While the health manpower shortage is indeed acute, I am convinced that the haphazard way in which our health services are organized is wasteful of manpower and is a significant factor in the less than optimal state of health care for the elderly. Sincerely yours, ALONZO S. YERBY, M.D., M.P.H., AMERICAN HOSPITAL ASSOCIATION, June 9, 1967. Hon. GEORGE A. SMATHERS, Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR SMATHERS: This statement is sent to you in reply to your letter of May 24, 1967. We hope the contents will be helpful in your committee's consideration of the subject of "Cost and Delivery of Health Services to Older Americans." The hospitals of the country, of course, have been continually concerned with the organization and provision of services to the elderly as they have been involved in the over-all efforts of hospitals to care for the total population. It is not an over-statement, I think, to say that the Medicare program would not have "gotten off the ground" except with the complete cooperation of the hospitals of the nation. Title 19 of the Social Security Act dealing with indigent and medically indigent persons will come into effect July 1 as the federal standards are to be implemented starting on that date. This program will gradually develop so as to involve a very large segment of the population and will without doubt be concerned with health services to large numbers of aged persons. Here, again, a successful implementation of Title 19 will be dependent upon full participation on the part of hospitals. This essential participation on the part of hospitals can only be assured if the financial needs of hospitals to provide community health services is fully recognized by the federal government. The following discussion is directed toward the questions raised in your letter to me: 1. Are rising medical costs causing special difficulties for the elderly? In the main, rising hospital costs for the aged are a problem to be faced by the federal government and particularly the Hospital Insurance Trust Fund. Therefore, for the aged beneficiaries themselves, escalation of hospital costs is quite limited in its impact and would become a major factor only for those aged individuals who have exhausted the benefits provided under Title 18. Even here, however, if states implement Title 19 in an appropriate manner, the escalation in costs of those who have exhausted their benefits under Title 18 will become a matter for state and federal governments under Title 19. The Medicare law provides, of course, that the $40 deductible for hospital admissions can be increased at stated intervals. However, it is not likely that this would become in any way a major factor for elderly persons. Services and supplies required by elderly persons who are not hospital patients may well suffer increased charges and thus affect the costs of health services to the elderly. However, we are not in a position to provide essential information on charges or costs outside of hospitals. It is conceivable increased costs in health services might occur insofar as the services of extended care facilities and organized home health programs are not available. An enderly person under such conditions has two choices: either do without the care or personally finance whatever may be available in the way of substitute care. This may involve seeking care in an institution which fails to qualify either as a hospital or extended care facility. This might be an unskilled nursing home or the care might be provided via periodical visits by a physician to the private home. Or, perhaps home nursing services may be obtained on some basis. In either instance, the cost of such care would have to be borne by the individual, completely or in part, and thus would subject such individual to the impact of escalating health care costs. 2. Do any of the elderly face insuperable obstacles in obtaining needed health services? There are three major aspects to obtaining health services: the availability of facilities, the availability of adequate personnel and the financing. By and large, the elderly are no different than the rest of the population in terms of the relationship which the existence of these three factors bears to their ability to obtain health services. There are acute shortages of certain categories of health personnel. The development of extended care services and home health services has an absolute relationship to the availability of adequate numbers of well trained nursing personnel. Thus, the existing major shortages of such personnel will directly affect the availability of these services, which are of particular importance to the elderly. The financial problem of the individual aged person is ameliorated through the passage of the Medicare law and if Title 19 is adequately developed by the states it should rather completely remove any financial obstacle to the obtaining of health services by the aged. It is obvious from the hospital occupancy figures being reported that substantially increased numbers of the aged are now receiving health services and this was a basic purpose of the Medicare law. 3. Are present health services remote geographically and sociologically from many of our older persons? There is already a widespread distribution of hospitals throughout the nation. For this reason and because of the availability of good highways and modern transportation, geographic location in terms of physical distance from a hospital facility is of quite minor importance today. The more important factor is time, and it is fact that there are a great many persons