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Public Law 89-97 as amended expands the social security system to provide for part payment for specified health care expenses for persons age 65 and over. This law affects indirectly the private and public cost and the availability of services to persons of all ages.

The Association urges amendment of Part B which provides for payment for physicians and related health services:

(1) to meet fully the total health care needs of beneficiaries;

(2) to develop reasonable cost criteria and encourage coordination and optimal utilization of skilled specialized personnel and facilities.

(1) Full coverage of health needs requires extension to needs not now covered. This includes preventive services and out-of-hospital prescribed drugs and biologicals.

Full coverage also requires control of out-of-pocket costs in services now under Medicare. This includes:

a. Elimination of deductible and co-insurance features now required.

b. Elimination of limits on home health services, out-patient hospital care, and psychiatric care.

c. Provision under Part A for payment to hospital-based specialists as part of the hospital charge. This would replace collection of fees from patients. Anesthesiology, pathology, radiology and psychiatry are the specialty fields involved. Also affected would be services of residents and interns.

(2) Encouraging of coordination helps assure that adequate specialized services of varied types will be rendered in relation to the continuity of patient care. Group practice mechanisms providing prepaid care on a per capita basis rather than fees for service should be recognized as a useful device for such coordination. Principles of organization and registration procedures should be defined and incentives provided for use of such programs in Medicare. (For example, costs of forming new prepaid groups could be absorbed.)

Elimination of deductibles and limits on service will reduce administrative costs to the trust fund and will assure that needed care will be sought and received. Elimination of deductibles for medical service and inclusion of specialist services in hospital charges will help hold down medical charges for the entire population.

These improvements will also help establish a more adequate type of coverage as the minimum to be extended to other social security beneficiaries in coming legislative sessions.


June 12, 1967.

Chairman, Subcommittee on Health of the Elderly, Special Committee on Aging,
New Senate Office Building, Washington, D.C.

DEAR SENATOR SMATHERS: In your letter of May 31 you asked for my thoughts on organization of health services for the elderly and methods of delivery of such services.

My response confines itself to selected aspects of the general topic of your inquiry.

(1) Build-up of home health services.

Changes in family living arrangements, urbanization of the population and medical advances make it necessary to foster a build up of organizations that can provide health services to individuals in their homes or in nursing homes. While progress has been made over the past seven years or so to establish under health department or general hospital auspices a complex of health services that would give support to private physicians in the care of patients outside of hospitals, we appear to be far from meeting needs.

The range of home health services should include nursing services (both professional and practical), therapy services (speech, physical, occupational, etc.) and homemaker services. Dental services also should be coordinated with the other health care, as well as supervisory services and such ambulance or other transportation services as would permit movement of patients to hospitals when required for effective care.

Adequate home health services, provided in accord with a doctrine of "pay-ability," not only would be of aid to those aged whose illness permits

of care in the home, but also to other groups in the population. For example, ready access to supervised nursing services would be of considerable support to working mothers whose children become ill and to relatives of disabled persons.

(2) Preventive health services.

To the extent that disabling conditions can be prevented or controlled it would appear to serve the national medical interest, as well as the welfare of the elderly, to provide an ancillary preventive health care program. For example, such a program might call upon health departments hospitals and other health agencies to provide diagnostic health examinations for the aged, with appropriate referrals to treatment and rehabilitative services as required.

Appropriate provision should be made for defining the state of medical knowledge about health examination and diagnostic procedures that offer some promise of reducing chronic illness or its impact. Authorization should be provided for implementing a program of health examinations and for referrals to facilities that can provide the care indicated for the patients. (3) Ancillary health worker training.

Special manpower (and womanpower) training programs should be enlarged to develop the ancillary health program staffing required to achieve adequate health care for the aged. Such a program, if well designed, not only would contribute importantly to attaining the objectives of the medicaid and medicare programs but also would contribute to the Nation's attack against poverty.

The training provided should not only build the health manpower skills needed, but also be concerned with health manpower attitudes toward the aged sick and dying.

It should emphasize that we have not been directly concerned in the administration of medicare and have little knowledge about the many specific problems that have evolved.

As we work with selected states, counties and cities toward the implementation of planning, programming, budgeting systems in the 5-5-5-project demonstration we shall observe more immediately the impact of the medicare program on hospital and health agency operations. Accordingly, we shall be in a better position a year from now than we are at present to respond to your inquiry about geographic and financial impacts.


Project Director.


July 12, 1967.


Chairman of the Subcommittee on Health of the Elderly,
Senate Special Committee on Aging,
Washington, D.C.

