I am not criticizing them for this attitude. It is a perfectly understandable one.

The end result, however, is that pressures are put on the doctors by the elderly patient and his family, to hospitalize the patient when he could be managed at home. And when he is hospitalized more pressure is exerted to keep the patient longer than is necessary. If you would like specific examples I can give them to you.

am very surprised at the questions that you have asked of the recent panel. This may be true that the statistics won't bear me out, this is a personal impression from my own experience with elderly patients that they want to stay in a few extra days and you let them stay in a few extra days.

Senator SMATHERS. In other words, when I was asking him about the statistics which they say are going to show that they do not stay as long?

Dr. NOLEN. Yes.

Senator SMATHERS. I was surprised about that indication, too.

They are not staying as long as they thought. What you say here seems to my ordinary layman's experience to be the case.

Dr. NOLEN. This, of course, is just based on my opinion. I have been chairman of the utilization committee on the hospital since it started so I have, at least in our hospital, a pretty good picture of what is going on.

The easy out for the doctor is to surrender to the pressure and keep the patient. Not so long that the utilization committee investigates the case; just 2 or 3 extra unnecessary days. But multiply these extra few days by thousands and the total extra expense is quite significant.

We realize this but it is very difficult to repeatedly spend our time arguing and explaining to patient and family that they must go home. Far easier to just give in.

A SWING OF THE PENDULUM

What I hope I have said, probably in a roundabout way, is that where before medicare the elderly might not have been getting enough medical care and the medical profession was not being adequately compensated for the care it did provide, now the pendulum has swung the other way.

The medicare patients are being overhospitalized and overtreated and, correspondingly, the medical profession consequently is being overcompensated for its services. The medicare program is and will be far more expensive than it should be.

Patients, hospital administrators, and doctors, like most other people, function on the premise that Government money is nobody's money and spend it carelessly, holding on to as much of it as they can for themselves.

The second question: "What kind of response did you receive to the article? Do you believe that many other physicians share your views?" Senator SMATHERS. Could I interrupt you there?

I don't know what you are going to say later on. You say patients are overhospitalized and overtreated, and that, correspondingly, the

medical profession is being overcompensated. I think that is a very important statement.

Do you agree that if the Members of the Congress finally come to this conclusion, as you have stated it, that greater impetus would be given to that which the doctors fear the most, Government regulation of fees and drug costs, et cetera?

I personally am opposed to such regulation, and I think most Senators are. But if what you say gets to be the general practice, then I don't know what other alternative there is, other than to bring on that which they most fear.

Now does that make sense to you?

Dr. NOLEN. I could not agree more. This was the purpose of the article as I wrote it. To emphasize that if this builds up into a significant factor then we are going to get just what we don't want.

In other words, when I say we are overcompensated, I am talking about situations where a patient comes in and she is in the hospital, you feel it is time that she can go home.

The family says, "Well, let her stay 3 or 4 more days." If we give into this, then we get paid for every day she is in the hospital, whatever we charge for a routine hospital call and the Government has to pay for those 3 or 4 extra days of hospitalization and they have to pay our fee.

What this medicare program has done is it throws a tremendous burden on us to get these patients out, it demands more time of us and diplomacy and everything else. We have to sit and argue with the patient that just because the Government says they can have all this time that it is not medically necessary and that they should be going home at this point.

I will give you another example. There is another article just this week in the Medical Economics and the title is "Medical Ethics and Medicare." He raises a question, he referred to the article I wrote. He said this is just bad ethics.

Well, I am not going to argue that point. I discuss it a little further here. But he raised the question of this type. A patient that he has, he is a urologist, has a chronic urinary tract infection.

THREE-DAY REQUIREMENT QUESTIONED

This man should be in a nursing home. The nursing home will charge for, we will say, 2 weeks or something like that. At any rate, the total bill for the nursing home would be $1,400.

Now if he admits that patient to the hospital for 3 days or whatever the minimum requirement is, he can then transfer the patient to the nursing home and instead of paying $1,400 the patient pays $400.

In other words, by admitting this patient to the hospital for a workup which is not really necessary but which could be medically justified, he will save the patient $1,000.

Now in a situation like that what do you do? Do you admit the patient for 3 or 4 days of hospitalization so you can save him $1,000 or do you send him directly to the nursing facility?

These are tough questions in medical ethics.
Senator SMATHERS. Let us stop right there.

I agree with you, it is tough, but this is where we have a responsibility here in Congress and the executive branch of the Government not to make that necessary. This is where we are at fault.

I am sorry that these administrators didn't stay here to hear this because these are the kinds of things that should be changed. The statute says that you have to be 3 days in the hospital before you can be eligible for extended care benefits under medicare, and because that is the law, as you say, you have the problem of putting him there first, so you can take him out and put him in the extended care facility. So our laws are sometimes unrealistic.

What can we do? We put the doctor in this case in a situation where he has to decide, "Well, I have to help the patient even though he really does not have to go to the hospital for 3 days."

That is what you are saying, is it not?

Dr. NOLAN. That is right. He does not need to.

Senator SMATHERS. He has to go to the hospital to qualify for extended care.

Dr. NOLAN. That is right.

Senator SMATHERS. Somewhere in there we have to turn back to the doctor a little more discretion. I think there are a number of illustrations of areas where we must trust the doctor's discretion.

What I am interested in as an individual Senator is how do we get the doctors and the executive branch of the Government to get together and eliminate these kinds of little silly rules and regulations which unnecessarily put the doctor on the spot, cost the Government more money, and encourage a doctor to do noneconomic things? Dr. NOLEN. I could not agree more with that.

Senator SMATHERS. The 3-day requirement in the statute-why did we put that in the statute? That does not make a lot of sense. The doctor ought to decide that.

Isn't that right?

