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marketplace. What we therefore should seek to do is reduce the differences in this market through improvements in its organization and productivity.

The sounder social programs are those that evolve because they are right for the time and place rather than those that are superimposed extraneously.

Ordinarily, the best way to create a competitive-market environment where one does not exist is by eliminating the barriers to competition. In the case at hand, however, I have been unable to find or think of any practicable way to put hospitals in a competitive framework, or to set physicians to competing with their associates.

Through regional health planning, it is possible to effect some significant economies among hospitals. But it is doubtful to me that such an approach is a substitute for the sort of buyer-seller price-and quality negotiating that is the essence of a competitive system.

Accordingly, I suggest in this paper that new, countervailing power arrangements be considered and, if deemed worthy, stimulated and nurtured. Through these, the effective, competitive conditions can be developed that are necessary, in my opinion, if health-care prices are to become market-responsive.

Several ideas of what these countervailing power arrangements might be have been presented. The one that seems the best for all, in my opinion, is that in which third parties adopt a new role—that of “agent” for the major group purchasers. In this role, the third parties would maintain their functions of risk control and health-care-money transfer, but in addition would act as negotiators and bargainers with the providers of health care. This would entail major changes in their product, their methods or procedure, and their perception of themselves.

As we look to the future, it seems inevitable that some, if not all, of the participants in the health-care model will have to change their viewpoints and behavior. Current positions are incompatible with our societal and economic values, and now the winds of change are blowing. Some will be actors, and some, reactors. It is difficult to say which group will be which; but certainly the third parties' group would seem from many viewpoints the best candidate for leadership if it can organize. If it doesn't, the task will devolve upon management and labor, or upon the Government.

ITEM 4: LETTER AND NEWSPAPER ARTICLE FROM MARION B. FOLSOM, HEALTH COUNCIL OF MONROE COUNTY, ROCHESTER, N.Y.

OCTOBER 16, 1968. DEAR SENATOR KENNEDY : The concise summary that appeared in the Democrat and Chronicle of a local study has some relevance to the Congress, I believe. It points to the fact that we need many more facilities and services which will keep persons independent. Specifically we need, as a community, a system of patient evaluation to prevent unnecessary placements in general hospitals, state mental hospitals, and nursing homes. If we are to stop misplacing these elderly people, we, in Monroe County, would require roughly 2,000 apartment units with supportive services, and 2,500 congregate living facilities.

Hopefully, we will be able to move on these problems under the Comprehensive Health Planning Act of 1966 (89–749) and the 1967 Partnership for Health Amendments. I hope there will be opportunity for consultation among the localities, the State, and the Federal government on local-State priorities and action. William J. Curran, Professor of Health Law, Harvard, comments in the American Journal of Public Health, June 1968, in an article entitled "Public Health and the Law: Comprehensive Health Planning: Audacious Law-Making," that “The legislation actually gives the local (area wide) planning agencies no power or authority."

Beyond this, comprehensive planning seems to be inadequately funded, and the responsibility for comprehensive planning is placed well below the Secretary's office in the Department of Health, Education, and Welf re.

We would be glad to send you a copy of the Health Care of the Aged Study if you or your staff would wish one. Sincerely,

MARION B. FOLSOM, [Enclosure)

[From the Rochester Democrat and Chronicle, Sept. 23, 1968)

MONROE CRITICALLY SHORT ON AGED CARE

(By Don Byington) A community study group said yesterday that 41 per cent of the elderly people in Monroe County who need health care are “either receiving no care or the wrong type of care."

It said, for instance, that there are 5,000 persons in the county who are senile but that most homes for the aged and nursing homes have a policy against admitting these people.

The group, headed by Marion B. Folsom, former secretary of health education and welfare, was composed of leaders in the health field and was generally self-critical. It put the blame for the current situation on two factors:

An "unsystematic and piecemeal growth of care facilities and service."

A change in emphasis by existing institutions, with resulting gaps. The five-year study noted that homes for the aged have tended to become nursing homes and that there is now a scarcity of "custodial care" facilities for older individuals who cannot get along by themselves but who do not need all of the health services of a nursing home.

