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Just one quick question and then I must go. Without objection I am going to ask the staff to continue the questions because I do want to be sure while you are here to get the benefit of your thinking.

What is the reaction of the medical profession to these proposals to organize medicare and some of these other problems to which you make reference on this kind of systematic overall basis?

Is this being received with great enthusiasm by AMA ?

Dr. ROEMER. I think the reaction is mixed, Mr. Chairman. There are sectors of the medical profession that are very responsive to these ideas; for example, physicians who on their own initiative organize group practice clinics, like the Mayo organization, the Oschner Clinic and so on, establishing first-rate teams of specialists.

There are physicians in the universities, in medical schools and great teaching centers, who see things this way. There are physicians who devote themselves to the study of these problems, like Dr. James here and other academic people, who share these views.

Senator MONDALE. Yes, but you are giving us examples

Dr. ROEMER. There are rank-and-file private practitioners who resist these ideas as they have resisted in the past voluntary health insurance, public health programs, better organization of the staffs of the hospitals, et cetera. But as these changes evolve, the interesting fact is that physicians adjust to the demand and cooperate with them.

For example, the kind of medical staff organization in the average general hospital in the United States today which was called for by the Joint Commission on the Accreditation of Hospitals was regarded as bureaucratic and totalitarian by physicians 25 years ago, but today is widely accepted.

The day-to-day care of patients in hospitals has tremendously improved just by the reason of the more systematic organization of the medical staffs.

Senator MONDALE. Of course, what you are proposing to do here goes far beyond the properly existing hospital. I would like to have Dr. James' reaction to that same question, the reaction of the medical profession.

Isn't it always true that the staffs of the medical schools and ad. vanced clinics like Mayo Clinic are more liberal and willing to accept these sorts of things?

Dr. ROEMER. The reason I mentioned hospitals, Mr. Chairman, is that there was the same resistance to the tightening up the organization of hospitals in the past, and my proposal is to apply the same kind of genius to take care of the ambulatory patient in his neighborhood.

Dr. James. I think what Dr. Roemer says is correct. There is nothing that is incompatible between the things we have been saying and the private practice in medicine.

As a matter of fact I was in Honolulu not too long ago and I was surprised to find that over 50 percent of the physicians in Hawaii operate under group practices, and group practice lends itself very readily to this kind of total approach.

Moreover the American Academy of General Practice has become keenly interested in this type of approach and are eager to develop more in the way of becoming true family physicians.

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The hospitals have taken leadership because they do have huge numbers of patients coming to their fragmented clinics.

Since they have this clientele to start with, by using the same funds and better organizing of their services, they can develop a family practice for this population very readily.

I think the private sector would object if the only way that the problem could be handled were by hospitals and by some kind of a Government organization, but the pattern is readily translated into the private sector.

Senator MONDALE. There is a story in the morning New York Times I will ask to be included in the record which quotes Dr. Milton Rouse of Dallas, president of the American Medical Association, who expressed concern at the increasing involvement of our National Government in the health field.

(The article follows:)

(From the New York Times, Wednesday, June 21, 1967] DOCTORS URGED TO COMBAT GOVERNMENT PLANNING-NEW A.M.A. HEAD Asks

STEPS TO FULFILL LOCAL NEEDS—CONVENTION EXHORTED TO BAR "THREAT" OF CENTRALIZATION

(By Donald Janson) ATLANTIC CITY, June 20_Dr. Milford 0. Rouse, new president of the American Medical Association, urged doctors today to step up efforts to curb government planning in the field of medicine.

In an inaugural address to the 116th annual convention of the association, the 64-year-old Dallas gastroenterologist said that the “threat" to the private practice of medicine had not stopped with Medicare and Medicaid.

"Judging by events of the last two years," he told some 1,000 physicians at Haddon Hall, "we must increase the effectiveness of our opposition."

About 9,000 physicians are registered at the convention.

Dr. Rouse said the Government was now "making its moves into areas where, to its own satisfaction at least, it is able to demonstrate unfilled needs for health care or health care planning." He urged that organized medicine meet the "crisis" by filling any vacuums it found in communitywide health planning before the Government did.

