Mr. Chairman, more than a quarter century of experience with social security legislation is ample proof that those who have expressed doubts and misgivings have been proved wrong by the record, and that whenever this committee has recommended sound improvements in the social security protection provided to the American people, the committee's wise judgment has been sustained.

In the words of the statement we presented to this committee in 1949:

The consumers league has long favored the adoption of social insurance as the best method of meeting the demands of individuals and families for basic economic security in a manner that gives the maximum of protection to the taxpayer and involves a minimum of interference in the running of our economy.

Indeed, we could apply to H.R. 4222 the opinion we expressed with respect to the original social security legislation in 1935. We consider H.R. 4222 also to be

a farsighted recognition of our needs and *** a long step forward toward a stabilized social order.

We therefore urge enactment of H.R. 4222, and in the words of the statement we presented to this committee in 1949:

The consumers league has long favored the adoption of social insurance as the best method of meeting the demand of individuals and families for basic economic security and in a manner that gives the maximum of protection to the taxpayers and involves a minimum of interference in the running of our economy.

Thank you very much.

Mr. BOGGS. Thank you, sir.
Are there any questions?

If not, we thank you.

Our next witness is Dr. Forrest E. Leffingwell, president-elect, American Society of Anesthesiologists. We are glad to have you, Doctor. You may proceed.

STATEMENT OF FORREST E. LEFFINGWELL, M.D., PRESIDENTELECT, AMERICAN SOCIETY OF ANESTHESIOLOGISTS; ACCOMPANIED BY JOHN LANSDALE, COUNSEL

Dr. LEFFINGWELL. Mr. Chairman and members of the committee, my name is Forrest E. Leffingwell. With me is Mr. John Lansdale, counsel for the American Society of Anesthesiologists, and we desire to thank this committee for the privilege of appearing before you at this time. I am a physician specializing in anesthesia and chairman of the Department of Anesthesiology, White Memorial Hospital in Los Angeles. I am professor of anesthesiology at the School of Medicine of Loma Linda University (until recently known as the College of Medical Evangelists), a school of the General Conference of the Seventh Day Adventists. I am myself a graduate of this school. I served in the Army of the United States for 5 years during World War II during which period I specialized in anesthesia. I was a lieutenant colonel at the time of my relief from active duty.

I am president-elect of the American Society of Anesthesiologists, in behalf of which organization I appear here. The American Society of Anesthesiologists is a scientific organization devoted to the advance of the art and science of anesthesia. The society has nearly

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6,900 members, of which approximately 6,200 are in the United States, and who, we believe, are nearly all of those physicians in the United States who specialize to any substantial degree in anesthesia.

I should add that I am secretary of the American Board of Anesthesiology and have been a member of such board for 6 years. This board has no direct connection with the American Society of Anesthesiologists. This is the agency which examines the qualifications of physician applicants who profess to have special expertness in anesthesia and which certifies to the qualifications of those who meet the board requirements.

I have devoted my professional activities solely to anesthesia for more than 20 years.

In appearing here on behalf of the American Society of Anesthesiologists, I do not desire to take a position either for or against the bill now under consideration by this committee. I have made no attempt to ascertain the views of the membership of our organization with respect to the proposed legislation, H.R. 4222.

My purpose here is to advise this committee as to the actual manner in which the physicians engaged in that specialty practice anesthesia because it appears to us that the portion of the bill relating to anesthesia is written upon the basis of an assumption as to a factual situation different from that which in truth exists. I should like to give you the facts as to how anesthesia is practiced and its position in medicine and then leave to the good sense of this committee and of the Congress how this matter should be handled with respect to the proposed legislation before your committee.

The bill H.R. 4222 provides in substance that the United States will pay, on behalf of those receiving social security benefits, in addition to the cash benefits, a substantial percentage of the cost of services customarily provided for by hospitals, either by the hospital itself or by others under arrangements with them made by the hospital.

In order, apparently, to guard against the eventuality that in some specific case the hospital customarily provides medical services not desired to be covered by this legislation, services rendered by physicians are specifically excluded except those services rendered by residents and interns in approved training programs and except those rendered by pathologists, radiologists, physiatrists or anesthesiologists. It is to this particular provision, under which anesthesiologists are excluded from the general physician exclusion that I wish to direct

attention.

