, or in instan - cenowherein the committee is asked to consider practice patterns involving an apparent ivreegulavity which, if demonstrated, is usually corvectible with- oul consideration ol action affecting future participation. Compliance with the guidelines is legally essential prior to committee action which cither directly or conditionally ailects future or continued participation by the provider, which provides tor a patter of reductions in fees billed by the provider, or the establishment of prior authorization requirements. lo. Referred to Commilice; Refereal to the Committee shall be in writing, and shall include a summ- arization of the nature of the matter to be considered, and a history of any previous ellorts to resolve the issues presented. AL the time of relerreal, Blue Shield shall advise the committee whether or not the matter appears to he so serious as to require complianee with the padehimes, nny case where Blue Shield has not stated that the guidelines ave applicable, the chanrman may nonetheless invoke the puidelines and he shall do soin any case as soon as it appears that the Committee nay wish to consider participation by or payment to the provider in the future. 2499 2. Notice of Hearing The provider shall be given written notice of any meeting at which the committee will receive evidence on the matter submitted, This notice shall be given by Blue Shield (with knowledge of the chairman) no less than ten (10) days prior to such heaving. The notice shall state the nature of the matter under submission. If particular cases ave to be discussed, the provider shall be furnished the patients! names, If the matter under submission volves a pattern of conduct or if it is imprac- cr, the provider shall be piven information sul tical lo ht specilie © cient to enable him to identity (he period involved and the nature of any procedures an question. - Alendance by the Provider: The provider shall he entitled to attend any committee meeting while evidence regarding him is received. The provider shall have the right to see any documentary material received by the committee, The provider shall be accorded adequate opportunity to present evidence on his own behalf, or to vebut any evidence offered against him, or to offer any explanation to the committee. The provider shall have the right to be accompanied by counsel, but counsel shall not be entitled to participate in any hearing unless the chairman or a norily of the committee determines that his parcticipation would be of assistinee to the committee. These hearings shall be intormal and the rules of courtroom evidence do not apply. I. Written Record: A written record shall be prepared im any case where the committee recommends action limiting or denying future or continued participation in the Medi-Cal program, including recommendations for imposition of requirements for prior authorization. In such cases, the record shall: a) dicate the date of any hearings and the persons in attendance. bh) Contzun or summarize all testimony. i) Include all documentary evidence received. d) Deserhe siny other evidence received. “) Contin the hindinps aod recommendations of the committee, mdicating, the vote on cach ticding and cecounmendation. 1) Include copies of notices to the provider. Nn 59-661 O - 71 - pt. 11 - 8 2500 5. Findings: In such cases, the committee shall make specilic findings on those issues which support any recommendation made. Causes for suspension are enumevated in Medi Cal Regulations, Section SEES, (copy attached as Appendix 1D, and the findings must state which provision or provisions thereof have heen violated by the provider. Insofar as is practical, reference should he made to specific testimony or other evi- dence supporting each Finding. Go The committee shall make a written recommendation as to action to he taken. In any case where the recommendation would impose conditions on luture payments, prior authorization, or participation, the committee shall indicate how the recommendations should be implemented. 7. Notice ol Dec 101: The provider shall he mailed a copy of the committee's lindings and recommendations upon issuance, and he shall be advised in writing as to appeal, mceluding his right to heaving before the provider’ State Associa- tron Appeals Committee, regardless of the provider's membership status with that Association. No Rehearing: The chatrman or a majority of the committee may grant a rehearing when it appears that the provider offers substantial new evidence which he could not reasonably have offered at the meeting, or when it appears that the committee has acted in error. 9. Report to the Department of Health Care Services It will he the responsibility of Blue Shield to forward the record of the review committee (or, if appealed, the Appeal Committee), inchiding the committee's findings and recommendations, to the Department of Health Cave Services, The Department of Health Care Services will initiate appropriate action, with appropriate notification to the provider. The chareman ob the committee or a member thereol will be given opportunity to he present and participate many administrative hearmgs conducted by the Department of Health Care Services, The first step in au effective control program is the development ard implementation of a "case -finding” program that will identity “suspects” tor investigation and review, At California Blue Shield the volume of claims handled (150. 000 daily) and the number of providers (78, 000) dictate that misuse, abuse and fraud tease finding! be computerized and an effective EDP System be employed to record utilization patterns, Blue Shield has developed a computerized standard utilization "data base, identical in all the programs it administers --- its own standard programs, Federal Employees, CHAMPUS, Title XIN and Medicare. The "base! takes the form of a calendar quarter of services, by county, within the county --- by provider, and within the provider --- by patient. The data is recorded on microfilm through a machine conversion from magnetic tape. Each microfilm represents the entive practice pattern of the provider tor the recorded quarter within one program: and because identical formats are used in all programs, the entire practice of the pro- vider (handled by Blue Shield) can be merged and visually displayed via microfilm viewing machines. The quarterly microfilm provides California Blue Shield with an evergrowing Library of "practice patterns’ of cach provider. It meludes provider name, address, license number, primary specialty, secondary specialty, patient's name, identifying numbers, diagnosis, procedure or treatment, date of ser- vice, amount paid, document number and cheek number, Since the inception of this quarterly microfilm program, late in 1966, Blue Shield has conducted "easeHinding' by running against this array of utiliza- tion data, a large number of "indicators" or selected procedures (chosen by Medical Advisors) tor their "abuse potential i list of the procedures and ratios used, to date, are included in Appendix IV). Fach indicator run apainst the data base produces a printout (on machine record paper) of the overall pattern of hehavior of all provider s and adentilies a pre-selected number with the highest ratios tor turther investigation, Fhe "mdieator’ syatem ol casetinding. although adequate during the initial phase of Blue Shield's utilization review program, has two major short — comings -- (I) it requires the selection of procedures or combinations of procedures to he tested, and (2) it imposes a 6 to 9 months delay in data accumulation hetore the indicators can be run against the quarter-ol service data ha 2502 on or before December 1, 1969, California Blue Shield will place in operation an entirely new and improved method of computer casctinding based upon the construction of Practice Pattern Norms for a peer group of physicians or "peer group’ in this instance is defined to be the physicians of a suppliers. Specialty need only be defined as the comparable specialty within a locality. area in which a doctor dircets his efforts as opposed to requiring board certification. Locality should provide a relevant structure for practicing policies and group urban, suburban and rural practices. A detailed outline of the new system is deseribed below: Practice pattern norms are developed for each peer group Ratio Analysis Lach physician is subjected hased upon ratio analysis of physician groups. to the computation of two ritios Tor cach procedure. I. Occurrence per Handreed Patients, Computed a Number of Frmes Procedure Performed “No 100 Number ol Patients Seen This ratio indicates the requeney of performance of a procedure on a piven patient and may indieate overutilization. For example: Let us assume that Doctor A is a general physician operating moa large urban area, He has seen Loh Medi-Cal patients in the time period und er-exammation and has billed Tor 350 routine office visits, When we com- pute his occurrence per hundred patients ratio we arrive at: 300 XN 100 200.0 175 Doctor 3, on the other hand, (who is mn Doctor A's peer group) has seen only 20 Medi Cal patients and has performed 70 route ollice visits, His occurr- cnee per hundeed patients ratio is: il No 100 IN. 0 0 In reviewang the above example, it becomes apparent that comparison can be made, regardless of volume, to derive a norm for a procedure within a peer aroup. 2503 Py developing this norm by peer group, we remove distoriion based upon of the physicim's practice specialty. For example, assume Poctor Co General Surgeon who performs most of his work im a hospital, He has seen 20 Medi-Cal patients, but has performed only 2 routine office visits, His occurrence per hundred patient ratio computes to NX 100 10.00 If this ratio were compared to the General Practice Ratios computed above the surgeon's practice would seem to be very much different when, in reality, he is practicing at about the norm for all surgeons in his locality. Abnormalities or deviations from the norm within a peer group could indi - cate that a physician was performing a given procedure on an inordinate number of patients and should be a candidate Tor case mv estigation. 2. Occurrences per 100 Services. Computed as: NX loo Total Number of Services This ratio provides the Division with a measure of utilization based upon services performed. This ratio, when compared to norms within a peer group, may determine if a procedure has been performed an inordinate number of times regardless ol patient count, For example: Let us assume that Doctor Xo Urologist, operating in an urban environment, has billed for 3 diagnostic eystoscopics and 25 cystoscopies with ureteral catheterization. He has performed 75 services in all for the time period in question, Computations ol the occurrence per hundred services ratio would show: ood NX 100 4.0 TH «liagnostic) X 100 J3.3 wreteral catheterization) Assuming that a peer group norm would essentially show the reverse of this practicing pattern, with most of the charges being tor the diagnostic procedure, it hecomes: apparent that a comparison to the norm will isolate this imdividual for further imvestigation. ¥ 2504 Peer Group Practice Pattern Norms Once the ratio analysis is done for cach provider, certain frequencies can he established for cach procedure within a peer group. For example. using the occurrence per hundred patients ratio, let us assume that the following ratios exist within a peer group lor extended office visits: Occurrence/Hundred Patients PIO A ioe vviman domain veh vin dhe o win -~ = BIOCUOV TIS ste cies nin sain no « THER 2% wis wll vw uin ~ < BROT C= fai 75 ern ald ss swe 5 vie oie Suis ne o£ uo DICE BY veo ms wim mimes wine wiles wid Boson infers wise no @ HTT Ae lg Mh BN PRES A w [52 BOGIOP 1 on svn swindon ols ste niin dale & « < VIOCLOITG vies nr sn s ur simrnn pind mn wus a =< VYOCEOE TH on vais a note vis wiv mand a BG wip dywion # Doclor n > — . . n DYICLOE A ins viv sus 2a vos vim a min 0 spi wiv ss. DY I frequency groupings are established for this procedure within the peer group we lind: No. Amt. No. Amt. No. Amt. No. Amt. No. Amt. No. Amt. 1 BG 1 50 2 75 1 85 | 90 1 35 The average of this distribution is 68.5. Obviously, using the average of this grouping as the norm docs not provide the desired result of pinpointing those physicians with the most abnormal pattem. Some measure of deviation from the mean must be established as a norm to allow for [lexability in isolating only those providers who grossly deviate {rom the norm. hi Tooking at anormal distribution we find that a curve is generated in a bell shape: moan 1 frequency volume - 10 - 2505 In reality, however, most curves plotted for any distribution will be of a different shape (i.e. skewed left or right), hence it is difticult to place a ‘norm’ on the curve and state that any provider who exceeds the ‘norm’ for that procedure is a possible offender. In some cuses the grouping may be so tight that there are no real 'offenders'. In order to establish 'norms' that vary with the type of curve being examined, Blue Shield has chosen standard deviation as the basis for measurement, Standard deviation alone, however, provides some of the same problems the average (or mean) concept present. In using a stan- dard deviation from the mean it may be that groupings will produce many oftenders or, conversely, no offenders, Other tactors entering into this problem include the division workload and the capability and availability ol trained stalf. For these reasons, it was felt that a flexible number of standard deviations from the mean should be used to determine the norm. Returning to our example, we can plot the curve indicated below: A Mean 1 | Standard Deviation A Mean + 75 Standard Deviation eee 2h Fonsi 1 d0 90 50 60 70 S090 100 10 120 130 or Computing a standard deviation we find it to he © Ia factor of 1.0 is applied to the standard deviation and added (o the average, 91 becomes the norm and Doctor I @t an occurrence per hunder patients of 125) becomes a candidate tor imvestigation. Assuming that the workload and stalling level of the Provider Review Division 1 such that more physicians may he vestigated, tas aorelatively simple matter to drop the factor to C75 and again apply at to the standard deviation and add the resalt to the mean. Note on the graph that this produces 2 doctors tor investigation. The sine technique can be used to produce any number ol provider candidates lor review depending upon the depth of analysis To be per - formed and the stat capability of the Division, 2506 Because standard deviation is computed based upon cach curve’s sproad, its variability will allow case investigations based upon cach procedure. For example, Curve A below shows a tight grouping around the mean, whereas Curve B shows a much looser grouping. mean ig Man > 60 60 | | ) { I Ho 50 ) Rl | | | | 10 10 | ! | 30 30 | | i 2 ! ' | | 10 10 | ) | | Ol we a sap Tat pay ear ote Cb | 100 120 L110 160 180 100 120 110 160 180 200 Curve A curve Bb Procedure 1. Procedure 2 Mean 110 Mean Lio Ss. 20 s. 00. 60 Haimg a factor of 1.0 we arrvive at point A for the norm on cach curve. Note that olfenders of the more tightly grouped Curve A are pointed out as readily as those over the Curve 3 norm. Fhe Use of Patterns Within a peer proup most providers will perfor: approsimately the same nrvoce - dures and, over aoperiod of time, approximately the same number, Providers who da not conform to these patterns should he reviewed tor possible overatiliza- Lion ol the Progranr, This 1s not to say that all overatilizers will offend the norms nor that all norm oftenders will he overutilizers. It means simply that by comparing a provider's practicing pattern to that of his peers certain abnormal practicing trends may be detected and specified for further investigation and advisor and committee review of warranted, 2507 Procedure Weighting After isolating exceptions tor cach procedure on the curve, weighting factors are applied to the providers who are flagged. These weighting factors ave applied to the providers who are flagged. hese weighting factors ave sup- plied by the Provider Review Division for all procedures with a high proba- bility of misutilization. The total weighting factor is accumulated for a pro- vider and those providers with the highest total weight are subjected to case investigation and review. In addition to the princess reports described above, this FLD PL system will produce the following secondary reports: ) Monthly Patient Profile exception listings printing out all recipients with ‘services from tour or more different providers during the data period --- cach provider to be listed, (2) Monthly reports ol year-to-date total payments, by provider, arranged in descending order. 3) Monthly reports of vear-to-date total payments, by provider, arvanged in provider number order. (1) Selected parameters upon request. (5) A Tull 6 months payment history ol pre-selected providers, on demand, (6) A review of selected providers on demand (by provider number) regardless of their practice pattern. (7) Identifying “no mateh' providers resulting mm "invalid claim’ and "no payment”. (Phese exception lists will be investigated and the Master Provider ile updated at required). In addition to computerized caselinding -- = both the current quarteriy para - meter system aud the new "patterns system -- California Blue Shield cmploys aoayvestem of "maoditicd pre-payment review! by Medical Advisors as aocaschindimg tool. This system, limited to 100 Med Cal providers at any one time, provides tor the review of one entire month's claims of a given provider by medical advisors. 2508 The procedure is operated an the following manner 1. Any advisor has the prerogative of nominating a provider as ac mdidace for pre-payment review, ©. When one of the 100 review positions becomes available, Medical Review Administration Department (the staf support unit of the Advisor Department) notifies the provider -candidate of the scheduled review and asks him to bundle his climes for one month and mail them to a special address. 3. Upon receipt, the claims are delivered to the reviewing advisor, 1. After review, the advisor Lakes one ol three actions: (1) Finding no misuse or abuse, the claims are entered into the payment system and the provider is released from review, h) Finding minor discrepancies, the advisor conducts an educational program with the provider, adjusting claim as indicated, and when satisfied thal the situation has been corrected, releases the provider from review, (¢) When the advisor review discloses gross misuse and abuse worthy of peer review by committee, the claims are forwarded to the Utilization Review Department tor Turther investigation, preparation, and presentation to the | Bn | I appropriate Peer Review Group. In addition to the modified pre payment review outlined above, the Utilization Andit and Review Department conducts a rotating random selection audit of 50 ch month, Fach pharmacy is asked to forward one month's claims drug lore: to the HAR Department for review by the Department's pharmacy reviewer. Other sources ol cases include complaimts and information from many individual sources as well as special requests from HEW, DHCS, and the State Legislature, CASE DEVELOPMENT AND REVIEW Caselindimg, is the begining of the review process, The second step is conduet - ing a proper investigation of the facts and preparing a case lor presentation to Review Committee (see attached copy of model case = Appendis Vy. Nest is presentation toa Review Committee @escribed im detail, above), and ease dis- position local peer review has been the accepted method of evaluation and corvection an Calilorm tor several years, and moour opinion, the only way to approach utihization control. The Blue Shield system as not punitive, but eather mtended to he corrective and educational. The mechanizm used most often by 2509 committees 1s that of "corvective review”. This is a technique of placing the errant provider in review by a Medical Advisor until his reporting practices become acceptable. The Fast step an the process is record keeping, we hone tound af neces sary to carctully document our program and its results so that when we appear betore legislative committees, ete. we are able to demonstrate our performance and that ol organized medicine in California, Our performance for 1968 is as follows: During the year, Blue Shield handled 551 Committee cases containing 21600 claims resulting in recoveries, reductions, and dele- tions of $319,000. The UAR Advisor in his reviews (not committee action) handled 188 cases, 10,000 claims, saving $118, 000. Division Staff handled 913 cases involving $66, 000. The total recovery by UAR (including Peer Review Committees, Division Advisors and Staff) since beginning of the department in February 1967, exceeds $1 million. During the same time period (since February 1967), the Medical Advisor Department has effected savings (through reduction of tees and deletion of services) of $9,700, 000, A two year Division total of $10, R71, 000. 2510 In the Forefront. Exhibit TI (b) \ Utilization and Peer Review Medicinc’s Privilege and Responsibility Rare W. SGHAFFARZICK, M.D. AND HARRY |. PARKE, San Francisco Peer review affords a privilege for medicine to participate in the shaping of its future. As a corollary, however, medicine must accept the responsibility of stewardship which attends this privilege. Physi- cians must he willing to participate even more actively in peer review. Properly, utilization review of professional medical services can be performed only by physicians. They may be assisted by informed lay personnel and by computer-derived data. In no instances, however, should judgment of medical necessity be rendered by computer alone. Although an important function of peer review is the control of health care costs, even more important is the evaluation of the quality of care provided the consumers—our patients. “Due process” must be an integral feature of peer review. Any provider must be given the opportunity to discuss his pattern of prac- tice with his peers, and an appellate mechanism must be available. Prospective, rather than retrospective review is preferable. al- though both approaches are necessary. Avrnouvan peer weview has been a recognized mechanism in California: medicine for many years, many states still have only rudimentary forms of peer review—or none at all. This oh- servation was made apparent during a confer- ence sponsored by the Council on Medical Services of the American Medical Association in November, 1969. The enactment of Public Law 89-97 (The “Medicare” Law) in 1985 provided stimulus for increasing the involvement of physi- cians in controlling utilization and costs of health care services, This stimulus continues to he a Phe author on Chil Medical Advisor, Calitornia $lae Shick) aml Trustee, Sto Frantis Memorial Hospial, San Francs (Schatta snk): Vice President. Calitornia Bloe Shield, Provider Review Di son (Parke). Rept requests tos Clad Medical Advisor Calin Blue Shield Rincon Annex. 1700 Box 868° San Dsenas, Ca 0s (De ROW Sehattazky 80 AUGUST 1970 + 115 + 2 potent one. In August 1969, the Chief Medical Officer of the Bureau of Health Insurance (BHT) of the Social Security Administration convened an ad hoe committee of medical representatives from several states to assist in the development of national guidelines concerning utilization. At the meeting the director of the BHI. who had just completed testimony hefore the Senate Fi nance Committee, made the discouraging state ment that. according to the temper of the Senate Finance Connuittee, “the period of accommoda- tion is over.” and that in its view medicine had been given an opportunity to exercise self-control and had been found wanting. The inference was that imless some more effective self-control could be exercised, it wonld be necessary for the Social Security: Administration to formulate restrictive 2511 regulations. Since that time, the Senate Finance Committee and other governmental agencies, both at the federal and state level, have been seeking wavs to contain the rapidly escalating cost of health care. Subsequently in May 1970 Representative Wilbur Mills (D-Ark.). chairman of the House Ways and Means Committee, re- sponded to a question raised by Representative Jerry Pettis (R-Calif.) by stating that the task of reviewing physicians” fees and services “LL will have to be by his peers, It has to be a doctor who is a peer of a doctor.™ If physicians are to preserve their franchise, it becomes imperative that they be increasingly in- volved in peer review. If the concept of “usual, customary or reasonable” is to prevail over that of fixed fee schedules and prescribed limitations of professional services, physicians must acknowl- edge the responsibility which attends the privi- lege and be willing to participate aggressively in peer review. Otherwise there is considerable danger that this responsibility and privilege will be abdicated to governmental agencies. The primary aim of peer review and utilization audit is directed at the quality of health care being provided and at cost control. Cost con- trol is often the more stressed, but quality is equally important. This observation cannot be emphasized strongly enough; for, in the last anal- vsis, all of our cfforts should be directed toward the benefit of our patients, and the ultimate beneficiary of peer review is the consumer, or patient. There are various levels of peer review. The first of these, of course, is the physician’s own action when rendering medical care or prescrib- ing services in or out of the hospital setting. The second level of peer review is performed by a variety of hospital committees such as tissue, medical record and utilization committees, The third level of review may occur at the county medical society in mediation committees. In California, in addition, decisions of a county medical society committee which have heen dis- puted by a provider, a patient or a carrier may be heard by a California Medical Association appeals committee. In instances of Medi-Cal (Title XIX) disputes, further appeal may be made to the Department of Health Care Serve ices. Finally, as a last resort, a case may be submitted to the civil courts. This provision of duc process is of paramount importance for the protection of all. parties concerned. Additional poor review may be provided in certain group practice situations, in toundations tor medical care and by such specialty organizations as the California Society for Internal Medicine and its component member societies. California Blue Shield and Peer Review With implementation in California of Title NIX of the Medicare Act in March 1966, and Title XVII in June 1966, California Blue Shield contracted to serve as a carrier for these massive programs. Since that time, a comprehensive and effective technique for utilization review has evolved as a joint venture of California Blue Shield, the Calitornia Medical Association, its component societies, the foundations for medical care, and the other associations that provide seryv- ices within Blue Shield administered programs. This has developed, over the past four vears, into a venture emploving the full-time services of a Blue Shield stall of 91 persons, the part- time services of 168 medical and allied health advisors, and 117 local review committees, con- sisting of 1,600 private practicing providers of care, who devote collectively more than 100.000 man hours annually to reviewing the utilization practices of their colleagues at an overall cost of $2 million a vear. The purpose of the system is to measure qual- ity of care and frequency of use against commu- nity norms in both Blue Shicld’s standard husi- ness and in the government sponsored programs administered by Blue Shield. Its main purpose is corrective and educational. not punitive. Its goal is cost and quality control with equity for provider, patient and the purchasers of health care. The California system is today's best hope for quality care at reasonable costs. Peer review is the keystone of the system. Primary utilization auditing as accomplished by computer. First, “peer group norms” are os- tablished, and the individual performance of cach member of the group is compared with the group norm. Providers whose pattern of practice differs by more than a predetermined amount are identified, and a hist of their performance is printed out of the computer along with the group norms. Bach “peer group” contains all the pro- viders of a specialty practicing in one locality CALIFORNIA MEDICINF 81 The Western fournal of Medicine 2512 for example. all gener, 1) practitioners an San Francisco County or all neurosurgeons in North- ern California. The size of the locality is con- structed to provide a sufficient number of the same specialty from similar socio-economic areas to provide a valid peer gronp. The “time frame” used is the most current three months. The data used are all payments made during that: time frame regardless of the date of service. The “peer group norm” established for cach procedure used by the group is the mathematical mean occur (or frequency of use) of that procedure expressed in ocenrrences per 100 patients, plus a preselected number or fraction of standard de viations. The number of times cach provider in the group performs a given procedure per 100 of his patients is tested against the peer group norm (mean plus standard deviations). and providers whose frequency of use exceeds the norm are listed and the complete detail of their practice is printed ont for review. renee AE raw data printed out of the computer are reviewed and tested for validity by a group of non physician analysts who verify such items as correctness of specialty classification and accu racy of input dati The analysis unit recovers all the provider's claims that were included in the computer "peer group norm comparison run” from storage. The graphic charts for cach procedure in which the claims analysis unit constructs provider has exceeded his group norm, demons strating the distribution of frequency per 100 patients of the group and the magnitude of the ion from the norm of the group. provider's dev Alter v charts, dhs and the computer printout are turned over to the Utilization Audit Department for development as a utilization case. The devel- inchides collection of all lidation by the analysis unit, the claims. 7a opment of the “ease” available data about the provider's practice and billing patterns: hospital and office records, oper- ative reports, past claims history current billing practic otal amount billed, total canonnt paid. umber of patients, ratio ol services per patient, All the data are then col logical order, and other suelifitems, lated amd arranged all services provided one patient in date order, all patients mn the This array we family grouped togethes of data is then reviewed hy teamed utilization personnel and a summary of the “patterns pre pared and forwarded. along with a complete set of claims and other data, to a medical advisor ol B82 AUGUST 1970 % Y1s + the provider's speci Lo for his review and recom mendation. This advisor review constitutes the “first level” of peer review lf the provider being reviewed practices in aither the San Francisco Bay Area or in the Los Angeles Ari, this “hest level re- view” is performed hy a Central Advisor—one who works at the Blue Shicld office in either San Francisco or Los Angeles. If the provider prac- tices in an arc other than Los Angeles or San Francisco, the case is reviewed by an Area Ad- visor in his locality. The reviewing advisor makes a determination of “acceptable” or “unacceptable” practice=based upon community standards of quality and use. 1 he finds the documentation represents 4 medically acceptable practice, the case is closed without further review. If his find- ing is an “unacceptable practice,” he may pro- ceed in one of two fashions=handle the matter himself, or refer the case to the local peer review committee serving the provider's component so- ciety area. Tn the vast majority of cases, and al- most always with “first unacceptables,” the re- view advisor attempts to resolve the matter pri- vately with the provider through a series of “ed- ucational interviews” and an ongoing “c review” of all the provider's claims which for a time are submitted direetly to the advisor rather than through the normal claims processing svs- tem. orrective During the interviews and ensuing corrective review, an attempt is made to improve the pro- vider's general quality of care and utilization practice to a level that meets the community standards. Medically unnecessary services are de- leted from the provider's clans, and recovery of money paid for ummecessary services docu- in the original case is instituted. The tive review” mented provider usually remains in “corre for several months. When the rey iewing atisfiod that the provider's practice consistently “corrective re- wlvisor is meets community standards, the view” process is discontinned. and the provider again submits his clans directly into the normal claims processing system: In the a tendency repeatedly to relapse into his pre- case ol the recidinast the provider with vious mode of helavior or in the case of the ob- vious misuser or abuser who clearly. with intent, grossly OVETUses of practices at a completely un- acceptable level of quality the veviewmg advisor, rather than electing to handle the case, will di 2513 rect that it be prepared for presentation to the review committee the “sec provider's local pe ond evel” of peer review, This committee is ap pointed by the Tocal county: medical societies, Clases going to peer review committees are usually of amore serions nature than those rou tine handled by advisors. Preparation of the wine, mcluding stall summaries and advisor com ments as of a formal nature Adequate notice Custally 13 divs dis given to the provider. Hes mvited to attend the committee review session “and is advised of his right to be accompained by dewad conmsel. A complete copy of the “ease” with dl supporting documentation is provided vice registered mail and he is mvited to bring am records, reports, claims or other documentation of fact he would Tike the committee to consider in reviewing the matter. Althongh review com mittee proceedings ne somewhat formal, and every effort is made to protect the nghts of the provider and afford hin “due process.” the hear ing is medical, not quasi-legal. The deterniina- tion to be nade is whether the provider's prac- tices medically acceptable as measured by pre vailing community standards of atilization and quality of care. As in the review by a medical advisor (the first level) the committee is asked to make a deter mination of “aceeptable™ or “unacceptable” price tice. bi the event the finding is “unacceptable” the committee is washed to recommend to Blue Shield a proper disposition of the case as well as take any society action the case wart wits. Recom mended dispositions usually take one or more of the following forms: I Recovery of funds paid for improperly billed Services, 2. Deletion of unnecessary services items from claims. Continous “corrective review” either by a Medical Advisor or by the committee, 4. In Medi-Cal cases (the California Medicaid Program—Title XIX), request that the Di- rector of the State program suspend the pro- vider from further participation in the pro- gram. 3. In Medi-Cal cases, request that a program restriction: be imposed by the Director re- ion by a quiring prior-to-service authori county consultant for certain procedures. In addition to the above reconumendations, connmittees may, and in certain cases should, recommend to thew appointing society that thc matter be reviewed In the society's ethios or pro fessional standards conmmttee. other society dis aplinary or education: commnttees. or that the society referring the case to the licensing board of the State for us attention Matters of trad and other violations of eri wal Law should be cand me Cabiforn are) ae terred to the proper authonties: hevies comnnt tees are no more competent to evaluate or deal with these matters than courts and Taw enforce ment agencies are competent to evaluate medical practice in relation to str ods of quality, utili- zation and costs The “finad Level” of peer review dis the provision of an appellate mechs, The California Medi cal Association and several of the allied health field associations we California lane cach estab lished a state devel committee of appeals which, acting on hehall of is association, provides a pro fessional appellide body to review the findings and recommendations of docal review commit- tees. The service of the state-level appellate body are available to patient. provider local committee and Bne Shickd regarding questions arising trom the delivery of. and sabiission of claims for, services provided undef Titles NV IH and XIN of Po. SO97. CHANIPUS, and standard health benefit contracts. Professional peer review as the kev to effective atilization review and the control of suse and . Computer anditing abuse of health care benef of utilization patterns is a function well with the capability of mamcarriers. The collection ot facts and records surrounding a case of possible niisuse, and preparing and presenting them to “peer few.” are time-consuming and expensive manual operations. but they are also within the capability of most carriers. The all-important in- aredient is the evistenee of the peer review mechanism that will examine the facts and render avalid medicalopinion in the light of community - Peer review in standards, custom and practic lifornia is nade possible by the tireless dedi- cation of 1.768 providers of health care and the commitment of organized medicine and the allied health care associations of the State to review utilization and control misuses and cost of health care, In recent months, representatives of the De- partment of Health Care Services, California Blue Shield and Blue Cross have conferred to develop CAIFORNIA MEDICINT 83 The Western Journal of Medicine 2514 a svstem of coordinated utilization review hee tween the carriers for physicians” and hospital services, While it is well recognized that the total costs for physicians” services make up a relatively small portion of the hadget for health cares and that the great majority of expense stenis from anstitutional cares it is still the physician who orders hospitalization and the treatment pro- vided therein, 1s, therefore, natural that physi- Vand institutional services should be consid- wed program of audit and cred ina coordi review, Sophisticated computer techniques will he applied in the same fashion as they are in the lifornia Blue Shield, with appropriate adaptation to hospital services. Again it should he cimphasized, however, that this tech EDS program for CC mire will he used prinarily for case-finding and amy apparent departures from the norm mast be where d by medical advisors and, HeCes studi str, 1 red to medical sociely committees. With the development of innovative forms ol health care delivery suchas pre-paid, group prac tice, stimulated by pending congressional legisla tion, the necessity for developing new techniques arent. An of utilization review has hecome apps ticipated problems imclude atilization: audit of sen Ces, In the case Sine panel” and “out-of pane ol capitation programs, it is possible there man be a tendency toward under-ntilization rather than the opposite. Hospital Utilization aud Peer Review In 1960, the Californie Medical Guidelines for Utilization Review.” Association published This is an excellent reference concerning the sub jects As ane example of implementation of these Cuidelines™ in 1965 the Utilization Committee of the St. Francis Memorial Hospital in San Fran- cisco reorganized its modus operandi. Jt was decided that rather than retrospective andit. daily prospective evaluation of the current patient The Utilization sis organized with a central nucleus of Consus Was more appropriate. Committ members, augmented bya rotating group of physicians serving as “monitor.” Fach nursing station” inc the hospital is assigned a0 physician monitor. In conference with the head nurse, at daily intervals, the monitor reviews the census with the following points in mind: Lo Was hospital admission indicated? Was the B4 AUGUST 1970 + 11) + 2 medical condition one which really required hospital services or could the case Tuve been managed onan out-patient basis? ostic procedures an 2 Were appropriate dia stituted an an efficient and orderly fashion to expedite confirmation of diagnosis Were eveessives unnecessan tests ordered or others omitted? Was consultation sohcited when indicated and was such consultation rendered prompt- Ih? 4 Was treatment ordered appropriately ? 