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Mr. JENSEN. Precisely. The senior citizens are forced to travel to Albuquerque, 60 miles away, and they incur those expenses of travel, but they do get their care there, because we cannot support it at the clinic.

If we could support it at the clinic, the clinic would break even, and health care would be accessible to these elderly people, so we think it would be a distinctly viable health resource.

Senator DOMENICI. Is it not true that in the normal operation of the center many of the services that you are performing in one of your satellite clinics are indeed performed within a more typical institution of medical delivery-the doctor's office, the clinic, or the hospital--and in fact, Medicare pays for a portion of that?

Mr. JENSEN. Right.

Senator DOMENICI. Medicare will not reimburse any services at your clinic?

Mr. JENSEN. That is correct, unless the doctor is onsite, and has actually rendered services to the patient. Medicare will not pay for any physician replacement activities, which is essentially what a nurse practitioner or a physician assistant is doing.

USE OF QUALIFIED PRACTITIONERS

They are doing this midlevel sort of thing that can be done by less than a physician, but still a highly qualified practitioner.

Senator DOMENICI. I would like to know-and perhaps you can review it in your spare time-how you feel about a bill introduced by Senator Church, the chairman of the Special Committee on Aging, that would encourage greater use of nurse practitioners. It is our understanding that it deals only with nursing homes, and certainly. you are not objecting to that; your testimony has to do with the method_differently, completely different in use.

Mr. JENSEN. We would certainly encourage that particular bill, but would like to see people move beyond that bill, and we recognize that midlevel practitioners should be reimbursed, if they are appropriately supervised, and not just in specific instances, but across the board. Senator DOMENICI. We thank you very much.

Mr. JENSEN. Thank you, Mr. Chairman.

Senator DOMENICI. Our next witness is Mr. Lester Rigby, director, Area Agency on Aging, Socorro.

Let me share with you a few thoughts, because it is relevant in much of the testimony.

The White House Conference on Aging, which many of you are aware of, certainly from the standpoint of ideas, indicated that it was desirable for this country to move to alternatives to the present institutions in terms of delivery of health care for senior citizens.

Much of the testimony today goes to that, but it is our observation on that very few objective improvements in changes go toward the kinds of things we have heard about this morning, away from typical institutional approaches. It is nowhere closer to reality today than it was when the 1971 White House Conference on Aging concluded.

Mr. Rigby comes from Socorro, which I assume most of us would call rural New Mexico, in the sense of distinguishing it from a metropolitan area like Albuquerque.

For those who have expressed concern to me privately today that we ought to zero in on rural health problems, I want you to know even if we cannot bring the formal hearing committee process to rural problems this year, I will attempt to have some informal hearings that will zero in on health delivery problems in rural New Mexico.

We will build it into our own itinerary between now and December, so we will have a chance to focus in on a couple of communities for a few hours on differences between metropolitan problems and rural problems. I think Mr. Rigby will speak to that, at least to some extent today, in his capacity as director of the Area Agency on Aging in Socorro.

Will you please proceed, sir.

STATEMENT OF LESTER RIGBY, DIRECTOR, AREA AGENCY ON AGING, SOCORRO, N. MEX.

Mr. RIGBY. Thank you very much, Senator, members of the Senate staff, and the people who are interested in the elderly. I am very glad to be here from the rural area, and it is certainly that. We have 10,900 people in 6,600 square miles, and that would indicate that we are rural residents. I also have two other counties, and one of them is even more rural, and that is Sierra County, and the other is a little more populated, which includes Dona Ana, the center being Las Cruces.

The elderly in the rural areas have the same problems as the elderly in urban areas. However, the rural dwellers problems are compounded by distance, disinterest, and monetary delimitations. They are not discriminated against because of race, creed, or ethnic background, but rather because of geography.

One of the most difficult problems in rural areas stems from the lack of advocacy. The provincial sociology is not only prevalent among the elderly, but it touches all of the rural institutions-the municipal and/or political management find money hard to come by, and much harder to get back into circulation, particularly to alleviate human distress. The levels of education, and lack of affluence fail to produce sustained leadership, and the rural elderly are more resistant to social services than those in urban areas. The vigor of the young is prominently missing because they leave the occupations of the soil for more promising opportunities.

