Mr. CARTER. I think these people should have the benefit of a test before ruling them out arbitrarily.

Mr. ROGERS. Thank you very much.

Mr. HASKINS. Thank you.

Mr. ROGERS. Our next witness is Mr. Leslie Lee, of Orlando, Fla., representing the Certified Laboratory Assistants Board of the American Society of Clinical Pathology.

STATEMENT OF LESLIE LEE, REPRESENTING THE CERTIFIED LABORATORY ASSISTANTS BOARD OF THE AMERICAN SOCIETY OF CLINICAL PATHOLOGY

Mr. LEE. Mr. Chairman, I would like to submit my statement for the record and add a few words of summation on some of the comments that have been made during the day.

Mr. ROGERS. That will be fine.

Mr. LEE. We have heard a lot about medical expenses and the increasing cost of hospitalization during the day, and during the entire testimony before this committee. It is rather important to note that about 75 or 80 percent of all of the costs of hospitals is payroll. So it is extremely important that personnel be adequate and be efficient. I have been in medical technology now for about 27 years, and during about 20 years of this I have been concerned with training of medical technologists and assistants. So this is not a new area to me at all.

I am extremely interested in some of the testimony that has been going on in the last few hours here. Until we have some sort of better standards for proficiency and hospital performance, I believe we will do very well to stick with the standards that have been set up and approved by the medical profession. Certainly the care of patients is medicine. Certainly the performance of laboratory tests is of prime importance in their care. I believe it is the prerogative of the medical profession to set the standards that are going to govern the laboratory work that is involved here.

I personally rather doubt that a licensing bill, a national licensing bill, is going to increase the number of people who are available. That is, indeed, I think the crux of the problem. It may do something to straighten out some of the questionable practices that are going on. But I believe the primary problem is the shortage of personnel.

Of course, this is the interests of the CLA board, which I represent. We feel that there are many laboratory tests that can be done by people who have less training than a college degree. They do, however, need to be adequately trained in a clinical situation under competent medical supervision. When they are working, they need still to be under competent supervision.

The CLA board has been set up to establish the standards and criteria for personnel in this particular echelon of laboratory work.

I would like to thank you very much for the opportunity to appear here. I have enjoyed the testimony very much. It has been very

educational.

(Mr. Lee's prepared statement follows:)

STATEMENT OF LESLIE LEE, MT (ASCP), REPRESENTING THE BOARD OF CERTIFIED LABORATORY ASSISTANTS OF THE AMERICAN SOCIETY OF CLINICAL PATHOLOGY

I am Leslie Lee, a Medical Technologist and Assistant Director of Laboratories of Orange Memorial Hospital in Orlando, Florida. I have been concerned with the training of medical laboratory presonnel for the past 20 years and am author of the Laboratory textbook, "Elementary Principles of Instruments". I am a member of the Board of Certified Laboratory Assistants of the American Society of Clinical Pathologists, which sets standards for the certification of medical laboratory assistants and for the approval of the schools in which they are trained. These workers are at the post-high school level and are being trained in programs from twelve to eighteen months.

To qualify for admission to such an approved training program, the student must be a high school graduate with some aptitude in science and math and students are encouraged, in most schools, to take additional courses in biology, chemistry and math. The Board requires that the course be at least twelve months in duration, that it cover a minimum required curriculum, and that it includes extensive practical clinical training in a hospital laboratory under the supervision of pathologists and technologists. The minimum curriculum for this program has been outlined in a training manual developed by the National Committee for Careers in Medical Technology for the United States Office of Education entitled "A Suggested Guide for a Training Program-Medical Laboratory Assistant". The Board is particularly concerned that the training include exposure to a wide variety of clinical material and adequate patient contact in an actual clinical laboratory situation.

Upon completion of this program, graduates are eligible to take a national examination conducted by the Board, which, if successfully completed. leads to certification as a Laboratory Assistant or CLA. Graduates of the two year junior college programs would also receive an associate degree.

Certified Laboratory Assistants work under the supervision of Pathologists or other Physicians and professional Medical Technologists who are trained at the baccalaureate level and who are in a position to take final responsibility for the tests performed. Laboratory Assistants, on the other hand, perform important though not critical tasks, thus relieving the hard-pressed Medical Technologists for the more complex and automated tests.

The Board of Certified Laboratory Assistants was organized in 1963 by the American Society of Clinical Pathologists working with the American Society of Medical Technologists to provide an adequately trained second level of laboratory worker. In the past four years 150 schools have been approved for training, including 21 financed under the Manpower Development and Training Act and 14 through provisions in the Vocational Education Acts. The rest are financed by hospitals or other private sources with no tuition or a minimal charge to cover the cost of books, uniforms and so forth. The capacity of the existing schools is 1,300 and is increasing each month. The schools are over 80% filled at the present time and many report a waiting list of applicants.

Since the first national examination was conducted in the Fall of 1964, 2,300 laboratory assistants have been certified, including those who took the certifying examination on the basis of previous training or experience. Many technicians with military lab training and experience have been certified in this way, for example.