5. Was the patient approaching a point in time where dismissal from the hospital properly should be anticipated and was the attend- ing physician making preparations for this dismissal? Was the Social Service: Department con- sulted sufficiently in advimee of dismissal to ngements for transfer to a long: nthe ar term facility or to home with suitable home health care services? Is there undersatilization? Should. for ex- ample. the patient with arrhythmia be placed in the cardiac care unit rather than award hed? ~1 It the physician monitor discovers possible over- or under utilization, he may attach a (ques tionnaire to the chart, requesting information trom the attending physician, on the case with the attending physician ona doe he may discuss tor-to-doctor level. The comunttee meets at intervals of two weeks to discuss problem cases, to document re certifi cation of patients on government programs, and to provide duc process for physicians who may wish to discuss their cases with the committee, In addition to the doctor members, the connnittee includes the directors of Nursing and Social Serv: ice member of the hospital administration. and These members are all in- a full-time secretary, volved in the team effort. The concept of daily, prospective review of the current hospital census provides several divi dends. First, of course, is the reduction in costs of hospitalization by optimizing duration of sta and prompt initiation of relevant diagnostic tests and therapeutic programs. Second. and even more important. the quality of care may be enhanced, the patient deriving. benefit trom more efficient Third, educational ex- perience is provided tor the members of the stall, and effective treatumint, 2515 Exhibit TI GOVERNMENT PROGRAMS ESTIMATED REDUCTIONS IN PHYSICIANS' BILLED CHARGES 1970 Prepared by: Corporate Planning & Research Division March 1971 59-661 O - 71 - pt. 11 - 9 2516 ESTIMATED REDUCTIONS FROM PHYSICIANS' BILLED CHARGES GOVERNMENT PROGRAMS, 1970 During 1970, the claims review operations of California Blue Shield and the Foundations resulted in reductions of $66,211, 000 from the amounts billed by physicians* in the three government programs. These reductions amounted to 12.1 percent of the total amounts billed. Of the total reductions of $66,211, 000; nearly 20 percent, or $13,087,000 is accounted for by the operation of MRAD and UAR and 80 percent or $53,124, 000 by the routine claims review of California Blue Shield and all claims review activities of the Foundations. Total reductions from billed charges for each of the government programs separately for the year 1970 are given in Table 1. Reductions in each quarter of the year for all programs combined are presented in Table 2 and for the individual programs in Table 3, 4 and 5. MRAD and UAR reductions are shown in Table 6 and Table 7 gives the percentage distribution of the reductions by source of reduction. * In the case of the Medi-Cal program, it appears that the figures related to all "medical" vendors and not to physicians alone. 2517 TABLE 1 ESTIMATED TOTAL REDUCTIONS FROM PHYSICIANS' BILLED CHARGES GOVERNMENT PROGRAMS 1970 (000 omitted) Reduction Amount Amount Program Billed Allowed* Amount Percent Medi- Cal? $289, 303 $249,439 $39,864 ** 13.8 Medicare 222,080 199,206 22,874 10.3 CHAMPUS 35, 808 32,335 3,473 9.7 Total $547,191 $480, 980 $66,211 12.1 a/ The amounts for Medi- Cal appear to include "medical" vendors other than Physicians. * Before deductions for deductibles, coinsurance, etc., except for Medi- Cal as noted below. ** Includes deductions for deductibles and coinsurance for Group II Medi-Cal beneficiaries -- approximately 8% of all Medi-Cal beneficiaries. 2518 TABLE 2 ESTIMATED TOTAL REDUCTIONS FROM PHYSICIANS' BILLED CHARGES Quarter First Quarter Second Quarter Third Quarter Fourth Quarter Total GOVERNMENT PROGRAMS COMBINED 1970 (000 omitted) Amount Amount Reduction Billed Allowed Amount Percent $138,733 $121,413 $17,320 12.5 130,720 116, 906 13,814 10.6 134,540 118,167 16,373 12.2 143,198 124,494 18,704 13.1 $547,191 $480, 980 $66,211 12.1 *k 2519 TABLE 3 MEDI-CAL ESTIMATED REDUCTIONS FROM PHYSICIANS' BILLED CHARGES 1970 (000 omitted) Reduction ** Quarter Billed* Paid* Amount Percent ‘First $ 61,542 $ 54,152 $ 7,390 12.0 Second 71,457 62,474 8,983 12.6 Third 73,126 62,600 10,526 14.4 Fourth 83,178 70,213 12, 965 15.6 Total & $289, 303 $249, 439 $39, 864 13.8 The totals given in the source for these figures appear to include vendors other than physicians such as optometrists, podiatrists, chiropractors, home health agencies, x-ray, laboratory and other vendors classified as "medical. Assumes paid amount on overlap claims is equivalent to billed amount. Note: These reductions include certain deductions for deductibles and coinsurance for Group II Medi- Cal beneficiaries, In the first quarter of 1970 such beneficiaries represented 8 percent of all Medi-Cal eligibles. Source: Quarterly Billed vs, Paid Input Report 2520 TABLE 4 MEDICARE ESTIMATED REDUCTIONS FROM PHYSICIANS' BILLED CHARGES 1970 (000 omitted) Reduction * Quarter Billed Allowed Amount Percent First $ 70,616 $ 61,325 $ 9,291 13.2 Second 52, 362 48,249 4,113 7.9 Third 49,170 44,618 4,552 9.3 Fourth 49, 932 45,014 4,918 _9.8 Total $222, 080 $199, 206 $22,874 10.3 * Reductions before deductions for deductibles and coinsurance Source: Quarterly Billed vs. Paid Input Report 2521 TABLE 5 CHAMPUS ESTIMATED REDUCTIONS FROM PHYSICIANS' BILLED CHARGES 1970 (000 omitted) - Reduction * Quarter Billed Allowed Amount Percent First (est.) $ 6,575 $ 5,936 $ 639 9.7 Second 6,901 6,183 718 10.4 Third 12,244 10, 949 1,295 10.6 Fourth 10,088 9,267 __ 821 _8.1 Total 1 $35,808 $32,335 $3,473 9.7 * Before deductions for deductibles and coinsurance First Quarter -- Estimated on basis of amount paid during this quarter. Source: Second, third and fourth quarters -- Billed vs. Paid Input Reports 2522 TABLE 6 REDUCTIONS RESULTING FROM OPERATIONS OF MEDICAL ADVISORS AND UTILIZATION AND AUDIT REVIEW GOVERNMENT PROGRAMS 1970 (000 omitted) Medical Utilization and Program Advisors* Audit Review Total Medi-Cal $11,209 $380 $11,589 Medicare 1,115 80 1,195 CHAMPUS 243 __60 303 Total $12,567 $520 $13, 087 * Includes reductions to profile limitations Source: Provider Review Annual Report 2523 TABLE 7 DISTRIBUTION OF REDUCTIONS FROM PHYSICIANS' BILLED CHARGES GOVERNMENT PROGRAMS 1970 (000 omitted) California Blue Shield MRAD and Routine Claims Review Utilization and Foundation Claims Total Reduction Audit Review Review Amount Percent Amount Percent Amount Percent Medi-Cal $39, 864 100.0 $11,589 29.1 $28,275 70.9 Medicare 22, 874 100.0 1,195 5.2 21,679 94,8 CHAMPUS 3,473 100.0 303 8.1 3,170 91.3 Total $66,211 100.0 $13,087 19.8 $53,124 80.2 Source: Derived from Tables 1 and 2. 2524 Exhiow Iv AGREE HLNT THIS AGREEMENT, made and entered into this 15th day of May 1970, at County of a State of California, by and between California Physicians' Service, dba california Blue Shield, hereinafter called the Contractor and the Foundation for Medical Care of TGs County hereinafter called the Foundation provides: A. Recitals i. The State of California, hereinafter known as the State, pursuant to the Agreement, hereinafter known as the Contract, entered into on the 19th day of February, 1966, with Contractor, has agreed that the Contractor shall perform enumerated duties which it is qualified to perform with respect to the California Medical Assistance Program, hereinafter known as Medi-Cal. The Contractor with the prior written consent of the Director of the Department of Health Care Services has the authority to subcontract to, or agree with, other qualified organizations to perform a part of the services to be provided by it under its Contract with the State. = 2525 iD The Foundation is experienced in nrocessina bills, invoices and statements, hereinafter known as claims, and in reviewina same to determine the reasonableness of charaes and in reviewina the quality of medical care rendered and the deqree of utilization. Services to be rendered by Foundation may include the followina, as hereinafter provided: a. Receive and organize claims from providers who have rendered covered services to eligible persons, known hereinafter as Beneficiaries. b. Determine whether claims received are in compliance with applicable Medi-Cal regulations and rulings and with such administrative guide- lines, medical policy and fee directives as may be provided the Foundation by the Contractor. Cc. Determine under applicable administrative requ- lations whether prior authorization is required for care given and, if needed, whether such authorization was obtained. If it was not obtained, the Foundation agrees to notify the provider and to enclose appropriate instructions when returning such claims to such provider. 2526 Install and irnlerent appronriate nrocecures: 1. To reject all claims not payable under aoplicable laws, requlations, and nedical nolicy cuidelines and 2. To notify the provider submittina the claims of their rejection and the reasons therefor. Approve claims for payment pursuant to the applicable laws, requlations and quidelines and forward same to the Contractor for further processina and payment as warranted. Furnish to the Contractor and the State of California Department of Health Care Services on written request such timely necessary information and rerorts as may be requested in writing. Maintain such records and afford such access thereto as the Contractor and the State of California Department of Health Care Services, by written request, finds necessary to assure the correctness and verification of the information and reports which may be required of the Contractor pursuant to the Medical Care Law. In conjunction with the Contractor, provide liaison and coordination with providers, with qroups and organizations representing such providers and with other interested groups, committees and similar bodies. 2527 28. In conjunction with the Contractor, assist oroviders in the development of procedures relatine to utilization practices. Assist in the application of safeauards, throuah the use of review and evaluation mechanisms acceotable to the Contractor and the State of California Department of Health Care Services, against unnecessary utilization of the provisions for care and services by providers, Beneficiaries and others, and recommend to the Contractor and the State of California Department of Health Care Services such action as appears warranted in cases of unnecessary utilization. Assist in the application of safequards related to fraud or abuse by providers, Beneficiaries and others, which shall include written notification to the Contractor and the State of California Department of Health Care Services on suspected fraud or abuse situations. Develop and revise as necessary, manuals or procedural delineations qoverning the Foundation's operations hereunder. 2528 =5s m. In conjunction with the Contractor, imnlenent nrocecures enabling providers to utilize other sources. of payment. n. Carry Workmen's Compensation and liability insurance, as an independent contractor, in such coverage and amounts as the law may require or otherwise as the Contractor may require and report such coverage and amounts to the Contractor. The specific services which Foundation shall provide shall be described in such addenda to this Aareement as shall be executed from time to time by the narties hereto. By such addenda, or any addendum, the scope of Foundation's duties hereunder may from time to time be increased or reduced, as the efficient administration of the Contract may require. B. Terms and Conditions NOW, THEREFORE, the parties do aqree as follows: 1. Foundation aqrees to provide any or all of the particular services described in paragraph A(4) of this Aareement, as required by any addendum to this Aareement executed by the parties, and to be hound by this Aareement and the terms and conditions of the Contract, which by this reference is made a part hereof and is incorporated herein. 2529 ye The Contractor acrees the Foundation shill ho wai=rurse! for adrinictrative costes incurred in tha serfsrrance dutios and the provisions of services mnsaant to tas oreenent unon the hasis nrovided in the Contract. It is the intent of the parties that such reimbursement conform to the no-nrofit, no- loss princinle set forth in Section BY of the Contract. Effective Date and Renewal This Aareement shall be effective on May 1, 1970 and shall remain in effect on a month to wenth hasis. Should the Contract lw the State and the Contractor he terminated, the Acrecnent between the Contractor and the Foundation will not be extended heyond the date of Contract termination. Cither the Lomr aceon or the Foundation "av terminate this Aarcement bv notifying the other party in writing at least thirty (30) davs prior to termination that the Aareement shall be terminated upon a specified date, which must be the last day of a month. Any termination of the Aqreement for whatever cause shall be subject tn the Liauidation conditions set forth in Section 4 below. Liquidation a. Following termination of this Agreement, it shall cease to apply to services rendered by providers to rliqible 2530 PAPSONS subsequent to the termination date, cut seall rerain in effect anc bindine en the foundation for ournoses of processing claims for services rendered to eliqible persons prior to the termination date and for such other duties related thereto as the Foundation has aaqreed to provide under this Aqreement. b. The Foundation shall be compensated for such services nrovided and dutics performed during the liquidation neriod in the same manner provided for services rendered and duties performed prior to the termination date. Compliance with Regulations A services under this Agreement shall be performed in accord- ance with the applicable law, requlations and administrative directives in effect at the time of performance. The Contractor shall keep the Foundation informed reaardina law, reaulations or directives, or any chanqes thereto. The Contractor will provide the Foundation with current information reaardinq providers whose services under the Medical Care Law have been lawfully terminated, suspended or restricted. Books and_Pecords The Foundation shall maintain books, records, documents and other evidence pertaining to administrative costs and expenses 2531 incurred under this Acreement to the extent ind in such detail as shall nraperly reflect all costs, direct and anvorticned, and other costs and exnenses of whatever nature for which reimbursement is claimed under the nrovisions of tnis Aaree- ment. The Foundation's accountina nrocedures and nractices shall conform to cenerally accentable accountina oractices and the costs properly annlicable to this Aareement shall be readily ascertainable therefrom. The Foundation shall submit ite statements of costs and other expenses to the Contractor on o monthly basis no later than the 14th day of the month subsequent to the month for which «uch accountina is submitted and shall be in such order and form as the Contractor ray specifv. The Contractor shall reimburse the Foundation for its administrative characes no later than the end of the month in which they are submitted. The Foundation anrees to make all cost and expense records available to the Contractor, the State and the United States at its offices at all reasonable times for inspection, audit or reproduction by any representative authorized by the Contractor, State or the United States. 7. Assianability This Agreement is not assianable by the Foundation either in whole or in part. 59-661 O - 71 - pt. 11 - 10 10. 2532 -Q. Anencments This Acreenent mav be amended bv written aareerent (uly executed by the Contractor and the Foundation. 1¢ is mutually understood and aareed that no alteration or variation in the terms of this Aareement shall be valic and bindina uoon the parties hereto unless made in writino and sianed by them. Communications The parties to this Agreement will each anpoint an individual having primary responsibility for the communications essential for the effectiveness of their mutual nerformance. Fair funloyment Practices The Foundation aqrees to be bound bv and to comply with: a. Standard Form 3, Fair Employment Practices fddendum, a cony of which is attached to, and by this reference made a part of this Agreement, and fy, Requlations and requirements in the field of Von-discrim- ination in Employment imposed by the Cecvernment of the linited States upon persons or corporations performing the functions undertaken by the Foundation under this Aqreement . 2533 -10- IN WITNLSS WHEREOF, This Agreement has been executed, in quadruplicate, by and on behalt of the parties hereto. DATED: 2. 27- To ] DATED: April 16, 1970 FOUNDATION FOR MEDICAL CARE OF [Eh CALIFORNIA PHYSICIANS' SERVICE ra ~ B lL AN Ae v(_grapiot (L. arfes W, Stewart kxccutive Secrghary Vice President = Operations ——— IE a Title APPROVED: LATED: ~~ May 14, 1970 STATE OF CALIFORNIA D ENT OF HEALTH CARE SERVICES t.arl VW, Brian,/MJD, Lirector Title 2534 ADDENDUM #1 TO AGREEMENT BE TWECN CALIFORNIA PHYSICIANS' SERVICE (CONTRACTOR) AND FouroaTION FOR MEDICAL CARE oF [JJfcoinTy This Addendum shall supplement the Agreement dated Mun 15. 1970 1970, between said Contractor and said Foundation pursuant to the terms thereof. Effective May 15, 1970 the Foundation in accordance with the terms of the Agreement shall: a. Process from receipt through keytaping all claims relating to care of Medi-Cal beneficiaries provided by physicians practicing in Sea State of California, except that such claims shall not include those relating to care of Medi-Cal beneficiaries who are also entitled to benefits under the Medicare Program (Title XVIII, the Social Security Act of 1965.) Identify in claims processed any potential or actual third party liability case and forward to the Contractor for his disposition such case data related thereto as the Contractor may require. Process claims for payment so as not to exceed the maximum fees allowable under the Medi-Cal payment system in effect for the county at the time services are rendered. 2535 Eftective Mon CLD 10 the Contractor, in accordance with the terms of the Agreement, shall: a, Receive key tape claims data from the Foundation and process such data so as to effect the payment of the physicians involved. Receive and process for payment the Medi-Cal portion of any claim submitted by a physician practicing in FE Counties for services to a beneficiary entitled to the benefits of both the Medi-Cal and Medicare Programs, Provide the foundation with microfilm paid claims history on a timely basis as follows: In provider sequence, data on claims processed by the l'oundation. In beneficiary sequence, data on claims processed for a Counties beneficiaries regardless of the place of service. In provider sequence, data on claims processed for beneficiaries of both Medicare and Medi-Cal receiving services from physicians practicing in ane I coontics d. Forviard to the Foundation for processina: ¥. Any Medi-Cal claims for services provided bv affected physicians sent directly to the Contractor. Any claims for services provided by these physicians ~N which relate to beneficiaries of both Medi-Cal and Medicare and which are rejected by Medicare as a non-benefit. e. Handle all malters pertaining to third party liability cases, potential or actual, based upon information to be provided by the Foundation as required bv the Contractor. f. Conduct reviews and claim audits on an onaoina basis to insure adequate quality control. 4. The Foundation shall continue to provide all other services as required by said Agreement and any prior Addendum not heretofore modified or revoked. 5. To the extent that this Addendum makes provision for services which relate to the processing of individual claims, it shall be applicable only as to the claims received on or after the effective date specified herein. ATED: 3-2 7- 7.0 DATED: April 16, 1970 FOUNDATION FOP MEDICAL CARE or [I county CALIFORNIA PHYSICIANS' SERVICE -) 2 2. By 3 Charles W, Stewart Mice President = Operations Title APPROVED: DATED Mav 14, 1970 STATL OF eaLIFeTIS VIC DIRECTOR 2537 aba 2? Io ACBLEENT BETHEL CALITNPNTA PHYSICIANS! SERVICE (CONTRACT) AND rounpe ror por spencar cave of [covey hic Addendur shall suoplenent the Aareement dated Mov 1a, i970 19770, between said Contractor and said Foundation nursuant to the terns thereof. Lffective July 1, 19750 the Foundation in accordance with the tern, of the Aareement shall: a. Process from receint throueoh keytanina all claims relating to caro of tedi-Cal beneficiaries provided bv dentists practicing bE Counties, State of California, except that such claims shall not include those relatino to care of edi-Cal beneficiaries who ‘are also entitled to benefits under the tedicare Proaram (Title XVIII, the Social Security Act of 1965.) b. [dentify in claims processed any potential or actual third party liability case and forward to the Contractor for his disposition such case data related thereto as the Contractor may require. <. Process claims for pavment so as not to exceed the maximum feen allowable under the Medi-Cal payment system in effect for the county at the time services are rendered. 2538 Lifted ive ah 1, 190 the Contractor, yn accor ance wath the terms of the Agrecment, shall: a. Receive Ley tape claims data from the Foundatién and process such data wo an Lo of fect the payment of the dentists involved. bh. Pocerve and process for payment the Medi-Cal portion of any Claim submitted by a dentist practicing in fan Counties tor services to a beneficiary entitled to the benefits of both the Medi-Cal and Medicare Programs. C. Provide the Foundation with microfilm paid claims history on a timely basis as follows: 1. In provider sequence, data on claims processed by the foundation. 2. In beneficiary sequence, data on claims processed for ios beneficiaries reoardless of the place of service. 3. In provider sequence, data on claims processed for beneficiaries of both Medicare and Medi-Cal receiving services from physicians practicing oi BE Counties. 2539 d. forward to the Foundation for processina: Ys Any Meai-Cal claims for services nrovided bv affected dentists sent directly to the Contractor. 2. Anv claims for services provided by these dentists which relate to beneficiaries of both Medi-Cal and Medicare and which are rejected by Medicare as a non-benefit. e. Handle all matters pertaining to third party liability cases, potential or actual, based upon information to be provided by the Foundation as required by the Contractor. f; Conduct reviews and claim audits on an ongoina basis to insure adequate quality control. q. The Foundation shall continue to provide all other services as required by said Agreement and any prior Addendum not heretofore modified or revoked, 5. To the extent that this Addendum makes provision for services which relate to the processing of individual claims, it shall be applicable only as to the claims received on or after the effective date specified herein. VATLD: 3-22-70 DATED \pnil 16, Iie FOUNDATION FOP MEDICAL CARE OF BE coun TY CALIFORNIA PHYSICIANS' SERVICE Ss By ; . #2 X Charles W, Stewart Vice President = Operations Title APPROVED: DATLD Mav 14, 1970 STATE OF CALIFORNIA DEPARTMENT OF, HEALTH CARL foodies J haer~— BY DIRECTOR 2540 FAIR tHPLUYMENT PRACTICES AGREN:UM ¥ In the pertormance of this contract, the Contractor will not discriminate against any employee ur applicant for employment because of race, color, re- ligion, ancestry, or national origin. The Contractor will take affirmative action to ensure thal applicants are employed, and that employees are treated durina employment, without regard to their race, color, religion, ancestry, or national origin. Such action shall include, but not be limited to, the following: employment, upgrading, demotion or transfer: recruitment or recruitment advertising; lay off or termination: rates of pay or other forms of compensation: and selection for training, including apprenticeship. Tne Contractor shall post in conspicuous places, available to employees and applicants for employment, notices to be provided by the State setting forth the provisions of this Fair Employment Practices section. Z. The Contractor will permit access to his records of employment, employ- ment advertisements, application forms, and otner pertinent cata and records oy the State Fair twployment Practice Commission, or any other agency of the State of California designated by the awarding authority, for the purposes of investigation Lo ascertain compliance with the Fair Employment Practices section of this contract. 3. Kemedies for Willful Violation: (a) The State may determine a willful violation of the Fair tmp loyment Practices provision to have occurred upon receipt of a4 final judgment having that effect from a court in an action to which Contractor was a party. or upon receipt of a written notice from the Fair Employ- ment Practices Commission that it has investigated and determined that the Contractor has violated the Fair Employment Practices Act and has issued an order, under Labor Code Section 1426, which has become final, or obtained an injunction under Labor Code Section 1429. (b) For willful violation of this Fair Lmployment Practices provision, the State shall have the right to terminate this contract either in whole or in part, and any loss or damage sustained by the State in securing the goods or services hereunder shall be borne and paid for by the Contractor and by his surety under the performance bond, if any, and the State may deduct from any moneys due or that tnereafter 8, may become due to the Contractor, the difference between . the price nemed in the contract and Lhe actual cost thereof to the State. STD. FORM 3 (4/65) 2541 SCI ULE OF ALLOWABLE ADMINISTRATIVE COTS The followina schedule of administrative expenses shall be chargeable at actual rates paid in accordance with the Contractor's usual scale of comoen- sation and actual costs. In cases where it is necessarv to prorate costs, reasonable estimates shall be acceptable. For the purpose of this contract, administrative costs shall fall in two cate- qories -- Direct Charaes and Apportioned Charges. Direct Charaes shall be those costs which are incurred and chargeable to the proaram as set forth in Schedule I. Apportioned Charqes shall be those costs that are incurred and chargeable to the program on a prorated basis as set forth in Schedule II. 2542 SCHEUULE I ADMINISTRATIVE EXPENSE CONTRACT .. DIRECT CHARGES = CLASSIFICATION EXPLANATION Salaries (includina salaries Based on actual ratas aoplicable to the paid in form of Annual Service proaram and consistent with Contractor's Recoanition): other activities. Overtime: Overtime necessarv to the proaram con- sistent with Contractor's other activities. Accrued Employee Benefits (A) Workmen's Comnensation - prevail- and (ther Payroll Fxpenses: ing rates for salaries charged. (B) FICA (Social Security) - prevailing rate for salaries charged. (C) SUI and FUl - prevailina rates for salaries charaed. (D) Pension costs - Prorate of pension plan contribution computed as follows: The ratio of salaries charged above as it relates to the total of all salaries charged for all proarams. The result- ing percentaae to be applied to proaram salaries to arrive at the pension costs chargeable to the proaram. (E) Payment of emnloyees' cost of aroup and other benefits consistent with Contractor's other activities. (F) Sick and vacation charaes as used. (6G) Other related pavroll expenses. forms & Printed Matter: Office Supplies: Other Materials & Supplies: Travel & Related Expenses: Telephone & Telearaph: Postage, Mailing Expense and Shipping Cost: Maintenance & Service Contracts: Utilities: 2543 EXPLANATION Charaes to be based upon actual cost of items purchased specificallv tor the pro- qram. Withdrawals from aeneral stock to be charaed on an actual basis, te include freiaoht charaes when anplicable. Same as above Same as above Cost of travel within the State and to contia- uous areas where care under the proaram is rendered, and related expenses of personnel engaged with proaram activities. Such costs to be on an actual basis for personnel enaaged in the proaram. Charaes for installation or disconnection of phone units. Charaes as necessary for phone usage to be as follows: (A) Direct Lines - 100% to the program (B) Trunk Lines - Prorate share of total cost of main trunk line based on weiahted averace of (1) phone units per depart- ment to total trunk line units, (2) weighted by experience on long distance phone usaae. Postage to be charaed for actual cost for out- going mail as reflected by meter readings and shippina costs. Actual charaes for maintenance and repairs for equipment used in connection with program. Prorated based on square footage or actual cost. CLASSI CATION Conference, Meetinos & Sundry | xpense: Freight: Other General Expense: Equipment Rental other than EDP or ADP: Use of Space: Professional Fees: Furniture & Lquipment: 2544 Expenses incurred tor conferences and meetings within the State. ano to include sundry exoenses incidental thereto. Charaed when anolicahble to the proaram. (A) [xpenses applicable to the program not covered in other expense class- ifications. (B) Rentals and other expenses borne by the Contractor which are incurred by him to obtain an overall fiscal benefit for the proaram; subject to prior written consent of the State. Rental of equipment necessary. Based on direct rental expense or pro-rata based on square footace. To include amorti- zation of any unexpircd term lease or of penalty costs connected therewith, with the express proviso that all leases in excess of one year must be annroved in writing by the State. Lecal, auditina, and other professional services required by the proaram. (A) Furniture and eauipment as and when purchased by the Contractor, such furniture anc equipment to be of the same general quality as Contractor's aeneral furniture and equipment. NOTL: Items of a cost of less than $50.00 necd not be carried into physical inventory records. CLASSIFICATION Taxes: Insurance: Other Fixed Expense: 2545 I EXPLATIATICN (C) Purchase of items of a cost in excess of $5,000.00 must be avproved in writina by the Staite prior to purchase. (C) Items of furniture and enuinment owned by Contractor and not purchased under (A), above, to be charged at a reasonable rental. When necessary, such charges will be prorated on the basis of usage. Taxes for which Contractor is liable and which are applicable under the program. Insurance coverane applicable to the program, consistent with Contractor's other activities. Other items or services expended for and chargeable to the program but not easily iden- tified in another classification. 2546 SCHEDULE IT ADMINISTRATIVE EXPENSE CONTRACT APPORTIONED CHARGES 5 CLASSIFICATION Management Personnel Expense: Internal Audit: Personnel Management: Switchboard & Telephone Pools: Professional Relations: General Accounting: Electronic Data Processing & Electronic Machine Accounting: Mail Processing: Purchasing: Building Maintenance: General Operations: EXPLANATION Prorated in a manner consistent with Con- tractor's general practice. Based on time devoted. Charge to be based upon ratio of number of personnel in the program to total personnel. Charge to be based upon ratio of number of phone units in program to total units or ratio of phone call volume. Charge to be based upon ratio of field calls made or time expended for the program to total field calls made or time expended for all programs. Same as Manaaement Personnel Fxpense. Charges to be based upon ratio of the programs job cost to total job cost. Resulting percentage applied to actual EDP and EMA costs to arrive at charge. Charge to be based on outgoing meter readings in dollars as it relates to meter readings in dollars for all programs. Same as Management Personnel Expense or based on periodic time studies. Charge to be based upon ratio of square feet utilized for program to total. In cases of direct rental of space, charges will be based on actual expense incurred. Expenses not covered by other classifications. 