I do not mind hearing that at all.
Does that answer your question?

Senator STEVENSON. That is very helpful; and I thank you again,

Dr. Betts.

Senator Cranston has returned now.

Senator CRANSTON. I regret very much I was not here during your testimony, but I was well represented by staff members, and I will myself read your statement in the record.

I thank you very much.

Senator Stevenson, I thank you very much.

Our next witness is Roy Snelson, chief, Prosthetics Amputee Center, Rancho Los Amigos Hospital, Downey, Calif.

We are particularly pleased to welcome you to this hearing.

Because of my interest in the field of rehabilitation, I have been aware of the outstanding work which has been done and continues to be done at your hospital in concert with Rancho Los Amigos Hospital, University of Southern California.

I want to thank you for taking your valuable time and coming such a long distance to give us the benefit of your experience and background and the sharing of your views with this committee.

I know your testimony will add to our knowledge and aid the committee in its study of the bills now before us.

STATEMENT OF ROY SNELSON, CHIEF, PROSTHETICS AMPUTEE CENTER, RANCHO LOS AMIGOS HOSPITAL, DOWNEY, CALIF.

Mr. SNELSON. Thank you, Senator.

I have submitted a written statement, and I think in the interest of time, I would like to summarize it.

Senator CRANSTON. I appreciate that a great deal because we do have some time problems. Your prepared statement will be submitted for the record at the conclusion of your testimony.

Mr. SNELSON. Our present system of care for the amputee was designed primarily for the World War II amputee, who was a young male in an area where other young males had the same problem; and it is product oriented.

Most of the research and training in the area of prosthetics has been product-oriented. This was satisfactory when we were dealing with young people.

However, today, about 90 percent of our amputees are in the older population; about 55 years of age.

Because of recent advancements in surgical care of amputees, about 80 percent now have their legs amputated between the foot and the knee, as opposed to 10 years ago when 80 percent of the amputations were between the knee and the hip.

This advancement of making these people below-the-knee amputees has created greater groups of patients with rehabilitation potential. The older patient, generally, if the leg is amputated above the knee, is not a candidate for ambulation.

The problems are different in the older amputee. Amputation is really a catastrophic illness. We have a tendency to look at things technically instead of an entire patient and his problems.

We have services available, but they are sometimes fragmented. For example, in some county hospitals a patient can come in if he

lives in that area, and if he has no means; but if he lives across the county line, or is not an indigent, he is not available for care.

I think we need someone who understands what is available for the patient and sees that the patient is made aware of it. We have a vocational rehabilitation system, but they cannot do anything until the patient has been referred to them by someone, and unfortunately the advent of medicaid has reduced their efforts in this area because in the past, in order for a patient to find funds for a phosthesis, he would be referred to a vocational rehabilitation counselor, and then enter the program.

Now the funds are available through group insurances; medicaid and other methods, and they may receive only a part of the care which really is not good.

The criteria we use in the United States for providing prosthetic care for older patients should be changed. It is: "Will they walk?" I think a patient has a right to feel normal, and if part of his body has been removed, it should be replaced whether he is going to walk

or not.

The greatest problem the patient has is not being able to walk again; it is the family problem. The average older amputee is about 55 years old and has children either in college or about that age. He faces the loss of a job, and, too many times, I see people who are in the middle-income bracket, who have had an amputation, and have great psychological problems.

They are out of work, and they do not know when they are going to go back to work. They lose their jobs. Once they lose their jobs, many times the family breaks up. Then the individual becomes indigent, and they are eligible for care in an amputee center.

I do not think this is correct, and it is certainly not the most inexpensive way to handle the problem. As a matter of fact, there are some agencies in some States that require a patient to survive a cancer operation for 5 years before they will provide prosthetic care, which is not a every humanized system.

In a center where you bring these people together, you have a tendency to treat them more as a whole person. They have the advantage of seeing other people in the center with the same thing wrong with them. You can lay out a program so they will have a better idea of where they are going, and when they are going to get back to work.

