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The National Health Institute has issued grants to some optometry schools in order to further research. As in most other professional fields, the big problem still remains-attracting sufficient numbers of well-trained persons to conduct studies in the field of aging. This is not an easy task, and is greatly dependent on our newly awakened public interest. The stimulation of additional funds for use by qualified teams of researchers in optometric colleges is a big step.

Each new year brings great strides of accomplishment and new hope to the aging, thanks to research in vision. Past research has given optometry a fruitful beginning into understanding the problems of vision; current research will serve as the road to complete understanding. Gratefully, the aging person may look forward to several more decades of productive, “seeing”, alert years—all because of the vision progress being made through research.

SUMMARY

America has entered into a new phase of social development. Greater life expectancy and a rapidly increasing older population has created new problems, more challenges, far greater potential for national growth and development.

Since 1900 the number of men and women over 65 has increased 412 times, while our total population has little better than doubled. Approximately 1 out of every 12 people are over 65, a total of about 15 million. By 1975, it is estimated the total will reach 21 million people. Another 40 million men and women are between the ages of 45 and 67. This means that almost 50 percent of our population is over 40.

Our country's great strength lies in our aging and aged. Here lies a vast and growing reservoir of energy and experience. Harness this power through un. handicapped vision . . give it expression, dignity and independence, and it becomes an asset. Allow it to degenerate, vegetate and become dependent, and it becomes a liability.

Our age of mechanization and automation has afforded a rise in our standard of living, but it has also increased the amount of leisure. Work has become more specialized requiring greater visual efficiency, leisure time has become broader, requiring better visual acuity for true enjoyment. The frequency of retirement has increased while age of retirement has decreased, requiring adequate visual acuity to keep the older person occupied. With these new-found "leisures”, many older people are making use of their freedom from family and work responsibility. But many find themselves having the desire, but being hampered by visual defects. The unfortunate part of it all, is that this is a period of life when the person has the experience, knowledge and desire to enjoy life to the utmost, and offer more to humanity.

Perhaps one of the most tragic aspects of old age is feeling dependent, lacking a sense of self-sufficiency, feeling as though not wanted. Much of this lack of confidence is the psychological results of physical handicaps, often those in the vision category.

Through research and development, optometry has surged forward to find new ways and means to keep the visual facilities comfortably active longer. Optometrists discovered long ago that they must prescribe not only for the task but also for the mode of life. This is being done more and more in order to aid the senior citizen. Bifocals, multifocals, coated lenses, light and environment studies, hardened lenses, microscopic lenses and contact lenses, among other optical aids, are serving to prolong the "seeing" life of the aging person.

There is much more to be learned . . much more that the senior citizen of tomorrow can look forward to and see than those of today. But the effort is a worthy and compensating one, because in the senior citizen, you have humanity at its highest level of mature judgment.

In "Federal Responsibilities in the Field of Aging", President Dwight D. Eisenhower said:

“In considering the changed circumstances presented by lengthening the life span, we must recognize older persons as individuals—not a class and their wide differences in needs, desires, and capacities. The great majority of older persons are capable of continuing their self-sufficiency and usefulness to the community if given the opportunity. Our task is to help in assuring that these opportunities are provided."

Vision is the precious sense that stimulates opportunities, and fulfills them after they have been established. We are looking forward to even a better life for the senior citizen through improved vision.

THE JEWISH HOSPITAL OF SAINT LOUIS,

St. Louis, Mo., June 15, 1967. Hon. GEORGE A. SMATHERS, Nero Senate Office Building, Special Committee on Aging, Washington, D.C.

DEAR SIR: In your letter of May 31, 1967, you kindly invited me to comment on a number of questions concerning the health-care of the elderly. In my reply, I shall take up each question separately.

