For the diagnostic and treatment facility category, under the existing Hill-Burton program, the diagnostic and treatment facilities existing in the general hospitals and other hospitals built, are part and parcel of the hospital. There are areas in this country, however, remote, isolated to some extent, in which it would be a disservice to put a hospital in the community. That community could not support that hospital. It costs, as a general rule of thumb, about a third of the construction cost to operate a hospital for a year. So for a community which is isolated like that and does not now have a hospital, there are good reasons for it. Chances are the reasons are that they could not support it if they built it. So the city fathers and people of the community say, "No, we do not want a hospital." There is a need, however, in that type of community, for a diagnostic facility where the instruments of precision can be made available to the physicians of the community and to the people to get more ready, more convenient diagnoses. It is surrounding that type of diagnostic treatment facility that the survey would for the most part be directed. In regard to rehabilitation facilities, there has never been a study made of the need for rehabilitation facilities on a national level. The medical profession in its operations do go to a certain extent in rehabilitation. Some of the more complicated hospitals have rendered great services in this regard. Rehabilitation does become a very definite part of the hospital. Here, however, the proposal encompasses not only the medical side of the rehabilitation but also the vocational side of rehabilitation. There has never been a survey in that area. Such a survey is needed as it is needed in all these four new categories before one could contemplate spending construction money. That, in general, is the story. Senator HILL. You would not have, really, two separate State plans, would you? Dr. CRONIN. No, sir; the same original plan with chapters. Dr. CRONIN. You would have chapters to cover these facilities as they relate to each other, and so on. In the single State plan, that is. Senator HILL. What you do, then, you got out and get this additional information which you seek and then what you would do, you would enlarge or augment your State plan based on this additional information which you seek, is that your thought? Dr. CRONIN. That is right, Senator. This is an amendment to the original hospital survey and construction legislation. The State plan would be one plan as an entity. The component parts of that plan would be added to now by these newer categories so that in the final analysis the State would have a single plan for their health resources within their State. But it would be broken down so that you could see the category such as rehabilitation, the category such as diagnostic facilities, and the nursing home, set out and treated by itself, yet in a way related to the general hospital, chronic hospital, tuberculosis hospital, and mental hospital, and so on, as part of the total armamentarium which the people of that State have to combat disease and maintain health. Senator HILL. That would be the type of your State plan, then? Senator HILL. I believe you still have under the existing law some $1,200,000 that you tell me has never been appropriated. What is that story? Dr. CRONIN. Congress last year rescinded the $1,200,000 that was in existence. Senator HILL. They did not rescind the authorization, did they? Dr. CRONIN. That is right, sir. Senator HILL. They rescinded the authorization? I do not think they did. Dr. CRONIN. They did not rescind the authorization. Senator HILL. There is a vast difference in that rescinding an appropriation and rescinding an authorization. They did not rescind the authorization, did they? Dr. CRONIN. They did not rescind the authorization. Senator HILL. What happened was that you had not used the $1,200,000 so they just Dr. CRONIN. We never got that $1,200,000. Mrs. HOBBY. That is the reason. Senator HILL. I think I should certainly amend my language because I am sure that had you gotten it you would have found good use for it. Dr. CRONIN. I would like to point out, although the authorization is still there, there is another step we have to go through between our Department and the Congress and that is the Budget Bureau; and Congress rescinded the appropriation last year. Senator HILL. If Congress rescinded really because the Budget Bureau did not ask it, is that not true? Dr. CRONIN. I would not say that, sir, exactly. Senator HILL. Mrs. Secretary, we talked about the difference in the cost of the chronic hospitals and your general hospitals shown there by the chart, it might be well if we had some idea as to the types of facilities as needed for the chronically ill, how they differ from the general hospitals. Mrs. HOBBY. I know vaguely but I am not going to offer my testimony when we can have it from Dr. Cronin. Dr. CRONIN. The costs of general hospitals, Senator would encompass such facilities as an operating room, an operating suite, oxygen piped through the walls to the beds of certain kinds of