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Senator WILLIAMs. Mr. Thomas, I know we have to adjourn—people have been sitting here for a long time, and you are entitled to a little luncheon—we will recess now. It is 20 minutes till 2.

Senator Randolph has a schedule problem. We will be due back at 2:15. That will give you a chance to have a long, leisurely 20-minute lunch.

(Whereupon, at 1:40 p.m., the subcommittee recessed, to reconvene at 2:15 p.m., the same day.)

AFTERNOON SESSION

Senator RANDOLPH. Our hearing will resume.

Will the witnesses now please identify themselves for the record. STATEMENT OF JUANITA C. DUDLEY, ASSISTANT REGIONAL DIREC

TOR, WESTERN REGIONAL OFFICE, NATIONAL URBAN LEAGUE

Mrs. DUDLEY. Thank you. I am Juanita C. Dudley,* assistant regional director, western regional office, National Urban League.

I am particularly concerned with health in the western regionwhich encompasses six States in which we presently have affiliates.

I have many concerns regarding the delivering of health care to the aged.

Accompanying me today is Dr. Clarence Littlejohn, health chairman of the Los Angeles Urban League.

He will try to answer some of the five questions—along with me that we were requested to answer.

For brevity, and because of the time, we will move very quickly through all of our questions without stopping.

Now it has been clearly established that payments under Medi-Cal to practitioners in the black and brown communities have been less than prompt and equitable. The fiscal agents, Blue Cross and Blue Shield explained that this county is divided into 16 regions and the payment scale varies in most of these regions.

The fiscal agents said that payments are rendered within a 3- to 4week period after submission and suggested that any problems that are existent are due to negligence and irresponsibility on the part of the submitting practitioner.

My office requested Blue Shield to run a check on a specific physician's file, and it was determined that none of the problems around payment were due to his errors. This physician had not received payment for any services rendered under the Medi-Cal program for the last 6 months.

Both Blue Cross and Blue Shield have stated that seminars are being held in the communities to help the practitioners correct deficiencies emanating from incorrectly filed forms, et cetera.

*See app. 1, p. 724,

SPEEDIER PROCESSING REQUESTED We have asked both the State department of welfare and the fiscal agents to insure a more speedy method of processing claims as it appears that the bogging down occurs equally as much in both areas.

We would like to request that a standardized set of procedures for all medical services under both title 18 and 19 be quickly implemented in line with the procedures that are followed with respect to 18 at present.

In answer to the second question: Are medicare and Medi-Cal programs sufficient to provide the services to those people most in need of the services? If not, what suggestions do you have for improvement ?

Medicare is the most significant innovation in the American Social Security system since 1935. It works especially well for most, though its major problem may be that it is contributing to a higher medical cost for the nonaged as well as the aged.

Ten percent of the aged are not eligible for social security pensions: After 1969, what happens to medical care for this percentage, which includes State and Federal Government retirees?

We would like to recommend that all 65-year-olds be included under the Medi-Cal insurance provisions of medicare, irrespective of their lack of coverage by social security.

In southern California 400,000 claims per year are made for medical care of the aged. This approximates a population of 32,000 persons per month. Blue Shield, the fiscal agent for title 19, states that they are receiving from 110,000 to 115,000 claims per day with 85,000 to 90,000 under Medi-Cal for the aged.

It would appear that Medi-Cal is being used as a secondary insurance plan for the elderly poor when medicare title 18 provisions have been exhausted. Compulsory hospitalization prior to a patient's movement into an extended care facility has filled existing hospital beds. It would appear that most of the aged poor are in need of lengthy institutional care due to inadequate home health care.

CUSTODIAL NURSING HOMES

We recommend that custodial nursing homes may be the answer to costly care, relieving hospitals for immediate needs. Frequently, the aged poor are unable to pay the first day's deductible and, consequently, continue to use the emergency room of public hospitals for regular medical needs.

It has been projected that a patient entering a custodial nursing home would remain there for his life expectancy, or about 412 years, since he would probably enter about age 82. We are urging title 18 and 19 coverage of custodial nursing care and there are obvious reasons why nursing home and extended care facilities are often unable to accept Medi-Cal (title 19) patients who are aged and poor. They are described as being less intelligent, less sophisticated, and more difficult to care for.

