"Are shortages of trained personnel in the medical and medical-related professions especially severe in fields that serve the elderly?" Definitely. They are specially severe in fields that serve the elderly. This has called for training programs to develop geriatric aids, volunteer corps, to operate in health services. The establishment of in-service training programs in hospitals and in extended care facilities. The Age Center of Worchester, with the Girls Trade High School and other educational facilities has attacked the problem. It is beyond the scope of the present facilities and funds presently available for the purpose to successfully cope with it. There is a great deal to be done other than to repeat facts such as those which are quoted from Professor Milton I. Roemer, University of California, Los Angeles. This involves private continuance as well as more, not less, sensitivity to the elderly in their midst. It involves care on the part of the government not to reduce its efforts because of the financial burdens imposed by the world situation. It is imperative that the experience of physicians as well as workers in other fields who have an interest and experience in the areas of health posed by the questions asked by Senator Smathers, shall not be buried by those who oppose the concept of Medicare and Medicaid simply because of a reputation which is still perpetuated against those who are said to have had, and still have "funny ideas about Medicare". Finally, I would like to direct attention to a special article in the New England Journal of Medicine of April 2, 1964 titled: "Leadership in American Medicine", by John G. Freymann, M.D. When it appeared it made a stir, particularly in the medical academic community. Dr. Freymann contended in his article that only a "Third Force" in American medicine could restore the constructive organization and inspired leadership in the voice of American medicine, the American Medical Association. The "Third Force" is defined by Dr. Freymann as "this new generation of particularly well educated physicians practicising outside univer-centers. . . "Nevertheless, with one foot firmly based on advanced training in scientific medicare and the other on private practice outside the academic sphere, it bridges the gap. (I.e. Between "town and gown", a categorization Freymann disliked.) Freymann voices the hope that as the result of the "Third Force", "with so many brilliant men among its members the medical profession should not have to abandon direction of its destiny to outside forces." This concept is excellent as far as it goes, but one more step is needed if leadership in American medicine is to become effective. It is the need for the individual physician as well as the local or district medical society to join in intimate community effort to improve Medicare which has meant so much to the millions of Older Americans. In this regard I can highly recommend the recent work of Robert Morris and Robert H. Binstock of Brandeis University, with the collaboration of Martin Rein (Columbia University Press, 1966) titled: "Feasible Planning for Social Change," critically reviewed in the New England Adage, January-February 1967. The collaborators discuss ways as the result of the experiences drawn from the records of the 3 year study of demonstration projects in Community organization for the elderly conducted in 4 of the 7 cities financed by the Ford Foundation project on Aging. They contend that it is necessary to overcome the wastes of enormous amounts of funds, and professional and citizen man-hours in social welfare planning as it is commonly conducted. These remedies are proposed: 1) differentiation among the planning efforts according to the types of changes sought, rather than to the social conditions under consideration; 2) systematic analysis of the factors that make the feasibility in various different types of planning. The Subcommittee Hearing on Costs and Delivery Of Health Services to Older Americans is commended for its efforts to "improve understanding of present inadequacies or difficulties in providing health services to the elderly and also to suggest actions that may be needed to solve present problems." It is hoped that its ongoing future efforts which are necessary will be most successful. Sincerely yours, SAMUEL BACHRACH, M.D., DOVER GENERAL HOSPITAL, INC., Hon. Senator HARRISON A. WILLIAMS, Jr., DEAR SENATOR WILLIAMS: Many thanks for your kind letter of July 6th. It is with real pleasure to forward to our good Senator George A. Smathers the literature that you so kindly asked my permission. I want you to know you are always at liberty to use any and all literature that I may send you as you so see fit. Wishing you well, with kindest regards as ever. NORMAN H. TOPPINGS, M.D., [Enclosure] C. T. BARKER, Director. DOVER GENERAL HOSPITAL, INC., President, University of Southern California, DEAR DR. TOPPINGS: I read with interest in The Week For Hospitals, Volume 3, No. 21, dated May 26, 1967, of the American Hospital Association, as per photostatic copy attached, that you have been named General Chairman of the National Conference on Medical Costs to be held in Washington, D.C., on June 27th and 28th. As a Hospital Director interested and concerned about both good health care, as well as reasonable cost, and living within the framework of a hospital for over twenty years, one can hardly believe that the cost could skyrocket