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It is really more even than a centipede. Maybe we should start getting all of the feet at one time.

For instance, what we do for the infant and the children in health care will have a lot to do with what they will require as aging citizens or the kind of care they received during their working years.

The kinds of health care that we are able to provide people in the middle span of their lives likewise will affect the health of the older citizen,

We see today a tragic paradox in the problem of the unemployed. While there are shortages of certain technicians, nurses, and other health service personnel, it seems that in the area of human needs, these human services, there is an unwillingness by the private sector to spend a buck.

The public sector is of course afraid of the cost pressure of taxes. So we are left here with people who are able and willing to provide human services, and because there is no proper organization in this area the abilities of these people are not being utilized.

My observation is that we are, for instance, willing to spend more money and more time in training the seeing eye dog to lead a blind person around than we are willing to spend on some individual who could take the hand of an older person and provide him the kind of human services required.

TEAMSTERS MULTIPHASIC SCREENING PROGRAM In the California Health Plan Alternatives Council, we are very much impressed with the successful program of multiphasic screening used by the Teamsters and the other unions in the food processing industry. About 20,000 workers are pressed every year through a mobile system of well-equipped vans.

We have evidence of how thousands not only receive annual checkups without cost, and with minimal inconvenience. A number of people, because of this early detection, became well, and in many, many cases had their lives saved.

There are certainly many ways that such a type of an examinationdetection of ailments—can be helpful with the health care of the aging.

This idea should be explored further. Not to be in conflict with what was said at this hearing about preventive medicine, I still have to see any sort of a multiphasic screening or any other type of preventive medicine program in the State of California for the aged.

It is not enough to say that you ought to have a family doctor. What was learned from the multiphasic screening in the food processing industry is that about 60 percent of those people don't have a family doctor. The family doctor is a yellow page of a telephone directory

Just telling them they should have a family doctor is not a form of preventive medicine. Certainly everyone should—it is like telling a person, “You ought to be well and not require medical services."

Observation indicates that the aged are not really, in many cases, receiving medical care but are housed in places that provide little more than custodial care.

Many of these people may be just lonely, and not sick, as Dr. Giorgi indicated. While this is probably prevalent in other age brackets, this

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may be peculiar to the aged. It may require new professions and vocations, schooled to fill some of the kinds of needs that the aged require, other than just medical care.

ELDERLY AS POWER Bloc My last word, if you will permit me—I am talking to a group of Senators--with about 10 percent of our population of 65 or over, I feel confident that some solutions will be found not only in the area of cost of medical care, but also in the quality of medical care. The large number of elderly people is a definite power bloc, and in this day and age when we group people into color power blocs, we call it the aging "grey power”.

And since 65 comes after 21, I need not remind anybody here of the pressures that this power can exert, or what change of direction it can make in our society-even in our medical establishment.

The California Health Plan Alternatives Committee wants to use its voice to help in this problem, not only because we are in a sort of symbiotic relationship with other groups wanting to improve our system of health, but also because we are also all aging together.

Mr. ORIOL. I would like to thank you very much for that statement.

I know you didn't have time in this statement to give a full description of what the Council on Health Plan Alternatives is, but we will get that in a letter statement.

But basically what this group is doing is making sure that current members of unions-is it limited to union members?

Mr. ALVIN. Yes

Mr. ORIOL (continuing) Are covered adequately by health plans, and in doing that, you discovered certain things in the delivery of services that you would like to see improved.

So that by the time this present group that you are working for now themselves become elderly, why, by having taken care of themselves at an earlier period of time, in a way they are contributing to the resolving of some of these problems concerned with the elderly.

Mr. ALVIN. Also, in addition to that, many of our plans now include not only coverage for the active employees, but for the employees upon

retirement. We are concerned certainly with our aging population and their health needs.

There is another important point on this, and that is that many of our plans provided medical services and health care services to retired people. When medicare care came into being, some of our members were already covered by union negotiated plans. Now who is going to pay the bill? Of course, the employers and unions-just as any other groups-choose to transfer the cost on to the Government, and this has been done in many cases. It has been a saving in many ways to our negotiated plans. Some of these costs to our plans now are borne by medicare.

On the other hand, however, we know that putting 10 percent of our population on medicare has an inflationary pressure on existing plans, so that in one way, we have benefited a little costwise but in another way have found the inflationary cost effects of medicare.

Mr. ORIOL. We want to develop that in questions to be addressed to the committee. You will submit for the record this Memorandum on Health Plan Alternatives ?*

Mr. Alvin. Yes, I will submit it.

Mr. ORIOL. I would like to acknowledge that Congressman Alphonso Bell is in the audience. If he has any time now, and wishes to address the committee

Mr. Bell. Thank you, Mr. Chairman. I have nothing to address to the committee at this time. Thank you.

Mr. ORIOL. And now I would like to call Mr. Donald Gormly, president of the California Association of Nursing Homes, Sanitariums, Rest Homes and Homes for the Aged, Inc.

I see Mr. Burch of the American Nursing Homes Association. Perhaps you would like to accompany Mr. Gormly.

Mr. Gormly, your appearance springs from discussions we had with the ANHA. I am glad to see you here.

Mr. Gormly. Yes. Additionally I have Mr. Clinton Jones from the California Nursing Homes Association.

We shortened our title. Our official title is-
Mr. ORIOL. Is it longer than this?

Mr. GORMLY. Well, in conversation we call it the California Nursing Homes Association.



