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housing project of about 10,000 or 12,000 people. There are about 1,500 aged people in this housing project. Since it was a public project, the hospital working with the city housing authority opened this clinic.

The city housing authority was delighted with it, and so as a matter of fact was Secretary Weaver when he visited it. The Public Housing Authority has asked that every time it puts up a public housing project it demands—not wants but demands that there be such a clinic in it.

So, a demonstration is beginning to take root and other such clinics are being developed. All new housing projects are going to make actual physical provision for such a clinic.

Mr. ORIOL. How are private housing developments doing?

Dr. JAMES. We are going to develop our own program in our own institutions. Satellite family practice units will be provided so that not only will we have them in our hospital but we will scatter them throughout east Harlem and central Harlem. We will have these clinics for the people in that area.

A group practice with several centers is a similar type approach. Individual physicians can team up and form groups to do this. There are innumerable ways to develop the supporting services.

Our medical center is talking now about teaming up with the health insurance plan, which is a group practice, and working out something with them.

There are all kinds of developments in this field which should be furthered.

Mr. ORIOL. I would like to note for the record that we have another New York Times article here. At the same time that Dr. Rouse was giving his viewpoint a Dr. Kerr White, professor of medical care at Johns Hopkins University, was testifying before the House committee warning that we might be on a path toward chaos in monolithic national health service unless we make changes in basic organization of our services.

I would like without objection to put this into the record and ask in writing for further discussion from our two witnesses.

(The document referred to follows_statement resumes on p. 102.)

[From the New York Times, Friday, June 23, 1967)

U.S. HEALTH CARE TERMED CHAOTIC—DOCTOR WARNS THE HOUSE OF MONOLITHIC

SERVICE PERIL

(By Harold M. Schmeck, Jr.) WASHINGTON, June 22—Health care in the United States might be on a path toward chaos and the eventual emergence of a monolithic national health service, a specialist told a House committee hearing today.

Dr. Kerr L. White, professor of medical care and hospitals at Johns Hopkins University, Baltimore, said changes were inevitable in the organization of medical care, but that the real question was the direction of change.

Dr. White said public dissatisfaction was mounting with deficiencies in the present system.

One possible outcome is a series of major breakdowns, chaos and, ultimately, the emergence of a vast national system, said Dr. White.

Such a system would be deplorable, he warned, because it would have a built-in rigidity, would hamper all change and improvement.

The preferable alternative, he said, is to encourage innovation, experimentation and evaluation of present health care methods. This requires research, but such research is seriously lacking, the doctor noted.

He testified before the House Committee on Interstate and Foreign Commerce, which is considering a law that would encourage health care research.

"In 1967, the total annual expenditures or costs, depending on your point of riew, of the health services industry, will be about $45-billion,” he said, “less than one-tenth of 1 per cent will be spent on examining the effectiveness and efficiency with which these vast resources are being used in the interests of the patients and potential customers."

To illustrate the kind of research he had in mind and its potential importance, Dr. White cited several studies.

One study, made several years ago in Britain, compared patient fatality rates in hospitals associated with medical schools or other teaching programs and nonteaching hospitals.

Comparison, disease by disease, showed twice as many deaths per 100 hospital admissions in the nonteaching hospitals.

Another study—by scientists at Yale about three years ago_showed that 20 per cent of patients admitted consecutively to one general hospital had bad reactions from drugs, diagnostic or other exploratory procedures. About 7 percent of the patients suffering the reactions died from them.

This kind of study should be repeated at many hospitals, Dr. White said, to see if it is a general experience.

Still another study, by a research team in Chicago, showed that moving an elderly person unexpectedly from one nursing home to another raised the death rate to twice what it would have been had the shift not been made.

In another British study, 19 general practioners in Wales kept notes on the drugs they prescribed during a two-month period. When making a prescription each doctor noted whether he thought the drug was definitely or probably effective for the disease in question or whether it was just possibly useful, or given primarily for its good psychological effect on the patient.

The study showed that only one-third of all the drugs were given because the doctors thought they would definitely, or probably, be useful.

All drugs carry some risk, Dr. White said. The moral of the story in this study, he said, is that doctors often give drugs where there is no clear need for them.

(Subsequent to the hearing, Senator Smathers wrote to Dr. White for additional views. The reply follows:)

THE JOHNS HOPKINS UNIVERSITY,
SCHOOL OF HYGIENE AND PUBLIC HEALTH,

Baltimore, Md., July 17, 1967.
Hon. GEORGE A. SMATHERS,
Chairman, Subcommittee on Health of the Elderly,
U.S. Senate,
Washington, D.C.

DEAR SENATOR SMATHERS : Thank you for your letter of July 7, I fully endorse the statements by Dr. George James, Professor Milton Roemer, and Dr. George Silver.

I enclose a copy of my testimony given before the House Committee on Interstate and Foreign Commerce as you requested.

