care in this country that have adopted these standards of performance and achievement. Senator SMATHERS. I want to ask you one other question in this connection. Do you think that what you are stating here this morning is the opinion and the judgment of most of the medical profession? Dr. SHEPS. No, it is not. It is the opinion and the judgment of an informed minority of the medical profession. [Applause.] May I say that it is interesting, however, to recognize that what I have reference to has been adopted in the best hospitals of this country. There is a precedent of longstanding progressive development in the general hospitals of this country that have adopted programs that require physicians to adhere to standards of performance and achievement. Also, they have methods of evaluating this and there is a long experience. What we don't have as much experience with is the evaluation of ambulatory care, particularly in physicians' offices. Senator SMATHERS. All right, sir. Thank you. Go ahead. FRAGMENTATION OF SERVICES Dr. SHEPS. The second point that emerges is that a major problem in health services for the aged is the fragmentation of services. The experience that we have accumulated with group-practice arrangements, organized home-care services, and the extension of services to our patients in nursing homes has clearly established, at least to our satisfaction, that the fragmentation characteristic of much of medical care in this country can indeed be overcome. 3. Many old people, particularly the poor, who live in the slums of our cities, are isolated from adequate medical care. This is so not only because of the fact that Dr. Brown mentioned, that generally the services of physicians and others are not as readily available as in the more well-to-do areas, but also because this important population group has not learned what good medical care means. Therefore they do not have adequate expectations and do not make sufficient demand for the care which they ought to have. For example, in our Gouverneur health services program, which has a 6-year history, the proportion of visits by people 65 years and over is still significantly less than the proportion this group represents in the population we serve whereas it ought to be greater than others. This is despite the fact that our program has been a very popular one and is being used increasingly every year. We have established a health education program to help solve this problem in our area. 4. We have learned also that the auxiliary personnel, who have learned about the framework of medical care and who understand the social background of our patients, can be extremely helpful to physicians, nurses, and social workers in following through and seeing to it that the plan of medical and social management is implemented fully. 5. We have also learned that social problems have a profound effect upon the ability to implement health measures. Adequate housing and job opportunities are among the examples of this. Therefore, the most effective health program for the elderly should include close, effective, daily working relationships between health and social agencies. I would suggest that the aim of health services for the elderly must be to maximize the potential of elderly people to live as human beings, as people who present both physical and social functions and needs. And we can do this, if the elderly get the care they need, when they need it, and where they need it-no more and no less. I think we know a great deal about how to do this, and many elements that need to be put together can be found demonstrated quite effectively in different parts of this country. But it is rare, indeed, if ever, that you can see all of them put together into a meaningful and effective program. There are some good examples in New York, one of which you are going to be seeing today. While there is clearly more that we can learn about these problems and their solution, I do not think that the implementation of programs should be delayed to await the results of further research. We already know a great deal which has been clearly established which is not yet being widely applied. And, I think it is the broad and full application of what we already know of the confrontations that I described at the beginning that I think needs attention. Hence, I would respectfully recommend two measures to the committee which I believe would expedite the application of what we already know. RECOMMENDATIONS FOR EDUCATION, DEMONSTRATIONS 1. Vigorous programs of special health education should be launched to help the elderly understand what they have to gain by obtaining appropriate health services and what these services are. 2. A special program of demonstrations should be launched in various parts of the country to establish clearly for the public, the professions, and institutions involved, what must be done to provide the full range of effective health and social services for the elderly. I would urge that these demonstrations should be carried out, not by grants, but through contracts that are made by appropriate Federal agencies. I make this suggestion because the contract mechanism is the one that has been demonstrated as providing the necessary opportunity for the agency which supplies the funds to see to it that the demonstration carries out the plan that has been developed fully, and therefore is more likely to reach its objective and, further, to insure that it is appropriately evaluated. This is to be distinguished from grants for research projects where this opportunity does not exist. The lessons from these demonstrations should then be widely publicized to the public and to professional groups and implemented in legislation so that programs may then be launched to provide equal opportunity for modern health services for all the elderly of our country without further delays." Thank you. Senator SMATHERS. Thank you, Doctor. [Applause.] All right. Our next witness is Dr. George G. Reader, director of comprehensive care and teaching program of Cornell Medical College. Dr. Reader. 7 For discussion of geriatric clinic at Beth Israel Hospital, see p. 570, app. 3. STATEMENT BY DR. READER Dr. READER. Thank you, Senator Smathers, for this opportunity to testify today. I have been director of a comprehensive care program at The New York Hospital-Cornell Medical Center since 1952. This was designed to improve the care of ambulatory patients, children as well as adults, and to provide a basis for teaching medical students the principles of comprehensive health care. As part of our endeavor, we have engaged in a number of studies and experiments and I want to tell you today about one of our experiments which I think bears on your discussion. This was an experiment conducted in collaboration with the city of New York, departments of health and welfare, and involved approximately 1,700 (1,681) welfare cases. We took people newly enrolled on welfare and divided them randomly into two groups. One group was offered a complete range of services by a group-practice organization within the comprehensive care program at the New York hospital; the other group was allowed to get their care in the usual way on their own. We have a number of findings from this study that was carried on over a 2-year period of observation and I have broken out some of them that specifically relate to the elderly in that group for today's presentation. I want to make a point, however, about some of the other people as well because I think it bears on your general concern. There were 2,500 people in the study group that were offered care. All of them did not respond to the invitation to come for care; some continued to go their own way, but they were still considered a part of that group. There were almost 1,700 (1,685) people in the control group who got their care under the ordinary welfare system. One of our early findings that we