Dr. Rouse said in an interview that his own Dallas County Medical Society, for example, was taking the initiative in investigating the need for new community health services, such as neighborhood health centers.

As for himself, he said, he still refuses to take patients who insist that their bills be assigned to a Medicare fiscal agent. Ma Medicare patients, he said, “have no need for government help.” He said more and more doctors were insisting upon direct billing.

Dr. Rouse said in his speech that "capitalism” was so seriously endangered by people who want "an all-powerful central government” that doctors must “concentrate more attention on the single obligation to protect the American way of life."

He said the profession was "faced with the concept of health care as a right rather than a privilege" and with "many additional social concepts" distressing to doctors.

He named some of these as "price and wage fixing," "emphasis on a nonprofit approach to medicine," "problems of free choice," "increasing coercion,” “special attacks in the drug field,” and “emphasis on the academic and institutional environment."

Dr. Rouse is considered much more conservative than the outgoing president of the A.M.A., Dr. Charles L. Hudson of Cleveland. He has characterized himself as an “independent conservative” and “a Democrat whose party has left him."

He has served three years as Speaker of the A.M.A.'s policymaking House of Delegates. He is a past president of the Texas Medical Association and the Southern Medical Association. He has been active in the ultraconservative Association of American Physicians and Surgeons. He is a former director of the Life Line Foundation of H. L. Hunt, Texas oil billionaire.

The 242-member House of Delegates unanimously adopted a statement earlier today saying there was no conflict between medical ethics and the loyalty oath administered to officers of the armed forces.

The statement was adopted as a rejection of the contention of Dr. Howard B. Levy that the physician's Hippocratic Oath might conflict with orders from military superiors.

Captain Levy, 30-year-old Brooklyn dermatologist, was convicted by a military court June 3 of willful disobedience of orders in refusing to train Special Forces medical aides to treat skin diseases in Vietnam, a war he called "a diabolical evil.” He was sentenced to three years in prison at hard labor and dismissed from the Army.

Senator MONDALE. Does that kind of attitude create a healthy environent for your proposals?

Dr. ROEMER. I think, Mr. Chairman, there has been a distorted view of the role of government by the private profession. The private physician is inextricably involved with government-Federal, State, and local-in treating several million medicare beneficiaries right now, a program that has worked out remarkably well despite its complexities.

He is involved with the government every day. This does not impede his freedom to make a decision on a diagnosis, to do what is good for the patient. In fact, it helps him to do what is good for the patient.

Senator MONDALE. I don't think we are getting anywhere on this particular argument because I am going to have to excuse myself. Thank you very much.

Dr. ROEMER. Yes, sir.

Mr. ORIOL. I have just a few questions. Both of you have described changes you would like to see for experiments already underway and you called for reorganization of existing services.

The first question is, Where does this reorganization begin? Is the Comprehensive Health Planning Act comprehensive enough to help create the kind of change you would like to see, or would you think that somehow community resources have to be organized and started ?

How do you go about reorganizing and getting the kind of changes you would like to have?

How To EFFECT CHANGE

Dr. James. First of all, with medicaid there are problems which we did not have before, Secondly, there are a number of places in the country where there are people who feel as Dr. Roemer and I feel and are doing something about it, and this is growing rapidly.

Thirdly, there are funds available for special projects such as Office of Economic Opportunity funds, the Public Health Service and some of the health services research funds of the National Institutes of Health.

I also believe it would be very good if the health services research center which has been planned for the Public Health Service gets underway so that it can provide additional stimulation and evaluation in many of these programs.

The question you are asking, I suppose, is what could be done by whom to stimulate more activity in this field. Now that we have money, although we could always use more, I suppose the holding of hearings such as this, anything which would call attention to the problems, would be highly important.

We were able to get fluoridation of the water supply in New York City by calling attention to the severe problems posed by dental care.

We can perhaps get some action against cigarette smoking some day by calling attention in no uncertain terms to the tremendous hazards of lung cancer.

The problems and cases such as Dr. Roemer and I have described today have not been made generally evident to the public. The public has felt that if there is a clinic, it is available; the individual is supposed to go there, and if he goes there he will get care.

