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provided through the health core facility are of special importance to the elderly as well as to other groups with multiple problems. The OEO neighborhood health centers have clearly demonstrated this.

The elderly are very much like the ghetto dwellers. They live in a segregated ghetto of their own-too often in a single room furnished apartment, suffering from retirement rot with nothing but time on their hands. At that stage, their problems are largely nonmedical.

It is not unrealistic to consider the use of the health core facility as a vehicle for training of the unemployed at all ages, not only as health agents, but as professional assistants of all types. The elderly would benefit greatly from this. They could be trained toward the second job in the pre- or post-retirement years. This would circumvent the destructiveness attendant on their loss of work role as well as permit additional income at a time when they need both very badly. We need such new careers in all the human services-especially medicine as well as other undermanned fields. This, too, involves the principle of improved allocation of resources. Do we really have a severe shortage of professional manpower or are we merely senselessly misusing our highly skilled groups?

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The proposed model, strategically located geographically, would permit availability to all age, ethnic, race, and economic sectors, which would be far better psychologically than systems requiring further segregation of any one of those groups-which is often demoralizing

of itself.

Comprehensive health care systems are absolutely essential if we are to promote preventive care. We really have no choice. We must concentrate our efforts in the pregeriatric years, or very soon we will face the prospect of geriatrics virtually absorbing the practice of

medicine.

SUMMARY

In summary, then, I am making a plea for more activism and less study; for new cardplayers; for government and/or private encouragement and facilitation of improved health care delivery models, not only for the geriatric patient, but for all ages; for better coordination of existing programs, rather than addition of new ones; for a consortium approach with a clearer definition of roles; and for greater involvement and participation at the actual service level: I have also proposed a new model which, in my experience as a practitioner, as well as a health care programer, seems to have some universality and replicability.

I hope this very busy committee will find it possible to examine and consider it. Your critique will be most valuable to me.

I could not possibly end this presentation without thanking you for permitting me to come. I expect to learn a great deal. I hope my remarks will offer some contribution to the solution rather than to the problem.

Mr. ORIOL. Didn't you say at a conference earlier this year that physicians spent only about 25 percent of their time in direct patient care? Dr. GIORGI. Yes; it has been estimated that physicians spend about 25 to 35 percent of their time in direct patient care. The rest of their time is spent in doing chores that could well be done by others-chores that do not require their highly specialized skills.

DUPLICATION OF EQUIPMENT AND PERSONNEL

Another factor in costs and shortages is that of unnecessary duplication. Dr. Littlejohn stated that overhead expenses in a doctor's office is about 50 percent. No wonder. Each doctor's office has a full component of expensive and scarce equipment and personnel which they use only part time. Such equipment and personnel should be used full time. The real culprit in exorbitant costs is duplication down the line-from the doctor's office to the hospital and other facilities for institutional care.

At this point, I would rather not talk about cost per se-I would prefer to talk about care quantitatively and qualitatively. Improved health for all our people must of necessity prove to be less costly in the end. And that improved care will not be effectuated only through financial quantitative commitment. It must come through commitment to much needed change. It will require heroic measures-but it can and must be done. It will not be easy but it may well be easier than our current antiquated, cumbersome system of senseless duplication, fragmentation, and almost complete disregard of consumer perspective and dynamic health education.

Thank you very much.

Mr. ORIOL. Dr. Giorgi, you can be sure that your proposed new model will receive a great deal of attention. I find myself with many questions which we can't go into in detail right now, but we would like to get more discussion on it.

Is any work going on at the national center for health service research and development along the lines you are recommending?

Dr. GIORGI. I will tell you-you know, the Scheuer amendment with new careers is working on this. They haven't done enough in the health field. I would like to see this applied

Mr. ORIOL. Could this be a specific recommendation?

Dr. GIORGI. I would like it to be, and you could make it in connection with the aged, teaching them the second job.

Mr. ORIOL. Well, some of the questions that we will throw at you after having read your proposal in detail are: What is this model for? Is this a model for Federal action-to promote developmentor is this a model for community action?

Our Federal programs, including the development of what you envision-or are they contradicting each other, perhaps, in some cases? We will address many questions to you along that line.

Dr. GIORGI. Thank you very much.

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

1. Your "Unified Health Care Delivery System"-which, as you said, would be of special usefulness to the elderly-is of great interest. Have you give any thought as to revisions in existing federal programs-or perhaps suggestions for entirely new programs-that could be helpful for establishment of such a system? Or do you envision development of this system as primarily a matter for private resources, with only supplemental incentives from the federal level? 2. You also suggested that the elderly might serve in useful "second careers" as health aides of one kind or another. In what roles could they be especially helpful?

3. Your observation that preventive care for the aged in California is "invisible" leads me to ask for your comments on what kind of services are needed but are not now provided.