In closing, I would urge your Committee to look with favor on any and all efforts which would encourage innovation, experimentation, and evaluation of our health services and our medical care delivery systems. In addition, I would encourage any efforts towards the systematization of health services into coordinated arrangements for delivering a full spectrum of services.

I hope these comments will be helpful. If I can be of any further assistance, please let me know. Yours sincerely,

KERR L. WHITE, M.D., Professor. (Enclosures.) STATEMENT OF KERR L. WHITE, M.D., PROFESSOR OF MEDICAL CARE

AND HOSPITALS, THE JOHNS HOPKINS UNIVERSITY Mr. Chairman, Members of the Committee, I welcome this opportunity to appear before you in support of HR 6418, and in particular of Section 304, pertaining to "Research and Development Relating to Health Facilities and Services".

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In addition to practicing interpal medicine for a number of years, I have had a long-standing interest and commitment to health services research. More recently I have been responsible for a research and training program in Health Services Administration and Medical Care Research. For about eight years I was a member of the Health Services Research Study Section of the Public Health Service and for four years (1962–66) I was Chairman of that group. Among our activities was the sponsorship of a two volume series of scholarly papers on the present scientific state of Health Services Research both in this country and abroad." The field is well-described in these papers. The needs and opportunities are defined, the methods delineated and the unsolved problems frankly presented. Clearly Health Services Research is a viable field; widely recognized in the United States and other countries.

This morning, I do not intend to dwell on the absurd position of the health services industry in the United States with respect to research and development. In 1967 the total annual expenditures or costs, depending on your point of view, of the health services industry, will be about 45 billion dollars. Less than one tenth of one percent will be spent on examining the effectiveness and efficiency with which these vast resources are being used in the interests of the patients and potential consumers. I doubt if there is any otehr industry, or even any other service system approaching this magnitude, which spends such a trivial part of its resources on research, development, and evaluation. The Bill before you is a small effortto remedy this imbalance. Although the economic arguments may be persuasive from the viewpoints of improving the efficiency with which health services are delivered, and of obtaining better value for the funds expended, there are, I believe, more cogent reasons for supporting HR 6418.

The arrangements for delivering needed medical care in this country are, I believe, less than optimal, in the light of our organizational, technological and scientific capabilities. Public dissatisfaction is mounting, and as some have predicted, reduction of financial barriers to medical care can only compound the organizational problems. The latter are infinitely more complex than the financial problems. Changes in the organizational arrangements for providing medical care are inevitable; the real question is the direction of change. One possibility is that we shall experience a series of major breakdowns in our health services system, and that, as a result, we will gradually move towards a monolithic national health service. I personally would deplore this; not because I am so worried about how doctors are to be paid, but because it would be so difficult to modify any vast national system. Built in rigidities would inevitably make the rapid introduction of desirable change based on new knowl. edge exceedingly difficult. The other alternative, and the one in keeping with our traditions of pluralism, diversity and healthy competition, is to positively encourage innovation, experimentation and evaluation of present and future arrangements for delivering scientific medicine through diverse health services arrangements and systems. In order to develop and evaluate these new methods of delivering medical care, I believe it is essential to encourage a tradition of research in health services which will emulate our accomplishments in biomedical or laboratory research. The present Bill is designed to encourage and stimulate this tradition.

There is no one "best" method for delivering medical care. I doubt if there ever will be or should be, in this country or elsewhere. Hopefully, there will be a continuing improvement in the arrangements for delivering medical care which is based on research and development. To undertake this work, we need to encourage health departments, hopsitals, professional associations, private entrepreneurs, voluntary agencies, group practices, universities, industries, research institutes and others with the capability and competence to undertake research in this field. My experience with the Health Services Research Study Section and my university responsibilities have persuaded me that there is rapidly growing interest in this field and, what is much more important, a substantial number of talented individuals who would like to undertake health services research. In addition to physicians, dentists, nurses and other health professionals, there are operations engineers, systems analysts, behavioral scientists, economists and others prepared to apply the methods of epidemiology, operations research, systems analysis and the social survey to the problems of

u Mainland, D., Health Services Research, Milbank Memorial Fund Quarterly, 44 : Nos. 3 and 4, pt. 2, 1966.

delivering optimal health services to all the people. Surely one percent of the total expenditure of the health services industry would not be an excessive amount to invest in this endeavor? This would amount to $450,000,000 annually. The appropriations proposed to you, for the next four years, do not approach this sum.

Let me now give you some concrete examples of health services research that have been completed. You are entitled to know what has been done, in addition to hearing suggestions about what can, should or might be done if you approve HR 6418.

One study has shown that the case/fatality rates, i.e. the number of patients dying per 100 admitted to hospitals, for a number of common diagnoses, are about twice as high in non-teaching hospitals as they are in teaching hospitals.