Almost anyone can survive 2 or 3 months away from his job. If he is going to be gone 6 months, 8 months or a year, then he is going to be replaced, and trying to get someone into a job who has had an amputation is much more difficult than getting back into the job he had before. I believe it will be a terribly expensive thing to do, and I recommend to the committee that it establish provisions for amputee centers similar to the spinal cord injury centers. I do not, of course, propose they be placed together because these are very different problems. Amputation to an older person is a catastrophic disease, and I think it would be a savings if we could get these people working rather than having them become unemployed. Once they become unemployed and become dependent, it is extremely difficult for them to return to work.

I believe that is all I have to say.

Senator CRANSTON. I thank you very much for that succinct summary. Your entire prepared statement will appear in the record.

I am particularly interested in that patient advocate suggestion which I think is fascinating, and innovative, and appears to have a lot of merit.

Mr. SNELSON. We have a patient advocate on our staff. I find that an amputee will talk to a patient advocate and give them information that other professionals cannot obtain.

They see someone with the same problem-I do not mean that the advocate will always be an amputee but I do think it would be helpful. Questions that, for some reason, they will ask the advocate they will not ask other professionals.

Someone has to cut through the red tape, know how to do it, and get it done, because once the thing reaches the level of administration, it becomes impersonal. Those of us who see the people have a greater feeling of urgency.

Senator CRANSTON. Could you submit to us for the record a quite detailed statement of how that patient advocate approach is working now, and any recommendations you have on making that a general program?

Mr. SNELSON. Yes, sir.

Senator CRANSTON. That will be very helpful.

How did you reach the figure of 311,000 amputees?

Mr. SNELSON. This figure is from the Advisory Council on Vocational Rehabilitation. They took the figures provided in England and extrapolated them for America, and I understand they also made visits to 250,000 homes. At best, it is a guess.

We are doing amputations at Rancho Los Amigos Hospital at the rate of 200 a year, and that is just one hospital, so I think the figure of 311,000 is probably low. In any event we do not know how many amputees there are in America, because a patient amputated in a private hospital just might go home and end up in a nursing home and no one would ever know.

Senator CRANSTON. What type of public information dissemination is needed that is not now being provided for amputees which would be of particular use both vocationally and medically?

Mr. SNELSON. One of the problems we have is the change in the amputation level. When an amputation was performed above the knee, rehabilitation did not seem to be a reasonable scheme, and was something that had to be done to save a life. I think the surgeon is the one who has to be made aware of what can be done.

We really need the amputee referred to the amputee center very soon after the amputation, because time is of the essence.

By choice we would like to talk to the person before the amputation if possible.

The strongest moving force for these kinds of things is the general public. For example, if you are in Los Angeles you know about the City of Hope. You know about it because the public knows about it.

Senator CRANSTON. It is apparent that you are advocating a categorical type of approach to treatment of amputees. Am I correct in understanding that you recommend this be done in concert with the spinal-cord injury centers, not through separate amputee centers?

Mr. SNELSON. No. It should be a separate amputee center. It would have been better to say we should have a separate category. It is quite reasonable in many cases they will be in the same institution, but I think the provision should be for separate amputee centers.

Senator CRANSTON. Would there be a savings involved if they were in the same institution and as close as possible relationship?

Mr. SNELSON. I would think there would be because there are a number of things in common between the treatment of an amputee and the c spinal-cord injured patient.

Senator CRANSTON. Could you expand on why you feel this categorical approach would be the best way of achieving the vocational potential for each amputee client?

Mr. SNELSON. Yes. People who deal with one problem become expert at it. People who see a problem on occasion do not become expert.

I think the worst thing that can happen to a patient is to be the only person in a hospital with an amputation. Unfortunately the people who probably get the poorest amputee care are those with the best means in a private hospital. They get tender loving care for too long a time.

In our center, for example, our team includes the vocational rehabilitation expert, counselors, physical therapists, psychologists, prosthetists, and physicians. Everybody is there, and we talk to each other, and involve the patient because we are a team.

