The staff of the association stands ready to consult further with this committee as it may request.

The CHAIRMAN. Dr. Groner, we thank you, sir, for bringing to the committee the statement of the views of the American Hospital Association.

Are there any questions?

Mr. King.

Mr. KING. Dr. Groner, the bill we are considering would provide hospital services to certain aged beneficiaries, but exclude the services of physicians. Is it not true that certain hospital services must of necessity be provided by physicians?

Dr. GRONER. This is certainly true, Congressman King, to eliminate the services of the physician as specified in this bill reduces the hospital element to a nursing home with an operating room so if we are talking about hospital care, I think these have to be included.

Mr. KING. Would you tell the committee what some of these hospital services are that are customarily provided by physicians?

Dr. GRONER. I think the major ones are enumerated in the bill: pathology, anesthesiology, medical education, internes, residents and the physiatrists.

Mr. KING. Would you tell us in general how hospitals customarily provide these services?

Dr. GRONER. As a general rule, and maybe I should briefly take them one at a time, in pathology, the director of the department is a highly trained specialist in pathology. The financial arrangements between the pathologist and the hospital vary from a salary basis to a percentage basis, and the hospitals pay the other people in the department, other than the professional men.

A very similar arrangement exists in the department of radiology where again the head of the department is a highly trained specialist in the field of radiology. Anesthesiology or anesthesia presents a little different picture in that these men do come in direct contact with the patients, where in most cases, the pathologist and radiologist do not.

All of these three are usually selected by the attending physician or the family's personal physician. In anesthesiology, I might add, most anesthetics in this country are not given by anesthesiologists, more of them by nurse anesthetists than any other group. The large majority are not given by M.D.'s. The field of physiatry is very similar to the field of radiology, for instance, or pathology, except that again the physician comes in contact with the patient more often.

In intern and resident programs, these men are M.D.'s who are furthering their medical education. To disrupt this program would mean a complete change, I would think, in concept of all medical education beyond the medical student level.

I hope that answers your question.

Mr. KING. Did I understand you, Doctor, to say that generally the anesthesiologists do not themselves administer the anesthetic.

Dr. GRONER. I say that the anesthesiologist comes in direct contact with his patient. Often the others do not, except the physiatrist. What I meant to say was that a large majority of the anesthetics in hospitals are not given by the physician group. This is a profession where there are not enough qualified doctors to meet the needs, although the number is increasing.

Mr. KING. That interests me because it runs completely contrary to the mass of correspondence that I have received from this professional I have understood from my correspondence that just the

contrary is true.

Dr. GRONER. I think that we can provide figures for you on the number of anesthetics given by physicians or anesthesiologists, other physicians, and the number given by nonmedical anesthetists and I am confident that the majority is given by nonmedical anesthetists. To disrupt this would make it impossible to give anesthetics. If we total all the M.D.'s who are available to give anesthetics, we would not have enough to give the anesthetics that are necessary for the patients. Mr. KING. I would be pleased to have that information, Doctor, if it would not be too much trouble.

Dr. GRONER. We will secure it, Congressman King.

Mr. KING. What, in your opinion, would be the effect upon the aged beneficiary if this legislation excluded all of these specialty services?

Dr. GRONER. I think I mentioned that you are moving toward a nursing home. I think one effect would be that other disciplines would also say they should be excluded. I mention nurses and pharmacists. Then you do move from a nursing home down to a hotel.

The bill, I think, with the deductible and the exclusion of physician's fees, I estimate, does not provide but 40 or 45 percent of the total costs. These medical specialist costs run another 25 percent, so you would be reducing the 40 to 45 percent by another 10 or 11 percent. Therefore, even in these so-called catastrophic cases the patient would would only get about one-third of his bill paid. I think these two effects would accrue.

Mr. KING. Is the patient-doctor relationship the same in the case of a pathologist and radiologist and anesthesiologist as it is with other private practitioner of medicine and surgery?

Dr. GRONER. No, sir. In my opinion, it is not, because it is not the same doctor-patient relationship. In very few instances, proportionately speaking, does the pathologist ever see his patient. Radiologists, do to a certain extent. Usually the pathologist or radiologist outside of the hospital is recommended by the patient's regular physician. The patient in the hospital comes under the jurisdiction of the medical specialist who is in charge of the hospital department, so I would say it is not the same relationship.

Mr. KING. Would the patient have available to him good hospital care without the services of the specialists mentioned?