A second study found that about 20% of consecutive patients admitted to a general hospital experienced an adverse reaction to a drug, treatment or investigative procedure. About 7% of these patients died from these reactions.

A third study showed that age-specific mortality rates for aged persons moved unexpectedly from one nursing home, to which they were accustomed, to another home, were twice as great as they would have been had the transfers not taken place.

A fourth study showed a direct and rather strong association between the length of patients' hospital stay for five common conditions, with the rate of nursing turnover in the hospitals studied. The higher the labor turnover among the nurses, the longer the patients stayed in the hospital.

In a fifth study of referral patterns to a university clinic, it was found that for only 10% of the referrals was there evidence in the medical records of any written communication from the referring physician which gave any medical information, even so much as the referring physician's diagnosis, or the area in which he thought the patient's problem lay.

In a sixth study, a group of general practitioners participated in an analysis of their own prescribing habits. They found that only about one third of their prescriptions were for drugs which they believed had a known specific or probably beneficial effect on the conditions for which they were being prescribed.

In a seventh study, samples of patients in two similar hospitals were studied to ascertain the amount and kind of nursing care needed by the patients. It was found in different parts of the country that for at least one third of the patients, doctors and nurses differed substantially with respect to the kind of nursing care needed by specific patients.

Finally, studies using identical methods in three different areas, each with different ratios of doctors, nurses and hospital beds available to the population, showed that four out of five persons experiencing "great discomfort” in the previous two weeks, from one or more of twelve common conditions, had not consulted a doctor about them during that period.

These are all brief examples of health services research bearing on the effectiveness of medical care and on the problems of organizing health services so that contemporary scientific knowledge can be delivered promptly to the people who need it and can benefit from it. Much of our biomedical research will be of little avail until we can make useful preventive, therapeutic and rehabilitative knowledge generated in the laboratory accessible to all the people. In essence, health services research is designed to reduce the gap between medical science and medical service.

To summarize, I have advanced three reasons why I believe we should rapidly increase our national effort in health services research. There is first the "eco nomic" argument. Our arrangements for delivering health services should be more efficient. The experience of other industries and service systems suggests that to spend 45 billion dollars a year without spending at least 1% on research, development, and evaluation may be wasteful.

There is the “organizational” argument. If we are to avoid chaos, if not collapse, in our present health services system, and if we are to move from what one observer has called a "cottage industry” to diverse responsible systems for delivering medical care, we should encourage innovation, experimentation, evaluation and healthy competition. To accomplish this we need to develop a tradition of competence and excellence in health services research which is the equal of our record in biomedical research.

Thirdly, and I believe most importantly, there is the “humanitarian" argument. It is through health services research that we can make health services themselves more effective. It is through prompt delivery of useful scientific knowledge that we have the greatest expectation of helping people at the earliest stages in the natural history of disease. Where we cannot cure disease, we can at least diminish disability and alleviate discomfort. That is what medical care is all about.

Thank you for allowing me to testify on behalf of HR 6418; I urge you to take favorable action.

Mr. MILLER. Mr. Oriol, taking a slightly different track on your question regarding home health services I have a question.

In your statement, Dr. James, on page 7 you make the observation that the Public Health Service showed approximately 70 medically directed home health care programs. Information available on the medicare program would indicate that a vastly larger number of home health care programs have been certified.

I would be interested if you have any comment on this.

Dr. JAMES. Yes. The Public Health Service report was only concerned with those home care programs which are medically directed. Every visiting nurse service in the country has home care services and there are others in county health departments that have been certified for home care to medicaid patients. A medically directed home care service means that there are physicians and physicians' services available to go to the home under medical direction.

This is an integrated complete home care program.
Mr. Oriol. Mr. Norman do you have a question?
Mr. NORMAN. Yes.

Dr. James and Dr. Roemer, both of you have discussed the desirability of group medical practice and Federal action to stimulate more group medical practice.

Is your recommendation of this type of delivery of health services based upon the economy of this method of providing health services or on the quality of services that can be provided or some other reason supporting group medical practice?

GROUP PRACTICE ADVANCES

Dr. ROEMER. The evidence is that both of those achievements are possible.

Mr. NORMAN. You can provide better medical service at less cost by group practice?

Dr. ROEMER. Yes. It so happens that the President's Advisory Commission on Health Manpower made a contract with my university to undertake a study of this nationally with respect to the very question you ask, the effects of group practice on quality and on economy.

The best evidence we could gather based on studies made over the last 30 years suggests that the teamwork idea found in group practice reduces the costs per unit of service and increases the quality of care in general.

Now, to back this up with facts and figures would take a long time, but this was our basic finding.

Mr. Oriol. Dr. Roemer, you have been working on a study of just this, have you?

Dr. ROEMER. Yes.
Mr. ORIOL. Will the findings or excerpts be available for our record!

Dr. ROEMER. This is now in the hands of the National Commission on Health Manpower.

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