A vital element of training at this level is the impression on the student of the importance of recognizing his limitations. The danger to the patient of improperly trained laboratory help whose reach exceeds their grasp cannot be overemphasized. This is one reason why training in proprietary schools without adequate medical supervision and patient contact is dangerous. Anyone presenting himself as a Medical Technologist and taking responsibility for tests affecting life and health of patients should have at least three years of science oriented college training and at least a year of actual hospital training under competent medical direction. The poorly prepared worker who tries and fails can kill the patient.

Junior colleges are beginning to express considerable interest in the Certified Laboratory Assistant program and the Board has been very interested in this development. In my own state of Florida a two year CLA program is beginning this Fall at Polk Junior College in Bartow. Part of the training will be given in the class rooms and part in the affiliated hospital laboratories. The students will be eligible to take the national certifying exam and will receive

an Associate in Science degree. The program meets the requirements of the college system as well as those of the profession. It has been reviewed by the Medical Technologist Consultant to the State Department of Education as well as the Advisory Committee for Laboratory Assistant Programs. Everyone is pleased with this arrangement and we feel it is an excellent framework which will be used in other community and junior colleges in Florida and elsewhere. Some of these are already in the planning stages at Lake Sumpter Junior College in Leesburg, Broward Junior College in Fort Lauderdale and Miami-Dade Junior College in Miami.

I wish to thank you for the opportunity of appearing before you. If you have any questions I will be glad to try to answer them.

Mr. ROGERS. Thank you for your presence here today.

Mr. CARTER. I think you have made a very good witness and have been very sensible in your observations.

Mr. LEE. Thank you.

Mr. ROGERS. Mr. Kyros?

Mr. KYROS. I have no questions, Mr. Chairman.

Mr. ROGERS. Thank you very much for your presence today, Mr. Lee. That concludes the list of witnesses. The committee stands adjourned subject to call of the Chair.

(The following material was submitted for the record:)

STATEMENT OF THE AMERICAN MEDICAL ASSOCIATION

Mr. Chairman and members of the committee, the American Medical Association appreciates this opportunity to present its views concerning H.R. 6418, the "Partnership for Health Amendments of 1967."

This bill would (1) extend for four years and expand Public Law 89-749, "Comprehensive Health Planning and Public Health Services Amendments of 1966," (2) require certain medical laboratories to be licensed by the Secretary of HEW, and (3) make other amendments to the Public Health Service Act. Our statement will be limited to items (1) and (2).

Last year, we appeared before this Committee and presented our views on S. 3008 and H.R. 13197, the predecessor bills from which Public Law 89-749 evolved. In enacting the law, the 89th Congress did not accept the six-year program for planning grants and the five-year health services program, but instead, while adopting the essential substance of the administration proposal, limited it to a two-year planning program and one-year program of formula and project health services grants, and reduced the appropriation authority originally sought.

At last year's hearings we stated a measure of approval of the legislative proposal-and a measure of disapproval. At that time we also suggested certain amendments which we considered would be beneficial and necessary to the program.

Briefly, the AMA offered endorsement of the concept of comprehensive health planning, noting that for some years the Association had played an active role encouraging such planning on a voluntary basis, local and areawide. At the same time, we voiced objection to the provisions of the law which would permit the furnishing of "public health services" and "health services" without any expressed limitation by this Congress as to the kind or scope of the services intended. (Attached as an appendix to our statement is a brief summary of our position stated at the hearings October 11, 1966, on S. 3008 and H.R. 13197, together with certain amendments we then recommended.)

We will now direct our comments to the provisions of H.R. 6418.

PROGRAM PLANNING-H.R. 6418

For many years the AMA has supported voluntary efforts in health planning-state, local and areawide. Planning is an inherent requirement if the desired program is to be properly organized and implemented in a manner that will

recognize the need for coordination and avoidance of unnecessary duplication of related programs. Many voluntary planning agencies-on a local and regional basis are effectively operating presently throughout our nation. Accordingly, the AMA supports the principle of health planning embodied in the legislation. Our support for health planning under P.L. 89-749 is conditioned upon the incorporation of the recommendations we made in our testimony before this Committee on October 11, 1966.

Alternate proposal for section 314(a)

There are, however, considerations which we believe warrant a complete reevaluation of the program under Section 314(a) under Public Law 89-749.

One of the underlying reasons for Public Law 89-749 was that it should avoid duplication of existing programs. From an analysis of this legislation, however, it is becoming apparent that this program cannot directly alter or remove duplication in existing federally supported programs where such duplication may exist. No authority exists in the law concerning modification of other programs. We believe that a different mechanism to avoid duplication, and at the same time provide coordination of the various programs existing within a state, would be more effective for this purpose. Therefore, we suggest that a State Commission be created in lieu of the planning agency. This Commission would be empowered to inquire into the operation of all government supported health programs and make periodic reports to the Governor, containing recommendations for improving existing programs and for the establishment of new progams. The Commission's functions would include responsibility for reviewing, evaluating and coordinating all government supported health programs in the State.

Public Law 89-749 states that the attainment of its goal depends on close intergovernmental collaboration. We believe that the coordinating commission referred to would be more effective in accomplishing coordination among the various programs.