in metropolitan centers that are further away time-wise from hospital facilities than are individuals in rural areas. The problems involved here, however, are not unique to the aged but are related to the whole population. We strongly believe that what we need in the country is better hospitals rather than more hospitals. It would be a great mistake to plan for a hospital at every crossroad. This would be most likely to result in a deterioration in the quality of health services. Medical advances increasingly dictate the need for concentrations of available equipment, facilities and personnel in centrally located facilities. Widely dispersed and fragmented units can be wasteful in the use of personnel. They would be extremely costly and would not elevate the quality of health care. Such an approach would not result in increased availability of "modern medicine" to the aged. In those instances where elderly persons fail to seek health services because of a fear of the costs or because of a strong sense of pride, the development of Medicare has probably done much to eliminate these barriers. There are undoubtedly elderly persons who refuse to seek medical care or refuse to be admitted to hospitals for other reasons; and, of course, this problem would have to be approached in other ways. 4. Are present Medicare and Medicaid policies intensifying old problems in the organization of health services or causing entirely new problems? Without doubt the existing provisions in respect to the services of radiologists and pathologists are intensifying old problems and developing new problems in hospitals. Also, without doubt the present provisions of the law in respect to outpatient services are nearly impossible of administration, are extremely costly to administer and quite likely are frustrating large numbers of older persons from utilizing the outpatient benefits of the Medicare law. The present provisions for outpatient services create such obstacles that certainly there is no incentive for institutions to develop such services. Hospitals throughout the nation are expressing their deep concern in respect to the reimbursement received for Medicare and, of course, this concern is magnified now that a decision has been reached to utilize the same basis of reimbursement under Title 19. The belief is increasing that any continuation of the present inadequate reimbursement and continuation of the basis of apportionment of costs now insisted upon by Social Security will inevitably lead to deterioration of hospital care. This situation poses very real problems for hospital boards of trustees in light of their responsibilities to the over-all community they serve. It is quite clear that a major role of hospitals in the future is going to be care for patients who are not confined to beds. The outpatient services and the diagnostic and treatment services are increasing dramatically. It is also obvious that the public more and more is turning to the hospital for the provision of medical services of all kinds. Undoubtedly, this trend is of importance to the elderly. The American Hospital Association is strongly in favor of group medical practice. The growing numbers of such groups reflect their increasing public acceptance. As the hospital develops increasingly as the center of health affairs in the community, it is obvious that increasing attention will be paid to such develop ments. Undoubtedly, therefore, the rendering of hospital services to the elderly as to the rest of the population will be affected by changes in organization which may result. Medicaid has thus far only really been implemented in some of the states. It is not yet clear how the program will develop in many states. There is a vast difference between programs of health services envisioned under Medicare as compared to Medicaid. Medicaid will in the main be directed towards individuals who are under 65 years of age. Most of those persons over 65 years of age are covered under Part B of Title 18 for physician services. The scope of benefits provided under Medicare are the same nationwide for all elderly who are eligible. Except for broad federal criteria, the benefits which the fifty states may decide to provide under Medicaid may vary greatly. Thus, at the present time it is not possible to evaluate the Medicaid program in terms of its effect on the organization of health services. This Association fully supports voluntary planning for health services, facilities and personnel. We are making every effort to assist hospitals in their participation in planning activities. Undoubtedly, as planning becomes fully implemented throughout the nation, there will be changes in the organization of health services affecting the elderly as well as all others of the population. 