Information on each of the individuals served and each of the services provided them, as in the California plan, could become the basis for quality control.

Senator WILLIAMS. Would the doctors welcome this opportunity to contribute their information?

Dr. BRESLOW. There are probably some physicians who resent the fact that they are, so to speak, locked into such a system, but I think it is to the credit of the California Medical Association, and California Blue Shield, that they have supported this system.

I think there might be some debate about the vigor with which there is pursuit of the so-called deviant practitioners. But there is no doubt about the overwhelming support of the medical profession, in California, for a system like this.

PREVENTIVE MEDICINE; MULTIPHASIC SCREENING

On the last item, in which I know I share a considerable interest with you, Senator Williams, namely the incorporation of preventive medicine in the form of multiphasic screening into Federal health programs, I would say that this is desirable and feasible.

It is technically and economically possible, as well as medically useful to detect evidence of many significant diseases by a series of simple tests, now largely automated or performed by technicians under medical direction. When these diseases such as diabetes, certain forms of heart disease and cancer, anemia, and many others are detected in their early stages, the outlook for success in treatment is much more favorable than if they are allowed to progress into advanced stages. In fact, the difference not infrequently is life or death.

Such tests are now often incorporated into comprehensive health examinations for industry executives. The American Medical Association for several years has offered them to physicians attending their annual convention. The Kaiser health plan in northern California provides them. A joint labor-management trust fund in the California cannery industry has made them available through a mobile unit to thousands of cannery employees scattered throughout the State.

Several hospitals are now planning to install multiphasic screening. I think that if it is good for all of these segments of society for physicians, for industry, for executives, for cannery workers and others then it has been tested well enough now to be able to say that it would be good for all the people.

Providing this service as part of Federal health programs would be a major contribution to improving health, especially for older persons who are more likely than younger persons to be affected by the chronic diseases that may be detected through multiphasic screening. It would be a positive contribution to health.

The success and growing acceptance of multiphasic screening make it timely for consideration of incorporation into Federal health programs.

Senator WILLIAMS. Are you familiar with the Kaiser program? Dr. BRESLOW. Kaiser health plan is the name for the plan, I think. Senator WILLIAMS. Are you familiar with how the-I talked about multiphasic screening. Someone, I don't know who it was, maybe it

was Bill Oriol, my trusted leader of the staff who had tabbed it "preventicare."

I have talked about the Kaiser-they were pioneers, I believe——— Dr. BRESLOW. Right.

Senator WILLIAMS. I have talked about them a great deal and said that this is proof that it can work. An early incipient disease can be detected. And the earlier it is detected, the more likely we are to avoid costly treatment or surgery.

Now, how do they work? Who are the people who come in there to get tested?

KAISER HEALTH PLAN

Dr. BRESLOW. In the Kaiser health plan-and I think it would be well if you had an opportunity, Senator, to actually visit the installation and see for yourself what is being done there the subscribers to the Kaiser health plan-that is, the individuals who are prepaid through their unions or employers or themselves-for health care Senator WILLIAMS. It is an in-house operation, is it?

Dr. BRESLOW. That is correct. These subscribers are eligible for examinations by physicians once a year, or oftener if necessary. A week or two before they see their own physician, they are scheduled to come in and have a series of tests called multiphasic screening.

When the physician sees the patient for the examination, he receives a brief history of the patient with the symptoms that the patient has written down ahead of time, and also the results from a quite wide array of laboratory, X-ray, and other tests. The physician can see these results when he first visits with the patient.

That means that he has a tremendous leap ahead in his examination. He doesn't have to order the tests of a routine sort that are included in multiphasic screening. He has the results when he first sees the patient.

He, of course, can and does follow up these screening tests with more elaborate examinations, X-ray, laboratory and others. This is the way it works in the Kaiser health plan.

They found a great economy as well as medical use for it.

Senator WILLIAMS. So it is a two-phase operation. The employee goes to the doctor, and then the doctor makes findings, and the next step would be the whole Kaiser program; is that it?

