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New York is also a typical example of the dilemma which medicare and medicaid have exposed: we have pumped millions of additional dollars into the system but we have not fundamentally reorganized the delivery of health services. People still go to the emergency rooms and clinics of our huge, impersonal municipal hospitals and wait for hours to see a doctor they have never seen before and are likely to never see again.

The hearings today will air many of these problems in the costs and delivery of health services. The task ahead is to shape our responses to the questions that will be posed today. In simple monetary terms, we cannot afford not to begin decentralizing health care into facilities less costly than hospitals, facilities which coincidentally are more accessible to the patient. We cannot afford not to begin using our health manpower more efficiently through group practice, and through the development of less costly forms of subprofessional manpower, both of which coincidentally will allow the development of new familybased practices that are more responsive to the needs of the patient. We cannot afford not to replace our present piecemeal financing of health care with a national system of health insurance which makes adequate health care a right for every American of every age. That is why these hearings are so important. That is why I am especially pleased to be here.

Senator KENNEDY. Thank you, Mr. Chairman. Let me state I am delighted to be here.

Senator SMATHERS. All right, Dr. Brown, you may proceed.
Senator KENNEDY. Excuse me, Dr. Brown.

Dr. BROWN. You are welcome, Senator Kennedy.

I was just making the point that in the past in other areas of the country as well as New York City, larger homes plus the close relationship with the family doctor often provided what seemed to be a workable pattern of care. People didn't live as long as they do now and therefore this was relatively effective. It provided what are the essential components of health care; that is, a basic living arrangement which ties an older person to a community and its associations and to a family as giving him the personal continuity of care which you describe so graphically, Senator Smathers, as lacking in our clinics and I agree with that.

However, in the past when the old system broke down, we moved our aged to either mental hospitals or public-home infirmaries and these were always conveniently located outside of the city so as not to trouble our conscience by the visibility of the misery of the aged. We continued to build in New York City these kinds of facilities through the fifties.

But the past is no longer working. In our vast urban areas, we now have a substantial number of aged who live alone. Where they have children with families, often these apartments are not large enough to allow these people to live with their families.

DECLINE OF FAMILY DOCTORING

Furthermore, family doctoring has completely broken down in the low-income areas of this city, and I speak of areas with at least 40 percent of the city's population. This is simply because private physi

cians are no longer settling or practicing in these areas. So the old pattern is really no longer a workable reality, and as a partial result of the breakdown in this old pattern, we have the following situation here in New York City:

Our city hospitals at any given time have at least 5 to 10 percent of their acute-care, general-care beds occupied by older people who are there because there is no other resource in the community. One could estimate the cost of this at $15 million to $25 million a year in the city hospitals alone.

We have in New York City a shortage of nursing-home beds, which we are in the process of correcting by construction planning largely under State loans. There is, however, increasing evidence that we will have a problem of older people remaining in nursing homes simply because again there is no other appropriate place for them to go and live.

Preliminary studies at our chronic-care facilities on Staten Island's Seaview Hospital indicate a substantial percentage of the population there. This is a chronic-care facility with nursing-home and publichome infirmary, a substantial percentage of the patients who would be better cared for at lower cost in the community. Our State mental institutions are crowded with older people who are not mentally ill in the ordinary sense, rather they are there largely because they are difficult to handle in any other facility.

What I really fear is that if the present trend continues where there are increasing numbers of aged where families are unable to care for their older members in their small apartments, where there are older people without families, and finally with the increasing shortage of neighborhood family doctors, that we shall have an immense institutional population of older people.

I fear this because while at times these institutions are necessary, most frequently they are the enemy of the older person and they, of course, will also represent a tremendous unnecessary drain on our tax dollar and our professional resources.

Now, given this formulation of the problem, let us turn to what we are trying to do about it in New York City and then what help we feel you can give us at the Federal level. The whole basis for our programing in New York City by the health services administration is the community, and this is because only in the community can health care be related to the real needs of older people, their need to continue to function, to relate to their cause, such as the churches, their synagogues, and if they have families, their families and friends.

