Medical Association's declaration of policy, they will not confer with, they will not associate with, they will not teach optometrists. In effect, optometrists will be barred from this initial program under the bill as introduced.

When H.R. 6027 was recently passed by the Senate, it included what was known as the Humphrey amendment, the purpose of which was to give the beneficiaries of that health care legislation, now Public Law 87-64, the free choice of any duly licensed practitioner. This amendment was stricken out in conference, which would seem to indicate that the House conferees were not in favor of the "Free Choice by Patient."

We hope that this does not represent the views of a majority of this committee, and that the amendment to H.R. 4222 which we propose, namely, on page 6 strike out lines 1 to 8, both inclusive, and insert in lieu thereof the following:

FREE CHOICE BY PATIENT

SEC. 1602. An individual entitled to have payment made under this title or any other title of the Social Security Act for health services furnished him may obtain such services from any provider of health services duly licensed to render the same by the State in which the service is performed and who is willing to accept compensation for such services at the rate which is in effect for providers of similar services.

We trust that the amendment will be incorporated in the bill; otherwise, Mr. Chairman and members of the committee, the American Optometric Association strongly opposes the passage of the bill.

The time allotted me was 5 minutes, and I have endeavored to keep within it. However, there is a great deal more information which I think this committee and Members of Congress should have concerning optometry and its place in the health care of our citizens. Therefore, I would like to have the privilege of filing a supplemental statement to be incorporated in the printed record.

Mr. KING. If you can get that to us within a very reasonable time, we will include it at this point in the record, Doctor. Dr. MCCRARY. Yes, sir.

(The supplemental statement referred to follows:)

SUPPLEMENT TO THE STATEMENT OF V. EUGENE MCCRARY, O.D., COLLEGE PARK, MD., ON BEHALF OF THE AMERICAN OPTOMETRIC ASSOCIATION

Mr. Chairman and members of the committee, again permit me to express to our association's appreciation of the courtesies extended to me at the time of my appearance before the committee on July 31, and the privilege accorded me of filing a supplemental statement to be incorporated in the record.

Due to the time limitation placed on my oral testimony before the committee, many pertinent facts were omitted concerning the optometric profession and its role in helping to provide the best vision care in the world for our citizens. I earnestly solicit the committee's consideration of the following supplemental information.

There are somewhere between 18,000 and 20,000 individuals licensed to practice optometry in one or more of the 50 States and the District of Columbia. In order to secure such a license, the individual must have successfully completed at least 5 years of study at the college level, including clinical practice, as well as successfully passed a State board examination. There are only 10 approved schools and colleges of optometry in the United States.

These are: the Illinois College of Optometry, Chicago, Ill.; Indiana Division of Optometry, Bloomington, Ind.; Los Angeles College of Optometry, Los Angeles, Calif.; Massachusetts College of Optometry, Boston, Mass.; Ohio State University School of Optometry, Columbus, Ohio; Pacific University College of

Optometry, Forest Grove, Oreg.; Pennsylvania State College of Optometry, Philadelphia, Pa.; Southern College of Optometry, Memphis, Tenn.; University of California School of Optometry, Berkeley, Calif.; and the University of Houston College of Optometry, Houston, Tex.

Approval of optometric schools and colleges is a function of the Council on Optometric Education of the American Optometric Association which regularly conducts inspections and evaluations of the colleges, curriculum, teaching staff, and physical facility. This activity assures the public of competent graduate optometrists who are well trained to practice their profession.

Our association, like most others in the health field, is composed of individual members in each of the 50 States and the District of Columbia. In most instances, the individual joins the local or State association and at the same time becomes a member of the national organization. More than 11,000 of the practicing optometrists belong to our association.

The work of the association is carried on by committees and departments, which include the council on optometric education; the department of education, the department of national affairs, the committee on military optometry (at this point I should like to point out that there are over 350 optometrists on active duty in the three branches of the armed services with ranks ranging from second lieutenant to colonel or their equivalents in the Navy), the committee on aid to the partially blind, the committee on contact lenses, the committee on ethics, the committee on international affairs, the committee on interprofessional relations, the committee on motorists' vision and highway safety, the committee on occupational vision, the committee on orthoptics and visual training, the committee on research, the committee on social and health care trends, the committee on standards, the committee on vision care of the aging, and the committee on visual problems of children and youth.

