we want some area planning, and if that is not comprehensive enough the State planning agency to come into it.

Mr. JENSEN. I think part of the question we have as far as the area planning group having veto power over hospital or health facilities. construction in that area, is that the relationship between the State planning organization and the area planning organization is the type of thing that should be worked out within each State. There are enough problems as far as developing these relationships between area and State planning agencies.

I am not saying this is a major problem but, of course, there are potential problems when you have various planning groups involved in the same area. I think most of the State health comprehensive planning agencies would rely very heavily on the opinion of the area comprehensive health planning agencies.

Mr. ROGERS. I would think so, or you would never get your State plan. At least that is our understanding when we passed the law, it was really up under the local areas, and to be coordinated in the State plans. So I hope that is being done in the States.

Let me ask you this, do you have the figures on how many States now have effective State health planning agencies?

Mr. JENSEN. I believe they have all organized such agencies.

Mr. ROGERS. I just wondered if you could tell us. You may not have this information, I just wondered if you could tell us how many are ready to function effectively now as of this date.

Mr. JENSEN. I believe the ability to coordinate health program planning is available in each of the States. I think that Dr. Guthrie. who is the president of the newly formed Academy of State Health Planning Directors, can give you a better assessment. But I think this effort of coordinating health program planning is a little dif ferent than the actual detailed planning involved. For example, the comprehensive health planning agencies will also want to look at the area and State comprehensive manpower plans as they relate to health manpower needs and personnel. This again can be a function of coordinating those efforts but not be involved in the detailed planning.

Mr. ROGERS. Now, let me ask you this: I notice you have some con'cern about the $10 million that has been proposed in the bill for emergency rooms. I wondered what your thinking was on the administration's proposal that was in their testimony of withholding 20 percent of the $150 million to be directed by HEW.

Mr. JENSEN. I believe the administration here again would be a bypassing of the States. I think we would want to look at it very closely as far as what they had in mind. I understand the administration is also going to take a close look as far as research efforts, I believe, going on under Hill-Burton funding, and I think they should evaluate whether this fund should be allotted for those to be held by the Secre tary in the same light as far as the results of their studies of the research money presently being operated.

Mr. ROGERS. It is my understanding then, you feel all research money and all demonstration money should go to the State for State determination.

Mr. JENSEN. I think this is something that you would want the Governor to comment on directly. I think that we do not make that statement, that there are certainly legitimate functions of carrying

out these, devising new methods of delivering health services. I think this can be done in cooperation with the States. It is going to go on. So we want to look at the details involved in each of these.

Mr. ROGERS. Yes. The committee would like to have a reaction, as soon as possible, if we could, if you could get that for us. I think that would be helpful.

(The information requested was not available to the committee at the time of printing.)

Mr. CARTER. Thank you, Mr. Chairman.

Certainly, I am interested in your presentation. I believe you stated, section 2 here, that you oppose proposals to bypass the States in funding of emergency room modernization. Does that apply also to construction of hospitals and so on, throughout the State?

Mr. JENSEN. As far as Hill-Burton funds are concerned?

Mr. CARTER. Yes.

Mr. JENSEN. Yes, we believe the Hill-Burton agency should continue its present function.

Mr. CARTER. I am inclined to agree with that. I do not know the State should be bypassed in this area. It seems they have done a right good job. They know the problems of the States. They are conversant with them and know where the money is needed.

Now, we had just a little dissension from that I believe this morning, in one way or the other by others, but I still feel the Governor of the State and his staff are the planning groups there and know where construction should be.

I would like to ask you about this idea of multiphasic screening clinics. Just what do you mean by that?

Mr. ROESCH. Well, again, Dr. Carter, I am not admittedly an expert on multiphasic screening process. I have had the opportunity to become somewhat familiar with them.

But we have had in Florida a number of requests from our universities and from medical groups concerning the development of this type thing. I do not know personally where the financial support would come from in terms of the Federal Government.

Mr. CARTER. What is the purpose of the multiphasic screening clinic? Mr. ROESCH. The purpose of it, of course, is primarily preventive

medicine.

Mr. CARTER. To find early disease?

Mr. ROESCH. Right.

Mr. CARTER. Cancer, tuberculosis, and such things as that.

Mr. ROESCH. As you no doubt are aware, we are grappling with all types of interesting things in terms of the use of public moneys; that is, would it be better now to invest dollars, you see, into something like multiphasic screening, or an immediate need. Whether we are philosophically for or against something is immaterial because we have to examine all of these things as part of our job.

Mr. CARTER. These would be diagnostic clinics, we might call them, in different areas.

Mr. ROESCH. Yes.

Mr. CARTER. What about personnel?

Mr. ROESCH. As far as personnel, I think I would defer this question to Mr. Barnaby.

Mr. BARNABY. I think that the area of staffing of the multiphasic screening program, whether it be a facility based in one community or

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mobile, which would certainly provide services to rural areas that are not currently covered, some of this personnel is available now.

Through the use of computers and diagnostic programs that are currently being done as, for example, Kaiser-Permanente is doing some of this and a lot of this type of work has been done by the Air Force and the armed services for determining medical problems, I believe, by using a combination of highly technical personnel in the computer area, as well as using a physician, and the physician must be the ultimate judge in all of these cases

Mr. CARTER. Where do you get the physicians for this?

Mr. BARNABY. Well, currently, about all the multiphasic health screening program will do is develop a profile, and a very quick profile, of what are some abnormalities that exist in this particular person. And they could be double starred as is being done at Kaiser Permanente, so they stand out. When the physician reads the case record, they stand out. Here is an abnormality, for example, on blood sugar, and he can immediately start this without spending an hour or two of workup with each patient.

