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person is pressured far more by the medical profession than any other profession that I can think of along life's way.

The above statements are not made in an unkind or derogatory manner. We have been floundering around for years and constantly criticizing hospital cost. Yet, too few people will speak the facts. The other is there is only a limited amount of people in the health field that will have the opportunity of knowing the cost problems involved.

The medical profession is a great one and certainly one of the most important to our way of life. Yet, we have our problems in controlling our health cost, with the largest percentage being controlled by the medical profession because of some of my opinions that I have already mentioned.

I further question if Boards of Trustees have out-used their usefulness, as in years gone by hospitals were established and it was the responsibility of Trutees to formulate policies, as well as find ways and means of financing the service to the patients. This meant that great interest and efforts had to be put forth by Trustees in raising sufficient funds, as well as greater interest in policy making for the financial protection to the patients, as well as responsible for good patient care.

Within the last decade, health insurance has grown by leaps and bounds, as well as other insurances of a growing nature, of compulsory compensation insurance, as well as local, state and federal aid in many directions. Liability insurance has grown far greater than history has ever known. We have gone through a long period of years where the economy of our great nation has been favorable for the earning power of our people, which all spells out that the health cost to our patients, community and nation has now reached a new plateau of financing, which has meant, to a large degree, that cost has been allowed to skyrocket, with Trustees not being concerned about raising funds.

We have further overlooked, in my opinion, that hospitals today are big business. Anyone selling to hospitals is selling at a profit, whether it be equipment, supplies, medicine, maintenance and repairs, etc. Employees today in hospitals are now earning a fair and more reasonable, justified salary equal to other walks of life in the categories of the many types of business that are placed under one roof of a hospital. Other benefits, likewise, have been granted to the employees, which they are well-deserving of, provided the service is rendered honestly and faithfully in their responsibility to the patients, the staff and the hospital.

Unfortunately, we have been unable to organize and operate hospitals with the same business-like manner that we find in other industries because of the few reasons I mentioned earlier in this letter. Also, in the hospital and health field, it is the opinion of the medical profession that great advancement has been made in research, equipment and treatment, which has brought about costly equipment, costly technicians and personnel to understand and use same.

It is further my opinion that much of the so-called advancement is questionable to the cost involved to the average person. The light that I am trying to reflect at this time is whether or not we are allowing any and all hospitals of a general nature to become experimental, diagnostic or research centers in treating the sick and injured, and are we getting away from the down to earth, right to the point illness of our patients and cure them so that they can return to the every-day way of life of caring for themselves and families? Is the common illness and quick return to the cure overlooked? Have we turned too strongly to research and specialties? Are we lowering the standards of every-day medicine, or are we giving the best of care to the every-day patient?

We now have with us Medicare, Public Law 89-97, which was passed by the 89th Congress on July 30, 1965 and became effective July 1, 1966. Here, too, I question if we are going to lower the standards of medical care to a group of people under 65 that must and should be in good physical condition to maintain their own livelihood, families, etc., and to have the health to work, produce and pay the necessary taxes to care for our citizens 65 and over under Medicare. With the growing percentage of Medicare patients being admitted to general hospitals, I am concerned about this most important point. I am in favor of Medicare. I am in favor of caring for our senior citizens. I am in favor of anything that is good for the people of our nation, provided it is done on an honorable, reasonable basis, in fairness, as much as possible, to all, although I am strongly of the opinion that we have fallen short of providing sufficient facilities for caring for a large percentage of our Medicare patients of a nursing home nature, more so than a general hospital.

Medicare now faces hospitals with the following problems: The nursing profession discouraged and becoming more so in caring for elderly people, more of a nursing home type patient than a general hospital, keeping them clean, feeding them, great patience that is needed in encouraging them patient-wise, in giving medications, keeping them under control of falling out of bed, falling out of chairs, etc. These patients are not general hospital patients and the nursing profession is being lowered because of the morale. The cost is great. Also, hospitals are now faced with general facilities, such as x-ray, medical laboratories, other trained technicians, such as electrocardiograms, electroencephalograms, etc., for patient care, which would be of value to the medical profession in ordering to restore health to the younger to return to their way of life, as I have spelled out previously in this letter.

