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were admitted to public assistance, they were called in and given a complete medical workup. They were seen in the outpatient department. They were followed on the wards. They were seen in nursing homes, and they were part of the regular home-care continuation program. In other words, they were given comprehensive, professionally competent fourth-stage medicine. We couldn't force them to come in, but between one-half and two-thirds did. Why the others did nt come in is another problem for later attention.

During the operation of the project, Cornell, for the first time, had to have signs printed in Spanish placed in the waiting room. This was a new population entering the institution and presenting new kinds of needs. Physicians at Cornell were now able to study health needs that existed in their area. Also, from the data on use, the people in this area rarely use home care services. They prefer to go to the clinic with their families to see the physician who is following them on a continuation basis. A study is also being made of the costs of the project.

A similar, but less costly, program was undertaken at St. Vincent's Hospital in New York City. This institution was given a small grant, and its staff approached the feedback and adaptation mechanism a little differently from Cornell's. They started with selected patients in the outpatient department. For some persons they had records, for some they did not. But they put the pieces together from the hospital records and manufactured a family record. Then they invited other family members to come for a medical examination, and thus they created a special family clinic. The program has had an enormous effect on outpatient care at St. Vincent's, and the staff has seen the value of such a program.

One institution is studying emergency room admissions to see to what degree these patients can be placed in a medical care system, doing more with them than merely pushing them through the revolving door and getting them out. This institution is also working with the health department on a number of joint clinics.

Another institution has investigated the prevalence of neuromuscular disorders in an area of New York City to determine what could be done to rehabilitate persons with these disorders. It is also studying whether rehabilitation services for stroke patients early in the course of the disease can prevent the disease from getting worse in terms of the rehabilitation potential.

One hospital opened a small branch clinic in a housing project having 1,500 elderly, medically indigent residents. Two internists who staff this clinic are able to prevent the need for 90 percent of the patients to attend the hospital clinic 4 miles away. This plan offers an enormously greater opportunity to reach aged patients, and it is bringing service to the patient in a most effective way.

A voluntary hospital in New York City is teaming up in a comprehensive program with a city hospital and the departments of health, mental health, and welfare. The director of the hospital is responsible for all of the health, hospital care, welfare medical care, and mental health care for more than 150,000 persons in Lower Manhattan. The attending staff of private physicians are caring for the patients who can afford private care, and the clinics are treating patients who are medically indigent. One of the first things the director found necessary was a number of satellite clinics. Although the number of outpatients tripled within 112 years, the project still is not reaching enough of the 150,000 people, and the director plans to open branch clinics.

One of the interesting byproducts of the projects in New York City is the development of positions in hospitals for experts in community care, and a large number of hospitals are now doing this. This is of particular interest because in this way the hospitals can recognize their responsibility for the unmet health needs of the community.

Finally, a word about categorical versus general approaches. In the past we have taken the viewpoint of an agency, a facility, or a profession. What we have to do is look from the patient's standpoint. The person who can teach an 11-year-old not to smoke is much more effective in the control of lung cancer than the chest surgeon. I think we are going to live with categorical specialists and categorical approaches for a long time. I think this is good and it is necessary, because we certainly want to know more and more. But on the other hand, at the point where the service reaches the patient, let us learn how to develop the ingenuity to integrate and coordinate our efforts around him.

APPENDIX 2

LETTERS AND STATEMENTS FROM INDIVIDUALS AND ORGANIZATIONS

WORCESTER, Mass., June 18, 1967. DEAR SENATOR SMATHERS: Thank you for inviting me to share my experience in the study of "the organization of health services today, and to determine whether our methods of delivering such services are raising costs to the elderly, or depriving them of even the opportunity to receive such services."

Primarily my statement is the result of personal experiences in the private practice of medicine. My observations are also derived as a member of a community hospital with teaching services for house officers, residency programs and a nursing school. At a community level I have also been Chairman of the Committee On Aging, Community Services of Greater Worcester, Inc., which participated in the seven (7) cities Ford Foundation Project on Aging.