Dr. GRONER. No, sir.

Mr. KING. How, generally, are these three specialists paid for their services, Doctor?

Dr. GRONER. There is great variance. In most of the governmental hospitals, Federal, State, and county, and even at the local level, they are paid on a salary. In most university affiliated hospitals they are paid on a salary. In the private hospitals the financial arrangements on the first four which were mentioned, radiologist, pathologist, anesthesiologist, and the physiatrist, vary from a salary to a percentage basis. Interns and residents, I think, universally are paid on a salary basis.

Mr. KING. It would seem the majority, then, would be on a salary

Dr. GRONER. If you were to load all interns and residents in the group, yes. In the voluntary hospitals, I think, it runs the gamut, but if you again were to add the State, local, city, and Federal hospitals and teaching hospitals, there probably would be a majority on a salary basis, although I do not know.

Mr. KING. To what extent do these specialists use nonmedical assistants?

Dr. GRONER. In pathology, radiology, and physiatry, a large majority of the people involved in this are not medical people. The anesthesiologist does not; interns and residents do not really have jurisdiction over lay employees.

I might, if you wish, give you some idea from my own institution. In the areas of pathology and radiology we have a total of about 140 individuals involved. Of the 140 approximately 10 are doctors in the radiology and pathology group. We have another six in the residency program. In anesthesiology, we have 17 nurse anesthetists, and 3 M.D. anesthesiologists. We do have anesthesiologists in private practice who come in and give approximately 20 percent of the anesthetics. This will give you some idea.

Mr. KING. All these nonmedical assistants must be paid by the hospital?

Dr. GRONER. All of the nonmedical assistants are generally paid by the hospital.

Mr. KING. Do you think, Doctor, that pathology, radiology, and anesthesiology services should be included as hospital services under this program regardless of the financial arrangements between the hospital and the specialists?

Dr. GRONER. Congressman, I think you have to include them if you are talking about hospital service. I do not think you are talking about hospital services without including these groups.

Mr. KING. How, generally, Doctor, do hospitals make the services of their pathology and radiology departments available to outpa

tients?

Dr. GRONER. This, too, varies. Again, if I may use my own institution, they are referred by their private physician. We have some who come to the specific person and then we do have work from hospitals in the outlying areas. I think this is a pattern which would probably be rather typical.

Mr. KING. Your institution is not unique in the sense that it would be out of the pattern generally followed?

Dr. GRONER. I think it is typical enough to show the pattern. I might add, Congressman, in many small hospitals there are virtually no outpatient services.

Mr. KING. Do you believe that with the enactment of this bill more hospitals would make the services available to outpatients?

Dr. GRONER. I think the increased financing of hospitals which would come under this bill would make it possible for hospitals that right now cannot quite afford it, to do so. How many, I do not know. Mr. KING. Do you believe that to the extent that such outpatient services are made available it would reduce admission of diagnostic inpatient services?

Dr. GRONER. This is a matter of opinion, I think, and I am sure that there are people on the other side who would disagree. I might

add if you exclude the medical specialist group from your bill, you exclude outpatient services. I think making outpatient services available is very fine and is improving the quality of care. I think this is a very, very fine step. My opinion is that I do not believe it would reduce the cost of care. I think it will increase the cost of care, for I think that the unsuspected diseases which may be uncovered will add more to care than the savings which would come from treating patients on the outpatient basis, rather than inpatient basis.

Mr. KING. Do you believe that with the $20 charge to the patient for each diagnostic workup, unnecessary use of these outpatient services would present a serious problem?

Dr. GRONER. No, sir; I do not. If I had a quarrel on this score, I would say that the $20 deductible is too high. I looked over some material very hurriedly from the Secretary, the information which he left with the committee, and I got the impression that it was their estimate that 80 percent of the cases would not be covered.

Mr. KING. In your statement, Doctor, you indicate that you are opposed to the use of the social security system for providing health benefits to the aged. The American Hospital Association House of Delegates said in 1958 that the use of social security mechanism to assist in the solution of problems of financing these needs may be necessary ultimately. Am I correct in my understanding, that position has not been changed?

Dr. GRONER. That is correct. We state two things in here in reference to the use of Federal funds. One, I do not see this right before me. One is that we think Federal funds are necessary, and I think that our support of the Kerr-Mills bill, our position since the 1940's, that Government responsibility is in the area of indigent medical care of the aged, is certainly in conformity with this.

