offered to different parts of your population is greater than what would be tolerated here. But a national health system that works here could not be made to work overnight in the U.S. You don't have such a homogeneous population as we do. We have no real unemployment. In the U.S., these people are going to draw heavily on your system. This will probably make the introduction of a general system very difficult at the start. I think you will have to move gradually."

Dr. Derek P. Stevenson, Secretary of the British Medical Association, has said, "If we were starting again, we probably would prefer to go bit by bit."

Clearly, there are pitfalls to be avoided, which will not be avoided if we go precipitantly into a national health scheme covering everyone, or even a large segment of the population, without further study and critical analysis. Let's not jump in before we know how deep the water is.

I've enjoyed the opportunity to testify before the Senate Health Subcommittee, and I appreciate the invitation. I hope that my remarks will be of some aid to the members in their deliberations. The St. Louis Medical Society will do anything it can to help increase the numbers of physicians and allied health personnel in this country. JOSEPH C. EDWARDS, M.D., President.

RESOLUTION ON PHYSICIAN'S ASSISTANT PROGRAMS

Whereas, There is a need for more physicians without a comparable increase in facilities for training physicians and insufficient medical school facilities, as well as qualified teachers for the near future, and

Whereas, Many physicians in private practice, especially those in group prac tice and many hospitals have to curtail some services to patients because of the lack of trained personnel, and

Whereas, There are programs to assist high school counselors to direct and encourage properly qualified students to enter the various paramedical careers, including medical and pharmacy schools, but few schools to train a Physician's Assistant, and

Whereas, Duke University Medical Center has an established training program for a Physician's Assistant to assist him in clinical and/or research endeavors; including learning to take patient histories, do physical examinations, start and regulate intravenous infusions, intubate the G.I. tract, do gastric lavages, biopsies, lumbar punctures, and other procedures classically performed by the doctor. He is trained to monitor vital signs, give medications, and keep progress records as formerly performed by nurses. He is also taught to operate certain diagnostic and therapeutic instruments, such as an E.C.G. machine, respirator, cardiac monitors and defibrillators, as well as to carry out extensive laboratory studies as commonly done by technicians. The program calls for intensive training in areas which would complement available health team talents without attempting to replace available talents.

They may enter Physician's Assistants two-year course after high school with certain biology and chemistry courses, or two years college preferably, work in research or diagnostic laboratories, renal centers, cardiac care units, hyperbaric chambers, or in a doctor's office or clinic of a group of doctors. Their clinical work will always be under the supervision of one or more physicians. One physician will be responsible for their work, and

Whereas, If such programs are to be regulated by the medical profession and the work of such graduates is to be controlled for the best interests of the patient, the physician and the graduate, there must be no graduates working except under direct supervision of a physician who is responsible for his work. There may be a national association of the Physician's Assistants but preferably under the guidance of the A.M.A. There should be no licensing of the Physician's Assistants or a certificate to practice anything as individual practitioners, therefore be it Resolved, That the House of Delegates of the Missouri State Medical Association go on record as favoring the training of Physician's Assistants in certain qualified medical centers under strict control of duly licensed physicians to work only as specified above, with limitations specified. JOSEPH C. EDWARDS, M.D., Chairman, Ad Hoc Committee MSMA, To Study a New Level of Medical Practitioner.

HOSPITAL ASSOCIATION AUTHORIZES ADDITION OF DIRECTOR OF PLANNING

DIRECTOR OF PLANNING TO BE ADDED TO HOSPITAL ASSOCIATION STAFF

The Board of Directors of the Hospital Association at a recent meeting authorized the addition of a Director of Planning to the Association's staff. He will serve as secretary to the Council on Planning and assist hospitals in the various areas of long-range planning and will offer guidance in dealing with governmental agencies at local, state and federal levels.

At the same meeting, the Board also voted to abandon the Association Cost Finding program and in its place, participate in the A.H.A. HAS program. It was pointed out that if the majority of hospitals participate in the activity through the Association, comparative cost data would be available to the Association and hospitals in the metropolitan area. Such data would compare costs here with hospitals in other major cities. Such information would be valuable to hospitals in the future in dealing with new developments such as prospective rate determination and the possibility of a community review board. It was agreed that the Association will pay the cost of participation by all member hospitals.

