7. The ledger and the receipts for each patient must be made available 8. Upon a patient's decease, a receipt must be obtained from next of 9. Upon a patient's decease, the ledger account of patient's incidental PERSONAL PROPERTY RECORD 1. All items of personal property in the custody of the nursing home 2. The patient's personal property must not be released without the 3. The nursing home operator must exercise careful judgment in the Only licensed nursing homes are classified by the State Department of Public Assistance. The Division of Medical Care encourages relatives to contribute toward the total cost of nursing home care. In furtherance of this policy, when possible source of revenue or contribution comes to the attention of a nursing home or nursing home operator which would result in a contribution, or an increase in contribution toward total care of a nursing home patient according to Department of Public Assistance classification of said patient, such nursing home or nursing home operator shall report such fact to the caseworker in charge of the case of the nursing home patient. Classified nursing homes shall not receive or accept money from a recipient of public assistance or from any one for or on behalf of said recipient, over, above, or in excess of the amount properly payable according to the Department of Public Assistance classification of such patient for nursing home care. Any nursing home or nursing home operator who accepts or receives money from any recipient in excess of the armcunt properly payable according to the Department of Public Assistance classification of such patient, or who accepts or receives from any other person for or on behalf of any welfare patients, any funds in excess of the amount properly payable according to the classification of such patient, shall be dropped from the list of classified nursing homes for which nursing home payments are approved. ### Dr. HUMISTON. The physicians of Washington have had some unique observations to make about the distribution of medical care. In the first place, we have county medical service bureaus, which are physician sponsored, and one of them has been in operation since 1917. Further, we have, for a number of years, acted as agents for the State department of public assistance in handling medical care under that program. Now, there are two points I have attempted to make in the treatise I have presented here. The first one is that we know that—at least in the case of the people in the State of Washington, whom we think are typical whenever they start getting into any kind of a plan of medical care, the demand on the part of the recipient of the care increases toward more comprehensive care. I think it is unnecessary to point the finger at people, as to what their objectives might be. In our experience, once people begin with some kind of a plan, they want it more comprehensive. And I think the pressure in that direction, if we start, might well be irresistible. The other point I make in this presentation is this: It takes two documents to run a program like this. All of us, I think including the Members of Congress, are at a serious disadvantage as to exactly what this bill might do, because we have only the bill. We do not have the necessary rules and regulations, and it takes both those documents to make one of these things work. In the State of Washington, we are quite familiar with working with these rules and regulations, and that is why I included them with this document. The thing that concerns me, and concerns us out there, is that the rules and regulations, because of the quantitative restrictions which are necessary, in order either to live up to the enumerated specifics of the act, be it Federal or State, or the budget requirements, make it necessary for the rules and regulations to include restrictions, which impair the quality of medical care. Now, as far as I am concerned personally, I do not too much care who pays for medical care, or how it is done, as long as we end up with the best quality medical care that can be obtained for each individual under the various circumstances under which he is going to receive his care. We know that in the State of Washington, for instance, under our welfare medical care program, patients get trusses instead of hernia operations. They get elastic stockings instead of vein strippings. And restrictions like this are unavoidable when medical care is furnished in kind by government. The thing that we do not want to see happen is that this type of regulation impairs the quality of the medical care of some very large segments of the population, such as all people over 65, or virtually all. We also have serious fears that this might spread to the entire population. Now, I am told that this is a double standard of medical care. And it is. But as long as we can tolerate it, and have to live with it, and try to obliterate it-as long as there is an island of regulated medical care in this large sea of other ways of providing medical care and paying for it, it is constantly up for comparison. We can see where the soft spots are, and we can try to remedy them, rather than impose this regulated medical care on everybody, which will give it to us as equals, but I think of inferior quality. The CHAIRMAN. Thank you, Doctor, for coming to the committee and taking the time to give us the benefit of your views. Are there any questions of Dr. Humiston? Thank you, Doctor. Mr. Caetleman, representing the National Association of American Federation of Senior Citizens? Dr. Larrick? Doctor, we saved you until the last, because we knew you would be the best; not because you brought your Congressman with you, though we are glad to have him. STATEMENT OF HON. GORDON H. SCHERER, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO Mr. SCHERER. Mr. Chairman and members of the committee, I would like the privilege of introducing a fellow Cincinnatian of mine. The CHAIRMAN. We appreciate your coming to do it. Mr. SCHERER. Dr. Larrick is a man of wide experience in the medical field in the United States. At the present time, he is the director of one of the top hospitals in the country, Christ Hospital in Cincinnati. He is currently serving as the president of the Greater Cincinnati Hospital Council. During the past year, he has had the opportunity to travel in England and Scotland, and there witness and study medical care as it exists in those two countries. He became medical director of Christ Hospital after many years of outstanding service as a practicing physician in the Middle West. It is with a great deal of pleasure that I have the privilege of presenting Dr. Larrick to the committee this afternoon. The CHAIRMAN. Thank you, Mr. Scherer, for presenting Dr. Larrick to us. Dr. Larrick, you are recognized, sir. STATEMENT OF LLOYD E. LARRICK, M.D., DIRECTOR, THE CHRIST HOSPITAL Dr. LARRICK. Mr. Chairman and members of the Committee on Ways and Means, thank you for the opportunity given me to comment on the Health