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V. A reference was made by Dr. Ament to the physician extender in anesthesia. This reference was made to substantiate his criticism of our recommendation that S. 1470 be amended so that the "qualified individual" mentioned in the legislation would have to be a nurse anesthetist. Inasmuch as the nurse anesthetist is the only qualified individual by training, other than the anesthesiologist, whose services are available nationwide, we stand by our recommendation.

There are several shortcomings related to the physician extender which we wish to point out. We believe it is misguided to think that physician extenders will for long accept only a salaried basis of reimbursement. Thus, we believe it is a mistake to think that physician extenders will work in situations where the anesthesiologist receives fee for service and the physician extender will be denied fee for service and will be content with a salary arrangement.

The physician extender cannot prictice individually and, legally, he can only perform when he is working with the anesthesiologist. In other words, we believe the anesthesiologist will have to be present. In a large number of small hospitals no anesthesiologist is available today nor are they likely to be available in the future. Therefore, a physician extender is not in a position to function at these hospitals.

From an economic standpoint we would point out that there is no evidence that the use of physician extenders has resulted in any decrease in the costs of health care. In fact physician extenders may have increased the cost of health care.

We would stress that we do not consider nurse anesthetists as physician extenders, and we do not wish to be so classified. Nurse anesthetists, in many situations, function exactly as the anethesiologist would function. In other words, only a physician may be substituted for those services provided by a nurse anesthetist.

The economics of the field anesthesia and the income of anesthesiologists were also discussed by Dr. Ament. In our letter to you of August 21, 1975, Mr. Chairman, we pointed out that, from the income figures which were available, it appeared that the incomes of anesthesiologists "will approximate five times those of the nurse anesthetists for delivering anesthesia services.” We believe, from information received and not on the basis of any studies which we have made, that Dr. Ament's statement about the income of non-salaried, free lance anesthesiologists was quite understated. In the conference called by former President Ford on the impact of inflation in health in 1974, a background paper developed by H.E.W. contained the following statement: "The greatest increase in net income in the five-year period (1968-1973) was for the specialities, with the highest incomes with anesthesiology registering the largest gain-44 percent." Recently we sought to obtain statements from nurse anesthetists with respect to specific situations, and we attach herewith one such statement which we have received and which indicates an income for anesthesiologists in the area of $150,000. From the knowledge of nurse anesthetists, as they have told us, such an income level is not at all unusual.

Dr. Ament also suggested that anesthesiologists were confronted with all of the increased costs of practice faced by practicing physicians generally. From our knowledge of the field this is not at all the situation. In fact, anesthesiologists traditionally do not have an office and generally do not employ nurses or other staff. In most instances the services, staff and facilities required by anesthesiologists are furnished to them by the hospitals in which they practice. We see no basis for attempting to justify increases in the cost of services rendered by anesthesiologists because of the greater costs encountered by physicians in general and in private practice in particular. Specifically, for each dollar charged by anesthesiologists the likely net income is substantially greater than that of most practicing physicians.

Several of the matters commented upon in this letter were not a part of our testimony, but, as they were brought up as part of the testimony of Dr. Ament and are thus a part of the printed testimony of the hearings, it is essential that we respond to the opportunity for comment which you suggested to us in order that the record be as factual and complete as possible.

If you wish ut to submit any additional information on any of the matters covered either in this letter or in the testimony which we presented, please let us know.

Sincerely,

Enclosure.

RUTH E. ECKLUND, CRNA,

President.

KOSCIUSKO Co. ANESTHESIA,
Warsaw, Ind., May 5, 1977.

A.A.N.A,

111 E. Wacker Drive,

Chicago, Ill.

Attn: Ms. Nancy Fevold, Deputy Executive Director.

DEAR MS. FEVOLD: In answer to your letter of April 20th concerning exploitation of nurse anesthetists by M.D. anesthesiologists, I feel I can reflect on the situation in Kalamazoo, Michigan. The two major hospitals in Kalamazoo are Bronson with twelve operating rooms and Borgess with eight operating rooms. The anesthesia coverage consists of a group of eleven M.D.'s and eighteen nurse anesthetists. The nurse anesthetists do 90% of the anesthesia and at any given time three of the M.D.'s are on vacation, leaving three M.D.'s per hospital for so-called supervision.

