these necessary resources for himself as an individual; and he also acts to assure that they will be available to his entire community, either through private or local governmental agencies.

It is the patient, and his ability to choose freely, that exact the utmost from the doctor-patient relationship. The physician who does not possess the confidence of his patient is handicapped in his effort to cope with disease. But so long as the patient is free to seek professional treatment without restraint, he can quickly find the physician in whom he does have confidence.

Given that confidence, a doctor's skill can sometimes surmount shortcomings in the facilities and resources available to him.

There are only two ways in which government can function in any medical care system. One way is helpful, the other is destructive. Government can supplement the effort of the individual patient. It can do this by helping finance the deficit between the total cost of care and what the patient can pay. This assistance in financing can be accomplished either through welfare programs or through the community's subsidizing of resources. Again, government can properly and helpfully act to supplement.

Government can also supplant the patient in his relationship with professional personnel and available resources. When it does so, it undertakes to decide for the patient what services should be provided and by whom. Having reached that decision, government then assumes the function of paying for those services.

H.R. 4222 falls in the latter category. In doing so, it overlooks the bedrock premise on which any high quality medical care system must be based:

Quality care can be obtained only when the needs of the individual patient are placed first, and financing is placed second.

Our own free system of medical care is aimed, first and foremost, at treatment of the illness.

Contrast this with a system under which government pays for care directly, rather than supplementing the private individual purchase of care, and the difference becomes obvious. Here the stress has been shifted from quality to cost.

It is axiomatic that first-rate medical care must be appropriate to the needs of the patient--medically, socially, economically and psychologically.

Under such a system, it is possible to control quality; for the patient helps control quality through his role as the person who selects

and pays for his care; and the professions help control it through the use of their professional skills.

Government programs, and voluntary programs, must be supports only--supports to the patient when costs exceed his means.

If the government supplants the individual as payer, though not as patient, government becomes the intruder--the third party striving vainly to reconcile the demands of the patient for high quality care and the demands of the taxpayer for an efficient use of tax funds.

These conflicting demands can be resolved by government in only the deciding factor in providing the care soon becomes not the need of the patient, but the money available to pay for the program.

one way:

When we seek to help the aged, we are seeking to cope with a human problem--in fact, with an entire spectrum of human needs and problems. Behind the statistics, with which the Committee has been bombarded, are individual men and women, as distinctly different from one another as their fingerprints. It seems to me that this important fact has been overlooked by those who support H.R. 4222. They ask us to assume that the only question in the minds of our aged population, their families, and the physicians who will care for them, is how to find the money to pay for the costs of health care.

Nothing could be further from the truth. Our aged patients want, and expect, what the rest of our patients want:

An interested, dedicated physician; the most competent care obtainable; and treatment with dignity as respected individuals--not as casually handled units on an impersonal, medical assembly-line.

Yet the accent is placed on financing, not quality, under H. R. 4222 --the dollar approach instead of the medical care approach is stressed. This preoccupation of H.R. 4222 with finances rather than quality is illustrated by the fact that the bill would limit the services to be provided. In terms of dollars, this makes sense. It is infinitely more controllable to pick a group of services, set specific standards and rates of payment for them, and confine government financing to those services alone. control of the use of tax funds is not the way to produce top grade medical

But

care.

Incomplete medical resources result in limited medical care.

Suppose the patient needs services not covered under the bill? Presumably he is required to obtain them on his own, at his own expense. He is, in effect, being asked to inhabit a medical world that is half public, half private.

This state of affairs would not continue for long, for a doubleentry system of this sort has predictable consequences.

First of all, H. R. 4222 as planned, defined and publicized, is intended to be a primary resource of medical care for the majority of our aged population. It is not intended to supplement private initiative in cases of emergency, as the Kerr-Mills Law does. Thus, the measure pits the overwhelming weight of governmental pressure against all other alternative plans--private or public. Ultimately, as expanded, there is no doubt it would drive these plans out of existence.

Second, the very limitations of H. R. 4222 would lead to irresistible pressures to extend benefits until the program became a complete, across-the-board medical program for the aged.

Third, there is an immediate psychological by-product of this legislation. It is being sold as the Administration's answer to the medico-economic problems of the aged. To the degree that Administration salesmanship is successful, the aged will come to expect that the services provided under the program will cover all their major medical needs. Thus, they and their children will be unwilling to accept, or undertake, any major course of therapy which does not fall for the most part under the coverage of the government plan.

Pressure will be exerted by the patient and his family upon the doctor, in the effort to force him to fit the treatment, willy-nilly, into the services provided by the program.

And too often the patient will postpone treatment until such time as it can be covered under the program--this on the assumption that the program takes care of all so-called "serious" conditions.