It said that about 20 per cent of the people now in nursing homes fall into this category. They could just as well be in some type of "congregate living facility'-if such a facility were available.

The five-year study of health care for the 61,832 persons in the county over 65 was supported by the Ford Foundation. It was conducted by the University of Rochester's department of preventive medicine and community health, the Health Council of Monroe County and the Council of Social Agencies. A report by the group also said :

For every elderly person receiving public health nursing service at home, there were four others judged to need it, but not getting it.

Between one-half and two-thirds of older patients were judged to be "misplaced” in terms of the kinds of health facilities and services they were receiving.

There is a need to include mental health services at all levels of care for the aged, as more than half of those in need of care have some kind of mental impairment.

That “sheer chance," such as the action of an ambulance driver, an emergency department attendant, or an admitting clerk, can decide the kind of care an elderly person ultimately receives. These “temporary misplacements," awaiting openings in the appropriate facility, have a way of becoming permanent misplacements.

ITEM 5: LETTER FROM JAY W. FRIEDMAN, D.D.S., ASSOCIATE RESEARCHER, UNIVERSITY OF CALIFORNIA, LOS ANGELES

JANUARY 14, 1969.

DEAR SENATOR WILLIAMS: The main problems confronting our population with respect to dental care are the shortage of personnel and allocated funds, the lack of organized programs for the direct provision of care, and the absence of qualitative standards and administrative controls. These problems apply across the board for all segments of the population. There is little prospect for their resolution in the near future without massive governmental assistance. This assistance will not be forthcoming until the federal government establishes dental health as a major priority among its goals. With these "givens" in mind, I shall comment on your questions.

1. "What, if any, Medicare coverage should there be for dental care?” Complete dental care should be included along with medical care. Dentistry is. after all, a specialty of medicine. The separation of dentistry from medicine is

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arbitrary but one cannot arbitrarily separate the oral cavity from the human body.

2. "What advantages and/or disadvantages do you see with regard to coverage of dental care under Medicare?" The major advantage is, of course, the compulsory allocation of funds for this specific purpose to assist the aged in receiving a needed health service they might not otherwise be able to afford. When these programs are attempted on a voluntary basis, there is always the risk of "adverse selection" of participants. But unless well-defined standards are established and adequate administrative controls applied, the surge in demand for dental care can endanger the fiscal soundness of the entire health care program, as happened recently in New York State's Medicaid. The main problem here is to overcome the dental society's traditional opposition to responsible controls—both qualitative and economic. In this latter respect, governmental programs should be based on fired-fee schedules rather than the “usual and customary" fees currently advocated by the dental society.

3. “What, if any, Federal legislation on dental problems and opportunities of the elderly would you recommend?" I tend to feel that the need is not for special legislation directed towards the elderly but rather for the population as a whole. The dental problems afflicting the aged do not differ substantially from those of younger persons. If we were to decide, nonetheless, that programs were to be established for the elderly, then I would like to see the establishment of federally sponsored health centers for the aged based on the principles of group practice and including a dental component. Though not specifically related to the dental problems of the aged, the anachronism of state dental licensing should be eliminated in favor of national licensure to allow dentists greater mobility. Some parts of the country attract more elderly persons. They therefore have greater need for dentists who should not be hampered in their movement by protectionist policies of state professional organizations.

4. "What, if any, Federal programs to prevent dental difficulties in old age would you recommend?" Dental difficulties of the aged have their origins in youth. The major preventive achievement in dentistry is fluoridation of public water supplies. Federal legislation should be developed to require fluoridation of all public water supplies to reduce the incidence of dental decay. This single procedure would be more effective and less costly than any programs of repairing teeth once the damage is done. Since the major problems of the aged are related to tooth-loss, it is the prevention of premature tooth loss that is most important.

