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The Health Care Facility Concept can well be used as a training Laboratory for all types of health career assistant and associate personnel. It can also be used as a vehicle for dynamic health education. The elderly are admirably suited to such careers by reason of their experiences, empathy and their great need to feel useful and wanted. Proper training can orient such multipurpose workers towards the direction of optimum self-sufficiency for their clients.

QUESTION NO. 6

My experience with O.E.C. health programs results from very active participation in the design and implementation of the Southcentral Multipurpose Health Services Center; a U.S.C. sponsored, O.E.O. funded Neighborhood Health Center in the community of Watts, Los Angeles. It is very difficult to discuss such health centers purely from the medical care standpoint. They were part of the larger parcel-The War on Poverty.

The intent of the Family Neighborhood Health Centers was to make use of health services as a wedge to correction of other inadequacies and inequities experienced by the disadvantaged such as poor education, poor housing, unemployment, etc. They promoted a total health concept in its broadest sense which, though admirable, inevitaably resulted in the introduction of numerous variables-each of which posed a threat to existing institutions, resulting in constant harassment from many sources, and repeated compromises which were too often paralyzing and disruptive.

Like other O.E.O. programs, the Family Neighborhood Health Centers were supposed to reduce the powerlessness of the poor. The impression was that they, rather than the establishment, were to be in command. This became impossible of achievement since the funding of the Health Centers was awarded to the establishment, and quite naturally the disadvantaged equated power with money. The term "maximal feasible participation" was never clearly defined which produced an inordinate amount of conflict in the design and operation of so highly technical and complex a structure as a large health center in which areas of competence are of great significance. Consumer perspective and participation is very necessary in all service programs. However, when this became confused with actual operation of the facility, chaos often resulted and threatened the proposed partnership.

Many problems were also inherent in the need for "year to year" funding. There were constant deadlines to meet in the way of reporting and re-budgeting. All of this interfered with smooth operation. Even more significant was the quite ridiculous assumption that professionals would leave either a good job with security or established practices to assume full time work with a program that could not guarantee employment beyond the one year term of the grant. The result was inevitable. Too many of these health centers either employ part time professionals or are understaffed-thus sacrificing the concept of continuity of care. A sense of the temporary was pervasive; certainly not conducive to feelings of security or stabliity.

Many of the clinics are free standing. Without guarantee of admission to the hospital, there is always the element of rejection by the hospital admitting physician. Attempts at true coordination with existing services and programs. even those funded by O.E.O., were constantly thwarted due to such things as differing philosophies and criteria for acceptance as well as manpower, budget, and space shortages on the part of other agencies and institutions. All of this greatly interfered with both continuity of care and implementation of the total health concept.

The inevitable result was further frustration and distrust on the part of the people who felt betrayed by promises unkept in the failure to achieve the goals of better health, better jobs, and better education.

In spite of all this, there is a definite danger of further frustration and distrust should these health centers be discontinued. However, before they proliferate further, I would think it mandatory to have a complete evaluation as to their efficiency, per capita operational costs, etc. I do not believe this has been done to date.

I do not think that O.E.O. Health Programs-as they are now designedcan effect coordination and unification of health care services-both of which are sorely needed. As a matter of fact, should they continue to expand beore proper evaluation, the end result may well be a shift of inequities through further dilution of funds and resources.

At the same time, I wish it clearly understood that I approve of the basic philosophy of the total health concept, and the War on Poverty, and the use of health care with relation to both. The concepts of consumer perspective and participation; health care teams; dynamic health education; peer related multipurpose workers as informed family advocates-all of these are of proven value not only to the poor but to all of us. There is no reason why these cannot be incorporated into a coordinated and Unified System rather than through creation of plans which enforce rigid geographic and economic eligibility standards, and are stll in reality "medicine for the poor".

We are indebted to O.E.O. for its energetic approach toward promotion of these concepts. It is now time to move on to a broader and more complete planone which addresses itself to the total problem of better health and health care to all with the least amount of threat to existing institutions. This can be accomplished if we are mindful of the fact that truly successful planning usually carries with it that which is good from the past; is pertinent to the present; and has some meaning for the future.