2547 Lay 24, 1971 The necring 714 ia Zan Francisco fziled to examine medicil care ia its full percpective, Undoubtedly, the gtatiztics which compared medical condi tad ‘tates with other couatries elucida erisie ig the W.E., nz crisis iz test torte out by the voriahility of beglth ¢aye in thie country. The icfont ty rate is alzcst twice cg hirh for zonwhites as vhites. Purthermore, although the infzat mortality rote for whites Lng been declining, the rate for anawhi act chaaged ayprecistly déurlag the past deczde., In two courties in .issiscipzi more than ten percent of all in- Lorasover, the hearing exemplified precent asdical xy a vw odo conditions, but failed to srovide inquisition m doctors recs Sentedly ignore the importsnee of good nutri- tion during pregaancy? Desearch coaplsted -:@ carly as the 1630's by Ltrauss and Rose linked metctolic torxemiz of o £3 <) — : by + 4 _- vill foe > J . late pregasney t ..ore important, the in- cidecnce of congenital anoanlics increases in the offspring of women who vere zaliourished during gestatioa, Lue to an gnpalling conbtliation of ignorance and in- indifference, many obstetricians in poverty-ctricken areas ) hiave not been able ef ¢ communicate with thelr pntients, Ixzpersonalization and condescending sttitudes svpeorsede raprort., Hundredz of doctors indiscriminately preccribe 59-661 O - 71 - pt, 11 - 11 2548 diuretics and azphetamines, while recommending low cslorie- lov salt diets to ohese pregnant women, Under cuch cir- gunstances, the occurence of abruptio placentas, coma, and convulsions inerescces markedly. There iz ao medical gvidence to document the popular myth that women chould not g2in more than twenty-five ic twenty-eight pounds Zurin m nztead, doctors should recnriend distc high ia protein and celelun, conszideriag weight gain of cecondary importance regardless of tne severity of the orecity. Iztrogenic disencaes cen te abolished only when the 2~dicel profecsinn strives to =nhance health rather than to ~axi- wize profits, dizordere ond ~hyzieel shnorvelities, “mny oO ry + 2 “+ Leir lives glready yictinized Ly yrziem, are fereed inte "eviant® roles a8 8 gonsepinnge of the rover- Tercting effects - of digcriniction, owen golitieisas £14 sespla ia ths medlgrl nrofession regulates the lives of la in woverty-atricken aresg, the 11ifs 2tylse of which % Joetors with condosceading attitwlen who praseribe ineffective drugs to their patients for fi-gncial reward sre the crimi-sls) “ith widga read utilizotion of propar medicsl treat- rent, many prascat Larricre ta fulfillneat ia life would be shattered. | ..craone ivbaleves,-w-ilepey, avd cervenlrsl pelay would 10 loarer he disesses of the protein deficient oor. 2549 lly es- tablizh z precefant for abolishing discriminatory 'ehaviour, asturally, the srescnt administration, which hoa navey displayed comnezsion for the poor, would dizeount tha chbove reasoning se unfourded an? revolutionary. Jowever, cvasmin- frome ‘of veferatce { ie, Pinon eeluniong rovidinT gr Arantn Waste Flake “A ian” ee ce 1 oynntapsnat 2 views oi L yez E, vem Hipp amd Bir Sammy 2 2aize : yonitads of Aagline onne tre comwmlcinong under Sapafally. the janrers of the Savgasritise sot arly Herel the fontisaay of Leola 2inh wa rs 2=20Penn WhO Yaaraadate Lane of thonesrds of women in trie gorinter, But Ticteced pttantively and 111 remcin nyescrnt auatn Af rR A~T hove TV ¢ T QTD yz > ign: care, 1 P A Pare TF Arre mA 2a + + Lor cynaeet on o ete; farmr? torzrds (nfirine thnt the governmentieances to »rotect to zedieal »rofeseism sod comms-ceg to rrotect the. vwonle, Testimony before the Senate Subcommittee on Health San Francisco, Calif. May 17, 1971 by the San Francisco Bay Area Chapter, Medical Committee for Human Rights The Medical Committee for Human Rights wishes to alert the people of the United States to the collapse of the American health care system. This collapse is clearly evident from the testimony of the health consumers who spoke here this morning. And the tragic experiences of these consumers can be multiplied a million-fold throughout doctors! offices, clinics and hospitals of the country. The problems which have lead to this health care collapse were mentioned this morning. 1) Fragmentation: patients are shunted from one specialist to another (both in mainstream medical practice and within prepaid group practices like Kaiser) with no doctor willing to take responsibility for the health of the whole person. 2) Econo- mic discrimination against the sick and the poor: the sick cammst get insurance, and thus cannot pay their health care bills; the poor cannot find care even if it is paid for. Because the poor are frequently black and brown, we call this racism in health care. 3) Discrimination against women: women receive the majority of medical care, yet the number of woman doctors is tiny. And male doctors often treat women as neurotic objects, handling their pregnancies, deliveries, and gynecological problems in a rou=- tine, disinterested--rather than in a personal, humanistic--manner. In addition, the burdens and complications of contraception have been placed upon women rather than shared with men. 4) Mystification: the medical profession refuses to explain to patients what is happening to themselves and to their bodies. 5) Uneven quality: numerous exam- ples of poor care were given this morning. These examples will continue until health care is demystified and people are allowed to enter, in an educated way, into the medical decisions which deeply affect their lives. These and sther features of the health care system reveal the need for a total restructuring of American health care. What is the fundamental principle of such a 2 Only in this way will the multibillion dollar institutions of health care begin to serve those who use these institutions. Because control of health care institutions should be transferred to the consumer of health care, the Bay Area Chapter of the Medical Committee for Human Rights cannot support any of the existing national health insurance proposals. None of these propo- sals actually shifts power from those who presently control the health care system to the consumer. Of all the bills, the Health Security Act leaves open a remote possibi- lity for consumer control of hospitals and health centers. However, this uncertain possibility is not enough. In the battle for control of health care institutions, medical societies, large corporations and medical schools will almost always beat out groups of consumers. Thus, health care legislation should state unequivocally that any money collected by a national financing mechanism be paid only to community-worker controlled institutions. (We say "community-worker control" because all the people who work in health centers and hospitals should work cooperatively with those who use these institutions in formulating policy.) What are the implications of this principle that ordinary people should gain power over their own lives in the area of health? First, it means that service--rather than profit--must be the governing force in the provision of health care. Profit-making should be abolished from health care. This means that doctors should not be paid by the fee-for-service method. Also, the huge industries with vast control over the health care system=—particularly the drug industry--must take on public, non-profit ownership. And private insurance companies have no place in the health care system; their function can be handled by a public system of taxation. Secondly, ordinary people will never have power over their own lives if a small group of wealthy people, with unlimited money, can buy hospitals and health centers, can buy politicians through huge campaign contributions, and can buy osglots minds through media advertising. Thus wealth must be redistributed=-from rich toward poor—- by truly progressive taxation in which the rich pay their share. In order to begin the work required to place these principles ints practice, the Medical Committee for Human Rights, at its national convention in April, 1971, decided to develop its own national health proposal. We wish here to state the gen- eral features of this proposal: 1. Health care will be free for everybody, and comprehensive (including educa- tional, preventive, diagnostic, therapeutic and rehabilitative elements of physical and mental health). 2. Health care will be financed by a national tax on total income or wealth which, unlike any existing tax, makes the rich pay their share. 3. Profit will be eliminated from the health care system; this means an end to fee-for-service payments, profit-making drug companies and other health related industries, and insurance companies. 4. A sufficient number of health workers will be trained at public expense to meet the needs of all people in every area of the country. 5. All health care institutions will be run by policy-making bodies democrati- cally elected by those who use 01 potentially use the institution, and by those who work in the institution. 6. Health care institutions within factories and other places of work will be controlled by those employed in that place of work. 7. Health worker schools will insure that each category of health worker has representation from minority groups, women and poor classes in proportion to their numbers in the general population. In order to reverse the present over-representation among doctors of white middle class males, applicants from minorities, women, and lower economic classes will be given preferential admission until present imbalances are eliminated. 8. Health worker education will be flexible such that workers, utilizing courses and on-the-job training, can move from one job to another. 9. Community-worker bodies will also be involved in policy formation in the areas of environmental and industrial health. 2553 Senator KexNepy. The subcommittee stands in recess. (Whereupon, at 11:30 a.m., the subcommittee recessed.) HEALTH CARE CRISIS IN AMERICA, 1971 TUESDAY, MAY 18, 1971 ; U.S. SENATE, SUBCOMMITTEE ON HEALTH OF THE CoMmMITTEE ON LABOR AND PuBLic WELFARE, Los Angeles, Calif. The Subcommittee on Health met at 12:55 p.m., in the Los Angeles County-USC Medical Center, Los Angeles, Calif., Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present : Senator Kennedy (presiding). Committee staff members present: LeRoy G. Goldman, professional staff member to the subcommittee; Jay B. Cutler, minority counsel to the subcommittee. Senator Kennepy. The subcommittee will come to order. I want to express my very warm appreciation to all of those here at the hospital who have been kind enough to help the staff arrange this hearing. We are very much in your debt. I also want to welcome all of you for joining us here today. Over the period of the last 11 weeks, the Senate Health Subcommittee has been holding extensive hearings on the health care crisis in this Nation. We heard for some 8 weeks from various professional witnesses represent- ing the American Medical Association, the hospital associations, Blue Cross and Blue Shield, plus many other different groups. After we con- cluded that part of the hearings, we traveled into New York City to consider the health crisis in a major urban area. After that, we trav- eled into Westchester County and Nassau County, two affluent coun- ties, to consider the quality of health care in those areas. Next, we traveled to West Virginia, which is the second most rural State in the Nation, to consider the health crisis in rural America. We traveled into Ohio and into Chicago, and then into Towa, again to get some feel for the nature of the health crisis in a rural State. We went to Nashville, Tenn., and to Denver, which have two of the great medical complexes in the Nation. Finally, we have been to San Francisco, now Los Angeles, and we return to Washington this evening. During that period of time we have tried to visit with different groups. We have also had sessions such as this, which will be open to some of the consumers who are touched by the health delivery system. We have also tried to meet with the deans of medical schools; we have tried to meet with residents and interns where we have had an oppor- tunity to do so; we have met with representatives of the insurance companies. We met with other providers of health care. We have gone to neighborhood health centers. (2555) 2556 Last night we visited the Mexican-American Pediatrics Center in East Los Angeles. Earlier today we visited the Watts Neighborhood Health Center, the Martin Luther King Center, and the Los Angeles County Hospital Outpatient Clinic. Later, having seen the facility here, we will go over to UCLA to talk to them about the contrasts which exist in facilities. We have tried over this period of time to get as broad an impression as we possibly can. We don’t think that from our visit here alone we are going to understand completely the health needs of the people in southern California. But we are going to try to put them in some perspective, based upon our hearings and studies and try as a result to have an impact on future health legislation. I think you can observe just so much in the hearing rooms in Wash- ington. You can have public hearings there, and you can listen to expert witnesses; but I have found since we have done the field hear- ings that our most dramatic comments have been from the consumers themselves. That is who we are here to listen to today. We have some charts which are to some extent self-explanatory. On this one you will see what it will cost in 1973 under the present health system. Those costs, which are out-of-pocket, private health insurance, public, and others such as Veterans’, DOD programs, and so forth, are diagrammed here. The costs of the administration’s pro- gram and the Health Security Act are diagramed here. We estimate the cost of the Health Security Act at $68 billion. HEW values it at $77 billion. I think our figures are more accurate. Figures at $68 bil- lion, you see, the result is that the American people are going to be spending $100 billion per year on health care by 1974, according to HEW. But the real question is how it will be spent. We are not here today to have hearings on national health insurance; but as the spon- sor of the Health Security Act, I am interested in it. In the next chart, you see a very brief summary of the various com- ponents of the health crisis in this country, which includes cost, man- power, quality, the delivery system, and too few consumers involved in decisionmaking. You get an indication from this next chart of what has been hap- pening to costs. You see the extraordinary increase in terms of hos- pital charges as compared to construction costs, and the comparison of doctor’s fees to construction costs. The increase in hospital charges has been rising at the rate of three times the consumer price index; doctors’ fees have doubled the rate of increase of the consumer price index over recent years. You see a comparison of the hospital day costs per patient day in Los Angeles in 1960—$44. In 1970, it was $142. In the next chart we find the ratio of doctors to population in Los An- geles. This reflects an enormous maldistribution of doctors in this community. This exists not only in the urban communities, but just as dramati- cally in rural America, perhaps ever more so. In this chart the principal aspects of S. 3 are shown. In this one, Los Angeles and different counties are diagrammed with respect to maternal mortality rates. You can get some kind of a view of the areas we are interested in from these charts. We will have seven witnesses who are consumers; they will tell their stories. Then we will hear from professional witnesses. We will try to 2557 have 15 or 20 minutes at the end of the hearings for those in the au- dience who would like to make some comment on the health care crisis. For any of those who will have been unable to make some presenta- tion, we hope you will write to me in care of the Senate Health Sub- committee, and we will include those comments in the record. We will keep the record open for a period of some days. ; ; I would like to indicate at the outside that the professional wit- nesses will be a panel representing organized labor, and Alex Gerber, who is a physician. We were to have heard from the Los Angeles County Medical Association, but they are going to be unable to be with us this afternoon. This, of course, is a disappointment to us. They have been following us quite closely, though, over a period of time. Even though they have expressed some reservation because they couldn’ make all of their statements in the time allotted to them, I might indi- cate that the AMA generally hasn’t missed out on our various hear- ings. When we were in Denver just a couple of days ago, they circu- lated this briefing paper. Representatives from the Colorado Medical Society, the Denver Medical Society, the surrounding county medical societies, and dental societies, representing the AHA and the CHA, were present at a briefing session held on April 30, 1971. In addition, the AMA had three staff people, a gentleman from Chicago who has been traveling throughout the country attending the hearings and taping them, and two AMA field representatives, one from Columbus and one from Denver, at the briefing session. The field representatives have been coming to hearings in their own regions, so there is great continuity among the AMA staff. We know that the AMA is here in the room. Wherever they might be, we want to extend a warm welcome to them, and if the doctors wonder where their increased dues are going, they are going toward sending four or five people around the country covering the hearings. In any event, we welcome them here. We are delighted that their representatives are with us. Our first witness will be Mr. Sumner Cotton. Mr. Cotton, we ap- preciate your being here. STATEMENT OF SUMNER COTTON, ATTORNEY Mr. Corrox. I kind of come here on a triparte mission, in a sense, because I am concerned, No. 1, as an attorney; I am concerned, No. 2, about. what is going on, being in the insurance business, but not ac- tively engaged in the insurance business. And, thirdly, perhaps a sub- jective portion, if you will, or perhaps an emotional one, if you will, 1s the particular medical event which is perhaps the primary reason that I am here. In any event, just briefly to detail a personal experience, as I say, I will try to be as objective, yet not trying to be totally objective, I think, 1s the event which occurred Senator Ken~epy. You work for an insurance company, is that right ? Mr. Corton. I no longer do. I have been in the insurance business about 12 years. So, I know the insurance industry quite well. At another time on another occasion we could go into some problems which I see there in the area of private insurance. 2558 But, basically, to the medical experience that occurred in 1970, just last year, my wife felt ill in 1968. She was in and out of the hospital, five or six times, and had diagnostic studies done. At that time I did have group insurance, so it was marvelous. But they could find nothing specifically wrong with her. She kept complaining of some discomfort, some illness, but they couldn't come up with any particular diagnosis. All diagnosticians please take note. Anyway, she obviously had several claims which were submitted to the private insurance carrier, the group carrier, 1969 went by rela- tively well. In June of 1970, while she was visiting back East, she was stricken with an aneurysm in the interior lobe section of the brain. When I left employment in the insurance industry as an insurance executive I tried to convert the group coverage to some meaningful private coverage, and despite having known a number of good under- writers, it was impossible for me to obtain any meaningful coverage for her. The basis for that was that she had lodged claims five or six times in the preceding year. They said to me—mnow, this is the personal kind of conversation I had with these gentlemen—“Wait a couple of years, old friend, and if she has had no further claims and she is in good health, why, we will get her some health insurance.” Well, that’s great, except before that period when she came down with the aneurysm and at that point was not only uninsurable, she was not insured. There was no insurance available on the street, with Blue Cross, or what-have-you. No one. Obviously, the financial burden that that event posed was quite substantial. Senator Kennepy. As I understand it, you did have some insur- ance and even worked for an insurance company for 10 to 12 years. When you took another job you lost your health insurance. Is that correct? Mr. Corton. Well, the group insurance. You can convert a portion of it, but you can’t convert the meaningful portion of it. } Sasinr Kenx~epy. But you feel it was virtually worthless. Is that right? Mr. Corton. Well, they were generous, obviously: a little 10, $15-a day plan, with minimal miscellaneous and minimal everything else. Senator Kennepy. But your wife was sick during this time. You were trying to get some other insurance. You were unable to do so. Mr. Corton. Well, she was sick and she wasn’t. They couldn’t pin- point what was wrong with her. Senator Kexnepy. But they couldn't pinpoint what was really wrong with her. Is that right ? Mr. Corron. Insurance companies don’t like to buy claims. Senator Kexxepy. Why not Mr. Corron. It hurts their profit. Senator Kennepy. So she was hospitalized and you got a bill. Is that right? Mr. Corton. Right. A substantial one. Right. Senator Kennepy. How much was the bill? Mr. Corton. Oh, the total bill was in excess of $13,000. Senator Kexnepy. $13,000? And how much of that $13,000 was covered by any insurance that you had ? Mr. Corton. Zero. 2559 Senator Kexnepy. You have got that bill now ? Mr. Corton. Not with me; no. Senator Kex~Eepy. Do you owe $13,000 ? Mr. Corton. I owe a very good portion of the $13,000, yes. Senator KENNEDY. Are you trying to pay that off now ? Mr. Corton. Attempting to. Ser Kexnepy. How long do you think it will take to pay that off ? Mr. Corton. Oh, good Lord. I suppose if I were lucky, maybe in a year; maybe two years. Senator Kennepy. Have you received any letters about the bill? Mr. Corton. I have gotten one communication from—this hospital was in your neck of the woods—Massachusetts General, and they sent a nice little note saying, “Okay, fellow, pay up or else we will take legal action.” Unfortunately, I think, they get people in a rather strange position, because they make you sign almost a confession of judgment. Senator Kennepy. They what? Mr. Corton. They have you sign a form which amounts almost to a confession of judgment. They can go into court in Boston, for instance, take judgment without giving you any due notice if you sign that document. Senator Kexn~epy. When do they usually ask you to sign that? Mr. Corton. Oh, right at the time. Senator KENNEDY. You mean when you go in ? Did they ask you to sign it? Mr. Corton. Oh, yes. Senator Kexnnepy. You mean when you brought your wife in for treatment they asked you to sign this? Mr. Corron. Right. Senator Kennepy. What is the effect of that document ? Mr. Corton. The document, of course, makes you liable, which is, the case whether you sign the document or not. It makes no difference. What they attempt to do is instill a kind of fright. Being an attorney, I said, “Forget about that. Let’s read this thing.” Senator KENNEDY. You are an attorney ? Mr. Corton. Yes. So, I just revised the document before I put my name to it. Senator KennNepy. You are going to try and pay that bill off? Is that right? Mr. Corton. I have no choice. Senator Kexnxepy. What do you think of a health system that pro- vides not only the pain, hardship and suffering which you have ex- perienced, and which your wife has experienced, but also the financial indebtedness ? Mr. Corton. Well, unfortunately, I just want to refer basically in terms of the health system, I think it is kind of a triumvirate. We have a problem, No. 1, with the soaring hospital costs that you have outlined here which is obviously true. The second and third prob- lems relate to the private insurance industry. The third problem is rel- ative to the people who they employ to market these products. There is a great deal of misrepresentation. There is a great deal of half- 2560 truths, if you will. And “X” buys a policy and “X” thinks he has “Y” and he doesn’t have “Y” at all. He has something less, in most cases. It is unfortunate that the industry itself, and I say this having been in the industry, hasn't really taken up the cudgel, taken up the challenge and really gone forward to the degree that they could. The industry is not known for its progressive nature, either in marketing products or in terms of management techniques. Senator Kennepy. They do pretty well in profits, don’t they ? Mr. Corron. Well, you have to distinguish between those companies which are stock companies and those which are not stock companies. The stock companies have stockholders and have profits. The nonstock companies are responsible to themselves. It is almost a self-indulgent, self-sustaining kind of management. Senator KENNEDY. Are you on the verge of bankruptcy ? Mr. Corron. Oh, I suppose if I were pushed into a corner right now, I would have no choice. Senator Kennepy. Thanks very much. Mr. Corton. Right. Senator KexNepy. Mr. Harry Sternberg. STATEMENT OF HARRY STERNBERG, RESIDENT OF LOS ANGELES Mr. Harry STERNBERG. I am here, Senator Kennedy, because I re- cently underwent open heart surgery. When I got my bill I was so outraged at the ridiculousness of the cost that I decided to contact the hospital, which was Cedars of Lebanon, and tell them I was not going to pay the bill until they justified every item that they have. I have a computer runout here of 14 pages, which is really unim- portant, because the important thing is that they have charges in there that were never incurred by me. For example, they have a pharmaceutical bill for $1,113. Senator Kennepy. How long were you in the hospital ? Mr. SternBerG. I was in the hospital for 19 days, 2 days prior to my operation, and I was in ICU for 9 days and, very candidly, was not aware of what was going on during those 9 days. But for 8 days I was given 80 pills, which I am now buying at an average of about b cents a pill, which means that in 9 days I was given approximately $120 worth of drugs for 9 consecutive days. And I defy them to justify a charge like that. Then they threw a laboratory charge of $2,382 at me. An inhalation therapy charge of $1,614. A charge called equipment nonortho for $200. And when I inquired I was told that I had a heating pad that I used for 3 hours, and for that incurred a charge of $200. Now, I was operated on on January 12 Senator Ken~Nepy. Is that on the bill now? Mr. SterNBERG. I am sorry ? Senator Kenney. Is that heating pad on the bill ? Mr. SternBERG. It is not called a heating pad. They call it equip- ment nonortho. I think perhaps they call it that to confuse the public. When I checked with the hospitals I was advised that that charge was for the 2561 heating pad that I used. I think it had some platinum running through 9 or something. But I really am in no position right now to state that. They also showed 36 I.V. units of charges incurred at the rate of from a dollar and a half to $3 each. And when I inquired, I was told it was either for a new needle or a new tube. When I asked my personal doctor if they change a needle or a tube whenever they change a bottle, he said, “Most unlikely.” They charged for 16 X-rays and 16 portable X-rays. Well, as I stated before, during the time I was in ICU I was not aware of what was going on. But I know that for the 10 days that I was not in ICU, I was given 8 X-rays for which I went down to the X-ray room to have them taken. Then the other thing that threw me was that when I got this little bill, which is, incidentally, the bill that anybody gets, and this com- puter runout bill is something that only one who inquires will receive, but when I got the original bill from the hospital it showed that the total that I owed them was $10,209 for the 19 days. Now, they auto- matically deduct the 80 percent that Blue Cross would pay. But, in- cluded in the bill was a little statement which stated that the 80 per- cent that they showed that Blue Cross would pay was an approximate amount. Senator Kennepy. Well, has Blue Cross paid that ? Mr. SternBERG. I have here the two notifications from Blue Cross which amounted to exactly the same amount that the hospital de- ducted. The point that I am trying to make is—— Senator KenNepy. So, Blue Cross went right ahead and paid them without question ? Mr. STERNBERG. Yes, without any question at all. Senator Kexnepy. Who pays the premiums on those Blue Cross policies? Mr. STERNBERG. I do, as an individual. Senator Kennepy. A lot of other people, too. Mr. SterNBERG. Oh, yes. Yes, of course. But I thought you were referring to my particular Senator KeNnepy. They paid whatever the hospital asked ? Mr. SterneerG. Well, in my particular case they did. And this was the second time that I was in the hospital within a 2-month period, because prior to the open heart surgery they do what is called a heart catheterization to determine whether open heart surgery is necessary. And TI was there for 2 days and incurred a bill of, $1,600. Again they automatically deducted the 80 percent that Blue Cross was supposed to pay, and Blue Cross picked it up without any questions. And then in that bill they had items that I did not incur. For ex- ample, again they charged for portable X-rays, when I took two X- rays that I went down to the X-ray room myself to take. Senator Kennepy. Why do you think Blue Cross just pays these bills without question ? . Mr. SterneErG. Well, very simply because based upon an article in Business Week, the majority of the board of directors of Blue Cross consists of either doctors or members of the boards of other hospitals. So, why should they complain about the fact that Blue Cross approves 2562 all of these bills, because Blue Cross just turns around and passes the cost on to the public. I just received notification from Blue Cross that my next billing—— Senator KenNepy. I was just going to ask how much the premiums have gone up for Blue Cross coverage. Mr. SternBERG. Well, my next billing will be an increase of 35 per- cent over my last billing. And within the last 2 years my Blue Cross premiums have increased 200 percent. I have an individual policy. Senator KexNepy. 200 percent ? Mr. SterNBERG. Yes. And that is without this last 35-percent increase. Senator Kexnepy. You have given us an example of where the consumer is just left right out in the cold. Mr. SterNBERG. Yes. There is no doubt about it. Senator Kex~epy. Because eventually, if Blue Cross pays that kind of bill, it is going to mean increased premiums for both yourself and other people as well. Mr. Sterneerc. Well, they have to get it someplace. Senator Kexnepy. And you are going to be required to pay that. Mr. SterNBERG. Yes. But don’t you think it represents a conflict of interest where the providers of medicine rather than the payers of medicine are a majority of the board of Blue Cross? Senator Kennepy. Well, I do. Mr. Ster~nBERG. Certainly I would say that this would be one of the most important spots to begin with. When I received this bill, I called the Los Angeles Medical Council because it was just such an outrageous item. I called to ask if a hos- pital could arbitrarily charge whatever they wanted to, and they advised me that all hospitals are required to publicly note an itemized list of all the charegs that they pass on to their patients. And when I mentioned this to Cedars of Lebanon, nobody there knew anything about it. If that is so, then they cannot charge more than the hos- pitals in the immediate area. But the point that T am trying to make is— Senator Kex~epy. Well, what do you think was sent to Blue Cross? Don’t they get that fully itemized bill ? Mr. STERNBERG. No. Senator Kex~epy. They just get the summation ¢ Mr. SterxBERG. They just get the summation, yes. They just get this. That’s all they are interested in. Senator Kexnepy. Then let’s see your bill. That’s the summation, and that’s the bill? Mr. SternBERG. This is the bill. It is a 14-page computer runout. And, of course, I guess the only justification for this is that every time a patient gets anything, or has anything done to them, an individual ticket is made out for it and these individual tickets, I guess, eventually are run through the computer and you get this computer runout. Senator Kexxepy. Now, when you were in the hospital were you required to pay something before they let you out? Mr. SterxBErG. Oh, yes. They wouldn’t let me out unless I gave them five—well, they wanted the 20 percent that was due between the difference that Blue Cross paid and that I owed. I told them I wanted to review the bill before I paid them anything. They said, that wasn’t 2563 possible. So they accepted a minimum payment of $500 before they allowed me to leave the hospital. Senator KEx~NEDY. You mean you couldn’t leave without paying ? Mr. SterxBERG. No. They wouldn’t let me out. You know, in order to get out of the hospital you have got to have a pass and have some- body take you out, particularly when you are in the condition that I was in after a serious operation. The reason that I asked for this computer runout was that after I had the heart catheterization done it seemed to me that there were some charges added on to it that were uncalled for. After I paid the bill I asked for a detailed bill and, sure enough, there were some items there that I did not incur. And when I realized that, it was then, prior to my being let out of the hospital after surgery, that I decided that the first thing I was going to do before paying the bill was to deter- mine whether I incurred all of the charges. Senator Kex~epy. Have you been over all the items on that bill ? Mr. SterNBERG. Yes. I sent your office a copy of this along with a letter. I realize that you have a couple of other things to do other than go through something like this. Senator Kenxepy. Would you hold that bill up for us? Mr. SternBERrG. I think there are 14 pages. Itemizing every con- ceivable item under the sun. Just to read the first page very quickly, these are each individual items: “M330, M330,” which means the room. “Telephone, telephone. Lab, lab, lab, lab, lab, lab, lab, lab, lab, lab, lab, electrocardiogram, X-ray chest, pharmacy, pharmacy, pharmacy, pharmacy, pharmacy, pharmacy, pharmacy, room, MICU,” which means ICU, “telephone, telephone, operating room, operating room, lab, lab, lab, lab, lab, lab” Senator Kex~epy. They spent a lot of time on that. Mr. SterNBERG. A lot of lab. And all of these figures, as I say, the Pen ones, lab fees total up to $2,382. And the pharmacy bill was 113. All T am trying to emphasize here is that there is no doubt in my mind that so many of these charges are either blown up way out of proportion accidentally on purpose—and I say accidentally on pur- pose because included 1n this bill is a charge for 12 pints of blood at $23 a pint. Now, prior to my entering the hospital, my B’nai B’rith group gave the Red Cross 14 pints of blood because that is what they estimated they were going to need for my operation. But the charges are there anyway for the blood, as well as for the administering of the blood. Now, in my particular case the administering of the blood involved nothing but dumping blood into a machine that was taking over the function of my heart, because in this kind of operation they disconnect the heart and the lungs and outside machines do the breath- ing and the pumping of your blood for you. So they charge you $10 a pint to just dump a pint of blood into a machine that is going to circu- late it through your body. : If you are getting the idea that I think that Cedars of Lebanon is a little out of range, you are being very conservative. Senator Kexnepy. OK; thank you very much, Mr. Sternberg. Mr. SternBERG. My pleasure to have been here, and T hope we ac- complish something worthwhile for the people of America. 