ROSSMOOR-CORTESE INSTITUTE FOR THE STUDY OF RETIREMENT AND AGING, DEAR SENATOR SMATHERS: I am William R. Larson, Associate Professor of Public Administration and Sociology at the University of Southern California. I am also Research Associate in the Rossmoor-Cortese Institute for the Study of Retirement and Aging at the same University. Dr. James E. Birren, Director of the Institute suggested that I write to you about the questions you had posed. I am pleased to take this opportunity to present my views on some of the current problems in health care and services for the aged. As a medical sociologist, my particular research interests lie in the urbanization and aging process as it affects the type and quality of health care provided for the elderly. At our Institute, we have just begun a pilot study of some of these matters under a contract with the U.S. Public Health Service (PH 110-94). A major characteristic of community medical care provisions that is often overlooked is the "two-way" nature of medical practice and care. Medical knowledge is primarily based on the cases and phenomenon which have been brought to medical attention. The early process of disease, the health medication habits, the behavior-altering attitudes, these are often unknowns to medical practitioners. What is needed is a system of medical data acquisition on a large scale, covering those special sub-populations such as the elderly. Currently popular programs for the development of "age-segregated" housing for older persons have the effect of isolating them from general community health facilities. Transportation routes, waiting time, fare costs and mobile unit design contribute to the difficulties the elderly meet in using public transport facilities. The recruitment of trainees into geriatric and gerontological fields has been dragging, since little "glamor" is attracted to care of the elderly. Although research on the aging process itself is in vogue, there seems to be few programs aimed at offering specialized and continuing education for physicians and paramedical personnel in the special needs of the aged. It would appear that concerted effort is needed which can deal with problems of transportation, spatial segregations, specialized education, and legislative integration with programs. I can envision a number of mobile clinics, operating on the newly developing multi-phasic screening principles, which could help to solve a number of the problems I've mentioned. By providing health data on a broad, community-wide scale, and using computer data storage techniques, such a system could allow physicians to get a far greater exposure to vital information on physiological, psychological, and social characteristics. By the use of educational system controlled by the data bank computers, physicians could participate in a learning experience. Community and public health organizations and personnel would have direct access to computer-based health information systems, allowing them to better plan for their involvement with those needing services. The major element lacking thus far in dealing with the special health problems of the aging seems to be the failure to develop an overall systems approach to health information. As I have described it, the several social sub-systems involved need to (be) considered simultaneously. The present plans under way at our Institute are examining this approach, and I hope these hearings will cause others to move in a similar direction. Thank you. WILLIAM R. LARSON, Ph. D., THE CITY OF NEW YORK, HEALTH SERVICES ADMINISTRATION, OFFICE OF PROGRAM PLANNING AND EVALUATION, June 23, 1967. DEAR SENATOR SMATHERS: This is in response to your letter of June 7th, 1967. There is no doubt that Medicare and Medicaid together will, when fully implemented, provide substantial fiscal relief to urban communities which have in the past provided a substantial portion of the hospital and nursing home care which low income elderly persons have required, out of their limited fiscal resources. It is also clear that Medicare, to the extent that its present benefits cover the medical expense of beneficiaries, provides for many elderly low and middle income persons the important element of human dignity and freedom from the worry of medical indigency by substituting entitlement to contributory insurance benefits for the previous welfare medical benefits available to them. Younger families, with elderly dependents, have also benefited from this new security, and many of them have in fact been relieved of drains on family income involved in paying for medical care costs for these elderly dependents. However, if the costs of medical care continue to rise as they have been in the last year or so, these increasing costs will create special difficulties for the elderly. Part of the fiscal relief provided by Medicare to both the community and to individual families will, in part, be cancelled out by these rising medical costs. As negotiated rates for hospital and physician reimbursement under taxfinanced, open-ended programs rise, these negotiated rates tend to become the prevailing rates. This can only result in higher costs for middle income families not covered by the Social Security Medicare programs-i.e., higher voluntary health insurance programs and, of course, increased out-of-pocket costs for the uninsured portion of the medical care expenditures. For such items as drugs, sick room supplies, dental care and other non-covered items, the elderly with fixed incomes are adversely affected by rising costs. Thus one enormously important area for public policy consideration is the impact of these developments on the entire area of non-subsidized medical care services, and especially on voluntary health