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The Advisory Council on Social Security might well have considered points and questions I raised in my report. Some of these appear in the Ways & Means Committee printed record (pages 2496–2502).

I would like guidance as to what use I am permitted to make of a carbon copy of my report, not being sure whether it is mine or belongs to the Social Security Administration.

Yours sincerely,

SIDNEY KORETZ.

FLORIDA NURSING HOME ASSOCIATION,

June 21, 1967.

DEAR SENATOR SMATHERS: I am responding to a letter forwarded to me by Mr. Cary Williams in regard to your hearings with the Special Senate Committee both currently and in the future on the subject of "Costs and Delivery of House Services to Older Americans".

I am writing from the point of view of the nursing home field on how it affects or is being affected by the current federal legislation.

Your first question regarding rising medical costs, the rising costs are, of course, causing difficulties for the elderly and everyone else, I might add, not merely the elderly.

Comment: I think especially the rising hospital costs are a burden to everybody, the elderly included. It appears to me that one of the major causes for this rise in hospital costs is the complete lack of any concern on the part of the federal government for efficiency of operation. This is in sharp contrast to other federal programs of competitive bidding, negotiated contract, incentive plans under the Defense Department and other similar ideas. In the health field, it is currently written on a cost-plus basis. It is actually encouraging inefficiency and rising costs. This, of course, reflects very strongly on the pocketbooks of all of your citizens.

2. Do many of the elderly face insurperable obstacles in obtaining needed health services?

Comment: It has been my experience here in dealing with numerous welfare clients over the years that while there are numerous obstacles in the way of obtaining service in time delays in getting service through socialized practices, that these are not insuperable and are part of the system of socialized services. I might add that private people experience similar delays when they go to their doctors. I can't remember getting into a doctor's office on time with an appointment any time in the recent past.

Here in St. Petersburg various services both at the Welfare Clinic level and in other Welfare programs have been speeded up and the Welfare Department, I feel, today is doing a substantially better job in serving the elderly and the indigent than they were doing a couple of years ago.

3. Are present health services remote geographically and sociologically from many of our older persons?

Comment: I can't answer this for the general area, but in the St. Petersburg area, it is quite the opposite. The health services are located right in the heart of the greatest concentration of elderly people as well as close to the greatest concentration of indigent people, so I would say that they are quite close both geographically and sociologically.

4. Are present Medicare and Medicaid policies intensifying old problems in the organization of health services or causing entirely new problems?

Comment: On this subject, I can speak with considerable authority both as Vice President of Region III of the American Nursing Home Association and as past president of the Florida Nursing Home Association. I think that many old problems in these fields have been solved by Medicare in Florida in that many of the older people are getting care that they did not get before. However, on the other hand, Medicare has created untold additional problems and entirely new problems and problems which are yet only on the horizon. I have never in my life been associated with anything that took so much time and effort, procedure, change, rechange, and new issues and ideas than the Medicare program has presented. While I recognize that this is somewhat inherent on all governmental programs, it seems to be unduly complicated in the Medicare Administration. I suspect that it will be equally complicated in the Medicaid Administration unless the Congress somehow changes these programs to the right incentives for efficiency of operations.

5. Are shortages of trained personnel in the medical and medical-related professions especially severe in the fields that serve the elderly?

Comment: There is no question that there are great shortages in the field, especially in the areas of nursing and nurse-related types of services. We are in great need in this area of expanded LPN training programs and Aide training programs. I think Pinellas County has done very well in that it has had an LPN school for many years which is accredited and will have two more schools this coming year under the State Vocational Education Program.

It has also done well in the Aide training program. We, at my three nursing homes, have graduated over 300 Aides under the State Vocational Program, but there are many more needed. It is needless to say that the minimum wage laws which will increase the cost of nursing each year for the next four years are, of course, increasing the general cost of all nursing care for all patients, and this, of course, is something that should be taken into account in the planning of new medical programs which are going to be much more costly than originally anticipated and much more costly than the current situation unless the federal government sincerely and seriously considers some sort of reward for efficient operation instead of penalizing the efficient operator and rewarding the inefficient one. My experience, broadened in the last year or so, shows that there is no necessary relationship at all between a non-profit medical-care institution and a proprietary medical-care institution or a governmental medicalcare institution. We have right in St. Petersburg some non-profit homes providing care at very reasonable rates; we have others providing care at rates substantially higher than the tax-paying institutions of first class quality. Likewise, we have proprietary institutions that are both efficient and inefficient and in each case, the patient in the inefficient institution really is suffering and the federal pocketbook is paying the bill directly or indirectly.

Final comment: May I commend to your consideration the fact that under the proposed Medicaid Programs in Florida and in some 20 other states, the proposal of HEW to cut off the supplementation in these states will grossly increase the cost of the Medicaid Program in the states and suggest that you look into this problem, especially in Florida which will be the worst hurt in the nation in terms of its own finances and suggest some sort of alternative legislative approach to phase out supplementation from January 1, 1969 over a 2, 3, or 4-year period rather than cutting it off. If it is cut off, the cost of medical care in Florida will rise astronomically and indirectly the cost of the private patient also as has been the case under Medicare.