Medicare patients have become costly patients to general hospitals by occupying beds that are only limited to nursing care. It is true that we have established throughout our nation screening committees, as well as utilization committees of the medical profession. Here again, I question throughout our nation the real effect of these committees, in action, and it is further my opinion that unless the people serving in the hospital field are given authority in controlling many of the factors of hospital cost and procedures and unless we in the hospital field are given honorable and cooperation support by the medical profession, unless the general public realizes that health care is costly and that hospitals should operate and care for the sick and injured and not be used to the large degree of making it a convenience for the patient, and family to be cared for in general hospitals rather than at home, unless the general public realizes that luxuries within hospitals must be curtailed and accepted by the general public, we have nothing else to look forward to than higher health cost. Unless a miracle should take place that the authorities and responsible people running and controlling hospitals, the medical profession and the general public were to work as a team in an acceptable, honorable fashion, much can be done to control health cost and still have good health care, or we will continue to be faced with high health cost.

The other is if our law-makers are sincere and concerned about Public Law 89-97 and our health cost, they will provide sufficient funds to build nursing and convalescing homes to be run under the supervision of a general hospital, where great economy can be used in still using the laboratory, x-ray and other facilities of a general hospital, when needed for Medicare patients in a convalescing nursing home type facility; not on a profit basis. I have reasons to believe that this would be the greatest answer to good patient care of the Medicare patient at a more reasonable cost to our taxpayers and patients cared for in general hospitals. I would challenge this thinking. Also, if we fail to accept the above, I personally feel we must look to some drastic action in order to correct the health cost without lowering the health standards.

Dr. Toppings, you have before you a most important and serious assignment, and I offer to you my fullest support and best wishes that you find some of the answers that we need to our way of life of good health care at reasonable cost. I am attaching some literature which spells out some of my thinking and experience in the hospital field, if you care to review same.

Also, I would be most appreciative to receive a copy of the report concerning the National Conference on Medical Cost of June 27th and 28th in Washington, D.C., when same is complete.

Thanking you for your time. Wishing you well with the utmost success in your assignment as Chairman of the National Conference on Medical Cost. Sincerely yours,

C. T. BARKER, Director.


Los Angeles, Calif., July 11, 1967.

DEAR SENATOR SMATHERS: I will welcome the opportunity to contribute at any time to further the goals of your Committee in improving the health of the elderly.

I have been impressed by the fact that the age specific death rates in this country for adults have not shown any improvement in recent years. This failure to gain, and in some cases an actual increase in mortality rate, suggests that

we have lost some ground in maintaining health. One should not conclude from this that our improved medical technology and medical research is irrelevant to the fundamental conditions, but rather, I suspect, infer that the environment has become increasingly adverse. As we broaden our inquiry to include some of the more remote antecedents of the level of health of middle-aged and older adults, we include many social and behavioral factors as well as the physical environment. The important variables in these relationships do not now fall within the purview of representative medical education. For this reason, medical services are best adapted to high quality care for hospitalizable conditions. I would infer from the present health scene that bio-medical research and medical education will have to broaden its scope to include more training and research on the remote antecedents of health problems of adults. This will place both the health practitioner and the bio-medical researcher in new relationships with other fields, the physical sciences on one hand and the social behavioral sciences on the other.

More immediately, however, one might infer that we are delivering specialized services too near the terminal stages of diseases and we should make efforts to deploy services earlier in the processes of chronic diseases. To deploy services implies early detection and a more developed system of preventive health than is now commonly organized.

Best wishes to the success of the inquiries and actions of your Subcommittee. Sincerely,





Los Angeles, Calif., June 16, 1967.