insurance. It seems inevitable that there will be increased public concern with prepayment for health insurance coverage for the entire population. This suggests that profound and quick study of the problems here involved, and of possible alternative course of action, should receive immediate attention in the Congress and in the states. It is too early to appraise what has been the impact of the new Social Security titles on the shortages of personnel, or on methods of utilizing the medical and medically related professions. It is not too soon to begin to make the observations and measures needed to assess these developments, and this New York City is now preparing to do. Both Medicare and Medicaid have resulted in increased demand for health services. Voluntary hospitals are over-crowded, and elderly patients seeking elective surgery must often wait a number of months for admission. Extended care facilities are in great demand, and there has been considerable difficulty in finding bed space. Home health care needs to be dramatically expanded. There are not enough agencies nor personnel to fill the need. Aged patients seeking care in outpatient clinics are often subjected to fragmented, de-personalized services that characterize many of our clinics. The result of all of these factors is that in many instances the present health services are remote, geographically and sociologically, from many of the elderly. However, this problem is not confined to the elderly. It is more intense among the aged. The possibilities of developing neighborhood health programs and restructuring organization of health services and personnel in relation to these neighborhoods, needs to be examined. It is quite clear that there is an intensified need for intermediate institutional arrangements of a satisfactory quality for aged persons-or, extended care facilities of the type encompassed by Medicare; improved quality and availability of nursing home type of accommodations; improved availability and quality of homes for the aged, on the one hand, and of organized services that will permit the aged to be maintained comfortably in the community, in preference to institutionalization in those cases where this is clearly the preferable arrangement. A major problem in the present program is the very great need to simplify enrollment and payment procedures, particularly under the Medicaid program. Because the Medicaid program went into effect so quickly, the necessary tooling-up period for developing procedures was not available. Funds to permit adequate staffing of health and welfare agencies administering the law should be increased, and incentive should be provided to try new approaches to these problems. Moreover, some of the State programs for Medicaid split the responsibility for the program between the health and welfare agencies. No matter how good the degree of cooperation between these groups, it is impossible to run a program of this magnitude effectively and efficiently under this split responsibility. There are shortages of trained personnel in the medical and medically related professions that serve the elderly. The elderly require more nursing care in hospitals and in extended care facilities. Nursing care in both of these is in short supply. Rehabilitation services are particularly needed for the elderly in home care programs, as well as in extended care facilities. Moreover, the presently available personnel in the medical and medically related professions need re-training in the special problems of the elderly. This is particularly true as regards the problems of mental health which present themselves in the elderly. Dental services and the services of podiatrists are especially important in the elderly, but the supply of dentists and podiatrists is not nearly enough for the demand. I hope that these comments are of some value to you and your Committee, and that they do not arrive too late to be of service. Dr. James G. Haughton, First Deputy Administrator in the Health Services Administration, will be glad to testify on these points at the hearings of your Committee, if you would like him to do so. Sincerely yours, PAUL M. DENSEN, SINAI HOSPITAL OF BALTIMORE, INC., DEAR SENATOR SMATHERS: I'm responding to your letter of May 31st and enclose a copy of the comments that I'm making at the American Geriatrics Society in Atlantic City in a panel on Medicare on the afternoon of June 16th. These comments include answers to some of the questions you raise in your letter. With approximately half of the elderly in this Country living on incomes at the poverty level or lower, it is obvious that the continued inflation of medical care costs affects this group with fixed incomes more than almost any other sector of the population. The poor elderly also meet tremendous obstacles in obtaining needed health services. They are not only faced with inadequate numbers of health personnel for their needs, but such personnel is not present in their own neighborhoods. In addition, the elderly are faced with real transportation problems to reach the health resources available in their community. When public transportation is not available, the elderly often cannot afford substitutes such as taxi fare to hospitals or clinics. Organized medical services do not exist and physicians' services are often not available on nights and weekends and so the aged find themselves forced to use emergency services of hospitals where they receive fragmented care and certainly not a plan of care adequate to their needs. Some of the necessary services for sensitive care of the older person such as home health aides, visiting housekeepers, meals-on-wheels, social services are in short supply or are simply not available. The entire concept