skills is being achieved. While each of these is only a minor stream in the larger flood, we do see group practice clinics, expanded hospital outpatient departments, neighborhood health centers for the poor, emerging regional hospital networks, liaisons between nursing homes and hospitals, and other intelligent arrangements that give us a glimpse of a better future.

We have heard from Dr. James this morning of the interesting developments in integration of health services in New York City.

Without taking the time to review all these significant recent developments, may I request the privilege of attaching as an appendix to these remarks a paper on this subject of "New Patterns of Organization for Providing Health Services" which I presented not long ago at the New York Academy of Medicine.

Senator MONDALE. Without objection it will appear in the appendix. Dr. ROEMER. Because of these hopeful signs of change, we can begin to see the shape of a new pattern of health service for the American people-young and old, rich and poor-in the years ahead. With appropriate leadership in the Federal Government and effective partnership between public and private resources, I think we can expect to achieve this picture in a generation from now:

COMPREHENSIVE HEALTH CENTERS

In each neighborhood there would be a comprehensive health center staffed by a team of general physicians, specialists, nurses, technicians, and aids. Everyone-not just the veteran or the pauper or the crippled child-would be served by a "primary physician," as the Millis report of the American Medical Association has recently defined him. Specialists would be called on for help as necessary. The mentally disturbed would be treated as well as the physically disabled. Dental care would also be provided, with reasonable use of dental technicians for the many simpler mechanical tasks. Laboratory and X-ray procedures would be done in the center, and drugs dispensed by the staff pharmacist. Preventive health examinations and screening tests for hidden disease would be done routinely with the aid of modern equipment and auxiliary staff.

Hospitalization, when necessary, would be provided at a good general facility of perhaps 300- to 500-bed capacity, where the full range of technical modalities could be offered. Institutional care of the mentally ill or the chronic sick would be given in special wings of the hospital or in affiliated units nearby. Several of the neighborhood health centers would be satellites to each such hospital, and their professional staffs would receive periodic continuing education in the hospital. Depending on the density and ecology of the population, the hospital would be professionally and administratively tied to other institutions in a regional network; at its hub would be a great medical center, where basic education of the health professions and medical research would be actively pursued.

The quality of health service would be subject to continuous surveillance, not just in the hospitals but throughout the system. Major surgery or other serious procedures would, of course, only be done by

9 See p. 236.

qualified specialists. Cultists would have no place, nor would patent, self-prescribed medications. Physicians or public health nurses would make home calls, as necessary, but no time would be wasted in a doctor's travel to five, or six separate hospitals as the current lack of system compels him to do. The patient would be treated as a whole person, monitored by a unified medical record which would move with him to a new health center if he changed his home. Whether he was a veteran or an injured worker or a welfare recipient or a parochial school child, whether his illness was infectious or mental or traumatic or neoplastic-he would be treated by the unified system, starting in a nearby neighborhood health center and branching to other resources as necessary.

ECONOMIC SUPPORT

The economic support for all this would be derived from the social devices of insurance and public revenues that we have seen evolving over the last 30 years or more. The underlying resources of personnel, equipment, facilities, and knowledge would be produced likewise by social planning and investment, both governmental and voluntary, as they are now at an increasing tempo. The personnel would be rewarded for their labor according to equitable principles of skill, seniority, and responsibility, and their contributions would also be recognized by appropriate social status. But the receipt of services by an individual would not depend on the amount or source of the money paid, nor on the diagnostic category of his disease, nor his social pedigree. It would be a right of his being an American.

This picture, Mr. Chairman, is not utopian. It is easily attainable within our resources, and, while I do not say it will reduce expenditures, it will permit health achievements at a far lesser cost than a policy of unplanned drift.

The new legislation on "comprehensive health planning" is, in my view, an important step in the right direction. Like the medicare law and the heart-cancer-stroke legislation, it is only a beginning. Positive stimulation is needed for promotion of group medical practice and neighborhood health centers not just in the slums on a very wide scale. Far more medical and allied personnel must be trained. The endless programs defined by category of person or category of disease must be replaced by health service organization based simply on geographic regionalization.