I am the Founding President of the Age Center of Worcester Area, Inc. This is a central non-profit agency devoted to development, implementing, and giving services to the Older American in the areas of information and referral, craft shop outlet for people to sell their creations, and a senior service volunteer corps.

For the past three years the Age Center has carried on a Nursing Home project with the aid of a U.S. Public Health grant. As Project Director of this project, we have attempted to study the effect of special consultative services in nursing homes.

I am also a member of the Subcommittee On Aging of the Massachusetts Medical Society.

The Worcester area has over 30,000 men and women 65 years old and over. This is over 10% of the total local population in the Worcester area.

I must again emphasize that my statement is entirely personal and specifically that derived from the local situation.

It is nearly a year since Medicare was launched, but the anticipated rush of patients never occurred. As the President of the American Medical Association has recently stated in effect, that doctors in hospitals are finding it less difficult to live with Medicare than they expected.

The question of our "rising medical costs causing special difficulties for the elderly" as far as I can determine, they are not. The only area that costs may cause difficulty are in the matter of drugs. For the most part, though individual drugs may be high and require purchase by the Medicare patient, this is not a severe obstacle. A Medicare patient requiring drugs which he is unable to pay for can receive them as the result of special plans developed by Roche & Co. a pharmaceutical manufacturer, as well as others, or with the help of the Medical Assistance Plan which is still in effect.

Medicare does not cover glasses for reading.

There may be difficulties in Medicare in the areas which it does not cover such as dentistry, hearing aids, cost of a wheel chair, or protheses. Medicare does pay for drugs that have to be injected.

Thus far I have noted very few Medicare patients who have been unable to afford the system of the "deductibles". This might possibly cause a special difficulty for the elderly, but in the Commonwealth of Massachusetts with its organization of MAA, Blue Cross-Blue Shield Medex I-II-III, assignment of fees by the physician to the State Street Trust Co. as a result of plan of the Massachusetts Medical Society, as well as private carriers, this difficulty has been fairly overcome.

The second question, "Do many of the elderly face insuperable obstacles in obtaining needed health services ?" There are no insuperable obstacles in obtaining needed health services if the community is sensitive to the elderly in their midst, and has attempted to organize its social and medical agencies so that attention can be given to locating and getting the elderly to the sites of the health services.

In the Worcester area the Age Center has focused its work on this through its referral center. The Social Security office, Blue Cross-Blue Shield office, those industries which allow their personnel sections to continue to advise their retired employees on insurance matters, are other sources of helping the elderly obtain needed health services.

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Perhaps one of the areas, the lack of generalists in the practice of medicine is slowly being felt not only as far as the elderly are concerned, but in the overall population. It is just as frequent in the elderly as in other age groups for them to seek a practitioner of medicine to fit their self diagnosis.

In regard to the question, “Are present health services remote geographically and sociologically from many of our older persons ?" Not in this area. However, it may be necessary for a knowledgeable individual or ageney to personally escort the older person to that service.

The question, “Are present Medicare and Medicaid policies intensifying old problems in the organization of health services or causing entirely new problems?' In my observation there are two parts to this answer although I have not been exposed except in one case to Medicaid. My experience in that one case would indicate thar until State Senator Beryl Cohen's Committee reported on the unwillingness of state welfare departments to acknowledge or provide Medicaid, there was little effort made to implement Title 19.

Present Medicare and Medicaid policies possibly are intensifying old problems in the organization of health services or causing entirely new problems.

In this regard I would refer to a special article titled : "Challenge of Surgery", George R. Dunlop, M.D., in the New England Journal of Medicine, March 30, 1967. In Dr. Dunlop's Presidential address delivered at the annual meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 21, 1966, he focuses on two moral issues American's face in their exploring adventure with Medicare.

The concern in the first place is with house staff training as the number of "charity” beds shrink because of Title 18 and 19. A suggestion is made for the establishment of special “team” specifically to care for Title 18 and 19 patients. The envisioned team would include a house staff with special prerogatives for care, and attending physicians who provide especially close supervision. Secondly, Dr. Dunlop calls for authoritarian reprimand for over. utilization and bed wastage.

