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to return the aged person after an illness to his family and community—in the absence of which the aged person is left no recourse but the futile, long-term, nursing home placement.

We have, in this affluent society, an opportunity to choose which new health programs are to be developed. It is important to recognize that the range of choice of health services is indeed a wide one. There are great benefits to be achieved in other health programs in addition to the benefits that can be achieved in the diagnosis and treatment of the acutely ill person. Both the fiscal realities of escalating hospital costs, but more important, the social gains to be achieved for the aged person, require that more attention be given to the whole spectrum of health services, from health maintenance and disease screening to rehabilitation.

STATEMENT OF MARY E. DAVIS, M.S.W., DIRECTOR OF SOCIAL SERVICES FOR THE CATHOLIC HOSPITAL ASSOCIATION

I wish to make it very clear at the outset that although these observations are directed to the health care of the aging, I believe that comprehensive health services are the right of every person regardless of age or economic condition. 1. "Medicare"-Title XVIII of the Social Security Act provides to insured beneficiaries payment for care in a hospital, extended care facility and for home health services. There are deductibles and co-insurance features which were one of several compromises made with providers of services in order to get the bill passed. No program of medical care should have deductibles or co-insurance. They are a financial barrier to the receipt of medical care and keep the poor from receiving it.

Title XIX-"Medicaid" was passed at the same time in order to supplement the basic provisions of Title XVIII. When a state has not implemented Title XIX, the aged poor are unable to make full use of benefits provided under "Medicare" because:

a. They have no way of paying the deductibles and co-insurance.

b. They cannot pay for nursing home or other types of long term care in addition to "extended care."

c. They cannot pay for drugs, dental care, glasses and other health services. I believe therefore that the Federal government should hold fast to the time limitations it has set for the states to get Title XIX-"Medicaid"-implemented, and hold to the present regulations within these time limitations for the provision of certain health services. We are all citizens of the United States and political boundaries should not prevent us from receiving what is a right for everyone.

2. I am becoming increasingly concerned with a growing trend in hospitals to gear services to the requirements of federal legislation. A prime example of this is the planning for and construction of "Extended Care Facilities" for people over 65 to meet Extended Care provisions under "Medicare"-Title XVIII. Extended Care is only one part of the continuum of care for people with long term illness and should be available to patients of any age who require it. Persons over 65, covered by Medicare, would have their care paid for under this program. Those not covered and persons under 65 might be covered through private insurance, Title XIX or other tax supported programs, or from their own funds. I am very concerned about this, because I see it as the beginning of a trend to organize health services to meet legislative requirements rather than the needs of ill and disabled persons, and this will kill initiative in the search for alternative and more appropriate ways of meeting their needs.

There is also I believe, a more grave danger that this trend could lead to the reinforcement of present methods of delivering health services rather than to the discovery of new methods. Blue Cross and other hospital insurance programs were organized to meet the cost of hospital care for individuals, because hospital care represented the largest expense in medical treatment. However, over the years, hospital insurance has been the chief reason for unnecessary utilization of hospital care by large numbers of patients who could better be cared for as out-patients or in their own homes or lesser care facilities. The trouble is that there is no insurance to cover these other kinds of care.

"Medicare" followed the same trend. Payment for hospital care is its first and major provision. Extended care and home health services were added only to offset the overutilization of hospital care, not because they offered a better

and more appropriate way of meeting a patient's medical care needs. Yet, early statistics show that surprisingly high percentage of the aged have used home health services without any hospitalization. It met their need. (I have always been very curious as to why the variety of methods of delivering medical care used at the Mayo Clinic have not been more widely imitated. The only answer seems to be that we have become "stuck" with hospitals!)

3. Health services for the poor are generally as poor as the poor themselves. They are also inaccessible because of geographic location, lack of coordination (specialities located in different places)—and more basically a complete lack of interest in and concern for the patient as a person. All of this could be changed if the private sector wanted to change it. A vacuum does not exist forever. Something moves into it.