1. Are rising medical costs causing special difficulties for the elderly?

Medicare benefits have, of course, greatly lightened the economic burden of illness upon the aged. Hospital costs have risen more sharply than any other medical expense over the last decade and, this aspect at least, is now covered by Plan A of Medicare. There are other areas of health care, however, which continue to present serious financial problems to the sick aged.

a. Drugs: The cost of drugs prescribed to the patient, not in a hospital, is not covered by medicare insurance. Drugs are often expensive, and many elderly patients find it difficult or impossible to purchase the medications needed to retain or restore their health.

b. Nursing home care is covered only as extended care for bri periods following hospitalization. Unfortunately, many aged patients must remain in nursing homes for long periods of time at a cost which they canot afford.

c. Preventive Care: Plan B of Medicare specifically excludes routine examinations and diagnostic procedures which might uncover illness at a latent stage. As a result, many elderly will not seek medical aid until they are actually ill, and the opportunity to prevent illness and incidentally reduce the overall cost of care for the individual is lost.

2. Do many of the elderly face insuperable obstacles in obtaining needed health services?

This problem appears to be most severe in rural areas which suffer from shortages of physicians and other health-care personnel. Here, the aged patient often competes unsuccessfully with younger patients for medical attention. Physicians, nurses, etc., usually prefer to treat younger patients whose diseases are confined and more quickly responsive to therapy.

The greater the shortage of physicians in a community, the more apparent is this attitude and the more disastrous to the welfare of the aged.

I believe that this problem is less acute in large cities which have more physicians per capita and which provide out-patient services in hospital clinics.

3. Are present health services remote geographically and sociologically from many of our older patients?

The sociological problems of health care for the elderly are complex and their needs are frequently not well met. The aged patient often suffers from several diseases at the same time, each of which may require the services of a specialist. As a result, the patient may find himself referred from one physician's office to another, or from one specialty clinic to the next. Yet nobody takes charge of the overall management and nobody pays attention to the social and emotional problems which are entwined with the illness. This may, of course, be true for patients of all age groups but this deficiency in the overall management becomes more serious and more frequent in the aged who are ill more often and to whom diseases are more frightening and more costly. In order to meet this problem, some health centers have established comprehensive geriatric clinics which deal with all of the medical and social aspects of the care of the aged. Unfortunately, such geriatric clinics are rare. In most centers the elderly patient may receive excellent care during the acute phase of an illness. However, once the critical stage has passed and the patient has been dismissed from the hospital, care again becomes fragmented and little attention is given to those measures which might prevent another acute breakdown.

I hope that federal legislation may eventually encourage the establishment of comprehensive geriatric centers which will give preventive care and out-patient care, as well as hospital care and home health services.

4. Are present Medicrae and Medicaid policies intensifying old problems in the organization of health services or causing entirely new problems?

Medicare, by providing hospital insurance is bringing too many patients to hospitals and keeping them there too long. This has seriously aggravated the shortage of hosptial beds. A patient should be at the proper place at the proper time, but it has been the experience of the past year that too many Medicare recipients remain in the hospital when they could just as well be treated in a nursing home or at home.

Medicare legislation provides for home health services. It has been our ex. perience, however, gained by operating a Training Center for Home Care, (under contract from the U.S. Public Health Service) that the establishment of such services is badly lagging. Home health services require the cooperation of several community agencies. Very often, hospitals, visiting nurses associations and local health departments find it difficult to get together for the establishment of home health services so vital to the care of the aged.

Obviously, not all aged patients can be managed at home. Those who show severe senile mental changes or who have no suitable home will require care in a custodial institution. But too many elderly sick who could have remained with their families wind up in nursing homes just because well organized home health services were not available to them. It was clearly the intent of Medicare Legislation to keep as many aged in the community as possible. However, concerted efforts will have to be made by State Health Departments, local agencies and the existing eight Home-Care Training Centers to combat the serious lag in the development of home health services.

Similar problems exist with regard to nursing home care. Nursing homes are important health care facilities. In many cases they could provide more than custodial care; they could be used as geriatric rehabilitation facilities and some of their residents, restored to an acceptable level of independence, could return to their homes. Some nursing homes have made the effort to increase the scope of care along these lines but many others have failed. Medicare legislation provides for affiliation agreements between hospitals and nursing homes. In most cases these agreements exist on paper only. Hospitals often fail to give necessary professional support to those nursing homes with which they are affiliated, and often the homes fail to seek the advice and guidance which could improve the level of care.

