for many years, but it is the increasing social assumption of those costs that has now made them so very visible and has catalyzed public

concern.

Senator MONDALE. This morning in the Washington Post there is an article by Marquis Childs on this very issue of skyrocketing cost. Would you object to having that article included in the record? Dr. ROEMER. It sounds very appropriate.

Senator MONDALE. If you have no objection, let us put it in the record at this point.

Dr. ROEMER. Of course.

(The article referred to follows:)

[From the Washington Post, June 23, 1967]

THE RISING COSTS OF MEDICAL CARE
(By Marquis Childs)

At least a half-dozen high-level conferences, both Government and private, are taking aim at the rapidly rising cost of medical care. The struggle to keep up with inflationary costs is nowhere more acute than with the hospital and the doctor's bill. A study prepared for the National Conference on Medical Costs next week shows that in 1966 the price of physicians' services increased 7.8 percent. In the last half of 1966 daily hospital charges rose 11.5 percent. The Medical Care Index went up 6.6 percent which was just double the percentage for last year's over-all explosive cost-of-living jump.

None of this is surprising to experts who follow the trends. They point out that the old order is giving way to revolutionary change with medical care in the forefront.

July 1 will mark the first anniversary of Medicare, a program covering 18,000,000 Americans over the age of 65. Medicaid is being developed in many states to provide medical help for low-income families. In a nation so long resistant to any Government participation in medicine, with many professionals denouncing "socialized medicine," this is indeed a revolution. And as in all revolutions the penalties at times seem to exceed the rewards.

What is more, the revolution is just beginning as the Johnson Administration takes a stern look at the facts of medical care in this country. Sargent Shriver, that affluent apostle of revolution, is attacking through his War on Poverty the shocking failure of the poor to benefit from America's high level of medical care. At a recent conference he came up with startling statements about what this failure means 60 percent of poor children receive no medical care and never see a dentist; the chance of a child dying before the age of one is 50 percent higher for the poor, the chance of dying before 35 four times greater.

As one line of attack six health centers have been established with the goal of making medicine accessible to the poor in city ghettos. Six more are on the way. Shriver is enlisting under his banner the American Medical Association and other organizations that might once have fought such an experiment.

But as the demand for medical care increases the pressure on the supply of services inevitably forces up the cost. The supply of doctors, and in particular general practitioners and pediatricians, is woefully short-a reminder that for years the AMA opposed expansion of medical education. The Vietnam war takes about 5,000 doctors a year for a two-year stint. To meet the demand, according to the study prepared for next week's conference, doctors are seeing more patients. One consequence of the pressure on inflation, as reflected in the steep rise in the cost of medical service, is in the wages of hospital workers. They have always been among the low paid, existing on marginal salaries in institutions that confused charitable intent with business administration.

That is now beginning to change as full employment-or comparatively full employment-opens other opportunities even for the unskilled and the semiskilled. The new minimum wage law, which covers hospital employes for the first time, provides that they must be paid a minimum of $1 an hour starting in 1967, $1.15 in 1968 and $1.30 in 1969. Hospital workers have rebelled against low wages, with nurses leading the way in strikes in a number of instances. "If hospital staff per patient continues to increase at recent rates, the total wage bill per patient day seems likely to increase from $27 in 1965 to about $38

in 1970 or 7 percent a year." the report on medical prices states, pointing out that one result of the wage squeeze is to increase the number of people who will share the work at marginal pay.

While the start of Medicare is often blamed for the rise in medical costs, the study finds that this is not true, at least insofar as the recent acceleration of the rate of increase in doctor's fees is concerned. Increased use of hospital space could even result in economies of operation and more effective use of available beds.

In presenting the report which will be the starting point for the conference John Gardner, Secretary of Health, Education, and Welfare, suggested a number of ways in which medical resources can be employed to greater advantage. The old patterns, Gardner was saying, simply will not suffice if the demand for more and better medical service is to be met at a reasonable cost. Concerned men and women throughout the country are seeking new and constructive channels for the forces of change at work in medicine and in almost every other area of American life.

Dr. ROEMER. The overall costs of health care have been rising faster than our gross national product. In 1930 all health expenditures claimed under 4 percent of our GNP. Now it is over 6 percent-a 50 percent higher share. Much of this rising cost is due to a greatly increased rate of utilization of health services by the people, surely a good thing. Another part of the rise has been due to improvements in the content and quality of care-improvements which would have meant much greater cost escalation, if it had not been for some automation of hospital service and increased use of auxiliary health personnel.