As has been stated so accurately by Professor Cervantes "the federal government is an enabling agency to promote the common welfare." (Lucius F. Cervantes, "Socialism and Health Care," Hospital Progress. September 1966, p. 86.) "Medicare" and "Medicaid" provide payment under certain minimum conditions for certain health services. The producers and providers of these services can go far beyond these minimums and they should! If they do not care enough for the poor to insure that the health services provided them are related to health needs rather than to ability to pay; if they are less in quality and quantity than those provided more affluent citizens, then government may truly move in because concerned citizens will force it to do so. The choice lies with the private sector of the health field.

STATEMENT OF SISTER MARY VINCENT, C.C.V.I., THE CARDINAL RITTER INSTITUTE, ST. LOUIS, MO.

We are all grateful for the passage of Medicare Legislation and recognize the fact that it has been a great help to some of our older people who are in need. However, we would recommend that an altogether different type program be designed to complement existing social legislation, with the philosophy of meeting the continuing health needs of the chronic and terminal patients.

For health care programs such as Title 18, we need to find measurements of self-providing capabilities which would form the basis of eliminating many who do not need assistance from such health care programs.

Elimination of all deductible and co-insurance features of the Medicare Program, removal of waiting periods and deadlines for enrollment. Deductibles form barriers to needed care for those least able to pay.

Replacement of the 65 year age requirement for Medicare benefits by a provision qualifying all women at age 62.

Extension of the coverage for drugs to all prescription drugs regardless of their association to a hospital confinement.

Extension of coverage to all surgical and orthopedic appliances and such items as wheelchairs, and hospital beds for home use, eye-glasses, hearing aids, podiatry, and everything pertaining to eye care and dental care.

Expand existing programs and encourage where needed, the starting of new education and training programs designed for health care personnel needed to provide the services made possible by existing and proposed legislation. Training and education should reflect the needs of the functions to be performed and not be put at an unrealistic level excluding many potential health care employees.

Make available to local community health service providers-grants-in-aid for the acquisition of additional staff to meet the quality standards of care for chronic and terminal patients.

WASHINGTON UNIVERSITY,

SCHOOL OF MEDICINE,
St. Louis, Mo., June 15, 1967.

Hon. ALFONSO J. CERVANTES,
Mayor of the City of St. Louis,
St. Louis, Mo.

DEAR MR. MAYOR: This letter is in reply to your letter of June 5, 1967, asking about costs and delivery of health services to older Americans.

Persons over the age of 65 not only require more hospitalization but stay longer. In Barnes Hospital, Medicare patients now stay 4.2 days or 42.4% longer

than non-Medicare patients. The ancillary service billings are $97.00 more than the average non-Medicare patient. Thus, with rising costs, some borderline patients face serious financial problems.

In addition, the traditional charity given by large private hospitals is not as effective as formerly for two reasons. First, the same dollar amount will not buy as much medical care and, second, the government policies will not permit these costs to be included as part of legitimate overhead charges. It seems to me that this particular reimbursement policy might be re-examined.

Yours sincerely,

WILLIAM H. DANFORTH, M.D. Vice Chancellor for Medical Affairs.

STATEMENT OF HOWARD C. OHLENDORF, CHAIRMAN, PLANNING COMMITTEE ON AGING, HEALTH AND WELFARE COUNCIL OF METROPOLITAN ST. LOUIS

As Chairman of the Planning Committee on Aging of the Health and Welfare Council of Metropolitan St. Louis, I was asked by the Honorable Alfonzo J. Cervantes, Mayor of St. Louis, to prepare some brief comments regarding problems, as I see them, of the cost and delivery of health services to older Americans. I have had contact with a number of individuals in the past few months regarding generally the problems of the elderly. The Health and Welfare Council is conducting a program sponsored by a Title III grant from the Older Americans Act. This program, called Aging Information and Direction Service (AIDS), is one of providing information and referral services to older adults. I could cite you case histories regarding some of these problems, but in the interest of time, I will merely describe the problems as I see them.

