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Mr. ORIOL. Mr. Skoien.



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Mr. SKOIEN. The only thing that I am going to repeat and emphasize is not only that statement this morning by Mrs. Russell, but also re-emphasize that California is the forerunner in these programs for health care for our senior citizens. We must utilize the seniors in their own health programs, and we will mobilize--and must mobilize--and motivate the existing public and private agencies to recognize the need and then proceed.

This is being done today by the California Commission on Aging at the level of the local community.

The Reagan administration is endeavoring to provide California with a sound administrative program for the citizens of our State.

Thank you.
Mr. ORIOL. Thank you very, very much.

Our next witness is another person who has been very helpful to the committee.

Dr. Elsie Giorgi from the School of Medicine at USC. You have a time problem. I hope we haven't caused you too big a time problem. STATEMENT OF DR. ELSIE A. GIORGI, ASSISTANT PROFESSOR,


Dr. GIORGI. I don't mind if you don't. At your request, I have prepared a statement. Before I start, however, I should like to make a few comments—if I may.

Today, I have been impressed with the great interest and concern of all who have appeared here. It is obvious that there is agreement as to the need for change. I must say, however, that I have been disappointed by the emphasis on funds rather than programs. We have much evidence that funds are no guarantee of service. This was particularly true of State government representatives. Mr. Mulder, for example, spoke of preventive care services for the elderly. He spoke about such services as if they were an actuality. Something Mr. Galbraith refers to as “word-fact”. Where are those services? If they are present, they are certainly invisible.

During the past 5 years, I have participated in many similar discussions. We constantly talk, exchange ideas, and plan ad infinitumand then nothing of significance happens. I think it's time to stop talking, stop blaming, and start doing. I hope this once, it will be different. I hope this committee will see to that. For the first time, I sense a motivation for doing. For the first time, I am encouraged. That's why I'm here.

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We really have no choice. We are at least 40 years behind. Unless we join forces toward the common goal of improved health care for our people, I do not think it is an exaggeration to predict that within the next 5 years, shortages will be so great, and costs so high that we

will have a black market in medicine with care extended only to those who can pay exorbitant amounts or who are agreeable to paying under the table in government funded programs.

No amount of additional funds will help. Until we design new systems; train new types of health manpower; effectively coordinate what is already there; and provide dynamic health education—those additional funds will only serve to further inflate costs without improving or providing adequate health care services. We have already seen this happen. We don't need more of the same. I think an important step would be to consider health facilities public utilities-subject to the same type of surveillance and regulation as public utilities. Why not? Health care is at least as important as our telephone and electric services. If such a system did nothing but prevent unnecessary duplication down the line-we would be well on our way to curtailing costs. This does not necessarily imply socialized medicine or government medicine. It would merely provide a much needed systems approach which the medical sector seems unable or unwilling to undertake. It is time for them to stop resisting new knowledge.

I appreciate your invitation to appear before your subcommittee on Health of the Elderly, with particular reference to the costs and delivery of health services to older Americans. I would like it clearly understood that my remarks are my own, and not to be interpreted as representative of any institution or organization with which I am affiliated.

TOTAL HEALTH At the outset, let me say that I find it impossible to confine my presentation to the elderly, since the health care of any age group really starts from birth or even before that. Man is inseparable not only from his physical and psychosocial environment, but also from his genetic inheritance. Total health involves careful attention to all of these in an integrated continuing and coordinated program. Neglect at any stage of growth and development requires increasingly heroic measures for correction of defects in later years. Dr. Robert Kemp expressed it exceedingly well. In speaking of the care of the previously neglected aging individual, he said—Why fix eyes that no longer want to see why fix feet that no longer want to walk? I certainly concur.


Equally neglected is this Nation's health care delivery system. It is now so sick and disorganized that nothing but heroic measures can possibly bring some order out of the chaos and ferment. I shall not bore you with a repetition of its inadequacies and inequities. These are already well known to you. Instead, I should like to devote this brief time to some comments on our almost hopelessly ineffective approach to correction of the defects and to some suggested alternative methods.

The current state of affairs did not happen overnight. In 1925, fully 40 years ago, the distinguished Dr. William Welch bemoaned the ever widening gap between highly advanced medical research and its clinical application. We have had no real change in medicine since the monumental Flexner studies of 1910–11. Dr. Flexner's assumption that

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advanced scientific research and education would automatically result in quality care has not been borne out. What is sorely needed right now is a clinical revolution-counterpart of the scientific revolution that followed the Flexner report. I do not intend revolution in an anarchistic sense, but rather to imply rapid change, for we are at least 40 years behind.

What has brought about this sudden state of emergency ? Many things, to be sure—but principally an enlightened public made aware of its right to good health, chiefly through medicare. That piece of legislation stimulated demand by providing funds and public education. It focused attention on the fact that funds do not necessarily provide services.

There are some who argue—was it wise to precipitate such a situation; to stimulate demand before services were available? Those who are concerned with quality and cost of care should not have wanted it any other way—for demand stimulates supply. If medicare accomplished nothing but this

and indeed it has done much more-it could rest on its laurels. Without its impact, we would most assuredly have continued as we were; each year losing ground progressively and paying more for less, while morbidity figures increase steadily as glaring evidence of our deficiencies—especially when compared with other nations of far less affluence and technologic skills.

Mr. ORIOL. May I interrupt, Dr. Giorgi? May I also say that demand might stimulate inflation—there are those who say that this sudden calling for services has caused too much demand for too little supply.