But a portion of the rising costs and the rising share of GNP required for health care has been due to the backward inefficiency and needless complexity of our health care system, noted briefly before. These wasteful inefficiencies, furthermore, must be measured more by their human toll than their drain of dollars.

THE STORY OF ONE PATIENT

May I take the time of a distinguished committee of the U.S. Senate to tell of one aged patient who, like most old people, suffered from multiple diagnoses? He had a serious eye problem-actually two diseases: glaucoma and keratitis-for which he received care at a nearby medical center, in the department of ophthalmology. His personal doctor, a good internist, however, had diagnosed a mild diabetes, and for this periodic visits were necessary to an office 8 miles away. Painful corns and bunions, impairing the ability to walk, were not within the speciality of the personal doctor, so these required periodic visits to a podiatrist at an office 6 miles in another direction. Dental care, in an effort to save the few remaining teeth, so that dentures would fit more firmly and food could be more properly chewed, required numerous visits to a dentist at still another location.

Then a bladder problem developed and prostatic disease was suspected. At about the same period, the patient showed lethargy and confusion, suggesting a mild cerebrovascular accident. The personal doctor made a home call and the decision was to hospitalize. A bed was not immediately available except in a small proprietary hospital which the family refused-and it was not till 10 days later that he could be admitted to a good voluntary general hospital 15 miles away. After X-rays, cystoscopy, and other examinations there, his treatment

was stabilized. In the workup, it was discovered that a drug the ophthalmologist had been prescribing for many months was causing serious side effects, which had been missed by the internist since these two specialists had never communicated with each other. The patient was then admitted to a sanatorium, selected for its closeness to the family home, so that visits from the patient's children would be possible daily.

This was one of the "better" nursing homes-it was certainly expensive enough at $32 a day paid by medicare-but this was evidently not costly enough to support a proper staff. After a few days, because of lack of proper surveillance, this aged patient was found roaming on the street. When this happened a second time, the commercial proprietor decided to discharge the patient as "too difficult to care for." It took 5 weeks of nursing care at home, with daily problems of incontinence of urine and feces, before a bed in another nursing home became available.

The latter facility proved to be better managed and the patient improved. After only 2 weeks, however, he was getting up from a chair one day, when he fell and fractured his left hip. This required an orthopedic surgeon, readmission to the hospital, and preparation for a major operation. But then complications to the diabetes set in, because of the traumatic shock of the fracture. A delay of over 24 hours in reporting a critical laboratory test nearly cost the patient's life at this time. Had the hospital been adequately staffed, this delay would not have occurred. A skillful operation, with a pinning of the broken bone, was done. Special-duty nurses costing $111 per day-over and above the medicare coverage of the hospital bill-had to be hired because of the shortage of regular hospital nurses.

I have not recounted the other details of multiple drug prescriptions, special services of an appliance shop to adjust the bed at home, the physical therapy required for a knee injury, and much more. This patient was my widowed father, who lived with my wife and me for 9 years after his retirement from 51 years of medical practice. My abbreviated account of his medical care problems applies only to the last year, or it would be much longer. Accounts like this could be told thousands of times over, each day in the United States, and would doubtless be more complex and disturbing for a family less well informed about the jungle of medical care delivery.

I was notified by telephone when I arrived in Washington late last night that my father had just died.

The problems in this, and thousands of similar cases, it may be noted, are not primarily financial. That side of it was handled. The problems for this and similar patients were and are a consequence of the crazy quilt of a fragmented nonsystem of health service delivery in our country. This was a case, incidentally, in a high-income section of a great metropolitan city; consider the comparable problems in a rural area or a blighted urban slum.

INNOVATIONS UNDERWAY

Yet, many important innovations have been developing in the organization of American health service in recent years. In numerous small ways, integration of the manifold specialties and paramedical

skills is being achieved. While each of these is only a minor stream in the larger flood, we do see group practice clinics, expanded hospital outpatient departments, neighborhood health centers for the poor, emerging regional hospital networks, liaisons between nursing homes and hospitals, and other intelligent arrangements that give us a glimpse of a better future.

We have heard from Dr. James this morning of the interesting developments in integration of health services in New York City.