Whatever experience may show as to whether the services, other than physician anesthesia, which would be supplied under this bill as a hospital service are in fact supplied by or through the hospital, it is clear, we believe, that anesthesia provided by physicians in other words, the service of an anesthesiologist-is not, generally speaking, regarded as or supplied as a hospital service.

The normal mode of practice for anesthesiologists is private practice in the same manner as substantially all of their professional colleagues on the hospital staff. They fix, bill, and collect their own fees. Their services are not included in the usual Blue Cross service contract. Almost universally Blue Cross covers anesthesia "when administered by an employee of the hospital." This does not normally

include anesthesia when administered by a physician. It normally does cover anesthesia administered by nurse technicians.

Blue Cross thus provides coverage in the approximate 60 percent of the cases in which anesthesia is administered by nurse technicians who are normally hospital employees. (This is based upon the ratio of the membership of the American Association of Nurse Anesthetists. to the sum of the membership of that association and the U.S. members of the ASA.) But in only a few cases is the relationship of an anesthesiologist with the hospital such that it can be said that the hospital customarily provides such physicians services or that the anesthesia is adminitered by an employee of the hospital.

Thus if it is intended that under H.R. 4222 there should be added to the benefits provided by social security the services normally and customarily provided by hospitals, you should eliminate from line 11, page 7, the words "or anesthesiology" and place "or" before the word "physiatry" in the same line.

Since my prepared statement was submitted to the committee I have had an opportunity to read what the Secretary of Health, Education, and Welfare says at page 56 of his report to this committee as follows, and I quote the Secretary:

The administration of anesthesia is carried out in part by nurse anesthesiologists, in part by other physicians, and in part by nurse anesthetists who are hospital employees and who act under the supervision of the operating surgeons. Anesthesiology as a medical specialty is a recent development, and arrangements for providing the service vary widely. Many accredited hospitals however, and some others assume responsibility for the availability of anesthesia service at all times, discharging this responsibility through an anesthesia department headed by one or more anesthesiologists who are either on salary or under contractual arrangements with the hopsitals. The administration proposal would provide payment for the services of nurse anesthetists, and also of those anesthesiologists who have assumed the responsibility for hospital service and who have agreed that the hospitals should bill, or collect the bills, for their services.

We have no quarrel with this statement by the Secretary as to the practice of anesthesia as far as it goes, but, if it is his intention to administer the bill if passed along the lines this statement implies, then the bill should be so written as to specifically set forth these provisions.

Your attention is directed to the fact that at page 7 under section 1603, subparagraph (a) (3), the term "inpatient hospital services" is defined to include such therapeutic items furnished by the hospital or by others under arrangements with them made by the hospital as

are

customarily furnished to inpatients either by such hospital or by others under such arrangements.

Then at page 31 under section 1606 (a) (1) a hospital is defined as an institution which, among other things

is primarily engaged in providing, by or under the supervision of physicians or surgeons, (A) diagnostic services and therapeutic services for surgical or medical diagnosis, treatment, and care of injured, disabled, or sick persons

In other words, this is exactly what the patient's doctor does for him. Thus, the term "arrangements" used in section 1603 (a) (3) must include the ordinary relationship of the patient's physician to the hospital when the physician is on the staff of the hospital. But for the specific exclusion of physicians their services might well be re

garded by the bill as hospital services. Thus, if it is intended to include physician anesthesia only when the physician is acting as an employee of the hospital rather than of the patient, we respectfully submit that the bill should be rewritten on this point. Actually, we are in such case talking about probably less than 6 percent of all anesthesia and I respectfully submit that the practical thing is simply to exclude physician and anesthesia all together as is recommended by my prepared statement.

If the bill is left as written, we believe the practical effect will be to put great pressure on physicians to turn what has always been a medical service into a hospital service. The fact that a substantial amount of anesthesia is actually administered by technicians does not gainsay that anesthesiology is and always has been the practice of medicine and a medical service which is not a hospital service.

