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for vote a $100,000,000 Bond issue in which the primary health item was $4,000,000 for a new Chronic Hospital. Prior to the inclusion of this item, the Mayor requested the Health and Welfare Council of Greater St. Louis (then known as the Social Planning Council) to appoint a committee of citizens, professional and lay, to evaluate the need for this Bond Issue item. This group of citizens found that the Greater St. Louis Community provided very little (private or public) for the chronically ill person other than acute in-patient medical services and long-term institutional care (primarily custodial). This committee, therefore, advised that the Chronic Hospital Bond Issue item should be included, but with a provision that the actual building be contingent upon the findings of a study of the “health needs" of the City of St. Louis. The Chronic Hospital Bond Issue item was approved by the voters and in 1956 the City contracted with the American Public Health Association to make the survey. Additional monies enabled the survey to be extended to the Greater St. Louis area. It was completed in 1957. Among its findings pertinent to the problem of the chronically ill were these :

1. The financing of the medical care for the indigent and medically indigent is a serious problem in the St. Louis area. In Missouri, the County (the City of St. Louis is not in a county and, therefore, must assume all of the usual county functions) has been deemed responsible for medical care, other than mental illness and tuberculosis.

2. Voluntary hospitals in the St. Louis area are primarily concerned with the short term acute case; where they are adding beds for chronic disease, the purpose is to provide rehabilitation for relatively short periods of time.

3. The City of St. Louis needs a separate department of Public Health and hospitals to discharge the City's responsibility for health of the public by planning and operating a single unified program of service that range from prevention through treatment and rehabilitation.

4. A new chronic hospital is not necessary, if the City of St. Louis develops a comprehensive integrated program of medical care for the aged. Emphasis should be placed on improving patient care through an increase in prepared personnel and in services and programs to make health services more readily available—other than in-patient hospital care. This should include home care, rehabilitation and improved services in the out-patient departments.

5. Home Care programs are relatively new in the City of St. Louis. There is one comprehensive program which is operated by the Jewish Hospital of St. Louis. A home care program should be established by the municipal hospitals; the voluntary hospitals, particularly the larger ones closely associated with medical schools, should explore the feasibility of

developing home care programs. Since the survey these actions have been taken by the City of St. Louis

1958 : The voters approved the creation of a single department of health and hospitals to be directed by a physician well qualified in public health and hospital administration and to be responsible to the Mayor. The director was appointed in January, 1959.

A long-term illness medical service (known as intermediate care) was established at Koch Hospital for the group of municipal hospitals with 3600 bed complement (two general, Max Starkloff and Homer G. Phillips Hospitals; one psychiatric, Malcolm Bliss Mental Center; one tuberculosis, Robert Koch Hospital; and one long-term chronic institution, (mostly custodial) St. Louis Chronic Hospital. This intermediate care service started as a 40 bed service and is now a 200 bed service with a waiting list. Medical nursing, social work, physical and occupational therapy were coordinated to provide comprehensive medical care. It includes intensive rehabilitation. The service has attained a significant level of effectiveness; approximately 70% of all live discharges return to their own homes directly or via home care, since the latter was established in 1960.

1960 (May) : An Information and Referral Center for the chronically ill was established by the Department of Health and Hospitals. It had existed earlier, from 1955–1958, as an activity of the St. Louis Chronic Hospital, which discontinued it in favor of a more traditional hospital admission procedure. Of the original Information and Referral Center the American Public Health Association Survey noted : “The experience of the Information and Referral Center not only justifies its continued operation, but its expansion into a Citywide adult counseling service for the chronically ill and aged." It was reestablished on just this basis, a City-wide service. This action was necessitated because Chronic Hospital had filled almost all of its 1500 beds—despite the fact that a new domiciliary of 100 bed established at Koch Hospital a short time previously was completely filled. In the original operation there were less tban 500 requests a year from chronically ill persons; in the first year of its reactivation there have been more than 800 requests. This increase is considered an index of the rise in incidence of illness requiring long term care.

Loug term patients are “persons suffering from chronic disease or impairments who require a prolonged period of care, that is, who are likely to need or who have received care for a continuous period of at least 30 days in a general hospital, or care for a continuous period of more than 3 months in another institution or at home, such care to include medical supervision and/or assistance in achieving a higher level of self-care and independence.”

1960 (September). A coordinated, medically directed, hospital-based Home Care Program was established by the Department of Health aud Hospitals.

By now there existed in the Department of Health and Hospitals these levels of care; acute in-patient, out-patient, intermediate care, long term institutional care, home care, and Information and Referral. Coordination was required to insure that the comprehensive needs of the long term patient were known and that he received the needed level of care; to this end, the Director of Health and Hospitals appointed a Long Term Illness Committee consisting of the Chiefs of Home Care, Intermediate Care, Physical Medicine and Rehabilitation, Psychiatric, Social Work and the Medical Director of the Chronic Hospital. This group, responsible to the Commissioner of Hospitals, delegated to its Chairman (Director of Home Care) the day-to-day decisions regarding the needs of long term patients and reserves for its weekly meetings those patient situations that are difficult and/or require administrative changes, and otherwise sets guidelines.

It should be noted that 63 per cent of all applications made to the Long Term Illness Committee came from either home, nursing homes, or from hospitals other than the public ones. From that group and the total group that was referred for long term illness care, approximately one-third have been feasible medically for Home Care. However, of the one-third that were thought medically suitable for Home Care, it should be noted approximately 20 per cent of those were accepted for Home Care and the remainder were not accepted. Of those not accepted a high percentage could have been accepted on a Home Care program providing they had a substitute home, a housekeeper, or meals on wheels.

As was stated previously, as a rule care in the acute hospital is merely the first stage in the program necessary for rehabilitation or for planning for long term care, either because of medical or social needs or both. Because of these long-range developments, the Director of Health and Hospitals, ordered the creation of the Long Term Illness Committee and the Home Care Department in 1960. The purpose of these two groups was to complement and coordinate the existing services of the two acute city hospitals, the intermediate, long term or rehabilitative divisions at Koch Hospital, Chronic Hospital and the Rehabilitative Division. The Information and Referral Center was created to provide accessibility to long term care planning for those citizens not under medical care within the municipal system.

Experience has demonstrated that planning for the future needs to be initiated as soon as the patient comes under care of a physician. Often this will be at the acute in-patient level; occasionally, it may be at the out-patient or emergency room levels. It should be realized that adequate planning cannot be started until the medical needs of the patient are known. The attending physician assumes the responsibility of identification of a patient's needs for long term planning and referral to the Long Term Illness Committee which provides direction and focuses on the planning needs. Over the seven years that this program has been in action, the sole purpose of the Long Term Illness Committee has been to coordinate planning, to determine the best level of care for the patient aimed at restoration to his community when possible. We have been able to significantly reduce the number of patients requiring long term institutional care and to increase the numbers of patients who can safely return to the community. A secondary result of this program has been the movement of patients from the hospital more rapidly and results in better teaching facilities for the hospitals and for the trainees in medicine.

While this program has worked in a public system, a few voluntary institutions have attempted to intiate similar systems. Increasingly the voluntary 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.


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 to gether. 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.


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 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 grer 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. corered 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 rut-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 coordina. tion- (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. Cer. vantes, “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 be cause concerned citizens will force it to do so. The choice lies with the private sector of the health field.


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.



St. Louis, Mo., June 15, 1967. Hon. ALFONSO J. CERVANTES, Mayor of the City of St. Louis, St. Louis, Mo.

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

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