These problems have, of course, existed for a long time. They have not been aggravated by Medicare. Rather, health care facilities have failed to utilize the opportunities which Medicare legislation is offering them.

5. Are shortages of trained personnel in the medical and medical-related professions especially severe in fields that serve the elderly ?

Shortages are critical in all health care professions. As pointed out before, the care of the aged is not attractive and for this reason facilities which serve the aged find it even harder than others to recruit personnel. Often they are forced to combat negative attitudes by offering higher salaries. This in turn tends to increase the cost of caring for the elderly.

I greatly appreciate your giving me the opportunity to express my opinions on this vital subject. Kindly let me know if you wish me to elaborate further on any of the points discussed. I shall be happy to be of service. Yours very truly,

FRANZ U. STEINBERG, M.D., Director, Department of Long-Term Care.

HARVARD UNIVERSITY,
SCHOOL OF PUBLIC HEALTH,

Boston, Ma88., June 19, 1967.
Hon. GEORGE A. SMATHERS,
Chairman, Subcommittec on Health of the Elderly
U.S. Senate, Special Committee on Aging
Washington, D.C.

DEAR SENATOR SMATHIERS : Your letter of May 31st arrived while I was absent from the office due to a recent illness. I regret that it was not possible for me to respond to your invitation to submit a statement for the hearings of the Subcommittee on the Health of the Elderly.

I believe that it is particularly appropriate to review the present status of health care for our aged citizens. Medicare has been of significant help in reducing but not eliminating the financial barrier to health care for persons over 67. Medicaid has not been implemented in a number of states and has had but token implementation in many states.

While the health manpower shortage is indeed acute, I am convinced that the haphazard way in which our health services are organized is wasteful of manpower and is a significant factor in the less than optimal state of health care for the elderly. Sincerely yours,

ALONZO S. YERBY, M.D., M.P.H.,

Professor and Head.

AMERICAN HOSPITAL ASSOCIATION,

June 9, 1967. Hon. GEORGE A. SMATHERS, Chairman, Subcommittee on Health of the Elderly, Special Committee on Aging, U.S. Senate, Washington, D.C.

DEAR SENATOR SMATHERS: This statement is sent to you in reply to your letter of May 24, 1967. We hope the contents will be helpful in your committee's consideration of the subject of "Cost and Delivery of Health Services to Older Americans." The hospitals of the country, of course, have been continually concerned with the organization and provision of services to the elderly as they have been involved in the over-all efforts of hospitals to care for the total population. It is not an over-statement, I think, to say that the Medicare program would not have “gotten off the ground" except with the complete cooperation of the hospitals of the nation.

Title 19 of the Social Security Act dealing with indigent and medically indigent persons will come into effect July 1 as the federal standards are to be implemented starting on that date. This program will gradually develop so as to involve a very large segment of the population and will without doubt be concerned with health services to large numbers of aged persons. Here, again, a successful implementation of Title 19 will be dependent upon full participation on the part of hospitals. This essential participation on the part of hospitals can only be assured if the financial needs of hospitals to provide community health services is fully recognized by the federal government.

The following discussion is directed toward the questions raised in your letter to me:

1. Are rising medical costs causing special difficulties for the elderly?

In the main, rising hospital costs for the aged are a problem to be faced by the federal government and particularly the Hospital Insurance Trust Fund. Therefore, for the aged beneficiaries themselves, escalation of hospital costs is quite limited in its impact and would become a major factor only for those aged individuals who have exhausted the benefits provided under Title 18. Even here, however, if states implement Title 19 in an appropriate manner, the escalation in (osts of those who have exhausted their benefits under Title 18 will become a matter for state and federal governments under Title 19.

The Medicare law provides, of course, that the $40 deductible for hospital admissions can be increased at stated intervals. However, it is not likely that this would become in any way a major factor for elderly persons.

Services and supplies required by elderly persons who are not hospital patients may well suffer increased charges and thus affect the costs of health services to the elderly. However, we are not in a position to provide essential information on charges or costs outside of hospitals.