Planning amendment under H.R. 6418

An amendment contained in H.R. 6418 would require that a state's plan under section 314(a), as amended by P.L. 89-749, provide for the State agency to assist each health care facility within the state to develop a plan for capital expenditures for replacement, modernization and expansion consistent with the plan developed in accordance with criteria of the Secretary of HEW. The state agency will also be required to periodically review the program of the health care facility and recommend modifications.

The State agency under section 314(a) has a broad planning authority in all sectors encompassing the whole scope of health within the state services, facilities and manpower, both public and private.

H.R. 6418 does not define "health care facilities." Such a broad term could conceivably include, among others, such facilities as a group practice establishment, a clinic, the nursing home, the public health station, the private or community hospital, the medical school and teaching hospital. Is it to be intended that all facilities-whether public or private, for profit or not for profit-must have their plans for replacement, modernization or expansion fit in with the state agency's conception of priority This State agency will be charged with jurisdiction over facilities serving not only its State exclusively, but others serving multi-state areas. Will its effect fall on facilities whether they are recipients of federal funds for construction or merely receiving payments for services? An extension of the authority of the State agency to include replacement, modernization and expansion of hospitals-whether public or private and whether for profit or not for profit-is not idle conjecture. The proposed amendment to H.R. 6418 must be read in conjunction with the proposed amendment in H.R. 5710 relating to medicare, which would cut off depreciation allowances to hospitals under its reasonable medicare cost formula where the hospital attempts rehabilitation, construction, or expansion without the approval of the appropriate state agency. Under the medicare amendment, the only agency specifically identified is the state planning agency under Public Law 89-749. It thus appears, for instance, that a hospital desiring expansion may become stymied as to its planning for expansion or modernization. Whereas approval of the Hill-Burton planning agency was sufficient where such funds were desired, under the Medicare Amendment it would be required to secure (in order not to lose the medicare depreciation allowance), in addition to approval of the Hill-Burton agency, the approval of the state planning agency. And even

where the hospital did not require Hill-Burton funds, the state planning agency's approval would still be required lest the hospital risk losing the medicare depreciation allowance. Thus a health care facility is controlled because it provides health care services, payment for which services (as distinguished from construction grants) is supported by the government.

It was our belief that the planning effected on a voluntary basis for hospitals, coupled with the approval required under the Hill-Burton program, was a satisfactorily working program. It had apparently worked so well that a witness for the administration, stated in his testimony last year in advocating the present "partnership for health" program: "We must extend and improve the kind of partnership in a dynamic Federal-State system that has been demonstrated so effectively in the Hill-Burton hospital construction program." The AMA supports the Hill-Burton program. We do not believe that the amendments proposed in H.R. 6418 and H.R. 5710 augur well for hospitals and other facilities covered thereunder and the voluntary system of planning which has developed under the Hill-Burton program.

AREA WIDE PLANNING

H.R. 6418 would extend the program under Public Law 89-749 of grants to provide for the development of comprehensive regional, metropolitan area, or other local area plans for coordination of existing and planned health services. The AMA has supported voluntary areawide planning. Accordingly, we support a continuation of this program, restating our hope that the grants, available to various groups, will stimulate voluntary private agencies to play a substantial role in planning activities.

COMPREHENSIVE "PUBLIC HEALTH SERVICES"

The AMA has supported, and continues to support, the furnishing of public health services. Our relationship with the U.S. Public Health Service has been one of longstanding support and cooperation. Our basic concern with this legislation is not that it would continue the provision of public health services-as such programs are unquestionably meritorious-nor is a basic concern the fact that proper public health services may now be expanded.

Appréhension fundamentally stems from the fact that the language of Public Law 89-749 contains no congressional expression concerning its intent as to the kind or scope of the services to be furnished. We recognize there is a supportable advantage in removing strict categorizátion of grant funds. To the other extreme, however, the categorical identification having been removed, there no longer appears any limitations on the health care which may be provided.

From testimony on this legislation by government officials, it would appear that there will be little limitation, if any.

Is it the intent that the Congress is authorizing a program of individual treatment for unidentified patients for unspecified conditions for unlimited services? As we read this bill, while the services are furnished under the auspices of "public health," the only required relationship to public health in furnishing services will be the relationship of the individual as a member of the public! It is clear that the lack of definition of "public health services" is, in effect, an invitation from Congress to unlimited expansion of "public health” beyond its traditional role in the community. With the purpose of the law stated as "marshaling of all health resources-national, State, and local-to assure comprehensive health services of high quality for every person" and there being no formal limitation on the scope of public health services funded under this law, there is an obvious potentiality for the State health agency to provide the medical treatment of individual patients, without limitation.

The American Medical Association has strongly supported flexibility of operation within the State and local health departments, as an effective tool for community health. We feel, however, that the distinction between the public and the private health sectors should be delineated by this Congress in more positive terms than a mere prohibition of interference with existing patterns of private professional practice.

In our testimony before this Committee in October 1966, we stated: "The American Medical Association cannot endorse an undefined program . . The American Medical Association would support grants for existing or new programs having a bearing on the public health. Assistance in proper public health activities to attack and control public health problems has unquestionable merit

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