hospitals have utilized the Long Term Illness Committee and the Information and Referral Center for judgments in handling difficult problems. It is apparent that there is a need for a community-wide approach to handling problems involving long term and rehabilitative care whether in the older individual or the person below 65. Communities or political subdivisions, i.e., counties, need to develop information and referral systems, home care services, and rehabilitative facilities. With the funding third party payments through Titles XVIII, XIX and Blue Cross, the physician must take the lead to see that the necessary facilities and administrative structure is available to offer his patients the care required and still retain the private practice of medicine. STATEMENT OF HERBERT R. DOMKE, M.D., DIRECTOR, DEPARTMENT OF HEALTH AND HOSPITALS, ST. LOUIS, MISSOURI In my opinion the greatest contribution of the United States Senate's Special Committee on Aging is to encourage better balance of Congressional attention to health needs of the aged. There is a spectrum of health needs which begins with the maintenance of health at one end, proceeds through phases of acute illness and rehabilitation, to return to the aged person's resumption or normal family and community activity. Most Congressional interest-and federal monies-are directed to the part of the health services spectrum which deals with management of illness in the hospital. On the other hand, there is relatively very little interest in programs of health maintenance and early detection of illness on the one hand, or rehabilitation and return to social function at the other end of the spectrum. For example, it is probable that more attention in this Congress has been directed to one aspect of financing hospital care, viz, capital depreciation accounting techniques, than has been given to early detection and rehabilitation taken together. There is, of course, a need for a sound policy for depreciation allowances, as there are also compelling reasons for continued development of medical and hospital diagnosis and treatment of acute, debilitating illness. And, of course, Medicare and other insurance programs have met a major need in financing hospital care, and deserve continued public and Congressional scrutiny. The problem is not that the sick person deserves less attention, but that we make a greater community and Congressional effort to maintain health or to return the patient to his family. There is an imbalance of attention, and there results an imbalance of appropriation of effort and-most important of allan imbalance of service to the aged citizen. As long as federal service and research project monies tend to focus on the obviously ill person, so also will local health agencies have to direct their attention to trying to improve services by trying to get their portion of available funds. It can and does happen that local health agencies must divert their limited planning resources to play "Grantsmanship.” Government fiscal trends in the past twenty years have produced a current situation where municipal government has no substantial funds to undertake new activities in health. The needed new local health services have become more and more dependent-and are now almost wholly dependent-upon federal funds. (It may very well be that if there is to be effective local planning and service that government tax policies may require revision to provide more adequately for local control.) The point, however, with regard to health services is that there is federal control of new health program development not only nationally, but locally. The responsibility, therefore, for Congress is especially great. Errors of emphasis in Congress will be multiplied in every local community. There is ample evidence (and much of it has been presented to Congress) to show that a great deal can be done in the detection of illness before symptoms are apparent. The field of screening of diseases is one that has had a rapid technological development, and there is agreement among competent national medical authorities that much can be achieved by greater community application of screening programs. Certainly, the present expense and the predicted escalation of expense of hospital care requires search for development of less expensive means of patient management. Greater Congressional funding and support for programs of out-patient care obviously offer one of the opportunities to reduce demand for expensive in-hospital care. Certainly, also, there are many competent authorities in Health, and Welfare, who believe that much can be done to return the aged person after an illness to his family and community—in the absence of which the aged person is left no recourse but the futile, long-term, nursing home placement. We have, in this affluent society, an opportunity to choose which new health programs are to be developed. It is important to recognize that the range of choice of health services is indeed a wide one. There are great benefits to be achieved in other health programs in addition to the benefits that can be achieved in the diagnosis and treatment of the acutely ill person. Both the fiscal realities of escalating hospital costs, but more important, the social gains to be achieved for the aged person, require that more attention be given to the whole spectrum of health services, from health maintenance and disease screening to rehabilitation. STATEMENT OF MARY E. DAVIS, M.S.W., DIRECTOR OF SOCIAL SERVICES FOR THE CATHOLIC HOSPITAL ASSOCIATION I wish to make it very clear at the outset that although these observations are directed to the health care of the aging, I believe that comprehensive health services are the right of every person regardless of age or economic condition. 