Dr. Giorgi. I think you are right. Demand in excess of supply inflates the cost. It always does—but it soon levels out because it outprices itself out of the market. I'm afraid that's what is currently happening to our prepaid health insurance plans. Any good which might be inherent in them is nullified when it becomes too expensive and unreasonable and untenable in costs. But there soon comes an end to that or it must go out of existence.

This Nation possesses the greatest potential for total and comprehensive health care. It boasts of the finest facilities, equipment, health manpower, and a generous national budget-all for the most part in advantageous ratio to population. What is needed is coordination of what is already there, and effective health education toward better health practices, as well as toward optimum use of existing services. Instead, we keep adding instant new programs, for the most part hastily and poorly thought out, which usually serve to further dilute our resources.

OVERDIAGNOSED AND UNDERTREATED In medical school, we learned that diagnosis puts us well on the way to treatment and recovery when cure is possible. We have repeatedly and effectively diagnosed the ills of our health care delivery system. They are not incurable. We should be well on the way to treatment and recovery—Instead, we persist in studying them over and over again. We are overdiagnosed and undertreated.

It has become obvious that current major governmental planning funds under Public Laws 89-239, 89–749, and even the National Center for Health Service Research and Development, are being allocated predominantly to more diagnosis, to education of the medical sector, and to training of planners. It is also obvious that the term “partner

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ship for planning” intended to involve-in the words of Dr. William Stewart-"by no means only the medical sector”—and not "the same old card players around the same old table”-is rapidly doing just the opposite.

Continued subsidy of existing institutions such as medical and public health schools has not, in the past, been effective in promoting adequate or significant change. Why do we expect it to do so now? Their role as advisers, educators, and their contributions in identifying unmet needs, are most valuable, indeed—but we cannot continue to overlook the fact that such institutions are not service oriented and not activists in a true sense.


What we need is to apply what those institutions have so effectively studied and diagnosed in the past. Basically, what is needed is a reallocation of existing resources into a coordinated, unified health care delivery system—and we need it right now.

To this end, why not channel a good part of those funds to activist service groups such as associations of health professionals? Why not enlist the expertise of the medical, dental, and public health schools to assist those groups in planning services based on what is already known? Why not grant fellowships under sponsorship of educational and allied institutions to individuals who are adept at planning, and at grantsmanship—with a view to assigning them to work with such groups toward implementation of alternative health care delivery models? To be sure, we are told that such planning funds are available under section 314E of Public Law 89-749—but to my knowledge, they are not very visible and those who might put such funds to use are just not good at drawing up proposals. I have no objection to educational institutions continuing their studies and their teaching of planners. I would just like to see them extend into the community and help other groups design service programs—both are of equal importance--and what better way to train planners than in the framework of service.

Why not have them also make contact with future doctors and dentists, at the medical school and residency training level, encouraging them to understand and consider participation in new approaches to delivery of health care services?

All of these would distribute funds and enhance participation at the service level—far more effective than continued study and planning at the institutional level, virtually in splendid isolation from current and future health practitioners.

I am being repeatedly requested by medical students, by medical residents in their last year of training, by practicing physicians, by large consumer groups such as Union-Management, and more recently by large scale proprietary hospital ownership groups and city planners involved in the design of new communities—to assist them in evolving and implementing comprehensive health care models.

The medical profession and organized medicine groups are publicly expressing interest in change. The practice of medicine is becoming increasingly difficult and emotionally unrewarding because of demands made upon it by the very complexities and multiple problems of daily



living, as well as by the increasing amount of administrative and managerial tasks imposed by very necessary government standards and health insurance regulations. It has become impossible for the physician to go it alone and to be it all. The time for change was never so propitious. Activism is needed as it never was before.

ALTERNATIVE HEALTH CARE DELIVERY PROPOSAL I have taken the liberty of appending to this paper, a suggested alternative health care delivery model, together with a recommended definition of roles for the various sectors involved in health care, including public, private, and philanthropy groups.* These comprised a proposal submitted by me to a private group interested in funding a Community Health Planning Foundation. We are still discussing this possibility:

There is no doubt that governmental action of the same kind could also effectively promote the development of such services. These papers are too long to permit reading here.

Briefly, the plan describes the creation of a unified health care delivery system, centering about comprehensive ambulatory diagnostic and care centers-called Health Care Facilities-pooling ancillary, paramedical, managerial, and administrative services, simultaneously permitting the one doctor/one patient relationship. It provides free and rapid transfer between the various components of the system and defines the role of each. These include the community-cottage-hospital, medical center, and extended care facilities and programs.

All services are supervised by the managing physician, coordinated by the health care team, and expedited by the family health agents. The latter is a new career-a peer related, informed advocate of the family. The plan coordinates existing services and is adapted at the individual community level-adding services only as the need for such addition is clearly demonstrated. It establishes effective quality and optimum utilization surveillance through a team approach. It is expected that savings in cost will result from the pooling and more sensible use of those parts of health care which are the most costlynamely: ancillary, administrative, managerial, and institutional.

The plan is offered as an alternative method. There is little doubt that the elderly would benefit greatly from it-perhaps more than any other group, since it permits easy availability and accesibility of all services through a single access, and also provides the means whereby they may be put more closely in touch with existing health services. Another service which is greatly needed by the elderly in urban areas, especially those that are relatively and absolutely homebound, is the meals-on-wheels concept. We should have more of this.

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The family health agent would be of great value in providing the elderly with information concerning their entitlement relative to governmental and other benefit programs. This type of medical manpower, together with other physical and emotional rehabilitation personnel

*See app. 1, pp. 727-734.

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