hometown, where I associated first with my pioneer physician father and subsequently with one of my two physician brothers.

All Academy of General Practice members are also members of the American Medical Association. In general we follow the lead of the AMA in national legislative matters, reserving the right to disagree on matters which especially affect general practice. We are solidly behind the AMA in objecting to the provision of medical or hospital care for the aged through the mechanism of the social security system. We backed the AMA in support of the Kerr-Mills bill and we are on record in our congress of delegates to support implementation of this law in the various States.

We in general practice feel that we know these older folks and their problems quite well. Most of them have a family doctor and whatever the final disposition of their medical problems, the family doctor is the first stop. To point up this fact I can tell you that in 1960 Marvin J. Taves, associate professor of sociology and supervisor of rural sociology at the University of Minnesota, directed a survey of 300 social security beneficiaries in Minnesota to explore attitudes, status, and characteristics of people over 65. Of those interviewed about 85 percent said they had seen a general practitioner during the previous year and about 15 percent said they had not seen their family doctor during the year. From my own experience with the elder citizen, I feel he does not need the type of help proposed in H.R. 4222. Previous social security legislation and the recent enactment of title VI of Public Law 86-778 provide wide coverage for those over 65 and include adequate provisions for those on old-age assistance as well as for those drawing social security.

In Minnesota, even prior to enactment of the Kerr-Mills bill, the recipients of old-age assistance were provided with adequate hospital and home care plus the services of their physician. Free choice was preserved and hospitalization was in the private hospital of their choosing. All this cost about $20,160,000 in 1959, according to the department of public welfare. The cost was shared about 52.8 percent by the Federal Government, 25.6 percent by the State, and about 21.6 percent by the counties.

Minnesota is not a rich State and our recent legislative session was beset by tax problems but there has been no thought of economizing on OAA-indeed, patients medically indigent but ineligible for one reason or another for OAA were recently granted doctor and hospital pay coverage equivalent to that granted to recipients of OAA. This was effected by joint action of the various county boards of commissioners and the State department of public welfare. Organized medicine's part in all this has not been small and is not small now. The Minnesota State Medical Association maintains close liaison with the Department of Public Welfare through a variety of interlocking committees and advisers and the county welfare units all have the advice of a local physician. The physicians of the State have cheerfully accepted greatly reduced fees for their services to recipients of ŎAA and public welfare. An instance of the close cooperation between physicians and the welfare boards occurs in the case of the typically independent oldster who wants to provide for himself, and does, but still may be elegible for OAA. He fears the threat of expensive hospitalization and the physician is able to qualify him for aid for this alone if the need arises. He draws nothing unless disaster strikes.

Several studies have been made in Minnesota as to actual hospital needs and usage by those over 65. One such study has been briefly alluded to previously, the report called "Minnesota's Aging Citizens, a report of the Minnesota planning committee for the White House Committee for the White House Conference on Aging. I am sure this material has been made available to this committee and I want to emphasize a few salient points tending to support my thesis that H.R. 4222 is not needed. One-half of the persons interviewed for this survey had a net worth of $10,000 or more. Forty-nine percent reported they had enough income to get by comfortably. Thirty-five percent said they had enough to get by, but no more, while 16 percent reported that their means were not enough to live on.

When the people in this group were asked about their health needs and whether or not they had received the medical care they needed, 87 percent declared they had no uncared-for needs. Of the remaining 13 percent, 40 percent said they had unmet medical needs and declared that medical care was too expensive. Another 20 percent of the 13 percent said their ailments were incurable, anyway, or nearly so.

Of all those interviewed, 40 percent had not been hospitalized at all, and 60 percent had spent varying amounts of time for one reason or another in hospitals during the year.

Of the total dollar spent for health care, 25 percent of the people interviewed had spent between zero and $49 during the year. About 59 percent had spent between zero and $200 and only 5 percent had spent $500 or over.

One question which was put to all of those people concerned availability of medical care if they could not afford to pay. It elicited the following response: Sixty-eight percent said they knew such care was available to them, and 22 percent said they did not know whether it was available or not. About 10 percent of them said they had made use of free services within the past 6 months and 73 percent said they never, rarely, or seldom made use of such services themselves.