It is conceivable increased costs in health services might occur insofar as the services of extended care facilities and organized home health programs are not arailable. An enderly person under such conditions has two choices: either do without the care or personally finance whatever may be available in the way of substitute care. This may involve seeking care in an institution which fails to qualify either as a hospital or extended care facility. This might be an unskilled nursing home or the care might be provided via periodical visits by a physician to the private home. Or, perhaps home nursing services may be obtained on some basis. In either instance, the cost of such care would have to be borne by the individual, completely or in part, and thus would subject such individual to the impact of escalating health care costs.

2. Do any of the elderly face insuperable obstacles in obtaining needed health services?

There are three major aspects to obtaining health services: the availability of facilities, the availability of adequate personnel and the financing. By and large, the elderly are no different than the rest of the population in terms of the relationship which the existence of these three factors bears to their ability to obtain health services. There are acute shortages of certain categories of health personnel. The development of extended care services and home health services has an absolute relationship to the availability of adequate numbers of well trained nursing personnel. Thus, the existing major shortages of such personnel will directly affect the availability of these services, which are of particular importance to the elderly. The financial problem of the individual aged person is ameliorated through the passage of the Medicare law and if Title 19 is adequately developed by the states it should rather completely remove any financial obstacle to the obtaining of health services by the aged. It is obvious from the hospital occupancy figures being reported that substantially increased numbers of the aged are now receiving health services and this was a basic purpose of the Medicare law.

3. Are present health services remote geographically and sociologically from many of our older persons ?

There is already a widespread distribution of hospitals throughout the nation. For this reason and because of the availability of good highways and modern transportation, geographic location in terms of physical distance from a hospital facility is of quite minor importance today. The more important factor is time, and it is fact that there are a great many persons in metropolitan centers that are further away time-wise from hospital facilities than are individuals in rural areas. The problems involved here, however, are not unique to the aged but are related to the whole population. We strongly believe that what we need in the country is better hospitals rather than more hospitals. It would be a great mistake to plan for a hospital at every crossroad. This would be most likely to result in a deterioration in the quality of health services. Medical advances increasingly dictate the need for concentrations of available equipment, facilities and personnel in centrally located facilities. Widely dispersed and fragmented units can be wasteful in the use of personnel. They would be extremely costly and would not elevate the quality of health care. Such an approach would not result in increased availability of "modern medicine” to the aged. In those instances where elderly persons fail to seek health services because of a fear of the costs or because of a strong sense of pride, the development of Medicare has probably done much to eliminate these barriers. There are undoubtedly elderly persons who refuse to seek medical care or refuse to be admitted to hospitals for other reasons; and, of course, this problem would have to be approached in other ways.

4. Are present Medicare and Medicaid policies intensifying old problems in the organization of health services or causing entirely new problems?

Without doubt the existing provisions in respect to the services of radiologists and pathologists are intensifying old problems and developing new problems in hospitals. Also, without doubt the present provisions of the law in respect to outpatient services are nearly impossible of administration, are extremely costly to administer and quite likely are frustrating large numbers of older persons from utilizing the outpatient benefits of the Medicare law. The present provisions for outpatient services create such obstacles that certainly there is no incentive for institutions to develop such services.

Hospitals throughout the nation are expressing their deep concern in respect to the reimbursement received for Medicare and, of course, this concern is magnified now that a decision has been reached to utilize the same basis of reimbursement under Title 19. The belief is increasing that any continuation of the present inadequate reimbursement and continuation of the basis of apportionment of costs now insisted upon by Social Security will inevitably lead to deterioration of hospital care. This situation poses very real problems for hospital boards of trustees in light of their responsibilities to the over-all community they serve.

It is quite clear that a major role of hospitals in the future is going to be care for patients who are not confined to beds. The outpatient services and the diag. nostic and treatment services are increasing dramatically. It is also obvious that the public more and more is turning to the hospital for the provision of medical services of all kinds. Undoubtedly, this trend is of importance to the elderly.

The American Hospital Association is strongly in favor of group medical practice. The growing numbers of such groups reflect their increasing public acceptance. As the hospital develops increasingly as the center of health affairs in the community, it is obvious that increasing attention will be paid to such develop

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