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ments. Undoubtedly, therefore, the rendering of hospital services to the elderly as to the rest of the population will be affected by changes in organization which may result.

Medicaid has thus far only really been implemented in some of the states. It is not yet clear how the program will develop in many states. There is a vast difference between programs of health services envisioned under Medicare as com pared to Medicaid. Medicaid will in the main be directed towards individuals who are under 65 years of age. Most of those persons over 65 years of age are covered under Part B of Title 18 for physician services. The scope of benefits provided under Medicare are the same nationwide for all elderly who are eligible. Except for broad federal criteria, the benefits which the fifty states may decide to provide under Medicaid may vary greatly. Thus, at the present time it is not possible to evaluate the Medicaid program in terms of its effect on the organization of health services.

This Association fully supports voluntary planning for health services, facilities and personnel. We are making every effort to assist hospitals in their participation in planning activities. Undoubtedly, as planning becomes fully implemented throughout the nation, there will be changes in the organization of health services affecting the elderly as well as all others of the population.

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

As stated previously, there are acute shortages in many areas of health personnel. These shortages affect the elderly as they do all other individuals requiring health care.

It is believed that physical therapy services are of particular importance to the rehabilitation of the elderly. Such services are included in the benefits of Medicare, and it may well be that the shortages of trained physical therapists restricts the availability of these rehabilitative services.

We have already referred to the shortages and need for greatly increased numbers of qualified nursing personnel and the fact that the lack of availability of such personnel will curtail certain of the services needed by the elderly. Also, current studies indicate that aged persons require a greater amount of nursing care than young persons, thus aggravating the impact of the shortage of nursing personnel upon care of the aged.

6. Can you give us recommendations for reducing paper work relating to Medicare? Do you feel that many Medicare recipients are confused by present procedures?

There are wide-spread reports from hospitals of the necessity of adding substantial numbers of personnel to carry the administrative burden of Medicare. Since we understand that similar procedures are to be followed under Title 19, we expect that such administrative costs will be further increased.

The various procedures which are required for Medicare are being studied carefully by the Social Security Administration, by the intermediaries and by hospitals. It is expected that improvements can be made in certain of the procedures. If deductibles now required are eliminated and a co-insurance factor substituted as we recommended in our testimony of March 8 before the Ways and Means Committee on the pending Medicare amendments, a great deal of administrative cost and confusion both for hospitals and for older recipients will be eliminated.

The requirement of physician written certification of medical need at the time of admission is an unnecessary duplication of effort and results in substantial delay in the processing of the forms and in hospitals receiving payment.

The present statute and regulations require hospitals to separate the costs of radiologists' and pathologists' services on the part of the hospital from the remuneration of the hospital-based radiologists and pathologists. This is time consuming especially when the hospital has been designated as collection agent for the physician and must claim payment on his behalf from another trust fund. Payments for physicians' services is subject to the $50 annual deductible while the hospital portion of payment for radiologists' and pathologists' services are not subject to a deductible. Similarly and even more expensive to administer and confusing to all who are involved, is the procedure for obtaining payment for outpatient diagnostic services. Here, again, the hospital must obtain payment froin one source, after first considering a $20 deductible, while the physicians' compensation must be obtained from another source and subject to the $50 annual deductible under Part B. Not only is this extremely difficult to understand but it results in very little payment to hospitals, physicians, and patients for outpatient care and in frequent waiving of potential benefits because of the complications inherent in trying to obtain payment. As presently written, the statute and regulations appear to provide no alternative to this overly complicated, expensive and less than satisfying arrangement. This Association has presented to the House Ways and Means Committee a specific proposal which we feel will alle. viate in large measure these problems. It is felt to be of utmost importance that every effort be made to reduce the problems, to eliminate unnecessary complexities and to avoid hospitals having to "channel their talents away from making positive contributions to the improvement of patient care."

It is our belief that continued efforts must be made by everyone concerned to inform the aged recipients of the intent and extent of the Medicare program. For example, the term "extended care facility” is widely misunderstood and many aged persons and their families have assumed this means all nursing homes. It is apparent also that the beneficiaries do not understand the application of the deductibles. Hospitals often find themselves in a difficult public relations problem as it falls upon them to try to justify an action taken by the Congress. As stated we do not intend to dwell on various problems related to physician services; but hospitals are, of course, continually made aware of the problems of Medicare beneficiaries in respect to the payment for physicians' services.

In the over-all as we view the problems associated with Medicare they fall into two categories : first, those which it is expected can be alleviated through experi. ence and administrative change; and secondly, those problems which seem to be inherent in the law and which will require legislative action for their correction.