CRITICAL NEED FOR DOCTORS

The critical need for doctors is prevalent throughout the rural area of this State. In a particular case of which I am aware, a scattered population of 2,800 is in dire need of a doctor. There is not a practicing physician or any medical facility extending from the city of Socorro to Springerville, Ariz.-a distance of 157 miles.

In an attempt to get a physician through the offices of the National Medical Service the hope of these people was thwarted by the failure of the area medical association to give its approval of the application. It is difficult for these people to understand why the decisions of the National Medical Service, in making awards, must depend upon the

whims of a professional association, which if it were truly professional, should be spearheading the search for qualified doctors for these rural areas instead of autocratically shutting the door to professional medical progress and support. This smacks of blackballing, which is an undesirable practice in private organizations, but must not be tolerated when it interferes with the public's interest.

Those elderly in rural areas and indeed in rural cities, must pay on the nose for the purchase of drugs. I mention elderly specifically because they have more health problems. Independent drugstores in rural areas charge from 50 to 300 percent more for drugs and medical supplies than the cutrate urban market. This highlights the fact that indigence and high cost have an unholy alliance. In an instance when I personally took the prescriptions of an elderly lady to a drugstore and was astounded at the cost, she merely acknowledged it by saying "them what has, gets." This old saw may not be dignified by good grammar, but one does not have to have a doctorate in economics to recognize the truism.

Transportation is a tremendous problem. Not only are there no public buses, no cabs, but the rural poor and the rural elderly usually own the least reliable private transportation. In cases of emergency, where each minute is important and the nearest doctor or hospital is from 25 to 80 miles distant, you have little difficulty in considering the probabilities.

The matter of long-term care is indeed a tragic matter. Those elderly who are no longer able to care for themselves, who are not acutely ill, but have reached the inevitable period of senility must be admitted to nursing homes. But the nursing homes are not located in rural areas. Those final helpless years must be spent isolated from family and friends.

All the money spent on programs for the aging-to induce the elderly to stay in the mainstream of life is thrown to the winds at this critical time in their lives. Too old to walk straight, too old to see the small print, too old to wash one's hair, they also become too old to enjoy the warmth of family and old friends. It makes one wonder about the loss of the three generation family, and the regression to our present status. They become displaced persons in a land of plenty. The social agencies dealing in health, aging, and welfare, or at least the workers in these agencies know that.

The per capita costs for service in the rural areas are greater than that in the urban areas. Thus the cost of outreach to the rural areas receive only the amount that's left over, which does not begin to meet the needs. Funded programs do not have the elasticity to provide help

in these remote areas.

Private resources in the rural areas are a great deal less than in urban areas. The smallness of religious groups, the absence of service clubs, the loss of protective members of the family group, and the insensitivity of the metropolitan areas, where the largess exists who fail to play a role or accept responsibility for adjacent rural areas are all contributing factors.

To finalize, the concept may be that the rural elderly have a row of corn, a row of chili, à patch of potatoes, a big fat hen, a bottle of

liniment, a bag of asafetida, a wood-burning stove, and a roof over their heads to fall back on, and their human sufferings are out of sight. While this may sound like Charles Dickens in the early 19th century, one may find, in some instances, that is not an overdramatization of how things are today-in the boondocks.

Senator DOMENICI. Thank you very much. Let me say that I am impressed with your observation about the lack of advocacy. I might say, however, you attribute the fact that one need not be a longtime resident of rural New Mexico to become an advocate for their needs. Some of you do not know that he is a transplant in New Mexico, and he did not come from rural anywhere. He came from New Jersey, in fact, he was the county commissioner, not somebody that worked out in the county. He was the mayor of a city. If we could find more advocates that so often are ranks, that do not have to have lived it, but understand it, perhaps the advocacy of rural health care would get a great boost. We greatly appreciate your observations. I do not think it is Dickens. I think it is for real.