NEIGHBORHOOD HEALTH CENTERS

To replace the missing family doctor in low-income areas and to replace partially the crowded clinics of our hospitals in New York City, we are instituting a massive program of neighborhood health centers. I understand you will see the project today headed by Dr. Harold Wise, which is nearby, and in many ways will show you specifically what I am talking about. Without going into the details, you will see basically what it does; it brings to people group practice connected with the hospital.

3 Description of project on p. 421-423.

Also this group practice is in the community and related to the community and its social institutions and its needs. It simplifies complex modern scientific care so that an older person can have the feeling of relying on a health unit and a health profession with which they can feel this personal tie, and I may tell you this personal relationship is essential in health care in the aged based on my own experience.

Now, connected with these neighborhood health centers, there must be home-care programs, special arrangements for the care of patients living in housing projects for the aged and social and physical rehabilitation projects. We did this kind of programing at Gouverneur and I can tell you it can be done and that it works.

In our planning for the health services administration in New York City, we have a goal: that there shall be no more chronic-care facilities, whether in hospitals or in mental institutions, that are isolated from the community; rather, all of these will be a part of a medical complex which consists of the neighborhood health center which you will see today and a hospital with extended-care facilities and mentalhealth facilities in the community.

We have talked a great deal about the need for home-care and other programs to keep people out of hospitals and get them out as soon as possible. I want to make it quite clear that we need similar programs to keep people out of mental-health and chronic hospitals and also to get them out once they are in.

The essence of this program is to provide alternate domiciliary facilities and a community-based medical care program which has ties to the various resources needed, whether it be community neighborhood care such as you will see, special shelter homes for the aged, a homecare program or a nursing-home program.

Now in our plan in this city we are continuing this neighborhood theme by the development, and a large development, of community mental health centers. These, as you know, are partially financed by Federal money. Here we will have day or night care, emergency care and ambulatory care for patients living at home.

ISOLATED CHRONIC CARE FACILITIES

In New York City we are reversing the policy that caused us to build, even as late as the 1940's and 1950's, chronic-care facilities in isolated areas. This important role, then, of living in the community, whether it be with the family or with old friends, must be restored and maintained.

The enemy of older people is social isolation and inactivity. Let me give you a few examples of this. While at Gouverneur, we organized a special program in which older people visited older people in nursing homes, providing activity for both. Let me give you another kind of example: We had a number of older people on home-care programs. We were able to keep them in the home because from time to time we would move the older person into a nursing home and give the family a vacation. This at the same time enables the more thorough evaluation of the patient's medical-care program.

Now, the problems that we have in New York City are really not that different from the other large urban areas, so I think I need to turn now to what I think you should do.

We need much more money for pilot neighborhood medical-care programs similar to the neighborhood health center of the Office of Economic Opportunity. I do not believe there should be specific funding for health projects for the aged but rather that the family programs such as those of the neighborhood health center should be strengthened and perhaps special provisions for the aged written in.* These kinds of grants will be absolutely essential if you are going to secure the best results for medicare and medicaid. It would be unconscionable for Congress to cut back on title 19 financing. This financing is absolutely essential to maintain the ongoing programs of health care for the aged which might be set up under the neighborhood program grants. If Congress must be concerned about the cost of these programs, they should then write in provisions strengthening the need for organized programs such as the neighborhood health center.

5

I would urge that title 18 financing be made more comprehensive so that it could be used more readily for the funding of the kinds of programs that I am talking about. Additional money is necessary for the construction of extended-care and nursing-home facilities adjacent to the hospital and located in the community.

Now, these facilities need not be the unpleasant end of the road that we so often see in New York City, but they can be something quite different, as has well been demonstrated by Switzerland in its magnificent combination of residential facilities and extended-care facilities which are both pleasant and preserve life.