59-661 O - 71 - pt. 11 - 12 2564 Senator Ken~epy. Thank you very much. Our next witness is Mrs. Birdell Moore. We will provide an op- portunity for the hospitals or doctors who are mentioned in these comments to respond. Mrs. Moore, we appreciate very much your being here. STATEMENT OF MRS. BIRDELL MOORE, MULTIPURPOSE HEALTH SERVICE, WATTS, LOS ANGELES Mrs. Biroern Moore. I am Birdell Moore from the Multipurpose Health Service Center in Watts. This is the thing I read in the newspaper, and I heard on television from newscasters, that Watts, a little, small culture of Los Angeles City, has the highest poverty in all Los Angeles, rates among the most in the Nation, the highest criminal record, crime records, the most unemployed people, and malnutrition. Yet millions of dollars have been sent to southern California in the name of Watts. Everybody, people talk about health. Health serves more than just taking a pill. You have to treat the total person. Comprehensive health care. This includes whatever the person needs, because we know that almost 50 percent of a person’s medical ailment, physical ailment, is mental. I had this problem myself. I know. And in coming out to Los Angeles County Hospital before the Multipurpose Health Center was established there, most times I did come to the clinic I didn’t make it back home. I was hospitalized because I had asthma or an ulcer attack from the strain of waiting, from the strain of not getting the answers to my questions that I wanted. You see one doctor, they tell you one thing, and then you come back to the hospitpal you want to see that doctor to find out his findings and a stranger walks in that room and asks you what you are doing here. And if nobody knows 5 J you are doing in a clinic, how can you have confidence in them ? Senator KexnNepy. How long does it take you to get to the County Hospital ? Mrs. Moore. Well, it tock me about an hour and a half. Sometimes it would be longer than that. Depends upon whether you catch a bus. Now, if you get out there in time to catch a bus that was coming, you could get there in about an hour and a half.If you didn’t, it would take you 2 or 3 hours. I was in San Francisco this last weekend and they were describing the President’s health plan. I asked many questions about it, and I ended up knowing that there wasn’t a damn thing in it for poor people. Nothing. Because I showed my condition with my legs like this, and with me having two heart attacks, chronic asthmatic condition, and I asked the planner what was in their insurance for me, and he told me I was a poor insurance risk. I said, “Well, now, yet you want the social service money that is for me where I can get my health problems taken care of to use for your planning to serve the people who are able to pay.” Well, what will I do, go out and shoot myself ? These are the things that the poor people is interested in. The con- tinuation of the little health service that they have, improving it, get- 2565 ting moneys that we can hire efficient doctors at the Multipurpose Health Center instead of having so many half, part-time job doctors, and have efficient staff to take care of the patients. We don’t mean just people getting pills, because we know compre- hensive health care means more than that, because if a person come in there hungry, the stomach is cramping together, they don’t need a pill. They need food. You find a little child with the stomach all swollen up, they don’t need so much of pills to go along with it. They need nursing food. It takes social workers, it takes health workers, to go out in these homes and search and find these kind of people, encourage them to come. You have to pay the staff to do this, because the people are too poor to volunteer. I volunteer my time because I am too damn old to work and too sick to work. So I volunteer my time to try to make myself feel a little bit more like a human being. And I have this. T would like to give it to you, if I may. Senator Ken~epy. Fine. Mrs. Moore. It is a statement from Birdell Moore and Alma Woods. And these are the problems, Mr. Kennedy, that are facing us in our community, with all the moneys that are coming into southern Cali- fornia and none of it ending up in Watts. Someone told me yesterday that they give so many million dollars to a new medical school in Watts, and TI asked them where it was, that I never did see it, because I know that it isn’t in Watts. But yet Watts got that money, so they said. So Watts don’t need any more, because we got it all. We haven’t got anything. Nothing. You can stand on one end of the streets in Watts, 103d, and count the vacant lots almost to the other end. And people ask what have been done since the riot. Noth- ing but tore down the buildings. Moved the people out into poor condi- tion, maybe better houses, but nowheres—no markets, no nothing. And welfare people with 12 and 13 children living in a community where there is no market. Well, now, you don’t do very much for people. Senator Kexxepy. Thank you very much. This is an excellent com- ment about how some of those people in a community such as Watts regard the health system. And I think this is an indictment of the health delivery system. It was pointed out by Mrs. Moore that there are a variety of features to it. But whether it 1s in terms of manpower, or availability of care, or transportation, or the ability and the quan- tity of people and facilities, all of these things have to be mentioned. I want to thank you very much for your comments. Mr. Gentz. Mr. Dale Gentz. Mrs. Moore. Thank you for coming so very much. We are so glad to have you here, Senator Kennedy. Senator Kex~Nepy, Mr. Gentz? STATEMENT OF DALE GENTZ, MEMBER, ADMINISTRATIVE STAFF OF A TEACHING HOSPITAL IN SOUTHERN CALIFORNIA Mr. Dare Gentz. Senator, thank you for letting me come. I feel very fortunate after hearing some of the stories that have been told here already. Perhaps I should feel unfortunate, because my problems started with what I would call the credit card. 2566 I have an insurance card, and insurance coverage. That seems to be the magic word when you want to seek medical care. My story is about my wife, Maxine. It began about a year ago last month when she de- veloped a back problem. Low back pain, which apparently is not an uncommon situation among the population. And she sought medical treatment from out local M.D. who put her in the hospital and put her in traction, prescribed therapy,whirlpool therapy, ultrasound therapy, pain medications, muscle relaxants; the whole gamut of conservative therapy. He did X-rays; found nothing. She did not improve, and they sent her home to continue basically the same things on an outpatient basis. For the next 5 months she lived on pain medications and muscle relaxants, neither of which did any good. He finally became fed up and referred her to an orthopedic specialist. He felt whatever was wrong was out of his hands. The orthopedic specialist repeated a lot of what was done pre- viously, and this was at a duplicator cost. Again, the magic word was that I had an insurance card, and was allowed to come to a private doctor rather than being sent to the public facilities. He found very little wrong with her and prescribed an orthopedic corset, which he told her to wear as long as she could tolerate it, which was about 1 week. This cost us $102.50. She continued on with more pain medications and more muscle relaxants for the next 5 months when she was unfortunate enough to fall and reinjure her back even more. She was admitted to the hospital at that time and the doctor who admitted her said, “I am aware of your case and I think it is about time we tried to find out what is the problem.” This was 8, 9 months after she first started going to the doctor. She was seen by another orthopedic specialist, because we were unhappy with what we received from the first one. And the specialist gave her a myelogram and found nothing. He kept her in the hospital for 2 weeks and got nowhere. She was discharged from the hospital at the end of January and scheduled to see a neurologist for an electromyogram to determine possible nerve involvement. In the meantime, we have a 2-year-old son, and one point that I have left out, I think, is that she was told to spend most of her time, as much as possible, flat on her back in bed. We don’t make a great deal of money, and we can’t afford a babysitter. I don’t have the time to take off work. So she didn’t spend very much time in bed. Her progress was very slow, if any at all. She saw the neurologist, who didn’t do what the specialist requested. Not only did he not do it, but he didn’t get the report out to our doctor. About a month went by and she was readmitted to the hospital. The doctor called in another neurologist at a duplicate cost, after never having received the information from the first one. They repeated— they did the test which had not been done the first time and they found what they thought was a herniated lumbar disc. At that time they scheduled her for surgery and sent her home, because surgery couldn’t be scheduled for a couple of days. She came home for 2 days and was readmitted to the hospital and she had surgery. Fortunately for her now, 10 weeks later, she finally 2567 had a good day. She felt very well Sunday. This is the first time in about 14 months. I think that the comment that was made by her orthopedic doctor the last time she was seen by him, which was about 11 days ago, was partic- ularly ironic because, after fooling around with this problem for 14 months, she was told by the doctor, “If we had found this in time, you would have been all well by now.” During that time she has incurred almost $8,000 worth of medical bills. That, I think, is a part of the problem. I have the good fortune, I guess, of having hospitalization. However, I have the misfortune of making just enough money so that I don’t qualify for any kind of assistance for what my insurance doesn’t cover. I now owe about $1,200, and I don’t really have any idea how I am going to be able to pay this bill.. The bills are distributed over several different places. One hospital with three bills, a total of about $600, and three doctors, each of whom are demanding immediate payment. In the past year our total costs which have not been covered by the insurance have been in the neighborhood of $1,700. I am trying to buy a home. I am in danger of losing it because I am not able to make these payments. I do the best I can, but it is not good enough for the people who I owe money to. I also have other obligations, of course. I am also trying to save money for my son’s education when he does get old enough to go to school. Tt is becoming very difficult for me. The doctors who have seen her have all tried what, I guess, has been their best. Most of them apparently didn’t know what to look for. It has had a great deal of effect on our own marriage. We have had a lot of disputes because we have been told time and time again by the doc- tor, “It is just something we can’t find out. We don’t know what is wrong with you. You will have to live with it.” Of course, that is now all changed. But it is very frustrating for someone to become dependent on the pain medications to exist, to not be able to participate in family activities. A 2-year-old who has spent about a third of his life with relatives, trying to identify who his fam- ily really is. He may see us 6 or 8 hours in a day ; perhaps not that much sometimes. He may not see his mother for weeks at a time when she is in the hospital. It is a great, great problem. We don’t know yet how much, if any, pyschological impairment there has been to his develop- ment. And we hope not very much. But, that is basically my story. Senator KenNeDY. You work in a hospital, do you not ? Mr. Gentz. Yes, sir; I do. I am on the administrative staff of a major teaching hospital in southern California. Senator Kennepy. So you probably have as much familiarity or understanding of how the system functions and works as anyone. Mr. GEnTz. Yes, sir; I certainly do. Senator Ken~epy. And still you have had not only the financial hardship of an additional $1,200 in bills, but this gets very much at the whole quality issue. Mr. Gentz. Yes, sir; it does. Senator Ken~epy. You had a policy, and you had some coverage, but you were just a consumer unable to determine or know whether 2568 you were getting good advice and good guidance for a period of some 12 months. Mr. Gentz. Yes, sir. Senator Ken~epy. And if you had been able to receive the best kind of advice in the beginning, you would have saved yourself and your family the pain, suffering, and hardship which you have endured. Mr. Gentz. That’s correct ; yes, sir. It became fairly clear after about 3 months that my wife had a problem which was orthopedic. The doctor who we normally go for treatment is a general practitioner, which means he has had 1 year of training beyond his medical school. It apparently was beyond him to find the problem. I don’t wish to condemn him for that. It is just that this is the limitation of his educa- tion. There is a place for general practitioners in our community; a very real place. However, one can’t go to an orthopedic specialist unless one is referred by one’s private doctor. I think I should relate a small act that may have some bearing on this. My general practitioner was the assistant on the surgery for my wife. Now, this is not unusual. This is common practice. It is perhaps ironic that my orthopedic surgeon has a partner who is also a specialist in orthopedic surgery, yet the assistant was a general practitioner who, again, has only had 1 year of training beyond medical school. When T found out that approximately 45 percent of his fee for assisting was not covered by the insurance or by the insurance sched- ule, T tried to find out why, and T was told that the standard fee for an assistant is 25 percent of the surgeon’s fee. And when I asked why, they responded by saying that an “assistant must be present because what would happen if your doctor died on the table while he was operating ? It seems to me that happens not very often. But when it happens to you it is most important because it is you or your family. However, it seems to me that what this really amounted to was, if you wanted a qualified doctor to be present, the partner in orthopedic surgery would be the appropriate person. And what IT am about to say, 1 think, is my own opinion. I don’t think it represents at all the place where I work because, again, it is a public hospital and things are different there. We have salaried physicians who don’t bill the patients for their treatment. But, what this amounts to is that the doctor has given the general practitioner a sophisticated form of fee splitting, and he is “kicking back” to the doctor a “thank you” for referring him a patient. You have no control over that. This is not my first experience with the assistant’s fees in surgery and involving my wife. And the first time was a similar situation. When I confr onted the doctor he said, “You can’t prove I wasn’t in the operating room.’ I saw him at the hospital that day. However, he was fully clothed about 2 minutes after my wife was brought out of surgery, which makes it difficult for me to believe. But, as he said, I can’t prove it. And he had to be there to close if the doctor died on the table, which didn’t happen. It is all very frustrating to run into this kind of thing, particularly 2569 when, allegedly, I know the shortcuts. I should know who the people are to contact to get what I want, and I can’t. Senator Kexxepy. Well, I want to thank you very much. This really raises the whole issue of quality and the importance of building quality control into a health system. It is quite apparent in terms of your own experience that quality has broken down. I think it reminds all of us of the importance of quality standards. We can imagine other cases who have had similar kinds of problems. I want to thank you very much for being with us today. Mr. Gentz. Thank you, Senator. Senator Kex~Nepy. Our next two witnesses will be Mrs. Aurora Rodarte and Mr. Fernando Chavez. We appreciate very much your coming here to be with us. STATEMENT OF MRS. AURORA RODARTE, RESIDENT Mrs. Aurora Roparte. I am Mrs. Rodarte and, well, my complaint is about the general hospital. And T am very nervous. Senator KENNEDY. Just bring that “mike” up a little closer. That’s fine. Mrs. Roparte. About 7 months ago my husband had a stroke, seizure, convulsion. I took him to the hospital. Here at the General, for observa- tion and treatment to find out what was wrong with him. Well, they kept him 3 days and the doctor told me that they couldn’t find any- thing wrong with him except a lot of pressure. And he was over- worked ; to go home. And he gave him a lot of painkillers and about 200 nerve pills, which I took, because I needed them. And so he told me to bring him back in November for a brain scan. So then about 20 days later he had another seizure about 5 in the afternoon. I rushed him to the General. The place was empty for once. It was no traffic,—nothing moving. It was really slow. So the doctor comes in and looks at him. And then my husband used to wear glasses, and he asked me if he was blind from one eye, and I told him no. So, he looked him over, and went out and then I asked the doctor, “Well, what is wrong ?” And he told me he had a seizure. Well maybe I am ignorant, but not not that ignorant. I knew he had something. So I told him, “Well, aren’t you going to keep him #” Because they had his records there. He says, “No, we are going to give him an injection and you take him home to calm him down.” So my husband couldn’t sit because after those seizures he got real weak. So I put him in a wheelchair. Then he started vomiting. The nurse gave him the injection. About half an hour later they took his blood pressure. The doctor disappeared. I was waiting for my brother- in-law to pick me up. He started vomiting. I couldn’t get no help. I couldn’t get anybody to give me any assistance. So I just did the best I could, and some doctor toward the reception desk asked me if they had already looked at the patient. I said, “Yes, but he is vomiting a lot. Can’t you do something 2” Well, one of them says, “Well, IT will give you a prescription to go and get at the pharmacist.” 2570 I says, “Well, can’t you keep him here ? Because I am sure something is wrong with him.” And he says, “Well, if the other doctor says to take him home, take him home.” Well, I took him home. No sooner than I got him home than my husband got another seizure. So after that, I wasn’t going to bring him back to the General, since they didn’t want to keep him. So that was a problem. I called the rescue squad again and the same ambulance driver went. So I rushed him to the White Memorial then. I asked them, “How can you treat a patient for something that you don’t know what he has?” Whatever they gave him, he couldn’ come out of that second seizure. He tried, and he was groggy. He just couldn’t. That blindness in his eyes meant that he was getting paralyzed already on one side. He was supposed to be one of the top neurologists, imagine what the interns could do. That is what made me mad. I told them that it was just malpractice. IT mean, if that’s the type of care they are going to give in an emergency, and you know that when something happens in an emergency no doctor will touch you. You have to rush him to an emergency hospital. So they told me, “You have a private doctor.” Yes, but in an emergency, what are emergency hospitals for? That is what T argued about. They did not give me the care free. The insurance covered it. And I wasn’t about to pay the balance either, because not for the care they gave him, because in his condition they made sure that he had that insurance. They made him sign papers first. It think it is wrong. Senator Kenvepy. What happened to your husband ? Mrs. Roparte. He died. Senator KennNepY. After Mrs. Roparte. About 5 hours later. Senator Ken~epy. Did you get a bill from the hospital ¢ Mrs. Roparte. Yes. I gave it back to them. I wasn’t about to pay. I didn’t sign nothing. My husband signed it. He was dead. I wasn’t about to pay, because I don’t think in the first place the service they gave him wasn’t any service and they were not doing it free. When I put him in the hospital it was for a complete observation, checkup, and every- thing. If that is the kind of care they are going to give the patient, what do they expect when you are going to come in on a charity case, like I am now, without insurance. Now I have to pay insurance because I don’t have any insurance because my husband died. Senator Kennepy. You don’t have any insurance ? Mrs. Roparte. No, I don’t. I have to get medical insurance. So I won- der what they are going to do; what kind of treatment they are going to give me. Senator Kenxepy. Thank you. Thank you very much. STATEMENT OF FERNANDO CHAVEZ, RESIDENT Mr. Fernanpo CHAVEZ. The reason T made my presentation in Span- ish is because another one of our gripes, not only with this institution but other private institutions within East Los Angeles, is a problem with the language barrier. And I would say that 85 percent of the total 2571 working force in this institution cannot understand nor speak Spanish, though about 45 percent of all the patients that enter this hospital, and private hospitals within East Los Angeles, are either Mexican or Mexican-American. Of the 45 percent, 25 percent cannot speak English at all. In this institution itself you have approximately, or a little over 8,000 employees. You have less than 6 percent with Spanish surnames. Here is a hospital that is situated in a predominantly Mexican American community, right in the middle of the barrio. Within a 5- mile radius of this hospital you have about 85 percent Mexican Ameri- cans. We in the past have been the last to receive any type of treatment because it takes them a while to find someone to interpret for the pati- ent. It is getting a little better now. They are moving a little slow, but in 1968 if they didn’t have a window washer or a janitor that could speak Spanish, I mean, that patient was just going to stay on the cor- ner, because nobody was going to bother about him. And you know, the problem still exists. And this is one of the problems that we have fought, we have asked Los Angeles Medical Cen- ter here to recruit other interpreters or have people in the ward could understand Spanish, because this is a problem that we have now. It is a problem that we have had in the past. It is a problem that we are going to have a hundred years from now. Not unless you wake up tomorrow morning and you read the papers and it says that Mexico was last seen floating down the Pacific and it is going to attach itself to Australia. But Mexico is there. We are here. We are going to have a problem of immigration. We have the inflow of immigrants coming in here by the thousands every day. These people, whether they are here legally or illegally have the right to medicine. And right now most, of our people do not come in for treatment because the fear of immigration, whether they are green card carriers or whether they are here illegally. If they are green card carriers and they have a bill, an outstanding bill with the Bureau of Resources and Collections, and they want to go back to visit Mexico, they cannot reenter. They cannot reenter if they have an outstanding bill. This is one of the problems that we have with immigration. We know for a fact that in all county facilities, welfare, hospitals, that you have immigration officers floating in and out of the hallways to try to see who is here legally and who is here illegally. Another problem that we face is the waiting that you have in this institution. We have seen people wait here anywhere from 4 to 8 hours. And a little longer, if you cannot speak the English language. But the whole problem is not with the facility itself but with the department, or the County of Los Angeles, Bureau of Resources and Collections. I would like to read you a letter. I will not give the man’s name unless you ask for it. We didn’t have enough time to contact this gentleman, or he would be here. But the letter reads: Dear Sir: Unless payment in full in the amount of $2,597.62 reaches this office by May 23d, 1969, or satisfactory arrangements to settle this account are made,, your case will be processed for legal action without further notice to you. Now, here is a man who takes home less than $90 a week. He has five children and his wife, and he gets a letter like this. Now, you know, this could blow anybody’s mind. 2572 Senator Ken~Nepy. What day did he get it? What date was it mailed ? Mr. CravEz. The letter was sent May 13. Senator Kex~epy. The letter was sent on May 13 asking for $2,000 in payment by May 231 Mr. Cuavez. Right. Ten days. Maybe 1 or 2 days, by the time he received it. What happens in cases like this is if these people need further treat- ment, they will not come back because they are already scared of a legal lawsuit. They don’t have the money for an attorney. They don’t even have the money to pay for a medical bill. So, if they have to come back for further treatment, they refuse to come back. Half of them are running around in all the communities like I say, in the white, in the black, in the Mexican-American, where their illnesses are never cured totally because of the fear of the Bureau of Resources and Collections. They have people here in this hopsital that even right after patients get out of surgery, and they don’t even know what is happening, come in with statement forms making the patients sign and saying, “Well, why Sony you pay $5 a month, because we know this is all you can afford.” Well, you can imagine paying $5 a month for a bill of $2,500, You know, the poor guy is going to be paying it for the rest of his natural life. And this not only affects the breadwinner, which it was in this case, but he will not even bring his children in to the hospital if they need medical attention, because of the tactics of the Bureau of Resources and Collections. Senator Kennepy. OK. Well, I want to thank you very much. Mrs. Robart. Well, thank you. Senator Kexnepy. Thank you for sharing your experiences and making these comments, Thank you very much. Mrs. Mapes; Mrs, Eva Mapes. STATEMENT OF MRS. EVA MAPES, RESIDENT Mrs. Mapes. I have been coordinating a coalition of consumers. Senator Kexnepy. You have got some young friends here. Mrs. Mares. Yes. These are my troops. Senator Kexxepy. Do you want to introduce them ? Mrs. Mares. Yes. That is Larry on the end. He is 9 years old. Maria is next to him. She is seven. And the big boy is David. He is 13. Senator Kexxepy. We are very glad that you are here. Are you missing some school today? Would you rather be in school or be here? Davip Mares. Here. Mrs. Mares. I have been coordinating a consumer group that in- cludes doctors and hopsitals, labor unions and social workers. They got together because of the medical cutbacks. And we have been stay- ing together just to try to keep on top of what the Governor has in mind about reforming the medical program. Senator Kex~epy. Have you figured that out yet ? Mrs. Mares. No. Daily I have been trying to keep track of the changes. It is a full-time job. And the reason that I became interested 2573 in this is because of my own experiences, and I will tell you what happened to me. 1 live alone with my three children, and one of them is an asthmatic child, and nearly every year of his life he must be hospitalized for double lobar pneumonia. We had been covered by group medical insurance since birth. But my husband left the company that he was with in order to buy his own business, so he had an insurance agent writing up the package deal for all of the insurance that you need when you go into business and the man didn’t write for the company that had provided the coverage in the past. So he said, “Well, no problem. I will just write you a new policy.” We didn’t really understand that our child had asthma. He had had a cold with a bronchial involvement about a month before, and the doctor had said to me in passing, “Let’s treat him as if he had asthma, because maybe he has had too many colds, and if we watch the things that he could be allergic to, he might not have so many colds.” He wrote “acute asthma” in the record, and I didn’t know it. A month later we were inthe hospital with him with pneumonia, and I went to a pediatrician who diagnosed him as an asthmatic child. He was in the hospital again about 2 weeks after that, and about halfway through the second hospitalization the insurance company notified us that we were being dropped, the whole family was being dropped because we had tried to defraud them. Senator Ken~epy. Tried to what ? Mrs. Mapes. Defraud them by denying that he had a preexisting condition. Senator Kennepy. The company said that ? Mrs. Mares. Yes. And we threatened to write to the insurance com- missioner, and all those things people do. But, you know, we didn’t do too much about it. And we went back to the doctor and he said, “Yes, they came and photographed his records.” And, “Well, I didn’t tell you that he had acute asthma, but, you know, that’s the way it goes. I can’t lie.” So we were left with several hundred dollars, I think close to about $1,000 in debt. We had been a middle-class family who believes in yearly checkups and trips to the dentist, but from that point on everything just dete- riorated. Our economic situation and our level of health care deterio- rated. It was, as I said, our first year in business, and we had gone into debt. We had a precarious financial situation. My husband lost the business. We couldn’t pay the taxes on our house, so we had become renters, and still are. Of course, there were medical, pharmacy and dental bills for other members of the family. We started a desensitivation program after that first hospitalization for the asthmatic child and that had to be stopped because we got up to around $400 with the pediatrician and he said, “Well, that’s tough, but I have doneall I can.” We didn’t make appointments for other needs we had because 1 couldn’t afford payment, and that is definitely a condition for getting an appointment in some doctors’ offices. 2574 Senator Kex~Nepy. Now, just to go back a little bit, you were covered by Blue Cross and you would still have been covered if you had been able to continue that policy. Is that correct? Mrs. Mares. Yes. Yes. Senator Kenxepy. But then because you got a new policy, and you were not covered and ran up all of these—your husband changed jobs, and you weren’t covered, and you ran up a good amount of medical bills. What was the amount, approximately ? Mrs. Mares. Oh, I think $1,500. Senator Kexnepy. $1,500. Mrs. Mapes. Which has never been paid because since then we had just a general deterioration of our home life, and now it is all mine to take care of. I am not with my husband now. And I think a lot of our problem was psychological, because you sort of lose your dignity when you lose your money, some way or another. Now, I—well, the first thing I did when I found myself alone was to go to the State, because I really didn’t know just where to start. When I finally got into the system and got a medical card, every- thing has just been fine. We had complete comprehensive care at the doctor of my choice, and my son has been hospitalized twice and I have been once. We had a broken leg. I think about, probably, $2,000 worth of medical care has been taken care of for this family by the State of California. And I don’t know how I could have held a good job that T had and made a stable home that I have and provided the emotional security that I have for the kids if I hadn’t had this boost up the ladder. It was a very critical point in our lives. Senator Kennepy. We have talked a good deal in the Congress and the Senate about catastrophic costs of illness. Usually, we hear from the consumers about very significant bills. But IT am always reminded that a thousand dollars can be just as catastrophic to one person as $5,000 or $10,000 to somebody else. And I think we should be mindful of this in legislation. I think you have pointed out so well, and as we have heard before today, that this is an extraordinary bill. A thousand dollars, $1,500, which 1s a lot of money, particularly when you have children, at any time. We can just see what your health bill and illness has done to your family and your children. I think this is an indict- ment of the system as well. Mrs. Mapes. Last December my security began to erode again. The State instituted many cutbacks in the medical program, and among the things that were cut out were the kinds of drugs that my child needs. He takes very expensive things because he is allergic to all the things that are in the formula. Further, the hospital that I was em- ployed in was destroyed by the earthquake of February 9. A few days ago I was notified by the medical program that I am no longer eligible because I lost my job; because I lost my working mother’s allowance. There are a lot of work expenses, connected expenses, like my car payment, and my babysitting, and transportation to and from work that made my income the right level. And I understand that that struc- trure of medical has been changed anyway, and even if I hadn’t lost my job, I still would iave been given a share to pay for medical care that I couldn’t have handled. That means that I have no choice except to go to the county hos- pital, and it means that every illness, large and small, is a day in the 2575 waiting room with the kids and a day off from the job I hope to have in fairly short order. And I can’t see my own physician, the one who has taken such good care of my boy. Another I have is that the county hospital fell down, too, in the earthquake. So I have to come about 25 miles when he is hos- pitalized, or not be with him at all because I have a job and a family to take care of at home. So I don’t know whether or not they have enough acute beds in the valley yet. They have quite a load. 1 guess they are working on it. I feel angry because I am working to the limits of my capacity to improve my potential so that my kids don’t feel like poor kids. Sometimes it seems like a losing battle, because the odds are stacked against people unless they have a large reserve of money or unless they have the right connections. I think most of the billions of dollars spent on the highly sophisticated technological advances are not filtering down to the average people. Unless you can go long distances or unless you have a doctor who puts you in the university hospital, you really don’t get to take advantage of space-age medicine. Most people are too busy paying their bills for sore throats and broken arms. Before we had medical coverage one of the children fell out of bed and broke her collar bone. It only means a harness for 6 weeks, really. There is nothing to do for a broken collar bone. And it costs $150 be- cause of the X-rays. It took me a long time to pay it. I had more than one letter from a collection agency. This is just before I went into Medi-Cal. The insurance policy I had at that time was like two dif- ferent coverages. So I decided to take my children to the hospital all at one time just for a routine checkup, even when they are not sick, and I would get a bill that T would have trouble paying even when employed. So I only take them when they are sick, and I wait a while to make sure they are really sick. That’s a dangerous game to play. I know a lot of mothers who do it, though. T think there are times when my son would have been to the hospital if I had gone in to see the doctor when he had a cold. Senator Kexxepy. We are putting economics ahead of health. Mrs. Mares. Yes. And I know better. I know a lot about peoples’ bodies just from reading things, and living. I’ve known about Govern- ment subsidies of big corporations and industries as long as I can remember, and I always thought it was necessary for the purpose of maintaining a healthy economy. But now I am wondering why some people in the Government believe that there is something morally wrong with people who are in financial trouble. They worry about Lockheed, but not the people. It seems to me that Government subsidies to keep people healthy are more important than anything else we are doing. Even if the Government werec oncerned with economics alone, taking care of the health of children and those who can’t afford care would be a lot more economical than what is happening now. Thank you. Senator Kex~xepy. Very good. Well, that was a very eloquent com- ment. It shows that despite all the efforts you have made for your family, the system doesn’t allow you to protect yourself. Just tell me as a matter of interest, have you ever heard from that insurance company again ? 