to fulfill the obligations that face us, in view of our other internal needs and also the very important world needs, which critically face us at the moment. Mr. KING. Dr. Isaacs. Dr. ISAACS. I am Dr. Ivan Isaacs, from Jacksonville, Fla. I am vice president of the Florida Radiological Society, which is a society of doctors in Florida who practice radiology, and I represent the opinion of that society. Mr. KING. Very good, Doctor, you may proceed with your statement as you wish, sir. STATEMENT OF DR. IVAN ISAACS, VICE PRESIDENT, FLORIDA RADIOLOGICAL SOCIETY Dr. ISAACS. Thank you, Mr. Chairman. OPPOSITION TO THE WHOLE PRINCIPLE OF THE PROPOSAL This bill is a proposal to levy an additional tax on incomes of workers from which the Federal Government is to provide and regulate certain elements of personal medical service to elderly people regardless of their ability to provide for themselves. The whole principle of this approach to medical care for the aged is fundamentally wrong, and we are opposed to the whole concept of this proposal. The basic error of this approach has been pointed out to your committee by many others. I am here only to spell out some particular inequities of this proposal which have not been given any great public exposure, since they are rather subordinate to the overwhelming evil of this whole measure. It is in the fear that this whole political give-away program may eventually be adopted, that I am appearing here to show how certain provisions of the bill should be eliminated or altered to somewhat diminish the injustice of this proposed system of medical care. OUTPATIENT HOSPITAL DIAGNOSTIC SERVICES INCLUDE PROFESSIONAL SERVICES OF DOCTORS I will confine my remarks to that portion of the proposal which provides for outpatient hospital diagnostic services, and I will refer specifically to X-ray diagnostic services. It is obvious that diognostic X-ray examinations comprise a very large part of all medical diagnostic services. It should be evident that the essence of these X-ray diagnostic services is the diagnostic opinion of the radiologist. When you receive an X-ray service you are receiving a physician's opinion, a professional medical service, so recognized by the AMA and by the medical practice acts and legal rulings in various States. PROPOSAL WOULD CONTROL PROFESSIONAL SERVICES OF DOCTORS It follows, then, that these proposed outpatient diagnostic services do involve provision of payment for, and control of certain professional services of doctors. This is contrary to the statements of administration spokesmen, who have made repeated public denials that this bill involves the services of doctors. I confronted Mr. Ribicoff with the public distortion of this fact in a letter, a copy of which 76123 0-61-pt. 4-9 is submitted to your committee. My answer came in a letter from Mr. Wilbur J. Cohen, and my accusation is not denied. I am providing you with Mr. Cohen's letter, from which I abstract the following comment: * we recognize that these services are similar or identical to services which are rendered by *** physicians in private offices. Let me repeat this. Mr. Cohen says "we recognize that these services are similar or identical to services which are rendered by physicians in private offices." NO FREE CHOICE OF PHYSICIANS Let me show you how this proposal would immediately bring Government control over an important segment of medical practice. Let us suppose that you have been coming to my office for many years: whenever you required my services for X-ray diagnosis. Now you pass the age of 65 and you are covered by this proposed law. Your personal physician tells you to get a series of diagnostic services, including some X-ray examinations that he thinks you should have. You find that these examinations will cost you $50. However, you can go to the local hospital and let the social security system pay the bill, except for the specified $20 deductible. You will tell me that since the Government will pay the bill, you will go to the hospital for your X-ray examinations. Behold. The Government has switched you from your old radiologist to another one. The Government has broken the relationship between physician and patient. But, Mr. Ribicoff, being ill-advised, will tell you that this proposal does not concern itself at all with doctors' services. It certainly does. PROPOSAL ORIENTED TO HOSPITAL CARE, DISCRIMINATORY AGAINST PRIVATE PRACTICE OF PHYSICIANS In another part of his letter, Mr. Wilbur Cohen designates our medical specialty of radiology among what he calls ancillary services which hospitals do. Hospitals do not do these services, but they do get doctors to perform them. My dictionary tells me that the word "ancillary" is derived from the Latin, meaning "pertaining to a handmaid." Gentlemen, I am not anybody's handmaid. I do not want to be Mr. Cohen's handmaid or any hospital administrator's handmaid. Under this proposal you are telling the patient that he can only go to the hospitals approved by the Department of Health, Education, and Welfare for certain medical diagnostic services. The Government thereby would legislate against the thousands of my capable accredited colleagues who are