Finally, increased funding of the Community Mental Health Centers Act is essential to strengthen return of mental health care as far as possible into the community.

HOSPITAL COSTS UP TO $100 A Day

Now, this kind of funding that I am talking about for neighborhood health centers, increased construction money for extended-care and psychiatric facilities, and special housing for the aged is expensive, but I think the alternative is perhaps more expensive. Hospital costs are now reaching $100 a day in New York City, and you may be interested in knowing that in at least one of our city hospitals, the charges to private patients are now $100 a day.

A Cornell University study of care given to a welfare population indicated that of the total costs of care, 32 percent of it went for chronic-institutional care. In our city facilities it costs us $10,000 to $12,000 a year to keep patients in these facilities. The costs of the individual solo care by physicians are soaring. You may have read in the New York Times this morning preliminary results of a study of one of our institutions where physicians provide care on salaries in which the costs are at least 20 percent below those beneath the surface. Now, unless the Congress moves decisively in the areas that I have mentioned, we face the danger that the money necessary to provide the kind of program I am talking about will be lost. Financing an unnecessary number of in-hospital days, unnecessary nursing-home days, unnecessary mental-hospital days will lose this money. The payment of

4 Additional discussion of this point at p. 375.

5 Medicaid amendments in the Social Security Amendments of 1967 (Public Law 90-248), resulted in reducing Federal medicaid funds to the States by an estimated $125,000,000 for fiscal year 1969; $60,000,000 of this amount represents the estimated reduction in medicaid funds to New York State for the year.

fees to private practitioners in urban areas will not only fail to produce results but will be inflationary.

So both courageous social vision and prudent fiscal consideration lead to the necessity of organized programs of community health care for the aged of our large cities.

Senator SMATHERS. All right, sir. Thank you very much, Dr. Brown. Let me, if I may, ask a few questions and then Senator Kennedy may ask questions he wants to ask.

On the last page, you say: "Financing an unnecessary number of inhospital days, unnecessary nursing-home days, and unnecessary mentalhospital days will destroy it."

In other words, what you are saying is, when there are unnecessary days you need the hospital, the nursing homes, or mental hospitals and we destroy the purpose of the program, which is to take care of those who need it.

Dr. BROWN. Destroy it in two ways. First of all, older institutions may not need it and are the enemy of older people. Let me give you several examples. It is not uncommon for an older person when hospitalized-and I am referring now to an acute procedure-to become disoriented. He was able to function at home around sights that were familiar, but once in a hospital, unfamiliar, he loses contact with reality.

It is not an uncommon experience, I am ashamed to say, that in some of our present chronic-care facilities, at the end of 2 or 3 months, patients lose all track of time. Their clothes are taken away, there is no relationship to the things that kept them in touch with life, they are moved out of the community and away from their friends. Now, this need not be, incidentally.

Now, both of the kinds of cares that I just mentioned are expensive; our hospital costs are approaching $100 a day in a few institutions. Our present inadequate city facilities are running close to $30 a day for chronic care of the type that I mentioned. Now, you can keep people out of these and get them out sooner if we have the kind of organized programs I am talking about, and that is what I mean about the money being lost.

Senator SMATHERS. I wanted to ask you how you were going to eliminate these people who are staying unnecessarily long in these institutions if we have no place to put them.

Dr. BROWN. Well, no; I think there are solutions. First of all, a substantial number of the older people in chronic-care facilities could be cared for in foster homes, provided it was continuing medical care; in homes with their families, provided there were home-care programs and the possibility of some relief from the family when needed.

It is also possible to maintain people in special projects or the housing projects for the aged, provided there is, on the site, health care and nursing and the possibility of bringing in meals.

Senator SMATHERS. You said that hospital costs are going up to as much as $100 a day. I don't know whether it has achieved that high altitude all over the country, but I do think that is almost nationwide. Now, what, in your judgment, are the reasons that hospital costs are rising?

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