On the subject of hospital insurance the response was as follows: About 60 percent of all the people interviewed carried some type of hospital insurance and the percentage rose to 71 percent among people over 65 in the metropolitan areas. The majority had purchased their insurance after age 50.

Another study was conducted by James Cosgriff, Sr., M.D., of Olivia, Minn., a general practitioner and former president of the Minnesota Academy of General Practice. The people covered in this survey were patients in the Renville County Hospital, Olivia, Minn., a general hospital having 41 beds and 10 bassinets. The study was carried on by the hospital administrator with the aid of the medical staff. It covered 256 patients with 350 hospital admissions. All of the patients studied were 65 years old or older and they constituted 21.5 percent of the total admissions. Of these, 14.8 percent were admitted for surgery and 85.2 percent were admitted for medical conditions. Their total hospital bills were classified as follows: Mode or most frequent figure $36; the median, $226; and the average, $350.54. Three-quarters of the patients used private resources. to pay their bills and 25 percent of the bills were paid by a Government agency. As of February 1, 1961, only 8.9 percent had not paid their hospital bills in full.

It is believed that evidence has been submitted to prove that extension of medical care to the aged is not needed in Minnesota. If we in Minnesota, not a rich State, can do this well, certainly other States can follow suit.

I will be the first to state that one of our big problems in private practice is the tendency of some patients to overutilize private prepaid hospital insurance plans such as Blue Cross. The attitude of the patient is that he has paid into it and he is going to take out of it. Under a plan paid for from social security funds the same attitude would prevail. This should not be true with OAA paying for hospitalization, but it may be. A recent survey in Minneapolis hospitals compared 3,200 consecutive hospitalizations paid for by OAA in Minneapolis private hospitals and a like number paid for by OAA at Minneapolis General Hospital. The average stay of the private hospital patients was 12.7 days, that of the General Hospital patients, 17.4 days. The figures for length of stay for all hospitalized patients are not exactly comparable but the figures read 6.5 days in the private hospitals and 12.5 days at Minneapolis General Hospital. It is my firm conviction that hospitalization under H.R. 4222 would result in further overutilization. I believe this has been true in Saskatchewan and under other compulsory health insurance plans.

I wish to thank the committee for the privilege of appearing before

you.

Mr. KING. Thank you, Doctor Blake. The committee appreciates your appearance. Are there any questions?

Mr. MASON. No questions.

Mr. KING. That will be all.

Thank you again.

Dr. BLAKE. Thank you, Mr. Chairman.
Mr. KING. Doctor Terris?

STATEMENT OF MILTON TERRIS, M.D., MEMBER, EXECUTIVE BOARD, AMERICAN PUBLIC HEALTH ASSOCIATION

Dr. TERRIS. The American Public Health Association with 13,000 members, plus an additional 20,000 members in State and affiliated public health associations, is representative of those persons in both official and voluntary agencies in Federal, State, and local positions who have dedicated their lives and talents to protecting and bettering the public's health. The vast majority of these persons-doctors, dentists, nurses, engineers, laboratory and social scientists, therapists, nutritionists, health educators, social workers, and medical care and hospital administrators are at work daily in the homes and communities of this Nation, laboring with their minds and hands to alleviate needless human suffering and attempting to elevate the ability of everyone to enjoy life as free as possible from the economic loss and pain of sickness.

The American Public Health Association recognizes that provision of health services for the aged represents one of our most emergent health problems today. Since 1958 we have supported the concept of increased provision of such services through appropriate forms of paid-up insurance. Provision of such insurance coverage is presently inadequate, when only 46 percent of persons 65 years and older have any degree of hospital insurance coverage. This fact assumes even

greater importance when we consider that one-half of the families, headed by persons 65 years and over, have incomes of less than $2,830 annually; and about one-half of them-46 percent-have savings of less than $500. Obviously some additional mechanism is urgently needed to extend insurance coverage for this age group.

We do not have, at the present time, a clear mandate from our membership to support any particular method of payment, either through social security or any other. But we do have a clear mandate and a wealth of professional experience and competence to speak on the organization for and the quality of any health services provided by virtue of any of the several Government-sponsored programs. Our testimony on H.R. 4222 will be concerned with the provision of measures which will assure maintenance of high quality and efficiency in the services to be provided.