so rapidly and the changes that have developed in the health and hospital field. In my opinion, some of the changes have been good and some have been very, very bad. Referring to hospital cost even before, and now that we have in effect Public Law 89-97, as of July 1, 1966, the following are a few of the main factors to control hospital cost, and it is not easy, mainly because hospitals are never closed. We render service around the clock. Also, personnel, supplies and equipment must be available within minutes. Therefore, controlling same is not easy, as well as far too often personnel are being paid and nothing being produced or services rendered. Hospital Directors' hands are far too often tied by the authority of the Board of Trustees that does not live that closely with hospital problems and cost. Likewise, the medical profession is not an easy group to control on a reasonable and honorable basis. Great cost involves: (1) Unnecessary duplication of paper work that has grown rapidly in the hospital field. Paper and reports do not cure the sick and injured. (2) Pilferage is a main factor to be controlled in the nature of a hospital service. (3) Waste, likewise, is a factor of high cost that must be controlled, and is not easy for many reasons. (4) Getting an honorable day's service from each employee for their salaries paid. (5) Controlling the medical profession is a costly factor and not an easy one and great cost is involved because of the medical pressures, far too often poorly evaluated on the part of hospitals or properly authorized people. (6) Patients being admitted to hospitals because of health insurance and/or other third party insurance that ordinarily would be taken care of at home. This is a great convenience for the patient, the family and the physician, but we must realize it is costly. Also, the general public today is demanding hospital care because it is a convenient factor, again for the family, with everyone working and no one at home to even take a little time or give a little attention to someone that may not be feeling up to par. Here again, if this is the type of hospital care and service the general public is demanding, we must realize it is going to be costly, unless it is controlled in a strong and honorable manner. (7) The medical profession practicing on the heavy side of legal protection at the expense of the hospital, the insurance company, the patient and now the taxpayers, with Medicare. (8) The medical profession is not hurt financially or responsible for financing hospital care. Therefore, they are not concerned about cost. (9) The medical profession having no control and not being able to control within, with the attitude that you must be a physician to make decisions. A lay person is pressured far more by the medical profession than any other profession that I can think of along life's way. The above statements are not made in an unkind or derogatory manner. We have been floundering around for years and constantly criticizing hospital cost. Yet, too few people will speak the facts. The other is there is only a limited amount of people in the health field that will have the opportunity of knowing the cost problems involved. The medical profession is a great one and certainly one of the most important to our way of life. Yet, we have our problems in controlling our health cost, with the largest percentage being controlled by the medical profession because of some of my opinions that I have already mentioned. I further question if Boards of Trustees have out-used their usefulness, as in years gone by hospitals were established and it was the responsibility of Trutees to formulate policies, as well as find ways and means of financing the service to the patients. This meant that great interest and efforts had to be put forth by Trustees in raising sufficient funds, as well as greater interest in policy making for the financial protection to the patients, as well as responsible for good patient care. Within the last decade, health insurance has grown by leaps and bounds, as well as other insurances of a growing nature, of compulsory compensation insurance, as well as local, state and federal aid in many directions. Liability insurance has grown far greater than history has ever known. We have gone through a long period of years where the economy of our great nation has been favorable for the earning power of our people, which all spells out that the health cost to our patients, community and nation has now reached a new plateau of financing, which has meant, to a large degree, that cost has been allowed to skyrocket, with Trustees not being concerned about raising funds. We have further overlooked, in my opinion, that hospitals today are big business. Anyone selling to hospitals is selling at a profit, whether it be equipment, supplies, medicine, maintenance and repairs, etc. Employees today in hospitals are now earning a fair and more reasonable, justified salary equal to other walks of life in the categories of the many types of business that are placed under one roof of a hospital. Other benefits, likewise, have been granted to the employees, which they are well-deserving of, provided the service is rendered honestly and faithfully in their responsibility to the patients, the staff and the hospital. Unfortunately, we have been unable to organize and operate hospitals with the same business-like manner that we find in other