of the American Medical Association, 1939, 113, 943-948); 1947-32 percent (Journal of the American Medical Association, 1947, 135, 1078-1081); 1960 and 1961-11 percent (Modern Hospital, March 1960, and Hospital Management, August 1961).

Twice as many radiologists now present bills to patients than was true 5 years ago. (American College of Radiology, annual report, May 1961, pp. 11-12). We are gradually eliminating hospital domination of the practice of radiology.

Six percent of radiologists are in full- or part-time office practice. Some 25 to 30 percent of patients referred to private office radiolologists are over 65.

Many of these offices will close if these patients can obtain free care in a hospital. Lacking the possibility of office practice, few physicians will enter radiology.

What is the practice of radiology? What do radiologists do?

From 85 to 90 percent of our work is in making diagnoses based upon our radiological examinations of patients, and from 10 to 15 percent in treating patients with diseases-principally cancer.

Probably 70 percent of all patients with cancer receive radiation therapy. A great percentage of cancers are first discovered by radiologic examination.

In connection with cancer, I have in my office a letter from a British radiologist seeking a position in the United States. He notes that under the British health plan the waiting time for radiation therapy of cancer is 4 months.

Cancers do not wait to grow and spread. He cannot practice acceptable radiology under these conditions. He wishes to immigrate.

In diagnosis, what do radiologists do? There is no system of the body that radiologists are not now examining with X-rays and radioisotopes. We are now able to predict strokes and recommend prophylactic surgery.

Our examinations of the kidneys and other organs now allow patients to avoid exploratory surgery that was at one time routine. We can now anticipate heart conditions prior to failure and recommend corrective surgical procedures.

With techniques combining fluoroscopy, television, and motion pictures, we can now study and restudy complex problems. I emphasize that this new knowledge belongs to men-not machines.

The University of Tennessee has recently invested $2 million in a new and magnificent department of radiology. This is not worth 1 red cent without radiologists who can medically interpret the data that this department will allow trained people to produce.

Radiologists have occupied a key role in radiation protection and safety-nationally and internationally-for over 40 years.

Since 1957, radiologists have presented over 15,000 programs on radiation protection to medical and other audiences. We assist government at all levels on legislative and other problems involving radiation protection and radiation disaster planning.

Since 1958, the college has distributed over 250,000 copies of a manual telling physicians how to minimize radiation hazards. Spanish and Portuguese editions have been distributed in Central and South America.

French and German translations are underway. Since 1959, a college motion picture, "Radiation: Physician and Patient," has been shown to a medical audience of over 100,000 throughout the world. During 1963, the college distributed approximately 6,000 kits of information on the radiological aspects of disaster planning. We have received favorable comment on this from Members of Congress, civil defense authorities from all over the United States, and others. Our plea is that Congress not legislatively destroy our medical specialty of radiology through enactment of H.R. 3920. We have served our patients and the public well. We desire very much to be able to continue to serve in the future.

(Attachments accompanying the statement are as follows:)

EXHIBIT

Efforts of the American College of Radiology to improve voluntary health insurance and local and State programs for the medically indigent are as follows:

1. To improve coverage and administration of voluntary medical care insurance programs, the American College of Radiology has developed, published and widely distributed:

(a) A relative value scale with which patients, insurers, unions, management, officials of medicare, the Federal Civil Service Commission, and others can judge the equity of charges for X-ray examinations, radiation therapy, and diagnostic and therapeutic uses of isotopes.

(b) A model clause for insurance contracts covering radiological services. (c) Model billing forms to assist in the administration of insurance claims covering radiology services.

2. We have consulted with the National Association of Blue Shield plans, individual Blue Shield plans, the Health Insurance Council, individual insurance companies, medicare officials, Federal Civil Service Commission officials, unions and management in efforts to broaden and improve insured radiological services. We continuously publish for college members and others information to assist in improving medical care insurance. We have financed an independent study, the purpose of which was to develop data useful in improving medical care and hospitalization insurance.

3. We work to advance business efficiency in the practice of radiology to the end that fees for radiology service can be maintained at the lowest level commensurate with high quality service. We have in publication a manual of radiology department administration; we are working on a revision of our Planning Guide for Radiologic Installations (1953). The Price, Waterhouse & Co., certified public accountants, have developed for us a uniform system of accounts for radiology offices and departments which will allow radiologists to improve operating efficiency. We sponsor workshops for residents in radiology training designed to improve education and radiologic economics.

4. We publish information in regard to State and community administered programs of health care for those in the population who are not self-sufficient. Any or all of the material referred to is available to the committee upon request.

Dr. CARROLL. Thank you very much.

The CHAIRMAN. Thank you, doctor. We appreciate your bringing to the committee the views of your group. Are there any questions of Dr. Carroll ?

Thank you, Dr. Carroll, and thank you for coming with him, Mr. Stronach.

Dr. CARROLL. Thank you, sir.

The CHAIRMAN. Dr. Šimpson?