maintaining well-equipped offices and holding themselves ready to render such services directly to patients as they have traditionally done through the years. Gentlemen, you would discriminate against the traditional system of free private enterprise which has operated so successfully in medicine as well as in other lines of endeavor in our country. POLITICAL DOMINATION OF MEDICAL PRACTICE Gentlemen, this is not the voice of a small group of doctors seeking to preserve their personal welfare. If you can make handmaids out of the radiologists, it will not be long before the whole medical profession will be absorbed into a politically dominated system, and the public will suffer from the mediocre brand of medicine which inevitably follows when the personal relationship of doctor and patient is severed. TOTAL PROPOSAL OPPOSED BUT MODIFICATIONS SUGGESTED IF UNDESIRABLE BASIC PRINCIPLE IS TO BE RETAINED As I said in the beginning, we are, of course, opposed to the whole principle of this kind of medical care for the aged, but if this unjust social security approach to medical care is to be adopted, and we pray that it will not be, let us at least try to keep it as free as possible from controlling the practice of medicine. If it is necessary that the Goverment pay for some doctors' services under such a program, let us say so openly, let us pay the doctors openly. Let us pay the doctor who is qualified to perform a specified medical diagnostic service. Let us not specify that a medical service rendered in a hospital will be paid for and the same identical service outside a hospital will not be made available to these beneficiaries. Let me remind you that the word "identical" is Mr. Wilbur J. Cohen's word, and for once I agree with him. Let us not take the back-door approach of paying hospitals to employ doctors to perform these services. The health of the American people will suffer if such discriminatory regulation of medical practice is invoked by our Government. Mr. Chairman, that is the end of my statement. I would like to have included in the record, if I may, my letter to Mr. Ribicoff, the reply I received from Mr. Cohen. I have submitted these documents to the committee, although they are not part of the mimeographed sheets that I have prepared. Mr. KING. Without objection, that will be ordered, Doctor. Does that conclude your statement? Dr. ISAACS. Yes, sir. Mr. KING. The committee appreciates, Doctor, your bringing to it your views on this important matter. Are there any questions? Thanks again, Doctor. (The above-mentioned correspondence follows:) DRS. HURT, ISAACS & JOHNSTON, Jacksonville, Fla., February 16, 1961. The Honorable ABRAHAM RIBICOFF, Secretary of the Department of Health, Education, and Welfare, DEAR MR. SECRETARY: The press has quoted you as telling the Senate Finance Committee that the administration plan "I have in mind *** does not cover doctors' fees, only hospital, nursing, and nursing-home care.” What of the outpatient diagnostic services covered in the administration's health bill? Surely you understand that these diagnostic services encompass a very large part of the everyday practice of medicine. These X-ray examinations and other diagnostic examinations are performed by doctors of medicine, and fees must be paid to these doctors of medicine. When these services are performed in the private offices of doctors of medicine, as most of them are, a fee is paid to the doctor. When performed in hospitals, the doctors' fees are often disguised as hospital charges. Still, there is a payment to the doctor for his services under the auspices of the hospital. Is the administration hiding behind the subterfuge that it will not be paying doctors' fees by establishing the hospital as a necessary intermediary between the patient and the diagnosing doctor of medicine? Is it not completely obvious that the administration bill does indeed cover the fees of doctors who do these diagnostic examinations, however the fee may be disguised? I will not dwell on these inconsistencies any further. The crux of this matter is that the bill so transparently and completely does deprive the patient of the privilege of going to the doctor of his choice for the performance of a diagnostic service. Yes, sir; it compels the patient to utilize the professional services of the doctor who has elected to practice as the tool of a lay hospital administration, a doctor who has given up his birthright to a direct personal relationship with his patient. The patient will no longer be free to obtain such services from the doctor of medicine who has built up his own practice under our blessed system of free private enterprise. Your bill is discriminatory, sir. It discriminates against me and it discrimi inates against my patient. Your bill would arbitrarily alter the methods of practicing medicine. I submit, sir, that the continued statements of administration spokesmen to the effect that this bill neither covers doctors' fees nor compromises the free choice of a doctor cannot represent anything but ignorance or deliberate misrepresentation. I am not going to enter into the whole argument against compulsory health insurance. You are not