5. Are shortages of trained personnel in the medical and medical related professions especially severe in fields that serve the elderly? As stated previously, there are acute shortages in many areas of health personnel. These shortages affect the elderly as they do all other individuals requiring health care. It is believed that physical therapy services are of particular importance to the rehabilitation of the elderly. Such services are included in the benefits of Medicare, and it may well be that the shortages of trained physical therapists restricts the availability of these rehabilitative services. We have already referred to the shortages and need for greatly increased numbers of qualified nursing personnel and the fact that the lack of availability of such personnel will curtail certain of the services needed by the elderly. Also, current studies indicate that aged persons require a greater amount of nursing care than young persons, thus aggravating the impact of the shortage of nursing personnel upon care of the aged. 6. Can you give us recommendations for reducing paper work relating to Medicare? Do you feel that many Medicare recipients are confused by present procedures? There are wide-spread reports from hospitals of the necessity of adding substantial numbers of personnel to carry the administrative burden of Medicare. Since we understand that similar procedures are to be followed under Title 19, we expect that such administrative costs will be further increased. The various procedures which are required for Medicare are being studied carefully by the Social Security Administration, by the intermediaries and by hospitals. It is expected that improvements can be made in certain of the procedures. If deductibles now required are eliminated and a co-insurance factor substituted as we recommended in our testimony of March 8 before the Ways and Means Committee on the pending Medicare amendments, a great deal of administrative cost and confusion both for hospitals and for older recipients will be eliminated. The requirement of physician written certification of medical need at the time of admission is an unnecessary duplication of effort and results in substantial delay in the processing of the forms and in hospitals receiving payment. The present statute and regulations require hospitals to separate the costs of radiologists' and pathologists' services on the part of the hospital from the remuneration of the hospital-based radiologists and pathologists. This is time consuming especially when the hospital has been designated as collection agent for the physician and must claim payment on his behalf from another trust fund. Payments for physicians' services is subject to the $50 annual deductible while the hospital portion of payment for radiologists' and pathologists' services are not subject to a deductible. Similarly and even more expensive to administer and confusing to all who are involved, is the procedure for obtaining payment for outpatient diagnostic services. Here, again, the hospital must obtain payment from one source, after first considering a $20 deductible, while the physicians' compensation must be obtained from another source and subject to the $50 annual deductible under Part B. Not only is this extremely difficult to understand but it results in very little payment to hospitals, physicians, and patients for outpatient care and in frequent waiving of potential benefits because of the complications inherent in trying to obtain payment. As presently written, the statute and regulations appear to provide no alternative to this overly complicated, expensive and less than satisfying arrangement. This Association has presented to the House Ways and Means Committee a specific proposal which we feel will alleviate in large measure these problems. It is felt to be of utmost importance that every effort be made to reduce the problems, to eliminate unnecessary complexities and to avoid hospitals having to "channel their talents away from making positive contributions to the improvement of patient care.' It is our belief that continued efforts must be made by everyone concerned to inform the aged recipients of the intent and extent of the Medicare program. For example, the term "extended care facility" is widely misunderstood and many aged persons and their families have assumed this means all nursing homes. It is apparent also that the beneficiaries do not understand the application of the deductibles. Hospitals often find themselves in a difficult public relations problem as it falls upon them to try to justify an action taken by the Congress. As stated we do not intend to dwell on various problems related to physician services; but hospitals are, of course, continually made aware of the problems of Medicare beneficiaries in respect to the payment for physicians' services. In the over-all as we view the problems associated with Medicare they fall into two categories: first, those which it is expected can be alleviated through experience and administrative change; and secondly, those problems which seem to be inherent in the law and which will require legislative action for their correction. While we have been pointing out various problems involved in the operation of Medicare, we must not overlook the fact that this law has made a most important contribution to high quality standards in the provision of health services. It is to the credit of the Congress that it required high standards for institutional participation, thus, assuring reasonably high quality of care to old people in this country. Medicare is at best a complicated law and because of its sheer size and implications it is unlikely that it will ever be simple to administer or completely understood by the beneficiaries. Some years ago the American Hospital Association strongly supported legislation promoting housing for the elderly. At that time we urged that as a matter of national policy the federal government not move solely in the direction of institutionalizing elderly persons. We pointed out that large numbers of the elderly would best be provided for through housing particularly adapted to their living needs and that to the fullest extent possible we should follow a national policy of providing incentives for the elderly to remain in a normal housing environment. The key to such a program would be to relate health services to the housing of the elderly in such a