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will begin, how many individuals will be served, and what variations there will be in services. I would also like to have your personal views on whether health screening should be included among Medicare benefits.

Once again I would like to thank you for your help and interest. We will welcome any other information you may care to send to us as the Subcommittee inquiry continues.



(The following reply was received:)




Silver Spring, Md., July 14, 1967.

Chairman, Subcommittee on Health of the Elderly,

U.S. Senate,

Washington, D.C.

DEAR MR. CHAIRMAN: This will reply to your letter of June 30, 1967, in which you ask for additional information related to testimony before the Subcommittee on June 22. The requested information follows:

1. Training of home health aides

The U.S. Public Health Service in cooperation with the Office of Economic Opportunity and Administration on Aging is currently sponsoring 16 Home Health Aide Pilot projects in ten States: Two are in Florida. Qualifications for the trainees for this project included age (over 45) and income (under OEO poverty levels). Both of these factors tend to increase the number of older Americans involved in the program.

The 16 projects have individualized programs of training. All, however, include classroom instruction as well as on-the-job supervised training as set forth in the guidelines for the program. The aides are trained in those aspects of personal care which a knowledgeable family member could undertake. All personal care is under the supervision of a registered nurse. The aides also learn to perform such household services as are essential to the patient's health care at home and necessary to prevent or postpone institutionalization.

Home Health Aide Service is one of the kinds of service which may be provided by home health agencies under Medicare. More than a third of the 1,800 home health agencies that have been certified include this service. Thus, both the aide and the recipient are often senior citizens.

2. Dr. George James' reference to “70 medically-directed home-care programs” Dr. James was referring to a 1964 survey of "coordinated home care programs,” a copy of which is enclosed. The study was limited by definition to programs that are "centrally administered and through coordinated planning, evaluation, and follow-up procedures provide[s] for physician-directed medical, nursing, social, and related services to selected patients at home." The term "physiciandirected" means that the direction and supervision of all patient services (medical, nursing, social, and related) are the responsibility of the attending physician -that is, the patient's personal physician. This does not mean that the agency which administered a home care program is directed by a physician. In the 70 programs to which Dr. James referred, only 39 were directed by physicians.

The significance of that study lies not so much in the number of such programs or how many patients they served in 1964 as in the pattern the programs provided for home health services under Medicare. As Dr. Cashman stated in the foreword to the study (see p. iii):

"Coordinated home care programs were the prototype for the development of the conditions of participation for home health agencies in Medicare. While, at the onset, these agencies can qualify for participation with only one therapeutic service in addition to skilled nursing care, they must have built into them the features that heretofore have been described as coordinated home care."

Charts 4 and 10 of the enclosed "Medicare-the First Nine Months," provide information on the extent to which home health services are available under that program to persons 65 years of age and older. There are 1,800 agencies. In the first nine months of Medicare, 173,000 persons were accepted for home health services (227,000 during the first full year). Thirty-five percent of the agencies provided skilled nursing and one additional service, the minimum required for

certification, but sixty-five percent provided two or more of the additional services which include physical, speech, or occupational therapy, medical social work, and home health aide service.

Although the recent increase in number of home health agencies has been significant, many are having financial problems and some of the new small ones are struggling to achieve the financial stability needed for survival. The enclosed "summary of developments in home health care following the enactment of Medicare and Medicaid" describes some of the additional efforts needed to strengthen existing programs and develop new ones where none now exist. We also enclose a "Guide for the Development and Administration of Coordinated Home Care Programs" which is used in these efforts.

3. Dexter Manor

As I stated in my testimony, the Dexter Manor project is now being supported locally; therefore, we no longer have a constant monitor of its progress. In order to get the latest information, we contacted Mrs. Raoda Plaza, Director of the Providence District Nursing Association-the sponsoring agency. Mrs. Plaza said that she would be pleased to prepare a brief report for the Subcommittee and that it would be sent to you promptly,

4. Multiphasic screening projects

The four adult health protection projects which involve automated multiphasic screening are moving into the operational phase. Pilot testing begins this month in Milwaukee. In New Orleans services will be offered by September; in Brooklyn, by November; and in Rhode Island, by May 1968. By the end of the first year of operation, the centers will have developed capacity for service to 6,000 persons per year.