1. "Medicare"-Title XVIII of the Social Security Act provides to insured beneficiaries payment for care in a hospital, extended care facility and for home health services. There are deductibles and co-insurance features which were one of several compromises made with providers of services in order to get the bill passed. No program of medical care should have deductibles or co-insurance. They are a financial barrier to the receipt of medical care and keep the poor from receiving it. Title XIX-"Medicaid" was passed at the same time in order to supplement the basic provisions of Title XVIII. When a state has not implemented Title XIX, the aged poor are unable to make full use of benefits provided under "Medicare" because: a. They have no way of paying the deductibles and co-insurance. b. They cannot pay for nursing home or other types of long term care in addition to "extended care." c. They cannot pay for drugs, dental care, glasses and other health services. I believe therefore that the Federal government should hold fast to the time limitations it has set for the states to get Title XIX-"Medicaid"-implemented, and hold to the present regulations within these time limitations for the provision of certain health services. We are all citizens of the United States and political boundaries should not prevent us from receiving what is a right for everyone. 2. I am becoming increasingly concerned with a growing trend in hospitals to gear services to the requirements of federal legislation. A prime example of this is the planning for and construction of "Extended Care Facilities" for people over 65 to meet Extended Care provisions under “Medicare”—Title XVIII. Extended Care is only one part of the continuum of care for people with long term illness and should be available to patients of any age who require it. Persons over 65, covered by Medicare, would have their care paid for under this program. Those not covered and persons under 65 might be covered through private insurance, Title XIX or other tax supported programs, or from their own funds. I am very concerned about this, because I see it as the beginning of a trend to organize health services to meet legislative requirements rather than the needs of ill and disabled persons, and this will kill initiative in the search for alternative and more appropriate ways of meeting their needs. There is also I believe, a more grave danger that this trend could lead to the reinforcement of present methods of delivering health services rather than to the discovery of new methods. Blue Cross and other hospital insurance programs were organized to meet the cost of hospital care for individuals, because hospital care represented the largest expense in medical treatment. However, over the years, hospital insurance has been the chief reason for unnecessary utilization of hospital care by large numbers of patients who could better be cared for as out-patients or in their own homes or lesser care facilities. The trouble is that there is no insurance to cover these other kinds of care. "Medicare" followed the same trend. Payment for hospital care is its first and major provision. Extended care and home health services were added only to offset the overutilization of hospital care, not because they offered a better and more appropriate way of meeting a patient's medical care needs. Yet, early statistics show that surprisingly high percentage of the aged have used home health services without any hospitalization. It met their need. (I have always been very curious as to why the variety of methods of delivering medical care used at the Mayo Clinic have not been more widely imitated. The only answer seems to be that we have become "stuck" with hospitals!) 3. Health services for the poor are generally as poor as the poor themselves. They are also inaccessible because of geographic location, lack of coordination (specialities located in different places)-and more basically a complete lack of interest in and concern for the patient as a person. All of this could be changed if the private sector wanted to change it. A vacuum does not exist forever. Something moves into it. As has been stated so accurately by Professor Cervantes "the federal government is an enabling agency to promote the common welfare." (Lucius F. Cervantes, "Socialism and Health Care," Hospital Progress. September 1966, p. 86.) "Medicare" and "Medicaid" provide payment under certain minimum conditions for certain health services. The producers and providers of these services can go far beyond these minimums and they should! If they do not care enough for the poor to insure that the health services provided them are related to health needs rather than to ability to pay; if they are less in quality and quantity than those provided more affluent citizens, then government may truly move in because concerned citizens will force it to do so. The choice lies with the private sector of the health field. STATEMENT OF SISTER MARY VINCENT, C.C.V.I., THE CARDINAL RITTER INSTITUTE, ST. LOUIS, MO. We are all grateful for the passage of Medicare Legislation and recognize the fact that it has been a great