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provided by the San Joaquin Local Health District and other community agencies. The program is too new to produce any meaningful statistics or obviously any conclusions.
REGIONAL MEDICAL PROGRAMS FOR ASSESSMENT OF QUALITY OF MEDICAL CARE
The San Joaquin County Medical Society, through its Foundation for Medical Care, last month an agreement with the California Committee on Regional Medical Programs. The agreement calls for the cooperative efforts of the Monterey County Medical Society's Foundation for Medical Care, the Santa Clara County Medical Society's Foundation for Medical Care, and our Foundation. These Foundations have agreed to a program whereby a statistically selected sample of cases of patients treated for heart disease, cancer, stroke and related diseases will for a period of time be reviewed by a committee of physicians in the three couties and the information transmitted to the California Coinmittee on Regional Medical Programs. Representatives from Stanford Medical School will cooperate in the program. After a review of the cases, an additional purpose of the program will be to develop programs required to supply any deficiencies in patient care which may appear as a result of such review.
SAN JOAQUIN FOUNDATION FOR MEDICAL CARE
No discussion of the review of services and the quality of medical care, utilization of medical manpower and the like would be complete without mention of the work of our Foundation for Medical Care. Established in May of 1954, the Foundation is a subsidiary corporation of the Medical Society. Membership in the Foundation is open to all practicing physicians in our county. The establishment of the Foundation arose out of public needs and desires for certainty of coverage and more comprehensive coverage. In addition, the Medical Society added the meaningful purpose of the review of quality of care rendered under any prepaid programs the Foundation might sponsor. Currently our Foundation for Medical Care is sponsoring prepaid programs that cover approximately one-half of the insured population of our county. These programs are underwritten by fifteen different insurance companies plus California Blue Shield and Blue Cross. Professional claims arising from these programs are reviewed by practicing physicians. This review has resulted in accumulated knowledge concerning quality of medical care rendered in our community. This awareness has led directly to individual education of physicians, general education of physicians through postgraduate courses and Medical Society programs and disciplinary action in cases where the educational process failed. In actuality, the Foundation for Medical Care represents a county-wide committee for medical audit, tissue, and utilization committee all rolled into one.
Our Medical Society's implementation of county-wide utilization review for extended care facilities has added another dimension to this type of actvity.
MEDICAL MANPOWER PROJECT
The U.C.L.A. School of Public Health, working through a grant from the Ford Foundation, is currently involved in a program with our Foundation for Medical Care entitled “Medical Manpower Project”. The purpose-to study and to try to relate the care of users of medical care to the type of care they are actually using. In this connection the study is attempting to learn in fine detail how many hours of doctor time, nurse time and technician time are required to provide specific care during the period of the study. A Foundation group with comprehensive coverage has been chosen for this study. The group is the International Longshoreman's Warehouseman's Union, Pacific Maritime Association Health and Welfare Program. A similar study for a similar period of time is being completed at the Ross Luce Clinic in Los Angeles.
In general we would conclude that our involvement in the various programs aforementioned has led directly to a realization on the part of the medical profession that we do have a definite and ever-increasing responsibility in the area of planning, health manpower and quality of medical care. There is also being developed on the part of our general public an awareness that their local medical profession is indeed interested in their well-being.
I would hope that future challenges, as yet unknown to us, will be met with ever-increasing vigilance and vigor by us all. REMARKS, 10th Councilor DISTRICT OFFICERS MEETING ON COMPREHENSIVE
HEALTH PLANNING, DECEMBER 2, 1967 (Presented by John 1. Morzumi, M.D., President, San Joaquin County Medical
Society, Stocklon, Calif.) That Public Law 89-749 is currently a law of the land, that comprehensive health planning is part of the public domain, that the highly individual circumstances of a given local community or political subdivision or a grouping of contiguous and mutually augmenting geographical entities must dictate the implementation of provisions of that law seem to be a logical interpretation of the impact of that law. It is true that one can argue about the semantics of the phrase "comprehensive health planning,” the precise meaning of which may be quite variable. We in San Joaquin have elected to assign as broad a meaning as is practical. This means that in any area of health problem where physicians are directly or indirectly involved, we mean to become more knowledgeable and lend our expertise.
Traditionally physicians everywhere were not only considered to be doctors to alleviate suffering, but highly educated and intelligent citizen leaders in matters of education and government civics. As American society became increasingly complex and as demand for acquisition and practical application of scientific knowledge became more intense, the individual physician unconsciously and gradually retreated from the sphere of the public health. The individual doctor. citizen became myopic and lived his life in the microcosm of his private practice. It is now time and opportunity for us to reacquire leadership in matters of health for the public commonweal. That is the challenge of Public Law 89–749.
It is obvious that some of the problems of a large metropolitan poverty population are quite different from those of a migrant agricultural group. The need for basic health care remains the same. There is immediate recognition that distance to be traveled, the type and cost of available transportation, the socioeconomic bases for the behavior patterns of such disparate groups greatly influences whether or not such persons can or do, indeed, seek medical care. Local knowledge of such determinates should dictate the directional course and alternatives that need to be discovered for reasonable solution of local problems.