Thanking you I am,

Yours very truly,

In January of 1976 the anesthesiologists dropped their liability malpractice coverage because they felt that since the C.R.N.A.'s were doing 90% of the anesthesia, the C.R.N.A.'s coverage would be adequate. Starting salaries for C.R.N.A.'s was approximately $16,500.00 to $21,000.00 maximum. The total income of Kalamazoo Anesthesiology was in excess of $2,000,000.00, but the total paid to C.R.N.A.'s was about $360,000.00, leaving approximately $150,000.00 per man for the anesthesiologists who did little anesthesia and had no liability coverage. Any inquiry for anesthesia practice at Bronson or Borgess is referred to Kalamazoo Anesthesiology P.C., and the hospital medical by-laws require M.D. supervision. Also there is no free lance C.R.N.A. anesthesia allowed in town. We feel that this is a prime example of exploitation of one profession by another and that our proposals on April 4th making the C.R.N.A. an independent anesthesia practitioner would confront the problems directly. I have first hand knowledge of this information as I was one of the C.R.N.A.'s in question for a period of five years.

I hope this example will help Mr. Williamson project the true situation of M.D. ghost billing and the exploitation of C.R.N.A.'s.

(Mrs.) MARILENE BEARDSLEE, C.R.N.A. Senator TALMADGE. The next witness is John Filer, Chairman, Aetna Life and Casualty Co. on behalf of Insurance Association of Connecticut.

STATEMENT OF JOHN H. FILER, CHAIRMAN AND CHIEF EXECUTIVE OFFICER, AETNA LIFE AND CASUALTY, ON BEHALF OF THE INSURANCE ASSOCIATION OF CONNECTICUT; ACCOMPANIED BY BURTON E. BURTON, SENIOR VICE PRESIDENT, GROUP DIVISION, AETNA

Mr. FILER. Mr. Chairman, my name is John Filer and I am chairman and chief executive officer of Aetna Life and Casualty Co. With me on my right is Mr. Burton, senior vice president and head of our group division of Aetna. We are appearing here today on behalf of the Insurance Association of Connecticut, which is a trade association of Connecticut domiciled insurance companies.

The companies currently write 30 percent of the commercial group health insurance which is sold in the United States. Our member companies, as leading members of the Health Insurance Association of America, support the testimony of the HIAA given earlier this week.

Our comments today will deal primarily with those elements with S. 1470 that are aimed as controlling hospital costs, a subject of direct interest to our companies as insurers and employers, and to our policyholders around the country.

We believe there is a need for immediate legislative action to help control hospital costs. S. 1470 takes a number of steps in the right direction. We believe the establishment of uniform financial reporting, the concept of a classification system for hospitals, comparisons between like hospitals to promote competition and efficiency, and the use of incentives and penalties all are elements which can lead to effective hospital cost control. We also strongly support the payment of funds to promote the closing or conversion of underutilized facilities. Likewise, we support tying reimbursement for capital expenditures to approval by the designated planning agency.

We would, however, offer the following observations and suggestions which we believe are crucial to the success of S. 1470 a a long-term solution to the hospital cost-control crisis.

First, the program should control hospital costs for all patients rather than applying only to medicare and medicaid reimbursement. Although the bill provides that hospitals may not increase the amounts due from others to offset reductions under this program, we believe this section is unenforceable.

Second, by limiting controls to routine operating costs and by excluding controls on ancillary services, the program only addresses 35 percent to 40 percent of hospital costs.

Senator Talmadge has, of course, already announced plans to address these first two points, and we support such changes.

Third, by using average per diem cost for routine services as a measurement of efficiency, the bill may encourage hospitals to lengthen average stay or change patient mix so as to reduce per diem costs.

Fourth, our major concern is that the bill does not provide for prospective review of hospital budgets and rates. Uniform financial reporting, classification and comparisons of hospitals, and the use of incentives and penalties, are steps which are consistent with prospective rate review. We believe review of overall budgets and rates is a crucial next step in this regulatory process. We believe prospective budget and rate review, exceptions review and many other elements of a cost control system can best be operated at the State level, subject to Federal guidelines. We urge vou to include strong incentives for the establishment of State prospective reimbursement systems and to grant exemptions from Federal controls to those States which establish such programs.

Our strong endorsement of State prospective reimbursement is based primarily on three things: (1) The need for close coordination between cost control programs and the planning, certificate of need and utilization review activities now being conducted at the local level; (2) the need for adequate input into the cost control process by the parties affected-providers and insurers as well as consumers; and (3) our experience in Connecticut and with Government Research Corp.

The Connecticut commission on hospitals and health care was established in 1973 and charged with the administration of the State's certificate of need law, with the review of all operations of institutional services, and with approval of hospital rates and budgets. Connecticut hospital prices had been rising at or above the national average, but in fiscal year 1975 and 1976, the Commission held the rate of increase in Connecticut hospital charges for individual services to 8.3 percent. and 9.6 percent respectively.