going to be swayed from your position on this and I respect your right to your opinions. But, if the Government is going to pay for doctors' services, let us say so openly. And let us not say that the doctor's service is only worth paying for when done in the confines of some overcrowded. impersonal, lay-dominated institution called a hospital. I most sincerely request some enlightenment with regard to the administration's position on the question I have raised. Please do not tell me that these outpatient diagnostic services are not the services of doctors of medicine. Sir, I have been performing these services on outpatients in my office for a good many years, and if these are not doctors' services, then I must have wasted a good many other years in training to perform them. Over 100 Florida radiologists and many of my fellow physicians here in Duval County will be most interested in a clarification of your position, which I earnestly hope will be forthcoming. Yours sincerely, IVAN ISAACS, M.D., Vice President, Florida Radiological Society. DEPARTMENT OF HEALTH, EDUCATION, And Welfare, IVAN ISAACS, M.D., Vice President, Florida Radiological Society, Jacksonville, Fla. DEAR DR. ISAACS: The press of many legislative duties has prevented me from replying sooner to your letter of February 16 addressed to Secretary Ribicoff. I trust you will forgive the delay. Your letter of February 16 raises a question that has been recognized by those who have been involved in framing the administration's health insurance recommendation. The decision to include hospital services but not physicians' services outside the hospital has necessitated the drawing of a line between the two, and there seems to be no way to draw the line that will be satisfactory in all respects to all those concerned. This difficulty is not unique to a Government-financed system; in one form or another it has been encountered in many private prepayment plans. To provide payment for hospital care, yet exclude altogether payment for the ancillary services which hospitals do and must make available would deprive the benefits of a substantial part of their value. Although we recognize that there is a medical component in these services and that they are similar or identical to services which are rendered by or under the supervision of physicians in private offices, we believe that they are nevertheless an essential part of an inpatient hospital benefit if it is to be meaningful to the beneficiaries. Accordingly, we concluded that coverage of the typical hospital ancillary services should be included in the administration's recommendation. The coverage of these services when rendered to hospital outpatients reflects primarily the desire to avoid or minimize the use of hospital beds for diagnostic work that can properly be performed on an ambulatory basis. You are, of course, familiar with the belief of some authorities that unnecessary use of beds often results from payment for these services when rendered to inpatients only. We have thought that the $20 deductible would mitigate, although admittedly it would not obviate altogether, the impact on nonhospital radiologists. Some physicians undoubtedly will take into consideration the fact that radiological services provided in hospital outpatient departments to aged beneficiaries would be paid for, to the extent that the cost exceeds the deductible, by the social security system. We are still considering these matters in connection with pending legislation. I appreciate your having written us. Sincerely yours, WILBUR J. COHEN, Assistant Secretary. STATEMENT OF NELL F. STEPHENS, LICENSED PRACTITIONER Mrs. STEPHENS. Mr. Chairman, I am Mrs. C. A. L. Stephens, licensed practitioner. I am sorry my name does not appear on your list. I usually do mine in writing and hand it in. The committee knows the work I have done for the past 11 years in trying to bring out just what this hearing has done. I wish to thank each and every member for all knowledge that you have gained on this subject and I hope that it will be most helpful. I am in opposition to this bill. Let me recall to you a fire we had in Washington at the Mount Vernon Nursing Home, the conditions of which I reported personally in 1954 and 1955 which were not gone into thoroughly. Had they been done so, those seven lives would have been saved. There are many unfit nursing homes in the District of Columbia. In behalf of all the people of the United States and the District of Columbia, let me beg of you do not place the care of the aged and aging under the social security system. We do not need socialized medicine and we nurses, along with doctors, will fight socialized medicine along with any form of socialism in the United States of America. May I present this statement for the committee to read? Mr. KING. Yes, you may. (The statement of Mrs. Stephens follows:) Congressman MILLS, WASHINGTON, D.C., August 4, 1961. Chairman, House Ways and Means Committee, MR. CHAIRMAN AND ALL MEMBERS OF THIS COMMITTEE AND THE U.S. CONGRESS: In opposition to H.R. 4222, I wish to state again and again all in America do not need "socialized medicine" or socialism in any form. We do need to |