In a large group practice, such as with which I am associated, we have for years had to retread the physicians from disease-oriented to patient-oriented ones, and it takes a varying length of time, according to the capabilities of the doctor himself. Sometimes within a year he is well oriented to patients and patients' families and their needs. I remember many years ago, as a young house officer out in the University of Washington, where for the first time in our large city hospitals we innovated the idea that the fellow coming in as an intern, if he continues his stay at that institution, would have the same medical clinic during all the whole time he was there, trying to bring the concept of patient-oriented care and family-oriented care, and you know the most amazing thing that happened at that time was physicians said the patients would learn to depend upon us. Of course, this is what we really want to have happen, to have the patients to depend upon the health care given with the doctor at the top of this team effort.

Let me say in regards to trying to gain more family physicians, I think a very important advance has occurred in the last 2 to 3 years with the development of the general practice residency of family practice, which I think has elevated the generalist, and, I hope, induces more young physicians to go into this area. Internists and pediatricians as primary physicians are also moving in this area. In the Board of Internal Medicine, there are two methods of procedure. One can do an internship year and 2 years of straight medical residency and come out as a diagnostician and family physician. If one desires to go on for more specialty work, then he can do this and come out as both a regular internist as well as a so-called subspecialist.

There is also a combination board at the present time between the internists and the pediatricians which gives the physician a scope of being able to take care of the man from the cradle to the grave. We think, again, this is mirroring what we really want in America, and that is more physicians who will take care of the primary health needs of the Americans.

Lastly, I would like to say that being from out of the Kansas City area, in Springfield, being in a nonmedical center town so far as a university medical center is concerned, that we are looking with interest to the Kansas City Medical Center, University of Missouri-Kansas City, because of the fact that we think eventually this medical center complex with its teaching may evolve into areas like our area.

Springfield has 1,500 beds in town. It is a large area that has a lot of referral practice. We think the model that is established here may well be the model that will be done with our area in 5 to 10 years, and we are looking with real interest in this area.

Let me say one other thing. I don't think all the hospital buildings have been lost, and I will cite one final thing, and that is that in some of the larger towns in the Ozark hills the funding of hospitals has really been a stimulus toward gaining good medical care.

Let me cite Lebanon, for example, where because of a fine hospital facility the generalists now numbering eight in number have gotten together as a group practice. They have availed themselves of a general surgeon and of a general internal medicine specialist, and in the aggregate provide complete medical care for that town. They man the hospital emergency room 24 hours a day on a rotation basis, and I would dare say for the first time in my knowledge of that town they are

rendering what I consider first-class care, patient oriented, and around the clock.

Thank you.

Senator EAGLETON. Thank you, doctor.

I don't want to be misconstrued. I don't think Hill-Burton was a total waste. I think on an occasion or two, in an instance or two, it went a little far.

Dr. MAPLE. Yes.

Senator EAGLETON. Say hello to Dr. Lurie for me, too.

Dr. MAPLE. Yes, I will.

Dr. BERRY. Senator Eagleton, I have only a few things to say, and I want to say this at first, though, that the dean of the developing medical school in his wisdom has assigned me a very narrow and small subject to talk about. I think this bodes good for the medical school, and he has this judgment about his personnel already.

I was assigned the subject of continuing education in the role of the medical school here and continuing education of the health professionals, of course, is something that is most desirable and it upgrades the care of people.

One of the things we are going to continually educate physicians and health workers is in their application of their profession more appropriately to the needs of the community. I think this is very adequately being discussed by those who have talked before me.

Senator EAGLETON. Do you have some ideas on how we might recapture some of those 12,000 nurses?

of

Dr. BERRY. I have some very good ideas about that, and I will echo what has been said. One of the things is, if we could take this corps nurses and make them physicians' assistants, we have already a builtin professionalism that we can't duplicate in any other way, if we can train them as physician assistants, and I have trained two now in about 6 months each to do things that are very appropriate. Senator EAGLETON. What is your specialty, doctor?

Dr. BERRY. Internal medicine.

Dr. MAPLE. We are cohorts.

Dr. BERRY. But don't worry about that.

I think if we then could get them into an economic bracket where it would be advantageous, say in an area where they get enough money that they could not afford not to act as health professionals, I think this would be one good way to do it. I believe most of these people, this will be the one lever which will get more of them in than any one thing. I really do.