I think that our position is unchanged, that we say that the use of social security may ultimately be necessary. I think our position is this: that we think advances have been made so far as the voluntary health programs are concerned and if we come to the point that we feel that the voluntary programs will not meet the needs, then in the interest of health care of the people of the country, we would support social security, in my opinion.

Mr. KING. Some of the most distinguished leaders in the hospital field, including the former president of the American Hospital Association, and the recipient of the 1961 Distinguished Service Award of the American Hospital Association publicly declared that hospital benefits for the aged can best be financed through the social security system. Do you think they are in any way representative of a significant number of your profession?

Dr. GRONER. There are administrators in the Nation who do favor the use of social security. In my opinion, if a vote had been taken of the house of delegates last year on do you or do you not-it was not defined to this extent-it would probably have been 2 to 1 against it. This is my opinion.

Mr. KING. They did vote to sustain their previous position. Mr. Chairman, at this point I would like to have inserted in the record a sheet or two that deal with hospital leaders of the country suggesting the social security method of financing.

The CHAIRMAN. Without objection, that material will be inserted at this point in the record.

(Information referred to follows:)

HOSPITAL LEADERS ENDORSING PRINCIPLE OF HEALTH CARE FOR THE AGED THROUGH SOCIAL SECURITY (OASDI)

Basil MacLean, M.D., former president of National Blue Cross Association; former president, American Hospital Association:

"I want to add my voice in support of the bill now before you which would provide health benefits to aged persons under the social security mechanism. * * * I have been in close contact with the problem for many years and in many capacities. As a physician, I have had an intimate look at the special and personal health needs of the aged. As a hospital administrator, I have seen that need reflected as a burden of obligatory and uncompensated service that acted as a constant drag upon the hospital's economic support and growth. As New York City commissioner of hospitals, I have seen these problems further translated into financial and social deficit for the entire community. As a president of the National Blue Cross Association, I participated firsthand in the attempt to meet some of these problems through existing voluntary prepayment organizations.

"A lifetime's experience has led me at last to conclude that the costs of care of the aged cannot be met, unaided, by the mechanisms of insurance or prepayment as they exist today. The aged simply cannot afford to buy from any of these the scope of care that is required, nor do the stern competitive realities permit any carrier, whether nonprofit or commercial, to provide benefits which are adequate at a price which is feasible for any but a small proportion of the aged" (letter to Hon. Wilbur D. Mills, February 5, 1960).

James P. Dixon, Jr., M.D., commissioner of health, city of Philadelphia, 1952 to 1959:

"Unpaid care has become such a drain on the resources of our hospitals that the quality and the availability of hospital services are seriously threatened.

"There are currently about 250,000 people on social security in the 5 counties of southeastern Pennsylvania, and these people use about 36 percent of all free care given in the area's 58 hospitals. If these beneficiaries were covered by hospital insurance, a third of our free care deficits would be wiped out. State and local grants could then be applied to the remaining two-thirds, and hospitals would be financially able to devote a much larger portion of their income to improvement of services and the raising of wages" (testimony on behalf of the Hospital Council of Philadelphia before the House Committee on Ways and Means, July 1959).

E. M. Bluestone, M.D., recipient of 1961 Distinguished Service Award of American Hospital Association; professor of public administration, New York University:

** the sheer humanity of those who are in approval [of the Forand bill] far outweighs the arguments of those who, motivated largely by professional self-protection (which I consider misguided and unprogressive) are in disapproval. Passage of this bill into law would be a boon for the great majority of our elderly population who have the right to look to our legislators for relief at a time in their lives when they may need it most. It has all the wholesome earmarks of voluntary prepaid medical care insurance with the added advantage of Government partnership to see to it that no citizen is neglected in the late time of his trouble."

Martin Cherkasky, M.D., director, Montefiore Hospital, New York City.

Dean A. Clark, M.D., director, Massachusetts General Hospital, Boston, Mass. Rt. Rev. Msgr. Edmand J. Goebel, director of hospitals, archdiocese of Milwaukee, Wis.

Jerome Preston, president, Massachusetts Memorial Hospitals.

Leonard S. Rosenfeld, M.D., director, Metropolitan Hospital, Detroit, Mich. Mr. KING. I would like to read it to the committee, Mr. Chairman, as I am quite impressed, but I do not want to take the time of the committee.