Our profession supports the American Optometric Foundation, the American Academy of Optometry, the Optometric Extension Program Foundation, and other groups dealing with research and postgraduate education in vision.

While the medical profession is permitted to perform the identical services rendered by our profession through exemption in the optometry laws, only a very small fraction of the practicing physicians and surgeons have taken postgraduate courses dealing with eye care, served their internship in an eye hospital, and passed the examination of the American Board of Ophthalmology. These men are especially qualified to perform eye surgery and to prescribe and administer medication for diseased eyes. For the most part, they are located in the larger centers of population with the result that the vast majority of our citizens, through both choice and necessity, when confronted with a visual problem first seek the services of an optometrist.

The vast majority of cases of cataract and glaucoma are first detected by optometrists and referred to opthalmologists for evaluation, final diagnosis, and treatment. Despite this fact, the American Medical Association, by house of delegate resolution, prohibits its members from teaching or conferring on a professional basis with members of our profession who in good conscience refer patients to them. Optometrists refer annually hundreds of thousands of patients to other health care professions when disease is detected or suspected, thus fulfilling a prominent role in the protection and preservation of the public health. Last year at the annual meeting of the American Public Health Association, Galem F. Kintner, O.D., a member of that association and of the District Board of Health of Lynden, Wash., submitted a paper setting forth the results of a survey on optometric referrals which is attached hereto as appendix A.

Many physicians seek our services for themselves and their families when it comes to prescribing lenses, including contacts and orthoptic or visual training. The American Medical Association has unsuccessfully opposed the granting of commissions to optometrists in the armed services and aiso opposed making optometric services available on an outpatient basis to entitled veterans. This last situation was only corrected by action of the 86th Congress in passage of Public Law 86-598 over strong medical opposition.

In our efforts to make optometric services available to veterans entitled to outpatient care, we were able to cite literally hundreds of cases of veterans in need of outpatient vision care but not entitled to it at Government expense who were referred by veteran facilities to optometric charitable clinics.

It is true that our profession is comparatively young in the health field, but there can be no question about the importance of vision in the age in which we live, nor can there be any question but that every one of our citizens over the age of 65 is in need of some form of vision care, the vast majority of which is and can continue to be furnished by optometrists. It is not only unrealistic but

un-American to set up a health care program which in anywise pertains to eye care that does not expressly provide that the beneficiaries of the program shall have not only the free choice of the individual practitioner, but also the right to choose as between the medical profession and the optometric profession. However, due to the fact that the medical profession is so firmly entrenched in all of the welfare organizations at the local, county, State, and National levels, it is impossible to make the services of our profession available to beneficiaries of a public health program unless Congress in unmistakable language provides that the individual beneficiary shall have the free choice of practitioner and profession.

We believe that it is in the public interest that the amendment we have suggested should be incorporated in the bill, and we trust that the committee will follow the precedent established by its predecessors when they reported out the 1950 amendment to the social security law and their colleagues on the Veterans' Affairs Committee which reported out the bill passed by the 86th Congress to make optometric services available on an optional basis to veterans entitled to outpatient vision care.

APPENDIX A

OPTOMETRIC REFERRALS

Most patients seeking the services of an optometrist have, or presume to have, symptoms of disorders connected with the eyes or their use. The optometrist, in taking a careful case history, observing the patient, making various tests and in evaluating his findings, must decide if solution of the patient's problem lies within his circumscribed field. This is differentiating activity requiring skill and understanding since many symptoms of visual disorders are similar to those manifest by a patient with general disease, dental, or eye health problems. If other than optometric services are required, the optometrist refers his patient to other health professions or agencies for further attention. Thus the optometrist in his routine practice regularly originates referrals to other professions as part of his responsibility to his patients. This report is concerned with various aspects of these referrals.