2576 Mrs. Mares. No. I wrote them a letter and they just—they never bothered to answer, that’s a fact. I forgot. Senator Kexxepy. They didn’t bother to answer? Mrs. Mapes. No. Senator KenNepy. Is it a local insurance company ? Mrs. Mares. It is Occidental, I don’t mind saying. Senator Kenney. Is that the one with that brand new building up there? You know where the premiums go. Mrs. Mapes. Yes. Senator KexNepy. Thank you very much, Mrs. Mapes. Thank you, children, for coming. We appreciate your presence here very much. Mrs. Shelene Eckerson. STATEMENT OF MRS. SHELENE ECKERSON, RESIDENT Mrs. SueLeENE EckersoN. Senator, I am a member of medicare. And I wanted to call to your attention this afternoon that I believe that the fraud that goes on in this program through doctors billing for service that hasn’t been rendered might be in a great way respon- sible for the medical troubles that medicare is having. Now, I find that old people are reluctant to report things of this sort. They are afraid of some sort of retribution; that they will lose service of some kind. And they don’t like to say anything about it when they are charged for X-rays that they never had, and when their doctor tells them, “Well, I have to charge this much because the Medical Association wants me to and I will be in trouble if I don’t.” So I would like to cite just one example of my own experience. My doctor sent in a bill to the insurance company for $270, which was a charge, she said, for surgery and general anesthetic. I was so shocked when I got this I just couldn’t understand it. And my minister became interested in it, and he called her and asked her what it was for. She said she had removed a bunion from my right foot. What had happened, really, was at that visit in her office that day, because my eyesight is poor and I had an ingrown toenail that I couldn’t trim very well, T couldn’t see well enough to do it, I just asked her if she would trim that. She immediately called her bookkeeper in to make an X-ray of my toe. That was made. And then I was taken into the treatment room where she shot some sort of Novocain, or something of that sort of thing, into the toe. She took her forceps and trimmed the toenail and that was it. Now, she told the insurance company when they asked about it, because my minister had gone to the insurance company, too, to see what they would do about it, that she had scraped the bone of the great toe of the left foot. This is an example of what can go on in medicare. IT don’t believe it is an isolated case. The minister called the Medical Association. They sent out an investigator. He took a statement from me. He examined my feet, both of them, and found no scars at all; that nothing had been done to them. She had given the insurance company a different story. We don’t know what the insurance company is doing about it. We don’t know what is going to happen from these investigations. Senator Kex~epy. Did you ever inquire of the insurance company ? Mrs. EckErsoN. Yes. 2577 Senator KexNepy. And what did they say to you when you brought this matter to their attention ? Mrs. Eckerson. That they would investigate it. And then they finally called me. After several weeks they called me and said that she had said that it was a bone scraping. But that T had had a general anesthesia. I hadn’t had any anesthesia of any kind except Senator Kenxepy. So they want ahead and paid it? ~ Mrs. Eckerson. Medicare allowed $240 of it. Senator Ken~Nepy. So they paid it; on behalf of medicare? Mrs. Eckerson. Medicare. The insurance company paid it, yes. Senator Kex~epy. The insurance company paid it? Mrs. Eckerson. Yes, they paid it. Senator Ken~epy. The just pass it on ? Mrs. Eckerson. Yes. That's it. Senator Kex~epy. The increase in charges that they are just passing back again to the consumer Mrs. Eckerson. Now, this doctor is still practicing, although she has been denied privileges in two or three hospitals there. But she continues to practice. A good many of her patients that I have seen are Mexican, and many of them do not speak English. Of course, many of them are old like IT am. Their sight isn’t too good and you just don’t like to read fine print. Senator Kexxepy. Thank you very much, Mrs. Eckerson. Thank you very much. That concludes the consumer part of the witnesses. Now we will go to the panel, and then Dr. Gerber. We are beginning to run into a time difficulty because we have just a little over a half hour remaining. But we will ask the professional witnesses if they will try to help us and summarize their testimony. I hope we will have at least 15 minutes to get some general comments from the audience. We want to welcome you gentlemen. Mr. Mohn, would you like to proceed? We have here today Mr. Mohn of the Teamsters, Mr. Piercy, of the ILWU, Mr. Arywitz from the federation, and Paul Schrade, from TUAW. Gentlemen, we welcome you. You can proceed. I don’t know if you prefer any particular order. STATEMENT OF EINAR MOHN, BROTHERHOOD OF TEAMSTERS Mr. Mon. Senator Kennedy, the sad story of America’s health is already too familiar to you for me to repeat it. But I think you should know that California’s unions have made an unusual effort to deal with health problems and the lessons we learned from that effort have led us to uncompromising support of S. 3, the Health Security Act. A few years ago several of us in labor began to meet regularly to talk about what we could do to improve health programs and stabilize the costs that were just beginning to run away from us. We believe that we held in our hands some considerable power with the health industry. We represented a little less than 2 million members and their families. We were spending in excess of $750 million annually in negotiated health benefits and millions more out of our pockets. And that out of our pockets represented at least 40 percent in excess of the $750 million. We thought that our purchasing power would give us leverage with the health industry. We were interested in supporting new forms of 2578 health organization and expanding such systems as prepaid group practice and hospital-based delivery systems. We also wanted the health insurance industry to help us in monitor- ing costs and quality and giving us information that we could use in measuring the performance of various kinas of providers. So we formed the California Council for Health Plan Alternatives Act as a research and educational development and policy coordinating body for the unions who were seeking the same goals. We have had excellent help and still do from many outstanding health professionals, economists, health administrators, universities, public services, and others. We have had many meetings of the major health provider organiza- tions telling them of the needs and the wants of our group and what we are willing to do to work cooperatively with them to achieve those wants. We try to develop positions and programs that would serve all Californians. We recognized that we could not just serve our union members, but that we were going to have to represent all consumers of health care. We are good bargainers with our employers. We know how to make the most of our situation when it comes to wages, working conditions, and those things that are part of the employer-employee relationship. But the health industry is something else. First, we need them. They don’t need us. Second, they have a good thing going the way it is and are not interested in change. Third, they know we can’t take consumer reprisals against them. We can’t boycott doctors or stay out of hospitals when we are sick. In other words, we learned the hard way that having millions to spend and millions of people needing services does not carry much weight with the health industry. The providers knew something else: they knew that medicare and medicaid were in trouble; that the Congress and the public generally were going to call for some major changes in those programs and the providers wanted to wait and see what happened in the national and State legislatures. Because health policy is now too big and too complex for us to handle in the marketplace because the big purchaser of health care is govern- ment, as great as it is, now at least $1 billion annually, our purchasing power is both too fragmented and too limited to bring real pressure on the health industry. Policy must be made by national and State legislatures, because that is where the real strength lies. So I and others became active in the Committee for National Health Insurance, and the California Council for Health Plan Alternatives is actively working on State legislation. We need all the assistance we can get, and it would appear to us at this time that there is nothing but legislation on a national level that is going to in any way materially change either the delivery system, the quality, or have anything to do with the availability of health for the people that need it. There is a great deal more in our experience that motivates us to support S. 3. Our bitter experience with private insurance, our lack of confidence in voluntary quality control methods in the health industry, our frustration in trying to get better distribution of health manpower 2579 and resources, all these and many more items of discontent all add up to the imperative that brings us here and brings you here. We need the Health Security Act now without compromise or quali- fication, and organized labor in California is devoting its resources to working for the passage of that bill in this Congress. Senator Kex~epy. Very good. Thanks very much. Mr. Piercy. STATEMENT OF WILLIAM PIERCY, OF THE INTERNATIONAL LONG- SHOREMEN AND WAREHOUSEMEN’S UNION, LOS ANGELES, CALIF. Mr. WirLiam Piercy. Americans are now spending some $70 billion a year for health care, more than double the amount spent 10 years ago. Over 60 percent of this growth, however, has gone to meet price inflation, not for additional services. During this period medical care costs have gone up twice as fast as the overall cost of living. Hospital costs alone have risen more than five times as fast. The sharper increases in medical care expenditure in recent years have not improved the quality of care, do not mean that more and more people have access to care, and are not indicative of a general improve- ment in health among the population. In fact, just the opposite is true. For millions of Americans, comprehensive preventive care has be- come too expensive and thus not available. The general level of health of the population, when measured in terms of life expectancy and in- fo mortality, has deteriorated relative to other countries in the world. By common census, our present health system is bankrupt and in a state of crisis. Five major causes of the system’s deficiencies can be readily cited : 1. The prevailing payment system, called “fee-for-service,” whereby practitioners charge a separate fee for each service ren- dered places a premium on sickness and encourages practitioners to charge all the market can bear. 2. The most common delivery system, solo practice, is ineffec- tive. Doctors practicing alone cannot deal with the wide range of ailments they are confronted with without sending their clients to specialists and away from their offices for laboratory and X-ray work. In addition, when practicing alone they alone must meet the high costs of equipment overhead. 3. The geographic distribution of available medical care serv- ices in both urban and rural areas is insufficient. In rural areas doctors and hospitals are often not available for miles around. In cities medical and dental practices are usually found in the high rent, affluent neighborhoods and are few and far between in ghettos and working class communities. 4. There is a critical shortage of a variety of medical care personnel, and there is poor use of existing manpower. Medical schools are simply not turning out enough doctors to meet public needs, and an increasing number of physicians is engaged in research rather than in treatment. 5. Government, both Federal and State levels, has failed to effectively respond to public needs. What is needed is a national health care system, one which is guided by two basic principles: 59-661 0—71—pt. 11—13 2580 1. Everyone should get the care he needs when he needs it for as long as he needs it and without regard to his ability to pay. 2. The quality and comprehensiveness of medical care should be as excellent as possible. After years of lobbying and educating by the International Long- shoremen’s & Warehousemen’s Union, and the rest of organized labor, there is now widespread support for national health care of one variety or another. Progressive forces led by such groups as the organized labor move- ment, the Committee of One Hundred for National Health Insurance, and the California Council for Health Plan Alternatives, have sup- ported legislative means to reform the entire existing system. Conservative forces, led by the AMA, various insurance company organizations, and backward elements of the two major parties, are sponsoring programs which will widen the availability of care but do nothing whatsoever to reform the basic ways in which such care is provided and paid for. The President’s plan has been attacked by the executive council of the AFL-CIO as being both piecemeal and inadequate. The council notes, and the TLLWU agrees, it places main reliance on discredited private insurance which has been largely responsible for the high cost, low quality medical care we have today. There is no indication that either the private insurance organizations or the providers of medical care would be subject to effective cost controls or quality incentives. In reviewing the competing proposals for national health care, the International Longshoremen’s and Warehousemen’s Union has kept in mind various factors which have directly contributed to our present medical care nightmare. Medical, dental, and hospital associations operating w ithout consumer involvement and direction have consist- ently failed to take the steps necessary to reform and revitalize the existing delivery system. The insurance companies, preoccupied with profitmaking, have merely stood in line for their slice of the action, failing to take any action whatsoever to protect the purchasing power of the medical care dollar and insure the quality of medical care provided. Programs such as medicare, which have allowed the providers of care to be compensated according to their usual and customary fees, have merely fanned the fires of inflation. There is absolutely no reason to believe that doctors, hospitals, and insurance companies can be relied on to create, develop, and administer a national health care system which serves the best interests of the American people. Their record in the past suggests dismal prospects about their ability to deliver in the future. We do not believe that just because a particular piece of legislation fraiands to create a national health care system that it deserves our support. In short, a bad bill which is poorly conceived and fails to come to grips with what is wrong with our present system would be worse than no bill at all. The recently concluded convention of the ILWU has gone on record in support of the National Health Security Act, S. 3 and TLR. 22. Tt is our firm conviction that this particular bill offers the most practical 2581 solution to our present medical care miseries. We joint with the rest of organized labor in urging its prompt enactment. Senator Kex~Nepy. Thank you very much. Mr. Arywitz? STATEMENT OF SIGMUND ARYWITZ, EXECUTIVE SECRETARY- TREASURER OF THE LOS ANGELES COUNTY FEDERATION OF LABOR, AFL-CIO Mr. Arywrrz. Senator Kennedy, I am Sigmund Arywitz, executive secretary-treasurer of the Los Angeles County Federation of Labor. I have a prepared statement here which, in the interest of time, I will submit for the record and make a few remarks which, hopefully, won't take as long as to read my statement. The Governor of California, in his efforts to drive a wedge between the rest of society and welfare recipients, has often made the point that he doesn’t think Medi-Cal recipients here should get better care than working people. The truth is that Medi-Cal recipients aren’t getting adequate care, and working people aren’t getting adequate care. And if there is any difference, the solution should be to get the best possible care for working people. In fact, the truth of the matter is that nobody in America is getting the kind of health services that this richest nation in the world should be able to provide. I would like to tell you a story. Last night the county federation had its delegates meeting, and a member took the floor and he asked : When will it be possible for a working man who is not yet 65 years old and is not eligible for any other kind of care to get the kind of Medicare he needs? He told the story of a son-in-law who had been economically wiped out by catastrophic illness. And it is for this reason that we feel that there is such a tremendous need for the enactment of S. 3. We in the labor movement have negotiated plans which go to some very great lengths in meeting the medical needs of our members, but we know that every time we get improvements in our economic pack- age the cost of the care goes up, the amount of care we are able to purchase is diminished, and we are in a never-ending cycle of paying more and more for less and less. We have come to the conclusion that only through a national com- prehensive health plan is it possible for everybody, working people, welfare recipients, and those of the higher middle class who even, whatever money they have, are not able to meet their medical needs, can get the kind of attention and care that they need. This is the reason that George Meany, the president of the AFL~ CIO, has stated that the enactment of S. 3 is labor’s No. 1 priority for this year. And T would like to take the pledge that throughout this country everybody in the labor movement is going to work tirelessly and do everything we can to make the enactment of S. 3 a reality. Thank you. (The prepared statement of Mr. Arywitz follows:) 2582 CHARTERED BY: American Federation of Labor and Congress of Industrial Organization 2130 WEST NINTH STREET Los Angeles County FEDERATION of LABOR, AFL-CIO LOS ANGELES, CALIFORNIA 90006 Telephone: (213) 381-5611 SICMUND ARYWITZ EXECUTIVE SECRETARY. TREASURER - TESTIMONY OF SIGMUND ARYWITZ Los Angeles County Federation of Labor AFL-CIO before the Subcommittee on Health Committee on Labor. and Public Welfare United States Senate Senator Edward M. Kennedy Chairman May 18, 1971 Los Angeles, California opeiu30 afl-cio 2583 Senator Kennedy: As you have undoubtedly observed, Los Angeles has a great variety of people, neighborhoods, and even climates. There is no other American community with as much diversity in style of living and structures as exists in this enormous metro- politan area. Our health services are equally diverse. From university medical centers to store front free clinics; from traditional community hospitals to health industry entrepreneurs, we have a little of everything, including two of the nation's oldest pre-paid group practice plans. "Diversity" has become one of those magic words to the AMA and other champions of the status quo. I recently heard the Health Security Act criticised because it would allegedly stunt the growth of "diverse" health systems and create a monolothic health plan. Obviously, the charge that S-3 is monolithic is false and the AMA knows it, But if diversity is such a fine thing to have, why hasn't it helped improve health care in Los Angeles, where there are almost as many kinds of health plans as there are automobiles? I think the answer is that most of our health plans vary only in the way the doctors and dentists profit from them and not in the way the patient is treated or the community is served. 2584 Ds As consumers, we do not have any real choices between health plans. The major pre-paid group practices have limited enrollment opportunities and in addition, Kaiser's rates in Los Angeles have risen as much as 33 per cent over the past two years for some groups (Teamster). That rate of increase puts Kaiser beyond the reach of many unions not to mention other less affluent population groups. _ Except in isolated cases--such as OEO programs and some union owned and operated services--there are no consumer sponsored programs, Much of our variety in health services in uncoordinated. Specialty services such as centers for eye care and multi-phasic health testing have spring up with little relationship to other services. In fact, diversity in Los Angeles is just another word for fragmentation. We are still forced to shop around among service organizations trying to piece together a comprehensive proaram for our families. > It is clear to us that coordination of health services can be achieved only when coordinated payment mechanisms are used. We have supported the capitation payment concept for some time, not because we want to make all health organizations just alike in every community, but because we see the capitation payment method as the key to making the providers of health care responsible for organizing services. 2585 -3- Another AMA battle cry heard a lot these days is that the Health Security Act goes too far too soon, that if every- one has health benefits, the system will be flooded and over- burdened. That argument is not only phoney, it assumes that the present system is worth continuing, and assumption that those of us who use the system are not willing to make. . It seems strange to me that the health industry--unlike any other industry in our society--is afraid of too much business. Is it because we have too little manpower? Maybe, but we know that the productivity of dentists and physicians can be greatly increased by the use of auxiliaries and even further increased by the use of new diagnostic and screening technology. Is it because we are short of facilities? We have too many hospital beds already, so that isn't the problem. The shortage lies in ambulatory care facilities, but we have learned over the years that those facilities won't be built until people can afford to pay for them and under present private insurance structures, we are having enough trouble keeping up with the cost of nespital care without being able to expand our ambulatory benefits. The real reason is a political one. Some elements of organized medicine know very well that if everyone in a community is financially able to pay for care, then everyone will demand it. 2586 -4- And if the health industry does not provide it, there will be demands made that the industry get itself organized so that the care is available. That means the industry will be forced to become responsible for the health of our communities and submit to some disciplines that do not now exist. But if we don't put the pressure on through universal coverage and uniform benefits, when does the magic day come when the doctors and dentists are ready? How will they tell us that they can now serve everyone? Will they hold a press conference in the year 2000, maybe, and say that they have now got themselves all together and are ready for everyone to receive health care? The health industry is never going to be ready and is never going to try to get ready until the public demands it. And the public can't demand it until we can pay for it. Underlying the argument that we need to go slow ist a pernicious and anti-social attitude. Some wealthy people are now getting complete health care and can afford it, even with the present system. Others are getting it at great sacrifice. Still others are facing financial ruin to get care. Still others must go through the humilitating welfare system to get help. And many others just don't get health care for financial reasons. When someone argues that we should not implement a universal and uniform health benefits package because it will. overload the system, he is really saying that we should keep out all those people who aren't getting care now until they can get care without inconveniencing the rest of us. And since the 2587 -5- people who aren't getting care are those unable to pay-- regardless of their medical needs--then the argument boils down to a statement that health care should he restricted to those able to pay until the health industry thinks it has room for those who can't. If it is true that the health industry can't care for more people, the only fair thing to do would be to refuse any services to some percentage of the population each year regarcless of their financial resources. That way, we could assure the health industry a predictable and manageable population. The rest would do without health care. Millions do without health care now, but only because they can't afford it, not because they don't need it. Obviously, my solution is absurd. But so is the argument that we can't open the doors to health care by removing the financial barriers. The lack of money is the least relevant and yet the dominant factor in preventing adequate health services. George Meany has said that the Health Security Act is the major legislative goal of the AFL-CIO. The need is clear-- your hearings here and in other cities across the country demonstrate that. And the time is now. We cannot afford more years of aimless drift in American health policy. 2588 Senator Kenx~epy. Thank you very much, Mr. Arywitz. Mr. Schrade, of the UAW. STATEMENT OF PAUL SCHRADE, UNITED AUTO WORKERS UNION, LOS ANGELES, CALIF. Mr. Scarape. I would like to thank you, Senator Kennedy, and the committee for sponsoring this legislation because it is so vital to every American. You are also witnessing here today what is true nationally, and that is those of us who are privileged to lead labor or, ganizations here in California are united behind S. 3 and ILR. 22. And although we have our disagreements, there is no disagreement on the need for na- tional health insurance. That, of course, means a commitment to work for S. 3 and H.R. 22 as well as to speak out for it. We of the UAW consider these hearings and the National Health Security Act as a tribute to the late Walter Reuther, because it was his determination and leadership that put together the Committee for National Health Insurance, and the movement of many groups to formulate the Health Security Act. The president of our union now, Leonard Woodcock, is now the chairman of that National Health Insurance Committee and has testi- fied and given the UAW’s position adequately in terms of the needs of legislation, in terms of the need for this kind of a program. I would like to point out, too, that health costs are not only expen- sive in and of themselves, but increasing health care costs helped create the General Motors strike which put some 400,000 members of our union on the bricks in order to prevent the General Motors Corp. from putting the burden of additional and increasing medical care costs on the back of workers. And we resisted that effort of General Motors. We struck that corporation, and we won on that issue. Yet, it is only a limited victory because collective bargaining more and more is not doing the job of providing adequate and high quality health care. And one other thing is happening to us in the aerospace industry. The cutbacks in defense and space, some of them legitimate, but with- out alternatives in terms of work for aerospace workers, means that we are narrowing our base further and further to finance programs and put health security agreements under collective-bargaining agree- ments 1n great jeopardy, ¢ as it does retirement programs as w ell. In the automobile industry, particularly here in southern California, imports are having a tremendous impact on this industry, which has forced the cutback of half of the production of the Chrysler assembly plant here in Los Angeles. Imports now have 43 percent of the market in southern California, as compared to 16 percent nationally, further reducing the number of workers involved in collective bargaining for health security pro- grams. In addition to the impact of imports, there is the impact of tech- nology and the slowdown, the deliberate slowdown, of the economy by the Nixon administration. All of these things put our collective-bar- gaining health programs in grave jeopardy. And we believe that our responsibility to all Americans is to support a national health insur- 2589 ance program for our members as well as other citizens who are not covered by collective-bargaining agreements. Fo these reasons, you have our commitment from the UAW, and certainly from the entire labor movement, behind your efforts to win on S. 3 in this session of the Congress. Thank you. Senator Ken~epy. I want to thank all of you gentlemen for appear- ing here. I have had a chance to familiarize myself with the various health programs that your unions provide, and they are among the most comprehensive in the country. But they are not, as you point out, as comprehensive as S. 3. I think the fact that you are interested insures that millions of others will get full coverage is a great tribute to your concerns about the working people and the older people and the younger people and all people in the country. You could say, “Well, we have a pretty good program and we will just let others shoot for themselves.” But that certainly hasn’t been the tradition of any of your organi- zations, and we appreciate it. Of course, we realize the enormous contributions that your groups have made to the development of the legislation, and helping and assisting us in the Senate and the Con- gress in the development of it. So we are enormously appreciative. Let me just ask you gentlemen if you don’t agree with me on this: I have difficulty in accepting the concept of the profit motive in the whole health system of this Nation. We think of free speech as a matter of right, free religion as a matter of right. I think Americans like to believe that quality education is a matter of right. We don’t have it yet, but I think people feel that health as a matter of right is an inher- ent part of at least the ideal we should seek. I feel that health is a matter of right. That is the underlying con- cept of S. 3, the Health Security Act. I wonder if you are troubled, as I am, in having a profit motive in the proposals that have been made by the administration? We don’t include the profit motive in the education of the young people, and the question I would like to ask is whether you agree with me that we shouldn’t include the profit motive in providing quality health. Mr. Arywrrz. Well, Senator, the problem goes beyond the profit motive. There is also the problem of the greed motive that some of these plans envisage. We agree with you that health care is a right, and there is certainly no need whatever for writing profit into the law. Mr. Scurape. Yes; I would hope that you would prevent that from becoming part of the law, because the profit motive is a very dangerous thing and a demeaning thing in terms of the people who are involved that way. Certainly we don’t want the profit motive in education or health. We have it in terms of war. And I think that that is one of the things that keeps us involved in the kind of war production and the wars that we are involved in, although it is not the only reason. So I would hope that the Senate of the United States and the House would stand up on this question and make health care a human right. Senator Kennepy. I want to thank you. Unless you have any fur- ther comments, thank you very much for appearing and the strong support that your organizations have been giving to this program. It will make a great deal of difference. Now, Dr. Gerber. 2590 Doctor, we welcome you here. I know you have some testimony. Why don’t you proceed in your own way? We have a time problem, but we are very interested in hearing from you, so why don’t you do the best you can? STATEMENT OF ALEX GERBER, M.D. LOS ANGELES, CALIF. Dr. Gerser. Thank you very much, Senator, for inviting me to discuss medical quality. Of course, I am painfully aware of the socioeconomic conditions which have led to some of the horror stories that I have heard this afternoon. But I am going to restrict myself to simply a discussion of the medical aspects of low quality or poor quality medical care. We claim that there is a crisis of medical care in this country, and how can this be? This country leads in industrial production and in the wizardry of our weapons systems, and certainly in the number of hospital room TV sets. And still we lag far behind many countries of the world in such indices of health care as infant mortality and mater- nal mortality and life expectancy. So it seems that there is an uneven texture to health care in this country because, unfortunately, World Health Organization statistics not only take into account what happens in San Marino, Calif., and in Scarsdale, N.Y, but also what happens in Harlem, and Appalachia, and on the Navajo Indian reservations. And when it is all homogenized in, we are found wanting in the balance. So, why isn’t the richest and the most powerful country in the world also the healthiest? I think I am most interested in trying to improve the quality of medical care by eliminating the double standard of medical practice. I think I first must qualify what I mean by quality medical care. I consider high quality medical care chiefly in the realm of the pro- fessional competence of those rendering this care and the facilities which they have available. I want to distinguish this, I want to make a distinction between quality medical care and equality of medical care. I think under any system of health care in this country we are going to, in a free economy society, have people ride first class and economy class on the health care plan. The important thing is not the accommodations of those passengers, but the fact that a single qualified pilot flies that plane for both classes of passengers. So, to me, the amenities of medical care are not nearly as important as the competency of those rendering the care. As a matter of fact, at this very hospital a patient in a six- or eight- bed room, sharing a common bathroom, waiting for laboratory tests, maybe waiting to get on the surgical schedule, can get far higher quality medical care than the weathiest patient in a private hospital with carpeted floors, color TV sets, electric beds and an intercom system to the nurse. The point is, that if that private patient had an incompetent doctor, and in my field if that patient had an unnecessary operation or an ineptly performed operation, he would have had a far lower degree of quality of medical care than the patient at this hospital who had a competent doctor operating upon them. 2591 Now, we are told that the measurement of quality is very elusive; that it is difficult to discuss competence of doctors. Now, I would agree that you can’t measure the competence of doctors in the same way that you can measure batting averages out to the third decimal point, or the percentage of completed passes by a quarterback. But certainly medicine knows how to distinguish between a superior quality medical care, excellent quality medical care, good medical care, poor medical care, and lousy medical care or, as Melvin Glasser would put it, rotten medical care. In my particular field of surgery, at the present time, there are many unnecessary and ineptly performed operations by unqualified and un- trained men. And these lead our statistics to go askew. Right here in California the medically indigent children under the Medi-Cal plan have their tonsils removed 10 times more frequently than the other children in the private sector of medicine. Senator Kex~epy. Well, now, President Nixon said it was only four times as many. Dr. Gerer. That may be the general average, but I happen to be familiar with the average in California. : Senator Kex~epy. No, four times as many in California. When I told that to the medical society up in San Francisco they said that the source wasn’t right. And then I indicated that it was President Nixon. Dr. Gerser. I think I know where that statistic came from, because a certain bureau in Washington called me about that statistic, It ap- pears in my book, as a matter of fact. The exact incidence of tonsillectomies among indigent children on the Medi-Cal program in California, those under the age of 16, is 40 per thousand. And I know plenty of fee-for-service group practice clinics where the incidence is only four per thousand. So, that makes it 10 times higher. Senator Kex~epy. Do we have too many surgeons in California? Dr. Gegeer. I don’t think so. I think that there probably is a mal- distribution of surgeons, Senator Kex~epy. Well, I mean, do we have too many tonsil- lectomies Dr. Gerer. Well, I would think so. Senator Ken~epy. You would think so? Dr. Gerser. Pardon ? Senator Kexnepy. You would think so? Dr. Gereer. Yes; because I think Swedish children are just as healthy as American children and the incidence of tonsillectomies in Sweden is one-tenth as high as it is in California. And I think these children who go to private fee-for-service clinics, or to the Kaiser Permanente Foundation for their health care Senator Kexxepy. Why do you think there are that number of surgical operations? } : Dr. Greer. Because we have a double standard of medical care in this country. Because we have one group of patients who get the very best that the world has to offer and another group of patients who get probably some of the worst. And the reason is that we do not control the practice of medicine strictly enough in our hospitals. Now, ostensibly, medical care in hospitals is controlled by the Joint Commission for the Accreditation of Hospitals. But figuratively and 2592 literally this is a “paper tiger” organization. They audit the quality of hospital charts far better than they audit the quality of patient care. And so we find that doctors who would be barred from operating at the veterans’ hospital, or at a well-regulated civilian hospital, can operate with impunity at some of the smaller unregulated hospitals in this country. That is why I say we have a double standard. To make it worse, you can’t tell the player by his number. It is per- fectly possible for a doctor who has not had a single day of surgical training in his life beyond his internship to list his name in the yellow pages of the directory as a surgeon, or in any other specialty, for that matter. There is no law that says that a doctor can’t call himself a pediatrician or a gynecologist, or what have you, just by self- proclamation. Evidently our laws are more concerned with bad food and mislabeled drugs than they are with bad medical practice and mislabeled doctors. Now, how are we going to adequately control the quality of hospital care? Senator Kennepy. Now, if you could try to take about 3 or 4 minutes and summarize Dr. Gerser. All right; all I can say is that we don’t have adequate controls at the present time. The external controls are bad because the joint commission has not lived up to its responsibility. Internal hospital controls by peer review do not have a very impres- sive record, or the abuses which I have cited would not have taken place. Certainly the insurance carriers, those who handle the purse strings, have been uninterested. They talk about computerized control of med- ical care at the present time, but I can assure you that if an untrained, unqualified surgeon performed an obsolete and unnecessary operation upon a young girl and the results were disastrous, which is a euphe- mism for you know what, the insurance company’s computers wouldn’t blink an eye if the fee that the doctor turned in was reasonable. So, I will close on a higher note than the way I started. I just want to congratulate you, at least, on introducing into your bill some quality controls, such things as seeing to it that laboratories perform up to a certain standard, national licensure of physicians, ongoing and con- tinuing education. But, most importantly in my field, the concept that any patient walking into a hospital should at least have the same protection that a passenger has when he steps into an airplane. That passenger is not concerned at all that the pilot is not qualified or trained to fly that plane, because that pilot is responsible for many human lives. I can assure you that anyone who is placed on an operating table also has his life jeopardized So I am most interested in seeing that surgical procedures are carried out by those who are trained to perform surgery. Senator Ken~epy. Thank you very much, Doctor. Now, we are supposed to adjourn at 3. We have about 10 minutes. Gerardo Martinez ? If you could, just take a couple of minutes. Will you tell us your name and where you live, Gerardo? 