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Mr. ROGERS. Should we have a provision in the law that if these facilities are used, it must be at the request of the person?

Mr. Dimas. Well, I would say that we do have present laws for involuntary basis, or a basis in which the crisis could be created so the person could be referred to the service. We do have our present commitment laws which allow us now to take a chronic alcoholic and commit him for his own protection.

Mr. Rogers. What I was thinking of was if a person agreed to begin a treatment that he must have, and in that voluntary commitment agreed to the conclusion

Mr. DIMAs. I would say if he does not agree to stay to its conclusion. If he does not, some other measures might be taken.

Mr. ROGERS. Would you give us your thinking on how that might be incorporated in what we are trying to do?

Mr. DIMAs. I think the St. Louis experience shows that nearly 91 percent of these clients accept the treatment and complete the detoxification treatment.

Mr. ROGERS. I would be interested in seeing how many repeats there are.

Mr. DIMAs. I think this afternon or tomorrow you will be hearing from Dr. Pittman, who is the founder of the United States first detoxification center.

Mr. ROGERS Dr. Carter?
Mr. CARTER. No questions.
Mr. ROGERS. Thank you very much.

The next witness, Nr. Nathan J. Stark, group vice president for operations, Hallmark Cards, Inc., Kansas City, Mo.



Mr. STARK. My operations have nothing to do with medicine.

Mr. ROGERS. I am not so sure. Don't you give get-well cards or something? Mr. STARK. I have been accused of that.

I am pleased to have this opportunity to be at this hearing on regional medical programs. I am, as you note from the title, a nonexpert in the health field.

A businessman interested in health programs is my category. As I listen to all these experts, many of whom I have heard of, and several of whom I have known, I asked myself the question, "What am I doing here?” But perhaps this is the new look in the nonprofessional's view of the health field.

I think that the need for citizen participation has been rather unfamiliar to most of those in many parts of the health field, but I believe it is fast becoming consumer oriented.

My credentials in the health field are as president of the Kansas City General Hospital and Medical Center, and as chairman of the Missouri regional medical program, and it is to this latter role that I wish to address my remarks.

My statement will be restricted to the Missouri program, since this is the one I am most familiar with, and it may be typical, or may be typical of what other programs are.

The final focus of our program is on the cooperative delivery and planning of the best possible health care to patients suffering from heart disease, cancer, stroke, and other related diseases, regardless of economic, educational, or geographical status.

The program utilizes maximum local planning and initiative with regional emphasis upon coordinaion of efforts and review of the quality of endeavors. Policy is set by a council representative of the public and professional leadership with advice from all groups in the region who have a bona fide interest in the delivery of health care.

Because of the stated intent of the program which was to improve care by increasing the effectiveness of present systems, attention in the Missouri program was directed to early detection of disease, methodology for systems to provide maximum economy and effectiveness, and initially a small number of models of delivery systems, planning for a service to a specific population of people without regard to the exact place in which that service might be rendered, but with emphasis on delivering the care as close to the patient's home as is consistent with economy and quality. In other words, we are people oriented.

Primary emphasis has been placed on the development of supportive services which utilize the newest in scientific technology. This includes a variety of services which can be furnished both to the physician and to the patient quickly and economically at any time anywhere in the region.

The present testing of computerized interpretation of EKG's for physicians in rural areas is a precise example. For screening purposes, and for the first time in history, the private practitioner participating in the model system has consultation for heart disease immediately available to him at every hour, 168 hours a week, at an estimated cost of less than $3 per interpretation.

Each interpretation can be backed up by a dial-a-phone lecture reference source, recorded on tape and also automatically available at all hours at the cost of a phone call.

These backup lectures will develop on a demand basis in accord with experience. A model of delivery systems is found in the Smithville project. Here building upon an existing rural system, maximum effort has been placed by the local advisory group and the State university medical school upon a sophisticated consultation and referral program.

In Smithville, the system extends into home care utilizing all available ancillary and auxiliary personnel. Faculty members of the university teach and consult with the local staff.

Financial assistance was given with a specific terminal date, at which time the system of care is projected to be self-supporting. The program provides for careful change of quality of care as a result of intensified support.

It is the plan of the Missouri program to establish and terminate final support for all demonstration projects in this manner in order to provide the opportunity for cooperative programs with a maximum of communities in the region.

Supporting services and later innovations will continue to be made available on a financially self-supporting basis to these cooperating communities so long as these are found to be mutually helpful.

A final facet of the program is the interdisciplinary research group in the university who are studying intensively the delivery system for health in the region, scientific devices which are needed but lacking at present, a communication facility which possibly could be adopted for purpose of the program.

The research group functions as a medical experiment station drawing together the talents of all university disciplines which can contribute to the definition or solution of health care problems.

Of the 21 bioengineering projects now active, I should like to mention two. One result of this research has been the development of a diagnostic chair, which simplifies the taking of a heart tracing. The chair reduces the time required for an EKG from about 20 minutes to less. Another piece of equipment developed by the engineers and the physicians working together is an electrolytic unit which has proved extremely helpful in speeding the healing of leg and body ulcers for the diabetics or patients who must be in bed for long periods, and these compact units can be taken home.

An added feature is an alarm system which reminds the patient to keep the bandage properly dampened.

Future programs could be summarized as the design of more model delivery systems in cooperation with the public and health professional involving finally the entire region, continued concentrated study of appropriate services designed to be self-supporting, the assistance to programs in providing for treatment of disease and rehabilitation of patients suffering from these categories of disease, and last, a translation of new ideas into action on behalf of the patient or the potential patient.

This is indeed an exciting, though wearing, time to be involved in health affairs. The regional medical program, to my mind, offers one of the best means for achieving optimal health for all people, who are in effect the real beneficiaries of regional medical programs.