While we have been pointing out various problems involved in the operation of Medicare, we must not overlook the fact that this law has made a most important contribution to high quality standards in the provision of health services. It is to the credit of the Congress that it required high standards for institutional partic. ipation, thus, assuring reasonably high quality of care to old people in this country. Medicare is at best a complicated law and because of its sheer size and implications it is unlikely that it will ever be simple to administer or completely understood by the beneficiaries.

Some years ago the American Hospital Association strongly supported legislation promoting housing for the elderly. At that time we urged that as a matter of national policy the federal government not move solely in the direction of insti. tutionalizing elderly persons. We pointed out that large numbers of the elderly would best be provided for through housing particularly adapted to their living needs and that to the fullest extent possible we should follow a national policy of providing incentives for the elderly to remain in a normal housing environment. The key to such a program would be to relate health services to the housing of the elderly in such a way that they would have available physician services, nursing care, frequent checkups, consultation and the reassurance which the elderly need. Thus, we urged that provision be made in housing programs for the elderly for minimal health facilities so that hospitals and physicians could develop programs to serve the elderly in their home environment.

We appreciate this opportunity of expressing our views to you and your distinguished committee, and we hope that this will contribute to the very commendable objectives of your hearings. We would appreciate your including this statement in the record of the hearings Sincerely yours,


Associate Director.


New Baltimore, Mich., June 16, 1967. Senator GEORGE A. SMATHERS, Chairman, Subcommittee on Health of the Elderly, U.S. Senate, Washington, D.C.

DEAR SIR: If you have heard testimony from Molly Guiney, you now have a deep insight into the Well-Being Project and the viewpoint of one of the most informed persons on the problems of aging in this country.

Where I live, in southeastern Michigan, the good Lord is provident and during a certain period of the year my old country place has what might almost be called a plethora of lilacs. On Memorial Day, my wife suggested we take some to the convalescent home nearby. We did. We encountered the faces of about twenty-five persons there. The experience has haunted me ever since. It was ghastly. From not one-neither the female nor the male persons present-could I draw a smile. They reacted like expired persons-figures in a mortuary_who somehow were still not dead but waiting to die. An attendant brusquely asked us who we wanted to see. When we told her, “No one in particular," she seemed disappointed; this was too inexact; it meant that we could not be routed to a specific place so that we would be removed from the premises as quickly as possible and in a stereotyped manner, Oh, what a travesty on time our presence meant!

This type of thing is a reflection on all of us. It is barbaric. It is uncivilized. One is young, one is middle-aged and one is old. At the third stage one is put into what is commonly called a nursing or convalescent hometo die.

Almost everyone at some point in his or her lifetime has entered a hospital. When you do this you say to yourself "I don't like the looks of this building, I don't like the smell of a hospital and I hope I can get out of here as quickly as possible.” If you go in for a serious operation, you know it will be two or three weeks. If it is a relatively minor matter, you know it will be a matter of a few days. Whatever the time element, your mind is focused on getting well again and getting out.

Unfortunately, the deposit of your person at the doorstep of a convalescent home has a far different connotation.

Psychologically, when you enter a hospital you are a whole person going in and you hope to be a whole person coming out.

For older persons going into a convalescent or nursing home, psychologically, you go in knowing that this is the end of the line-you are to be there until you die.

This is horribly inhumane, and not in keeping with the humane thinking of society today.

Ninety per cent of the present nursing homes would have it so. It is economically more feasible to admit a patient, figure out the arrangement for payment and keep that person in bed or in a semi-invalid condition until the expirant breathes his last. Then, a bed opens up and another patient can be admitted.

It need not be so. The knowledge of medicine today has advanced to such a degree that two thirds of the persons entering nursing homes could be returned to their own homes if application of this knowledge could practically be put to use and these patients had a home to which they could return. I have seen demonstration projects that prove this out. For instance, a public health nurse in Detroit, if my memory serves me correctly, picked out five stroke cases in as many nursing homes and set out to teach the staff how to treat stroke cases. Three out of the five were returned to their own homes, one expired and one remained in the nursing home.

The profit motive in nursing homes has made a mockery out of the intent of such places.

I strongly advocate that all nursing homes be publicly owned and administered. This is, of course, a general statement that should in no way take away the rights of existence for non-profit homes. Many of these are engaged in highly meritorious service.

But the present arrangement in which most persons are treated in non-profit hospitals where the professional impetus is to make people well regardless of cost while at the next stage most people are taken to for-profit nursing homes where the incentive is to take care of people at the lowest possible cost to the nursing home operator is senseless.