There is little variation between centers in the services offered. Each program performs tests or measurements to obtain an array of similar data on composition of body fluids, functioning and condition of the organs and systems, and the like. There is, however, some variation in the techniques used to obtain the data. For example, identification of breast tumors is being accomplished in three of the projects by mammography-x-ray-and in the other by manual examination. As another example, in glaucoma testing, one center is using an electronic instrument to measure intraocular tension, while the others employ a manuallyoperated instrument.

The primary variation between projects is in the type of sponsoring agency. They are being done by a State health department (Rhode Island), a city health department (Milwaukee), a community hospital (Brooklyn, N.Y.) and a school of public health (New Orleans). Since a critical objective of the program is to develop and demonstrate methodology for providing these health protection services in an open community, this variation is an essential aspect of the activity. With a different relationship to the total health service system in the community, each type of agency may employ a different approach to providing a community service. These projects offer a mechanism for testing and evaluating these approaches.

A second important variation is in the character of the populations served. Activities to inform and educate the population about this service, and to encourage participation, are being designed to reach different kinds of populations. Also relationships of the program to the medical care resources vary according to population, and techniques of working with, for example, both private and clinic physicians are being developed.

Finally, I feel that screening should not be given high priority-as a Medicare benefit. Screening is certainly valuable when applied to the aged population. However, it is much more valuable when applied among aging adults. Early identification and control of disease in this group would prevent much of the long-term illness and disability we now see among our older people. I feel, however, that regular health testing of those in the 35 to 60 age group is a related but separate issue and should be so dealt with.

For the population considered "aged" and now covered by Medicare, I believe there are other benefits which ought to be proposed before screening comes under serious discussion.

If we can be of further assistance, please let us know.

Sincerely yours,


Assistant Surgeon General, Director, Bureau of Health Services.

Senator SMATHERS. Let me ask a couple of questions of Mr. David again about medicaid. How many States did you say have it and how many don't have it?

Mr. DAVID. Of the total of 54 jurisdiction, Mr. Chairman, including the District of Columbia and Puerto Rico, 29 have a medicaid program in operation. In 15 more, plans to install these programs are underway. There are only 10 jurisdictions that have no plans to establish a medicaid program under title XIX.

Senator SMATHERS. What are those 10? Do you have them with you? Mr. DAVID. No, sir.


Senator SMATHERS Do you know whether my State of Florida has a medicaid program?

Dr. SILVER. The Florida State Legislature voted down the program that had been submitted to them and there is considerable agitation now for reconsideration. The medical society wants it.

Senator SMATHERS. The Florida Medical Society is for it. I assume the old people are for it.

Dr. SILVER. Yes.

Senator SMATHERS. Who is against it?

Dr. SILVER. The legislature.

Senator SMATHERS. Do you know whether the Florida State Senate voted up or down?

Dr. SILVER. I really don't know, sir.

Senator SMATHERS. I am informed this morning that the Florida State Senate has passed it, but the lower House voted it down. Is it not a fact that under medicaid that the Federal Government provides funds on a ratio of 3 to 1?

Dr. SILVER. It varies, sir.

Senator SMATHERS. What would be the situation in Florida?

Dr. SILVER. I would have to find out precisely. I would not want to say.

Senator SMATHERS. If I stated it is 3 to 1, would you say I would be very far off base?

Dr. SILVER. That is reasonable.

Senator SMATHERS. So if Florida put up $15 million, Florida would have gotten back $45 million; is that correct?

Dr. SILVER. That is about right.

Senator SMATHERS. Do you think that Florida has many old people? What is your information on that?

Dr. SILVER. Florida has more than its fair share of old people as compared to the national average, sir.

Senator SMATHERS. We are delighted to have them. However, we have a large number of them who are in need. Does it make much sense to you that the Florida State Legislature would turn down an opportunity to take care of its medically indigent, when by putting up $15 million they would get back approximately $45 million?

Dr. SILVER. No, sir; not when they are spending more than that now and that they would be getting a greater share from the Federal Government if they participated in the medicaid program.

Senator SMATHERS. Right.