Dr. Simpson, we welcome you to the committee. Will you please identify yourself for the record? We shall be glad to recognize you.

STATEMENT OF GAITHEL L. SIMPSON, M.D., IMMEDIATE PAST PRESIDENT, THE KENTUCKY STATE MEDICAL ASSOCIATION, ACCOMPANIED BY ROBERT GROGAN, FIELD SECRETARY

Dr. SIMPSON. Mr. Chairman and members of the committee, I am Dr. Gaithel L. Simpson, from Greenville, in western Kentucky, where I have a specialty practice of general surgery. I am the immediate past president of the Kentucky State Medical Association and the present chairman of the Governor's Advisory Council for Medical Assistance. I have with me Mr. Bob Grogan, a field secretary of the Kentucky State Medical Association, as an information source.

After learning of the time available for our testimony before this committee, we have taken our original statement, which is before you, and extracted portions thereof in order to stay within the time limit. The CHAIRMAN. You want this entire statement in the record, however, Doctor?

Dr. SIMPSON. Yes, sir; and addendum of one page which will be in addition to this short presentation.

The CHAIRMAN. Without objection that material will be included in the record. You are recognized.

(The material referred to follows:)

STATEMENT OF THE KENTUCKY STATE MEDICAL ASSOCIATION ON H.R. 3920 BY GAITHEL L. SIMPSON, M.D.

Mr. Chairman and members of the committee, I am Dr. Gaithel L. Simpson from Greenville, in western Kentucky, where I have a specialty practice of general surgery. I am the immediate past president of the Kentucky State Medical Association and had the privilege of appearing here with Dr. Robert C. Long in 1961 during this committee's consideration of H.R. 4222.

As a practicing physician, I have been personally involved in the problem of medical care for those in need. This experience increased as a result of my serving as chairman of the Medical Service Committee of the Kentucky State Medical Association from 1950 to 1960, and as chairman of the Governor's Advisory Council for Medical Assistance since its inception which includes public assistance programs as well as MAA in Kentucky.

The Kentucky State Medical Association is composed of approximately 2,200 practicing physicians. The association was founded in 1851 with the continuing purpose of extending and elevating the quality of medical science and knowledge, to raise and maintain the standards of medical education and to better the medical profession's service to its patients by uniting with similar State medical societies to form and maintain the American Medical Association. It is consistent and with these purposes that the physicians of Kentucky be represented here today to present evidence to this committee of the adequacy of our current MAA program and to offer information on the scope of coverage under nongovernmental health insurance plans.

UNWARRANTED CRITICISM

In spite of Kentucky not being a wealthy State, it was preceded only by Michigan and West Virginia in enacting enabling Kerr-Mills legislation. With this accomplishment the Kentucky Kerr-Mills program hase been criticized in the past, and continues to be misrepresented, as being too limited in benefits, too rigid in its eligibility requirements, and too inefficient in terms of administrative costs. We know, and would like to respectfully demonstrate to you, that these criticisms are not warranted.

ELIGIBILITY LIBERALIZED

Kentucky's indigent medical care program, which includes MAA, was inaugurated on January 1, 1961. This was a new program and we had no guidelines from past experience to assist in formulating our benefit structure. Under

standably, Kentucky wanted the program to grow and develop in a manner both orderly and fiscally sound, so the program began modestly. Since that time, however, it has been revised and expanded as experience and need have demonstrated the desirability to change. For example:

On January 1, 1961, the MAA program was open to persons 65 years of age or older residing in Kentucky who had an annual income of not more than $1,000 if single, and $1,500 if married. The same year, in September 1961, gross annual income was raised to $1,200 for single persons and $1,800 for married couples. This year, on April 1, 1963, the eligibility requirements were further liberalized and the annual gross income limits for single persons were raised to $1,600 and for married couples to $2,400.

At the inception of the program, our department of economic security estimated that 87,000 of our population over age 65 were potentially eligible for MAA benefits. By June 30, 1963, 19,025 had applied and of this number 16,903 qualified. Because of deaths, accumulation of assets, other sources of income, and transferring from MAA to OAA, only 11,936 recipients were eligible to receive benefits.

EXPANSION OF BENEFITS

Initially, our MAA program benefits were broad in scope but somewhat limited in extent. The physicians were paid for two home and office visits per month and the hospital was paid for 3 days of service. This, however, did not mean that patients were summarily discharged from the hospital at the conclusion of 3 days' stay. They continued to receive necessary hospitalization and medical care just as they have for past years. Physicians visits to the hospital were not included in the coverage and only certain emergency care by dentists were allowed. Physicians, being taxpayers, agreed as an association that they would be willing to eliminate physicians' fees for in-hospital visits.

The program benefits have been expanded and today the recipients are now eligible to receive hospital care for 10 days per hospital admission, and without limitations on the number of admissions. Among other improvements in the program are dental services which now may include extractions and fillings and the treatment of conditions involving pain, infection, or hemorrhage. Patients are entitled to 18 physician home or office visits per year with additional home and office visits where necessary by authorization.