DEAR SENATOR SMATHERS: The staff in the office of Dr. C. J. Wagner, Director of the Bureau of Health Services, United States Public Health Service, has contacted our agency, as they felt we would be in a better position to give you and your Committee follow-up on the Dexter Manor Story as told by the pamphlet "Portraits in Community Health".

First of all could I tell you how pleased we are that you were able to use some of the material in the very well prepared pamphlet. We feel this venture demonstrates federal, state, local, public and private agencies working together.

We were more than appreciative of the financial assistance and the fine guidance contributed throughout the project by the Public Health Service.

Since the completion of the demonstration we have not only continued the program at Dexter Manor but have extended it to two additional projects for the elderly. The second program was established at Hartford Park Housing where presently approximately more than 700 elderly people are living. Unlike Dexter Manor this project is made up of scattered units, but we have essentially the same plan operating; namely, an office in a central area where the nurse has daily consultation hours. People can bring their problems to her and she can give them correct advice and referral to the proper agency. If the people are in need

of direct nursing care in the home arrangements are made for this. We have continued to use as our entrance to people's home the completion of the Tenant Emergency Card which in so many instances we have found helpful.

In June 1966 the Providence Housing Authority opened another single story building called Bradford House. Once again, as at Dexter Manor, the architectural plans included space for the nurse on the first floor. Most tenants frequent this floor daily as the housing office, the laundry and the craft and meeting rooms are all on this floor. About 300 elderly people live at Bradford House which is no more than five minutes by car from Dexter Manor. This proximity enables one nurse to provide similar service to the residents of both buildings.

At Hartford Park from January 1 to December 31, 1966 as well as daily office hours a total of 1,212 visits were made for direct nursing care and 183 visits for health instruction. A screening program for chest conditions was also carried out through cooperative effort.

At Bradford House from June 1 to December 31, 1966 a total of 174 visits were made to give direct nursing care and 204 health instruction visits were provided. We did learn that clerical services are not necessary at each project so all clerical details for the nurses assigned to the projects are handled by the office staff at our headquarters. The social worker from the Department of Social Welfare continues to visit and have consultation hours in each of the three units. The social worker originally employed in the Dexter Manor project is now on the staff of our Association and is also available for service.

Here in Providence we are still enthusiastic about this approach for our Association has continued to have the support of the Providence Housing Authority, the Rhode Island Department of Health and Social Welfare and the residents themselves.

For many years the value of home nursing visits made by public health nurses for the prevention and early detection of disease have been found to be efficacious in helping to secure early diagnosis and treatment for the young age groups in the population.

As a result of our experience we are convinced that the public health nurse is well equipped to carry out this same type of approach with the elderly. If we can be of assistance do not hesitate to contact us. Sincerely,



STATEMENT OF RUSSELL KOCH, O.D., FOR THE AMERICAN OPTOMETRIC ASSOCIATION Mr. Chairman and Members of the Committee, thank you for the opportunity to again present the views of the American Optometric Association on the subject of vision care for older Americans. I am Dr. Russell M. Koch, Chairman of AOA's Committee on Vision Care of the Aging. I engage in the private practice of optometry in Elk City, Oklahoma. As a Committee Chairman, I speak on behalf of more than 17,000 full-time practicing optometrists located in over 5,000 communities throughout the Nation.

Members of the optometric profession have always directed their attention to the vision problems of those people in their communities who are approaching the golden years of life because almost without exception these people need the services of a doctor of optometry. We have learned about the specialized problems these people encounter in obtaining health services at reasonable cost.

In 1957, our Colorado Optometric Association affiliate retained Donald A. Seastone, Professor of Economics at the University of Denver, as a consultant to investigate the cost of vision care for Aged Pensioners of Colorado. The results of that investigation were conveyed to Mr. Guy Justus, then Director of Colorado's Public Welfare Department. A copy of that report is appended to this statement for your records.

The proposal conveyed to Mr. Justus projected several alternate methods for controlling costs as well as controlling any possible abuses in providing vision services to Aged Pensioners. This proposal was one of the earliest attempts optometry made to arrange for delivering vision care services for these special optometric patients as a group.

Shortly after making this proposal, our profession participated in making arrangements for and attending the White House Conference on Aging. Our

report to that Conference, titled "The Senior Citizen and Optometry," is also appended to this statement.

The report's Forward contains a statement by Dr. Ralph E. Wick of Rapid City, South Dakota, then Chairman of AOA's Committee on Vision Care of the Aging. He said:

"Today, we realize that reduced visual efficiency is nothing to be ashamed of. It occurs in both old and young alike. In the aging person, it is a natural physiological change that takes place. When properly corrected, vision offers the senior citizen the facilities to indulge in all his regular activities with interest, vigor, and visual efficiency.