Well, I want to state for the record that I think the legislature did a very unwise thing in turning it down and I am satisfied that if most of the members of the legislature had understood what the problem was and what the answer to the problem was, they would not have turned it down. I don't want to turn this into a political forum at the moment other than to say that I think our distinguished Governor, who advised against it, made a very serious mistake and I think he will live and learn that he has made a mistake.

Now, after making that as a sort of nonpolitical statement, we will proceed with our hearing.

Gentlemen, Bill Oriol wants to make a contribution.

Mr. ORIOL. I want to note that several questions will be sent in writing because of our time problem this morning from the chairman and possibly from Senator Moss, too. So there will be additional questions.

Senator SMATHERS. Now, gentlemen, we are through with you. You did fine. You are not only good speakers, but you are good listeners. Dr. SILVER. Thank you, Senator.

Senator SMATHERS. Thank you.

Our next witness is Dr. William A. Nolen of Litchfield, Minn. He is going to testify with respect to the charges made for patients under medicare. We might later put his article about medical economics into the record.

Doctor, we are delighted to have you and you may proceed as you like.

STATEMENT OF DR. WILLIAM A. NOLEN, LITCHFIELD, MINN. Dr. NOLEN. Thank you very much for the invitation to testify, Senator.

Perhaps I better identify myself so that my remarks can be taken in the proper context. I am in the private practice of general surgery. I do the surgery for a clinic in a small town in Minnesota. I am the only surgeon in the county. I am a fellow of the American College of Surgeons and diplomat of the American Board of Surgery.

My coming here was precipitated by an article which I published in Medical Economics in February entitled, "Are Doctors Profiteering on Medicare?" 7

This stimulated some queries from your committee and some suggested questions and the suggestion that I might expand on this testimony or on this article a little bit in my testimony today. This is what I have done.

I will quote the questions and then testify with the answers that I have written.

Your article in the February 20 issue of Medical Economics was a forthright account of disquieting questions you are now asking about charges made to patients under Medicare. I would very much like to have you elaborate on the matters you discussed in that article.

My article in the February 20 issue of Medical Economics was written as a warning to my associates in the medical profession. I was

7 See p. 49.

and am afraid that doctors are going to take advantage of the medicare program to get as much money as they can from the Government. If this happens it will, I suspect, lead to increasingly strict control of medicine by the Government, an eventuality that no doctor engaged in the private practice of medicine wants.

This is, of course, my own personal fear. It is reflected in many of the articles that I read in the medical

Senator SMATHERS. Run that by me once more.

You said you are afraid that the doctors are going to do what?

Dr. NOLEN. We are afraid that our medical practices are going to come further and further under the control of the Government and my purpose in writing this article was to warn my colleagues in medicine that if we do not use the medicare program with extreme discretion that we are apt to bring this down on our heads even more rapidly than we assume it will

Senator SMATHERS. If you don't use it with discretion you will bring what down on your heads?

Dr. NOLEN. Further Government control of medicine.


Dr. NOLEN. We doctors, like our patients, act as if the Government's money is nobody's money. If the patient isn't going to have to pay us for our services out of his own pocket then he doesn't care how much we charge and neither do we.

I realize that the Government will only pay 80 percent of our usual fee; but if the other 20 percent hurts the patient, we can always discount it.

As long as the Government is paying out money, let us get as big a share as we can. After all we're just getting back some of our tax money. I am aware of the fallacies in this reasoning; I am simply presenting what I conceive of as the doctor's attitude toward medicare.


Why do I think this is the attitude that dominates the thinking of the medical profession? From personal experience and my exposure to medical practices in various places.

When I was at Bellevue Hospital in New York City, as an intern and resident in surgery, I never worried about the expense incurred in caring for a patient. Neither did anyone else on the house staff. We knew the patients weren't going to pay for it. Money was never a factor. As a consequence we were, in retrospect, exceedingly wasteful. We ordered X-rays, laboratory studies, and medications many times when we didn't really need them. It was easier to order them and they might serve a purpose. There was certainly no financial reason not to order them. We didn't make any money for ourselves but we didn't worry about wasting the city's money.

Now, there are arguments that can be advanced to the defendant's position. We can say this is a training institution and that it is actually necessary for doctors to order these studies in order to learn that they don't need them.

This argument has been advanced in other articles. However, this argument to my way of thinking does not carry much weight because

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