services, the medical services in particular; and obstetrical services. Senator HILL. You would not need those in your chronic-disease hospitals, would you? Dr. CRONIN. That is right, sir. I think that answers your question. Senator HILL. You said something about the rules Dr. CRONIN. There are recreation rooms in the chronic-disease hospital which you probably would not have in the general hospital because in the chronic-disease hospital those folks are going to be there for much longer periods of time. Just because it is a hospital they do not have to stay in bed all the time. The general-hospital patients, most of them, are for the most part in bed, are up for a few days and then sent home to continue with care. In the chronic hospital they must continue their care there, and many of these people might even be lifetime patients in that chronic hospital. I could even think of infirmary additions, if you will, to an old folks' home where the life care was carried on because of the medical needs of a person in the infirmary of the old folk's home. You would not need these piped oxygen outlets; you would not ned an operating suite; would not need obstetrical services, and so on. Those, in general, are the things that would reduce the cost. Senator HILL. You mean in a chronic hospital you would not have any facilities there for surgical attention? Dr. CRONIN. Senator Hill, in a chronic hospital as an entity, there would be surgical facilities, I would like to point out that these chronic beds are in facilities that would be chronic hospitals as a single entity, and also would be in chronic units of general hospitals. The chronic hospital as an entity would have a surgical room. It would not be the type of surgical room that you would need to set up in a general hospital where not only could they take care of the fractured hip of the old person who fell, but they might have to do a brain tumor operation. The brain tumor operation done on the older age group in the chronic hospital would be very rare because that type of case would be moved over to the acute general hospital where the nursing care could be much more intensive from a specialty point of view, than would the general nursing care given to the chronic case in the chronic hospital or in chronic unit of a general hospital. Senator HILL. If you had a chronic unit in a general hospital, you would have all your equipment and facilities there right under the same roof, would you not? Dr. CRONIN. That is right, sir. But the cost to build the chronic bed would not be inclusive of the other. Senator HILL. I understand that, but it would be exclusive of the facilities in the general hospital to which the chronic hospital was connected. What I was thinking was in terms of the chronic hospital that was not a unit of a general hospital. That is, built by itself. Where it was built by itself Dr. CRONIN. It would have all the conventional services of a hospital. Senator HILL. All the medical and surgical and conventional services of a hospital. Dr. CRONIN. That is right. Senator HILL. That is what I would think you would have to have. Dr. CRONIN. That is why that bed cost more nearly approximates the general hospital bed cost. Senator HILL. Because you would have to have these medical and surgical facilities there. Dr. CRONIN. That is right; and equipment. Senator HILL. How do you draw a distinction between a chronicdisease facility and a nursing-home facility? Dr. CRONIN. The chronic-disease facility is the one which more approximates the hospital. It could be a hospital or a unit of a hospital. The nursing-home facility would be where they would not have, for example, a physician in residence such as a hospital does in its intern or its resident physicians. The physicians attending the patients would be on a visiting basis. In the nursing-home facility, also, we would hope they would have the patients' food and so on under the dietitian's supervision whereas in the hospital you would have a dietitian there on the ground. In the nursing home the dietetic service could be rendered on a consultation basis, but the dietitian would not be in residence at the nursing home. The nursing home, by and large, would be much smaller than the chronic-disease hospital per se. The type of nursing care given in the nursing home would be general-nursing care as compared to more specific nursing care for the types of cases in the chronic-disease hospital. Chronic disease hospital cases probably could not exist out in the nonhospital facility which does not have as tight medical and nursing supervision. Senator HILL. You would have medical services although on a visiting basis. The difference there, then, would be your chronic; you would have, as you say, your doctors right there in your chronic hospital, whereas on your nursing home, you would still have the services but more on a visiting basis, is that correct? Dr. CRONIN. One other thing that is important here in my opinion is that these nursing homes under this proposal could be built within the hometown of the individual who became ill and needed care. The patient, the chronic patient, would not have