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We would wonder if this is not based on the differential in terms of revenue between the two programs per patient. Once again, we emphasize the need for standardizing in all States payments for care under title 18 and 19.

In answer to question No. 4: "What suggestions do you have for increasing health services manpower in a densely populated, essentially urban area, or are there now such shortages of manpower ?"

Health services manpower in Los Angeles County is taken from the Los Angeles County Medical Society figures which include a total of 11,964 practitioners. Attached is a chart showing the actual breakdown in numbers and the ratio per 1,000 to the population.

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Note: Total includes all non-Federal physicians. Private practice includes solo, partnership, group, or physician employed by another physician in practice involving patient care. Hospital practice includes interns, residents, fellows, and full-time physician staff.

Source: California Medical Association, Bureau of Research and Planning: Reference Book on Selected Health Manpower Data, tables 1 and 2, containing previously unpublished data provided by American Medical Association.

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We estimate that there are approximately 450 Negro practitioners in Los Angeles County with a large percentage working in public health or other clinical and group settings.

Senator RANDOLPH. Just a moment, Mrs. Dudley. According to your written statement it is 350. Was there an error?

Mrs. Dudley. I am sorry; yes. It is 450.

We are also aware of the very small number of minorities now in attendance at the major medical schools in this county, realizing that the decrease in medical manpower will be more keenly noted within the next 3 to 5 years.

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PARAMEDICAL TRAINING URGED

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We urge an expansion of paramedical training in the areas of home health aides, nursing and other allied fields. We have launched a program to help secure training for returning Vietnam veterans who served ably on the battlefield as medics. We hope that Hill-Burton funds could be extended to update and reclaim many of the existing medical facilities which are being phased out of use.

Comprehensive health planning coupled with regional medical programs for heart, cancer, and stroke must look carefully at the use of an incorporation of the paramedic in their plans for extending better health care to disabled and aged at the lowest level.

Preventive multiphasic health screening at the community level appears to be an obvious solution to high medical costs as so clearly evidenced by group programs such as Kaiser Permanente Foundation of California and the HIP plan in New York. Effective delivery of

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any health service can only be measured in terms of care to the patient.

When we discuss children and their health problems, we quickly look at the mortality rate of the area concerned.

When we discuss the aged, we also examine the mortality rate, yet these crude death rates do not give us a true picture of the causes and effects. We must examine them for reasons.

When the aged reach the hospital in extremis and die within a 24-hour period, we do not consider this a problem of the receiving hospital, but rather the nursing home that waited until the last moment to hospitalize the patient.

Medical schools might extend their training to provide wardbound services in nursing homes in order to prevent patients having to enter the hospital too early or too late.

Senator RANDOLPH. Mrs. Dudley, the nursing homes that waited until the last moment to hospitalize the patient—now, did the nursing home do this because of its interest in making another dollar, or was it because in the nursing home there was no one who realized the need of the patient for hospital care?

Mrs. DUDLEY. I would not wish to indict all nursing homes in terms of that statement. But I do feel very strongly that many times the patients are sent to the hospital during the middle of the night, or during periods when the doctor may not have been in the nursing home to look at the patient.

I think that most treatments are at the request of the visiting physician who goes to the nursing home to see the patient—unless there is an accident—the patient falls out of the bed and breaks an arm, which is a very obvious infirmity that can only be taken care within the boundaries of a hospital.

Senator RANDOLPH. Then you would relieve, in general, the nursing home of the responsibility ?

Mrs. DUDLEY. Yes, I believe that most of the treatments are directed by the visiting physician in that nursing home.

Senator RANDOLPH. The reason I ask you that question is because you really hadn't differentiated here between the nursing home and the physician who made the examination.

Now, I am not trying to draw any comparisons—odious or otherwise.

Mrs. DUDLEY. This is why I suggested that possibly the schools of medicine might use their training physicians to do ward rounds in nursing homes as they are doing in some of the training hospitals.

