be

I have been particularly interested in this provision in S. 191, ginning on page 21, with which we are all familiar, that if the Surgeon General refuses to approve any application under section 625, the applicant or any State is dissatisfied with the Surgeon General's action under subsection (a) of this section, such applicant may appeal to the United States circuit court of appeals for the circuit in which the State is located, and so forth.

It seems to me that is just a broader application in the relationship between the State agency and the Federal Government, puts a broader application of the other principle which I think you and I both oppose; that is, allowing individuals to go in and appeal a decision of a State agency, and I think that is a matter that we must study pretty carefully as we proceed with this bill before we become involved in a court procedure in the handling of Federal-aid programs, that from my viewpoint contains grave danger of breaking down the administration of such programs.

I believe unless you have something further, we will let you go at this time, and we certainly appreciate your appearance before the committee.

STATEMENT OF R. L. SENSENICH, M. D., SOUTH BEND, IND., CHAIRMAN, BOARD OF TRUSTEES, AMERICAN MEDICAL ASSOCIATION

Mr. PRIEST. Will you give your full name and identify yourself for the record, doctor.

Dr. SENSENICH. My name is R. L. Sensenich. I am a member of the board of trustees of the American Medical Association, and am appearing for them as chairman of the board.

Mr. Chairman, in order to save the time of the committee, I have prepared a statement here and, if I may, ask that the statement be included in the report of my testimony.

Mr. PRIEST. That is quite all right, sir.

Dr. SENSENICH. The American Medical Association, through its house of delegates, its board of trustees and its officers representing a membership of more than 125,000 physicians, supports the Hospital Survey and Construction Act, S. 191, now under consideration. May I convey to the committee the appreciation of the board of trustees for the opportunity to present this statement for the American Medical Association.

The American Medical Association will soon complete 100 years. of its existence devoted to improving the standards of quality of medical service, and broadening the distribution of the best medical care to all of the people.

The bill under consideration provides for construction of hospital facilities after need has been determined. Those who are responsible for the preparation of the bill and for its later modification, after study and conference with those experienced in the use of facilities for medical care, are to be congratulated for the basic soundness and broad vision evident in the proposed legislation.

Outstanding is the basic conception that there shall be local determination of needs and local control of administration with a minimum of Federal definition of an over-all plan acceptable to the Federal hospital council.

In this bill there has been full recognition of the fact that conditions relating to health and hospital problems vary greatly in different parts of the country. A plan for the construction or restoration of hospital facilities for a populous, highly urbanized State would obviously be unsuited to a sparsely populated State of limited agricultural possibilities. An economically ill-favored tenant-farmer State would present needs different in many respects from either of the above areas. This bill, S. 191, appears to provide a maximum of flexible adaptation to local conditions with a minimum of undesirable uniformity and regimentation.

The question of Government contribution to the maintenance of hospital facilities provided on the basis of substantial Government grants has been discussed. Admittedly, there will be those in each community who will be unable to pay for hospital care as well as those who are able to pay. The hospital facilities established under the provisions of this bill will be for the care of all the people.

I think we need to avoid confusion from the standpoint of thinking of these facilities only as something to meet the need of small groups or economically ill-favored areas.

However, different types of illness require special provisions for treatment to meet the particular needs. Tuberculosis requires special hospitals and provision for longer periods of hospitalization with some measure of isolation. Most tuberculosis hospitals are owned by State and county units of government. County tuberculosis hospitals are frequently reimbursed by State funds at a fixed amount per patient per day. The care of the insane has long been recognized as a responsibility of government.

Mr. WINTER. You mean hospital care for just a certain particular thing or by reason of the fact that they are aged and decrepit, have to be taken care of?

Dr. SENSENICH. By reason of chronic illness; very frequently they have cerebral hemorrhage or so-called stroke or an advanced nephritis or something of that kind.

Chronic illness, especially the slowly progressive illness of the aged, requires long periods of hospitalization and beds cannot be given over for the care of these patients when they are needed for the care of the acutely ill. This will probably lead to the eventual establishment of hospitals for the chronically ill. This need is being surveyed at the present time.