With the advent of Medicare, older individuals qualifying under the program, who previously used the out-patient clinic services provided at City Hospitals, are now billed the full fee for a clinic visit, whereas prior to Medicare, they were billed approximately one-eighth of this amount. This is very frustrating to many of them who are living on reduced or fixed incomes and cannot afford to pay this fee. Once the hospital has billed the patient in the amount of the $50 deductible, they are no longer billed for services. They are, however, charged the 20% of the full clinic fee at each clinic visit. If the patient could not pay the $50 deductible fee, or the following 20%, this is collectable under Medicare as a bad debt. It would seem that some different way of handling this situation could be arranged to alleviate the personal suffering and worry on the part of the older patient.

Another problem that still faces us is in the area of nursing home care. The quality of much of the nursing home care available today still leaves much to be desired. A nursing home can be licensed by the State of Missouri as a professional or practical nursing facility. At the time the inspection of the home for licensure takes place, the home may meet staffing standards. However, one month after licensure, staffing may change, which means an inadequate staff available to provide needed and requested services. This is an unfortunate situation and I recognize the many problems involved in staffing nursing homes today, but I do feel that something should be done to more adequately insure that a home which is to receive payment for a certain quality and quantity of care, is qualified to provide that care. This might be in the form of inspection teams, which would periodically inspect these nursing homes on an unannounced basis. There are nursing homes in operation in Missouri and St. Louis which have repeated and numerous violations at the time of their "regular" inspections by authorities. It seem that it is very difficult to revoke the license of a nursing home operator. When the inspectors do find a situation which warrants and allows them to bring action against a nursing home operator, only the violations found at the last inspection are permissable as evidence. The past history of the operation of the home, no matter how deplorable, is not used. It is possible, also, for operators to obtain continuances for lengthy periods of time, meanwhile continuing to operate their home in a manner which does not meet standards. Something needs to be done about this where there is federal money involved.

It is also brought to my attention that in many cases medical records kept in the nursing home may not be adequate to insure the patient a continuity of quality care necessary to promote their living in as optimum a situation as their illness or disability will permit.

Some provision should be made to insure that each patient in an extended care or other nursing facility have a medical and social re-evaluation and diagnosis at least each year. This is required for those patients receiving Medicare payments but for those on public assistance, this may not be the case. It would seem that far too often an individual patient is diagnosed and evaluated upon admission to a home and cared for on the basis of this diagnosis for too extended a period of time, even though their medical situation might have changed during this time. We have tried in this country for some time to promote the idea that when an older person goes into an institution, he be made to feel that this institution is in fact his home while he is there. Nursing home, homes for the aged, and domiciliary care facility operators have come a long way in recognizing the need for this kind of philosophy of care. Now we have a situation in which an extended care facility may provide both a residential and domiciliary care facility and a nursing home facility. Suppose a person living in the domiciliary facility could benefit from some home health services. Could not these home services be provided to them in the domiciliary facility from the nursing home facility. This, I believe, needs some clarification and redefinition.

We have many elderly living in public housing projects. Getting services to people in public housing would seem, at first glance, to be an easy matter due to the fact that you have such a large number of clients living in close proximity. This does not always prove to be the case. The problems of people in public housing are of such a magnitude as to be overwhelming. One is struck by the amount of difference which exists between public housing designed specifically for the elderly and public housing designed generally for the total community. For example, in public housing for the elderly, the elevators stop on every floor, and there is more community space available. I ask you, is this disparity desirable? Suppose an older person lives in public housing where the elevators may not stop on every floor. If this person becomes ill, they may be requested to climb many steps in order to get to and from their apartment and the services in the community which they may require. Of course, for some medical reasons these elderly can have their apartment changed and be placed on a floor where they have access of an elevator, but I submit to you, gentlemen, that this reshuffling of human beings in degrading and frustrating.

Another problem which I would present to you today is the one of the older person's ability to travel distances to get to services they need. We have facilities in a metropolitan area designed to provide services to many of our elderly, but whether the individual can get to that service is another matter. I am sure we have heard time and again about the need of localizing services. Providing services where people live is of great importance.

There is still much confusion on the part of the elderly about Medicare benefits. A need still exists to acquaint them with their rights under the legislation. Many elderly still fear to utilize services available under the new law.