uncovered by analyzing the welfare records was that there was such a tremendous turnover of cases on welfare that over a 2-year period, people could be expected to be off welfare 50 percent of the time. This even included the old-age assistance category, although they were off welfare less than the average. I think the implication of this is plain because the mechanisms for payment for medical care are only available during the periods when people are on welfare. Title 19 of the Social Security Act has served to attempt to correct this by creating a medically indígent program that will care for our people both on and off welfare. Our welfare services-and I suspect this is true all over the countryspend 90 percent of their effort getting people off welfare, but this is mainly a bookkeeping operation because they are back on welfare in a few months, and people at this social level obviously do not improve in health during the period they are off; in fact they may often become worse because they are not getting needed services. We find that many of our respondents, for example, told us when they were off welfare they thought they could not get medical care through the usual offices provided for them; they thought they could only get it if they went back on welfare. We also discovered that this group was an extremely ill group, they were much sicker than the rest of the population. The elderly, as you might expect, were even sicker than the others. 83-481-68-pt. 2- 4 I think the interesting feature about the finding in this regard was that those 65 and up actually were a little better than the people immediately younger than them. Beginning at about age 45 but particularly from age 50 to 60 people in over 50 percent of the instances complained of symptoms and these when examined turned out to be indicative of serious illness in many cases. So the elderly actually were not in as great need in our study as those who were younger. PRE-65 HEALTH DIFFICULTIES We have reason to believe from other studies that possibly people in the decade just before 65 are actually going through a kind of crisis where they need help more and that after they reach the point of 65 they enter a more tranquil period. It would therefore seem reasonable that this group just under 65 should have care extended to them which might then make them better in the over-65 period of their lives. We also found that when people go on welfare, just prior to enrolling they are often quite sick. There is a spike in their symptoms and in utilization of medical services at that point, which suggests that new enrollees on welfare should have a complete medical examination at that time. We also found, as you might expect, that utilization of medical services was highest in the over-65 patients. Actually, although they were not quite as symptomatic as those a little younger, they made better use of the services. The over-65 people in our population gave us the best response to our invitation. Seventy-five percent of them came and they all were, on examination, quite ill but not as ill as those we examined in the age group just below. Twenty percent, however, of the over-65 group required nursinghome care during the 2 years that we saw them, so this was a group who had illnesses that not only required admission to the hospital but beyond that really needed prolonged care as well. Concerning the implications of our findings to the implementation of medicaid, I think the point that I made first that medicaid should solve the problem of welfare turnover is very important. Obviously the level of eligibility at which medicaid is set will make a difference. It should be above the level of eligibility for welfare and perhaps should be as high as in New York State. I don't want to get into that argument today, but I think that, as has been said by my colleagues, the fee-for-service principle tends to make for more expensive service and essentially rewards the doctor for building up his practice as a piecework operation. It does not reward group practice: in fact it militates against an organized program of services and against preventive medicine. We were able to give a comprehensive program of services to the people in our study because we had a grant from the Health Research Council of New York City and were able to work out a capitation arrangement with the department of welfare, so we had in a sense a prepaid group practice. It was only because of this feature, however, that we were able to give complete services effectively to the group that we studied. I think that further experiment is still needed. Dr. Sheps is right when he says the principles of medical care are well understood. There is a definite body of knowledge about medical services and hospital operations. However, I think the application of the principles is not as well understood and there is a great deal of need still for innovation. There must be some way of financing this that does not put the entire onus on someone's being able to write a proper grant proposal to get the funds, because the people who are innovators and program developers are not always the objective scientists who can write a proper grant proposal and justify their explorations in scientific terms. EVALUATION OF INNOVATIONS On the other hand, I think an evaluation of these innovations is essential and a body of methodological knowledge is needed in this area that is not yet available to us and is not available to those in the Department of Health, Education, and Welfare. For this reason the Department of Health, Education, and Welfare does need a health services research center to develop expertise in evaluation which could then be applied to the various attempts at innovation around the country and to the application of recognized medical care principles. One of the questions that has come up in the past about the sick elderly is that they are isolated from health services. Did our experiment help that? Did we extend ourselves outside of a large medical center? I can say that we did not solve the problem of isolation. One of the biggest problems we had in fact was that those who lived furthest away were least likely to come. I think the people who live in slum areas need services close to them, particularly old people who have difficulty traveling, and that we must reach out to them. I think neighborhood health projects are certainly one very rational way of reaching out. Other attempts at solving this problem must undoubtedly be made. I have also been asked about the question of whether medicaid and medicare, because they pay for medical services for the old and indigent, would wipe away the charity image, as I had once hoped. I think that the answer is that it has not yet wiped away the charity image, because medicaid requires a means test and because of it has raised the argument as to whether people have a right to medical care. The president of the American Medical Association recently stated that people don't have a right to medical care, it is a privilege, and only those who can afford it should have the privilege extended to them. I think this is still a terrible problem in our country of whether we can get rid of the charity image, but I think it comes down to the question of how physicians are paid. Dr. Brown said that it is easy to get doctors to work in the slum areas. I think he has been lucky so far. I don't think it is easy to get doctors to work in the slum areas. It is not easy to offer them salaries to work when they can make more money in fee for service private practice. In think the answer to it, though, may be that doctors should be paid in a variety of ways. If you can give them a useful experience, a feeling of satisfaction in their work, you don't have to pay them as much in salary. If we can relate the work they do in a slum area to a teaching hospital where they also get satisfactions from the work they |