industries because of the few reasons I mentioned earlier in this letter. Also, in the hospital and health field, it is the opinion of the medical profession that great advancement has been made in research, equipment and treatment, which has brought about costly equipment, costly technicians and personnel to understand and use same. It is further my opinion that much of the so-called advancement is questionable to the cost involved to the average person. The light that I am trying to reflect at this time is whether or not we are allowing any and all hospitals of a general nature to become experimental, diagnostic or research centers in treating the sick and injured, and are we getting away from the down to earth, right to the point illness of our patients and cure them so that they can return to the every-day way of life of caring for themselves and families? Is the common illness and quick return to the cure overlooked? Have we turned too strongly to research and specialties? Are we lowering the standards of every-day medicine, or are we giving the best of care to the every-day patient? We now have with us Medicare, Public Law 89-97, which was passed by the 89th Congress on July 30, 1965 and became effective July 1, 1966. Here, too, I question if we are going to lower the standards of medical care to a group of people under 65 that must and should be in good physical condition to maintain their own livelihood, families, etc., and to have the health to work, produce and pay the necessary taxes to care for our citizens 65 and over under Medicare. With the growing percentage of Medicare patients being admitted to general hospitals, I am concerned about this most important point. I am in favor of Medicare. I am in favor of caring for our senior citizens. I am in favor of anything that is good for the people of our nation, provided it is done on an honorable, reasonable basis, in fairness, as much as possible, to all, although I am strongly of the opinion that we have fallen short of providing sufficient facilities for caring for a large percentage of our Medicare patients of a nursing home nature, more so than a general hospital. Medicare now faces hospitals with the following problems: The nursing profession discouraged and becoming more so in caring for elderly people, more of a nursing home type patient than a general hospital, keeping them clean, feeding them, great patience that is needed in encouraging them patient-wise, in giving medications, keeping them under control of falling out of bed, falling out of chairs, etc. These patients are not general hospital patients and the nursing profession is being lowered because of the morale. The cost is great. Also, hospitals are now faced with general facilities, such as x-ray, medical laboratories, other trained technicians, such as electrocardiograms, electroencephalograms, etc., for patient care, which would be of value to the medical profession in ordering to restore health to the younger to return to their way of life, as I have spelled out previously in this letter. Medicare patients have become costly patients to general hospitals by occupying beds that are only limited to nursing care. It is true that we have established throughout our nation screening committees, as well as utilization committees of the medical profession. Here again, I question throughout our nation the real effect of these committees, in action, and it is further my opinion that unless the people serving in the hospital field are given authority in controlling many of the factors of hospital cost and procedures and unless we in the hospital field are given honorable and cooperation support by the medical profession, unless the general public realizes that health care is costly and that hospitals should operate and care for the sick and injured and not be used to the large degree of making it a convenience for the patient, and family to be cared for in general hospitals rather than at home, unless the general public realizes that luxuries within hospitals must be curtailed and accepted by the general public, we have nothing else to look forward to than higher health cost. Unless a miracle should take place that the authorities and responsible people running and controlling hospitals, the medical profession and the general public were to work as a team in an acceptable, honorable fashion, much can be done to control health cost and still have good health care, or we will continue to be faced with high health cost. The other is if our law-makers are sincere and concerned about Public Law 89-97 and our health cost, they will provide sufficient funds to build nursing and convalescing homes to be run under the supervision of a general hospital, where great economy can be used in still using the laboratory, x-ray and other facilities of a general hospital, when needed for Medicare patients in a convalescing nursing home type facility; not on a profit basis. I have reasons to believe that this would be the greatest answer to good patient care of the Medicare patient at a more reasonable cost to our taxpayers and patients cared for in general hospitals. I would challenge this thinking. Also, if we fail to accept the above, I personally feel we must look to some drastic action in order to correct the health cost without lowering the health standards. Dr. Toppings, you have before you a most important and serious assignment, and I offer to you my fullest support