Senator RANDOLPH. Thank you, Mrs. Dudley.

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

1. Mrs. Dudley's statement indicates that the California State Department of Welfare was asked to "insure a more speedy method of processing claims.” What was the reply to this inquiry?

2. May we have additional details on your program to help secure training for returning Vietnam veterans who served in combat as medics? Would their services be especially helpful in providing services needed by the elderly with chronic illness, perhaps in nursing homes?

3. What is the “differential in terms of revenue” nursing care reimbursement under the Medi-Cal and Medicare programs in California ?

4. Has the OEO Neighborhood Health Center been of help in providing needed services in ghetto areas? If so, would you care to see an extension of such services?

24–798—69—pt. 3—45

(The following reply was received :)

1. Enclosed is a copy of the letter which I wrote to Spencer Williams, Director of Human Relations, State of California.* His reply was: (1) that it was too costly to establish a computer center in Southern California, and (2) plans are underway for each certified recipient to have more than one eligibility card in order to facilitate faster service.

Since our hearing before your committee, much has happened in California, relative to an investigation report of Medical abuses by the office of the State Attorney General. I feel that as a result, changes in the processing of claims by the fiscal agent Blue Shield will be made. (See newspaper article attached.)

2. The Los Angeles Urban League has a Department of Veterans' Affairs. Meetings were held with the Director of the Veterans' Administration Hospital, Director of Para-medical training at the Lutheran Hospital and other educators in order to establish para-medical training centers for returning Vietnam veterans who had ably served as medics while on duty. State Senator Dymally, Cbairman, Senate Health & Welfare Committee, introduced legislation (which is described in enclosed bill) to facilitate returning Veterans getting credit for their military training. We feel that those Veterans have a wealth of on-the-job training in para-medical care. There must be a transitional use of these men and women at a pay scale that would be inducing. I've noted that nursing homes have a high percentage of male nursing staff which is reflective of the acceptance by men of the para-medical professions.

3. Blue Shield and Blue Cross have described the "differential in terms of revenue nursing care reimbursement” as follows:

Medicare-pays for costs incurred on a cost-plus basis.

Medi-Cal-A ceiling is placed on care. California State Department of Finance allows a maximum of $14 per day. (Most facilities are paid at an average rate of $8 per day.) The fiscal intermediary sets the fee for each facility on the basis of information submitted by the facility. On January 1, 1969, all nursing home facilities will be certified under Medical in the state; we questioned their efforts to weed out the less desirable facilities.

4. The Watts OEO Center, as well as others in the United States, are providing major health care to their communities. Barriers to acceptance of this care range from undemocratic geographic boundaries to over-subscribed emergency room use. Aged patients need immediate emergency treatment when threatening heart failure.

Community multi-service units of health care offer this needed care. I would hope that multi-phasic, multi-service centers of health are to be a way of life in the future in America. Emphasis on multi-phasic screening for preventative health must be stressed as an important adjunct to this service.

I hope that your four questions have been adequately answered. We have very definite feelings about the use of the returning veteran, and would hope that his role could be spelled out nationally in this field of health care. California has become receptive. The AMA Emergency Health Forum of 1968 was asked by me, to consider the use of the Veteran Medic also. They felt that the pay-scale for such services were much too low to induce their interest status and commensurate pay can be achieved, I think.

Senator RANDOLPH. Dr. Littlejohn will now speak to you regarding questions 1 and 3.

STATEMENT OF CLARENCE G. LITTLEJOHN, M.D., FAAP, MEMBER,

BOARD OF DIRECTORS AND CHAIRMAN OF HEALTH COMMITTEE, URBAN LEAGUE OF GREATER LOS ANGELES

Dr. LITTLEJOHN. Honorable Chairman, Members of the subcommittee, I am Dr. Clarence G. Littlejohn, member of the board of directors of the Los Angeles Urban League and the health chairman of this organization.

I am practicing pediatrician and pediatrics cardiologist on the staff of several major and minor hospitals of the city. I am a volunteer pro

*See app. 1, p. 724.

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