HOSPITAL ADMINISTRATORS, MEMBERS OF BOARDS OF TRUSTEES ALARMED AT PROPOSED CHANGES IN SOCIAL SECURITY LAW

A bill providing for major revisions in the Social Security Act, including Medicare and Medicaid programs, which is pending before the Senate Finance Committee has drawn strong criticism from St. Louis area hospital administrators and trustees. The bill, H.R. 17550, has already passed the House.

Administrators and trustees were urged to contact Missouri and Illinois Senators in opposition to the bill following analyses by the A.H.A. and the Association.

Some of the provisions of the bill, as passed by the House, could lead to arbitrary dictatorial actions by federal agencies involved in health care programs Some requirements, it is believed, would be serious intrusions into hospital management prerogatives guaranteed by the original Medicare law.

ADVANCES IN MEDICAL CARE COMPARED TO RISING HOSPITAL COSTS IS THEME OF ADDRESS TO ROTARIANS BY JOHN R. ECKRICH

"If a person would only listen to the critics of rising hospital costs, he would never hear that some of the great blessings of our century are the advances in hospital-medical care," John R. Eckrich told those attending a meeting of the Rotary Club of St. Louis held at the Gateway Hotel on August 6.

Mr. Eckrich, president of Lutheran Hospital and immediate past president of the Hospital Association, outlined the contemporary hospital situation comparing today's high level and quality of care to the past.

He pointed out, "In 1925, one out of every four surgical patients died. Today, this has dropped to less than one in one hundred and the extensiveness of surgical procedures has grown considerably. In 1937, only one out of every seven persons suffering from cancer could be saved. Today, it is one out of three. In 1900, a newborn baby, on the average, could be expected to live to age 48. By 1940, this had gone to 63, and today it is 70.5 years. Since 1945, deaths from all diseases are down 59% and some specific categories down 90%.

"The average American today spends almost one day for each year of his life in a general hospital. Just twenty years ago, one-third of the American babies were born at home. Today, more than 95% are born in the hospital with a healthier start in life," Mr. Eckrich said. "But this has not been accomplished without cost," Mr. Eckrich pointed out.

He asked the question, "What value does one put on a fluoroscopy radiographic room and its equipment? Ten years ago, this room could be fully equipped for $10,000. Five years ago it was still only $30,000. Today, the minimum cost would be $100 000.

Mr. Eckrich said that wages and fringe benefits amount to 60 to 70% of total hospital operating costs in contrast to industry where salaries are, generally, only 28% of costs.

"Hospitals sell service rather than products and as you all know, service usually comes high. Patients still like T.L.C. (Tender Loving Care) and this can only

be given by people who are serving other people,” Mr. Eckrich said. And with this, adequate medical and hospital care is increasingly viewed as an essential rather than a privilege.

He noted that, even though we are the world's leader in medicine, "we are the 21st in longevity and 16th in infant mortality." "Something is wrong," he said, "but correction can only increase demands on hospitals, health care personnel, and the health care delivery system."

[From St. Louis Medicine, 1970]

THE PRESIDENT'S PAGE*

(By Joseph C. Edwards, M.D., President)

Dear Members, some 170 million Americans receive fair-to-excellent medical care. To provide the other 30 or 40 million people with medical care equal to that of the 170 million would, by present standards, mean doubling the number of physicians. This is impossible in the next 25 or 30 years.

A crash program to train paramedical personnel as physicians' assistants and aides would help extend the ability of the physician supervisor to help more patients than he can now treat alone. It is undesirable to license non-medical personnel to make diagnoses and to treat people. They should have a certificate of competence to measure the training they have passed satisfactorily. This should not empower them to work alone-only under the supervision of a physician. They should be required to report any change in residence to the state or national employment agency empowered to issue the registration after examination of a properly executed certificate. The physician supervisor, as well as the assistant, must have integrity, as must anyone trusted with the health and personal problems of a patient.