At this point in time, with relation to health care services, I feel that experience has taught us that the perference of both recipients and providers of services leans heavily toward a one to one relationship in connection with the very "personal" services. Comprehensiveness, and reasonable cost as well as the other factors described can still be achieved through pooling of the less "personal" aspects of health care such as clinical tests, other special para-medical and ancillary services, and the administrative and managerial components—all of which traditionally lend themselves much more readily to grouping.

Mr. ORIOL. Our next witness is Mr. Cass Alvin, representing the council for health plan alternatives.

If Senator Williams were here, he would greet you as a fellow steelworker.

Mr. ALVIN. Yes. Thank you.

STATEMENT OF CASS ALVIN, EDUCATION COORDINATOR, UNITED STEELWORKERS OF AMERICA

Mr. ALVIN. My name is Cass Alvin, and I am representing the California Council for Health Plan Alternatives, which is comprised of trade unions in California, both AFL and CIO, as well as the independents and the State and regional bodies.

This is a problem of time where I am unable to make a formal presentation on behalf of the council.

We will, with your committee's permission, Mr. Chairman, submit the council's views at a later time, and we will continue to do so as we work together, unraveling some of the mysteries of the rising costs of health services, and we will submit from time to time some of the ideas and suggestions we have for improving the efficiency of health care services and its quality.

I would like to confine my remarks to a few observations.

I would like to say first of all that following Dr. Gorgi is not a very easy job. I think she touches just about all the observations that can possibly be made. She is one of the consultants to our council on health planning alternatives, and we value her imagination and creativity in this field.

The California Council for Health Plan Alternatives grew out of the need of trade unions for a coordinated effort in tackling the problem of how best can we provide our members quality medical care at the lowest possible price.

Our experience in this field was at first limited. We bargained for a few cents. We went to a vendor, an insurance carrier, who would

indemnify our members to some extent for the cost associated with hospital and surgery.

Over the years we have gone back annually to our employers, shook their pockets, stacked more money on the table, enlarging to a small degree the coverage of the insurers' plan, adding new and sometimes questionable benefits only to return again to take more money in lieu of wages, and turning it over in a lump sum premium to an insurance intermediary.

HEALTH PLAN ALTERNATIVES COMMITTEE

With but few notable exceptions, like the Kaiser plan, that was the only way open to us. And that is all that is open to us presently-that is, until we started our work with California Health Plan Alternatives committee.

What we in fact, are doing is what you in Government are doing about the dollars that are going to the health care for the aged. You and we in labor, as the consuming groups apparently are yet unable to make an impression on most of the medical establishment which needs to know the thinking of the consumer.

We are the representatives of the people who pay the bill.

We in labor grow weary of chasing the dog's tail, finding ourselves in this whirl of putting more money into our plans and not making any appreciable headway.

We can't get out because as yet there is no alternative for our mem

bers.

The prepaid union negotiated medical plans in the State of California amount annually to about a quarter of a billion dollars-this is a lot of money. We are the largest single consumer of health plans in the private sector.

We have been trying to get at the root causes of some of the rising costs and looking for standards by which we can improve the quality of medical care. We don't think you can separate quality from the cost.

It matters very little to a person who can't afford a medical plan what the quality or costs are. If the cost gets so prohibitive that you can't obtain medical care, then quality is of little value. We think the two have to go together.

We think we have found, up to now, some alternatives to some of the rising costs. What complicates our problem and complicates the problem of your committee is that it is almost impossible to get available data, or even a rationale for the rising medical and hospital costs from those who have the figures but who are reluctant to release them.

No secret was ever guarded as carefully as the figures behind the fantastic escalation of medical costs-the hospital and doctor costs. I suspect this will continue to be the case until those who pay the bill -the consumers, we in the labor unions and you in governmentinsist on some kind of an accountability from the purveyors of medical services, and that the data upon which they base their cost assumptions are exposed to public scrutiny.

POSITION OF LABOR UNIONS

California labor unions, by now experienced in the inflationary phase of the State medicare program, are not accepting the recommendation by the California Medical Association and the Blue Shield that the 60 percentile basis for charges for medical procedures be raised to the 90 percentile level.

