Mr. PETTIS. I think that is a rather fascinating story to go from eight to 80 physicians in a short period of time in an innercity program. It is something to which this committee should give some consideration.

Dr. BOYLE. They could give care on a one-to-one basis to most people they wanted to take care of.

Mr. PETTIS. Thank you, Mr. Chairman.

The CHAIRMAN. Are there any further questions?

If not, we thank you, Dr. Boyle for coming.

Dr. BOYLE. Thank you.

The CHAIRMAN. The American Association of Clinical Urologists, Dr. Russell Carson and Dr. Charles A. Hoffman.

If you will identify yourselves and the gentleman at the table with you for the record we will be glad to recognize you, sir.

STATEMENT OF DR. RUSSELL CARSON, SECRETARY-TREASURER, AMERICAN ASSOCIATION OF CLINICAL UROLOGISTS; ACCOMPANIED BY DR. CHARLES A. HOFFMAN

Dr. CARSON. Mr. Chairman and members of the committee, I am Dr. Russell Carson of Fort Lauderdale, Fla.

With me here at the table is Dr. Charles A. Hoffman of Huntington, W. Va.

We regret that Dr. Tom Nesbit had a previous speaking engagement this morning and could not come. He sends his regrets also to Representative Fulton.

The CHAIRMAN. We are glad to have you with us, both of you, and you are recognized.

Dr. CARSON. I am a practicing urologist in private practice. I am also the secretary-treasurer of the American Association of Clinical Urologists, board certified, and a member of the American Urological Association, the International Society of D'Urologie, and so forth.

Dr. Hoffman is also a practicing urologist, also a past president of the American Association of Clinical Urologists, past president of the American Urological Association, and currently president-elect of the American Medical Association.

As representatives of the specialty of urology, we would like to make recommendations to you about the form of health insurance legislation which we believe would be most beneficial for the average American. Our governing body has determined that the needs of our patients would be best met by certain provisions of the American Medical Association's medicredit bill, H.R. 4960. While we will not comment on the specific financing mechanism, that is, tax credits, we wish to support the basic concepts as provided in the medicredit bill which will offer health care protection in the best interests of our patients.

Our reason for not commenting on tax credits is because our group does not posess sufficient knowledge in this area so that we might offer worthwhile testimony as to the best about financing. We do, however, feel that the use of voluntary participation and of the private health insurance industry for administration are worthwhile attributes of their plan. The features of the medicredit proposal which provide

insurance protection for the medically needy and catastrophic coverage for all, will meet the special situations of medical need and occasional medical hardship of the patients we serve.

Gentlemen, we as urologists, approximately 6,000 strong, represent an important specialty in medicine having concern primarily with diseases of the vital kidney and urinary tract which affects persons at the two extremes of life span. Our specialty has developed the subspecialty of pediatric urology. In the fall years of life we are confronted with the geriatric, degenerative diseases of the kidney, prostate, and so forth. Both of these age periods are of especial interest to you of this committee in your concern for the providing of and continuing availability of adequate, fair and reasonably priced medical care for all who need the care. As urologists we are concerned with congenital defects of the urinary tract, a system of organs subject to more, and certainly as serious, birth defects as any organ system of the body and with critical life threatening infections of infancy and childhood, and with disease such as nephrosis and nephritis which cripple the child for the remainder of life.

We are concerned with the conditions of the aging person such as high blood pressure, pyelonephritis-infections of the kidney-kidney stone disease, and with the most frequent cancer of the adult male, and so forth, that involving the prostate gland. We are vitally involved in organ preservation and transplantation. The major long-term lifeproviding success in this area has been that of kidney transplantation. To illustrate the problems which confront some of our patients, may I give you a couple of examples. Take the case of the young family with two children like the one I visited in the University of Florida a month ago where the 8-year-old youngster is now enrolled and doing well in grade school, his sister is 12 and just going into high school, his mother is in nursing training and his father is studying at the University School of Architecture.