A study done by Dr. Trusell in New York with the Teamsters Union clientele showed that 40 percent of the medical care received by the population was grossly poor care and 95 percent of the people were well satisfied with them.

So we have to make these facts evident, we have to get people to be dissatisfied with the way things are and then they will demand better methods of doing it, and the methods are available.

Now we do not have a sufficient manpower supply in this country of people dedicated to developing these improved programs.

These people have to be trained. Those centers which are capable of doing this kind of program have to be in a position to train others. There should be much ferment along these lines over and above what there now is.

If you are suggesting possible ways for the Federal Government to take some leadership, I would suggest that the supported demonstrations, the development of training programs for others into what these demonstrations can accomplish, the support of the health services research center of the Public Health Service would all be excellent steps.

Åbove all, methods should be developed to make the American people aware of the conditions as they are now and that there are corrective measures which can be taken.

Mr. Oriol. Dr. Roemer, you mentioned the Comprehensive Health Planning Act. As I understand it, this act will funnel funds to States so that the State can plan properly for its own needs.

Do you think that this will encourage the type of development you are talking about?

Dr. ROEMER. I think it will, Mr. Oriol, because it will help to make visible the problems of fragmentation and inefficiency that we have both discussed. It will also help to produce data which will educate the public as Dr. James has just suggested.

RISING COSTS TO FORCE CHANGE

It seems to me that the problem of rising costs is going to be one of the strongest educational instruments to clarify that our system of providing health care is not as efficient and effective as it could be.

Throughout the whole history of medical care developments in the world, the problem of rising costs has stimulated improved patterns of organization.

In addition to the suggestions that Dr. James has made, I would agree with those and add one or two others. I think the Federal Government can promote integration of specialty services for ambulatory patients—that is, for patients not in the hospital—by subsidy of group medical practice.

Now this is a private mechanism, the idea of group medical practice, but it can be facilitated by grants or even loans of money for the tasks of organization of group practice clinics and for the organization of prepayment systems to go with them. I think much could be done also by subsidizing or encouraging hospitals through grants to develop outpatient services on a more comprehensive basis.

Such grants could promote what Dr. James described in New York at the Beth Israel Hospital on a much wider scale. There is a very interesting development in the hospital field, what some people have called the "explosion" of emergency room services.

Here is a remarkable increase in the use of hospital emergency rooms by ordinary people, not just the poor.

Mr. ORIOL. Would this be especially true of the elderly?

Dr. ROEMER. Yes. A high proportion of the emergency-room patients are the elderly but the point is that these are not organized clinics. There are a lot of people who come to the hospital today whenever they are sick, not just for hemorrhages or other emergencies but for almost anything, day or night.

There has been an enormous increase in this demand, which I think reflects the problem of unmet need for general medical care in the population.

THE KAISER-PERMANENTE PLAN We have some other models that I think are worth looking at, especially the prepaid group practice plans like the large one in my State, the Kaiser-Permanente Health Plan. Here is a health program with over 1 million members who are getting comprehensive medical care through health centers and hospitals tied to them on a prepaid basis.

This model I think can be greatly extended if it is assisted through promotion by the Federal Government. I think the State comprehensive planning activities will help to make visible this kind of approach to the problems of medical care for the aged and the young.

Mr. ORIOL. I take it you were encouraged last year when Congress passed legislation to give assistance for construction of group health practice facilities. Do you see any other ways in which incentives could be provided!

Dr. ROEMER. I think that was an important first step. In addition to aid in construction, assistance in the organization of group practice would be valuable, through provision of consultation services and even loans to provide for organization of medical staffs.

For example, the Kaiser-Permanente Health Plan was started by a far-seeing industrialist who had to put hundreds of thousands of dollars into the idea before the first patient was seen.

The Health Insurance Plan of Greater New York is doing a magnificent job, and yet it required something like half a million dollars or more just to get the plan started in 1947, before the first patient saw the first doctor.

A lot of organizational efforts are needed along the way. This money has been provided in the past by philanthropic foundations, by indus

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