We have some innovations, and we have discussed these. One of the innovations we have is an area-wide community residency. I have been assigned the job of doing this through the medical school at my usual fee. I have been very delighted at the response of the area hospitals in that everybody supports this effort 100 percent. We have this not just in the planning stage, but we have it in the developing stage, and it is already on its way. We are going to start recruiting this month.

I would like to say for the group here that we think, and I am sure that your coming here with your investigation and with this group has added a good bit to our knowledge of what is going on nationally, and I am sure that it has helped us immeasurably for you just to be here, Senator.

Senator EAGLETON. Thank you, doctor.

My thanks to all four of you gentlemen, all of you, and particularly the doctor who came from Springfield, and all of you in giving of your time and interest. I know you have made a significant contribution not only to these hearings but also to the development of the new medical center.

Ladies and gentlemen, with your indulgence we will take perhaps a 10- or 12-minute break and reconvene, according to that clock, at 1:20. (Whereupon, the subcommittee recessed at 1:05 p.m. to reconvene at 1:20 p.m.)

AFTERNOON SESSION

Senator EAGLETON. We will go back into session now, if we may, and hear from a group who address themselves to community support and interest:

Dr. Samuel U. Rogers, director, Wayne Miner Neighborhood Health Center; Mrs. Pauline Smith, president of the advisory board, Wayne Miner Neighborhood Health Center; and James I. Threatt, director, model cities program, Kansas City, Mo.

You may start, Mr. Threatt.

STATEMENTS OF SAMUEL U. RODGERS, M.D., DIRECTOR, WAYNE MINER NEIGHBORHOOD HEALTH CENTER; MRS. PAULINE SMITH, PRESIDENT OF THE ADVISORY BOARD, WAYNE MINER NEIGHBORHOOD HEALTH CENTER; AND JAMES I. THREATT, DIRECTOR, MODEL CITIES PROGRAM, KANSAS CITY, MO.

Mr. THREATT. First I would like to read just a brief statement. The Kanass City, Mo., model cities program has identified many of the health problems in the model neighborhood: high infant mortality, high rates of communicable and chronic disease, high incidence of mental disease, environmental health hazards, and others. These are not unusual problems. All urban areas suffer the same hardships.

Some of the causes of these problems are well known: insufficient health manpower and facilities, a fragmented and uncoordinated medical care system, lack of an adequate financing mechanism, practically nonexistent national health policies, and inadequate public health education.

The problems and their causes and some workable solutions have been known for some time. It is part of model cities' role as a demonstration agency to show how some of these solutions might be applied. With this in mind, the following programs have been initiated:

One, a comprehensive health center will provide complete physician services, dental care, social services, public health nursing, home health aids, child care, and transportation services for all modelneighborhood residents. The center will employ 102 people with many trainee-level positions. The center will be coordinated with the Wayne Miner Health Center, General Hospital, and the new medical school. Seven model neighborhood residents serve on the health center's board of directors with an additional seven members representing various health agencies.

The health center is a multipurpose group practice-an arrangement which has proved to be most beneficial to the patient. True compre

hensive care is demonstrated by providing services which make medical care more accessible and acceptable to the patient.

Second is a health insurance program. This is a pilot project to determine the procedures necessary for setting up a health insurance program for all Model Neighborhood residents. Two thousand patients were selected at random from those Wayne Miner Health Center patients who have no other insurance, such as medicare or medicaid, to pay their bills when they require hospitalization. Blue Cross and Blue Shield, Wayne Miner Health Center, the city health department, and model cities are cooperating to implement this project. There are no deductible or coinsurance provisions.

The insurance program went into operation July 1, 1970. If the plan for year two is approved by HUD, the number of persons covered will be increased to about 5,000 persons.

Model cities is providing more hospital facilities through two projects, Martin Luther King Hospital and General Hospital Expansion. Third, model cities is contributing $1 million to help build the new Dr. Martin Luther King, Jr., Memorial Hospital. Minority labor will be used in the construction of this hospital. In addition, the hospital will provide training for model neighborhood residents in health career jobs, maintain a 24-hour emergency service, and reserve 5 percent of its beds for medically indigent patients.