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GROUP VERSUS PRIVATE DENTAL PRACTICE

5. "What, if any, legislative or administrative actions by the Federal government would you recommend to stimulate and encourage greater use of dental auxiliaries?" Again, we need to eliminate the archaic state restrictive controls by developing rational national enabling legislation to permit more sophisticated use of dental auxiliaries. The main concern is that the average private, solo practitioner mas himself not be sophisticated enough or trustworthy enough to pass on the economic advantages of auxiliaries to the consumer. More important, however, is that greater controls are necessary to assure quality. But it is extremely difficult to exercise controls over solo practitioners. Also private solo practice is very inefficient. In a detailed study of a group dental practice in Los Angeles I have found the group practice to be 50 to 90 percent more efficient than the arerage private dentists. I feel it is extremely important that the Federal government assist in the organization and financing of group dental practices no only for its economic advantages but also for its potential of greater production of servires, i.e., more care for more people. These groups could be even more produrtive if they were allowed to expand the functions of auxiliary personnel.

A very important area for investigation is the training and utilization of dental hygienists. These persons, mainly women, are in the main grously overtrained for the services they provide. This field should be onened up to men as rell as women. There is need for a large number of lesser skilled persons to do routine prophylaxis (cleaning) and for more highly trained dental hygienists who would really be periodontal therapists. The Federal government should actively promnte developments along these lines.

6. "Is there a shortage of dental auxiliary personnel, and, if so, what Federal action would you recommend to cure this shortage?” I have already commented on some aspects of this question. Given adequate numbers and utilization of auxiliaries it is possible that there are almost as many dentists as are required.

At any rate, regardless of whether there are enough dentists or not, there is a vast shortage of certain types of auxiliaries—mainly dental hygienists or their equivalent. We have approximately 100,000 active dentists in the United States but only 8.000 dental hygienists. We probably need as many hygienists as dentists since prophylaxis is one of the most important preventive procedures. For example, past age 35 most teeth are lost from pyorrhea which has its origins for the most part from tartar deposits on the teeth. Therefore, preventivé oral hygienic procedures are directly related to the ultimate dental health of the aged, provided they are begun early in life and continued periodically.

There is also a shortage of skilled dental technicians. This would become worse with the expansion of prepaid group practices, especially if technicians were to be employed on the staffs. Currently, most training of dental technicians is by commercial firms, vocational schools, and apprenticeship. I would like to see Federal support given to the development of dental technician training schools in university dental schools so that dental technicians and dental students can learn to work together from the beginning of their careers.

But again, all of these suggestions are based upon a higher degree of organization of health care services, mainly through development of group practices. Training of more personnel will be wasted if there do not exist organizations capable of employing them. Solo practice is too inefficient to employ the variety and numbers of auxiliary personnel that are necessary to maximize productive efficiency.

MEDICAL AND DENTAL NEEDS OF ELDERLY 7. "How well do you think Medicaid (Title XIX) is serving the dental needs of the elderly, and what, if any, recommendations would you have for making this program more responsive to the dental needs of this age group?" Medicaid is not serving very well for the simple reason that the majority of eligible persons fail to utilize the programs. In California, for example, probably not more than 15 percent of eligibles seek dental care in any one year, and California has one of the best programs in the nation. Those that seek care do not necessarily receive the best care since preventive services often are valued lower (re: fees) than prosthetic services such as dentures. Dentists can make three or four times as much per hour on dentures as compared with filling and cleaning of teeth!

Another problem relating to elderly persons eligible for Medicaid is the maldistribution of dentists. Dentists tend to locate in the middle class areas, not the urban ghettos where most of the aged poor reside. Therefore, programs should be developed to bring dentists to these areas. The best way would be for the state and/or federal government to establish group practice programs in these areas. The key to the success of these programs is good administration. Unfortunately, there appears to be a dearth of good dental administrators in this country. We urgently need training programs developed in schools of public health in dental care administration. These programs require Federal financing since the universities do not have the funds to support them locally.

8. “To what extent do you believe that failure or inability to receive proper dental care results in medical conditions covered by Medicare, thus forcing Medicare expenditures by the government and individual which could have been prevented ?" Not much. I am enclosing the complete paper on “Dentistry in the Geriatric Patient : Mutilation by Consensus" which expressed my views on this matter quite completely. (The article brought to your attention was abstracted from this paper).