MATCHING REQUIREMENTS

I want to ask you one question dealing with the Older Americans Act, as it deals with rural areas. Is there a difficulty in meeting the matching requirements of 75/25 for community services for nutrition? Mr. RIGBY. Well, normally we can meet in-kind contributions until we reach 25. After 25, it becomes an extremely difficult problem.

Senator DOMENICI. So you meet it with service and the like? It would be almost impossible if it were truly dollar for dollar?

Mr. RIGBY. It just is not there, not dollar for dollar. In-kind, it is, Senator DOMENICI. Do you feel, as I understand your description of so-called established ways of funding the needs of society, that the county commissions, mayors, and their functions are finding it very difficult to bridge the transition from the more established roles to the role that requires that they be involved in the kind of program you are discussing? Is that correct?

Mr. RIGBY. That is correct. It takes a great deal of selling actually from outside social groups.

Senator DOMENICI. We thank you very much and appreciate your coming here.

Mr. RIGBY. Thank you for the very nice compliment.

Senator DOMENICI. I want to comment on that part of the discussion, Mr. Rigby, that has to do with drugs and rural America. I hope you understand there are an awful lot of people concerned, and that there is an effort to try to solve this problem.

There are a number of bills in the Congress, and a number of actions to try to zero in on how to get doctors or adequate professional medical people into rural America.

Nobody has solved the problem yet. We will take the one observation you have about who ought to certify what into consideration. We were unaware that we had that kind of problem existing, but if there are any suggestions as to how we can better encourage doctors, through legislation or otherwise, we would greatly appreciate it.

It is a very longstanding and difficult problem. We are nearing the end of the hearing, and I want to remind you that if you want a

copy of this transcript, which the Special Committee on Aging will make available to those who attend these hearings, you will have to leave your name and address at the door.

There is no other way we have of getting it to you. If you leave your name and address you will in due time receive a copy from the committee for your own use, or use in your activities, and you pursue it because we are discussing what is imperative to you here today.

Our next witness is Dr. Eric Best, president, Albuquerque-Bernalillo County Medical Society, Albuquerque. Is Dr. Best here?

Doctor, we appreciate your taking the time out to come here, and I know that we could spend a lot of time talking together, and asking questions of you.

We do not have the time, but I know of your willingness to discuss the problems so we would appreciate it if you would make your statement within the time allotted.

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STATEMENT OF ERIC BEST, M.D., PRESIDENT, ALBUQUERQUEBERNALILLO COUNTY MEDICAL SOCIETY, ALBUQUERQUE, N. MEX.

Dr. BEST. I would like to thank the committee to allow me to appear. Before I go into my formal statement, I should comment on Mr. Rigby's comment about the medical societies, the figures in rural communities.

The medical societies per se have nothing to do with the physician's practice. In fact, you need not be a member of the medical society to practice in New Mexico. One needs to meet the licensing requirements of the State to be able to practice in the city of your choice. The State medical society has recognized the needs of rural medicine, and we have this year formed a committee on rural health and also a committee on aging, and we hope we will be able to work with your committee, in formulating certain policies.

I have only a few general comments to make, and I would like to start by saying that the World Health Organization defined health as a state of complete physical, mental, and social well-being, and not merely the lack of disease and infirmity.

The significant health problems of the aged is the ability to adapt to the problems of chronic illness. Approximately 25 percent of the elderly have major problems of adaptability, because of a problem in chronic illness. Medical care to date has been directed at handling a few problems primarily, and not at the chronic problems that many of the elderly have a burden with.

I think we need to formulate a system of support which is different than what we are routinely concerned with. I think the elderly by and large need to have programs directed at personal care, which would include hygiene, personal hygiene, grooming, dressing, and so forth. They also need supportive medical care, they need extension of the physician in areas that have been mentioned by many here today, in the form of practitioners, social workers, outreach workers, and so on.

This we need to be involved in, and certainly I think your committee, and the Government, has taken steps in this direction. I think more needs to be done.

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