Nursing homes which meet the "high criteria of attainment" requirements are eligible to participate on a reimbursement cost basis for 120 days per recipient per calendar year. An entirely new benefit has also been added. Medical assistance to the aged recipients who need skilled nursing home care are now eligible to receive benefits for an indefinite period, with all licensed nursing homes eligible to participate in this portion of the program on a flat rate basis. MAA recipients who need custodial-type care likewise receive benefits for an indefinite period.

PROJECTED EXPANSION OF PROGRAM

Although, the Kentucky MAA program has been repeatedly broadened and liberalized since its inception, it will not stand still at present levels. Already the program has been projected into the future and further expansion is planned. On July 1, 1965, eligibility will be further liberalized by increasing the annual gross income limits to $2,400 for single persons and $3,000 for married couples. Benefits have also been projected to July 1965. Payment for hospitalization will be increased from 10 to 14 days with a provision for an extension of an additional 7 days upon authorization. Physicians' coverage will be increased, as will coverage for dental work which will be expanded to include diagnosis and treatment of dental illnesses and the repair of dentures. Provision for "high criteria" nursing home care will be still further expanded to 180 days and home nursing visits will be added as an entirely new feature of the program.

The Kentucky MAA program has been well accepted by our elderly people, as well as by the vendors of medical service; i.e., hospitals, nursing homes, pharmacists, physicians, and dentists. With the expansion of the hospital benefit period to 10 days per admission, it is now estimated that the program covers 77 percent of the cost incurred by hospitals on program beneficiaries and pays for the total cost incurred by approximately 82 percent of those admitted under the program.

As time goes on, and Kentucky's experience grows, the program will be subjected to even further revision. In this way, soundly and with an understand

ing of the needs of our people, Kentucky is developing a program of medical assistance for the medically needy in which the Kentucky State Medical Association takes pride. A program intentionally contained in a modest beginning is maturing into a record of continuing progress.

ADMINISTRATIVE COSTS

Finally, the question of "administrative costs" which have been the object of some concern to those who choose not to believe in Kerr-Mills, the facts should again be examined. In the first 3 or 4 months of the program, administrative costs were approximately $1.24 for each dollar of benefits paid. It should be remembered, however, that the entire concept was new and it took a great deal of money to hire and train staff, set up necessary mechanisms of administration: i.e., rent, office equipment, etc., and develop efficient methods of operation. It also took time to bring into the program those needing financial help. Today, the program's administrative costs are only 8 percent of the total, with a foreseeable lowering to 5 percent. It appears then that in the relatively short time that Kerr-Mills has been implemented in Kentucky administrative costs have fallen from an initial 124 percent to 8.12 percent as of June 30, 1963. We believe that this answers the charge of excessive administrative cost and demonstrates the ability of Kentucky to care for those who need help in an economic and efficient manner.

MORE OF THE KENTUCKY STORY

Obviously, the Kentucky story is more than our medical assistance to the aged program. Of the 3 million people living in Kentucky, the Health Insurance Institute has reported that as of December 31, 1961, over 1.8 million have purchased health care coverage either through a commercial insurance company or through Blue Cross-Blue Shield. We know that over 85,000 of our aged are covered by Blue Cross-Blue Shield plans alone, and it would be a realistic assumption to place the number of those over 65 who are covered by a commercial insurance policy at about the same figure. Of the 292,000 senior citizens, in Kentucky, approximately 170,000 are protected by privately purchased voluntary health care coverage.

In addition to those presently covered by the voluntary prepayment system. private industries such as Southern Bell Telephone & Telegraph Co., Ford Motor Co., General Motors, United Mine Workers, Green River Steel, Newport Steel, and Armco Steel are now providing health care programs for their retired employees. Other volunteer groups, labor, management, medicine, teaching profession, local government, and the people themselves in Kentucky, have demonstrated beyond the slightest doubt that through our voluntary efforts we are caring for those unable to provide medical care for themselves.

During the 3 years of the Kerr-Mills' existence in Kentucky, we have had an opportunity to observe its growth and we know it is providing an ever-increasing service to MAA recipients. Private insurance and voluntary efforts continue to grow and fill the needs of the people of our State.

On behalf of the physicians of Kentucky, therefore, I urge this committee not to recommend the enactment of any legislation establishing additional Federal medical programs.

May I express the appreciation of the Kentucky State Medical Association to this committee for granting us the opportunity to present these data to you.

Dr. SIMPSON. Thank you, sir.

The Kentucky Kerr-Mills program has been criticized and misrepresented as being too limited in benefits, too rigid in its eligibility requirements, and too inefficient in terms of administrative costs.

Kentucky's MAA program was a modest one inaugurated on January 1, 1961. Since that time, however, it has been revised and expanded as experience and need have demonstrated the desirability of change. For example:

On January 1, 1961, the MAA program applied to persons with an annual income of $1,000 if single and $1,500 if married. Through progressive steps, these limits are now $1,600 for single persons and $2,400 for couples.