Everett Shocket, M.D. of Miami, Florida, has protested vigorously and logically to this concept in a letter captioned “Training an Authoritarian in Surgery”, in a letter to the New England Journal of Medicine, page 1263, June 1, 1967. Dr. Shocket objected to segregation of Title 18 and 19 patients from other patients because they are poor. His second objection is against regimentation and authoritarianism as a means of solving over utilization and bed wastage.

Undoubtedly there is intensification of old problems in the organization of health services or causing entirely new problems.

Perhaps one of the most significant is the development of authoritarianism within those private groups which have been bitterly opposed to Medicare, and to which Dr. Shocket has revealingly alluded to in his letter to the New England Journal of Medicine.

Present Medicare policies regarding the approval of extended care facilities are causing difficulties in almost all the questions to be discussed in your June hearings.

There are many adequate extended care facilities that can never simulate a hospital. It is hardly believeable that even the “accepted" extended care facilities can be a small hospital, with all the difficulties which will be discussed in your hearing. “Approved" extended care facilities have become difficult to enter if the patient requires a great deal of care; even with the extra payment provided by Medicare for extra nursing service.

It is difficult to see how the elderly requiring nursing home care can afford $35,000 or more for annual cost of nursing home care when this is more than they probably could have earned in any one year of their earning years.

The subject of Home Health Care and Nursing services is also a difficult one to analyze. Worcester is fortunate in that the Visiting Nurse Association is organizing these services. However the dilema of the shift of responsibility from the home to hospital or extended care facility will have to be solved.

Rehabilitation and physical therapy facilities require greater development. Here again, personnel shortages, new and wider concepts of treatment and financial aid are needed.

"Are shortages of trained personnel in the medical and medical-related professions especially severe in fields that serve the elderly?" Definitely. They are specially severe in fields that serve the elderly. This has called for training programs to develop geriatric aids, volunteer corps, to operate in health services. The establishment of in-service training programs in hospitals and in extended care facilities. The Age Center of Worchester, with the Girls Trade High School and other educational facilities has attacked the problem. It is beyond the scope of the present facilities and funds presently available for the purpose to successfully cope with it.

There is a great deal to be done other than to repeat facts such as those which are quoted from Professor Milton I. Roemer, University of California, Los Angeles. This involves private continuance as well as more, not less, sensitivity to the elderly in their midst.

It involves care on the part of the government not to reduce its efforts because of the financial burdens imposed by the world situation. It is imperative that the experience of physicians as well as workers in other fields who have an interest and experience in the areas of health posed by the questions asked by Senator Smathers, shall not be buried by those who oppose the concept of Medicare and Medicaid simply because of a reputation which is still perpetuated against those who are said to have had, and still have "funny ideas about Medicare".

Finally, I would like to direct attention to a special article in the New England Journal of Medicine of April 2, 1964 titled : “Leadership in American Medicine", by John G. Freymann, M.D. When it appeared it made a stir, particularly in the medical academic community. Dr. Freymann contended in his article that only a “Third Force" in American medicine could restore the constructive organization and inspired leadership in the voice of American medicine, the American Medical Association.

The "Third Force" is defined by Dr. Freymann as “this new generation of particularly well educated physicians practicising outside univer-centers. . . ." "Nevertheless, with one foot firmly based on advanced training in scientific medicare and the other on private practice outside the academic sphere, it bridges the gap. (I.e. Between "town and gown", a categorization Freymann disliked.)

Freymann voices the hope that as the result of the “Third Force", "with so many brilliant men among its members the medical profession should not have to abandon direction of its destiny to outside forces." This concept is excellent as far as it goes, but one more step is needed if leadership in American medicine is to become effective. It is the need for the individual physician as well as the local or district medical society to join in intimate community effort to improve Medicare which has meant so much to the millions of Older Americans.

In this regard I can highly recommend the recent work of Robert Morris and Robert H. Binstock of Brandeis University, with the collaboration of Martin Rein (Columbia University Press, 1966) titled: "Feasible Planning for Social Change," critically reviewed in the New England Adage, January-February 1967. The collaborators discuss ways as the result of the experiences drawn from the records of the 3 year study of demonstration projects in Community organization for the elderly conducted in 4 of the 7 cities financed by the Ford Foundation project on Aging. They contend that it is necessary to overcome the wastes of enormous amounts of funds, and professional and citizen man-hours in social welfare planning as it is commonly conducted. These remedies are proposed : 1) differentiation among the planning efforts according to the types of changes sought, rather than to the social conditions under consideration; 2) systematic analysis of the factors that make the feasibility in various different types of planning.