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DEAR SENATOR: In connection with the hearings scheduled for June 19, I am enclosing a policy statement of our organization on Title XVIII of P.L. 89-97 It calls for extension of coverage to preventive services and out-of-hospital prescriptions. It also calls for elimination of deductibles, co-insurance, and limits on certain services. Change in methods of paying hospital-based specialists, and encouragement of group practice are also advocated.

The Public Health Association of New York City, an affiliate of the American Public Health Association, has a membership of individuals working in health professions and of agencies concerned with the public health. With all best wishes for your subcommittee's activity,

Yours sincerely,

CHARLOTTE MULLER, Ph. D.,

President.

[Enclosure]

NEW YORK CITY PUBLIC HEALTH ASSOCIATION RESOLUTION ON PART B, TITLE XVIII, PUBLIC LAW 89-97, AS AMENDED

The New York City Public Health Association's legislative objective is to assure the availability and provision of adequate total health care at reasonable cost for all people.

Public Law 89-97 as amended expands the social security system to provide for part payment for specified health care expenses for persons age 65 and over. This law affects indirectly the private and public cost and the availability of services to persons of all ages.

The Association urges amendment of Part B which provides for payment for physicians and related health services:

(1) to meet fully the total health care needs of beneficiaries;

(2) to develop reasonable cost criteria and encourage coordination and optimal utilization of skilled specialized personnel and facilities.

(1) Full coverage of health needs requires extension to needs not now covered. This includes preventive services and out-of-hospital prescribed drugs and biologicals.

Full coverage also requires control of out-of-pocket costs in services now under Medicare. This includes:

a. Elimination of deductible and co-insurance features now required.

b. Elimination of limits on home health services, out-patient hospital care, and psychiatric care.

c. Provision under Part A for payment to hospital-based specialists as part of the hospital charge. This would replace collection of fees from patients. Anesthesiology, pathology, radiology and psychiatry are the specialty fields involved. Also affected would be services of residents and interns.

(2) Encouraging of coordination helps assure that adequate specialized services of varied types will be rendered in relation to the continuity of patient care. Group practice mechanisms providing prepaid care on a per capita basis rather than fees for service should be recognized as a useful device for such coordination. Principles of organization and registration procedures should be defined and incentives provided for use of such programs in Medicare. (For example, costs of forming new prepaid groups could be absorbed.)

Elimination of deductibles and limits on service will reduce administrative costs to the trust fund and will assure that needed care will be sought and received. Elimination of deductibles for medical service and inclusion of specialist services in hospital charges will help hold down medical charges for the entire population.

These improvements will also help establish a more adequate type of coverage as the minimum to be extended to other social security beneficiaries in coming legislative sessions.

THE GEORGE WASHINGTON UNIVERSITY,

June 12, 1967.

Hon. GEORGE A. SMATHERS,
Chairman, Subcommittee on Health of the Elderly, Special Committee on Aging,
New Senate Office Building, Washington, D.C.

DEAR SENATOR SMATHERS: In your letter of May 31 you asked for my thoughts on organization of health services for the elderly and methods of delivery of such services.

My response confines itself to selected aspects of the general topic of your inquiry.

(1) Build-up of home health services.

Changes in family living arrangements, urbanization of the population and medical advances make it necessary to foster a build up of organizations that can provide health services to individuals in their homes or in nursing homes. While progress has been made over the past seven years or so to establish under health department or general hospital auspices a complex of health services that would give support to private physicians in the care of patients outside of hospitals, we appear to be far from meeting needs.

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The range of home health services should include nursing services (both professional and practical), therapy services (speech, physical, occupational, etc.) and homemaker services. Dental services also should be coordinated with the other health care, as well as supervisory services and such ambulance or other transportation services as would permit movement of patients to hospitals when required for effective care.

Adequate home health services, provided in accord with a doctrine of "pay-ability," not only would be of aid to those aged whose illness permits

of care in the home, but also to other groups in the population. For example, ready access to supervised nursing services would be of considerable support to working mothers whose children become ill and to relatives of disabled persons.

(2) Preventive health services.

To the extent that disabling conditions can be prevented or controlled it would appear to serve the national medical interest, as well as the welfare of the elderly, to provide an ancillary preventive health care program. For example, such a program might call upon health departments hospitals and other health agencies to provide diagnostic health examinations for the aged, with appropriate referrals to treatment and rehabilitative services as required.

Appropriate provision should be made for defining the state of medical knowledge about health examination and diagnostic procedures that offer some promise of reducing chronic illness or its impact. Authorization should be provided for implementing a program of health examinations and for referrals to facilities that can provide the care indicated for the patients. (3) Ancillary health worker training.

Special manpower (and womanpower) training programs should be enlarged to develop the ancillary health program staffing required to achieve adequate health care for the aged. Such a program, if well designed, not only would contribute importantly to attaining the objectives of the medicaid and medicare programs but also would contribute to the Nation's attack against poverty.

The training provided should not only build the health manpower skills needed, but also be concerned with health manpower attitudes toward the aged sick and dying.