A common complaint of older persons is that the cost of various services has gone up since Medicare became operational. Until they reach the $50 deductable limit, this causes a hardship in many cases.

I do not envy the task of this Subcommittee but believe me when I say that you have my sincerest support and best wishes for finding solutions to some of our country's most pressing problems.

JEWISH CENTER FOR AGED,

St. Louis, Mo., June 16, 1967.

L

Mayor ALFONSO J. CERVANTES,

City Hall,

St. Louis, Mo.

DEAR MAYOR CERVANTES: I hope that this letter is received in time, by you, for submission of your testimony to Senator Smathers' Committee.

The thinking expressed in this letter is part of the problem which I reviewed in my letter to you of June 9, 1967.

The legislative definition of "a spell of illness" is very detrimental to the benefits of many elderly people of advanced age who cannot move from a nursing institution or an Extended Care Facility.

A resident of such an institution who becomes acutely ill at the beginning of the year and is hospitalized, say for the maximum of ninety days and then returned to the Extended Care Facility, say for a maximum of the one hundred

days benefits, cannot become eligible again during the year for any hospital benefits unless transferred out of the Extended Care Facility or nursing home to a domiciliary center for sixty days.

As I mentioned, such transfer would be detrimental, and in many instances, dangerous to the health of the advanced chronically ill aged. As a result they are not able to end "a spell of illness" and lose the benefits mentioned in the Medicare Law.

This inequity has become quite obvious and serious, and many efforts have been made to secure legislative change; but to no avail.

I hope your testimony can emphasize this point and help secure remedial legislation.

Sincerely yours,

SAMUEL ZIBIT, Executive Director.

Hon. ALFONSO J. CERVANTES,
Mayor of St. Louis,

City Hall,

St. Louis, Mo.

THE CARDINAL RITTER INSTITUTE,
St. Louis, Mo., June 8, 1967.

DEAR MAYOR CERVANTES: A giant step has been taken to enactment of Medicare legislation in bringing to the older people within society the quality and quantity of medical and health care which is their right.

The exposure and services provided by the Medicare Program have enabled us in our activities to experience and appreciate the enormous benefits being made available to society. However, in addition hereto it is focusing our attention on numerous additional aspects of health care needs which must still be considered. One example might be elimination of all deductible and co-insurance features of the Medicare Program, removal of waiting period and deadlines for enrollment. Deductibles form barriers to needed care for those least able to pay.

Secondly, extension of coverage for drugs regardless of their association to hospital confinement.

I hope these comments will be of some help.
Sincerely,

REV. ROBERT P. SLATTERY,

Director.

Mr. ORIOL. NOW, I call the last witness, Mrs. Mary Guiney, who is project director for Project Well-Being in Detroit, Mich., and planning consultant on aging to the United Community Services of Metropolitan Detroit and who has so many honors and a history of work on the project relating to the elderly and others in need of health that we will insert this description we have in the record.

(The information follows:)

BIOGRAPHICAL NOTES ON MARY K. GUINEY, ACSW, PLANNING CONSULTANT, SERVICES TO THE AGING, UNITED COMMUNITY SERVICES OF METROPOLITAN DETROIT

The welfare of Senior Citizens has commanded the devoted energies of Mrs. Mary (Molly) Guiney for more than a quarter of a century. Regarded as one of the nation's foremost authorities on the aging, she has been Planning Consultant for Services to the Aging, United Community Services of Metropolitan Detroit (UCS), since 1953.

Mrs. Guiney's major responsibility currently at UCS is as administrator of Detroit's "Well-Being Project for the Aging". Regarded as a "first" in the nation, this Project was launched in June, 1964, as a three-year demonstration program to help older people maintain their health and precious personal independence in their own homes. It receives its major financial support from a U.S. Public Health Service grant and is being carried out in three geographic areas of Detroit which was high concentrations of older residents.

A native of Rochester, New York, graduated from the Rochester Institute of Technology and later completed studies at the New York School of Social Work at Columbia University.

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