The visual system is a generous window to a number of the patient's health problems. While the optometrist's area of service includes refraction and coordination problems (with lenses, orthoptics, subnormal visual aids, etc.) his field of investigation includes much more in determining the state of health of the patient and his visual system. Case histories are revealing: The reflexes of the eyes and adnexa are rich sources of neurological information; the appearance of blood vessels, tissue structure and pigmentation are prime indicators of both general disease and localized diseases of the eye. The normal physiology and anatomy of the eyes is so well understood that any deviation from it is readily recognized by the observant optometrist.

As the optometrist originates many referrals his activities often partake of the nature of the general practitioner, rather than that of a specialist. Even though the public is becoming more sophisticated in its self-diagnosis and hence its choice of health specialists, the fact is that a great number of people with vague symptoms come first to the optometrist. In serving these patients the optometrist frequently consults with the general practitioner to insure correct referral. Conditions requiring medical or surgical treatment of the eyes are generally referred directly to an ophthalmologist. Close cooperation between the optometrist and the consultant contributes to more efficient use of the community health resources.

FORM OF REFERRALS

Referrals of patients by optometrists take many forms depending upon the factors that the patient's problem and degree of urgency may present. It may on one hand be such an acute situation that he actually accompanies the patient to the physician conferring with him on the signs and symptoms that actuated the referral. At the other end of the scale the optometrist may decide that the patient need only be given the recommendation that he see his physician or dentist at his early convenience. Between these two extremes are all gradations, with all types of communication between the optometrist and the other members of the health care professions to whom he sends his patient.

In general the form of referrals can be divided into two groups: The desirable but elective and the more formal or specific referral. The former presents the larger portion of the direction of optometrists to their patients to seek the service

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of others. These referrals are for conditions of less than an acute nature. Dental caries, periodic health examinations, obesity, hygiene, and such subjects of health management are examples of the matters that an optometrist typically calls to the patient's attention. Rare indeed is the older patient that does not need some encouragement for better health management.

This present study is concerned with the more formal or specific type of referral, characterized by the fact that the optometrist initiates not only the motivation of the patient to seek the services of others but also initiates the communications with the essential third party to whom the patient is referred. In this type of referral the optometrist not only determines that the patient needs the services of others but that these services are required at an early date and with more certainty than the product of casual conversation or direction. These referrals are generally made to a specific practitioner or office always consulting the patient on his choice. Communication is between principals and typically generates more return discussion between them in the patient's interest. To date, no information with an authoritative background was available on this subject of optometric referrals. In the development of their activities, several committees of the American Optometric Association deemed that such a study would be desirable for several reasons: To provide information essential to proper development of the profession in a changing world; to provide information for the optimum development of interprofessional relations; and to develop information which could be used to improve the educational preparation of optometrists.

THE QUESTIONNAIRE

In order to provide a source of material for the current study on optometric referrals, a questionnaire was designed. It was mailed to a random sampling of 1,350 optometrists who were asked to return one copy each month for 6 consecutive months. Of the 306 who responded by returning the first month's questionnaire, 133 completed the entire series. A total of 1,360 monthly questionnaires were returned.

The questionnaire asked for information on the optometrist's age and length of practice, the population of his city, and the number of patient visits for that month. It asked about the number of eye physicians in the locality and the number of miles to the nearest eye physician. The age and sex of each patient referred that month and the number of years the patient had been served were included. Referrals were categorized to ophthalmologists, general practitioners of medicine, dentists, other optometrists, and others, and their record of formal acknowledgment of the patient's appearance was listed.

DISTRIBUTION OF REFERRALS

Responses to the questionnaire were well distributed geographically with a fair division between urban and rural areas as shown by table 1. There was no essential difference between the data from rural and urban areas. In four States the urban optometrists referred more patients and in the other four groups the rural referrals were greater.