It should emphasize that we have not been directly concerned in the administration of medicare and have little knowledge about the many specific problems that have evolved.

As we work with selected states, counties and cities toward the implementation of planning, programming, budgeting systems in the 5-5-5-project demonstration we shall observe more immediately the impact of the medicare program on hospital and health agency operations. Accordingly, we shall be in a better position a year from now than we are at present to respond to your inquiry about geographic and financial impacts.

Sincerely.

Dr. SELMA J. MUSHKIN,
Project Director.

THE PROVIDENCE DISTRICT NURSING ASSOCIATION,

July 12, 1967.

Hon. GEORGE A. SMATHERS,

Chairman of the Subcommittee on Health of the Elderly,
Senate Special Committee on Aging,
Washington, D.C.

DEAR SENATOR SMATHERS: The staff in the office of Dr. C. J. Wagner, Director of the Bureau of Health Services, United States Public Health Service, has contacted our agency, as they felt we would be in a better position to give you and your Committee follow-up on the Dexter Manor Story as told by the pamphlet "Portraits in Community Health".

First of all could I tell you how pleased we are that you were able to use some of the material in the very well prepared pamphlet. We feel this venture demonstrates federal, state, local, public and private agencies working together.

We were more than appreciative of the financial assistance and the fine guidance contributed throughout the project by the Public Health Service.

Since the completion of the demonstration we have not only continued the program at Dexter Manor but have extended it to two additional projects for the elderly. The second program was established at Hartford Park Housing where presently approximately more than 700 elderly people are living. Unlike Dexter Manor this project is made up of scattered units, but we have essentially the same plan operating; namely, an office in a central area where the nurse has daily consultation hours. People can bring their problems to her and she can give them correct advice and referral to the proper agency. If the people are in need

of direct nursing care in the home arrangements are made for this. We have continued to use as our entrance to people's home the completion of the Tenant Emergency Card which in so many instances we have found helpful.

In June 1966 the Providence Housing Authority opened another single story building called Bradford House. Once again, as at Dexter Manor, the architectural plans included space for the nurse on the first floor. Most tenants frequent this floor daily as the housing office, the laundry and the craft and meeting rooms are all on this floor. About 300 elderly people live at Bradford House which is no more than five minutes by car from Dexter Manor. This proximity enables one nurse to provide similar service to the residents of both buildings.

At Hartford Park from January 1 to December 31, 1966 as well as daily office hours a total of 1,212 visits were made for direct nursing care and 183 visits for health instruction. A screening program for chest conditions was also carried out through cooperative effort.

At Bradford House from June 1 to December 31, 1966 a total of 174 visits were made to give direct nursing care and 204 health instruction visits were provided. We did learn that clerical services are not necessary at each project so all clerical details for the nurses assigned to the projects are handled by the office staff at our headquarters. The social worker from the Department of Social Welfare continues to visit and have consultation hours in each of the three units. The social worker originally employed in the Dexter Manor project is now on the staff of our Association and is also available for service.

Here in Providence we are still enthusiastic about this approach for our Association has continued to have the support of the Providence Housing Authority, the Rhode Island Department of Health and Social Welfare and the residents themselves.

For many years the value of home nursing visits made by public health nurses for the prevention and early detection of disease have been found to be efficacious in helping to secure early diagnosis and treatment for the young age groups in the population.

As a result of our experience we are convinced that the public health nurse is well equipped to carry out this same type of approach with the elderly. If we can be of assistance do not hesitate to contact us. Sincerely,

RHODA W. PLAZA,

Director.

STATEMENT OF RUSSELL KOCH, O.D., FOR THE AMERICAN OPTOMETRIC ASSOCIATION Mr. Chairman and Members of the Committee, thank you for the opportunity to again present the views of the American Optometric Association on the subject of vision care for older Americans. I am Dr. Russell M. Koch, Chairman of AOA's Committee on Vision Care of the Aging. I engage in the private practice of optometry in Elk City, Oklahoma. As a Committee Chairman, I speak on behalf of more than 17,000 full-time practicing optometrists located in over 5,000 communities throughout the Nation.

Members of the optometric profession have always directed their attention to the vision problems of those people in their communities who are approaching the golden years of life because almost without exception these people need the services of a doctor of optometry. We have learned about the specialized problems these people encounter in obtaining health services at reasonable cost.

In 1957, our Colorado Optometric Association affiliate retained Donald A. Seastone, Professor of Economics at the University of Denver, as a consultant to investigate the cost of vision care for Aged Pensioners of Colorado. The results of that investigation were conveyed to Mr. Guy Justus, then Director of Colorado's Public Welfare Department. A copy of that report is appended to this statement for your records.

The proposal conveyed to Mr. Justus projected several alternate methods for controlling costs as well as controlling any possible abuses in providing vision services to Aged Pensioners. This proposal was one of the earliest attempts optometry made to arrange for delivering vision care services for these special optometric patients as a group.

Shortly after making this proposal, our profession participated in making arrangements for and attending the White House Conference on Aging. Our

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