We in San Joaquin County, or as a matter of fact, any other planner at the State or Federal level, are in no position to direct or implement the health care of the people of Watts. On the other hand, for example, we have recently learned what must be done for the migrant farmworkers in our area. For 10 years we attempted to establish some type of pilot program not only to render care but also to develop methods for analyzing migrant farmworker needs and programs to meet their needs. We thought that a prepaid plan with participation by growers and grower groups might permit these workers to obtain medical care. We were not successful in promoting that scheme. However, in April of this year, we successfully implemented a program. An outline of that program is in the paper submitted to the Western Conference on Future Directions and Decisions in Medical Care recently concluded in Chandler, Ariz.
We learned some lessons which need to be mentioned. It was vital in the planning stage and subsequent application of our proposal to both State and Federal agencies that we not only had acquiescense but active cooperation and participation of the local health department officer. He had certain expertise regarding the numerous funds that might be available and the form and letter of our application which would be most conducive to favorable action. His, in fact, was the agency which the previous year attempted with some success in having residents from our county hospital to man such a clinic. This year volunteer doctors from our community went at night to two fixed clinics operated at two large labor camps built and sponsored by the local political subdivision. These were maintained each week night from 7 to 10 p.m., or whatever time it took to take care of sick people. They were referred to consultants when necessary and given specific date and time appointments for special problems. Many in turn failed to keep these appointments. I am not implying, therefore, that consultants should be available at these clinics, for that would not be efficient use of medical manpower. What I am saying is that we realized that this group of people who depend on a seasonal harvest as their sole means of making money to maintain themselves
economically independent would not and could not take time off during their maximum earning hours or days to seek and obtain medical care unless they were seriously ill. They feel that they could not afford care not because of the doctor's bill necessarily, but because of loss of income time. Thus we needed to seek them out and convey medical care to them even at night. This, then, reveals the need to educate these people in prophylactic care, that it is economical to seek care earlier to prevent more serious illness which would require additional medical manpower and expense. The righteous platitude of "let them come to us” was and is inadequate if not irresponsible. So we recognize not only pure medical needs but the efficient utilization of medical manpower within the context of present times and local situations. This may not be comprehensive but it is responsible health planning. As a part of the whole problem of health planning it is comprehendible and certainly a measurable contribution to comprehensive health planning.
What I have just related is, of course, only a small segment of a recognizable hiatus in health care and planning which can be found in all communities. There are other examples of doctor and medical society involvement with the local community. Presently we are engaged in a survey in identification of the lessadvantaged population groups in Stockton and San Joaquin County. The county hospital administration has completed an independent survey of the sources of origin of its inpatient and outpatient load and is preparing an official report. Individual physicians, the medical society, the public health officer, and people residing in disadvantaged areas will be conducting surveys of the medical needs of such areas. Our county medical society is engaged in a study of the county hospital which is located 5 miles outside of Stockton from which originate the majority of the hospital patient load including those who seek emergency care and clinic visits. It is essential to collect and collate these pieces of intelligence in order to be able to come up with meaningful and integrated recommendations. Another example-an approved rehabilitation center is 40 to 50 miles distant in a mountain community because it was able to utilize facilities which used to be primarily used for the care of tubercular patients in our area. There is reason at least to question the efficient utilization of such facilities for the geographical area that it purports to serve. In a recent conversation with an old friend of mine I learned that a small, relatively isolated community in Wyoming was the site of a full rehabilitation facility with a resident physiatrist, orthotist, and other supporting personnel. Of course, the people of that community and the physicians using or wishing to utilize such a facility should influentially participate in the decision of appropriate and efficient medical utilization of that facility. When an air pollution conference was held 2 months ago in Fresno, we were fortunate enough to find a local physician who was intensely interested in that topic and who has acquired a certain expertise. He will serve as liaison and resource man between the medical community and local government agencies.
The control of agricultural cultivation to prevent peat dust problem is an area that by local ordinance is vested in the office of the district attorney in my community. Do we not need his expertise, and does he not need our knowledge and advice? Obviously example after example can be cited such as alcoholic and mental health clinics, highway safety and education, drug abuse control and education, noise abatement, and even zoning practices as affecting the totality of community health. After all, isn't this what comprehensive health planning is about?
Due to special circumstances in the organizational make-up, the executive administrative personnel and devices available in the San Joaquin Medical Society, we may be able to do a few more things than in other counties but even we cannot cope with the total problem nor do we want to. For comprehensive health planning is a function of and for the entire community and not the sole domain of doctors. Hence lay and medical thought leaders, including the local public health department, have formulated a steering committee for organizing the San Joaquin Comprehensive Health Planning Association to which interested health organizations, governmental agencies, and other interested community groups have been invited to appoint representatives. This group will select a board of directors to represent proportionately the consumer public and the health profession and will draft the articles of incorporation and bylaws. The initial support is from the medical society but in a very short while we would need financial support from the county government and anticipate a request for planning funds under the provisions of Public Law 89–749. This, then, is a summary and analysis of what Public Law 89–749 means to us in San Joaquin County. If we have assisted you in your understanding it better, let me say that we do not pretend to know it all. We also seek information and advice from others who experience similar and comparable problems and who have sought and found solutions.