2593 STATEMENT OF GERARDO MARTINEZ, OF SAN FERNANDO VALLEY, CALIF. Mr. GErarpo MARTINEZ. Yes. My name is Gerardo Martinez, and 1 live in the San Fernando Valley. Senator Kennedy, I would like to preface my statement by urging this committee that any future hearings that may be held in the Southwest, a greater effort shall be made by your staff in trying to seek the opinion of the Mexican American community as the prob- lems that we have, especially in health, are compounded by unique variables that are not part of the rest of the national picture in regard to the problems in health. The particular experience which I have, negative experience, if I may say, in regard to medical health is that my daughter, who was born after 6 months’ pregnancy, weighed 1 pound and 4 ounces, and was given only one chance out of 20 to live. She is an adopted daughter. She was born in this hospital. The mother was destitute, and was presented with a bill of $5,000 after 3 months of being here in this stitution. We are fortunate enough, my family, in being one of a very few within the Mexican American community that do have job-related insurance. We are insured with a group carrier, Kaiser. I have to take my daughter at the age of 8 months, who is still very much under- weight, at noon because she developed clear signs of To very ill; high temperature, very high, 103, difficulty in breathing, every sign for a lay person to notice that the child was very sick. I have to call first. I call first to find out if they will be able to get the charts, or whatever, and be ready when we arrived. I was informed that I could not take the child as it was noon and the doctors had to take a lunch break and they were only able to take care of emergencies. This is a lay person that answers the phones, and this type of service, and he is not a registered nurse, or anybody else that have any type of medical treatment, as I was able to find out later, or medical edu- cation that would be able to diagnose, even by phone, which T am sure even the best doctor will not attempt, to be able to judge that a child in that particular case as I explained it would be able to wait an hour and a half until the doctor will see her. I decided not to wait for him to call the doctor for him to tell me his advice whether to take her or not, but to take her immediately. There again 1 have to face just the receptionist, no one that has been trained in any way in the medical field. I was advised again that if I had called and the doctor had advised me to bring the child in. T refer again to the previous conversation a few minutes earlier over the, phone, and the people got very upset. Nevertheless, I was able to force my way, and I do mean force my way, in order to get a doctor to see the child. The baby was found to have what the doctor, after he knew every- thing that had been going on between me and the receptionist, qualified as a touch of pneumonia, was put under oxygen and was kept in the hospital. } My question was that after this happened I tried to reach the medi- cal director of the institution because I well know that in that partic- 2594 ular geographic area many of the people that are insured to them as they are job related are Mexican American and many do not speak the language. And if IT had not been able to speak the language, I am sure that I wouldn’t have been able to make that hour and a half and get my child to be treated immediately. Now, I don’t know, doctors on the outside who I have talked to about it assured me that under those circumstances it could have been fatal. This I do not know. But I do know that the child was very sick and needed treatment and yet the treatment that you are getting through your insurance, which is not free because we are paying $35 per month for this, plus $7 that the employer pays for it, we are not able to get it. Trying to reach the medical director, IT was informed that he will not receive anybody and that I will have to write a letter to him and explain why do I want to meet with him. I would like to at this point emphasize that I was not violently seeking a meeting with him, but I was trying to be as polite and as calm as anybody can be. Finally, T have to write a letter asking, with copies to the insurance commissioner of the State, and to some people that are supposed to be the parent company in California, in Oakland, Calif., trying to seek an appointment with the medical director in order to find out if this is a practice in this place. IT was told that I was—as I requested that I be—he would be giving his own time inorder to insure that I be able to see him, I was told that at 7 o’clock in the morning: Senator Ken~epy. Can I ask you to take about one more minute? Mr. Martinez. I was told that medical care should be judged by doctors, not lay people. And it was not my business. And there were doctors who should sign the medical way it should be administered. I happen to disagree with that when it is the life of my own child that is at stake. I am sure everybody would agree with that. Senator Kexxepy. You could tell when your child was sick, couldn’t you? Mr. MarriNEZ, Yes. Senator Kexnepy. You could understand that very clearly? ‘Mr. MARTINEZ. Yes. Senator Kex~epy. And all you were trying to do was to get some treatment for her? Mr. Martinez. Yes; but the point, Senator, is that many of our people in the Mexican community cannot bypass those barriers that are being put in front of us like the one that was put in front of me. I happen to be pushy, and I can find my way through. But they will not find their way through in more than 60 percent of the cases, and that child could have died if it would be somebody else’s child. Senator Kex~epy. Thank you very much. Dr. Rex Green will be the next witness. He is a house officer. STATEMENT OF REX GREEN, M.D., LOS ANGELES Dr. Green. Thank you, Senator Kennedy. Senator Kex~epy. We will ask you to keep within the time limit. Dr. Green. I realize that the brain can’t absorb what the rear end can’t endure. 2595 My organization has a 2-year history of activism for patient care issues in this hospital, and I would like to briefly share with you some of our problems and our aspirations. Two years ago we became confronted with an untenable situation here where we felt the number of patient admissions to the medical service was beyond where we could deliver any decent semblance of adequate medical care. So through a long series of discussions and threats, and what-have-you, we have finally come this last year to serve ‘a lawsuit against the administrators of our hospital and the Board of Supervisors of Los Angeles. The basis of our lawsuit is because we don’t have any answers to our problems. We are bitterly frustrated by these problems. They are ex- tremely complex. There is no simple solution, though we have tried. But we have discovered in our efforts in the last 2 years that we are not administrators. We don’t really know how to run a hospital very well. At best, we know how to identify our own problems as physicians here and we seem to have many opportunities to identify these from 1 day to the next. The substance of our suit is, and at least it is important to us, we feel as physicians, our organization, that it is unprofessional and un- ethical to deliver two-standard medical care. We have asked our board of supervisors to enjoin the hospital administrators to prevent our delivery of this care in the future, and at least to prevent the delivery of patients to beds which don’t exist in this hospital. I am sure you recall this morning mention that the utilization of some medical wards is greater than 100 percent in this hospital. Senator Kex~epy. Which means what? Dr. Green. Which means that patients go on beds in the public hall- way with no privacy, no facilities for their care. On that level, the problem seems simple. But it is not. We have tried. Again I say we are not administrators and we are not politicians. We have tried to find answers for 2 years. We wish there were some forthcoming. So, rather than dwell on the history of our frustrations, I would just like to briefly mention a few things we hope to get results in in the future. Our greatest worry is a fear that there is a great deal of preoccupation and competition only on one aspect of medical care, and that is the financial aspect. We feel there is a tremendous problem Senator Kex~Nepy. Finances come before health ? Dr. Green. Yes, always; we feel that there is a tremendous prob- lem in that the structure of medical care has to be changed. When Dr. Bauer mentioned this morning that if a patient feels he is an emergency he is an emergency, we feel that is true. There is an abso- lute need for access to medical care. Patients can’t just be left sitting because a physician or one paramedical person feels that might be an emergency case. But, more importantly, the whole structure of care needs to be reanalyzed. The anachronisms of having university hospitals which are tax-supported, but which the taxpayer can’t get into, and the county hospitals, which the taxpayers pay for but can get into some- times at their jeopardy, and so forth. The complexities are endless. 59-661 O - 71 - pt. 11 - 14 2596 We hope these issues are not lost in the effort just simply to pay for the cost of medical care. Senator Kenxnepy. That’s a good comment. He tells it like it is. Mike Wood ? 1s he here ? Mike Wood ? STATEMENT OF MIKE WO00D, RESIDENT Mr. Woop. Can I have more than 1 minute ? Senator Ken~epy. The same as Mr. Martinez and Dr. Rex Green. If you can do it in less time, we will appreciate that. Mr. Woop. I will try to read as fast as I can. In 1967, out of the hippie subculture a new model of health care delivery was derived, basically, free clinics organized by the com- munities for the communities, the purpose being as stated in one of the particular bylaws: to serve that portion of the community whose needs are not adequately met by existing facilities. In southern California the free clinic concept has grown from one free clinic which opened in 1968 to 30 now, treating originally 20,000 people in 1968, 200,000 in 1970, and this year we expect to treat over 300,000 people. The statistics don’t mean a whole lot, except the fact that a need is being fulfilled in the community. We don’t lecture, moralize, judge, or preach. We help. We don’t look down our noses or assume someone a lesser person because he is black, Indian, Chicano, Oriental, or poor. We only help. The free clinics are supported by donations of staff and volunteers. Our average cost per patient is about $2. The clinics try to help anyone in any way and to treat the whole person rather than a symptom. The services in the clinic range from medical, dental, psycho- logical counseling, legal, job counseling, food, schools, as well as many others. The increasing emergency situation in health care, one of our county hospitals is going to have to close their doors to certain cases that are not being met by the Government. Medi-Cal cutbacks. The local gov- ernment doesn’t have the money to do the job, much less keep up with it, and the community can’t be expected to fully support the clinics. The free clinics are, have been, and will continue to do their best with what they have, a feeling, which is the most important factor. We don’t think of our job as being our brothers keeper, but rather his friend, his helper, and his brother. I feel that our priorities in this country must be reevaluated. For example, if the money spent on one rocket that is sent up and blown up, was taken and spent in the free clinic thing, the free clinics could do a job that would be unparalleled in the history of this country as far as the health care delivery is concerned. The Constitution of our country has great rhetoric guaranteeing a lot of rights. These have been lost and misinterpreted. Rockets, the SST, the southeast Asia war do not protect or fulfill any of these rights. Education is considered a right and is even considered a law. Health seems to be considered a privilege. It is not a privilege, Health, in my opinion, is life. And life is one of those supposed rights that we are guaranteed by the Constitution. 2597 With your bill we are embarking on national health insurance which will enable the consumer to receive the health care that he deserves and needs. The free clinics, as providers of medical services, as well as social related services, look forward to comprehensive national medical health insurance with humanization. I emphasize that again: with humanization. During the interim, until it is implemented, the free clinics of California need support to continue to help serve the people that we do. I would like to thank you for the time. Senator Kex~epy. Thank you. Good statement. (Whereupon the hearing was adjourned at 3:10 p.m.) IE gi i Ran oy SC oo - . R 5 « re tl al — &. a RL 4 8 yh Mel B = i) = x 3 io ow = “ign w oo ® T= Se = J Ta oe ) 4 gi Misa ol 4 np "oe J + Jas TR na ) Al . os wy vy i af Ee to EL ships ETH Ee Yn ii =o Fp me Seb " y = JAW oF EL Ry I i CAL N LE i - fired Be * A ine ¥ "= Mily Aw TTA ; c B Sk vase ion dt es 3 3 £8 : i HEALTH CARE CRISIS IN AMERICA, 1971 TUESDAY, MAY 18, 1971 U.S. SENATE, SUBCOMMITTEE ON HEALTH OF THE CoMMITTEE ON LABOR AND PuBric WELFARE, Los Angeles, Calif. The Subcommittee on Health met at 4:20 p.m. in the UCLA Medi- cal Center, Los Angeles, Calif., Senator Edward M. Kennedy (chair- man of the subcommittee) presiding. Present : Senator Kennedy (presiding). Committee staff present: LeRoy G. Goldman, professional staff member to the subcommittee; Jay B. Cutler, minority counsel to the subcommittee. Senator Kex~epy. The meeting will come to order. We have an hour, maybe less; about 55 minutes. Perhaps it would be useful if every- body identified themselves, just so we get some kind of feel for who is here and the various groups that are present. A lot of you may know each other, but perhaps not. We want to thank the staff of the school for being kind enough to permit us to have this extremely fine facility and to make the arrange- ments. We will just start off by introducing each other. Mr. McKix~ey. I am Vermont McKinney, Director of the TBA program in Venice and also with the Venice Health Council, trying to meet the needs of the Venice community. Dr. Meningorr. Sherman Melinkoff, M.D., dean, UCLA Medical School. Dr. TranqQuapa. I am Bob Tranquada, associate dean of the USC Medical School. Dr. Speruvan. Mitchell Spellman, dean of the Drew Postgraduate Medical School. Mr. Brayton. Donald Brayton, coordinator of area IV, California regional medical program. Mrs. Busou. Mrs. Lynn Busch, administrator of the Venice Health Council. Mr. CantreERAs. David Cantreras, president of the Venice Health Council. Mr. Dimrrrorr. Steve Dimitroff, assistant manager, Venice Service Center. Dr. Bresrow. Lester Breslow, professor, chairman of the Depart- ment of Community Medicine, UCLA. Mr. Hargis. Jeff Harris, fourth-year medical student from UCLA with an interest in pediatrics and public health. (2599) 2600 Mr. Fercuson. Randy Ferguson, community organizer, East Los Angeles health task force. Mr. Magrinez. Claude Martinez, East Los Angeles Congress of Mexican-American Unity, a local development corporation. Mr. Comacuo. Andy Comacho, East Los Angeles Health Center. Mrs. Guzman. Carmen Guzman, also of the East Los Angeles Health Center, but also a community person from East Los Angeles. Orca Tamskac. Olga Tamskac, dental patient and also medical technologist. Mr. Fepousky. Stephen Fedousky, fourth-year medical student. Miss FreLps. Anastasia Fields, Southeast Community Health Council. a Mr. Skow. Jim Skow, senior surgical resident, UCLA Medical enter. Mr. McKay. Bob McKay, resident in psychiatry. Dr. MeLinKorFF. And there is Harry Parker. Senator Kex~eny. Well, I think one of the things that I would be interested in, and perhaps some of you might comment on, is the role of this medical institution in the community and what is expected of it by the community. How realistic is it to expect that an institution like this is able to meet these needs? What ought to be done to try to change it? Maybe we can start off with this, and then we will move from there. What is your feeling about the role that this institution should play in the community? STATEMENT OF VERMONT McKINNEY, DIRECTOR OF THE TBA PROGRAM IN VENICE AND THE VENICE HEALTH COUNCIL Mr. McKinney. Well, maybe I can start. We see this university as having the resources and being able to get to those resources to help the nearby private community. We feel that no longer can a hospital of this nature remain in their own ivory tower, so to speak, and not particularly relate to minority communities. And I am talking about poor black and poor Chicanos. At this point we have been knocking at the doors here to try to point up an acute problem in the poverty areas, which is drugs, and it is a national issue. We are trying to get the staff here to relate to us in relation to the overall drug problem. We are con- cerned that if this institution is getting at the question, the real ques- tions in the health field, and trying to improve the health care of the people, and particularly of the people who have done without good health care, that they have to begin to relate to the community. People have to begin to come down, there has to be many, many more sitting down at a table like this with people who really have some real needs. And we think that there is no question, the community doesn’t have the resources. They don’t have the contacts. The way things are set up, they are almost caught in a vacuum. We think that at this point, in terms of this being a teaching institution, that the way to learn about the real needs, that doctors, nurses, everyone concerned is going to have to get out in the community. We are talking about trying to develop a concept of street doctors, and that would mean that doctors have to be close to the people in the 2601 community that are really having the problems and whose needs aren’t being met. We know that the resources are here, but this means some official change in direction from the departments of psychiatry, and from other parts of the hospital, to begin to move in this direction. We know right now that in terms of inadequate health care in the communities, there are more people from the Venice area who know what is happening. This community has been isolated, and we need support. Some of the people in the community, and also some of the major providers, such as Dr. Breslow, and some other people in this area, have gotten together to try to look at what can really be done in terms of endowment, and the health crisis, and I believe there is a health crisis in this country. There is more crisis than just health crisis, so far as that is con- cerned, but there is definitely a health crisis also. And we have people, of all kinds and ages suffering. But I think that we have to start sit- ting down at the table and not just presenting more tokenism to poor people, but allow poor people to really participate in the decision- making process. This is what I am concerned about. We are raising certain ques- tions about citizen participation, particularly for those that have been excluded, and that means from the board which may be established from HEW all the way down. From the top down, we are talking about citizen participation and involvement of the minority com- munities in decisionmaking when it comes to the delivery of health services. And this is important, very important, when it comes to the people who feel excluded. I think also that those who are presenting certain kinds of health plans, such as yourself, must visit those communities, let them know what kinds of things are being thought about, and how they can possibly have input to these considerations. What kind of input can they have? Right now we are trying to form what we call the health congress for this area to allow the presentations of certain kinds of bills and other things, to the people so they begin to understand. This health congress, we are trying to establish in September, and we would like people like you to come down and present what you really see, you know, as an answer to the health crisis in this country. STATEMENT OF MRS. LYNN BUSCH, ADMINISTRATOR OF THE VENICE HEALTH COUNCIL Mrs. Busch. I think there is one more issue that should be brought up, and I think that there is a dichotomy in health care delivery that causes a great deal of confusion. For instance, in our area, which is in such close proximity to UCLA, the Venice-Santa Monica area, we, on one hand, are hearing about national health insurance and improved health delivery systems, and on the other hand the consumers are hearing about budget cuts and fee increases. You hear it at places like UCLA, which causes a great deal of confusion in terms of health care delivery. Too, there are situations that don’t function well. Last summer, there were some students who were to be studying health problems, 2602 and in Venice we may have made a mistake. We assumed that a couple of students would be coming down to study the local health problems that are within 13 miles of the university. Instead, they were sent to Alaska and Arizona. And I think that this represents a situation that creates a lot of problems for the people who are in the general area of these big institutions, that could be helped easily. STATEMENT OF JEFF HARRIS, FOURTH-YEAR MEDICAL STUDENT FROM UCLA Mr. Harris. I would like to go on from there. I think the university has done a few positive things, one of them being: Dr. MeLinkorr. Thanks, Jeff. Mr. Harris (continuing). One of them being working with the Charles Troost School, and that development. Another being working with RMP and OEO involving the health care network in the San Fernando Valley. But I think they have been very deficient in exposing medical students and house officers to any other situation than the traditional hospital settings. We don’t really have any formal out- patient experience as students, as a requirement in our curriculum. We really don’t get out and wrestle with some of the community needs as they are in the neighborhoods. And I think Venice is one example where we could be doing more and helping out, perhaps, with the community, to set up a neighborhood health center that would inter- lock with UCLA. But I think if we are going to look to solutions in the future as far as health care delivery systems, we have to have students and young professionals getting involved in that solution process early in their training. Senator Kexnepy. Does the community want young interns coming out to it? Or does it feel that this is just sort of a continuation of the teaching process and, “They are using us poor people as guinea pigs”? How do they react to that? Mr. Harris. I think there is some—— Senator Kenxnepv. Well, maybe they have—I don’t know, how do you react to it? Do you want an Outreach program from this university with some of their topflight students going on out, that does have some supporting help and assistance from the school? Or would the community feel that, “Here comes some young students and interns and they are practicing their medicine on poor people”? What is your reaction ? STATEMENT OF ANDY COMACHO, EAST LOS ANGELES HEALTH CENTER Mr. Comacnuo. Well, my response to that, coming from the East Los Angeles area and working closer with the medical center of the Univer- sity of Southern California, I don’t think we want interns and resi- dents out there practicing medicine. But they can help us do other things, such as planning, such as program development for the area, for the community ; program development for the health network that we mentioned, for instance. They would have the inside information as to what goes into the programs of that nature. 2603 They could also help recruit minority people, minority students into the medical schools and the schools of allied health. But I don’t think that the poor people want second-class medicine. I don’t think we want interns and residents practicing on us. I don’t really think that that is what we want. Senator Kenxepy. What kind of medicine do you think is practiced here? Mr. Comacno. I really don’t know. I don’t know too much about UCLA because Venice and Westwood, west Los Angeles and Santa Monica areas are more closer to the university here, where east Los Angeles is quite a way off. And I don’t know how many people from east Los Angeles would be coming out this far for medical service, or psychiatric services. Mr. McKin~Ney. We think it is primarily research oriented, as far as the practice of medicine here, and we are saying that it has to in- clude service at the same time. And we have had people coming from the community saying they have been treated like guinea pigs, or there is a wall, and other kinds of things that happen here because this is a strange world to them as compared to down in the community. And so we recognize it as institutionalized racism. We know this. The community people want some kind of services, but they know it goes back to costs again. The cost factor comes up again and the poor people can’t go any place to get services, so that they have to become research animals because they can’t afford to pay for the med- ical services. Mr. Frreuson. Senator Kennedy, I think that you will find that the same problem exists here as in the Los Angeles-USC Medical Center, with the medical staff not speaking Spanish and not being able to communicate with the patients that are Spanish speaking. We at the health task force do get complaints from Spanish-speaking peo- ple in this area that utilize this facility, and they are the same. They bring their children up, the doctor can’t make a proper diag- nosis or can’t dispense the medication properly because of the language barrier, and this definitely should be corrected in terms of Spanish- speaking representation on the staff of the medical center. Training for these paraprofessions should be set up so the Mexican Americans and Spanish-speaking people can be included in the medical profession. Senator Kennepy. Why don’t we talk just a little bit about the minorities in the medical schools. STATEMENT OF MISS ANASTASIA FIELDS, SOUTHEAST COMMUNITY HEALTH COUNCIL Miss Fierps. I am Anastasia Fields, from Southeast Community Health Council. We are in a unique position. UCLA is so far removed from us, it is something we read about, or see on television. And we reecive very little contact or benefits from the school in our community. At the same time, USC General Hospital is quite a distance from us, but that is the place that we are most closely connected with. A part of our concern is that we have few or no black or Chicano administrators or doctors. The patients go into the hospital, but the training that is received is not brought back into the community. We 2604 have no avenue to bring it back into the community. We have been trying to determine how many black students graduate from USC, and how many black students have graduated from UCLA in the medical, dental, and nursing departments. I can’t quote a definite fig- ure, but we do know that it 1s a very limited number, and with as many people as there are in Los Angeles and the surrounding area it seems that we should be able to have more of the minority all the way from the administration down, rather than to have maybe a far-away assist- ant. This would help, especially with this language barrier. Back to our unique position. We have little services in our area. Our community council has been working on an emergency service, an interim service. We work very hard on it. But then when the cutbacks came, we found that we couldn’t get any money. So a part of our con- cern is students. There is a 2-year nursing course in the junior colleges. We are not objecting to this, but the tuition, and the costs of going to a 4-year college is rather prohibitive for the minority students. We are wondering if there isn’t some adjustment that can be made wherein these students who are interested in the medical professions ony have some assistance in attending the 4-year school to begin with. STATEMENT OF RANDY FERGUSON, COMMUNITY ORGANIZER, EAST LOS ANGELES HEALTH TASK FORCE Mr. Fereuson. Senator Kennedy, I think there is another problem that may be contributed to here today. There is a problem of repre- sentation of community people. I don’t believe that there has been much effort to notify the community people in Los Angeles and in east Los Angeles that you were going to be here today. And they, you know, didn’t really have the opportunity to come up here. At the medical center, I was there about 1:30, 2 o’clock, and I found the community people were being locked out and kept out, and there were nurses and county employees and professional people allowed to come in. There was about 500 people there, and I think 75 percent of them were county employees. And the community people were in the hallways and could not come in. I think that this is another problem that we have. The people keep the community people away from decisionmaking places and from attending the meetings where, maybe, they could have some effective mput. Senator Kenxepy. You mean at the last hearing you couldn’t get in ? Mr. Fercuson. That’s right. I believe a sergeant at the door told me that he didn’t care where I was from, that he wasn’t going to let me in the door. This is the type of attitude that you run into. Senator Kex~epy. I think in fairness it was pretty crowded. I think that they opened it up later on. I did hear that there was a pretty good flow of people through there. But, obviously, this is important. We all have these difficulties that we face in terms of notification and sufficient time, because the Senate is in session at this time. But I think that we ought to make a better effort at it. 2605 STATEMENT OF MRS. CARMEN GUZMAN, OF THE EAST LOS ANGELES HEALTH CENTER Mrs. Guzaan. Senator Kennedy, I don’t think that is an excuse, because I think we are going to have to sacrifice many things. It is time that we—if you are coming from so far to listen to us—communi- cate with you. I do not see Indians here. I do not see Asians here. The Asians, too, are hurting by the bilingual communication, or not being able to speak English. And they come and they have their problems, too. They are more conservative and they probably are not coming in on this yet. Yesterday I heard a young man at the end say, “Senator Kennedy, are you going to do anything about the narcotics or the police brutality ?” I have brought you some literature from East Los Angeles, and I hope you read it on your way back, and maybe we can, through the health task force, continue to send you literature. We have been too busy with other things that we haven't communicated in this way, but without having a comprehensive help in every area with creative ideas from people who know what is a in the community, or with the people suffering in narcotics, or child guidance, or family planning, we are never going to get anywhere. And these things have to be in- cluded in whatever insurance you have. It has to be pinpointed, which way it can be done better. Only the people who live there can help you. No matter what, if you do not arrive here, we would understand. A lot of poor people cannot get out. That’s all T have. Thank you. STATEMENT OF MISS OLGA TAMSKAC, DENTAL PATIENT AND MEDICAL TECHNOLOGIST Miss Tamskac. I think we need a better, well-informed public, and the communication media is ideal because children of junior high school age are discussing among themselves programs that have been on TV, and they are very intelligent, mature. And another thing, the reaction of former patients of UCLA is nothing but favorable. And in my own experience with the dental clinic, they are so thorough and so competent that I have no excuse to complain, nor have I heard complaints. Mrs. Buscu. You know, the people in the individual communities know full well what the major problems are, and each community has problems that are universal, and at the same time they have prob- lems that are unique to that particular area, a particular ethnic group population. I think one of the biggest problems that all of us are faced with 1s m-o-n-e-y. I heard the lady—I am sorry, I forget your name—from the south- east talking about money to help students to get into the health profession. We need money to implement the drug programs and family planning programs that Mrs. Lewis was talking about in east 2606 Los Angeles. In a community like our own, which is a small com- munity compared to southeast, or east Los Angeles, we have on our own, with creative and innovative ideas coming from the community, established our own medical center on a very small premise compared to something like UCLA. Like Mr. Harris was talking about. We have gained the backup support from UCLA and from two other major hospitals in the area. We are struggling for survival. We have managed to open up a clinic under control and super- vision of the community that relates to the problems in our own community, and we have managed to gain the support of the hospitals in the area. We have seen over 2,000 patients in 8 months. Probably many of them would not have received any medical care if we had not been right there in our own community. And now we are facing doom. And in a short period of time we may be forced to close our doors because of lack of money. We have spent, I guess, maybe 50 percent of our time just struggling for funds. There seems to be a real problem with filtering money from the top to the bottom where people are struggling to do things for them- selves and where they have managed to get things done, and then these programs fall apart; are crucified, really, by lack of small amounts of money. These small neighborhood programs don’t cost as much as sustain- ing a war in Vietnam, or other big projects that this country manages to keep going. We are not talking about billions and billions and billions and billions of dollars to keep small health clinics going in individual communities or small drug programs going. We are talking about money in terms of thousands of dollars and hundreds of thousands of dollars. And it certainly seems to me that there needs to be a change somewhere in the system for dividing money in this country so that these programs can be given life instead of death sentences. Mr. FrrausoN. Senator, community people look at the medical in- stitution as a place where their illness is held. Institutions usually look at what they are doing as teaching, research, and healing also. But what I would like to interject is, perhaps, another function of our city, or of the medical school and the hospital, and that is an economic function. The hospital, both here at this medical center at UCLA and the USC Medical Center, purchases goods. They buy quite a lot. Quite a lot, of economic units, But where do they usually buy it? The USC Medical Center is based, and it is right in east Loos Angeles, one of the largest buyers of goods in that community, and T venture to say that less than 2 percent of their budget, other than personnel, is spent inside of that community. I don’t want to add to the indictments that have gone on here today, but I would think that it behooves the administrators of these medical centers that they should encourage economic develop- ment in their community. This would help the problem that the young lady here was talking about for programs. It would help to bring alive a community, and I am speaking of east Los Angeles right now, that is dying. If a hos- pital’s function is to save lives, I submit that a community has a life that has to continue in existence, and if the university closes its eyes 2607 to the surrounding community, then it is not fulfilling its function. And again I submit to you that these administrators should begin to think in terms of bringing to life a community that is dying. Miss Tamskac. I would like to see more paramedical courses intro- duced into the junior colleges and into the regular colleges, also. There seems to be a lack of training in particular colleges, anyway. STATEMENT OF STEPHEN FEDOUSKY, FOURTH-YEAR MEDICAL STUDENT, UCLA Mr. Fepousky. I don't believe that there is a resentment and reaction to interns and residents going to the community. UCLA dental school has created the Venice clinic for impoverished people, and the reaction is nothing but very good. And I think they are getting the same treat- ment, as families of much higher income are getting here at UCLA. I think that it is important to recognize, that there is a good reaction in the community. STATEMENT OF MISS ANASTASIA FIELDS, SOUTHEAST COMMUNITY HEALTH COUNCIL Miss Fierps. Well, in my community I should like to see more assistance from our University of Southern California. We sit just outside of their boundaries, and health is an overall thing. Homes are just rundown. It seems that the medical department could encourage the architectural department to lend some assistance to people in the community in planning to redevelop our cleanup—not necessarily cleanup, because the area is old. But we need a redevelopment program. However, the people who live in the area are senior citizens, or they are on welfare. And the people who own the homes are absentee land- lords. But those people who do own the homes are senior citizens who are not willing to pay to rebuild the whole area. But they would re- pair their homes. And it seems that the improvement of the home would improve the thinking of the people, or the overall health of the people who live in the area. It would help to eliminate some of the rodents and the other problems, that we are having. So, to me, and to some of us in our group, it does seem that this health thing would sort of trickle down into the other departments of the school. Transportation is a big problem in our area, even from the school, from the home to the General Hospital. You know, those are big problems. It seems that the school could help us work out some means of transportation that is more convenient than having to ride about an hour to get out to the hospital. Senator Ken~epy. What do you think is at least a partial answer to bringing health into the communities? I mean, do most of you sub- seribe to the neighborhood health center concept, or do you find prob- lems with it? What direction would you think? Mrs. Busca. If it could be financed in a way that is part of an on- going and workable health network, then I think, it is the ideal health program because you are talking about health services within walking distances of people who are trapped by things like she was talking 2608 about, lack of transportation. But it should be a way of filtering people into the major services. You can’t possibly talk about putting a hos- pital in every couple of blocks in each little community. But if you talk about a mininetwork that filters people into the major services, and then filters them back into the community, a place that is well-equipped enough to do the necessary followup, and that has the backing and the finances to move the people into these institutions where the costs usually prohibit their using it and then back into the community, I think 1t 1s the ideal answer in the small communities. Mr. Fereuson. Senator Kennedy, I would like to ask for your com- mitment to look into the plan that the East Los Angeles health task force has for a comprehensive health network. It is a plan to deliver a first-class medical system, first-class medical care to the community. It has community input. And I think that if the universities, the Gov- ernment, that deal in medical services would let the community people do the work, have the input, have the say-so, that we would be a lot better off in terms of meeting the needs that do exist in the community. If we can have your support, after you see the plans that have gone into this, it would be greatly appreciated. Alcoholism is something that I would like to talk to you about a little bit. I think there are about 400,000 alcoholics in the county of Los Angeles. And out of that 400,000, I think 85 is the percentage of alcoholics in the east Los Angeles area. The work that has been done in alcoholism is very minute. The problem is so intense, and yet there hasn’t been that much input by, again, the universities, the Govern- ment facilities, at all. There is the problem again, of language. The Pebiom of money. The problem of giving quality care to alcoholics, one by the people that have the expertise, the recovered alcoholics, the people that know the problem. This is another problem that we have. Senator Kennepy. We have your program. I received it last night down there, and I am extremely interested in it. Mrs. Guzman. I wanted to add one more thing, Senator, because I don’t think that you have dealt with Mexican people. (Mrs. Guzman addresses the subcommittee in the Spanish language.) Mrs. Guzman. Now, the reason I am talking to you that way, Sen- ator, is that many of our parents or mothers do come very recently from Mexico, and many of the families, the head of the family is the man, whether he has a lot of money, little money, or no money. He has a say-so if the wife goes to the clinic to get a Pap test, or to practice family planning. We have need to do a great job in education. And like Randy says, we don’t even have any alcoholism treatment. We don’t have it in any area. And we haven’t even touched mental health, and all the areas; just name them. Nothing has been done. fo Now last night you saw that beautiful little child and youth clinic. But do you remember how you climbed that hill? Did you walk it? Senator Kexxepy. No. Mrs. Guzman. Did you see the beautiful lights when you were com- ing down in your automobile ? Senator Kennepy. Yes. We got there just at sunset. 