As near as can be determined, there are 18,500 optometrists in active practice in this country at the present time. If these data are projected on the basis of the total number of optometrists in active practice it can be estimated that in the United States optometrists received 37,368,000 patient visits annually. Of these, 818,360 patients are formally referred to others for some type of health service. Of all formal referrals, 86.55 percent were made to some branch of medicine. As would be expected, the larger share of referrals were made to ophthalmologists; 53.7 percent being made to them and 32.8 percent to general practitioners. Referrals to the general practitioner would be greater if full data on the desirable-but-elective type of referral were available. According to the study 3.3 percent of the formal referrals were made to dentists. Of the balance, 5.1 percent were made to other optometrists and 5 percent to other miscellaneous health personnel.

If this same distribution holds for the entire optometric profession it would be projected to this annual total of referrals:

Ophthalmology –

General practice

Dentistry

Optometrists..

Miscellaneous_.

Patients 439, 460

271, 622

26, 990

41, 736

40, 918

REFERRALS BY AGE OF OPTOMETRIST

In order to determine if there was any signficant difference in referrals among older and younger optometrists, or in the number of years in practice, the data in tables 2 and 3 were compiled. These tables show a higher rate of referrals by older optometrists, though the returns from those over age 65 were too few to be fully significant. The higher percentage of referrals by the older optometrist reflects the higher average age of his patients which keeps pace with his own increased years. The incidence of health problems increases with the age of the patient. This pattern holds true when referrals are grouped in accordance with the number of years the optometrist has been in practice. The rate of referrals increases with the number of years, with a significant jump when the optometrist arrives at the 51-to-65 age level or has been in practice 16 to 30 years. Referrals to his colleagues also increase from less than 1 percent on the under-50 group to 5.5 percent in the over-50 group.

REFERRALS BY SEX

There were 2,543 females and 2,076 males referred by optometrists in this study. This represents 81.6 males to 100 females. This follows closely the study made of optometric practices, in California, in 1956. This demonstrated that the optometrist sees 80.8 males to 100 females in his regular practice.

ACKNOWLEDGEMENT OF REFERRALS

The best interests of the public are served with the fullest and freest two-way communications between the optometrist and the referee. The findings of the optometrist contribute to the understanding and remedial care of patients which he refers. The knowledge communicated by the referee to the optometrist adds to the latter's learning and skills. It also helps him to plan the subsequent visual care of the patient which was referred.

On the 2,772 referrals that were directed to ophthalmologists, in this study, 71.3 percent were acknowledged, either in conversation or by written communication. Of the 1,683 referrals to physicians in general practice, 45.5 percent were acknowledged. The difference is significant and may be explained by several factors. The greater area of mutual interest will increase the frequency of communications between optometrists and ophthalmologists. The smaller number of ophthalmologists than general practitioners will mean more referrals to individual eye physicians by optometrists. This, in turn, will build a greater rapport between the two. Also, by the very nature of their practice, most specialists are more adept at maintaining communications with those who refer to them.

FUTURE STUDY

This study of formal referrals, from optometrists to other health professions, as searches for information generally do, points to other avenues for inquiry and study. It would be desirable to make a broader study, covering a more representative group of optometrists, and giving more attention to desirable-but-elect type of referral. It should include a search of information on better screening methods and procedures for determination by optometrists of any deviation in normal function. A study could be made of communications between optometrists and other professional people. This could point out the relationship of frequency of referrals as related to the acknowledgment of them. It might be directed to searching for better techniques for communication between professional people. It would be desirable to know what constitutes "patient visits" at an optometrist's office and what relationship exists in the frequency of the various kinds of visits.

CONCLUSIONS

(1) Optometrists see a large volume of patients, many of whom exhibit signs and register symptoms of disease and malfunction that fall outside the scope of their service. If the present sampling is projected to the 18,500 optometrists in active service it represents 37,368,000 patient visits per year.

(2) Projecting the 2.19 percent of referrals to patient visits in this study shows that optometrists refer 818,360 people to others for health services.

(3) The greater share (53.7 percent) of optometric referrals is made to ophthalmologists according to this study. This represents 439,460 patients.