The bill must be flexible and must be arranged to meet the particular needs of not only certain areas, but certain groups within those areas. A study of the indigent group reveals a great concentration of chronic, incurable disease—the crippled and the mentally inadequate. The number of those temporarily medically indigent is relatively small. A general hospital in the average community under present economic conditions will be practically self-supporting if the individual indigent is given assistance by local responsible authorities.

Mr. WINTER. What is the basis of average community, when they say that, what do you mean?

Dr. SENSENICH. I mean that the average agricultural community, the average urban community, the community of reasonably prosperous farms.

Mr. WINTER. How far do you reach out from, say, a given point of a community, from a town say 1,500 to 2,000 population?

Dr. SENSENICH. I should say that with the proper organization of medical facilities, most of the States are sufficiently well financed to be able to take care of the majority of their needs.

Experience has found that in the case of short term indigency, not the chronically crippled or the insane, the average individual is sufficiently able to take care of himself and pay for short periods of hospitalization.

Do I make that clear?

Mr. WINTER. Except for this, what I was trying to get in my mind is, we provide, in the provisions of this bill, for the community centers. I have in mind, if you have a county, say, 24 miles square, that would have eight or nine towns in it, from 1,000 to 1,500 to 2,500 population, is it the intention that each one of those communities should be eligible to have one of these community hospitals or centers, whatever you may term them, in that particular county?

Dr. SENSENICH. I am glad to discuss that, Mr. Winter, for this reason, that those facilities, in the main, are only subdivisions of the work that is ordinarily carried on in a hospital, which means hospital laboratory facilities, beds, and the X-ray and other equipment necessary to make diagnoses.

My personal impression is that with the reasonably modern organization in the community and roads that probably, in the main, those people would be better off transported to a regional hospital for their necessary diagnostic work and care if that is required, than to have a multitude of small units which, within themselves, offer some difficulties of administration, the reason being that there are not enough pathologists, that is, not enough physician pathologists who could possibly man an enormous number of these small diagnostic units, nor would they be satisfied with employment. There would not be volume sufficient for that.

Mr. WINTER. I understood the testimony here yesterday that was not the purpose of these local centers, that they were to have a few beds in which the doctors of the community, from the county health officer association or whatever might be in there, to take care of the few cases that might come in on the spur of the moment, emergencies, and that they would then be transferred, if, necessary, to the base hospital, or whatever you might call it. It just looks to me like we might be getting into the same position that we are in, so far as post offices are concerned, we would have every little town and village and community and city of 2,500 or 3,000 or 4,000 saying "Well, so-and-so got one, we ought to have one, we are paying taxes."

Do you not think that the bill somewhere should define the areas to be served?

Dr. SENSENICH. That is rather difficult. I agree, Mr. Winter, with exactly what you have said about small units. We went through that same thing in the early days in the treatment of tuberculosis. We thought that we needed a tuberculosis hospital in each county. After all, most of them proved to be boarding houses, because you could not afford the personnel and the facilities to give the best care. My own thought would be that if we are going to have emergency treatment or emergency diagnostic facilities they should be rather more like the out-patient department of a hospital where you have the supervision by someone competent to supervise and have per

sonnel working under the supervision of that group. They would serve, as you just referred to, Mr. Winter, as an emergency place at which the patients would be sorted and would either return to their home or would go on to the hospital for further care.

Mr. WINTER. Most States have done practically that self-same thing in their school system, by putting in the bus systems and transporting the children to central schools which are much better than the one-room, two-room small schools that we used to have, and we are getting a better system of education by reason of that fact.

I was just wondering if there was not some way in which we could determine what the size and area of the unit should be.

Dr. SENSENICH. I think an effort was made to do that in the bill. On page 8, paragraph (c), it is provided:

The number of public health centers and the general method of distribution of such centers throughout the State, which, for the purposes of this title, shall not exceed one per 30,000 population, except that in States having less than 12 persons per square mile, it shall not exceed one per 20,000 population.

I am not sure as to how that formula was worked out.