"A greatly increased life span (from 20 to 30 years of age during the Roman Empire, to 40 years of age by 1850, to 50 years of age at the turn of the century, to almost 70 years of age today, and even more tomorrow) has created many problems for the human being. Much the same, it has created new areas of research for the ophthalmic professions. Increased longevity has changed our pattern of life, and our modern environment makes more and more demands on vision that optometry must cope with and conquer.

"From a clinical viewpoint in optometry, a demarkation had to be made to indicate where youth ends and aging begins. Through studies, the age of 40 was found to be the place in life where presbyopia (a clinical classification for ‘old age' vision deficiencies) begins. The actual age depends on the individual, but by the age of 50 to 55, the process has taken place in nearly all persons, and some type of visual correction is necessary.

"Since presbyopia appears around the age of 40....(long before most companies even consider retiring their employees.... at least 30 years prior to the end of today's life expectancy), it become apparent that vision is no longer a problem of the aged, but rather the aging.

"Optometry gives special attention to the vision problems of our senior generation. Recognizing the physiological and psychological changes that accompany normal aging, optometry is concerned with visual acuity, refraction, accommodation, and the visual neuromuscular system. Optical aids and clinical techniques used offer every American a more productive, comfortable, self-sufficient life, even in the late years, through good vision care."

On page 12 of this White House Conference Report you will find three general headings relating to delivery systems for opometric care which were in effect then and which continue. Dr. Wick stated concerning these systems:

"Because opometry's interest is so keen and its function so important in alleviating problems of the senior citizen, it is only natural that many community projects are spear-headed by local and state optometric societies." The three systems that have proven successful are:


Community vision screenings are conducted at cost to the patients. This is a valuable community project because it enables aged individuals who have reduced or limited incomes, because of their physical limitations, to obtain good vision care. Should S. 513, the Adult Health Protection Act, introduced this year by Senator Harrison A. Williams pass this Congress, our Association envisions that more of these individuals will receive care at a cost they can afford.

Many of the clinics just described have been conducted in cooperation with the public health departments, service clubs, and other organizations within local communities. Vision clinic programs can be arranged in most communities upon request.


This is another type of community project in which citizen's groups and local optometrists cooperate for the welfare of the community's indigent aged. The citizen's groups contribute ophthalmic material, while the optometrists contribute their time. This is a very valuable combination that can benefit a large number of otherwise neglected senior citizens.

As you are well aware, the provision of vision care and ophthalmic materials is optional with the various states under Title XIX of the Social Security Act. Only sixteen states provide reimbursement or payment to vendors for optometric care and then, most states do not pay the total cost.

Title XVIII of the Social Security Act excludes "eye examinations for the purpose of fitting, prescribing or supplying eyeglasses." Consequently, most older

Americans find it necessary to pay out-of-pocket for vision care when they must have it.

For those people unable to pay for needed optometric services, optometry is developing philanthropic centers where individuals receive care without obligating themselves for a current claim or later payment. At present, optometric centers are located in: New York City; Denver; Atlanta; Miami Beach; Oakland, California, Harrisburg, Penna.; and East Lansing, Michigan. More are being organized. Two of these optometric centers, Denver and Oakland, have received partial funding from the Office of Economic Opportunity.

Additionally, in New Jersey and Pennsylvania, visiting mobil vision care units, partially financed by state trucking associations and Lions Clubs, travel to convenient locations where the elderly have their homes and provide care.


As the title suggests, this program is designed specifically to benefit aged individuals in nursing homes and shut-ins. This care is particularly valuable in smaller communities and smaller nursing homes which do not retain regular staff optometrists.

Where this program operates, local optometric societies provide panels of local optometrists, who provide visual screening services for the homes. They also offer consultation on methods for improving lighting conditions, general environment, types of printed reading material to be provided, and other services helpful to comfort and aid of the partially sighted or blind aged patient.

In presenting figures on prevalence of defective vision ("Eye Care," a term generally used to indicate surgical or medical care of eye disease and/or injury, is not included), the effect of age must be recognized as one of the most variable factors, yet one which can be weighed with a reasonable degree of accuracy.

The Life Extension Institute has compiled figures on a study of 10,924 male and 11,694 female subscribers. In making these tests, the criterion upon which the person was declared "defective" was his inability to read normal Snellen or Jaeger test letters with either eye. We believe this study is particularly significant because it provides a year by year percentage showing the attrition of age, as well as a comparative value for the factor of sex. There were two approaches:

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Studies by the U.S. Department of Health, Education and Welfare indicate that per capita costs of personal health services for those age 65 and over total approximately 21⁄2 times more than costs for the rest of the population. As would be expected because most of the aged do not have earnings from employ

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