The candidate for training in such a physicians'-assistants program must be carefully screened for character and integrity, as well as scholarship ability, just as medical students are screened, although the academic requirements need not be as high as for prospective medical students.

Registered nurses and former medical corpsmen from the armed services would be good candidates for physicians' helpers. In lieu of more physicians, such well trained, patient-service-oriented personnel, with tact and integrity, would allow the physician to spend more time on the more personal and complex parts of the examination and treatment of more patients than he can now attend by doing it all himself. The American Academy of Pediatrics has such a training program already.

The basic responsibility for the solution to these problems should be on the shoulders of practicing physicians, on an Advisory Committee with the medical schools and junior college and college administrators. These problems involve the entire community and the nation as well. Each community has a slightly different problem, just as medical care is different for large cities than for neighborhoods and smaller cities. There would also be a difference in the training of those to help in rural and small town areas from specialized hospital intensivecare units and outpatient clinics. Medical-legal-liability problems may arise, but solutions must be found here too.

All of us must contribute our ideas to this and other problems. We welcome your ideas. Please send them to us. Would you, as an individual physician, or in a group in the hospital, welcome such an assistant at a salary to eventually be $1,000 a month, as today's values go?

Dear Members, Secretary of HEW, Robert H. Finch announced that the Government intends to use its $14 billion expenditure for Medicare and Medicaid to reshape the nation's health care delivery system. This of course would require Congressional action. The part that concerns us most as physicians is a new proposal with built-in incentives for practitioners to align themselves in group practice. The new program would guarantee the elderly under Medicare and eventually the poor under Medicaid, additional preventive health services at a contract rate to be negotiated by the Government, probably at a lower level than at present Medicare expenditures.

The following are excerpts from selected issues of St. Louis Medicine.

Mr. Finch hopes that such organizations as medical societies, hospitals, medical schools and physician groups would be eligible to offer such contract services. It is being labeled as a "preventacare" program for Medicare beneficiaries.

In addition to this, in order to stem rising health care costs, legislation has been proposed to replace cost-plus payments to hospitals with payments negotiated in advance. Control of reimbursement of physicians' fees has been proposed as an amendment as well as other experiments in new methods in health financing.

On the subject of doctors' fees, Secretary Finch repeated his formal proposal that Medicare's recognition of fee increases "be limited so that such increases do not occur at a rate greater than for prices generally." We have no assurance that the future fee increases under Medicare would move upward in proportion to the relevant increases in appropriate wage and price indices, although that has been stated by Mr. Finch.

It sounds to some like heresy to even propose that a group such as a medical society could offer its members some type of group incorporation so that they would be in a position to offer such services to any groups desiring them or any insurance company wishing to underwrite certain services at a certain fee schedule to be arrived at by the various specialty societies composing the medical society group and to be tied in to an automatic cost-of-living increase and subject to review at intervals, say, annually. In addition to preventing any inequities, as far as fees are concerned, the doctor would not be locked into a program for several years without any increases or finding that it cost more to provide those services than originally had been estimated. He would then reconsider and renegotiate at certain intervals. It might be well for some planning to be done in this regard; if we can still maintain the fee for service in principle, then we would not need it. If we don't and we aren't successful in this, despite all efforts, then we would not be caught with having to accept something that the authorities insisted we take all along without proper regard for the proper reimbursement of our services.

I would commend to you the AMA Newsletter from the Council on Legislative Activities, 535 North Dearborn Street, Chicago, Illinois, 60610, which is a weekly report on the national medical legislation, "Legislative Round-up" in brief, which is only 2 to 4 pages, in the April 24 letter there are listed over 21 bills dealing with medical affairs, with just a sentence or two explaining the intent of the bill and its status in Congress. All physicians interested in what is happening on the Federal scene would do well to subscribe to this by writing to the AMA to get on the list and each member can then write their Congressman concerning these bills because the bills are listed on two pages by their members.