Where a nonphysician actually administers anesthesia, a physician, usually the operating surgeon, must take responsibility for it and must make the medical decisions required. To illustrate, the actual giving of a hypodermic may not be the practice of medicine, but the decisions whether and when to give it, and how much, are the practice of medicine.

Accordingly, organized medicine has always taken the position that anesthesia is the practice of medicine. The burden of the primary responsibility of the surgeon in difficult cases and the potent and lethal character of the newer anesthetic drugs, are among the facts that created the demand which has resulted in the speciality of anesthesia-which has resulted in the addition to the operating team of a physician whose sole responsibility it is to keep the patient alive and operable while the surgeon does his difficult and delicate work.

I do not wish to rest the points which I make here today on legal grounds. However, I am advised by counsel that the medical decisions required during and with respect to anesthesia is the practice of medicine. I am prepared to submit to you a memorandum on this subject should you desire it.

A survey of those physicians engaged in the practice of anesthesia discloses that in the year 1960, out of 6,529 answering the inquiry, 4,613 were in private practice; 822 were in training in anesthesia; 300 were in the service of the United States; and 794 were not in private practice.

If we exclude those in training and in the service of the U.S. Government, there are thus less than 15 percent of those physicians engaged in the practice of anesthesia who are not in private practice of anesthesia. Moreover, included in this 15 percent are the faculties of medical schools in those schools where the faculty is full time, and those engaged in non-Federal public health and preventive medicine and the like.

Thus, we believe that substantially less than 15 percent of the physicians who specialize in anesthesia are now working for hospitals under conditions which permit the hospitals to sell their services to patients or to the Government. My work in organized medicine and on the American Board of Anesthesiology brings me in contact with anesthesiologists throughout the country and these figures conform to my personal observations.

Anesthesia as a medical specialty is quite new and began to develop in any substantial way only as late as the 1940's when it received great impetus from the experience in our military hospitals during World War II. In recent years, surgeons have developed skills far beyond the capacity of medical science to keep the patient alive during surgery. In consequence, new and potent anesthetic drugs and highly refined techniques were developed. These, however, are dangerous and require the utmost skill and medical judgment in their management. The development of anesthesiology as a specialty has made possible the successful utilization of the highly developed skills of our surgeons upon very poor risk patients and for the performance of operations of a character not even attempted a few years ago.

I am advised that on Monday in the course of his oral testimony Secretary Ribicoff made a statement that a patient does not know who gives his anesthetic, in effect that there is no personal relationship between the anesthesiologist and his patient.

With respect to the physician anesthetist in private practice the Secretary appears to have been misinformed, or his experience is limited to those hospitals in which anesthesia is a hospital service. I do not say that all doctors at all times give the very best care possible, but good anesthesia practice requires that an anesthesiologist interview his patient prior to anesthesia, prescribe his medication, plan the management of his anesthesia, and provide postanesthetic care throughout his recovery.

The need for anesthesiologists is very great and the need is growing at a rate which exceeds the present output of our training centers. If our specialty is to keep apace of this rapid growth, we strongly believe that it is essential not to interfere with the opportunity to enter private practice and that the anesthesiologist must enjoy the dignity of receiving the same treatment as that accorded to the other branches of medicine.

We believe that it is not your desire to change the mode of practice of one of the newest and most vital of medical specialties and we earnestly and respectfully solicit your favorable consideration of the matters here presented.

Mr. BOGGS. Are there any questions?

Mr. ULLMAN. Mr. Chairman.

Mr. Boggs. Mr. Ullman.

Mr. ULLMAN. Doctor, you are recommending that anesthesiologists be excluded from the legislation, but not nurse anesthesiologists; is that right?

Dr. LEFFINGWELL. That is right, sir.

Mr. ULLMAN. Do you not feel that this might tend to increase the number of those who depend upon nurse anesthesiologists and in some way reduce the number who call upon you and your profession?

Dr. LEFFINGWELL. That is a situation which exists at the present time, Congressman Ullman. The Blue Cross contracts cover nurse anesthesia. They do not cover physician anesthesia. At the present moment and for the foreseeable future, there is a shortage of individuals who are capable of administering anesthesia, both in the nurse technician field and in the field of medical anesthesia. It is my belief that no act, which you imply in your question, will bring about any substantial change in the present practice.