way that they would have available physician services, nursing care, frequent checkups, consultation and the reassurance which the elderly need. Thus, we urged that provision be made in housing programs for the elderly for minimal health facilities so that hospitals and physicians could develop programs to serve the elderly in their home environment. We appreciate this opportunity of expressing our views to you and your distinguished committee, and we hope that this will contribute to the very commendable objectives of your hearings. We would appreciate your including this statement in the record of the hearings. Sincerely yours, Senator GEORGE A. SMATHERS, KENNETH WILLIAMSON, Associate Director. ANCHOR BAY BEACON, New Baltimore, Mich., June 16, 1967. Chairman, Subcommittee on Health of the Elderly, U.S. Senate, Washington, D.C. DEAR SIR: If you have heard testimony from Molly Guiney, you now have a deep insight into the Well-Being Project and the viewpoint of one of the most informed persons on the problems of aging in this country. Where I live, in southeastern Michigan, the good Lord is provident and during a certain period of the year my old country place has what might almost be called a plethora of lilacs. On Memorial Day, my wife suggested we take some to the convalescent home nearby. We did. We encountered the faces of about twenty-five persons there. The experience has haunted me ever since. It was ghastly. From not one-neither the female nor the male persons present-could I draw a smile. They reacted like expired persons-figures in a mortuary-who somehow were still not dead but waiting to die. An attendant brusquely asked us who we wanted to see. When we told her, "No one in particular," she seemed disappointed; this was too inexact; it meant that we could not be routed to a specific place so that we would be removed from the premises as quickly as possible and in a stereotyped manner. Oh, what a travesty on time our presence meant! This type of thing is a reflection on all of us. It is barbaric. It is uncivilized. One is young, one is middle-aged and one is old. At the third stage one is put into what is commonly called a nursing or convalescent home to die. Almost everyone at some point in his or her lifetime has entered a hospital. When you do this you say to yourself "I don't like the looks of this building, I don't like the smell of a hospital and I hope I can get out of here as quickly as possible." If you go in for a serious operation, you know it will be two or three weeks. If it is a relatively minor matter, you know it will be a matter of a few days. Whatever the time element, your mind is focused on getting well again and getting out. Unfortunately, the deposit of your person at the doorstep of a convalescent home has a far different connotation. Psychologically, when you enter a hospital you are a whole person going in and you hope to be a whole person coming out. For older persons going into a convalescent or nursing home, psychologically, you go in knowing that this is the end of the line-you are to be there until you die. This is horribly inhumane, and not in keeping with the humane thinking of society today. Ninety per cent of the present nursing homes would have it so. It is economically more feasible to admit a patient, figure out the arrangement for payment and keep that person in bed or in a semi-invalid condition until the expirant breathes his last. Then, a bed opens up and another patient can be admitted. It need not be so. The knowledge of medicine today has advanced to such a degree that two thirds of the persons entering nursing homes could be returned to their own homes if application of this knowledge could practically be put to use and these patients had a home to which they could return. I have seen demonstration projects that prove this out. For instance, a public health nurse in Detroit, if my memory serves me correctly, picked out five stroke cases in as many nursing homes and set out to teach the staff how to treat stroke cases. Three out of the five were returned to their own homes, one expired and one remained in the nursing home. The profit motive in nursing homes has made a mockery out of the intent of such places. I strongly advocate that all nursing homes be publicly owned and administered. This is, of course, a general statement that should in no way take away the rights of existence for non-profit homes. Many of these are engaged in highly meritorious service. But the present arrangement in which most persons are treated in non-profit hospitals where the professional impetus is to make people well regardless of cost while at the next stage most people are taken to for-profit nursing homes where the incentive is to take care of people at the lowest possible cost to the nursing home operator is senseless. It is hardly in keeping with our times. The Well-Being Project was not created to keep persons out of nursing homes. But it has substantially served this purpose. It was created to do a direct service job for older persons. The federal grant came under the heading of health but it is a well-known fact that health is only many problems that face older persons. I have already pointed out the one of the psychological factor. Finances, lack of communication and loneliness -particularly loneliness-are probably more important components of the total picture. The Metropolitan Detroit Committee on Aging sponsored a number of in depth studies on the question of what are the needs of older persons. These go back to the late 1950's and early 60's. In Detroit's largest public housing project, |