to leave his home community to go to a geographical area where there is a chronic hospital. I think that we have found out that the highest death rate of people going to these chronic institutions, the big ones, as we know today, occurs in the first 3 months. Part of them die because they had certain physical ailments that caused their death. On the other hand, I feel that there is a therapeutic effect of love from people of their own coming to see them. It has a very beneficial effect on patients. Senator HILL. That applies in all hospitals, does it not? Dr. CRONIN. That is right, sir, but if a person has to go a hundred miles and be hospitalized their son and daughter will come the first time to see them, in the first month; and then because sometimes it is a depressing venture for us to take, we being human as we are, do not make that second venture. I know I have seen patients that had every reason to live from a medical point of view but no reason to do so in their own mind, so they basically rolled over and did not care to go on. By putting these nursing homes in these smaller communities, closer to the families of people, I think we can help solve this problem which is not a nice one. Senator HILL. Let me ask you this: Have not chronic-disease hospitals had a good priority within the States? Dr. CRONIN. The chronic-disease hospitals have enjoyed perhaps one of the highest priorities of the States. The attitude of the various peoples within the State to build a chronic-disease hospital is predicated on several things: One, their knowledge of the general hospital is quite sufficient. They know what it is. Their knowledge of what is a chronic hospital is based on really their experience with what happens in the general hospital and the need for general hospital care; and the cost of general hospital care. It is only within the last few years that we have realized that the cost of the chronic patient does not have to be as high as it is for the average patient admitted to the general hospital. Senator HILL. Is it for the reasons that you have stated in spite of the fact they have had this high priority that we have not built more chronic-disease hospitals? Dr. CRONIN. I think the first reason, Senator Hill, why there has not been too much done-3,000 beds out 106,000 in the program, in the chronic area is the fact that people know what a general hospital is. You can stimulate interest if a group in a community wants to build a hospital in the general hospital category. Second, is the difficulty in acquiring a sponsor for a chronic hospital when the chronic hospital patient is there over 30 days and the cost is a protracted one which more seriously taps the financial resources of the people who go into those institutions. Senator HILL. Have applications for chronic facilities been denied that you know of? Dr. CRONIN. None that I know of. Senator HILL. Just have not been made? Dr. CRONIN. That is right. Senator HILL. Well, now, your shortage of nursing homes, is this due to a lack of financing facilities or to a lack of funds to pay for the care? Dr. CRONIN. An element of lack of cost to pay for the care must be considered. There are a great number of nursing homes in this country. Some of them are good. Some of them are not so good. The big problem is the basic education, I think, of the people of the country as to what kinds of services are more conveniently adaptable to the requirements of the people with these illnesses. Then, when a person feels that he is going to have to do something, he is going to figure out how can he do it. He gets assistance on what is the best way to do it. We are now coming to an understanding that the best way to take care of some of these chronic patients is not in the general hospital but is in the kind of an institution that does not cost as much to keep them there. Senator HILL. Let me ask you this, speaking about nursing homes: They serve the chronically ill, do they not? Dr. CRONIN. That is right. Senator HILL. Why are they not covered under the present act? Dr. CRONIN. Under the present act? Senator HILL. I am not talking about your regulations. Dr. CRONIN. Under the present act, the nursing home from a legal point of view, I think, could be covered. Senator HILL. Could be covered? Dr. CRONIN. Yes. However, we have had over 6 years of operation, and there is something in the way of what has been done that indicated that the nursing home was not going to be covered and built under the Hill-Burton program. As a result, under the President's proposal, it is pointing up that fact by categorically earmarking $10 million for nursing homes to try to stimulate and catalyze something to be done in that area. The foundation for this, basically, is that nothing has been done for 7 years with the $600 million of Federal funds and the additional matching $1,200 million of local and State money in regard to nursing homes. Senator HILL. Hasn't the Public Health Service had a regulation that excluded them? Dr. CRONIN. The regulations excluded the nursing home and I would like to point out that the regulations are not solely the Public 46293-54-pt. 1—5 |