Mr. GORMLY. Mr. Chairman, members of the special committee, my name is Donald Gormly. I am President of the California Nursing Homes Association. I am also a regional vice president of the American Nursing Home Association-representing region VIII, the Western States—and in that capacity I serve on the executive board of the national body.

On behalf of the California State Association and the American Nursing Home Association we wish to extend our appreciation and thanks to Chairman Williams, Senator Moss, Senator Randolph, and other members of the committee for the leadership you have demonstrated and the concern you have expressed for the elderly, and for your efforts in strengthening the medical care programs for the aged. We wish also to express our appreciation for the cooperation extended by this committee in the past.

We stand ready to continue or cooperation in the effort to achieve our common goal: to make a better life for our senior citizens by providing quality health services to them.

Mr. ORIOL. Mr. Gormly, if I may interrupt. You mentioned Senator Moss—and that is Moss of Utah, and he had hoped to be here today, especially because he is chairman of our Subcommittee on Long Term Care.

You can be sure a copy of your statement will be sent to him.

*See app. 1, p. 734.

Mr. GORMLY. We will appreciate that. Thank you.

Mr. Chairman, we as providers of health services in California comprise an organization of 1,300 private facilities, with approximately 55,000 medical care beds. All are licensed by the State; mostly as nursing and convalescent homes, and some as mental hygiene long term care facilities.

Virtually all of these institutions—both proprietary and taxexempt-currently provide services to patients under the title 19 program, known in this State as Medi-Cal, and to which I shall hereinafter refer.

Of equal interest is the fact that over half of these facilities over 700 in number-are title 18 medicare-certified, thus forming by far the largest State group of extended care facilities--ECFS-in the Nation.

In addition, our California membership includes hundreds of residential care homes and institutions—all of them licensed. I mention this group particularly because of its increasing importance and potential as this committee weighs the advisability of defining various levels of aged and needy patient care to meet more exactly the needs of the individual elderly and convalescent ill.

I might add that our State association is dedicated first and foremost to the constant betterment of patient care. As a demonstration of this, a primary requirement of membership for each facility is State licensure, and the meeting of State-set standards of care. Conversely, loss of licensure terminates membership:

In the light of our prime interest in the patient, then, I will respond briefly to the suggested question: What has been the effect of the medicare and Medi-Cal programs upon the kind of services provided by our member institutions--and what recommendations do we have for further legislative or policy change?


In general, there seems little doubt that the two programs have resulted in higher standards throughout California. In fact, the newly required title 19 Medi-Cal or skilled nursing home standards are nearly approaching Title 18 medicare standards in terms of costs.

Our California association has just completed a cross section study of 309 facilities to find there is now only 44 cents difference per patient day between a Medi-Cal skilled nursing home and a freestanding ECF. On the average, then, Medi-Cal standards are catching up cost wise with medicare.

Mr. Oriol. May I ask why you so pointedly say “costwise?” What other comparisons might be made!

Mr. GORMLY. Well, the standards of the title 19 program have been elevated, and they have, in fact, come up almost to the medicare standards, and this in effect raised the cost-standardwise they have to

Mr. ORIOL. So that cost follows standards?
Mr. Gormly. Yes, they are going down the same road.

The basic reason for this growing similarity is easy to identify: it is the increasing nurse staffing requirement--the major cost item in today's nursing and convalescent home. Nevertheless, the delivery of good quality nursing care in these Medi-Cal institutions constitutes government's biggest bargain in health care for the elderly and needy-at a time when general hospital care costs are soaring toward the hundred-dollar mark per patient day.

Mr. Chairman, despite the foregoing analysis favoring improved patient care standards overall, we are confronted with many obstacles in our efforts to deliver services efficiently and economically.

California providers are not unique in this regard because standards and regulations are promulgated at the Federal level but implemented at the State level often with inconsistent, rigid, and inflexible interpretations.

Further, we in California nursing homes live with the necessity of pleasing several governmental masters. Federal HEW sets skilled nursing home standards as a title 19 requirement. The State department of public health has separate licensure standards in many ways in difference with the Federal program.

The department of health care services administers title 19 standards, adding its own inspired regulations and interpretations. And last, but by no means least, the State department of finance-unconcerned with patient care standards—unilaterally sets the budget.

Mr. ORIOL. That department of health care services—that's the State department of health care services; is it?

Mr. GORMLY. Yes. These are State agencies I am talking about.

Thus our facilities have been and continue to be caught and squeezed between demands for higher and higher standards, while denied just recompense for providing care to our elderly.

In the interest of time, Mr. Chairman, we would like to conclude with brief references to three specific problem areas, by way of responding to the question in your opening statement: "Are present medicare and Medi-Cal policies intensifying old problems in the organization of health services or causing entirely new problems?”


Mr. Chairman, the American Nursing Home Association has had a longstanding controversy with the Social Security Administration concerning definition of a “spell of illness" for purposes of determining covered and noncovered benefits under title 18. I will not take up the committee's time now, but with your permission submit for the record excerpts from association testimony before the Senate Finance Committee on H.R. 12080—1967 amendments to the Social Security Act, which discussed this issue in detail.* We feel this is a good example where an existing policy denies the elderly benefits which Congress intended them to have.


Another area of concern to both nursing homes and the beneficiaries is the retroactive denial of benefits after beneficiaries have been certified for services. This is the result of social security guidelines being interpreted by fiscal intermediaries in a manner offering no flexibility. In effect, the intermediary overrides the utilization review commit

*See app. 1, p. 739.

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