Insurance Benefits Act of 1961. Positive convictions evolve from my experience which include private practice of medicine in the fields of general practice and then specialty practice of anesthesiology; Army service; and now hospital administration. Currently, I also serve as president of the Greater Cincinnati Hospital Council and have within the year witnessed health care in England and Scotland. My opposition to H.R. 4222 results from my consideration of the following facts. NEED All people over age 65 are not medically indigent. It is not necessary for me to repeat numbers of people who participate in social security, hold other Government or company pensions, are employed, own private annuities, have an independent income in the form of interest, dividends, or rent, have liquid assets, or obtain old age assistance, and from this receive medical care. Yet many in need are not covered by social security. Because Cincinnati has been described as "the city closest to the heart of America," I shall relate my testimony to a matrix of professional and community experience in southwestern Ohio. Principles under which we have operated and the needs of our area can be readily translated to any American community. Hamilton County has an estimated 900,000 people. We conservatively estimate a group of 83,000 senior citizens. Establishment of an arbitrary age cutoff point for giving or denying needed help is unfair to all segments of the population. Need and not age determines our community planning. Of 7,500 people needing assistance from Ohio's old-age program only 1,200 had major medical problems. Our community chest, founded in 1915, brings together more than 125 health and welfare agencies. In 1960 allocations of nearly $2.5 million went to agencies specifically dedicated to health care, and of this amount, nearly $500,000 was shared by those agencies providing care to those classified as "aged." In this same year the State of Ohio's old-age assistance program, with matching Government funds, spent about $969,000 for the medical needs of this group in this area. Approximately $572,000 was spent for inhospital care and $397,000 for other health care expenditures. I repeat, only 1,200 of the 7,500 people needing assistance had major health problems. A portion of the $2.9 million spent by the Hamilton County Welfare Department went for health care of those over 65. Parenthetically, the expenditures of this group have increased from $1.6 million in 1957 to an anticipated $3 million in 1961 and this department is almost unique in the United States in meeting, in full, the cost of hospitalization of not only welfare clients, but also medically indigent. This is being done on a local-State matching program without Federal assistance at a time when some municipalities are excluding or curtailing help to some categories. I believe we have demonstrated that our aged population, both economically and medically indigent, are protected through existing Federal, State, and local government programs, by private philanthropy, and by communitywide integration of all programs through efforts of voluntary, privately supported agencies. Responsibility for integration is a local matter. Our public health federation, established in 1915, is a meeting place for leaders of all health agencies, where all community resources are brought to bear to solve problems. Its vigor and growth stem from the active support of all purveyors of health services. I should like to add that Cincinnati has for many years had a nursing home ordinance, promoted by the public health federation and carried out by the health department. Included in any team approach to health planning is the physician. The 80-member coordinating committee of our public health federation includes 28 physicians who are in active practice. Approximately 500 of the 1,400 members of the academy of medicine contribute to the health care of those who cannot afford it; in clinics, by assistance to visiting nurses, and by work in private hospitals, while all 1,400 contribute part or all of the care to their own patients who are in need. American democracy is based on the concept of individual equality and responsibility. Turning to Washington for nationwide solution to local problems weakens that concept. Destruction of community initiative for self-improvement as engendered in H.R. 4222 strikes a heavy blow. CONFLICTS WITHIN THE BILL Conflicts written into the proposed legislation will interfere with American health care, the greatest in the world today as attested to by the flow of trainees into this country. Prohibition against interference to the contrary, a few such conflicts in H.R. 4222 will be listed: (1) The patient does not have free choice when only those hospitals, nursing homes, or agencies with which an agreement is in effect, may be approved for payment. (2) Medical services are offered in the fields of pathology, radiology, physiatry, and anesthesiology and by interns and residents in a teaching program-all as hospital services. This is in direct conflict with many State laws. A corporation cannot practice medicine. The Board of Medical Examiners of the State of Oregon, in order "to carry out the statutory duty imposed upon the board" requested from each hospital a copy of any contract with radiologists so as to insure compliance with laws prohibiting corporate practice. (3) Unlimited authority for control and supervision, and interference, lies in the hands of the Secretary of HEW when a hospital is defined as an institution which— meets such other conditions *** as the Secretary may find necessary (4) It is proposed that the amount paid for services— shall be the reasonable cost of such services, as determined in accordance with regulations establishing the method or methods to be used in determining such costs for various types or classes of institutions, services, and agencies. Standards for quality of hospital services would be leveled by budgetary needs of the regulating body. At that time interference would have determined a standard level for medical care for all groups. EFFECT OF PROPOSED LEGISLATION ON HEALTH CARE It is human to demand that to which one is entitled. With free care, this would increase and our acute general hospitals would become institutions for chronic care. This would affect our national economy. Inability to obtain early care will protract illnesses. While we symptomatically treat for months an incurable cancer patient, a wage earner would be waiting this same number of months for a hernia repair which would permit him to be gainfully employed. We have just opened a new wing for our hospital providing a 100-percent increase in beds. Today after 1 year, we have a 4- to 6-week waiting period for elective admissions and a 1- to 2-week waiting period for urgent admissions. The need today is for nursing homes and old-age living quarters. Lacking these and with Government provision of hospital care, our hospitals would be filled with those over 65. This is con |