It is hardly in keeping with our times.

The Well-Being Project was not created to keep persons out of nursing homes. But it has substantially served this purpose.

It was created to do a direct service job for older persons. The federal grant came under the heading of health but it is a well-known fact that health is only many problems that face older persons. I have already pointed out the one of the psychological factor. Finances, lack of communication and loneliness --particularly loneliness—are probably more important components of the total picture.

The Metropolitan Detroit Committee on Aging sponsored a number of in depth studies on the question of what are the needs of older persons. These go back to the late 1950's and early 60's. In Detroit's largest public housing project, Herman Gardens, we studied the wants of close to 1,000 older persons, possibly more. Was it health? Was it something else that caused them worry? We found out. It was a multiplicity of problems. With a social worker, Lois Pettit, I participated in in dept studies of older persons living in hotels, in rooming houses, in private homes. Stories on all of these subjects, including a story on a public health clinic at Herman Gardens, are available.

We found out.
What to do next?

The Well-Being Project with a highly skilled social worker and a registered nurse with public health training, working as a team, without rigid controls at the neighborhood level was the answer. We did not want these teams to make intricate detailed reports. Either you give service or get reports.

The program is not one hundred per cent perfect. As these workers become better established in their communities the time spent on aggressive visitation in their neighbor hoods decreased. These are highly dedicated workers. In another type of service one might recommend bringing in a new team-always with the intent of putting on the muscle to visit more people in their homes. But when you deal with old people change is a factor you can do without.

If not too many social scientists get involved, the Well-Being. Project, not easily defined because it deals with human beings in the best method to cope with human beings, offers a formula, or a principle, if you will, that should be duplicated on a broader scale throughout the Detroit area and applied in every community throughout the country.

While I am on the subject of aging I would like to take this opportunity to make a couple of other points.

On the question of insurance I have had a devilish time trying to figure out how to get the protection through Medicare and two private insurance policies for my own eighty-five-year-old mother-in-law. My wife nags me because she says as an expert I should have all the answers. I have developed a fair understanding of what I am doing. I have appealed to other experts, such as Bill Fitch in Washington, and they in turn indicate that the problem is so involved they don't have all the answers. God pity the old person who does not have someone helping him,

Recently, at a hospital in Detroit I overheard an older person tell the snippy clerk dressed in a nurse's uniform at the desk, "The hell with all this stuff. So, I'll pay my bill and let it go at that.”

Most doctors and most hospitals don't give a damn how the patient makes out with respect to his own pocketbook. All they are concerned with is the responsibility incumbent upon them. The doctor treats. The hospital wants payment for its services. How the patient is reimbursed is the patient's business. And I'm afraid that nine out of ten older persons do not have the knowledge to pierce through all of the red tape to get what he or she is entitled to.

All laws such as Medicare should be simplified. And doctors, hospitals and nursing homes that do not subscribe to the system in full, including the task of processing the claims of their patients, should be stricken from the approved list.

All of this in addition to the requirements concerned with high standards of


The government should take into consideration the need for keeping older persons-except those chonically ill-in their own homes. My mother-in-law and I fight like cats and dogs. But she is a part of our family life. She takes part in taking care of her great grandchildren. She has duties and chores. And as much as she gripes at age 85 she also laughs and gets great satisfaction out of being part of life. Furthermore, she is never told that she may be taken to a nursing home. She has a home.

I regret that I could not participate in your hearing in person. I was informed that your meager expense allowance permits coverage for only one person per project. I have had close to forty years in newspaper. work, first in Chicago and then Detroit. I was with the Detroit Free Press for 26 years—for about the last 15 as a reporter in the social sciences covering mental health, the aging and the handicapped-and I left there about Feb. 1.

One of the reasons is that I came to the conclusion the “big," monopolistic press is not interested in doing a real job of serving people. The communications field is dominated by the motives of big business. I felt I could build up a weekly newspaper to the point of economic and professional status so that the real purpose of a newspaper could be preserved: to give top quality news to its readers and serve its community. When that goal is reached I can then, again, become a spokesman for those who cannot speak for themselves on a wider basis. For the time being it was not economically possible for me to be there-although my heart is entirely with what you are doing.

Maybe, sometime, the rules can be changed to the extent that you can have the privilege of hearing from persons who may have something to offer, whether they are on a payroll or not and whether they can afford to pay their expenses to appear or not.

I am completely dedicated to the spirit of the Well-Being Project. It has a purpose. To me, keeping people from the despicable prospect of being victims of a nursing home is enough. Sincerely yours,


83-481 0-67-pt. 1-21

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