help to some of our older people who are in need. However, we would recommend that an altogether different type program be designed to complement existing social legislation, with the philosophy of meeting the continuing health needs of the chronic and terminal patients. For health care programs such as Title 18, we need to find measurements of self-providing capabilities which would form the basis of eliminating many who do not need assistance from such health care programs. Elimination of all deductible and co-insurance features of the Medicare Program, removal of waiting periods and deadlines for enrollment. Deductibles form barriers to needed care for those least able to pay. Replacement of the 65 year age requirement for Medicare benefits by a provision qualifying all women at age 62. Extension of the coverage for drugs to all prescription drugs regardless of their association to a hospital confinement. Extension of coverage to all surgical and orthopedic appliances and such items as wheelchairs, and hospital beds for home use, eye-glasses, hearing aids, podiatry, and everything pertaining to eye care and dental care. Expand existing programs and encourage where needed, the starting of new education and training programs designed for health care personnel needed to provide the services made possible by existing and proposed legislation. Training and education should reflect the needs of the functions to be performed and not be put at an unrealistic level excluding many potential health care employees. Make available to local community health service providers-grants-in-aid for the acquisition of additional staff to meet the quality standards of care for chronic and terminal patients. WASHINGTON UNIVERSITY, SCHOOL OF MEDICINE, Hon. ALFONSO J. CERVANTES, DEAR MR. MAYOR: This letter is in reply to your letter of June 5, 1967, asking about costs and delivery of health services to older Americans. Persons over the age of 65 not only require more hospitalization but stay longer. In Barnes Hospital, Medicare patients now stay 4.2 days or 42.4% longer than non-Medicare patients. The ancillary service billings are $97.00 more than the average non-Medicare patient. Thus, with rising costs, some borderline patients face serious financial problems. In addition, the traditional charity given by large private hospitals is not as effective as formerly for two reasons. First, the same dollar amount will not buy as much medical care and, second, the government policies will not permit these costs to be included as part of legitimate overhead charges. It seems to me that this particular reimbursement policy might be re-examined. Yours sincerely, WILLIAM H. DANFORTH, M.D. Vice Chancellor for Medical Affairs. STATEMENT OF HOWARD C. OHLENDORF, CHAIRMAN, PLANNING COMMITTEE ON AGING, HEALTH AND WELFARE COUNCIL OF METROPOLITAN ST. LOUIS As Chairman of the Planning Committee on Aging of the Health and Welfare Council of Metropolitan St. Louis, I was asked by the Honorable Alfonzo J. Cervantes, Mayor of St. Louis, to prepare some brief comments regarding problems, as I see them, of the cost and delivery of health services to older Americans. I have had contact with a number of individuals in the past few months regarding generally the problems of the elderly. The Health and Welfare Council is conducting a program sponsored by a Title III grant from the Older Americans Act. This program, called Aging Information and Direction Service (AIDS), is one of providing information and referral services to older adults. I could cite you case histories regarding some of these problems, but in the interest of time, I will merely describe the problems as I see them. With the advent of Medicare, older individuals qualifying under the program, who previously used the out-patient clinic services provided at City Hospitals, are now billed the full fee for a clinic visit, whereas prior to Medicare, they were billed approximately one-eighth of this amount. This is very frustrating to many of them who are living on reduced or fixed incomes and cannot afford to pay this fee. Once the hospital has billed the patient in the amount of the $50 deductible, they are no longer billed for services. They are, however, charged the 20% of the full clinic fee at each clinic visit. If the patient could not pay the $50 deductible fee, or the following 20%, this is collectable under Medicare as a bad debt. It would seem that some different way of handling this situation could be arranged to alleviate the personal suffering and worry on the part of the older patient. Another problem that still faces us is in the area of nursing home care. The quality of much of the nursing home care available today still leaves much to be desired. A nursing home can be licensed by the State of Missouri as a professional or practical nursing facility. At the time the inspection of the home for licensure takes place, the home may meet staffing standards. However, one month after licensure, staffing may change, which means an inadequate staff available to provide needed and requested services. This is an unfortunate situation and I recognize the many problems involved in staffing nursing homes today, but I do feel that something should be done to more adequately insure that a home which is to receive payment for a certain quality and quantity of care, is qualified to provide that care. This might be in the form of inspection teams, which would periodically inspect these