2609 Mrs. Guzman. It is a very high hill. Very high. And at one time there was no transportation. Imagine a woman carrying a child up to 8 or 9 months, close to 9 months, in the rain and in the hot sun. Not until recently did they start putting a little bus going up there. Why did they put that thing up there? And imagine two people who need a job, they don’t have the fare for that. Even the three tokens, we call that the TJ bus. Now it is a little higher. For years and years while this was built, they had to climb that hill. By the time you got there I don’t think you even wanted a job or you wanted to go to the clinic. Now they have that transportation. I just wanted to let you know. But as far as our culture or the culture of the Orientals or the Indian, we must respect their dignity. We must respect their ideals. We must respect their ways of living. And we will make a better America be- cause we contribute something beautiful. We cannot be a melting pot. I don’t think it is a very attractive thing to have everything look alike. I think it is more beautiful, like in art, where you have a variety. So, we must look into the culture of the pople and service those people as they need it, just like Liynn says. She knows in her area how much they have fought, not only for the English-speaking people, but they have a wonderful way of even getting translators or having Spanish-speaking people. But this we have to really go back to the individual people in their own culture and their own—Ilike if I went to your area and I forced you to eat chili beans, which a lot of Anglos try to make me eat chili beans, because that’s all I know how to eat when I work in the home. They make me a big pot of chili beans. I say, “What’s that for?” They say, “Well, Carmen, don’t you eat chili beans?” You know, even though we are poor, and everything, I know how to eat filet mignon, lobster, crab. And now they have TV—I would like to have a home something like those rich people have, The chil- dren see Cadillacs, and television has opened the eyes of the people. We want a little piece of that. We are never going to get it if we don’t get out of poverty, which is the worst thing, more than anything else. If we alleviate some of the poverty, I think we are going to have a little answer to some of our problems. Mr. McKixxey. How does the plan that you are proposing affect poor people? Senator Kex~xepy. Well, it is going to provide one standard of qual- ity health care for all people, not just poor people, but for all people. And that is to be recognized. It will be universal. It will be compre- hensive. It will be a matter of right and it will be of one standard. And that is obviously one thing that we don’t have. Mrs. Busca. How will it affect the people in this country who are not employed? Senator Ken~epy. It will cover them. That’s one difference between our program and the administration’s program. 2610 The administrations’ program doesn’t include unemployed people unless they have children. It didn’t in their initial recommendation. But this does. This is universal. It is comprehensive, Mrs. Busca. How is it set up to meet the costs for the people who are of no income or an income that prohibits medical care? Senator Kennepy. They have every right to go and utilize the sys- tem. There are no deductibles, no coinsurance. It eliminates those fea- tures. And they have as a matter of right to fully utilize the system. Mrs. Busca. Without cost ? Senator Ken~epy. It is based upon funding under two mechanisms. One is funding through the income tax system, and the other from employers’-employees’ tax, which is 1 percent for employees and 3.5 percent for employers. Self-employed persons pay 2.5 percent. Benefits are universal and comprehensive. A matter of right. Mrs. Busch. Can I ask another question? Excuse me, I want to get one more thing. How do the neighborhood health networks that we were talking about a little bit earlier fit into that program ? Senator Kexnxepy. They will be developed. They will be encouraged. We will find new ways of creating additional kinds of neighborhood health services in the community. The importance of preventive care is emphasized under the Health Security Act. Mrs. Busca. Will it provide funding for health, neighborhood health centers like our own ? Senator KENNEDY. Yes. Mrs. Busch. Before they die? Senator Kex~epy. Yes, it will. Mr. McKinney. What will be the makeup of the board ? Senator Kennepy. Well, it could include consumers. The best ex- amples, I would think, would be the health boards of federally funded OEO programs. And they are made up of individuals within those communities. The purpose is to bring the consumer into the whole health system. And that is what we are attempting to do. Mr. McKinzey. How would that affect the doctor’s role in it? Senator Kexxepy. Well, in what respect? The doctor would be en- couraged to go into prepaid group practice, but he will also be per- mitted to practice fee-for-service. It would provide front-end budget- ing. That means you will allocate a certain amount of money that will be spent for health needs for the country. You don’t have the wide-open situation which you have at the present time. I think it is the best way of getting costs under control. Mrs. Buscn. If I may, are you talking about the consumers in direct planning roles? Senator Kexxepy. Yes. Mrs. Buse. And in decisionmaking roles? Or are you talking about more “consumer input”? Senator Kexnepy. No; Tam talking about them in active policy roles, in the development of this program. 2611 Mrs. Busca. Then my other question is, How do we define con- sumers? Anyone who consumes medical services? Or are you talking specifically about the poor and near-poor consumers ? Senator Kexxepy. Well, I think it is up to the community. It is a reflection of those that live in the community and are going to be utilizing the services. That's the best way that I know how to do it. Miss Tamskac. How will your program affect dentistry, or is it included ? Senator Kexxepy. It includes children up to 15 years of age, and it moves inclusion of them in 2-year steps up to 25 years of age. It is the only program that includes dental care. Let me ask just the medical school how you feel that the university can help in Hecting the kinds of concerns that have been expressed here by these people? Dr. MeLinkorr. Well, Senator, I would like to say that there have been a number of misconceptions expressed which I don’t have time to explain in detail, as you can understand. Senator KexNepy. Yes. Dr. MeLinkorr. Though I would be happy to if we did have time on some other occasion. But let me just say briefly that no one at this hospital is treated like an animal or a guinea pig or experimented on. Everybody who comes here is treated to the best of the abilities of the faculty here, and staff, and is treated with dignity and all the medical expertise that we know how to summon. We are very actively working on programs, for instance, in drug abuse. Dr. West and Dr. Parker have just recently launched such a program. I think some reference was made to some ways we have tried to help in Venice, and so on. But I would like to say this: We are in favor of a plan to make it possible for everyone in the United States to have the best possible medical care. I don’t think the medical schools in the country can provide all the medical care that is needed. The medical school does have an obligation to provide education of the best quality because no matter how much money people have to pay for medical care, if the doctor who is there to provide it fis a fathead, whether the health care is prepaid or spotpaid, if the doctor is a fat- head it is not going to be very good care. And so we feel that we do have an obligation which we are fulfilling to the best of our ability with the limitations in funds to provide good doctors. And that, we think, is our central objective. Mr. McKin~EY. You know, we have to determine, and I was talking to Dr. West about this yesterday. Yesterday we had a meeting: Dr. West. Seems like last week, but it was just yesterday. Mr. McKinNEy. Yes. In fact, we were talking about really an official policy, and this is what we mean in terms of input from the community. And it is like if this hospital is set up primarily for research and training purposes, then the community, in terms of priority, is third on the list. Or it may not be on the list at all. 59-661 O - 71 - pt. 11 - 15 2612 When we come to official policy, the community gets things by having to beg if, in fact, they get anything. Either the community has to beg or take. They either have to come humble and beg, or take. Those are the only two ways in terms of moving toward official policy changes, where there is going to be a way for poor people to get community services, or to become a part of the training and research, and other such things that are going on. Then we think that some official policies are going to have to be put on paper and put out, and show in writing how the people are going to be able to participate and get services and at the same time participate in some training to answer the questions of the unknown. We know one of those big unknowns that no one really talks about too much on the national level is alcoholism. Senator Kennepy. It ought to be talked about and something done about it. I just say that there are people who are trying to respond. That is what we have to try to do, get those who are representa- tives of the community interests and try to work these things out, working together with some of you. That is why we are here. If we weren't interested, we wouldn’t be here. But we are, I think it is a good comment. Maybe just a final comment, then we are going to have to run. Mr. Comacno. I would just like to revive your question that was never answered as to what the university is doing for the minorities. I think we have the dean of the UCLA Medical School and the dean of the University of Southern California, and also Dr. Spellman, who is the dean of the Martin Luther King, or the King-Drew post- graduate school, and I would like to have them answer that question. The question was never answered. You heard here about lack of education of people of the east Los Angeles area, and I just want to tell you how many health educators we have, bilingual health educators, in the county of Los Angeles. We have about 1.6 million Spanish surnamed Americans in the county of Los Angeles, and we have two health educators that have grad- uated from a graduate school in health education. I don’t know how many people are in this school of public health here at UCLA. I don’t know how many people are in the Valley State College School of Public Health or in the school in Berkeley. But I don’t think they are graduating too many minority students out of the schools, either the school of public health or the medical students. I would like to have an answer from the deans here today as to how many minority students are in their classes and what size classes they have. Dr. Merinkorr. We have 136 freshmen, 135 freshmen at UCLA. Fourteen are black students, nine are Mexican-American, seven are Oriental. We don’t have any quotas. We take the best students we can find. We spend a great deal of time searching out qualified students among minority groups. 2613 Mr. Comacuo. And what about your selection committee—do you have minority representation there ? Dr. MeLiNnkorr. We certainly do. We have many minority people on our faculty, and many of them are on the admissions committee. Senator Kexnepy. Thank you very much. STATEMENT OF MITCHELL SPELLMAN, M.D., DEAN OF THE DREW POSTGRADUATE MEDICAL SCHOOL Dr. SpeLuman. Drew postgraduate school doesn’t have under- graduate medical students, that is to say it doesn’t give medical degrees. What it is trying to do in this area, as a matter of fact, is privately provide scholarships to minority students in the country, and through this the funds through the whole span of health occupa- tions, not only medicine and dentistry, but nursing and allied health professions, tuition costs, tutoring, or whatever the needs may be. The Drew School recently was granted a Federal contract and is going to assemble a faculty of the allied health sciences and assemble a consortium of institutions ranging from high schools at one end and universities at the other, and try to develop a system of accrediting so that one institution accepts the accreditation of another. We can then increase the pool of minority students and those stu- dents aspiring to medicine or dentistry could enter the schools that can train them in the consortium. STATEMENT OF ROBERT TRANQUADA, M.D., ASSOCIATE DEAN OF THE USC MEDICAL SCHOOL Dr. TrRaNnQuUADA. Senator, let me respond in the interests of USC. The incoming class of 96 in September will have 10 Chicanos and nine blacks. The representation in this year’s freshman class, again of 96, is approximately that. I think 18 total, about equally divided. And the numbers above that are smaller. We are making an effort. It is not enough. Senator Kex~epy. What about in the nursing school 4 Dr. TraxQuapa. The nursing school does not have such a good rec- ord. Some special efforts have been made. Dr. Meuinkorr. I don’t have the figures available, Senator. I can get them for you. It is a separate school. a Senator Kex~Eepy. Yes, all right, thank you very much for coming. At this point I order all statements of those who could not attend and other pertinent material submitted for the record. (The material referred to follows :) Wo IN REPLY: REFER TO 2614 UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF MEDICINE 2025 ZONAL AVENUE LOS ANGELES, CALIFORNIA 90033 225-1511 DEPARTMENT OF MEDICINE 225-3118 tay 17, 1971 Prevalent problems encountered in the American Free Indian Clinic Alcoholism. Psychiatric problems including overt schizophrenia, mild to severe endogenous and exogenous depressive reactions and mild to severe anxiety reactions. Much of the stress is directly related to (a). Lack of employment. (b). Loss of or lack of MediCal support. (ec). Inability to obtain or lack of knowledge of ald in the form of welfare grants, food stamps, or job training. (d). Although I have not had ccntact with such a case, the high rate of suicides amoung the indians in urban areas is well documented. Lack of prenatal care. There 1s no means presently to insure that the prenatal patients we see receive any care before delivery. Infant immunization and preventive care 1s not good as many of the mothers become very discouraged about visiting Public Health Centers. Immediate Needs. {1}. Adequate pharmacological suprlies. We should be able to maintain a large enough stock so that we don't have to give adults pediatric suspensions, or have to substitute one drug for another we would rather use, ie tetracycline may have to be substituted for amphicillin. (2). Adequate funding to run prcgram as it now stands, no grandiose (3). amount, assurance of several hundred dollars a month would make a blg difference. A continuing recruitment program of indian personnel for training immediately in clinic skills. More indian aides are needed to assist the Indian nurses now working in the clinic. Future Needs. (1). Recruitment of students for training in all of the health sciences, particularly physicians. USC School of Medicire is carrying on a minority recruitment program. I hope to get students exposed this summer to IN REPLY: REFER TO 2615 UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF MEDICINE 2028 ZONAL AVENUE LOS ANGELES, CALIFORNIA 90033 228.1511 DEPARTMENT OF MEDICINE 225.3115 {2}. possibilities of training in the medical sciences in cooperation with the Community Medicine department at UGS. The American Indian Free Clinic should be expanded slowly to full day operation and addition of more rocms as more indians are recruited to participate in running the clinic. Non-indians should not be assigned responsible.roles and should only give suggestion when asked. It will not work for us to build a big new beautiful clinic and/or hospital and tell the indians how to run it. They have to do it themselves. Funds should be made available,without strings attached, for administration by the indians as they organize expansion. It cannot be overemphasized that the indians can and should be given the means to run this clinic without us telling them what to do. Some of us try to americanize the indians, some of us empathize with them, some of us criticize, but we will never understand them because they do not think as we do. The indian should be free to continue his heritage of religion, crafts and trital life without any interference on cur part but with our active encouragementin the $form of ade quate Funding whic he man oes. Thank you, £ : [Gig imr Lois Boyler, MD Assistant Professor of Medicine | zy SUT Mar 24 2616 (3181 Lampoon Ave., # 235 Urange, altfouniz 92668, May 2058 1971. jain Edward, Kennedy, fess VC he was quails ply ip qitanl yous hearing in Los Angeles £ Leatimony re Lp gm fas iy uly ote Ss dood [tes ge Lue earns aI under Medi ane, and hex 2 2 the Zen i Helly 1% liedicare dedicae poll 5701.05 and, I paid ay no was small, ] dep sodning es b ecome Bl if these no bet iil v lowe coin, So plan folly we 4 outrageous hospital bill I even sa gd ue hve ed pond of bills in our Life time. (an yo bgping | grb ital ch over four hundned doddaras ons » 2 i A 2 doy o over % six hundred dollars, and, AVL medicine in ten 2 closty co, the bill necapit- Sion # v Cl wr copy of pigher fon on infon- ne ) Mth 7 pg am sending other copies to other — When I first saw the bill, foi pfoaly odaited to nietany h funds, a0 2 Li 2 nn post Sip Spas i “apd go pet, n fal ro Loa font Ci eos LS be, f {7 nH od ” Lod Togelen, G1 017, ich und oy ey and. are buying more acco to po iu you please do me one favor? I would like Zo hav . the name of the chairman of the denate committee, which each year eels on what_hospitals are changing Medicare; Fo unote my ol he oil but received no answers 1 wild be glad i 2 hospital bill to the oo anking you in advance, I am A Lecd RK. Nappa 2617 v . 1’ | Hospital Go of Blonaiiin el, Fret Find fant General Hospital from Jon. 30 oo Feb, k 7 Helly, | X-Ray Laboratory egy Posmay Miscellaneous | boos | {Sand | . Er or arora rat ABBE whining: Py 00S BO een 13 GEG een 5 om is 156255 101.25 3 130.00! 19.00 12.00 25 50.75 -— = B7.00 a CATOIE eel © E8007 25 HD —-1 $0.25 1,0%.50" 2 130.00 19.00 118.000 28260 | 63.25 — 612.85) 1,644.35 330.00 eee 3250 [50.25 73.00 —- 75. 203.00! bo IO 19.00 eee 120.95 0 12.75 —- M70. 443.80 5 (30.00) mem CO 4sS0L 0.20 101.25 (337.95 0 38.050 2,8%.75 6 130.00 west» ween) IRE 6525 —- 250! 308.2 7. 150.00 25.00 | 50,50 63.85 | 140.25 —- 409.60) 3,465.85 8S 5.00 Sr (200) IB140; 70.05 ir. owe 290.15 3756.00. 9 Passed amy at 3:45 aume Febe 9th. 176.00 95.20 24:99 less 47.20} 3903.20 0. © wns 22,50 G5 meee | or] 2.851 5990.05 7,156.00 170,00. 491.00 1,440.00 721. 10.00 3,991.05, 3 Jat : | i Paid by Medi 3390L.05 LABRATGRY (HAR 5 i CTRL SUPPLY (CHARGES | | p 90.59 Complete Blood Counts | 1°35 125.00 Dressings : 2 3.50 Urinalysis, i 24 4.00 (athaters 5 90.00 K GS | 3 5.25 Ortho Surg Susplies 13 72000 Cultures-icrobiology, | 4 174.75 Intravenous Solutions ; % 190.00 Blood (Chemistry. i 61 135.00 ‘Special Equip (Rent) ' 20 15.00 Special (hemisiny, | 9 70.35 Surgical Supplies ! 3 30.00 Atten Hour Calls, | 2 75.00 Pulmonary Function i rp ——t—— 13 832.50 Inhalation Therapy i ; 491.00 Total Laboratory ro J ; 50 ln 7 ! i | 8 1,441.10 Total (Central Supply (hayes. | j | ! ' | i - SPECIAL EXAMINATIONS 11. ANGIOGRAMS 12. ARTERIOGRAMS 13. VENOGRAMS 14, AORTOGRAMS 15. PLANIGRAMS 16. TUBOGRAMS 17. PELVIMETRY 18. INJECTION OF SINUS TRACT THORACIC 20. OTHER 21, CHEST 22. HEART STUDY SKELETAL 30. OTHER 31. RIBS 32, SHOULDERS 33. PELVIS 34. HIPS 35. EXTREMITIES SPINE 40. OTHER 41. CERVICAL 42. DORSAL 43. LUMBAR 44. LUMBOSACRA 45. COCCYX EXPLANATION OF CODES X-Rays HEAD 50. OTHER 51. SKULL 52. SINUSES 53. FACIAL BONES 54. MASTOIDS $5. ORBIT 56. EYE FOR FOREIGN BODY 57. TEETH 58. ENCEPHALOGRAM 59. VENTRICULOGRAM L GASTRO-INTESTINAL & ABDOMEN 60. OTHER 61. ESOPHAGUS 62. UPPER G.I. TRACT 63. G.I. SERIES 64. BARIUM ENEMA 65. AIR CONTRAST ENEMA 66. ABDOMEN GALL BLADDER 70. OTHER 71. GALL BLADDER URINARY TRACT 80. OTHER 81. KUB (KIDNEYS, URETERS & BLADDER) 82. I.V. PYELOGRAM 83. RETROGRADE PYELOGRAM 84. CYSTOGRAM 85. URETHROGRAM X-RAY THERAPY OR RADIUM 90. OTHER 91. RADIOACTIVE UPTAKE STUDIES $2. RADIOACTIVE ISOTOPE THERAPY AFTER HOUR CALL 23. BRONCHOGRAM 46. DORSO LUMBAR 72. GALL BLADDER WITHDVE 93. T.C. 24. FLUOROSCOPY 47. MYELOGRAM 73. CHOLANGIOGRAM 94. R.C. LABORATORY MEDICAL SUPPLIES & SERVICES PHARMACY COMPLETE BLOCD COUNT . URINALYSIS-UR'NE TESTS V/BC AND DIFFERENTIAL SEROLOGY E.K.G. HOLTER E.K.G. BLEEDING & CLOTTING TIME R.B.C. & HEMOGLOZIN SIMPLE SMEAR CEREBRCSPINAL FUUID jl. £0. 12, E.M.G. 13. CULTURE(S)-MiCROBICLOGY 14. BLCOD CHEMISTRY 15. TYPE & CROSSMATCH 16. PROTHROMBIN 1IME 17. GLUCOSE TOLERANCE 18. BIOPSY 19. PATHOLOGY 20. SPECIAL CHEMISTRY 21. SEDIMENTATION RATE 22. HEMATOCRIT 23. HEMANTIGEN 24. VECTOCARDIOGRAM 25. PLATELET CCUNT 26. SICKLE CELL MOUNT 27. BONE MARROW STUDY coPNOMELN 28. LUPUS ERYTHEMATESUS PREP. 29. SKIN TESTS 30. TOXICOLOGY 31, AFTER HOUR CALL 32. OTHER “oLoNausLN- CRESSINGS & OTHER TRAYS CATHETERS & CATKE ORTHOPEDIC SURG. SUPPLIES INTRAVENOUS SOLUTIONS CRUTCHES SFECIAL EQUIPMENT (RENT) TRANSFUSICN TRAYS OTHER . SURGICAL SUPPLIES . ANESTHETIC SUPPLIES —RUSMONARY SUNCTLD *APFPLICABLE ONLY IFfHOSP. DCES NOT HAVE SERVICE OF INHALA 7 ER TRAYS . TRACTION CR BELT — INITIAL SET-UP CHARGE i N ION THERAPY DEPT, eper foe 1. INJECTIONS, MISC. 2. INJECTIONS, MULTIPLE 3. INJECTIONS, ANTIBIOTIC, ETC. 4. ORAL MEDICATION(S) 5. SALES TAX 10. OTHER 11. PRESCRIPTIONS MISCELLANEOUS TELEVISION RENTAL ZLEPHONE & TELEGRAMS GUEST TRAYS DOCTOR MEALS EXCESSIVE LINEN BLOOD REC CROSS SERVICE CHARGE EMERGENCY ROOM 10. PROFESSIONAL FEE 11. SPEECH THERAPY 12. NUCLEAR MEDICINE 13. PHYSIO THERAPY-IN & OUT 14. GASTRO LAB 15. OVERNIGHT GUEST BED 16. OTHER CoNpOEwN EXTRA INSURANCE-PAFI3S F!LED 8192 - " PALM HARBOR GENERAL HOSPITAL _ elven p30 FLATOW, CENTRAL ACCOUNTING OF FJCES HOSPITAL NG. ty ng Gor —_ 4 POST OFFICE BOX 6053% = TERMINAL. ANNEX ay Beeld fa sly Said Lae oy MY eG hi LOS ANGELES, CALIFORNIA 90060 > AER TR . wt (213) 483-4770 vo , 'ROOMNS, . ind ery CRNIGE weaves LAL OR. Hn 28 P2650 t Ihe PRIETTO % ATTENDING Hive RATE TIME ADMITTED: | - i} <-"BATE ADMITTED? Vastly iy DISCHARGE Tim Discyghek, Date: 2 ==. NR ELT oE or EA TO DE TE Ta Tran 11 7 ’ DATE DAILY CARE XRAY LARORATORY CENTRAL SUPPLY PHARMACY OPERATING ROOM | MISCELLANEOUS - “treoits BALANCE CODE | AMOUNT | CODE| AMOUNT | CODE| AMOUNT | CODE | AMOUNT | oruwiavmoom | CHARGE | coDE Bal FD \ 546585 “ 50.00 L. 1 2.7" > 2.3% , 4 1¢ : 1312 $3 | ; LAG # | 2.500 " - 5 051.08 T'S CERIIFIES A: ITS, RUE1.05 —————— - Wi) a . wer . lps = RE TrnrQEN nl ity 202 : 91% HOU 100 i REFRFSENIING selon ¢ hy - VE DEY ASTA4ES ig HISPITAL got! | 2 Vint Toth Sed 39%).0 . 49/.00 74.95 10-80 3721 a Sian ay TOTAL CHARGES ~ 5 x FRYE eT 3 TIS . L = 24na lf fs Slo ~ TT —s DATEL vo. SIGNED BY CHARGES OR CREDITS NOT IN BUSINESS OFFICE AT * 40 TNSURED TIME OF DISCHARGE WILL BE BILLED LATER. 6192 PATIENT PALM HARBOR GENERAL HOSPITAL , : 3 as Pp CENTRAL ACCOUNTING OFFICES © HoseiTAL NO. 4 5 ® AODRESS ‘ POST OFFICE BOX 60533 -- TERMINAL ANNEX 7] he sg LOS ANGELES, CALIFORNIA $0060 ‘ oY (213) 483-4770 ROOM NO. 3 CITY STATE rt oeNn ’ zie i . CALFED fe, PRIETTC . ATTENDING BHYSICIA seal . n-9-n / RATE: TIME ADMITTED: . DATE ADMITTED: i aly DISCHARGE TIM !/ DISCHARGE DATE: , L DISTRIBUTION OF CHARGES (SEE REVERSE SIDE FOR CODE DESCRIPTION) DATE DAILY CARE X-RAY LABORATORY CENTRAL SUPPLY PHARMACY OPERATING ROOM MISCELLANEOUS CREDITS BALANCE CODE AMOUNT CODE AMOUNT CODE AMOUNT CODE AMOUNT DELIVERY ROOM CHARGE CODE “ag nr iif - 2 AEC > . 7 5 ; a - : r % l 4 9 58.25 4 Tl S| 2%.00 ' ; oS i 4 DoH L400 2352435 . 4 3 bL2: 3056.25 = 15 Sexes Lec 33 205 1 ? vi * {4s + 1 1 1 4 ; # 4 ' 5 ft 1110400 3 35.295 5 TOTAL CHARGES . seems mee mr —————————— ary PTE 19 SIGNED BY CHARCES OR CREDITS NOT IN BUSINESS OFF OFFICE AT TNSURED S! E OF DISCHARGE WILL BE BILLED LA 029¢ PATIENT PALM HARBOR GENERAL HOSPITAL fo tt 3 X 3 TIES, amor CENTRAL ACCOUNTING OFFICES HOSPITAL NO. 35 _1_(760-M ACDRESS POST OFFICE BOX 60533 — TERMINAL ANNEX . LOS ANGELES, CALIFORNIA 30060 1312: y ve. (213) 483-4770 RooMND.. . 302 city zie O:inga, Colif ATTENDING PHYSICIAN Dry otto, M RATE: TIME ADMITTED] +A 7° DATE ADMITTED] DISCHARGE TIME: DISCHARGE DATE: = CISTRIBUTION OF CHARGES (SEC REVERSE SIC rom CODE DESCRIPTION] CATE DAILY CARE X-RAY LABORATORY CENTRAL SUPPLY PHARMACY OPERATING ROOM MISCELLANEOUS CREDITS BALANCE CODE | AMOUNT | CODE| AMOUNT | CODE| AMOUNT | CODE| AMOUNT | orunEmvmoom | CHARGE | cook 2 TW i SALFOR o -' LE4435 + 2 5 4 . i I 3n 130.00 I 750113 | 6150 14 120012 | 3500 EL.pS is 12.00 % 3.75 © 0 6 0 1 5 1 2400 i 7.00 Ln dS = 5 1.00 3 9 53M | 4 . ? 225 2039.10 tN 13000121 | 1200 123 e % & 1 24 = | “YEE 1 215 . 1 Py. > & ~ I 7.66 = %.00 L 700 4 4.00 L sacle 2.00 . 2536.80 © 130.09 y 20 13| e350 < 2.29 4 150 4 E29 a 150 G 14.00 TOTAL CHARGES VEN PHT, oaTE 19—— SIGNED BY CHARGES OR CREDITS NOT IN BUSINESS OFFICE AT F 40 TNSURED TIME OF DISCHARGE WILL BE BILLED LATER. 129¢ PATIENTS | PALM HARBOR GENERAL HOSPITAL + CENTRAL ACCOUNTING OFFICES POST OFFICE BOX 60533 —~ TERMINAL ANNEX - HOSPITAL NO. ooRESS Zw | =07G0-} » “ LOS ANGELES, CALIFORNIA 90060 le | -07G0-H (213) 483-4770 ROOM NO. 700.2 city CRANGE STATE (AL FCA zip - Sir Jes a2 ALBEGOEA : 4 OE, PRET - ATTENDING Ea! =TTO RATE TIME ADMITTED: Tr DATE ADMITTED: 1 “yu DISCHARGE TIME: DISCHARGE DATE: DISTRIBUTION OF CHARGES (367 REVERSE SIE FOR COOL DESCRIPTION] CATE DAILY CARE X-RAY LABORATORY CENTRAL SUPPLY PHARMACY OPERATING ROOM MISCELLANEOUS CREDITS BALANCE CODE | AMOUNT | CODE| AMOUNT | CODE| AMOUNT | CODE] AMOUNT | oruwiAvmoom | CHARGE | cooe BAL Ful \ } ® : ~ $23.00 | A 4 21.00 i 7.88 4 4.00 , y 5 > | 280 hl hs, 4 4.00 Lu315¢ \ 2 13004] 21 1200) 3% 5G 4 7500 1 gel wo 7200 i4 os) 13 [124.50 ¥ ome no i] 22 12 ngl 3 22 Sl Jol 9 S25 3 y 3 2 > 6 o i 4 Y F " A $1 £5 x \ 2 ¥ 3 . “a 4 ~ 4 &o 3 2 2 1| 262s 5 31 2500 4 i 0.00 : i io 2.09 : 1.44432 he BD. TOTAL CHARGES 3 DATE 1% SIGNED BY CHARGES OR CREDITS NOT IN BUSINESS SFFice AT TIME OF DISCHARGE WILI RE RIL FN I ATI 329g PALM HARBOR GENERAL HOSPITAL IR Era CENTRAL ACCOUNTING OFFICES HOSPITAL NO. PATIENT v ADDRESS L POST OFFICE BOX 60513 ~ TEM 4INAL ANNEX - oe LOS ANGELES, CALIFORNIA 90060 TDD oy Eating (213) 483-4770 ROOM NO. Ne=d Rory sears zip L. SHARID?, iD. /P/FRIETTO,MCS ATTENDING PHYSICIAN RATE: Time aomiTTeD: 13 770.) oaTeE ADmiTrED: T= il a] DISCHARGE TIME: DISCHARGE DATE: DISTRIBUTION OF CHARGES [16C REVERSE SIE ron COOL DEsch DATE DAILY CARE X-RAY LABORATORY CENTRAL SUPPLY PHARMACY OPERATING ROOM | MISCELLANEOUS CREDITS BALANCE CODE AMOUNT CODE AMOUNT CODE AMOUNT CODE AMOUNT DEL VERY ROOM CHARGE CODE - ar 30 50.00 (gd | “v.00 1500 y 93 1500 m Gh Hu.00 529 5 10.c0 = -T PlaT 13709 60.00 104.25 - % ee V3 5 Ran de . 53023 | 130033 5.00 23 “6 |Z | 2400 2 i5.0¢C | 2 350 1 03 } ig | 3180 J a - . ‘ 1 | 750 et 1 3 Lo , . o v { i LE 4 % 525 i % i 3 £71.25 ( ~ 1 nA 4 x, yw ‘ aU ~ 1 Lip vis 3 ppee | ola . is < Les TY Olea e 4 & o 1 wl < L. I 1259 = 3 20 k * : 1.00 fi 4 a7: , . “| 2 7 1 : | > 15.0¢0 z > ca hI cL 3.00 1 ag] 4 2% 1 —h.01 tid heM'% td. FYa TOTAL CHARGES “4 % ; , ey Ae ' oaTE 19 siGnED BRL dogiide EX CHARGES OR CREDITS NOT IN BUSINESS OFFICE AT a0 TIME OF DISCHARGE WILL BE BILLED LATER. €29¢C 2624 TESTIMONY OF MRS. JUANITA C. DUDLEY, ASSISTANT REGIONAL DIRECTOR, NATIONAL URBAN LEAGUE, INC., WESTERN OFFICE Mr. Chairman, Members of the Committee, thank you for the opportunity to present to you my concerns and suggestions around health care for all Americans. As director of Health and Welfare of the National Urban League in the West, I have shared the frustrations of many health care advocates in analyzing the eight or more health bills which are now before the Congress. Whitney M. Young, Jr., our late director, served as a member of the committee of 100 which presented a health care program to Congress. Our National Health Advisory Committee has also presented a report “Toward a National Health Program.” I will present this report to your committee with copies of my testimony. Some of the problems we are anxious to have you made aware of are as follows: Problems 1. Peer review of quality medical care. Peer review has been in practice as long as we've had licensed medicine. That system has proved to be inadequate. If health is a utility, as described by Gordon Cummings of the American Hospital Association, such as other public services are; then a commission of non-owned, non-providing reviewers must be brought into review the quality of care being given. Medicine and its ancillary health services have been provided under the mystique that “only the doctor knows what’s best” much too long. We have a highly intelligent, highly informed and highly concerned consumer today! Veri- fication of this concern is consumer participation in Watts Multi-purpose Health Center, Comprehensive Health Planning Councils and Regional Medical Pro- grams in this state and county. 2. Use of provided owned, low quality hospital and clinic facilities. Pride of present ownership is not reflected in upgrading and coverage of such facilities i.e., doctors are on call—mo round-the-clock coverage by a physician. Dr. Alex Gerber wrote The Gerber Report from the vantage point of his role as senior attending surgeon at the Los Angeles County USC Hospital—one of the largest hospitals in America. Dr. Gerber describes the over-utilization of surgery as a primary cause of the overcrowded hospitals today as evidenced in privately owned facilities. He also describes the quality of that surgery as less than the best. An emphasis on quality care is in no way correlated to high cost of medical care. All bills presently before the Congress relate to the cost of health care. This includes most well publicized plans of the AMA, American Hospital Associ- ation, Health Insurance Association of America, the Administration Plan, and others. One of the major private health insurance companies in America has its board loaded with physicians and other health care providers. That same com- 2625 pany pays a physician in a gilded ghetto (Beverly Hills) a higher price, for the same service rendered, than is paid a physician in the inner city ghetto. This is based on the only differential that may exist in the two practices—the square footage cost of rent! The ghetto physician then tries to see twice as many pa- tients per day in order to realize the same income as his Wilshire area colleague. What will the new cost analysis per patient offer him. I describe this fiscal dichotomy, for the patient is once again the victim of such fiscal games. 3. Health Maintenance Organizations : This is a new nomenclature to both the health care providers as well as the consumers. Yet, it describes well known prototypes: Kaiser Foundation of Cal- ifornia, HIP of New York, Ross Loos of Los Angeles. As many groups begin forming HMO's, it appears that the triad of their plan- ners (the economist, provider and marketing analyst) have not felt the need to include the consumer. The emphasis is once again on the “cost,” not quality. The major serendipitous factor appears to be emphasis on preventative health care. Will they lower the high infant mortality rate by design, or close the galloping rate of infectious hepatitis, or lower the rate of pandemic venereal diseases? Will fatal heart attacks be decreased due to better emergency care? Will drug ad- diction and mental health be covered? We suggest that before HMO’s are awarded contracts on behalf of consumers that they present a plan for elimination of some of the aforementioned health problems. We further suggest that a marketing survey for cost analysis also include an epidemiological report on the incidence and rate of diseases for the catchment area under negotiation. Only then can a measure of effectiveness of their delivery of health care for that population be determined. Many health bills state that standards will be determined by state councils or boards. Will all HMO units have the same standards; or as in medicare and medicaid, will the standards vary for the type of class of population served? Will the infamous “grandfather clause” be used to sweep inferior facilities into competition with newly upgraded or newly constructed facilities? 4. Manpower : The upgrading and use of paraprofessionals in delivering health care is a most important factor, both as a financial stabilizer as well as an opportunity to close the critical manpower shortage. Our concern is that hastily proposed train- ing programs may not be sufficient to prepare sub-professionals to take over the total role of medical doctors in hospitals, clinics or offices. We are also concerned that such use of sub-professionals will not be used by medical professionals as a means of helping minorities out of medical schools. We've progressed slowly in this area since 1964. UCLA has a single (one), black senior in its medical school. Their extension program for training sub-professionals has much better percentage figures. 