and development of comprehensive health teams brought to the neighborhoods where the elderly live is yet to be implemented. Medicare may indeed have intensified some of the problems affecting the organization of health services in the interest of the elderly. Since the legislative mandate of Medicare and to a lesser degree, Medicaid is to purchase care from the providers of service in the traditional fragmented fashion-fee for service care, it leaves much to be desired at this time in promoting a program for organizing the services for the elderly with a plan of care. Up to now, there has been little encouragement of payment for comprehensive care programs and without such emphasis, the providers of traditional services in the health field will not be impelled to organize themselves in the interest of total care for the elderly. Your committee, I hope will consider the uncovered cost of drugs, regular eye care and dental care as serious defects in the present Medicare legislation. Finally, we have found the coinsurance features, the deductibles to both confuse and work a hardship on the elderly. The coinsurance features are also difficult to administer and perhaps your committee will concern itself with the cost to society in personnel and money by the law's mandatory coinsurance features. Sincerely yours, FRANK F. FURSTENBERG, M.D., Medical Director. [Enclosure] IMPACT OF TITLE XVIII ON OUTPATIENT DEPARTMENTS My formal assignment is to bring to you some of the changes Title XVIII has had on the outpatient departments. To do this I share my observations with you concerning the fate of Medicare patients in outpatient departments since the program's inception almost a year ago. Our group at Sinai Hospital has often speculated on whether Title XVIII has been good, bad or indifferent for the aged person seeking care in the clinics and emergency services of the hospital. Have the rights and the payments intrinsic in XVIII produced more and better care for the elderly in the clinics of our hospitals in this Country? While I'm not privy to any survey of the changes and the problems that the aged have encountered in the Country's outpatient departments since last July, our experience at Sinai Hospital and my knowledge of other outpatient departments in Baltimore and elsewhere allow me to make a number of disquieting comments. Older persons, the chronic sick and children in ever-increasing numbers continue to seek care in the outpatient departments in hospitals in urban areas. The elderly are by and large the poor and the medically indigent, formerly the KerrMills recipients and now the Title XIX aged. The care they receive in outpatient departments is fragmented, impersonal and given with little dignity. There have been few efforts by the hospitals to give these aged persons services which include a plan of care, comprehensive in scope, with continuous responsibility by designated health personnel. Services have not been designed to maintain the older person independently in his community medically and emotionally secure with maximal usefulness to himself, his family and society. An opportunity offered itself at Sinai Hospital six years ago to develop a professional group consisting of physicians, nurses, social workers and other health personnel to give continuous seven day-a-week, around the clock care to the elderly, delivering their primary medical services in the outpatient department setting. This team also gave indicated services in the home, the nursing home and the hospital. At present about 500 patients from our hospital district have selected our hospital outpatient department for this care. These patients are largely Social Security beneficiaries with limited income and classical of the geriatric patients who frequent the clinics of our Country. We are keenly aware how Medicare has affected these persons and are also conversant with its affect on other persons 65 and older who use our outpatient department for regular and emergency services. There is no data as yet tabulated that I'm aware of which would give us facts of trends and usage patterns by the aged of the hospital clinics a year after Medicare, but in my conversations with outpatient department administrators in Baltimore and in a number of large urban hospital outpatient departments elsewhere there has been no sharp trend indicating increase or decrease in clinic use by the persons 65 and older. More important is the evidence that Medicare has not made any real difference in the services given in the quality of care or in the organization of care. Some of us have speculated why the aged person has not left the outpatient department to return to a personal private physician now that this course can be taken if he has Part B Coverage. Is it because the poor and some of the ethnic groups feel that they obtain better or more interested care in the outpatient clinics or their favorite institutions than they do in the neighborhood physicians' offices? There are institutions who have been concerned with the chronic sick and the aged in Baltimore, both the Baltimore City Hospitals and Sinai Hospital have emphasized special programs for these needy persons. Do the elderly continue to come to the hospital because private medicine has deserted the poverty areas in the central cities where many of the aged reside and though the aged may now be able to pay for care, physician's services are in short supply, absent at night and week ends? Is it because many of these multi-problem, economically marginal individuals present such troublesome social problems that the solo practitioner is illy-equipped to handle these problems and for which his physician time is too valuable? Or is it because Medicare is so complex with its