nursing homes on an unannounced basis. There are nursing homes in operation in Missouri and St. Louis which have repeated and numerous violations at the time of their "regular" inspections by authorities. It seem that it is very difficult to revoke the license of a nursing home operator. When the inspectors do find a situation which warrants and allows them to bring action against a nursing home operator, only the violations found at the last inspection are permissable as evidence. The past history of the operation of the home, no matter how deplorable, is not used. It is possible, also, for operators to obtain continuances for lengthy periods of time, meanwhile continuing to operate their home in a manner which does not meet standards. Something needs to be done about this where there is federal money involved. It is also brought to my attention that in many cases medical records kept in the nursing home may not be adequate to insure the patient a continuity of quality care necessary to promote their living in as optimum a situation as their illness or disability will permit. Some provision should be made to insure that each patient in an extended care or other nursing facility have a medical and social re-evaluation and diagnosis at least each year. This is required for those patients receiving Medicare payments but for those on public assistance, this may not be the case. It would seem that far too often an individual patient is diagnosed and evaluated upon admission to a home and cared for on the basis of this diagnosis for too extended a period of time, even though their medical situation might have changed during this time. We have tried in this country for some time to promote the idea that when an older person goes into an institution, he be made to feel that this institution is in fact his home while he is there. Nursing home, homes for the aged, and domiciliary care facility operators have come a long way in recognizing the need for this kind of philosophy of care. Now we have a situation in which an extended care facility may provide both a residential and domiciliary care facility and a nursing home facility. Suppose a person living in the domiciliary facility could benefit from some home health services. Could not these home services be provided to them in the domiciliary facility from the nursing home facility. This, I believe, needs some clarification and redefinition. We have many elderly living in public housing projects. Getting services to people in public housing would seem, at first glance, to be an easy matter due to the fact that you have such a large number of clients living in close proximity. This does not always prove to be the case. The problems of people in public housing are of such a magnitude as to be overwhelming. One is struck by the amount of difference which exists between public housing designed specifically for the elderly and public housing designed generally for the total community. For example, in public housing for the elderly, the elevators stop on every floor, and there is more community space available. I ask you, is this disparity desirable? Suppose an older person lives in public housing where the elevators may not stop on every floor. If this person becomes ill, they may be requested to climb many steps in order to get to and from their apartment and the services in the community which they may require. Of course, for some medical reasons these elderly can have their apartment changed and be placed on a floor where they have access of an elevator, but I submit to you, gentlemen, that this reshuffling of human beings in degrading and frustrating. Another problem which I would present to you today is the one of the older person's ability to travel distances to get to services they need. We have facilities in a metropolitan area designed to provide services to many of our elderly, but whether the individual can get to that service is another matter. I am sure we have heard time and again about the need of localizing services. Providing services where people live is of great importance. There is still much confusion on the part of the elderly about Medicare benefits. A need still exists to acquaint them with their rights under the legislation. Many elderly still fear to utilize services available under the new law. A common complaint of older persons is that the cost of various services has gone up since Medicare became operational. Until they reach the $50 deductable limit, this causes a hardship in many cases. say that I do not envy the task of this Subcommittee but believe me when you have my sincerest support and best wishes for finding solutions to some of our country's most pressing problems. JEWISH CENTER FOR AGED, Mayor ALFONSO J. CERVANTES, City Hall, St. Louis, Mo. DEAR MAYOR CERVANTES: I hope that this letter is received in time, by you, for submission of your testimony to Senator Smathers' Committee. The thinking expressed in this letter is part of the problem which I reviewed in my letter to you of June 9, 1967. The legislative definition of "a spell of illness" is very detrimental to the benefits of many elderly people of advanced age who cannot move from a nursing institution or an Extended Care Facility. A resident of such an institution who becomes acutely ill at the beginning of the year and is hospitalized, say for the maximum of ninety days and then returned to the Extended Care Facility, say for a maximum of the one hundred |