If these changes evolve, the health needs of older Americans, as well as everyone else, will be met at a level of which our Nation could be proud and of which we are certainly capable. I thank you very much. Senator MONDALE. Thank you, Dr. Roemer. Needless to say, we all join in expressing our condolences on the passing of your father and we are grateful to you for proceeding with your testimony despite that tragedy.

I thought it was interesting that the two examples, the example of your father and the one that Dr. James cited, were so similar and the conclusions that one must draw about a better organization of our services were very similar and parallel each other very closely.

Unfortunately I have to excuse myself because I have to be over at another committee.

Just one quick question and then I must go. Without objection I am going to ask the staff to continue the questions because I do want to be sure while you are here to get the benefit of your thinking.

What is the reaction of the medical profession to these proposals to organize medicare and some of these other problems to which you make reference on this kind of systematic overall basis?

Is this being received with great enthusiasm by AMA?

Dr. ROEMER. I think the reaction is mixed, Mr. Chairman. There are sectors of the medical profession that are very responsive to these ideas; for example, physicians who on their own initiative organize group practice clinics, like the Mayo organization, the Oschner Clinic and so on, establishing first-rate teams of specialists.

There are physicians in the universities, in medical schools and great teaching centers, who see things this way. There are physicians who devote themselves to the study of these problems, like Dr. James here and other academic people, who share these views.

Senator MONDALE. Yes, but you are giving us examples

Dr. ROEMER. There are rank-and-file private practitioners who resist these ideas as they have resisted in the past voluntary health insurance, public health programs, better organization of the staffs of the hospitals, et cetera. But as these changes evolve, the interesting fact is that physicians adjust to the demand and cooperate with them.

For example, the kind of medical staff organization in the average general hospital in the United States today which was called for by the Joint Commission on the Accreditation of Hospitals was regarded as bureaucratic and totalitarian by physicians 25 years ago, but today is widely accepted.

The day-to-day care of patients in hospitals has tremendously improved just by the reason of the more systematic organization of the medical staffs.

Senator MONDALE. Of course, what you are proposing to do here goes far beyond the properly existing hospital. I would like to have Dr. James' reaction to that same question, the reaction of the medical profession.

Isn't it always true that the staffs of the medical schools and advanced clinics like Mayo Clinic are more liberal and willing to accept these sorts of things?

Dr. ROEMER. The reason I mentioned hospitals, Mr. Chairman, is that there was the same resistance to the tightening up the organization of hospitals in the past, and my proposal is to apply the same kind of genius to take care of the ambulatory patient in his neighborhood.

Dr. JAMES. I think what Dr. Roemer says is correct. There is nothing that is incompatible between the things we have been saying and the private practice in medicine.

As a matter of fact I was in Honolulu not too long ago and I was surprised to find that over 50 percent of the physicians in Hawaii operate under group practices, and group practice lends itself very readily to this kind of total approach.

Moreover the American Academy of General Practice has become keenly interested in this type of approach and are eager to develop more in the way of becoming true family physicians.

The hospitals have taken leadership because they do have huge numbers of patients coming to their fragmented clinics.

Since they have this clientele to start with, by using the same funds and better organizing of their services, they can develop a family practice for this population very readily.

I think the private sector would object if the only way that the problem could be handled were by hospitals and by some kind of a Government organization, but the pattern is readily translated into the private sector.

Senator MONDALE. There is a story in the morning New York Times I will ask to be included in the record which quotes Dr. Milton Rouse of Dallas, president of the American Medical Association, who expressed concern at the increasing involvement of our National Government in the health field.

(The article follows:)

[From the New York Times, Wednesday, June 21, 1967]

DOCTORS URGED TO COMBAT GOVERNMENT PLANNING NEW A.M.A. HEAD ASKS STEPS TO FULFILL LOCAL NEEDS-CONVENTION EXHORTED TO BAR "THREAT" OF CENTRALIZATION

(By Donald Janson)

ATLANTIC CITY, June 20-Dr. Milford O. Rouse, new president of the American Medical Association, urged doctors today to step up efforts to curb government planning in the field of medicine.

In an inaugural address to the 116th annual convention of the association, the 64-year-old Dallas gastroenterologist said that the "threat" to the private practice of medicine had not stopped with Medicare and Medicaid.