Dr. GIANELLI. Then I just happen to have a few pictures of our pewest addition, a mobile clinic. They are just snapshots. If I can have one minute I will explain it briefly.
Senator WILLIAMS. Can we look at them while you are talking, Doctor?
Dr. GIANELLI. You may. This is how we are spending our money for the U.S. Public Health Service. We are representing this unit.
Senator WILLIAMS. This picture shows a trailer.
Dr. GIANELLI. This is a trailer. We are renting it because our actuary said that this was the best way to handle it and also in the off season we remove the partitions and it doubles as a blood bank collecting unit. We have a four-county area and we will take this around and secure blood donations from the other counties.
Senator Williams. You have one trailer in this mobile unit?
Dr. GIANELLI. We have one trailer. It goes to five different locations in the counties. People enter at one end and are processed. There are five forms that have to be filled out. They can go down a narrow corridor to the nurse's station at the other end if that is indicated, such as in children who are there just for immunizations and do not have to see the physician. The central area contains doctor's consultation room, examining room, toilet, and wash basin.
Senator WILLIAMS. You mentioned skin testing for TB. Is that part of this mobile unit's activity?
Dr. GIANELLI. Yes, sir.
Senator Williams. Did you hear the presentation of our last witness, Mr. White?
Dr. GIANELLI. Was that the last speaker?
Dr. GIANELLI. I couldn't hear him too well. I heard some of his remarks. I didn't hear the early part of his presentation.
Senator Williams. He has about 1,200 workers at peak season. He is obviously trying to make available to his workers the various health services that are now becoming available under the Migrant Health Act. It is not complete by any means.
Are you getting that kind of cooperation from the growers in your community?
Dr. GIANELLI. We are not.
Senator Williams. Is there anything you could do to persuade them that it is good business to have workers who are in good health?
Dr. GIANELLI. Well, as I indicated, we spent 6 years trying to do this. They are living in a different world, a world that we have left behind, of noninvolvement, and of individual identification rather than group identification. You just can't get these people to change overnight. They feel as though it is somebody else's responsibility.
I made a remark to the California Farm Bureau Federation meeting which I was asked to address a couple of months ago. The statement was made after my presentation by one of the growers that they didn't see where this was their responsibility and I pointed out to them that
this past winter through redevelopment we had torn down nine blocks of central Stockton which housed the single men that were engaged in agriculture primarily, and because we had an exceptionally wet winter for California that these people were hungry and cold, and ill, and they organized themselves and marched upon the mayor's residence asking for help. His remark too was, “The city of Stockton has no responsibility toward you.''
About 3 months ago we recalled the mayor so that perhaps there is some hope.
Senator Williams. That is by petition of how many people? How do you do that?
Dr. GIANELLI. You have to sign up a certain percentage. I don't know what it is offhand.
Senator WILLIAMS. Then it goes on the ballot? Dr. GIANELLI. And it went on the ballot, right. Senator WILLIAMS. I am not going to ask which party was involved. We will leave well enough alone.
Dr. GIANELLI. It is possible.
Mr. BLACKWELL. Dr. Gianelli, in your statement you refer to this current budget request of $315,000. Ny arithmetic indicates that you received about $162,000 of your request. Is my arithmetic correct?
Dr. GIANELLI. Yes, sir.
Mr. BLACKWELL. The men in your profession generally are not known to be big spenders so I am assuming that your original figure Was a fairly large request, is that correct?
Dr. GIANELLI. The largest item that was not funded was the request for hospitalization and this was not allowed because of lack of funds.
Now, we had to more or less guess at the amount that we would need for hospitalization. Actually I am surprised that the figure was only some $11,000, as you saw. I mean we had 36 patients, as the record shows, who were hospitalized and their hospitalization cost is $11,000. Of course, it would cost more if they were in private hospitals, not from the standpoint of hospital cost, but there would be a fee for service charge of the private physician because these people were taken care of by house officers in the employ of the county. But it is a good deal for the county to work with. I mean we have a commitment from the county board of supervisors for matching funds. California is on a 50-50 basis matching funds to $50,000. It is good business for them, too. They have 100-percent coverage for these people now. If we put them in a private hospital they drop their cost by 50 percent. But they know, of course, we are not going to let these people who need hospitalization and treatment get away.
Mr. BLACKWELL. Do you have an estimate on the number of the migrant population that you did reach with your project services?
Dr. GIANELLI. Well, from the figures that I have given you it is 'oughly 20 percent.
Mr. BLACKWELL. Are you speaking in reference to the 14,000 nigrants?
Dr. GIANELLI. Somewhere along 12,000 or 14,000. I was talking bout 12,000. Mr. BLACKWELL. Do you know the per capita investment in perons reached?