and best wishes that you find some of the answers that we need to our way of life of good health care at reasonable cost. I am attaching some literature which spells out some of my thinking and experience in the hospital field, if you care to review same. Also, I would be most appreciative to receive a copy of the report concerning the National Conference on Medical Cost of June 27th and 28th in Washington, D.C., when same is complete. Thanking you for your time. Wishing you well with the utmost success in your assignment as Chairman of the National Conference on Medical Cost. Sincerely yours, C. T. BARKER, Director. ROSSMOOR-CORTESE INSTITUTE FOR THE STUDY OF RETIREMENT AND AGING, DEAR SENATOR SMATHERS: I will welcome the opportunity to contribute at any time to further the goals of your Committee in improving the health of the elderly. I have been impressed by the fact that the age specific death rates in this country for adults have not shown any improvement in recent years. This failure to gain, and in some cases an actual increase in mortality rate, suggests that we have lost some ground in maintaining health. One should not conclude from this that our improved medical technology and medical research is irrelevant to the fundamental conditions, but rather, I suspect, infer that the environment has become increasingly adverse. As we broaden our inquiry to include some of the more remote antecedents of the level of health of middle-aged and older adults, we include many social and behavioral factors as well as the physical environment. The important variables in these relationships do not now fall within the purview of representative medical education. For this reason, medical services are best adapted to high quality care for hospitalizable conditions. I would infer from the present health scene that bio-medical research and medical education will have to broaden its scope to include more training and research on the remote antecedents of health problems of adults. This will place both the health practitioner and the bio-medical researcher in new relationships with other fields, the physical sciences on one hand and the social behavioral sciences on the other. More immediately, however, one might infer that we are delivering specialized services too near the terminal stages of diseases and we should make efforts to deploy services earlier in the processes of chronic diseases. To deploy services implies early detection and a more developed system of preventive health than is now commonly organized. Best wishes to the success of the inquiries and actions of your Subcommittee. Sincerely, JAMES E. BIRREN, Ph. D., Director. ROSSMOOR-CORTESE INSTITUTE FOR THE STUDY OF RETIREMENT AND AGING, Los Angeles, Calif., June 16, 1967. DEAR SENATOR SMATHERS: I am pleased to make a statement to the Subcommittee on Health of the Elderly. I regret, however, that because of my teaching schedule I will not be able to attend the hearings on June 19th. One of the limitations of the way health services are organized is that the needs for health services cannot be anticipated while individual health problems are in their early stages. This is particularly true in the elderly. Individuals over the age of sixtyfive commonly suffer limitations of mobility and cannot travel easily to medical centers. Also, health services tend to be geographically ad psychologically remote from older persons. For this reason, they infrequently present themselves to health specialists unless a personal problem is advanced or acute in nature. At that time, the costs are high. Insufficient effort has been devoted to ways of anticipating the need for specialized health services to the elderly. I have personally known aged persons who have had to receive dramatic and expensive care because the organization of health services did not lead to the early detection of incipient illness when intervention would have been less expensive and certainly more productive. The existence of Medicare and Medicaid does not solve the problem of making health services more easily available to older persons early in the development of serious illness. In this regard, I believe there is a notable shortage of trained personnel who have the background, conceptually and technically, to attack the problems. Public health personel can be trained in this area, although it must be said that until now they have been mostly concerned with matters other than health services to the aged. Schools of medicine may be encouraged to establish Departments of Community Health to train needed personnel. The issues appear to be less a matter of the quality of the technical health services than of how these health services are deployed and brought to the individual as early as possible in the course of an illness. This later matter is an area of study for medicine and for the behavioral and social sciences. I personally have not been impressed that we have made any notable recent improvements in the health of middle-aged and retired persons. This is not intended to be a criticism of the quality of services but rather a comment about the need for broader study of health in relation to age and the delivery of services. It also occurs to me that The National Commission on Community Health Services may have examined the position of the elderly and their health needs in the total context of the quality of health in America. Sincerely, JAMES E. BIRREN, Director. |