This family came to me 7 years ago with a child whose congenital defect had practically destroyed both kidneys, I have seen him almost every month for 7 years until the last year. This is the 8-year-old child I have just referred to. It has taken nine operations and about a year and a half of hospitalization to salvage this youngster, at a cost of approximately $15,000. He is now doing well in his grade school. Financing in this case was no problem because the father was in the Army and the medical care needed was subsidized for the family by the military service. This would have hardly been possible in any other circumstance or it would have been a financial burden too great for any young family to have afforded. We are happy that the Medicredit bill which we support has a catastrophic provision which would take care of an example such as this.

Let me give you another example at the other end of the lifespan. It is an example of a gentleman of 81 years who, for the past 5 years, has been under constant treatment by radical surgery, cobalt therapy and medication, and so forth for the control of a cancer of the prostate. This man, who is dependent on his social security and a small life savings and who is without a retirement fund, and who does not qualify for medicaid, has been able to receive adequate treatment, pay his doctor bills, and maintain his dignity through the assistance of

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medicare. Here again the medicredit proposal will maintain this portion of the health care package; it does not seek to repeal medicare.

We are appearing before you today with a request, a plea to make it possible for all Americans to obtain truly needed health care, but at the same time protect the taxpaying citizen by not giving away that which is not needed.

Ideally we need recipients who are sufficiently informed about how to use the health care which is available to them.

We do not believe that the Federal Government should be involved in the direct delivery of health care, but should be limited in its activities to assisting in the financing, when necessary, of such health care facets as—

(1) The financing of basic and catastrophic health care.

(2) Assisting in the development of and distribution of health care personnel by incentives and adequate supply; that is, manpower legislation.

(3) Assisting in providing for adequate health facilities; that is, the Hill-Burton Act and others; and

(4) Providing for basic health education, disease prevention, and physical fitness which are the real bases of preventive medicine.

We deplore any nationalized conception and forced labor approach to medical care. Ask my patient who arrived from Havana, Cuba, last Monday how he fared with his free government medicine. Ask not the system, but the housewife of South Hampton, England, or Upsalla, Sweden, which she would prefer, the clinic line and 3-minute consultation or a visit to her own family doctor in Hagerstown, Md., or some other town in the United States. I did just that years ago. Mr. Chairman, we appreciate the opportunity afforded our association to comment on the problem before you. If our association can be of assistance next year when your committee is engaged in executive sessions, please don't hesitate to call on us.

We thank you very much.

The CHAIRMAN. Dr. Carson, we thank you, sir, for your very fine statement. We appreciate what you have said.

Are there any questions of Dr. Carson? If not, we thank you again, sir.

Dr. CARSON. Thank you very much.

The CHAIRMAN. Dr. Murray Elkins.

Dr. Elkins, if you will identify yourself for our record we will be glad to recognize you, sir.

STATEMENT OF DR. MURRAY ELKINS, QUEENS COUNTY, N.Y.

Dr. ELKINS. Mr. Chairman and members of the committee, my name is Dr. Murray Elkins. I am president-elect of the Medical Society of the County of Queens, New York City. I am a graduate of the Jefferson Medical College of Philadelphia, class of 1933.

Although I am president-elect of the Medical Society of the County of Queens in New York City my remarks will not be as its spokesman. I shall speak as an individual, as a general practitioner, as a family physician for more than 35 years.

With the exception of 311⁄2 years as a captain in the Medical Corps of the Army of the United States in World War II, I have served my

patients in the low- and medium-income community of Howard Beach. I have office hours. I treat my patients in Peninsula Hospital Center when they require hospital care. I have delivered more than 1,500 babies. I make house calls.

This presentation will cover five areas.

1. The so-called national health crisis: During the past two decades when demand for every day all inclusive medical care has risen rapidly the supply of family physicians has steadily declined. Approximately 8,500 new physicians have been graduated from our medical colleges per year. With present increased enrollment there

should be about 12,000.

Since less than 3 percent enter general practice there will only be about 360 new family physicians graduated per year, about seven per State, hardly enough to replace the older age group being lost by retirement and death. If the enrollment of new physicians were doubled or trebled, there would still be a paucity of family physicians whether practice were to continue in its present form, under national control, or by group practice.