Fourth, the General Hospital outpatient clinic expansion.

The addition of two clinic floors to the existing three-story diag nostic and treatment center at Kansas City General Hospital will provide space to expand outpatient service for the medically indigent. This additional space will make it possible to provide general medicine, medical specialty, and surgical subspecialty outpatient backup to the Wayne Miner and Model Cities Health Centers. In addition, the outpatient department will participate in the medical school's docent program.

While attempting to meet the needs in community mental health and environmental health, we are making career opportunities available to model neighborhood residents. For example, seven community residents were hired and trained as mental health aides by the Western Missouri Mental Health Center. These residents will work with other mental health workers, the Wayne Miner Health Center staff, and the Model Cities Health Center personnel in helping residents with emotional problems.

Fifth, the housing code inspectors.

Model neighborhood residents have been hired as housing code inspector trainees. The trainees will be trained by the city health department to become housing inspectors and will be assigned to the model neighborhood. These trainees will not only inspect homes but will also help residents secure low-cost loans and grants for home improvements.

Special effort is being made to fill the health-manpower gap by training model neighborhood residents. The University of Missouri at Kansas City-Metropolitan Junior College Career Development Training Consortium, funded by model cities, will work closely with the medical school and the neighborhood health centers to develop long-range career development programs for model cities residents. These residents typically will have no previous experience in health

care or will be locked into positions with no opportunities for advancement. Initial training will focus on such positions as pharmacist assistant, medical assistant, laboratory assistant, X-ray assistant, medical records transcriber, and home health aide. The program will utilize full-pay released time to enable trainees to take additional course work at Metropolitan Junior College or the University of Missouri at Kansas City. This training will lead to certification, an A.A. degree, B.A. degree, or higher for those who wish to continue in various health fields.

Model cities is working with Kansas City's health agencies and the planners of the new medical school to mold a unified approach to health care for all citizens. All residents should be able to share in a single health delivery system which provides comprehensive care without regard to personal financial status. With more efficient utilization of our manpower facilities, and financial resources and the establishment of national health goals, the isolated subsystems of care for the poor, now so prevalent, will become a thing of the past.

That is the statement I have to make.

Senator EAGLETON. Thank you very much.

(The prepared statement of Mr. Threatt follows:)

PREPARED STATEMENT OF JAMES I. THREATT, DIRECTOR, MODEL CITIES PROGRAM, KANSAS CITY, Mo.

The Kansas City, Missouri, Model Cities Program has identified many of the health problems in the Model Neighborhood: high infant mortality, high rates of communicable and chronic disease, high incidence of mental disease, environmental health hazards, and others. These are not unusual problems. All urban areas suffer the same hardships.

Some of the causes of these problems are well known: insufficient health manpower and facilities, a fragmented and uncoordinated medical care system, lack of an adequate financing mechanism, practically nonexistent national health policies, and inadequate public health education.

The problems and their causes and some workable solutions have been known for some time. It is part of Model Cities role as a demostration agency to show how some of these solutions might be applied. With this in mind, the following programs have been initiated.

The comprehensive health center will provide complete physician services, dental care, social services, public health nursing, home health aides, child care, and transportation services for all Model Neighborhood residents. The center will employ 102 people with many trainee level positions. The center will be coordinated with the Wayne Miner Health Center, General Hospital, and the new medical school. Seven Model Neighborhood residents serve on the Health Center's Board of Directors with an additional seven members representing various health agencies.

The health center is a multipurpose group practice-an arrangement which has proved to be most beneficial to the patient. True comprehensive care is demonstrated by providing services which make medical care more accessible and acceptable to the patient.

This is a pilot project to determine the procedures necessary for setting up a health insurance program for all Model Neighborhood residents. Two thousand patients were selected at random from those Wayne Miner Health Center patients who have no other insurance, such as Medicare or Medicaid, to pay their bills when they require hospitalization. Blue Cross and Blue Shield, Wayne Miner Health Center, the City Health Department, and Model Cities are cooperating to implement this project. There are no deductible or co-insurance provisions. The insurance program went into operation July 1, 1970. If the plan for Year Two is approved by HUD, the number of persons covered will be increased to about 5,000 persons.

Model Cities is providing more hospital facilities through two projectsMartin Luther King Hospital and General Hospital Expansion.