2626 JASON I. GREEN, M.D. 9735 WILSHIRE BOULEVARD BEVERLY HILLS, CALIFORNIA 902i2 TELEPHONE 274-0223 GENERAL SURGERY August 24, 1971 Philip Caper, M.D. Senate Health Subcommittee Committee on Labor and Public Welfare Washington, D. C. 20510 Dear Doctor Caper: Thank you very much for your letter of July 29, 1971 which un- fortunately I did not receive until two days ago. At your invitation I will be happy to submit my thoughts regarding Health Care Delivery in the United States. Health Care costs must be subdivided into medical (physician) costs, hospital and others. To group them together only confuses the issue and places the blame for high costs solely upon doctors, whereas most of the costs increase has been in hospital bills. There is no question, however, that methods of lLealth care del- ivery and financing must change. With regards to delivery I believe it is advantageous to both physicians and the general public for doctors to practice in multi-specialty groups. The difficulties encountered with doctors practicing in individual offices in terms of patients getting to and from various doc- tors as well as the high cost to the physician of maintaining these offices has made them anachronistic. These groups should be large enough to provide all necessary and commonly used medi- cal services but not so large as to become impersonal, cold, albeit efficient medical "factories". Many patients here in the Sou- thern California area describe Kaiser Permanente in the latter terms. There is an intangible but crucial personal rela- tionship between doctor and patient that must be preserved pri- marily for the welfare of the patient. As concerns the financing of Health Care Delivery this too must be modified. No patient should want for good care nor be bank- rupted in the process of obtaining it. I believe every human being has a right to good medical care. I believe it would be impossible financially to continue on a fee-for-service basis. It might be possible on the other hand, for regional fee schedules to be established which would be a compromise between what the physicians would feel to be adequate and what the govern- ment and/or insurance carriers felt reasonable. The problems we have experienced in the past have been primarily with the fiscal intermediaries who have been most arbitrary and delinquent in their payments. If any sort of fee-for-service (fee schedule) system is to continue these inequities must be removed. 2627 To: Philip Caper, M.D. From: Jason I. Green, M.D. PAGE TWO Currently there seems to be a strong momentum developing for pre-paid programs. There is nothing inherently wrong with them and they may ultimately prove to be the best solution. I would only caution that they are as yet untested (except in selected age and occupational groups) and pose the potential threat of underutilization with gross patient dissatisfaction and even- tual political backlash affecting those who advocated them initially. I would suggest pilot programs be developed and results carefully analyzed before embarking on this method as a major source of health care delivery. I would also emphasize again that groups of varying size and not just the medical corporate giants be allowed to participate in these pilot programs. Finally, I would point out that in a trillion dollar economy such as this nation enjoys there is no question but that money is available for health care. The only question is the old one of ordering of priorities. This is the crucial question that must be answered by the people themselves through their elected representatives. Health care is costly. The cost can probably be reduced. But whether the financing is through private sources, fiscal intermediaries, or directly through the federal government I think that Congress must be honest and explicit in stating very clearly to the general public that the health of this nation is of paramount importance to all of us and deserves top priority for expenditures. Thank you very much for giving me this opportunity to express my views. Very truly yourg, 7, Jason I. Green, M.D. JIG/pg 59-661 O - 71 - pt, 11 - 16 2628 Senator KENNEDY. At this point IT order printed statements of those who were unable to be heard or could not attend : (The information referred to follows:) THE TRUE CRISIS (By James S. McCaughan, Jr., M.D., Central Ohio Medical Clinic, Columbus, Ohio) At a time when the very foundations of medicine are being threatened, I think the voice of the people who are “on the firing line giving health care” should be heard, and not just those of politicians, union leaders, professors of medical eco- nomics, group health association presidents, etc. Therefore, the following is the testimony I would have made had I been able to testify in person. I am James McCaughan, M.D., and I practice general and thoracic surgery in Columbus, Ohio where I am on the staffs of several hospitals, one of which is located in the ghetto. I am also the Chief of Surgery at the Columbus State School for the mentally retarded. In the course of my medical career I was trained in a university and had training and experience in community hospitals, state-owned mental hospitals, city-owned general hospitals and military hospi- tals. I have been on the teaching staff of three medical schools, have had Ameri- can Cancer Association and National Heart Association fellowships and several grants for research. Being actively engaged in taking care of ill people I do not have the time nor the huge monies nor facilities to prepare masses of data; how- ever as a person actively participating in medicine and doing the work and not just accumulating data, and as a person who will have to continue in the sys- tem, I think I have some observations which cannot be made by any other group of people. The rise in the cost of medical care is being called exorbitant, and the private physician is being charged as one of the main culprits. The same chart is re- peatedly brought out showing physicians’ fees rose 50% during the past decade while the Consumer Price Index rose only 20%. These speakers do not point out that the Bureau of Labor Statistics shows that the prices of all services are up 509% since 1957-59 compared to 209% for commodities. Medical care is a service, not a commodity. U.S, News, December 8, 1969, using U.S. Dept. of Labor sta- tistics reported that while medical care had risen 12.99% since 1967, insurance and finance costs had risen 21.49%, public transportation 13%, meals at res- taurants 12.7%, shoes 12.7%, meats, poultry and fish 13.6%, and owning a home 18.29%. The cost of the U.S. Congress has risen 156%, federal employee wages rose 105%, and non-professional hopital workers wages rose over 200% during the last decade. While the Consumer Price Index rose only 5.5% and physicians’ fees rose 8.1% in the past year, the U.S. News and World Report of February 15, 1971 showed last year’s average increase of pay of union workers including wages and fringes were: bricklayers 15%, building laborers 15%, carpenters 13%, elec- tricians 129%, painters 129, plasterers 129%, plumbers 149%, and in the construc- tion industry wage increases are being sought of over 100% over the next three years. Remember, physicians have no fringe benefits, no paid vacations, no paid retirement plans, no paid health plans, Malpractice insurance costs have risen over 300% in the last five years. The quality of medicine in this country is claimed inferior because of a sup- posedly higher infant mortality, the United States being thirteenth in selected countries. However, no cognizance is given to the fact that in some of these countries that have a supposedly low infant mortality, such as Sweden which is No. 1, a birth does not have to be reported for five years and a death might never be reported. In some of these countries the father, not the physician, voluntarily reports births; the criteria for live births are not the same in all countries. The Demographic Year Book of the United Nations, from which this information is taken, spends five pages pointing out why statistics of different countries are not necessarily comparable. “Answers to these questions will not be found through comparison of disconnected studies with varying study de- signs. Although few comparisons may be possible, fortuitously, they lack the assurance which is to be derived from a well designed study planned to give answers to specific questions”. In The Netherlands, which ranks No. 2, only 609% of infants are delivered by physicians. 2629 The life expectancy at birth for males in the United States is eighteenth, with 66.8 years in 1965 compared to Sweden with 71.6 years. Does this mean that more men in the United States smoke and die of cancer of the lungs, that we have a greater incidence of coronary artery disease, or that we have more auto- mobile accidents involving men? I don’t think it can mean it is due to inferior medical care because the same United Nations Demographic Year Book of 1968 shows in Sweden the deaths per 100,000 population due to pulmonary tubercu- losis are 25% greater, suicide 959% greater, benign peptic ulcers 789, greater, pneumonia 849% greater, influenza 1869 greater, benign prostatic hypertrophy 116% greater, neplasm 25.59% greater, stroke 13.7% greater, diabetes 5% greater than in the United States. Poor quality medical care or unavailability of medical care is blamed as the major if not only factor for a greater incidence of disease among the poor in this country by those promoting national health insurance. United Auto Workers’ president, Leonard Woodcock, states: “In almost every category the rate of serious illness among the poor is two or three times higher than the popula- tion as a whole”. “The United States is seventh in maternal mortality”. “Among the poor in this country, infant mortality rates are five times greater than among the affluent”. Every other socio-economic pressure or influence or cause is completely dis- regarded, and inferior medical care is blamed for these sad statistics. I would like to present a case history to show you some of the real problems and let you try to fix the cause. I received a call at 3 o'clock one morning to come to an emer- gency room in the ghetto area. A nineteen year old black girl was brought in by the rescue squad after being stabbed in the chest during a fight with another girl in a bar. When I arrived there about twenty minutes later I observed that the veins in the girl's arms were sclerosed and she stated this was from shoot- ing heroin. When I asked her how she got the money for this she stated by prosti- tuting. On further examination of her I found she was about five months pregnant. She also had a seven month old child at home. She presently was re- ceiving Aid For Dependent Children. After I treated this girl, about 4 o’clock in the morning, an elderly black woman came to the door of the emergency room with a little four or five year old neatly dressed black girl. They wanted to know if the little girl could see “Auntie”, who was lying on the litter in the emergency room. Many of the problems of the ghetto and the poor are summed up in this one case. If this nineteen year old girl or her unborn child died during or after birth it would only be statistics, and accordingly her death will be attributed to poor med- ical care. If this black girl dies of an overdose of heroin, alcoholism, or tubercu- losis, or syphillis or stab wound at an age earlier than expected for the non-poor, statistics will show it attributable to poor or inadequate medical care. When there are problems, the least we can expect is the whole truth. Although this nineteen year old girl presents a tragic problem, far more signifi- cant is the problem of the four or five year old child, because left in this environ- ment chances of her winding up on a slab ten or fifteen years from now would seem to be almost one hundred percent. Besides that, she probably will have a couple of children of her own, and the children of the nineteen year old girl pre- sented will be out on the street. You can put one of President Nixon's Health Maintenance Organizations or even a private physician next to this child and you will never appreciably improve the quality or quantity of her life until you change the socio-economic environ- ment she lives in or remove her from it. Senator Dominick on April 15, 1971 stated, “In truth, infant mortality for the most part is a social rather than a medical problem. Factors such as poverty, malnutrition, poor housing, poor education and racial or ethnic differences are much more highly correlated with infant mortality than such factors as the num- ber of physicians or hospitals.” “Somewhere out of such a free debate, a national concensus must develop, con- census that rests on facts and solid theory, not on the whims of doing something to improve the situation or on notions of reaping political credit for the final product.” In Philadelphia during an influenza epidemic IT walked the Puerto Rican and black ghetto streets at 1:00 A.M. seeing patients, and as I would leave one anart- ment building somebody would call from across the street to go see them. These people were being ravaged by this epidemic. They live in tenements with two 2630 or three children sleeping in each bed, four to six adults in a 12 x 12 room, roaches running over the beds and kitchen table. About this time a television program showed the squalid living conditions of South American natives. I could have filmed that program right in the center of Philadelphia. On another occasion, in the middle of the night, under police protection I de- livered an unregistered black woman in a third-floor apartment where there was no electricity—only kerosene lamps. However, only six blocks away the best maternity care was available, free, at the Jefferson Medical College. These people do not have inferior medical care, they have inferior everything. The spread of disease is dependent upon sanitation, nutrition, education, living habits, ete. More people die and are injured by stabbings and gunshot wounds in the ghetto areas than in the rest of the population. Why are these deaths not blamed on poor medical care? Senator Yarborough stated in Senate hearings in 1970 that there are “thou- sands of small towns and countless urban slum areas where our citizens go years without seeing a doctor . . . All of this is because it is economically more at- tractive to work in Austin rather than Three Rivers, Texas”. If financial rewards were the only reason for practicing medicine, most physi- cians would leave the big cities and go to these small communities where there is a demand for them. However, as with every other human being and profession there are many factors that enter into a physician’s choice for a region to prac- tice. It is true, there are not many physicians in certain areas of the country; however, there are not many lawyers or other professional people there either. Some physicians choose certain climates; others are influenced by wanting to move away from their home; others want to remain close to their home; the availability of cultural and educational facilities are a strong influence on many people ; the physical safety of working in certain areas is a factor. Many physi- cians and nurses will not make night calls to the hospital in the ghetto area that I attend because they have to drive through the ghetto area to get to it. I have a friend who is a surgeon in Cincinnati and every time he makes an emergency call at night in a certain section of the city, he carries a loaded 38 revolver on the seat beside him. Thus merely providing financial incentives to practice in these areas will not have much of an attraction. This is especially true in light of the harrassment and discreditation that honest physicians and dentists have received when they went into these areas and worked there day and night at reduced fees and still made large sums of money because of the prodigious amount of work they were doing. They were immediately suspect and denounced as being greedy over-utiliz- ers, and investigated by the government. The public is being told that they will receive the same or better care under a national health program than they now receive from private physicians and it won't cost them any more money. The Department of Health, Education and Welfare itself has estimated the Health Security Act will cost over $77 billion annually by 1974 or over $1000 per worker annually whether ill or not. What evidence do we have from past experience with government intervention in medicine that this new government medicine will be better? John Gilligan, Governor of Ohio, had motion pictures taken of conditions at the State Hospital for the mentally insane to be distributed around Ohio to show the horrible con- ditions that exist in a state-owned hospital. As a private physician as well as the chief of surgery at the state school for the mentally retarded in Columbus, 1 can state, conditions exist at the School which would not be tolerated for one day in a private hospital. The Division of Mental Hygiene notified Ohio’s twenty-six State Hospitals in March 1971 that doctors not licensed in Ohio could be barred from practicing in state facilities. In the past, limited licenses were issued for doctors who had not passed state medical board examinations so they could work in state facilities. This is still prevalent. The Veterans Administration Hospital system with 166 separate institutions and a 1.9 billion dollar annual budget is one of the largest socialized medical systems in the world. This is a “true system” compared to the private medical system that Mr. Leonard Woodcock called “uncoordinated, wasteful, over- specialized . . . absolutely incapable of meeting the real health needs of the public”. The physicians and all personnel are paid by the federal government. All equipment and facilities are owned by the federal government. Patients receive free care unlimited. 2631 On June 1, 1970 Senator Edward Kennedy made a speech in Congress asking unanimous consent that Senator Allen Cranston’s testimony about the inadequacy of the VA Hospital system be accepted into the Congressional Record. He intro- duced the statement, “it is disgracefully understaffed, with standards for below those of the average community hospital. Many wards remain closed for want of personnel, the rest are strained with overcrowding. Facilities for long-term treatment and rehabilitation, indispensable for the kind of paralytic injuries Sapegially common in this war of landmines and boobytraps, are generally inferior”. Reports of the VA’s own Chief of Services were entered into the Congressional Record such as: “tight budget policies have imposed serious fiscal constraints on our abilities to employ adequate personnel and provide necessary facilities”; . insufficient equipment, insufficient personnel and grossly inadequate sup- port in the crucial areas of pathology, radiology and clinical laboratory and physical medicine”; “. . . radiology equipment is obsolete in the worst sense of the word, broken down in the very true sense of the word”. Mark J. Musser, M.D., Chief Medical Director of the Veterans Administration stated in the A.M.A. News of March 8, 1971 in response to a question on the future of the VA Hospital system if some form of national health plan arrived: “We set out to do two things, first to determine how the VA as a health care and delivery system might better relate and hopefully cooperate with the private sector. Second, to determine how we can modify the resources of the VA so it has an expanding capability and is more responsive to the needs of a wide variety of patients—who some day might not be solely veterans”. This system of socialized medicine, the VA Hospital system that Senator Kennedy and the Veterans Affairs Sub-Committee have denounced as “holding back on giving first-class treatment when they are brought home in wheelchairs and stretchers”, will be expanded to the private sector. The Journal of the American Hospital Association of August 1970 shows the average stay in a private community short-term general hospital was 8.3 days in 1969. The average stay in a government hospital of the same type was 19.9 days. A major factor in this is certainly the fact that the appropriations for the VA Hospitals are strongly dependent upon the number of patient days of the year before, and since the hospitals are not one hundred percent utilized patients are kept in the hospital longer for the same operation or illness than in a private hospital. When the length of stay is multiplied by the cost per day and compared for identical operations or disease, the cost for a particular opera- tion in a government hospital far exceeds that in a private community hospital. A special committee on municipal hospital services appointed by Mayor James Tate to study the future of Philadelphia General Hospital (a city-owned service which received $30,961,946 for fiscal 1970) reported on April 20, 1970: “The present PGH is obsolete and beyond economic renovation. This manner of allo- cating money deals with health problems too late, costs the most, and does little to prevent illness. Administrative and management inefficiencies, were found in present operations of city personnel health programs”. Per-diem charges in the Philadelphia General Hospital on June 17, 1970 were: in-patients $68.00, clinic visits $25.00, receiving ward visit $20.00. The average private physician office visit charge is less than $10.00. Joseph T. English, M.D., president of the New York City Health and Hospitals Corporation warned Mayor John Lindsay in a letter in April 1971 that as many as eight of New York’s municipal hospitals may have to be closed in wake of fi- nancial difficulties. Jersey City’s Margaret Hague Maternity Hospital, a 250 bed county facility may have to be closed on July 1, 1971 since it had a three million dollar deficit in 1970. Similar reports can be made for Massachusetts General, Cook County General and other city and county-owned hospitals. While stationed at Portsmouth Naval Hospital as a general surgeon, I fre- quently was assigned to the walk-in clinic to see the ambulatory ill. These peo- ple might have colds, gastroenteritis, allergies, etc. When they would return for their next visit they usually saw another physician who was a specialist in an- other field such as urology or psychiatry, and on a subsequent visit they prob- ably saw a third physician. The U.S. Public Health Service is another completely socialized system with physicians and all personnel being paid by the government, all facilities owned by the government, and patients receiving free care. HEW Secretary L. A. Rich- 2632 ardson testified before Merchant Marine & Fisheries Committee that eight U.S. Public Health Service Hospitals and thirty Clinics may have to be closed because of “our inability to continue to provide medical care of high quality . . . through an increasingly inefficient and outmoded system”. Thus, in the government systems we have already experienced we have found no panacea for the health problem but actually a type of care which is inferior to that provided by the private sector. Let us be quite candid, as Senator Kennedy stated in his speech on January 25, 1971 in the Senate: “Financial, professional and other incentives are built into the program to move the health care system toward organized arrangements for patient care”. This will consist mainly of having a Board set fees for private physicians and allocating the amount of money for this type of practice as the residual of money not used for capitation payments. Let there be no mistake, most of these plans presented are either directly or indirectly aimed at eliminat- ing the private physician fee-for-service practice of medicine and establishing a per-capita pre-paid system similar to the Kaiser-Permanente type. What will this mean? Dr. Sidney R. Garfield, the founder of the Kaiser-Permanente system, has stated: “In our experience a removal of the fee-for-service overloads the system and, since the well and the worried-well people are a considerable portion of our entry mix, the usurping of available doctors’ time by healthy people actually interferes with the care of the sick.” While non-medical people are espousing the great advantages of the pre-paid capita system. Dr. Clifford H. Keene, presi- dent and chief administrative officer of the Kaiser Health Plan Hospitals, who should be in a position to know better than anyone else the effect of this plan, when asked what effect pre-paid clinics had on the quality of care to patients stated: “I do not know”. Statements are made that more surgery is done on a fee-for-service basis than in pre-paid per-capita systems, with allegations that this is for financial reasons— that the surgeries are unnecessary. However, in the pre-paid per-capita system it is to the doctor's advantage not to operate. In other words, he is being paid much like welfare recipients, i.e. for not doing something. Who can say whether you need to have your hernia fixed this month or next year, or you need to have your veins stripped this month or next year, when there is an incentive financially not to do it. If you are willing to accept the premise that there are surgeons who will operate unnecessarily for fees, you must then accept the premise that there would be surgeons who would not operate in order to have a greater profit. Similarly, it is not to the advantage of the Kaiser system physicians to have less than 100% hospital occupancy. In an extensive study of the Kaiser system, Greer Williams, in Modern Hospital, Feb. 1971, states that in 1970 certain Kaiser hosiptals in the Los Angeles and San Diego areas reported occupancy rates be- tween 100-1109%. “This comes about by the patient being scheduled for major surgery without an available empty bed. He is prepared as an ambulatory patient, goes to the recovery room after surgery, and waits there for a hospital bed as- signment. If a bed does not become available the administrative and nursing staff review the patient list to see who can be sent home, to another hospital, or to an extended care facility. If the backup is too large, the staff reviews the elective surgery schedule and postpones operations that ‘will keep’.” When schedules become crowded they exercise their own priority system, based not on “health care as a human right”, “a meaningful doctor/patient rela- tionship”, or “first come first serve”, but on “sickest first”. To have more beds available for the sick would mean building more hospitals and decreasing the profit. A fundamental principle of the Kaiser Health Plan has been “to insist that all subscribers shall have, upon joining or upon periodic renewal of contract, the opportunity to choose from two or more alternative health plans. This policy not only insures that enrollment will be voluntary within the employee group, but introduces open-market competition into a quasimonopolistic tradition of partially insured doctor and hospital bills paid through a plan imposed on the group by an employer arrangement with a single carrier supporting a fee-for- service system”. This has been felt absolutely necessary to maintain the quality of the closed panel system. Senator Kennedy has said “patients everywhere face a bewildering array of health personnel who know more and more about one disease or organ, but less and less about the whole patient”. Yet these plans propose to eliminate the pri- vate physician/patient relationship and promote systems in which the patient/ doctor relationship is further destroyed. Patients for these plans are told they 2633 will receive the same or better quality care and attention than they would receive from a private physician. : However, a surgeon in Los Angeles told me when he was a resident in surgery, not Board-eligible, not Board-certified, in a Kaiser Hospital, he did twelve appendectomies one night himself. He also stated that if there was a major case to be done, the staff man would come in and help him. However, the staff men usually did not like to come in during the night (it should be noted there is no financial incentive for them to do so). If a patient had a bowel obstruction the staff man frequently would instruct the resident to put down a Levine tube, give IV fluids and get the patient in shape to be operated on in the morning. When I asked this surgeon if this was the way he wanted to be treated, he said “no”. When I asked him if that was the way he practiced now that he is in private practice, he said “no”. James V. Maloney, M.D., in the presidential address at the 31st annual meet- ing of the Society of University Surgeons, gave a “Report on the Role of Eco- nomic Motivation in the Performance of Medical School Faculty”. He com- pared “the effect of intellectual motivation and economic motivation on patient care and teaching and on the extent to which individual faculty members in institutions were meeting the needs of society in the field of medical education”. After an extensive survey he concluded, “without economic incentive, clinical faculty of medical schools will not accept personal involvement in the care of the sick if they have any reasonable alternative which permits them to maintain their self respect”. Rashi Fein, Professor of Economics of Medicine at Harvard School of Medi- cine and a member of the faculty of the John Fitzgerald Kennedy School of Government and a vociferous proponent of national health insurance stated in Technology Review of April 1970, “A right to quality of care? A right to what amenities that accompany care? A right to how short a waiting period in a physician’s office? Available how close to a person's residence? Available in what quantity ?”. In the Kaiser-Permanente system waiting times for appointments commonly run from “three to six weeks”, and in one large Kaiser-Permanente group, as high as fifty-five days. Each group has its cut-off point, beyond which appoint- ments are not made. Dr. Cecil Cutting, executive director of the Permanente Medical Group in North Carolina states, ‘one of our big problems is developing an appointment system that will screen members so the sick can get in for service and yet the well and the worried-well can appropriately be taken care of without swamping our physicians”. Since 1966 the Kaiser plan rates have increased an average of 11-149. Prior to that they had increased an average of 6-89 annually. Private physician fees only rose 8.19% last year, yet the private physician is still blamed for the rising cost of medical care although the Social Security Administration’s own data showed that only 159 of the total cost of medical care of those over 65 was due to the physician’s fees. Stated another way, if the physician had worked for Saiting there would only have been a 159 savings in the cost of Medicare for What other catastrophic events are we witnessing since the advent of Medi- care-Medicaid intervention into medicine in 1966? MEDI-CAL is in serious financial difficulties, Thomas Bryant, M.D., Medical Affairs Director of the O.E.O. declared that Medicaid is an “unmitigated disaster”. These pieces of leg- islation were passed when the medical profession warned that they would be disasters. Above and beyond these problems, however, the loss of the fee-for-service, private physician/patient relationship will strike at the very core of the founda- tions of medicine, and here lies the true medical crisis and the true disaster that lies ahead. . Again I turn to Mr. Rashi Fein, one of the main proponents for national health Insurance on a pre-paid per-capita basis. In his testimony September 24, 1970 before the Committee on Labor and Public Welfare of the U.S. Senate, he said: “One of the deficiencies in the production of health services is that the indi- vidual providers, institutions and people, do not really see themselves—or function as if they were—part of a larger system. They are concerned with those patients that come through their doors but often seem less aware of the large number of people who do not find their way of entry into the system”. In his testimony before the Sub-Committee on Health of the U.S. Labor and Public Welfare Committee February 23, 1971 he stated: “A traditional financing ap- 2634 Jzoasn will maintain the traditional delivery system organization—and we need change”. Hippocrates Oath has guided and maintained the ethics of the medical profession for centuries. It states: “I will use that regimen which, according to my ability and judgement, shall be for the welfare of the sick, and I will refrain from that which shall be baneful and injurious. If any shall ask of me a drug to produce death, I will not give it. Nor will I suggest such counsel. In like manner I will not give a woman a destructive pessary”. When a private physician has a patient, his only concern is, and must be, the welfare of that patient. When you are ill and go to a physician you do not want him to be concerned about the overall welfare of the masses or whether the money spent to keep an old patient alive would be better utilized elsewhere. I treat mentally retarded children, and we operate on them and treat them medically with the same zeal, care and attention that we would treat you, although we know that even if they get well from their acute illness they will be wards of the state, still will have to be maintained in institutions, still will have to be fed and looked after, and still will be a drain on the financial resources of society. If we let this overwhelming obligation to the patient be destroyed we will be destroying one of the few remaining fundamental moral principles left in this country. What indication do we have that this can be destroyed by government inter- vention? Already another fundamental principle in medicine i8 being destroyed. Again from Hippocrates, “What in the life of men I shall see or hear, in my practice or without my practice, which should not be made public, this will I hold in silence, believing that such things should not be spoken”. It has always been considered a necessity and a right that the patient who has tried to commit suicide, the girl who has had an illigitimate pregnancy, a woman who has had cancer, a man who has had syphillis, know that what trans- pires between him and his physican is absolutely confidential. Right now, today, under Medicare and Blue Cross this privacy is being invaded without the patient or physician knowing it. When the patient enters a hospital he is required to sign an authorization for release of information. Following his discharge, Blue Cross or Medicare carriers merely write to the Medical Records Section of the hospital for a complete copy of progress notes or the complete chart of that patient, and it is being forwarded. The patient knows nothing of this, the physi- cian knows nothing of this. Thus, even though the Medicare guide states that the history and physical and other information are not to be solicited, it is being done. Therefore, anyone who enters the hospital can have his personal history and physical examination reviewed by persons unknown. In Louisiana a hospital refused to violate the patient's trust and refused to comply with these requests for complete chart copies, and had its Medicare and Medicaid funds cut off summarily. Why is it now necessary, when it never has been necessary before, for third party insurance firms to have complete copies of charts? Why should the patient’s personal history become the property of the government ? Why should the government be able to use economic force to invade the privacy of its citizens? Most patients do not realize when they ac- cept Medicare and Blue Cross of Central Ohio that they automatically waive these rights. Thus we already have government invasion of the individual's privacy, and the idea is being promoted that the physician must consider the welfare of society in general above the welfare of the individual. In 1910 the Flexner Report maintained that we had too many “fly-by-night” medical schools and too many people practicing medicine who are unqualified. The answer to this problem was the creation of higher standards and more strin- gent requirements to be a practitioner of medicine. Hippocrates Oath states: “. . . and to teach his art if they shall wish to learn it, without fear or stipulation ; to impart a knowledge by precept, by lecture, and by every other mode of instruction to my sens, to the sons of my teacher, and to pupils who are bound by stipulation and oath, according to the law of medicine, but to no other.” Foday we ave coming 180° around from 1910. We are told the quality of medicine is poor, and we must improve this by developing a vast bedy of lay para-medical personnel. There are radiologists proposing that x-rays be surveyed by trained technicians ; proctologists suggesting routine sigmoidoscoples be performed by para-medical technicians; corpsmen being trained to make housecalls to the extent that the patient “waves goodbye and says ‘so-long Doc.” the nursing profession has abandoned the scrub-nurse to the operating room technician. 2635 Here is the True Medical Crisis: the loss of the private physician-patient relationship, where the physician reaches his responsible decision not by con- sidering the economics, nor by considering the influence an action might have on the rest of society, but on the basis of what is best for this individual patient ; the destruction of the private physician-patient confidentiality ; the move from quality medical care to homogeneous mediocrity. Senator Ken~epy. Thank you very much. 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