There is hardly a medical delivery care problem that could not be solved by adequate numbers of family physicians available to give all people the primary care they urgently require and deserve.

Who is going to make the house calls sick people need? The present generation of general practitioners, family physicians if you will, are vanishing Americans, retiring out and dying out after many decades devoted to individual and family service. They are an army of foot soldiers being decimated by attrition and death without numerical replacements.

Mr. Chairman, it is gratifying for me to note that in the past 2 weeks since this was prepared, Congress has passed legislation to encourage physicians to enter family practice.

2. The incredible waste of hundreds of millions of dollars in the medicaid program:

(a) Medicaid in New York City pays from about $13 to $65.41 per patient per visit to a hospital clinic. The average is about $35.

(b) The same clinic physician treating the same patient providing the same medical service in his office receives $4.80 less a 20-percent coinsurance feature now in effect, or $3.84.

(c) It requires only simple arithmetic to ascertain that for every million medicaid clinic visits compared with the same visits to doctors' offices the net savings in medicaid funds would be more than $30 million. This does not include the additional huge sums paid to outpatient clinic physicians working on a $15- to $30-per-session basis. (d) The great majority of medicaid patients return to clinics for routine, repeated, and frequently unnecessary expensive laboratory and X-ray examinations.

(e) Add the unnecessary visits these patients make merely for refills of their allowed monthly supply of medication (again at an average of $35 per clinic visit).

(f) A taxpayers' suit was reported in the public press to prevent busing of schoolchildren eligible for medicaid to a private hospital for routine medical examinations. The cost at school was $3.50 per child. The same physical examination at the hospital clinic was a mere $35.57.

These facts and figures are well known to medicaid and health officials in New York City. They were sent to four city councilmen. I offered them as testimony at a congressional hearing on June 5, 1971, in Queens. They are part of the Congressional Record. I forwarded the information to three U.S. Congressmen but none seemed to really listen or care. Only one replied to my letters.

3. Ghetto medicine: Much has been written and said concerning lack of access to medical care by people living in slums and ghettos. This is untrue. Medical services are available to all whether in physician's office, clinic, health center, or hospital emergency room.

Critics quote statistics revealing increased incidence of disease and higher mortality figures in ghettos. Mortality statistics of whites to nonwhites are shocking: 6 years' shorter life expectancy, twice the infant mortality, a greater maternal mortality. It is deplorable and appalling to have slum areas without a doctor. But change in the system of delivering medical care will not reduce these figures. The problem is hardly soluble by encouraging or forcibly compelling physicians into these slums. The rational solution is elimination of the slums, demolition of the ghettos, transplantation of our underprivileged people from the unclean, from the abominable, from the contaminated, where disease and deprivation are rampant, to the clean, the livable, the healthy.

How can a devoted physician and his family brave the dangers lurking in the ghettos? Physicians are being mugged, robbed, stabbed, shot, murdered. They are being mugged making house calls, they are being robbed in their offices, they are being murdered by the very ghetto dwellers they dedicate themselves to serve.

The number of physicians practicing in Queens and in our neighboring county of Brooklyn has been drastically reduced because of this threat. Many doctors' offices are locked. Some have security guards at the door. Others have permits for and carry guns. Those who have moved out have done so to protect themselves and their families from attack.

4. Group practice:

Many are convinced that comprehensive prepaid group practice is the most desirable, most economic method of delivering highest quality medical care to the people of the United States. The Kaiser-Permanente plan in the West and the health insurance plan in the East are frequently mentioned as the epitome of medical practice, as the master plans after which future medical practice should be patterned. Yet, though there has been open enrollment for many years and frequent advertisements in the press, a relatively small percentage of the public has chosen the golden opportunity to avail itself of these closed panel panacea-promising medical care plans.

Where employees have been coerced or otherwise mandated into a closed panel group by their employers, many continue to utilize it for only routine, relatively minor conditions, but seek "their own physician or surgeon" when major illness strikes.

The Kaiser Foundation health plan in northern California has raised its rates 9 percent, the third raise in less than 2 years. The big closed panel considered to be a model of cost effectiveness by some governmental advocates increased rates 7.5 percent early in 1970 and