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and disability in our country, the opportunities for preventing or curing these conditions and the problems we face in combating these major foes of premature death and disability. It so happens that four conditions: Heart disease, cancer, stroke, and accidents, make up 70 percent of all deaths among Americans, while heart disease, arthritis and rheumatism, impairment of back, hips and lower extremities, mental and nervous disorders and hypertension represent 40 percent of the reasons for disability among our population. Therefore, it is in these areas that we need to concentrate if we are to make a significant impact on disease rates in the country.

The major factors contributing to death from heart disease, cancer, and stroke in the United States have been well established by epidemiological and laboratory studies. Factors for which the incidence is most consistent include, for cardiovascular disease-overnutrition (especially with regard to fat and cholesterol intake), hypertension, excessive cigarette smoking and physical inactivity; for cancer-excessive tobacco usage, nutritional deficiencies and excesses, and certain occupational exposures; and for highway accidents, alcoholism and drug abuse, poor highway, and automobile designs.

Thus, in a society where infectious diseases have been largely overcome through sanitary measures, immunization, and antibiotics, the major causes for today's death toll are chronic diseases. This death toll is largely due to unhealthy lifestyles, unhealthy working environments, and disease-inducing products. If we are to prevent these diseases, we need to concentrate on their causes.

PROBLEMS OF DISEASE PREVENTION

It may be asked why, if etiological factors of certain diseases have been established, there hasn't been more progress in the prevention of these diseases. Among the reasons for this failure are man's apparent apathy toward anything preventive-whether with regard to energy conservation, highway safety programs, or health. We tend to live for the present, believing that the future will take care of itself. We also seem to suffer from an illusion of immortality, apparently related to our inability to face death. The problem is further compounded because doctors are trained mainly in therapeutic medicine; and because reimbursement for medical care is nearly totally geared toward therapy. Given these facts, adding that preventive advice given to patients is not as dramatic in public or private terms as combating symptomatic diseases, it is little wonder that many of today's physicians do not stand in the vanguard for the cause of prevention.

The hospital system is another part of the problem. Our hospitals deal primarily with cure, not prevention. Since reimbursement is aimed mainly at inpatient, rather than ambulatory care, and since hospitals are reimbursed for therapeutic rather than preventive care, it is not surprising that the latter is being neglected.

These attitudes are reflected in current practices of the health insurance industry which, again, concentrates largely on reimbursement for therapy for specific disease symptoms and not on prevention. It is unrealistic to expect that the medical and allied professions, in an economic climate such as ours, will behave any differently than any other

segment of society. As long as our society provides economic incentives primarily for therapeutic care, it will be therapeutic care which receives the most attention.

Yet, we know from medical history that the world's major diseases did not succumb to therapy alone; instead the only time they were ever eradicated was when effective preventive measures were applied. This lesson from history also applies to chronic noncommunicable diseases such as cardiovascular disease, cancer, and chronic pulmonary disease'diseases which have a long latent period, which by and large are not likely to be cured in their later stages, but which are often preventable.

RECOMMENDED MEASURES

The following attempts to crystalize the major steps which can lower costs and contribute to a better health care program than the one we presently have.

1. First of all, we, as a nation, must resolve that health care ranks as one of our country's major goals. To accomplish this goal requires the cooperative efforts of various segments of society. It is obvious that the medical profession cannot, by itself, determine which type of a health system would be best for the country. Industry, labor, economists, health insurance experts, Congress, and the public at large need to coordinate their expertise with that of the health professionals in order to arrive at a health care delivery system which is best suited to the needs of the United States.

2. In order to improve the health care delivery system, both medically and economically, several measures should be included in whatever type of national health insurance system is contemplated.

The system must accentuate financial incentives for ambulatory care. Existing hospitals should be reorganized so that they can provide, in addition to therapeutic care, efficient ambulatory care for their communities. Appropriate incentives should also be given to physicians to provide preventive care. Included in this care should also be: Immunizations, maternal and child care, pre- and postnatal care, general health education and motivation, as well as therapeutic care. The ambulatory care unit thus includes both preventive-primary and secondary-and therapeutic programs. The preventive care programs should be of the short- and long-range type and should modify their services in line with the specific needs of various population groups. The ambulatory preventive care program should be extended into the schools where meaningful health programs are currently almost nonexistent. Effective preventive medicine as is the case with education in general-has its greatest impact on the young.