Without taking the time to review all these significant recent developments, may I request the privilege of attaching as an appendix to these remarks a paper on this subject of "New Patterns of Organization for Providing Health Services" which I presented not long ago at the New York Academy of Medicine.

Senator MONDALE. Without objection it will appear in the appendix. Dr. ROEMER. Because of these hopeful signs of change, we can begin to see the shape of a new pattern of health service for the American people-young and old, rich and poor-in the years ahead. With appropriate leadership in the Federal Government and effective partnership between public and private resources, I think we can expect to achieve this picture in a generation from now:

COMPREHENSIVE HEALTH CENTERS

In each neighborhood there would be a comprehensive health center staffed by a team of general physicians, specialists, nurses, technicians, and aids. Everyone-not just the veteran or the pauper or the crippled child-would be served by a "primary physician," as the Millis report of the American Medical Association has recently defined him. Specialists would be called on for help as necessary. The mentally disturbed would be treated as well as the physically disabled. Dental care would also be provided, with reasonable use of dental technicians for the many simpler mechanical tasks. Laboratory and X-ray procedures would be done in the center, and drugs dispensed by the staff pharmacist. Preventive health examinations and screening tests for hidden disease would be done routinely with the aid of modern equipment and auxiliary staff.

Hospitalization, when necessary, would be provided at a good general facility of perhaps 300- to 500-bed capacity, where the full range of technical modalities could be offered. Institutional care of the mentally ill or the chronic sick would be given in special wings of the hospital or in affiliated units nearby. Several of the neighborhood health centers would be satellites to each such hospital, and their professional staffs would receive periodic continuing education in the hospital. Depending on the density and ecology of the population, the hospital would be professionally and administratively tied to other institutions in a regional network; at its hub would be a great medical center, where basic education of the health professions and medical research would be actively pursued.

The quality of health service would be subject to continuous surveillance, not just in the hospitals but throughout the system. Major surgery or other serious procedures would, of course, only be done by

See p. 236.

qualified specialists. Cultists would have no place, nor would patent, self-prescribed medications. Physicians or public health nurses would make home calls, as necessary, but no time would be wasted in a doctor's travel to five, or six separate hospitals-as the current lack of system compels him to do. The patient would be treated as a whole. person, monitored by a unified medical record which would move with him to a new health center if he changed his home. Whether he was a veteran or an injured worker or a welfare recipient or a parochial school child, whether his illness was infectious or mental or traumatic or neoplastic-he would be treated by the unified system, starting in a nearby neighborhood health center and branching to other resources as necessary.

ECONOMIC SUPPORT

The economic support for all this would be derived from the social devices of insurance and public revenues that we have seen evolving over the last 30 years or more. The underlying resources of personnel, equipment, facilities, and knowledge would be produced likewise by social planning and investment, both governmental and voluntary, as they are now at an increasing tempo. The personnel would be rewarded for their labor according to equitable principles of skill, seniority, and responsibility, and their contributions would also be recognized by appropriate social status. But the receipt of services by an individual would not depend on the amount or source of the money paid, nor on the diagnostic category of his disease, nor his social pedigree. It would be a right of his being an American.

This picture, Mr. Chairman, is not utopian. It is easily attainable within our resources, and, while I do not say it will reduce expenditures, it will permit health achievements at a far lesser cost than a policy of unplanned drift.

The new legislation on "comprehensive health planning" is, in my view, an important step in the right direction. Like the medicare law and the heart-cancer-stroke legislation, it is only a beginning. Positive stimulation is needed for promotion of group medical practice and neighborhood health centers-not just in the slums on a very wide scale. Far more medical and allied personnel must be trained. The endless programs defined by category of person or category of disease must be replaced by health service organization based simply on geographic regionalization.

If these changes evolve, the health needs of older Americans, as well as everyone else, will be met at a level of which our Nation could be proud and of which we are certainly capable. I thank you very much. Senator MONDALE. Thank you, Dr. Roemer. Needless to say, we all join in expressing our condolences on the passing of your father and we are grateful to you for proceeding with your testimony despite that tragedy.

I thought it was interesting that the two examples, the example of your father and the one that Dr. James cited, were so similar and the conclusions that one must draw about a better organization of our services were very similar and parallel each other very closely. Unfortunately I have to excuse myself because I have to be over at another committee.