Dr. SCHEELE. These are primarily State hospitals, although I believe in the overall planning private beds are accounted for, but actually the ratios are very much on the side of public beds in this field. I might say at this point-and this is a bit of digression that this projected mental health bed need is based on a concept of putting most mental health patients in a mental health institution of the ordinary type. Actually, the program that Mrs. Hobby is describing to you this morning would, I am sure, take some of the pressure off for some of these beds. Among these older people, there are some who have hardening of the arteries of their brain, who are senile, and a bit disoriented. Because of these conditions they are often committed by State courts or by voluntary commitment, family commitment, to regular mental institutions. Many of them could probably be cared for in less elaborate facilities, even in nursing homes if there were an adequate number. So that the projected need is, in a sense, a variable depending on the total spread of facilities that exists in any period of time. Senator PURTELL. Does the number of acceptable beds that you have shown there, Doctor, make any allowance for the large number of existing beds for civilians in Federal hospitals including some 50,000 beds in the Veterans' Administration establishments? Dr. SCHEELE. That is not included. One could lower these bars on the chart if one took the Veterans' Administration beds into account. Senator PURTELL. Ought we not to take that into consideration since you are using that as a base for determining the number of beds per thousand of population and they are part of the population? Dr. SCHEELE. We could probably reduce the ratios that we are using by a small fraction and have a more accurate picture. I might point out, however, that we still have a need, and we would only take off a small portion of this bar if we dropped the VA beds. Senator HILL. Doctor, you say about 200,000 general hospital beds are needed; 350,000 mental. How many now in chronic? Dr. SCHEELE. Two hundred and forty thousand, approximately. Senator HILL. Two hundred and forty thousand, approximately, chronic. And how many tuberculosis? Dr. SCHEELE. In the tuberculosis field, approximately 40,000. Dr. SCHEELE. In this next chart (D) we have projected these shortages and accomplishments in percentages as contrasted with numbers or thousands of beds in the former chart. Here we see the greatest unmet need, 88 percent, is in this field of chronic beds; 31 percent unmet in general beds; 48 percent mental, and 26 percent tuberculosis. Senator PURTELL. Are there any other questions the committee wishes to ask before those charts are taken down? Proceed with the rest of the charts, if you will, Doctor. Dr. SCHEELE. It is interesting to project this shortage of chronic beds against some of the changes which are occurring in our population. For example (chart D), in 1900, when our national population was approximately 76 million, we had 3 million people (shown here in purple), 65 years of age and over. By 1950, our population had doubled to approximately 151 million. But our population age 65 years of age and over had quadrupled to 12 million. During the same period of time, life expectancy had increased from 49 years to !T 68 years. We have tried in this next chart to show some of the changing health picture. 27 quFortex sit Senator HILL, Doctor, how much of that, roughly speaking, is due to the fact that we save the lives of so many more infants today than we did?o Dr. SCHEELE, You cannot give a percentage figure but it is a very large factor. Senator HILL. The infants do not die today like they did o Dr. SCHEELE, Many babies were lost in the early days of life because of infant diarrhea and other, infections whereas today, the average infant that is born has a chance to get up into this bar, which shows an expectancy of 68 years. This is a very simple chart (E) because we have chosen only four groups of diseases to show here so that the, chart would not be too confusing. Infectious diseases have declined, as shown here by the reduction in the TB deaths, and the reduction in influenza and pneumonia deaths, both running in the neighborhood of, 200 per 100,000 in 1900 and dropping down to 25 or 35 in 1950. However, with the increasing life expectancy, with the reduction of these diseases which often kill in the earlier years of life (though influenza and pneumonia and TB kill in older years, too) we see more people coming into the age when chronic illnesses such as cancer, cardiovascular diseases, begin to take their, toll... Over this same period of time we see an increase in cancer deaths, and an increase in heart and cardiovascular deaths in very substantial amount. In the field of cardiovascular disease from approximately 340 per 100,000 in 1900 up to about 510 or 520 in 1950. Senator HILL. Do you think that increase is as precipitate as the chart would show, or the fact that old age, a lot of times people die of cancer, did die and it was not diagnosed. Dr. SCHEELE. We never can say, that our charts, our mortality data or morbidity or illness data, are completely accurate because there are missed cases. In cancer, generally