I would certainly urge the support and the continuation of this program.

Now I have here an organization chart of the Missouri regional program which I would like to offer for the record.

Mr. Rogers. The committee would be very pleased to have that, and it will be made a part of the record at this point.

(The document referred to follows:)



(a) Policy is set by representatives of the public and the practicing profession upon advice from :

Medical schools.
State departments related to health.
Voluntary organizations.

All health professional organizations.
(A total of more than 50 people read and comment upon each Proposal.)

(6) Planning is for a selected population of people regardless of where they may ultimately receive their care. This permits maximum use of communication mechanisms already established between the many involved groups.

(c) Planning and operations are kept administratively separate.

2. ORGANIZATIONAL PATTERN The Project Review Committee consists of the head or his delegate from the schools of osteopathy and medicine, the Division of Health, Director of Welfare and Director of Mental Diseases. This committee serves as an advisory body to the Council on all proposals.

An Advisory council, nominated by the Project Review Committee and appointed by the Governor, serves as the governing body. The 12 members serve staggered terms, no person's service to exceed six years. Members may not be drawn from University staff.

The Liaison Committee is composed of elected or appointed representatives sent by each state-wide voluntary or professional organization which has applied to and been accepted by the Council. The 24 members serve as a reaction panel on all projects for Council.

The University of Missouri serves as trustee for funds for the Missouri Regional Program,

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For the Kansas City area a special Metropolitan Liaison Committee has been formed. Members include five local citizens and two representatives from each of the Advisory Councils of the two regions (Kansas and Missouri) which overlap in the Kansas City area. This committee also serves in an advisory capacity to the two Regional Councils for all projects which fall within the six county urban area of Kansas City.

A special, local planning force has been assigned to Kansas City by the Missouri regional program.

No matter how a region is described, ultimately it must interact with other regions. Modifications of the Kansas City committee have been developed with three of the other adjoining regional programs and similar plans are under discussion with a number of other regions which also adjoin Missouri.

Mr. STARK. I submit for the record three separate publications of the Academy of General Practice as evidence of cooperative efforts between the practicing physician and the program.

Mr. Rogers. We will receive those for the committee file.
Thank you very much.
Dr. Carter?

Mr. CARTER. I just want to compliment this gentleman upon the paper that he has delivered here today, and to say that I think it is a very healthy sign when men of his evident ability take part in such programs as this. Thank you.

Mr. ROGERS. I would like to second those sentiments. I think it is excellent, and we do need more and more people to involve themselves in the health field other than just the scientific community, and I wonder if you could give us an example--you say the design of more model delivery systems. What is your thinking there?

Mr. STARK. Two that I have specifically in mind: One would be the Smithville project located in a rural area about 15 miles from Kansas City where they are designing a program for the first time to give complete continuity of care from the time the patient is seen in the diagnostic stage through the treatment stage and then into the rehabilitation stage.

Another one is that taking place in Springfield, Mo., at the community hospital. A cardiovascular program is in force where they are treating the cardiac patient and also training nurses and doctors in the care, treatment, and rehabilitation of cardiac patients. This is a part of the current operational grant and is working out very well.

There are six or seven programs in operation, or being proposed now, in community hospitals.

Mr. ROGERS. Thank you very much. We appreciate your being here today.

Our next witness who has a 4 o'clock plane, I believe, is Dr. Amos Bratrude. We appreciate your presence here today. Your Congressman, Tom Foley, spoke to me on the floor and said he wanted to be here to personally introduce you to the committee and regrets he cannot be. He is in committee himself.




Dr. BRATRUDE. I was sent here today by the Washington Medical Association, and I have the blessing of the Association of General Practitioners.

I am Dr. Amos P. Bratrude and am in general practice in Omak, Wash. I have a common failing with all people who have moved West, and that is our adopted home has become very important to us, and so you'll excuse me if I give you a few words about Omak. It is a rather typical western community of about 4,500 people. The prime industries are logging, apple orchards, and cattle. The biggest single event of the year is the Omak stampede with what we consider, a world-famous suicide race. It is a nice community and my 9 years there have been very pleasurable. I am married and have four children, and as a father am beginning to experience the rigors of a teenage daughter.

I was raised in the Middle West. My father was a general practitioner in a small town by the name of Antioch, Ill. Upon deciding where to practice, there were several things I was sure that I wanted.

I wanted a community with a hospital in it. I have always been very interested in general practice but could see no reason to choose a community that was large enough to have a well established specialist group. I wanted to choose a community that I felt had some promise of growth so that I could eventually have the type of medical practice that I was interested in. This; namely, is a group of three, four, or five doctors who are quite interested in the practice of medicine, but also want to be free to pursue academic and recreational activities. I am now the senior man of a four-man group, and the reason that I can be here today is that I have three excellent partners that are covering for me.

Those were the practical reasons for choosing Omak. The emotional ones are that the country just immediately appealed to me. I enjoy hunting and fishing and being outside, and all these things were available. We have been 15 months in a new hospital with 32 beds, and a staff of seven physicians. Of course, four of these are of our group. It is quite interesting to me to go to various meetings and seminars and hear people discuss the problems of a small hospital. Invariably these people consider anything from 100 to 150 beds to be a small hospital. Consequently, their discussions of problems that might occur there have no bearing at all on what happens in a hospital of 32 beds. I had always been quite interested in the broader problems of medicine, and when the opportunity came to me from the Washington-Alaska regional medical program I welcomed it.

I would be the first to admit that I had a rather biased viewpoint when I joined the Washington-Alaska regional medical program board. I had been raised of fairly conservative parentage and had a decidedly jaundiced opinion of the role I thought Government was playing in medicine. It is quite surprising to find out at the first advisory com

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