4. I am not certain I understand your references to a possible "black market" for health services. Do you mean that the onset of a program such as MediCal has increased demand for health services to the extent that Medi-Cal participants will be willing to pay some kind of premium to give them access to scarce health personnel? Or did you envision a more general problem?

5. You and other witnesses emphasized the need for health education, and yet I find myself wondering just how such education could reach the general public, especially the elderly. Do you have suggestions for increasing the effectiveness of educational efforts?

6. You began to discuss OEO health programs and indicated that you might have additional thoughts on that subject. Is it possible for you to give us additional discussion for our hearing record?

(The following reply was received:)

QUESTION NO. 1

My statements regarding development of a Unified Health Care Delivery System through private resources were expressed out of desperation. It is obvious that those institutions which might have been expected to be prime movers in behalf of unmet needs-namely, government (public health), profession schools, and the medical/dental professional organizations—seem powerless to perform. A conjoint effort on the part of all of these would be ideal. It is long overdue. Each of these seems blocked-perhaps because they refuse to recognize the fact that they are unable to "go it alone". They need help from other sectors. The approach is too complex for the health sector alone. A multi and interdisciplinary consortium is necessary. For this reason, I proposed a privately funded Community Health Planning Foundation as a means of providing such a consortium. There is no reason why the same approach cannot be sponsored by government. As a matter of fact, in view of an enlightened public's indignation over the inadequacies, inequities, and exorbitant costs of health care it may soon become mandatory for government to assume leadership. We already have much evidence that a very large consumer of services-the labor movement-is becoming quite militant in this direction. The Health Care of a Nation is one of the prime responsibilities of government. In this connection, as things stand at present, government— functionally, at least—has been placed in the position of responsibility without authority-extremely untenable to say the least.

SWEDISH SYSTEM

I would like very much to see a Unified System developed through government sponsorship-primarily along the same lines as the Swedish System developed under the leadership of Dr. Arthur Engel, former Director/General of the Swedish National Board of Health, so well described in his 1968 Michael M. Davis Lecture-Planning and Spontaneity in the Development of the Swedish Health System. This could easily be done without infringement on the one patient/one doctor concept which seems to be the main basic concern of both the provider and recipient of services.

However, if government does assume leadership it should take the form of promotion of effective planning for service rather than direct ownership, direct operation, or continued funding of educational or institutional groups in isolation from service groups.

Central to the Unified Health Care Delivery System is the Health Core Facility already described. This is a single access Ambulatory Care Facility either free standing or hospital based. As such, it lends itself very well to government sponsorship along the same lines as the Hill-Burton or Hill-Harris concepts. To be most effective, this would require new legislation and a new program. This legislation should be carefully designed to include provision for all the components already mentioned in the description of the Unified Health Care Delivery System. I would like to see funding provided to associations of professionals (not just doctors) preferably on a long term, low interest loan basis, rather than on a matching funds basis. I would also like to see provision made for community participation and Federal public utility regulation as well as a more equitable plan for prepayment either directly or through health insurance fiscal agents. The "Catchment area" concept should be maintained to avoid duplication and might even be extended to include "adoption" of a contiguous community where a medical vacuum exists. The latter could become a satellite of the central Health

Core Facility. Very important, also would be the provision that optimum use be made of existing facilities and programs before new ones are added. In those areas where adequate facilities and programs already exist, funding can be directed towards their consolidation and coordination.

All of this could be detailed by the framers of the new legislation. While it is important that the legislation be quite specific, it is equally important that it be looked upon as a guideline rather than a blueprint. It should detail only the basic essentials guaranteeing optimum service; optimum use of facilities, equipment, and manpower; equitable care to all; and reasonable cost. All this must then be regionally adapted with services individually rendered, family centered, and community oriented. This is by no means "pie-in-the-sky". It has already been done in other nations-why not by ours?

I feel that only through new legislation can we achieve an overall concept. Continued additions and rebuilding on shaky foundations of old programs which have remained isolated from each other-and have failed miserably-gets us nowhere.

Equally ineffective is the senseless addition of new programs addressing themselves to a small part of the larger problem. They only serve to further fragment and to dilute all resources. A new program of this type may not necessarily require a great deal of additional funds. Since the keynote is primarily coordination of existing services, it can be partially funded through optimum use of existing funds.

It should be noted that organized medicine has already indicated approval of ambulatory care centers. I refer to Dr. Milford Rouse's statement in the November 27th, 1967 issue of the Journal of the American Medical Association. The California Medical Association has also been very interested in "promoting the art and science of medicine and the betterment of public health". In California Medicine of May, 1968, it calls for a "flexible and informed advocacy" on the part of the medical profession and envisions "individual physicians and organized medicine as a powerful and effective force for better health and better health care in this Nation". They are asking for inclusion in planning. I find this very encouraging.