"Judging by events of the last two years," he told some 1,000 physicians at Haddon Hall, "we must increase the effectiveness of our opposition."

About 9,000 physicians are registered at the convention.

Dr. Rouse said the Government was now "making its moves into areas where, to its own satisfaction at least, it is able to demonstrate unfilled needs for health care or health care planning." He urged that organized medicine meet the "crisis" by filling any vacuums it found in communitywide health planning before the Government did.

Dr. Rouse said in an interview that his own Dallas County Medical Society, for example, was taking the initiative in investigating the need for new community health services, such as neighborhood health centers.

As for himself, he said, he still refuses to take patients who insist that their bills be assigned to a Medicare fiscal agent. Many Medicare patients, he said, "have no need for government help." He said more and more doctors were insisting upon direct billing.

Dr. Rouse said in his speech that "capitalism" was so seriously endangered by people who want "an all-powerful central government" that doctors must "concentrate more attention on the single obligation to protect the American way of life."

He said the profession was "faced with the concept of health care as a right rather than a privilege" and with "many additional social concepts" distressing to doctors.

He named some of these as "price and wage fixing," "emphasis on a nonprofit approach to medicine," "problems of free choice," "increasing coercion," "special attacks in the drug field," and "emphasis on the academic and institutional environment."

Dr. Rouse is considered much more conservative than the outgoing president of the A.M.A., Dr. Charles L. Hudson of Cleveland. He has characterized himself as an "independent conservative" and "a Democrat whose party has left him."

He has served three years as Speaker of the A.M.A.'s policymaking House of Delegates. He is a past president of the Texas Medical Association and the Southern Medical Association. He has been active in the ultraconservative As

sociation of American Physicians and Surgeons. He is a former director of the Life Line Foundation of H. L. Hunt, Texas oil billionaire.

The 242-member House of Delegates unanimously adopted a statement earlier today saying there was no conflict between medical ethics and the loyalty oath administered to officers of the armed forces.

The statement was adopted as a rejection of the contention of Dr. Howard B. Levy that the physician's Hippocratic Oath might conflict with orders from military superiors.

Captain Levy, 30-year-old Brooklyn dermatologist, was convicted by a military court June 3 of willful disobedience of orders in refusing to train Special Forces medical aides to treat skin diseases in Vietnam, a war he called "a diabolical evil.” He was sentenced to three years in prison at hard labor and dismissed from the Army.

Senator MONDALE. Does that kind of attitude create a healthy environent for your proposals?

Dr. ROEMER. I think, Mr. Chairman, there has been a distorted view of the role of government by the private profession. The private physician is inextricably involved with government-Federal, State, and local-in treating several million medicare beneficiaries right now, a program that has worked out remarkably well despite its complexities.

He is involved with the government every day. This does not impede his freedom to make a decision on a diagnosis, to do what is good for the patient. In fact, it helps him to do what is good for the patient. Senator MONDALE. I don't think we are getting anywhere on this particular argument because I am going to have to excuse myself. Thank you very much.

Dr. ROEMER. Yes, sir.

Mr. ORIOL. I have just a few questions. Both of you have described changes you would like to see for experiments already underway and you called for reorganization of existing services.

The first question is, Where does this reorganization begin? Is the Comprehensive Health Planning Act comprehensive enough to help create the kind of change you would like to see, or would you think that somehow community resources have to be organized and started? How do you go about reorganizing and getting the kind of changes you would like to have?

How To EFFECT CHANGE

Dr. JAMES. First of all, with medicaid there are problems which we did not have before, Secondly, there are a number of places in the country where there are people who feel as Dr. Roemer and I feel and are doing something about it, and this is growing rapidly.

Thirdly, there are funds available for special projects such as Office of Economic Opportunity funds, the Public Health Service and some of the health services research funds of the National Institutes of Health.

I also believe it would be very good if the health services research center which has been planned for the Public Health Service gets underway so that it can provide additional stimulation and evaluation in many of these programs.

The question you are asking, I suppose, is what could be done by whom to stimulate more activity in this field. Now that we have money, although we could always use more, I suppose the holding of