3. Ambulatory care delivery programs can, to a large extent be carried out by allied health professionals, nurses, medical corps men, health educators, behaviorial psychologists and sociologists who, under the overall supervision of physicians, in many instances can undertake effective therapeutic programs and significantly help in modifying the lifestyles of our people and in detecting early disease.

4. A national health insurance program should not only provide effective ambulatory and preventive care programs but should also provide incentives for the public and the health care delivery system to see to it that such health services are effectively utilized.

5. Recognizing that individuals will always represent the weakest link in preventive procedures, in addition to providing meaningful incentives to utilize cost-effective preventive services, emphasis should be placed on "managerial" preventive measures. These include further development of less harmful smoking products—a measure especially recommended for a society which is likely to continue to condone smoking as socially acceptable and the modification of American food products toward developing a "prudent" diet, one low in fat and cholesterol and thus more commensurate with today's reduced caloric expenditures, as well as a diet that leads to proper growth of our poor and underprivileged. Managerial preventive medicine also includes reducing workers' exposure to harmful elements through legislation and making certain that no new harmful components are introduced into the environment. It also includes the enforcement of speed limits which, in addition to saving lives, would also help in the conservation of energy. Existing laws with respect to drunken driving and automobile and highway safety should be vigorously enforced.

6. It is suggested that all preventive programs as currently conducted by various branches of HEW and other governmental agencies, be coordinated and supervised by an Office of Disease Prevention to be heated by a Deputy Assistant Secretary reporting directly to the Assistant Secretary.

Finally, I would like to bring the following recommendations to your immediate consideration, that:

7. In any authorization for national health insurance-even in the initial development stage-Specific allocation equal to one-tenth of 1 percent of the dollar authorization be directed toward preventive medicine, research, and evaluation of existing systems.

8. That the chairman with the advice of the committee direct the Secretary of HEW to appoint a task force on preventive medicine for the purposes of examining, on an across-the-board basis, the extent that preventive medicine is presently being practiced for the purpose of determining specific feasibility as to what is accomplishable through preventive medicine.

9. That the chairman with the consent of the committee direct the Secretary of HEW to report within 90 days on the extent of the taxpayer-supported research in the area of evaluating the cost benefit of preventive medicine.

10. That the chairman direct every witness to address themselves to the specific question of how the financial cost of disease care can be reduced through preventive medicine.

In summary, we have emphasized the roles which ambulatory care, preventive care, allied health professionals can, and should play in a national health insurance program. It should be emphasized that all such programs should be continuously scrutinized for their cost effectiveness and cost benefits.

Preventive medicine, if properly advanced, can make a major impact-both medically and economically-on the high rate of disease in this country. It requires a full-time coordinated effort for its goals and aspirations to be fulfilled. We have also set forth the obstacles-scientific, economic, and human-which face the proponents of preventive medicine. To overcome these obstacles requires the understanding and the support of the people and, consequently, the Congress. Congress,

through its legislative powers and particularly through its influence on a national health Insurance program, has the opportunity to make ours a healthier society, one with the lowest infant mortality and highest longevity, and one where our motto of "dying young in life, as late as possible" will be fulfilled. With the scientific evidence available today, with the cooperation of the medical and allied health fessionals, and with the determination of the American people, along with legislative stimulus from the Congress, we can make the realization of this motto come true in our lifetime.

STATEMENT OF JOHN G. FREYMANN, M.D.

Dr. FREYMANN. I am John Gordon Freymann, a physician, member of the family practice faculty at the University of Connecticut, and the president of the National Fund for Medical Education. I would like to assure Mr. Duncan I have taken care of patients for 25 years and I am still taking care of them now. I have never been in full-time private practice but I think it is the care of patients, not one's ways of collecting fees that is important. So I understand the problems.