Mr. WINTER. I am not, either. That is the reason I asked the question. I am not clear in my mind how it works.

Dr. SENSENICH. In my own statement, with reference to that, I state that the public-health center is a fairly new and experimental facility and much depends upon the character of the activities contemplated. Educational work in public health is highly important. If activities are contemplated beyond those now regularly carried on by public health agencies, those activities and their relation to the medical care of the community, require further study and observation. We need to be cautious about the matter of setting up a lot of little units.

Mr. WINTER. This section that you referred to, subsection (c) that you read, and then subsection (a) of section 622, there is a proviso in there:

Provided, That for the purposes of this title, the total of such beds for any State shall not exceed four and one-half per thousand population.

Dr. SENSENICH. That is right.

Mr. WINTER. Now, then, you might in a given area have 10 beds for the population of 1,000, and it may drop down in another area to two, and still you could justify it under this section that you have just read. Dr. SENSENICH. I have made two further observations in my statement with reference to that, Mr. Winter.

Mr. WINTER. Doctor, do not let me interrupt you. Just go ahead. Dr. SENSENICH. I am glad to discuss it at this time. That is all right. The maximum number of public-health centers in proportion to population provided for in this act would seem to be adequate if all of the means of health education in the community are utilized. They would be essentially concerned with health education rather than the care of the sick, except possibly in areas of very special need where they should function as an out-patient department of some hospital that is able to take care of them.

No single plan for financial aid in hospital maintenance would be suitable for the provision of the best medical care for each individual in such widely different categories. The bill is sufficiently flexible to be useful in whatever portion of the field of hospital care that need

is demonstrated. The introduction of any plan for financing maintenance would render the bill less flexible and would add greatly to the complexity of the administration of the act. The support of the indigent can be provided by more direct methods from other sources. An effort has been made in the act to provide a formula under which the number of beds to be provided in a given area would be in proportion to the patient needs. The science of medicine progresses rapidly and the development of new methods of treatment, very successful in saving lives, frequently requires greatly increased hospitalization of patients. The number of hospital beds per population, even in general hospitals, varies in proportion as the beds of those hospitals are occupied by types of illness running a long course in communities where there is no other provision for the care of chronic illness.

Housing in limited quarters requires a greater proportion of those ill to be hospitalized. The formula provided in this act seems to be well-founded, and the distribution of facilities within the State is left to the decision of the State and local agencies after a survey of the local needs. The purpose of the act is to secure facilities in areas in need and not to add an unnecessary surplus in areas well provided for. Progress of medical science and continued study of the effectiveness of hospital planning may make it necessary to revise this formula at a not greatly distant date, but the provision here made would seem to be sound, based upon the information now available.

Some Government institutions classified as general hospitals, because of the type of cases admitted, have had a relatively high percentage of patients long in residence where the care has been more nearly domiciliary than medical. Beds thus occupied are, therefore, not available for the care of acute general medical and surgical cases. I judge that this matter could be properly considered in the State

survey.

The point that you make, Mr. Winter, that you may have beds of all types, some available for acute cases, some that are not, your distribution in institutions where there are chronically ill people, must of necessity be considered in the local study and in recommendations made with reference to State aid. It is something that cannot be defined in so many beds. It will need the experience and the honest and careful survey of the whole situation to determine exactly what needs to be done.

Mr. WINTER. The point I was getting at, the reason I had that in mind is that, in my State of Kansas, in the western part of the State, you can find county after county that will not have over 1,000 or 1,500 people in the entire county. They are 24 miles square and 30 miles square. You can get into quite an area.

Now, then, the actual hospital needs of those people in that area are just as great per thousand as it is anywhere else, and yet, in order to serve them, you could not very well base it on either one of these formulas set out in this bill.

Dr. SENSENICH. I realize that that could not be accurate.

Mr. PRIEST. Will you yield for a question?

Mr. WINTER. Yes.

Mr. PRIEST. Does the gentleman recall, or do you recall, Doctor, whether the question of this formula was developed during the hearings on S. 191 before the Senate committee?