Here we come to the doctor's dilemma.

Let us say that a patient needs treatment of a sort not covered

by the program and therefore not reimbursable under it.

The physician is confronted with two unsatisfactory courses of action, neither of which contributes to the provision of quality medical

care.

On the one hand, he may follow his best professional judgment and refuse to recommend a course of treatment covered under the program. For example, he may decide the patient is better treated at the physician's office and that hospitalization is not required. In such a case, it is not unlikely that the patient will go to another physician, hoping for a different professional judgment; or that he will postpone the treatment he needs.

Alternatively, the physician may accept the patient's plea that he can finance the cost of care only through the mechanism of H. R. 4222, and then choose the lesser of two evils--treatment in an improper facility simply because it is covered by the program; or no treatment at all because the patient refuses to undergo treatment except at government expense. In

this case, the physician's medical decision has been influenced by nonprofessional considerations. Further, if the doctor accedes to the patient's request, however unwillingly, he risks censure by the "hospitalization utilization committee" and the possible rejection of his claim by HEW.

I do not claim, Mr. Chairman, that some individual patients might not receive perfectly adequate treatment under the program. Many undoubtedly would, for the needs of their cases would fall within the bill's imposed limitations. Others may receive quality medical care because the skill of individual practitioners can sometimes surmount the limitations placed upon it by the requirements of a particular program.

But many of the aged will receive a lower quality of medical care simply because the services covered do not represent the full range of facilities required by the physician for optimal treatment. You cannot reduce the physician's armamentarium of treatment facilities without reducing the effect of his skill in the process.

I have pointed out that the physician's alternatives would be the unsatisfactory courses of choosing poorer treatment rather than no treatment at all. Let me also mention that H. R. 4222 provides for payment only on certification by the attending physician that the services provided were "required" for the patient's treatment. That word "required" is in the language of the bill.

Now if a doctor decides it is better to put a patient in a hospital, although this may not be the best method of treatment, rather than see the patient postpone a needed course of therapy, can he--or should he--attest that treatment was "required"? Is the sometime need to choose reimbursable courses of treatment for the patient's financial sake sufficient ethical justification to warrant an untrue attestation?

Implicit in the measure, Mr. Chairman, is the physician's responsibility to keep the cost of the program under control. This would be a difficult, if not impossible burden to bear, unless the physician is willing to shift the emphasis, along with the government, from quality to dollars in his approach to the provision of health care.

Any governmental effort to control the cost and use of health services through fiscal means alone is almost certain to fail. It is rather like trying to control highway accidents by manipulating insurance premiums. Safe driving is influenced by many factors--good roads, stop lights, traffic policemen, driver training, licensing practices, law enforcement, and many other things.

The same applies to the cost and use of health services.

In the very effort to control this program, government inevitably Would thrust its way deeper and deeper into the field of medical services. It could not avoid this. And before long, the government would be preoccupied with efforts to regulate quality, regulate distribution, regulate

the providers of the health care which it purchased.

This is not an area in which government should operate--or

can operate--without disastrous effects.

Let me remind the Committee that the practice of medicine involves the constant exercise of professional judgment. The physician must constantly choose between action and inaction, surgery or medical treatment, hospital or outpatient care, one drug or another. The decisions involved are momentous, for they involve health or illness, and sometimes life or death.

Must these decisions be further complicated by the current conditio of the HEW budget? Would the physician's power to decide a health problem on its own merits be influenced for better or worse by government pressures, say, to restrict hospital admissions in the interests of economy?

I think the answers to these questions are clear, Mr. Chairman. We know what our patients want from us. And we know under what conditions physicians must practice if they are to continue to deliver high quality medical care.

Doctors want to be responsible for their patients to the limit of their competence. They want freedom to give their best effort in their offices, operating rooms, and other areas of practice. They want privacy in their dealings with their patients, not the intruding presence of govern

ment.

Physicians oppose any course of action that will erode the wholly voluntary relationship now existing between doctor and patient. Members of Congress and the public should not make the mistake of taking America's high quality of medical care for granted. Because it is high under our present system does not guarantee that it will remain high in the hands of non-professional government administrators.

To the contrary: the quality of medical care under our present system is high because of the very nature of that system--free, thus far, of government regimentation.

If H.R. 4222 became law, those most immediately affected by a deteriorating quality of health care would be, of course, those of the aged who are covered.

But they wouldn't be the only ones. Patients of all ages would also experience this loss of quality. For the whole is equal to the sum of its parts; and if we lower the quality of care provided to one segment of our population, we lower the quality for the entire population of which that segment is a part.

H.R. 4222 would introduce into our system of freely practiced