Henry Ford said that history is bunk. I will not argue the point, but history is the only way I know to understand the complex and seemingly irrational organization of the American health care system. My assignment is to take the subcommittee through a brief history to show how our system got to be the way it is. To do this, I will trace three chains of causation which, woven together, have produced what we have today. These three chains are: (1) The organization of health facilities, with particular reference to short-term hospitals; (2) the education of the health professions, with particular reference to physicians; and (3) the financing of health services.

ORGANIZATION OF HEALTH FACILITIES

Pennsylvania Hospital in Philadelphia was the first voluntarythat is, private, nonprofit-hospital in the Nation. Opened in 1750, it was a faithful copy of the hospitals of London. These institutions had evolved a peculiar, tripartite organization over the centuries. I am interested to find that Mr. Pike is a member of this tripartite organization.

The board of trustees, which owned the corporation, was a mechanism for governance that replaced the church after Henry VIII abolished the monasteries in 1536. The hospital administration was employed by the trustees, but the medical staff was an independent cadre of private practitioners. They were not employees because the original hospitals were hospices for the poor. Centuries passed before they became places exclusively for the sick where an attending staff of doctors was needed. Hospitals eventually employed some doctors, but they were apprentice physicians or surgeons.

This medieval model, brought to the Colonies from the mother country, is still followed throughout the United States. All of our voluntary hospitals, secular and religious, have this same basic organization. So do most city and country hospitals, although here the trustees may be elected or appointed officials. The administrative staffs are employed by the trustees, as are the apprentice doctors whom we

now call residents. In the last 25 years, many hospitals have hired full-time, salaried doctors to head major departments such as surgery and internal medicine. But the vast majority of doctors working in these hospitals are practitioners who receive the privilege of using the facilities from the trustees and are paid directly for their services by their patients or by third-party payers.

In spite of their long history, hospitals played a minor role in the American health care system until the 20th century. In 1873, there were only 178 nongovernmental hospitals; by 1909 there were 4,359. Even then, however, hospitals were still primarily places for the poor. Anyone who could afford it was cared for-even operated on-at home. By the 1920's surgery had moved into hospitals, but in 1940, 44 percent of American babies were still delivered at home. Internists were even slower than the obstetricians. Not until the discovery of a panoply of "wonder drugs" and invention of a variety of highly technical diagnostic and treatment techniques did departments of internal medicine become the key components of every hospital they are today.

The magnitude of the change in hospitals-from havens for the poor to social necessity for all-is reflected in the following figures. Between 1936 and 1973, the number of hospital admissions per thousand population rose from 61 to 145. One American in 10 is now admitted to a short-stay hospital at least once every year.

The place of in-patient hospital facilities in the American health care system is important to this committee because half of all national health expenditures occur in this milieu. However, I have another, perhaps more important reason for emphasizing hospitals. They have become the nuclei for medical practice in many, if not most, communities.

Use of hospital ambulatory facilities for diagnosis and treatment has risen far more rapidly than in-patient admissions. Ambulatory visits now exceed admissions by 5 to 1. But since nearly 90 percent of all doctor-patient encounters still occur in doctors' offices, isn't this where the action really is? Yes, if one looks at volume instead of expenditures, the action is in doctors' offices. However, the gravitational pull of hospitals is having a pronounced effect on where these offices are located. Across the Nation, doctors' offices are clustering more and more around hospitals. Thus, although direct fiscal links between hospitals and doctors are infrequent, in a functional sense each hospital has become, or is rapidly becoming, a community health center, or, if you will, a center for community health delivery.

This close association among doctors and hospitals is peculiar to the United States and Canada. In every other major nation, doctors are rigidly divided into an elite cadre of hospital-based specialists, who are usually salaried, and a larger group of less specialized or primary physicians who care for ambulatory patients and are denied access to hospitals. In contrast, the American doctor without hospital privileges is an exception. In fact, the discovery that several thousand doctors in New York City had no hospital association was viewed as scandalous.

I come to the end of this first chain of causation in the evolution of our health care system with this point: The machinery for delivering personal health services to the American people may be divided roughly into 6,000-plus clusters. Each of these consists of a relatively

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