Dr. NOLEN. I certainly agree; yes.

Senator SMATHERS. Why don't we get something to change that? Mr. ORIOL. Doctor, would you care to see something which would enable the doctor to certify that this patient should receive nursing home care rather than going through the 3-day process?

How would you like to see it done? Do you have a suggestion for the ultimate process?

Dr. NOLEN. Well, I am inherently against a lot of regulations but I certainly think this would save a lot of money and it would take a lot of strain off of the problem of ethics that the doctors face.

I mean, I don't know, myself, how I would react to a situation like that. This is one of the points I am making, we react to medicare patients in a different way than we act to the private paying patient. Mr. ORIOL. Take it back to the hospital care that he does not really need but it can be justified if he has to

Dr. NOLEN. I would forgo this.

Mr. ORIOL. Send him to the nursing home at the great additional cost. Doctor, if the law were changed, could we rely on the doctor's sense of ethics and his knowledge of medicine to give him the ability to sign a certificate saying that this person should go to a nursing home?

Dr. NOLEN. Certainly. There is no advantage to the doctor putting him in the hospital first. Yes; I certainly agree.

Mr. ORIOL. What is your idea?

Dr. CHINN. As I remember it, if this provision did not exist there would be a great many people in nursing homes in whom there was inadequately documented medical data.

If I understand it properly, this is one of the reasons that this was put in there. Now, how you can resolve this, I of course, don't know at this point, what mechanisms one might design to resolve this.

Senator SMATHERS. Mr. Frantz reminds me this was an issue during 1965 in the conference on the social security-medicare bill that year. I was in the conference which acted on the House and the Senate versions of that bill, and I recall that Congressman Mills was concerned about the possibility you have discussed, and he held the view that if the medicare beneficiary went to the hospital it would prove that he was sick enough to justify his receiving extended care benefits under medicare.

Now we come back to the reverse: by putting medicare beneficiaries in the hospital sometimes we are giving them a treatment that they don't need when in fact all they ever needed was to go to extended care facilities.

This is a situation we will try to resolve, because obviously, eliminating this requirement would save the Government a great deal of money and at the same time take the doctors off the spot. It seems to me we've got to trust the doctors somewhere. We're encouraging the doctor to do an unethical thing by the present rule. We are encouraging the doctor to send him to the hospital when he does not need to go to the hospital.

Is that right?

Dr. NOLEN. Yes, that is right.

Dr. CHINN. Do you feel, Dr. Nolen, that, generally speaking, economic considerations are as great as you are portraying here today? Do you feel that, indeed, both from the point of view of the physician and from the point of view of the patient that this overall dominance of money is dictated for medical care to the degree that you imply? Dr. NOLEN. Not at all. I am sorry I am implying this.

ATTITUDES TOWARD GOVERNMENT FUNDS

Probably I am because I am trying to emphasize a point. The point that I am trying to make is this: that actually we think less about money with the medicare patient, we think more about money with a private patient. We are not so conscious of what the medicare patient has to spend, what his medical care costs him as we are with the private patient.

We are careless with the funds of the Government. We are not out to make a fortune on the Government. We are afraid for our own livelihood, we are afraid for what is going to happen to us in the future.

I say, "we." I am using this rhetorically. I think that it is not that we are dominated by the money; I don't think this is the point that I am trying to make at all. I am just saying that we are kind of careless about the Government's money. We are not as thoughtful about it.

If a man has to reach into his pocket and pull out $10 and hand it to your secretary for a chest X-ray, you think a little longer about it

and you are apt to discuss the situation with him some more than if the $10 is going to come from this nonentity, this Government—not nonentity.

I am sure that is a very poor choice of terms, but it is an impersonal thing. You don't worry about it. This is what I am afraid of. We have got to convince doctors that they have to give just as much thought to the charges to a medicare patient as they do to a private patient and it is a very difficult thing to do.

These are the examples that I am giving you. I have been exposed to it before in my practice in the city hospitals, in the State hospitals, and in the Army and you just do not think about money. You are careless with it because it is the Government's money and you don't have to worry about it. Let us just get away from the doctors' ethics and the profit motive.

I brought in this because I am not sure but what it might be a factor. It is hard to say about some of these things; it is very difficult to say why you ordered the X-ray. You are going to make $6. Let us assume you are going to make $6 and you order the X-ray.

If the man says, "You ordered this because you wanted to make $6," and you say, "No, I ordered it because the patient might need it," now he is not going to believe you and subconsciously I don't know myself sometimes why we do these things.

I can justify it, though, in any court. I can say he needed this but with the private patient I would wait a while.

If we could only convince doctors that they would have to think about medicare patients the same way they think about private patients, then I don't think this problem would exist.

I am very cynical about the probabilities of convincing them along those lines because we are skeptical about the Government.

Shall I go on?

Senator SMATHERS. But you have got to keep making that speech of yours to the Medical Society and hope they will continue to invite you to make it.

Dr. NOLEN. I hope they do.

Senator SMATHERS. Because what they fear the most is likely to happen just as a result of what you are talking about here, a feeling subconsciously that it is nobody's money. I think that is a very apt illustration.

Dr. CHINN. Regardless of whether the money comes from professional judges or whether or not quality medical care calls for this X-ray is indeed true regardless of where the money comes from.

This is an issue that the medical profession must face, what is quality medical care regardless of where the money is coming from, whether it is out of the pocket of the individual or the Government Treasury, it seems to me, not as to whether that person needs that X-ray in order for the doctor to deliver quality service.

This is idealistic. I am quite aware, I agree it is a very delicate subject but still basic to the whole problem which we

Dr. NOLEN. I agree this is the decision but what I am saying is that subconsciously your term of "quality medicare" is modified by economic circumstances.

Senator SMATHERS. All right, sir.

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