Senator CRANSTON. Getting back to the S.C.I. centers and amputee centers, what would be the main shared elements in your opinion? Would this result in savings in one way or another?

Mr. SNELSON. I am trying to think of our own center, and probably the greatest advantage we have is just the concept of how a center works, with people there.

We are separated geographically by about a mile. We have nothing in common except the administration of the hospital, of course.

Senator CRANSTON. Suppose they were in the same place. Do you want to give a bit of thought to that and supply us for the record your thoughts?

Mr. SNELSON. Yes.

Senator CRANSTON. I should think that there would be some fairly substantial savings if they were coordinated in the same institution, and I wish you would think that through and give us your thoughts. What information is available on the profile of the typical amputee today?

Mr. SNELSON. We have conducted such a study at Rancho Los Amigos Hospital, and also one has been conducted at Wayne State, and the age is about 55 years, and the amputation as a result of diabetes or arteriosclerosis.

One thing that we did find in our center, of 131 diabetics referred for amputation, 36 of these people were treated in other manners and were not amputated.

Senator CRANSTON. Are there any estimates that you consider reliable regarding the number of amputees by sex and age?

Mr. SNELSON. About 90 percent, the best we can estimate, are in the older age group. There does not seem to be any difference between male and female. I think they are about 50-50.

Senator CRANSTON. What do you mean by older age group?
Mr. SNELSON. Persons 55 years and older.

Senator CRANSTON. I am impressed by your stress on the need for a family-oriented approach to an amputee's rehabilitation. Would you suggest a program comparable to the VA blind center program, where during the last week of a 13-week program for the blind patient's

rehabilitation the patient's family is brought to the center to be counseled and trained along with the patient?

Mr. SNELSON. Yes. As a matter of fact, a part of the amputee's rehabilitation could better be done if you had a motel-type arrangement across the street where the family could spend time with the patient, because it seems to be very important to the patient how the family is going to react when he has to go home.

We teach them many things, and they get home, and, for example, maybe they cannot get the prosthesis on correctly. This creates a small family crisis. If these people could come and live with the amputee in the last few weeks. I think it would be a terrific advantage.

Also it would be a lot cheaper, because you could keep a patient in a motel, and this would be much less expensive than a longer stay in the hospital.

Senator CRANSTON. Do you do that presently at Rancho?

Mr. SNELSON. No, we do not have the funds. We would like to do

that.

We also humanize the program because we are sensitive to treating people as a person.

The problems a patient relates to the professionals are not always the problems. The patient will learn very quickly in the hospital if he says he has a pain, the staff listens. If he says he is unhappy or he feels badly, nobody pays any attention to him.

Sometimes these problems are far greater than the physical prob

lems.

Senator CRANSTON. In your own set of priorities, what importance do you place on this matter of family care?

Mr. SNELSON. It would be very high, because in the last analysis the person who determines whether he has been successfully rehabilitated is the patient, and I would put family counseling and holding the family together as the main goal-if you can keep the family together over the crisis, it will probably stay together.

Senator CRANSTON. You feel it is well worth expending the sums that are necessary for this?

Mr. SNELSON. It certainly is.

Senator CRANSTON. What is the cost range involved in amputation and application of prosthesis for a single limb?

Mr. SNELSON. That will vary. Under ideal situations, a person who is amputated below the knee, if we have complete control and there are no other extenuating medical problems—I have had patients in the hospital have their legs amputated-we can fit a prosthesis on in the operating room, and we walk in the next day, and they are back to work in the next week.

In a situation like that, the cost could average around $120 a day. The prosthesis is a minor part of it, around $400.

But if you do not make things work, and the patient becomes indigent, then the costs run into the hundreds of thousands of dollars because they will live on welfare the rest of their lives.

We find once a patient gets on welfare, it is extremely difficult to get him to become self-supporting.

Senator CRANSTON. I thank you very much. Thank you again for coming so far and making a great sacrifice to be here.

(The prepared statement of Mr. Snelson follows:)