deductibles, co-insurance features, and lack of coverage for drugs, as well as lack of cash in the hands of many of the elderly that they prefer to cope with the impersonal outpatient departments rather than feel as second-class citizens in the solo practitioner's office because they have to ask the physician to accept assignment for payments of services? There probably is no single answer for the use of the outpatient departments by the Medicare beneficiaries. There is little question, however, that since Title XVIII basically seeks to purchase services from providers of care for its beneficiaries, it does almost nothing in social planning for the elderly and thus it has not affected the organization of services in the interests of the aged. Indeed, in our own institution, we have had some unhappy experiences with some of the patients in our program since Medicare. Thus, a patient referred for surgical consultation or who develops an acute surgical entity may see a surgeon in our outpatient department or emergency service, who now considers this patient with Part B insurance as a potential and actual private patient and proceeds with his therapeutic regime with little or no regard for the patient's previous care or in total planning for his after-care. Without casting any aspersions on my surgical colleagues, I know that they often do this with their own middle-class patients, but such an individual or his family is able at times to break through the jungle of fragmented care, plan for himself and often then pay for such private services. It is the marginal aged person who, though he has benefitted by the rights of Medicare, is still unable to cope with its deterrents, uncovered needs for service and cannot find services that may not exist for the poor. Frustrating examples that we have experienced in our Aging Center are exemplified by the patient with prostate disease who was admitted without consultation with his personal physician in our group to the genito-urinary service and received necessary surgery without consultation with our staff. There was the orthopedic emergency admitted, operated and discharged to an extended care facility and then the patient was told by the orthopedist that he did not make visits to the nursing home and only then was the physician in our Comprehensive Care Program called. On another occasion, a patient with a cataract, told that she needed surgery, exercised her right to ask for the best in eye care and was admitted to the hospital for operation by one of our best eye physicians who ran into difficulty while the patient was under anesthesia and then called an internist who did not know the patient to give immediate consultation rather than using her personal physician, an equally competent internist, a member of our program. Now we are a hospital that prides itself on the high quality of inpatient care and if incidents such as these can happen as often as they have in our institution, what happens elsewhere where there is no organized program to help this minority group that is unable to compete in the private sector for quality care? And what happens when the Medicare patient presents himself acutely ill in the emergency services of the hospitals of the Country? He is admitted either to the service area or to the private side with a designated physician. Inpatient services are perhaps regularly given with high quality, but on discharge what happens? Does the hospital physician follow his cardiac patient into the home or the extended care facility? Is the patient recovering from a cerebral accident followed by the interested hospital staff physician after hospital discharge? I'm afraid that the urban hospitals have understandably not felt the responsibility for continuity of care and often have staff physicians who limit themselves to hospital and office practice. The teaching of house officers does not usually include concern about the patient who cannot return to the institution for follow-up care. I wonder what studies in the continuity of care for discharged Medicare patients with continuing illness requiring home and institutional care would show in specific reference to the implementation of care by any primary health team.. Sinai has had an organized hospital-based Home Care program, part of our Aging Center since 1961. With the advent of Medicare, the program has gradually double in size and involved the private practitioner in some depth for the first time. It has expedited patient discharge from the hospital and brought an awareness of home health services to the physician. Often the physician has had to think in terms of home health services for the first time because the patients and families have become aware and ask about the specific benefits of this program. There is no question that we were having limited success with an excellent hospital-based Home Care Program until Medicare financed its benefits and the stress for better utilization of beds on the private side influenced the participation of physicians in the home health services and so expanded the scope of our outpatient benefits of a hospital-based home care program. Now, in all fairness to Mr. Hess, Medicare was not conceived as a comprehensive health program for the elderly. Indeed, having watched the legislation go through Congress and accommodate to the diverse political forces and then later having participated in a number of the working groups of the Social Security Administration in developing guidelines for the present program, I marvel that we have come so far in so short a time. The outpatient department problems are really not central to the main thrust of Title XVIII. In a better-conceived total program for the aged, there could have been more emphasis on prevention |