Dr. BRESLOW. The basis for the diagnosis and treatment plan is this survey which can be carried out now quite effectively through these series of tests organized, as has been done in the Kaiser health plan and in many other situations as well.

Senator WILLIAMS. I didn't know that there were two phases, to tell you the truth.

Dr. BRESLOW. Many of us feel that this is the best way to provide this service. You go first for the screening tests, provided incidentally at offhours, evenings, and so on, so as to make it more convenient for patients. This also uses their equipment most effectively.

Then the results are assembled by computer and given back to the physician at what you call the second phase, when he has an appointment to see the physician.

Now, multiphasic screening itself is of course just a series of tests, with results and the referral. All of this is of no value unless it is followed up by the patient's physician.

Senator WILLIAMS. Why does he have to go through the screening process with the physician? Why not just go right into the multiphase operation? Isn't that supposed to determine

Dr. BRESLOW. Well, he does go directly into the multiphasic screening.

Senator WILLIAMS. I understand he went to a doctor first.

Dr. BRESLOW. I am sorry if I gave that impression. He has the appointment with the physician scheduled, but before he sees the physician-a week or two before-he has the multiphasic screening. Senator WILLIAMS. So the first phase is the

Dr. BRESLOW. The multiphasic screening.
Senator WILLIAMS. I understand.

Dr. BRESLOW. I am sorry if I didn't make that clear.
Senator WILLIAMS. I am sorry I misunderstood that.

Dr. BRESLOW. The point is the findings from the multiphasic screening are referred to the physician.

Senator WILLIAMS. That I understand.

Would you recommend that as a national program?
Dr. BRESLOW. Yes, I would.

EXPERIENCE JUSTIFIES NATIONAL PROGRAM

Senator WILLIAMS. By the Federal Government?

Dr. BRESLOW. I would; I would recommend that as a national program.

I think we have had sufficient experience with it in different forms, different places, different circumstances, that it is certainly justifiable as a national program.

It is something like the situation with respect to home care, a few years ago. There were some demonstrations of home care. There were some questions as to how useful it might be, whether it should be incorporated into a national program. When the issue arose about incorporating home care into medicare, some asked whether we had sufficient experience with it, whether there were sufficient resources for home care available to justify putting it into medicare.

Many of us, at that time, took the same position that I would take now with respect to that multiphasic screening. We have had sufficient experience with it. It is sufficiently well known in the medical community that, if the Federal government were to incorporate it into a national program, then it would expand with the impetus of the funds available to pay for it.

Senator WILLIAMS. Are there any dissenters on that point?
Any dissenters?

Mr. CUBBLER. As a matter of fact, it would be required for children after July 1, 1969, as a result of the 1967 amendments.

As long as it is used only for the purpose of identifying diseases in order to treat them, rather than excluding them from the program, it is a very, very good idea, sir.

Senator WILLIAMS. Will you identify yourself for our record?
Mr. CUBBLER. Charles Cubbler, C-u-b-b-l-e-r.

Senator WILLIAMS. Dr. Breslow, you don't look as healthy as the last time we worked together on arbitrary labor. I don't think you have been taking enough grapes. [Laughter.]

Dr. BRESLOW. We use grapes for a lot of things in California. I recall one time studying the problem of quackery in the treatment of cancer. We found that grapes were being offered as a cure for cancer, and action had to be taken against the individual who was advocating and offering that particular form of treatment.

I am sorry that my voice is hoarse.

Senator WILLIAMS. No, I was only kidding you about that. It hurt me when grapes were being served on the plane coming out, and they looked so good. But they were the forbidden fruit, because of the current boycott.

I wish we could get that all straightened out-but that's another matter entirely-bringing order, harmony, and agreement in the farm labor situation.

Dr. BRESLOW. The progress that you and others in the Senate and the Congress have made with respect to health services for farm workers, migratory workers, has been quite important in bringing to the attention of the whole body politic the situation of farmworkers in California and elsewhere.

I think it is generally true that health services, as supported by government in such situations as the migratory labor camps are more widely accepted than some other approaches to the problem.

I hope that you will continue to pursue your interest in that matter of assuring that at least minimum health services are brought to people in that situation.