This proposed change would tend to bring all the medical costs up to the 90 percentile, and would bring about an automatic escalation. If there is any remaining money in the Medi-Cal program, once this change is instituted, the surplus would be wiped out and the increased costs will have to be made up by going again to the legislature for

more money.

We were told this was necessary to keep more doctors interested in handling medicare patients. Incidentally, it was said that there were 18,000 doctors in California involved in the Medi-Cal practice. What wasn't stated was how many of those doctors charge fees over and above what is provided under the medicare and the Medi-Cal programs.

We in the Council object to this proposal made by the California. Medical Association. For what use your committee could make of our testimony, and to all parties concerned in this State, I would like to submit our thinking on this matter as a matter of record to your committee.

You may ask what costs of medical and medicare have to do with the medical costs and delivery of health care of all others. Our experience in trade union prepaid medical expense plans, convinces us that it is all a part of the same ball of wax. It cannot be separated.

Every movement, every development in the medical care field has a relation to the other.

When medicare became operational, for instance, millions of aged people, who before could not afford medical services, saw hope and took their illness to the same establishment that serves all the others, including trade union members who were covered by prepaid medical plans, and all others in the community deriving health care services from the same establishment.

Something is bound to happen. You start paying more for the same or even paying more for less. Sometimes you get services you don't need, and you pay more for them. We don't think this will stop unless something is done, until we regulate by consumer pressures the price rates of medical care or until we find alternative ways-some new systems of delivering medical care not only for the aged but for all the people.

It is like the old jar of jam. Unless there is some control over it, an awful lot of well-intentioned people find themselves all covered with the stuff. This will keep going on as long as this jar continues to be refilled and no controls put over it.

I don't say this as a pointed charge against any segment of the medical establishment. We have, as has been earlier indicated, some cooperation from the California Medical Association, and much to the credit of our committee, I think we are doing what you are doing with

these committee hearings; starting to have a dialog with the medical establishment.

We are, for the first time, talking with the people who deliver the medical care services to our people.

Talking with intermediaries I think is a waste of time. While we appreciate the insurance companies and other intermediaries-they have got their little playpens. They have taken a lot of health plan negotiators out to lunches, but we just don't think we have had any success with them.

We don't think they can effectively change the method of delivery of medical care services or in any way control the price. We think they are really a part of the entire system, and no changes are likely to come from them at all.

The economic forces being what they are, I don't think the equation will ever change unless there are consumer pressures. What we need is more and more competition in this field of medical care.

I am a member of the hospital advisory board, and I am appalled at the gross inefficiencies that go into our hospitals. Even the purchasing of the necessary paraphernalia for hospitals indicates that there must be some kind of a fungus growing which allows costs to rise without any checks or controls.

One example, for instance, we have an employer under contract with our union who makes bicycles. But in addition to making bicycles, he makes wheelchairs.

Now, the same kinds of skills-making bicycles-go into making wheelchairs. About the same kind of material goes into a wheelchair as goes into a bicycle, and yet the hospital pays about 10 times as much for a wheelchair as a consumer pays for a well-made bicycle.

Actually, the amount of material and labor that go into making bicycles and a wheelchair are almost identical.

It seems that no one seems to care about the cost that goes into hospitals. No one apparently cares about such items of cost so long as someone else is paying the bills. In the health care business there are not the kinds of pressures we find in the rest of the marketplace.

"PIECEMEAL" HEALTH PROGRAMS

We ought to look at the health of the whole community. We may be exceedingly wasteful by just fashioning our system to serve a particular segment.

What we are doing at present is having medicine for the rich, medicine for the poor, for the old, for the young, for the black, for the white, for the rural community, for the urban center. I think we must start thinking about medicine as something to be delivered on a community wide basis, so that we don't have the segregation problems-we don't have rich people involved in one kind of medical care and the poor in another kind-the black in one, the white in another.

It is understandable why this occurs. Many times Government programs come about in a piecemeal fashion, and we all hope that once such programs are started, they will serve as a foot in the door for the rest of the community.

We have been doing this, in part, for years, one foot at a time in the door-and I suggest that this is more than just a two-legged problem.

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