I am not satisfied with these brief responses. But your questions were so comprehensive that anything less than a dissertation with background and supporting data for the opinions expressed would be unsatisfactory. Nonetheless, I hope you will find these remarks for some interest and value. Needless to say, I would be glad to offer assistance (and opinions) in the future since we share common concern for the well-being of our compatriots-old and young together. Sincerely,

JAY W. FRIEDMAX, D.D.S., M.P.H.,

Associate Researcher. [Enclosure)

EXHIBIT A. DENTISTRY IN THE GERIATRIC PATIENT*

MUTILATION BY CONSENSUS

(By Jay W. Friedman, D.D.S., M.P.H.) Approximately 50% of Americans have lost all their teeth by age 63. More than two-thirds are totally edentulous by age 75. It is obvious that dental care for the geriatric patient is overwhelmingly characterized by the extraction of his teeth. This massive destruction of the mouth is not the result of an insidious, unpreventable disease process of aging. Rather, it is the result of little concern by the public for the preservation of teeth, and the regressive social character of the dental profession which has the technical knowledge but has failed to develop the manpower necessary to apply it on a universal scale. To be sure, there are degenerative processes of the oral mechanism with aging. But these processes can be modified to such an extent that the vast majority of the population could retain teeth throughout life.

The degenerative dental condition of the geriatric patient generally is a product of cumulative neglect which begins in childhood and progresses to a state of partial and then total edentulatism (Fig. 1). But neglect is not a simple function of disinterest or negativism, although both these attitudes are present to an alarming degree. It is also a function of relative social, economic, and health values. Little social stigma is attached to loss of teeth even though we have advanced beyond the stage where it is viewed as a “coming of age." Economically, dental care is relatively low on the priority of expenditures. The simple fact is that the United States is a commodity culture in which the acquisition and consumption of manufactured goods are conditioned needs taking precedence over what are considered nonessential health care servires. Although dental neglect inevitably leads to pain and infection which require treatment. the loss of teeth either singly or totally does not represent a significant health hazard. Conditions leading to the loss of teeth may be hazardous to health, but once the teeth are lost the person is nearly the same physiologically. However, there may be serious social and psychological hazards which have untoward effects on the person's well-being.

To place these remarks in perspective, the function of the dentition, the diseases that ravage it, and the knowledge and techniques that are known to preserve it are reviewed.” Function of the dentition

The most obvious function of teeth is the mastication of food in preparation for digestion. Incisors are designed for tearing and cutting up food and molars for shredding and grinding it prior to swallowing. Saliva lubricates the food bolus and supplies enzymes which begin the digestive process in the mouth. Prior to forks and knives, this process undoubtedly was of great importance. But with the development of processed foods and the emphasis on the soft texture of cooked foods the physiologic importance of mastication has declined. Edentulous persons do not necessarily suffer from an inability to masticate foods properly. Prehistorically, human teeth also functioned as weapons of aggression and defense as they do presently among the lower animals. However, man has subsequently developed more efficient weapons. Teeth also are sexual symbols as evidenced by their implied virility in the advertising media. Loss of teeth can be equated with loss of virility which is certainly an important psychological factor in the process of aging. Therefore, the geriatric patient may accent the loss of his teeth, but want them replaced with an esthetically attractive artificial denture. Teeth also are important in speech. Many sounds are denendent upon the position of the tongue and lips against the dentition. Yet it is apparent that edentulous patients are not at a loss for words, so this function also should not be overemphasized. In short, teeth have their functions but they are not essential to the longevity of the species in the modern world. It would be a grievous error, however, to view the dentition as a dispensable vestige with little more significance than the appendix.

* Reprinted from Geriatrics. Vol. 23. pp. 98-107, August 1968. Copyright 1968, by Lancert Publications, Inc.

1 Loss of Teeth. Health Statistics from the U.S. National Health Surger: 1.s. Depart. ment of Health, Education, and Welfare, Public Health Service, PHS Publ. No. 585-B22. Wash.

? Current Therany in Dentistry. Vols. 1 and 2. Edited by H. M. Goldman. S. P. Forrest, D. C. Byrd, and R. E. McDonald. St. Louis : The C. V. Mosby Co., 1964.

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