Senator WILLIAMS. Well, that isn't germane to our discussion, but I am glad you made the statement.

The last time we were out here talking about migratory workers we had Senator Bob Kennedy with us, and he certainly made an impact upon the farm community.

Senator RANDOLPH. Mr. Chairman, at that point I do want to mention, and I do want the record to indicate that as you had this colloquy with the doctor, that President Johnson yesterday signed the Medical Services Act of 1968, and as you well know, there is a provision in that act for medical care for the migrants of this Nation. That is a part of the complex, overall program, which has been enacted into law.

I don't want to be pollyanaish at this point, but I want the record to reflect that the Congress of the United States has perhaps made errors and committed mistakes, but that the recent Congresses have been most energetic and effective in moving forward the programs of health in the United States of America.

I don't want to attempt to be partisan whatsoever, but I do think that the record is one which is very clear, very understandable, to those who will study what we have been doing.

We may have retraced our steps, at times, for reasons, but just this one act alone, doctor, and Mr. Chairman, passed by this Congress and signed into law yesterday, it is a notable, a significant advance in program for the persons who need the medical care.

I compliment our chairman and this committee who have done so very much in our Subcommittee on Migratory Labor, and the Labor and Public Welfare Committee.

But you know, I think it is necessary these days to sometimes speak in praise of something-and not constantly to be negative. There are mistakes made and errors committed, and programs that are short

changed, but I for one want to keep in balance the good with what I called the bad. [Applause.]

Senator WILLIAMS. I wish that the reporter would record that there was applause at that point.

Dr. BRESLOW. Senator, I would like, if we have just a minute, to go back to a question that was raised with respect to testimony that an earlier speaker gave on the Medi-Cal program.

MEDI-CAL BUDGET CONTROVERSY

I am not sure that I fully and directly answered the question concerning the estimates of cost of the Medi-Cal program. During its first year in office the Reagan administration publicized such wild estimates of the cost of Medi-Cal that it seems the distortion of statistics could have only been either malicious or based upon gross ignorance.

The allegations that Medi-Cal would bankrupt the State apparently were designed to frighten taxpayers. Such allegations certainly had the effect of seriously disrupting the program by forcing cutbacks under the threat of runaway costs.

In fact, the original estimates of Medi-Cal costs and budgeted for the March 1966 to June 1967 period were very close to actual expenditures for that period. In the subsequent year-the one just ended in June 1968-expenditures were way under the conservative budget that was prepared under the fanfare of headlines about runaway costs.

Senator WILLIAMS. Very good. Thank you very much.

Dr. BRESLOW. Thank you, Senator.

(Subsequent to the hearing, Senator Williams asked the following questions in a letter to Dr. Breslow :)

1. Your prepared statement said that many individuals in California and elsewhere have endeavored to link up Medi-Cal with the quality standards of Medicare. May we have a summary of the suggestions most often made?

2. How would you implement your recommendation to "incorporate into all Federal medical care programs a legislative framework for establishing standards of quality." What programs would be thus affected? Would any be of special importance to the elderly?

3. Your strong recommendation for adequate health data systems in federally supported health programs is of great interest to the Subcommittee. In your suggestion that the Committee "explore this system in detail with a view to incorporating some such data system into all medical care programs supported by federal funds," what do you see as the major questions that should be explored?

(The following reply was received:)

DEAR SENATOR WILLIAMS:

UNIVERSITY OF CALIFORNIA, LOS ANGELES,

Los Angeles, Calif., November 26, 1968.

The way to link up Medi-Cal (the California version of Medicaid) with Medicare is simply to require that all services paid for by Medi-Cal must conform to the standards established for Medicare. This policy would disallow payment for care under Medi-Cal in hospitals, laboratories, home health agencies or other facilities whenever these facilities had not been certified for participation in Medicare.

For example, this policy would not permit what many regard as dissipation of Medi-Cal funds in individual home services that are not a part of organized home health agency services.

Each state, of course, could establish such requirements for its Medicaid program, but it would be far preferable to have this established nationwide as in Medicare.