RECENT CHANGES IN MEDICARE APPROVED BY THE HOUSE WAYS AND MEANS COMMITTEE Dear Members, Limits on "reasonable costs" of the providers of medical care under the Medicare Act based on comparisons of costs of covered services by various classes of providers in the same geographical area would be set by the authority to be given to the Secretary of HEW.

Payment for services to hospital patients by teaching physicians would be authorized to hospitals where medical school staffs now furnish them without charge to the hospital.

HOSPITAL COSTS

Each state would be permitted to pay hospitals on the basis of their own determination or reasonable costs, provided there is assurance that the Medicare program would pay the actual cost of coverage of hospitalization of Medicare patients.

EXPENDITURES

The Secretary of HEW would establish specific periods of time by medical conditions for which the patient would be allowed to stay in a hospital for treatment and then be presumed to require an extended care level of service in an extended care facility. This then removes a medical decision out of the hands of the patient's physician and gives the authority to a bureaucrat in the office of the Secretary of HEW!

Write your Congressman and especially those on the House Ways and Means Committee-every patient with a myocardial infarction or with a certain frac

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ture or stroke would be presumed to require a certain number of days to be set arbitrarily by someone other than the patient's physician.

If they would say as an insurance policy, only "X" number of days is provided for anyone in such an extended care facility, then everyone will have to pay for any care beyond their limit, it would be more logical. To say that a government program financed by taxpayers will leave medical decisions as to length of stay required for the proper treatment of the patient in the hands of a disinterested layman in a district office in Washington is absurd.

UTILIZATION REVIEW

The new changes approved by the House Ways and Means Committee require hospitals and skilled nursing homes participating in Medicare and Maternal and Child Health programs to have the same utilization review committee with the same function as in the medicare program. Thus everyone in the health and hospital administration is paid for their time on such committees with the physician, without whose professional knowledge and experience the committee could not function properly, who is not paid. With several hours a week being demanded for physicians to serve at each hospital, and more and more being required, some compensation for him, a donation to a charity fund or medical society fund should be made.

Also program review teams would be established to furnish the Secretary of HEW professional advice in carrying out this authority to terminate or suspend payments to providers who advise the Medicare program.

Dear Members, it is becoming increasingly apparent that the medical profes sion must devote some of its time to utilization review. Where the individual hospital committees do not do a good job or do not function, third-party intermediaries question more and more of the patient's stay in the hospital. At present, there is no mechanism for reversing the decisions of the intermediaries' clerks or committees, even though the hospital committee does a good job and feels, after careful perusal of the facts, that the recent stay was justified in a particular instance. The action of the lay clerks on the insurance committees of the intermediaries apparently is final. These duties often are relegated to clerks by the third-party payers, because M.D.'s or R.N.'s usually are not available for such work.

There should be redress for physicians under Public Law 89-97 (Medical Law), Section 1801:

"Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided or over selection, tenure or compensation of any officer or employee of any institution, agency or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency or person."

The intermediary for Medicare, however, has authority by law to refuse payment in cases in which it feels that the medical record does not substantiate a need for admission or for further hospital stay.

If the hospital utilization-review committees function properly, there should be no occasion for third-party reviewers to deny claims on the grounds that the services rendered are unjustified. It is up to staff physicians to complete satisfactory histories or physical examinations, or to see that they are completed, with adequate progress notes, daily or every other day, and with orders in the chart for treatment, to demonstrate to third-party reviewers that the hospital stay was justified and medically necessary.

If an occasional hospital utilization-review committee does not do its job adequately, the hospital's staff organization should see that this is done, in order to protect both the patient and the physician. Then the Medical Society can lend its support to see that justice is done, obviating the need for decisions by lay personnel working for third-party carriers.

The voluntary, rotating form of committee requires that practicing physicians donate their time every few years to pass on such matters as these, with the aid of the paid hospital clerical staff. This is an added burden on the physician's time, which he can ill afford. Some physicians would like to eliminate the utilization-review chore entirely as a staff function. But clearly, the system would not operate to the patients' or the doctors' best advantage if we did. With the insurance laws and practices as they are and with the scarcity of hospital beds, it is