speaking, in recent studies that have been done, show that death recording has been quite accurate, I suppose they have not been quite as accurate back in this period of time. In fact, there were instances in which States did not have complete registration of deaths in those early days. a However, we feel quite sure of our data in the cancer field because we have been able to do incidence studies in a number of our major cities and have been able to do accurate studies of hospital data on patients and deaths in hospitals. Projecting those against the nationally col lected data, leads us to believe that we have quite accurate figures; we haven't had an increase in cancer of any given type except pos sibly lung cancer. As far as we can tell, we have had an-absolute increase because of the changing age composition of our population. Senator LEHMAN. Is the increase in heart disease demonstrated in every age class or is it largely demonstrated in the higher age groups? Dr. SCHEELE. It is demonstrated in the higher age groups to a greater extent. However, we do have deaths in all age groups, sometimes from rheumatic heart disease which comes from infection. It is the great waster of children and may cause death, although antibiotics and some of the other newer methods of treatment give us good tools, if these chindren are found early, to help them survive and help them actually come out with very little heart damage. Senator GOLDWATER. Mr. Chairman, may I ask a question? Senator PURTELL. We will be very happy to have you ask a question. Senator GOLDWATER. Getting back to the need in the tuberculosis field for beds, that need as you show it on the chart has been based on total of State needs, is that correct? Dr. SCHEELE. That is correct. Senator GOLDWATER. Have you projected the need from this chronic disease rise chart against that total? I ask that question because it looks to me like the tuberculosis is approaching the controllable stage where we get it down to around zero. Have you taken that into consideration in the bed outlook? Dr. SCHEELE. It is taken into consideration to this extent: The bill the committee is considering this morning is taking cognizance primarily of this increase in illness which require long-term hospitalization. In other words, the bill itself provides assistance in the area of our rising chronic disease problem. So that, to that extent, it is not deemphasizing the importance of completing the job in tuberculosis. On the other hand, it is adding new emphasis in these other areas. I might say that we do not have to worry about overbuilding our TB beds, because if we arrive at the point in our States where we have more than we need, these beds can be used as chronic disease beds generally. They are not lost. Senator GOLDWATER. Are you going to do any revision in that field, just for the information of the committee, as I say, in the next few weeks. Dr. SCHEELE. No, sir; we have no plans to do that. Senator GOLDWATER. That is something I think you might do. It is a suggestion for not right now, but I think you should take into consideration the fact that tuberculosis is approaching a controllable situation. We might encourage the overdevelopment of tubercular beds. Dr. SCHEELE. I might point out Senator GOLDWATER. It would be much easier when you do it, even though it is a little more expensive originally, it would be much easier to develop beds that are really needed, in the really needed fields-I mean general hospital beds where I know the cost is far greater per bed, but it is a difficult thing to switch a tubercular sanitarium over to a general hospital. I would not want to see us get way out on a limb where we might not need it in 5 to 10 years. Dr. SCHEELE. I should point out at this time that in the program the planning that is done is done by the States, the State hospital authorities, and they are cognizant of the overall changing pattern of requirements for hospitalization. I feel confident that without any urging on our part, we will continue to see some fall-off in interest in building additional tuberculosis beds because the States are not going to build them for care of patients who will be in most instances public charges, if they do not have to. They see their problem com 46293-54-pt. 1- 3 ing toward an end point; and all of our State institutions are using some of the newer drugs which are very valuable treatment adjuncts. I think the very thing that you have described as necessary is actually happening in our States and will continue to happen. I do not believe that any, shall I say, change in the basic law is necessary to speed that up. I do not believe that any great effort on the part of the Public Health Service in terms of our contract with the States is necessary, either. I believe this will flow naturally from the technical knowledge of our changing picture in tuberculosis. Senator GOLDWATER. Thank you. Dr. SCHEELE. We are well aware of the fact that patients who are older, 65 years of age and over, require on the average twice as much. hospital care, twice as many hospital days of care in a year, as those in ages under 65 years. One study (chart F) indicated that 2,051 days were required by 1,000 persons 65 years of age and