ALTERNATIVES FOR GOVERNMENT INVOLVEMENT

If new legislation is not feasible, alternative methods for government involvement could include the following.

1. Extension or revision of PL 89-239 (Regional Medical Program) to include implementation of a Unified System.

2. Revision of PL 89-749 (Comprehensive Planning Act) promoting a closer relationship between sections 314C and 314E so that training of planners can be done in the framework of service and involvement of practitioners of all disciplines in designing a Unified System.

3. Revision of the O.E.O. Family Neighborhood Health Center concept towards incorporation into a Unified System. It is far better when services to all groups can be rendered through common facilities. Accessibility can be arranged through strategic location of services as well as by provision of transportation when needed.

QUESTION NO. 2

The elderly are too often forced to retire at a time when they are still very capable of function. This is especially true of those who are employed in the "over manned" fields. Labor Union regulations also promote such retirement. Too often those regulations are motivated towards making room for new membership.

I would like to see us educate and train such retirees towards a "second job" in the "under manned" fields such as health aides and assistants of all typesboth those already existent and new careers. These could include medical aides. laboratory assistants, X-ray technicians, home health aides, nurses' aides, social service aides, health education aides, multipurpose workers (new careers), etc. Aides in education are also desperately needed. I think the retiree should be trained prior to retirement through the mechanism of a sabbatical.

The concept of the multiphasic worker is further discussed in answer to question five. The idea of training for a "second job" in the pre-retirement years was described in the paper-The Sabbatical in Industry*-previously submitted to your committee.

*Retained in committee files.

QUESTION NO. 3

As far as I know, there is no provision for periodic health examinations. To my knowledge, such services are not reimbursable under either Titles XVIII or XIX. A program providing periodic multiphasic screening tied to a physician examination would go a long way towards preventive care. It would be even more successful if it were performed in the pre-geriatric years. In addition to detecting disease and disruption prior to the irreversible stage, such health examinations might even provide some means for surveillance and circumvention of such abuses as over-testing and excessive visits by providing a general, social, and biochemical reference audit and profile on each patient.

It would have been very feasible to make provision for this through Medicare. It is very customary to request health evaluation in conjunction with health insurance. Medicare is mediated through the mechanism of social security which is an insurance plan.

Such periodic examinations, including multiphasic screening, can decrease the time required for a complete checkup from about two hours to one-half hour or less. This will help circumvent professional manpower shortages. It has been estimated that, if every person in this country were to have an annual complete health examination under present methods; it would require about forty-five hours out of each practicing physician's week. Obviously this is not feasible. Decreasing the time to one quarter of the present required time would obviously assist this immeasurably.

The type of complete audit permitted through a well designed periodic multiphasic screening program may even provide a means for determining priorities on professional time. At the very least, this is worth testing and demonstrating. The Health Core Facility Concept provides a vehicle for such testing and demonstration.

QUESTION NO. 4

By "black market" in medicine, I meant that services will soon be so scarce and the cost so high that only those who can pay "premium" fees will be able to secure health care. I also referred to currently existing practices of "hidden" additional costs to institutionalized Medicare patients which take the form of such things as extra charges for telephones which are not requested by the patient; and extra charges for family visitor parking equally unsolicited; as well as other abuses recently reported in connection with the California MediCal program. The acceptance of the patient into the facility becomes contingent on such "tributes". This and other types of "under the table" payment have a definite "black market" flavor since they involve illegal practices as well as "premium" and "tribute" payments.

QUESTION NO. 5

Some of us are frequently requested to speak to groups of elderly people. They are very avid for information concerning nutrition, medicines, and the more commonly occurring chronic illnesses such as arthritis, cancer, heart disease. stroke, diabetes, etc. There is a striking lack of knowledge as to these as well as to the proper use of health services. We will never have true "quality care" until the patient faces his doctor with adequate knowledge as to what is being told to him as well as to his entitlement. Without such knowledge, the elderly— who are constantly being told; "what do you expect at your age"-often wait until it's too late to present for care.

One of the better ways to provide such health education is through the informed advocacy of properly trained peer groups such as new career multipurpose workers health ombudsmen. This could be a "second job" for retirees.

Many years of observing patients in clinics as well as in my own practice have taught me that a great deal of the therapy is in reality done by peer related lay groups. Repeatedly, I have observed them consulting cashiers, attendants. porters, secretaries, etc. after leaving the doctor either for additional information or for clarification of confusing orders given by the professional staff.

Multipurpose workers of this type could be used in clinics. They could also visit Homebound Medicare recipients in their homes and could conduct community teaching sessions in schools, churches, clubs, etc. There is little doubt that they could reduce the need for scarce professional services and for unnecessary medications-too often given to "get rid" of the patient. It has been correctly estimated that about 80 to 85 percent of people presenting to the physician just need someone to "talk to".

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