DEAR SENATOR SMATHERS: I am pleased to make a statement to the Subcommittee on Health of the Elderly. I regret, however, that because of my teaching schedule I will not be able to attend the hearings on June 19th. One of the limitations of the way health services are organized is that the needs for health services cannot be anticipated while individual health problems are in their early stages. This is particularly true in the elderly. Individuals over the age of sixtyfive commonly suffer limitations of mobility and cannot travel easily to medical centers. Also, health services tend to be geographically ad psychologically remote from older persons. For this reason, they infrequently present themselves to health specialists unless a personal problem is advanced or acute in nature. At that time, the costs are high.

Insufficient effort has been devoted to ways of anticipating the need for specialized health services to the elderly. I have personally known aged persons who have had to receive dramatic and expensive care because the organization of health services did not lead to the early detection of incipient illness when intervention would have been less expensive and certainly more productive. The existence of Medicare and Medicaid does not solve the problem of making health services more easily available to older persons early in the development of serious illness. In this regard, I believe there is a notable shortage of trained personnel who have the background, conceptually and technically, to attack the problems. Public health personel can be trained in this area, although it must be said that until now they have been mostly concerned with matters other than health services to the aged. Schools of medicine may be encouraged to establish Departments of Community Health to train needed personnel. The issues appear to be less a matter of the quality of the technical health services than of how these health services are deployed and brought to the individual as early as possible in the course of an illness. This later matter is an area of study for medicine and for the behavioral and social sciences.

I personally have not been impressed that we have made any notable recent improvements in the health of middle-aged and retired persons. This is not intended to be a criticism of the quality of services but rather a comment about the need for broader study of health in relation to age and the delivery of services. It also occurs to me that The National Commission on Community Health Services may have examined the position of the elderly and their health needs in the total context of the quality of health in America.





LOS ANGELES, CALIF., June 20, 1967.

DEAR SENATOR SMATHERS: I am William R. Larson, Associate Professor of Public Administration and Sociology at the University of Southern California. I am also Research Associate in the Rossmoor-Cortese Institute for the Study of Retirement and Aging at the same University. Dr. James E. Birren, Director of the Institute suggested that I write to you about the questions you had posed. I am pleased to take this opportunity to present my views on some of the current problems in health care and services for the aged. As a medical sociologist, my particular research interests lie in the urbanization and aging process as it affects the type and quality of health care provided for the elderly. At our Institute, we have just begun a pilot study of some of these matters under a contract with the U.S. Public Health Service (PH 110-94).

A major characteristic of community medical care provisions that is often overlooked is the "two-way" nature of medical practice and care. Medical knowledge is primarily based on the cases and phenomenon which have been brought to medical attention. The early process of disease, the health medication habits, the behavior-altering attitudes, these are often unknowns to medical practitioners. What is needed is a system of medical data acquisition on a large scale, covering those special sub-populations such as the elderly.

Currently popular programs for the development of "age-segregated" housing for older persons have the effect of isolating them from general community health facilities. Transportation routes, waiting time, fare costs and mobile unit design contribute to the difficulties the elderly meet in using public transport facilities.

The recruitment of trainees into geriatric and gerontological fields has been dragging, since little "glamor" is attracted to care of the elderly. Although research on the aging process itself is in vogue, there seems to be few programs aimed at offering specialized and continuing education for physicians and paramedical personnel in the special needs of the aged.

It would appear that concerted effort is needed which can deal with problems of transportation, spatial segregations, specialized education, and legislative integration with programs.

I can envision a number of mobile clinics, operating on the newly developing multi-phasic screening principles, which could help to solve a number of the problems I've mentioned. By providing health data on a broad, community-wide scale, and using computer data storage techniques, such a system could allow physicians to get a far greater exposure to vital information on physiological, psychological, and social characteristics. By the use of educational system controlled by the data bank computers, physicians could participate in a learning experience. Community and public health organizations and personnel would have direct access to computer-based health information systems, allowing them to better plan for their involvement with those needing services.

The major element lacking thus far in dealing with the special health problems of the aging seems to be the failure to develop an overall systems approach to health information. As I have described it, the several social sub-systems involved need to (be) considered simultaneously. The present plans under way at our Institute are examining this approach, and I hope these hearings will cause others to move in a similar direction. Thank you.