over-in other words, 2 days per person, while 1,045 days of hospitalization were required per 1,000 people under 65 years-in other words, 1 day per person. Senator GOLDWATER. That is the average? Dr. SCHEELE. That is the average. Senator GOLDWATER. That is 1 day in the hospital? Dr. SCHEELE. Average per person. Fortunately, most of us are not average, and wo do not have any days, and other unfortunates have 5, 10, or 15 or more days. This is overall per thousand people. But it works out in simplest terms to 2 days, a little over 2 days if you are 65 or over, compared with 1 day if you are under 65. How, then, can we provide for more economical care for the older age group and others who require longer term care? In this chart (G) we have shown some of the national averages in cost per patient-day. Our general hospitals, which normally care for acute patients and short-term patients for periods under 30 days, according to the American Hospital Association study, cost approximately $18.35 per day, compared with chronic beds for patients who are hospitalized longer than 30 days, where the national average case is running in the neighborhood of $6.36 per day. In nursing homes, we do not have average figures because there is a considerable spread in our data, and they are not complete; but in studies that have been done, we find that average daily patient costs are running between $2 and $8. So we see that through the provision of more chronic hospital beds, through the provision of more nursing home beds, we can provide a more economical method for the care of our long-term patients. Mrs. HOBBY. Thank you, Dr. Scheele. Mr. Chairman, it seems to me that we can draw three conclusions from this information that Dr. Scheele has just presented. First, what has been done so far in improving and expanding our hospitals has been especially inadequate with respect to beds for the chronically ill. Second, our shortage of chronic beds is expensive, for it has led to the crowding of chronically ill patients into our general hospitals— which are the most costly to operate and which are needed for patients with acute conditions. Third, the relative demand for chronic facilities will continue to rise in the future because of our aging population. A fourth conclusion, although not specifically illustrated in the charts themselves, is that the need for institutional bed care must be minimized by placing greater emphasis on preventive health services. Under the present program relatively little attention has been given to outpatient departments of hospitals and other centers for the diagnosis and treatment of ambulatory patients—that is, those who do not require bed care. Such diagnostic and treatment clinics are essential if our communities are to have well-balanced medical services at a cost which they can afford. The bill you are now considering contains five major proposals, in accordance with the President's recommendations, for achieving a better balanced program. 1. SURVEY AND PLANNING Following the precedent of the original Hospital Survey and Construction Act, the bill authorizes an appropriation of $2 million, to remain available until expended, for grants to assist the States in surveying their existing facilities in the categories covered by the bill, and in developing revised State plans and construction programs. The minimum grant to any State for this purpose would be $25,000. Every State would be required to match these funds on a dollar-fordollar basis. The importance of this survey and planning feature in assuring the sound investment of construction funds cannot be too strongly emphasized. The surveys made under the original act have contributed greatly to the success of the program. For the first time in the Nation's history each State and Territory undertook an orderly inventory and appraisal of its existing hospital and public health center facilities, and developed a comprehensive statewide plan for expanding and improving these facilities in accordance with the most urgent needs. These State plans will need to be revised to conform to the provisions of S. 2758 since 3 of the 4 construction categories covered by the bill are new or broadened. 2. FACILITIES FOR THE CHRONICALLY ILL For each of the 3 remaining fiscal years of the present program, the bill would authorize appropriations of $20 million specifically earmarked for grants for construction of nonprofit hospitals for the chronically ill and impaired. In terms of program categories, this provision is new only in emphasis, for such facilities are now authorized under the present act. The purpose of this new emphasis is to stimulate and accelerate the construction of hospital beds for the increasing number of persons with long-term illnesses who require hospitalization, but who do not need care in facilities as expensive to construct and operate as the general hospital. While the language of the bill refers to "hospitals for the chronically ill and impaired," it should not be inferred that these will always be institutions independent of general hospitals. On the contrary, it is probable that many of the units constructed with the aid of these grants will simply be wings or other structures related to a general |