Because of increased utilization of services, the rate of increase in total hospital revenues in Connecticut was approximately 16 percent. in fiscal 1975 and 1976. This is still below the national average of 19.5 percent in 1975 and 22.3 percent in 1976. The commission has saved Connecticut consumers an estimated $35 million since 1973, and it has done so without adversely affecting the quality of care.

Of course, Connecticut has not been without its problems. The commission has recently been concentrating its efforts on controlling total hospital revenues, recognizing that price control is not necessarily cost control. Since 1973, it has also become apparent that more procedural safeguards were needed in the rate review process, and that the commission needed the expertise of third party payers. These changes have been made under recent legislation.

Since 1973, the process of hospital cost control in Connecticut has matured from a regulatory point of view. A Federal program which sets guidelines for prospective reimbursement operated at a State level could benefit from such refinements.

Along with representatives of hospitals, employers, unions, State regulators and third party payers, we recently participated in an 8 month review and analysis of prospective reimbursement which was sponsored by Government Research Corp. Although the final work product does not represent a system which the participants as a group would necessarily recommend or support, we believe it is a workable and effective proposal, and we will submit a copy of the report for the record.1 Essentially, the proposal suggests prospective reimbursement operated under Federal standards, but run at the local levels by State commissions.

In conclusion, we urge you to enact a cost control program which applies to all patients, and which places equal emphasis on quality of care, on hospitals' need to be adequately reimbursed for all legitimate elements of cost, and on the public's need to have the rate of increase in hospital costs controlled.

State prospective reimbursement can help accomplish this goal. The concept has been put to the test in Connecticut in Maryland and in a number of other States. It offers the local expertise and knowledge with a Federal system could never achieve, is capable of a more sophisticated in-depth look at particular hospital operations than a Federal system, and offers the flexibility needed to become an extremely effective regulatory process.

We offer you and your staff any assistance we can provide.

Senator TALMADGE. Thank you, Mr. Filer. I want you to know how much we appreciate the support which you have expressed for S. 1470. I did, however, want to respond to two of the concerns expressed on page 2 of your statement.

You say that by using average per diem costs for routine services as a measure of efficiency that the bill may encourage hospitals to lengthen average stay or change patient mix so as to reduce per diem.

cost.

The bill does provide where a hospital deliberately alters its patient mix to do exactly what you say, reimbursement would be adjusted to

1 The report referred to will be made a part of the official committee file.

reflect any manipulation. Insofar as length of average stay, the answer to any artificial game-playing along those lines is effective professional review.

As a practical matter, based upon our study, the differences in average stay, length of stay, do not seem to particularly affect the adjusted per diem cost.

The effect of shorter stays for a given illness is reflected more in the per diem cost of the services such as laboratory, pharmacy and X-ray. You have indicated that your major concern is that the bill does not provide for prospective review of hospital emergency rates. While we may not specifically provide for that type of review, the bill does authorize an exception where a State system, does a better job. Thus of the system in Connecticut which you refer to and Maryland which you refer to, results in less costs that would otherwise occur under the particular reimbursement mechanism, we would accept that.

Senator Curtis?

Senator CURTIS. I have no questions.

Senator TALMADGE. Thank you very much for your contribution, Mr. Filer.

The next witness is Dr. Richard C. Reba, president, American College of Nuclear Physicians; accompanied by Dr. Eugene L. Saenger, chairman, governmental affairs commission and Kenneth L. Nicolas, executive staff.

It is a pleasure to see you again, Doctor.

STATEMENT OF RICHARD C. REBA, M.D., PRESIDENT, AMERICAN COLLEGE OF NUCLEAR PHYSICIANS; ACCOMPANIED BY JOHN DRING AND KENNETH L. NICOLAS, EXECUTIVE STAFF

Dr. REBA. I am Richard C. Reba, a physician and a director of the division of nuclear medicine at George Washington University, and I am currently the president of the American College of Nuclear Physicians. With me is Mr. John Dring and Mr. Kenneth Nicolas of the executive staff of our college.

The statement that we are making to you is on behalf of the American College of Nuclear Physicians which represents physicians in a new and growing specialty now recognized by various branches of the Federal Government, the Departments of HEW, DOD, as well as organized medicine.

The specialists of this discipline are certified in nuclear medicine by the American Board of Nuclear Medicine, in nuclear radiology by the American Board of Radiology and in nuclear pathology by the American Board of Pathology.

The practice of nuclear medicine includes procedures by which radiopharmaceuticals are administered to patients and images then obtained by nuclear detectors and various electronic devices. These procedures thereby provide an image of the distribution of the labeled drugs and thus aid in medical diagnosis.

In addition, there are tests of function of organs and tissues where radioactive drugs are administered and the flow of these compounds is followed to determine whether or not the organs are working nor

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