The health of our senior citizens is definitely impeded by barriers to obtaining needed medical care. These barriers are of two kinds: One financial, the other relates to personnel and facilities. There is no question that the financial barriers are very important; the aged have greater needs for health care than other segments of the population, while their financial resources are much more limited.

In addition to the financial barriers, however, there are serious limitations in the availability and the organization of the general and special health services needed by the aged. Acute general hospital services and physicians' services are, by and large, available in relatively sufficient quantity. Furthermore, the quality of these services, while it varies considerably, is undergoing significant improvement as a result of State hospital licensure laws, the work of the Joint Commission on Accreditation of Hospitals, and the activities of the various medical specialty boards.

In other areas of health service organization, however, the situation. is quite different. Chronic disease hospitals, home nursing services, organized home care programs, and rehabilitation services-all of which are absolutely essential to providing medical care for the agedare in extremely short supply and actually do not exist in many communities. Also, while it is true that nursing homes are available to a greater or lesser extent, their quality is generally so poor that we may justifiably state that skilled nursing home care worthy of the name is unavailable to the vast majority of the aged who need such care.

Furthermore, the question of coordinating services and facilities to provide continuity of care is of the utmost importance for the aged, since they suffer from chronic diseases and the status of their illness and the kind of care needed varies from one time to the next. Without proper organization to achieve coordination, the all too common phenomenon of misutilization occurs: old pepole who should be at home are kept in hospitals, those who should be in hospitals are allowed to remain in nursing homes, and so forth. Needed coordination, unfortunately, is a rare phenomenon in our local communities.

It is for these reasons that the American Public Health Association has urged the Congress to enact the community health services and facilities bill, H.R. 4998 and S. 1071, in order that a beginning can be made to fill the gaps in home nursing services, organized home care programs, and nonprofit nursing home facilities. We recognize that this will only be a beginning, and a modest one at that, but believe that

it will provide the framework for much greater expansion of these services in the near future to meet the urgent needs of the aged. It is our hope that in the implementation of such legislation, adequate attention will be paid to the need to develop a balanced network of services with proper coordination to provide maximum continuity of care, that is, to assure that the right person is getting the right kind of care in the right place at the right time.

From this standpoint, we approve the proposal in H.R. 4222 to provide not only inpatient hospital care, but a wide spectrum of outof-hospital and home services. This is essential to provide proper medical care for the individual. If only inhospital care were to be paid for, the inevitable result would be to fill our hospitals with persons who do not require such care. Not only would costs be inflated unnecessarily, but the individuals themselves would be receiving improper care which would have an adverse effect on their health. Hospitals are good only for those who need them; those who do not, run serious risks of "institutionitis," of becoming so dependent on the institution that it becomes difficult or impossible to return them to family and community life.

The inclusion of outpatient hospital diagnostic services is a valuable feature of the proposed legislation. However, it does not appear logical to us to limit such services to diagnosis only. Most outpatient hospital services in this country do not separate diagnosis and treatment, and it makes little sense to pay for diagnostic services to an ambulatory patient and then refuse to pay for further supervision of his care on the same basis. Inevitably he will use the service that is paid for the inhospital service which he doesn't need-instead of receiving appropriate care on an outpatient basis.

One of the most significant and valuable features of the bill is the inclusion of home health services. This will make it possible for many older persons, who are now receiving inappropriate hospital care, to be discharged to their homes to receive nursing and other home health services. Furthermore, the availability, through H.R. 4222, of funds to pay for this type of care will provide the financial basis for further expansion of such services.

Home nursing programs and organized home care programs in the United States have for many years now been established by nonprofit organizations such as visiting nurse associations, voluntary and public hospitals, and local health departments. These agencies have developed a fine reputation for humane, devoted, and individualized care of high quality. They have worked very closely with the medical profession in developing their procedures and in providing the best possible care for their patients. The American Public Health Association, therefore, approves the definition of home health agencies set forth in H.R. 4222, which safeguards the further development of this tradition by limiting participation to nonprofit organizations and public agencies. This will prevent the organization of substandard home nursing or home care programs established not primarily to serve the aged sick but rather to take advantage of the possibilities of receiving payment for inadequate services of poor quality and to profiteer thereby at the expense of the elderly. It is our hope that the regulations adopted for the administration of this or similar legislation will fully implement the intent of this definition to safeguard the quality of the home health services which will be provided.