Medical Evaluation Data Systems,

Project Director.




June 23, 1967.

DEAR SENATOR SMATHERS: This is in response to your letter of June 7th, 1967. There is no doubt that Medicare and Medicaid together will, when fully implemented, provide substantial fiscal relief to urban communities which have in the past provided a substantial portion of the hospital and nursing home care which low income elderly persons have required, out of their limited fiscal


It is also clear that Medicare, to the extent that its present benefits cover the medical expense of beneficiaries, provides for many elderly low and middle income persons the important element of human dignity and freedom from the worry of medical indigency by substituting entitlement to contributory insurance benefits for the previous welfare medical benefits available to them. Younger families, with elderly dependents, have also benefited from this new security, and many of them have in fact been relieved of drains on family income involved in paying for medical care costs for these elderly dependents. However, if the costs of medical care continue to rise as they have been in the last year or so, these increasing costs will create special difficulties for the elderly. Part of the fiscal relief provided by Medicare to both the community and to individual families will, in part, be cancelled out by these rising medical costs. As negotiated rates for hospital and physician reimbursement under taxfinanced, open-ended programs rise, these negotiated rates tend to become the prevailing rates. This can only result in higher costs for middle income families not covered by the Social Security Medicare programs-i.e., higher voluntary health insurance programs and, of course, increased out-of-pocket costs for the uninsured portion of the medical care expenditures. For such items as drugs, sick room supplies, dental care and other non-covered items, the elderly with fixed incomes are adversely affected by rising costs.

Thus one enormously important area for public policy consideration is the impact of these developments on the entire area of non-subsidized medical care services, and especially on voluntary health insurance. It seems inevitable that there will be increased public concern with prepayment for health insurance coverage for the entire population. This suggests that profound and quick study of the problems here involved, and of possible alternative course of action, should receive immediate attention in the Congress and in the states.

It is too early to appraise what has been the impact of the new Social Security titles on the shortages of personnel, or on methods of utilizing the medical and medically related professions. It is not too soon to begin to make the observations and measures needed to assess these developments, and this New York City is now preparing to do.

Both Medicare and Medicaid have resulted in increased demand for health services. Voluntary hospitals are over-crowded, and elderly patients seeking elective surgery must often wait a number of months for admission. Extended care facilities are in great demand, and there has been considerable difficulty in finding bed space. Home health care needs to be dramatically expanded. There are not enough agencies nor personnel to fill the need. Aged patients seeking care in outpatient clinics are often subjected to fragmented, de-personalized services that characterize many of our clinics. The result of all of these factors is that in many instances the present health services are remote, geographically and sociologically, from many of the elderly. However, this problem is not confined to the elderly. It is more intense among the aged. The possibilities of developing neighborhood health programs and restructuring organization of health services and personnel in relation to these neighborhoods, needs to be examined.

It is quite clear that there is an intensified need for intermediate institutional arrangements of a satisfactory quality for aged persons-or, extended care facilities of the type encompassed by Medicare; improved quality and availability of nursing home type of accommodations; improved availability and quality of homes for the aged, on the one hand, and of organized services that will permit the aged to be maintained comfortably in the community, in preference to institutionalization in those cases where this is clearly the preferable arrangement. A major problem in the present program is the very great need to simplify enrollment and payment procedures, particularly under the Medicaid program. Because the Medicaid program went into effect so quickly, the necessary tooling-up period for developing procedures was not available. Funds to permit adequate staffing of health and welfare agencies administering the law should be increased, and incentive should be provided to try new approaches to these problems. Moreover, some of the State programs for Medicaid split the responsibility for the program between the health and welfare agencies. No matter how good the degree of cooperation between these groups, it is impossible to run a program of this magnitude effectively and efficiently under this split responsibility. There are shortages of trained personnel in the medical and medically related professions that serve the elderly. The elderly require more nursing care in hospitals and in extended care facilities. Nursing care in both of these is in short

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