The Subcommittee Hearing on Costs and Delivery Of Health Services to Older Americans is commended for its efforts to "improve understanding of present inadequacies or difficulties in providing health services to the elderly and also to suggest actions that may be needed to solve present problems." It is hoped that its ongoing future efforts which are necessary will be most successful. Sincerely yours,

SAMUEL BACHRACH, M.D.,

Project Direotor,
Age Center of Worcester Area, Inc.

DOVER GENERAL HOSPITAL, INC.,

Dover, N.J., July 11, 1967.
Hon. Senator HARRISON A. WILLIAMS, Jr.,
U.S. Senate, Washington, D.C.

DEAR SENATOR WILLIAMS: Many thanks for your kind letter of July 6th. It is with real pleasure to forward to our good Senator George A. Smathers the literature that you so kindly asked my permission.

I want you to know you are always at liberty to use any and all literature
that I may send you as you so see fit.
Wishing you well, with kindest regards as ever.
Sincerely,

C. T. BARKER, Director.
[Enclosure]

DOVER GENERAL HOSPITAL, INC.,

Dover, N.J., June 7, 1967.
NORMAN H. TOPPINGS, M.D.,
President, University of Southern California,
Los Angeles, Calif.

DEAR DR. TOPPINGS: I read with interest in The Week For Hospitals, Volume 3, No. 21, dated May 26, 1967, of the American Hospital Association, as per photostatic copy attached, that you have been named General Chairman of the National Conference on Medical Costs to be held in Washington, D.C., on June 27th and 28th.

As a Hospital Director interested and concerned about both good health care, as well as reasonable cost, and living within the framework of a hospital for over twenty years, one can hardly believe that the cost could skyrocket so rapidly and the changes that have developed in the health and hospital field. In my opinion, some of the changes have been good and some have been very, very bad.

Referring to hospital cost even before, and now that we have in effect Public Law 89–97, as of July 1, 1966, the following are a few of the main factors to control hospital cost, and it is not easy, mainly because hospitals are never closed. We render service around the clock. Also, personnel, supplies and equipment must be available within minutes. Therefore, controlling same is not easy, as well as far too often personnel are being paid and nothing being produced or services rendered. Hospital Directors' hands are far too often tied by the authority of the Board of Trustees that does not live that closely with hospital problems and cost. Likewise, the medical profession is not an easy group to control on a reasonable and honorable basis. Great cost involves :

(1) Unnecessary duplication of paper work that has grown rapidly in the hospital field. Paper and reports do not cure the sick and injured.

(2) Pilferage is a main factor to be controlled in the nature of a hospital service.

(3) Waste, likewise, is a factor of high cost that must be controlled, and is not easy for many reasons.

(4) Getting an honorable day's service from each employee for their salaries paid.

(5) Controlling the medical profession is a costly factor and not an easy one and great cost is involved because of the medical pressures, far too often poorly evaluated on the part of hospitals or properly authorized people.

(6) Patients being admitted to hospitals because of health insurance and/or other third party insurance that ordinarily would be taken care of at home. This is a great convenience for the patient, the family and the physician, but we must realize it is costly. Also, the general public today is demanding hospital care because it is a convenient factor, again for the family, with everyone working and no one at home to even take a little time or give a little attention to someone that may not be feeling up to par. Here again, if this is the type of hospital care and service the general public is demanding, we must realize it is going to be costly, unless it is controlled in a strong and honorable manner.

(7) The medical profession practicing on the heavy side of legal protection at the expense of the hospital, the insurance company, the patient and now the taxpayers, with Medicare.

(8) The medical profession is not hurt financially or responsible for financing hospital care. Therefore, they are not concerned about cost.

(9) The medical profession having no control and not being able to control within, with the attitude that you must be a physician to make decisions. A lay

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