What it is really doing is multiplying the hands of the physician, so he can handle and see many more people as a result of already having a prediagnostic workup by using some of this equipment.

Mr. CARTER. I understand that; and it is fine the Kaiser Foundation does this. But you have never explained to me how this is to be done by the State, where it has to be organized, and so on.

Mr. BARNABY. I think that the role of the State and the role of the Federal Government might be in providing possible funds for the simulation of the interest of this type of a program. And from that point on

Mr. CARTER. They would hire a group of physicians to go about or as you said, perhaps mobile clinics

Mr. BARNABY. That would be one approach.

Mr. CARTER. Yes. Who would be the clientele, what people would you run through these multiphasic screening clinics? Would anyone have access to this?

Mr. BARNABY. I think it would be available to those people and again

Mr. CARTER. To everyone, or to the poor and underprivileged? Mr. BARNABY. They would certainly be one element of the people who should be getting care who are not getting it now.

Mr. CARTER. You have not answered my question. Is it for all people or just one particular group?

Mr. BARNABY. I think the freedom of choice of using this type of facility or using a private physician should be up to the patient.

Mr. CARTER. Regardless of what that patient might have, if he is a rich man or poor man, he should be able to use this State-financed program

Mr. BARNABY. Or federally financed.

Mr. CARTER (continuing). Or whatever you might say.

Mr. BARNABY. But there should be fees charged to people so we do not usurp the role of the physician; usurp his practice, because there would be immediate resistance to this and I am not in line with providing these types of services free.

Mr. CARTER. Fees should be charged. You mean for poor people out of the ghettos when they are screened, they should be charged fees? They do not have the money.

Mr. BARNABY. I think in line with what is currently provided under the State indigent program, the people that need the care, the State could provide.

Mr. CARTER. Medicaid people, for instance, you think that they should be screened with little charge is that correct-people on medicaid? If you would say that, I would certainly agree. I think that they should be, but for wealthy people to go through multiphasic screening, people of means, I feel perhaps they should pay for that themselves, don't you.

Mr. BARNABY. I agree.

Mr. ROESCH. May I say something, Dr. Carter?

Mr. CARTER. Yes, sir.

Mr. ROESCH. As I understand this thing, this would not be just necessarily a governmental program. From some of the conversations that I have had with business people and with practicing physicians, the idea is to make a private enterprise or some sort of grouping together of elements, basically operated by the free enterprise structure for this purpose.

Now, I am informed that this is not entirely possible. I am sure you are aware of the fact these ideas are not coming from me in terms of originating them.

Mr. CARTER. Yes, sir. Of course, in many of our States, we do have screening centers at the present time. Our public health services offer quite a few services such as that. For instance, we have mobile tuberculosis units which go about the area X-raying people, and they have been of great help.

Also, they provide services for examination of women who have possible uterine cancer, do Pap smears on them.

This, of course, applies to the poor people. Well, I think it should, I think we should offer all of the help to them we can. When you get into multiphasic screening clinics which apply to everyone, this is quite a departure from the present practice of physicians throughout our country, and the programs throughout our country.

Thank you very much.

Mr. ROGERS. Mr. Preyer?

Mr. PREYER. One question of Mr. Jensen.

I wonder if the Governors' conference had any discussion concerning the revision of the allocation formula, and I am speaking of the squaring formula. The contention is that the squaring per capita income as used in the formula weights the formula disproportionately in favor of a low per capita income State. This is discriminating against the highly urbanized States such as New York, California, at the expense of others.

A quick look at hte tables would seem to indicate that doing away with this formula would result in approximately half of the States in the Union getting more funds out of the formula. The lower per capita income States, among which I am surprised to find Florida, would get a little less.

Governors are traditionally jealous of giving away any money and are fighting for their share of it. I thought it would be of interest if the Governors did agree with the revised formula.

Mr. JENSEN. There has not been any discussion among the Governors as far as this specific proposal, at least to my knowledge. And because of the very factors that you pointed out, that half the States would get more and half would get less, I would doubt whether there would be a concensus among the Governors on the allocation formula. Mr. PREYER. They would have to wrestle for it.

Mr. ROGERS. If the gentleman will permit, I might say in doing away with the formula, which has been recommended by everyone, because the impetus has been placed on the rural areas, we would allow the States to set priorities within the State as to whether they want to go ahead and help in the rural area wherever the need.

The allocation funds will no longer be just squaring the per capita figure in the population, but there will be, according to the bill, one of the bills we put in with most of the subcommittees, the need for the facility would be a factor that we do not know what it will be. So to say one State will receive less than and others more, I do not think is a correct statement at this point, because it is quite possible that Florida's needs may be far more than New York's. So that would be a part of the new formula of need per capita income and population.

That is why we put in the need factor because this is what we want to get to, the need, no matter whether it is in your rural area or urban area and this is the new formula factor we would try to develop.

Mr. PREYER. You would eliminate the mechanical determination. Mr. ROGERS. Automatically the dumping of the per capita, but they did not include need to the present formula, which I think is outmoded. I think we should include need.

Mr. JARMAN. Mr. Hastings?

Mr. HASTINGS. Just one question, Mr. Jensen.

You made reference at least twice to increased cost of hospital health care as a direct result of implementation of medicaid.

In line with that, does the National Governors' Conference have any recommendations as to the changes in medicaid?

Mr. JENSEN. I believe one of the recommendations was to abandon the mandated costs-plus formula now used for determining reimbursements under the medicaid program.

Also, I referred in my testimony to a document presented to the Governors, as a discussion piece, which was "Moderating the Cost of Hospital Care." (See p. 127.)

In that document there are some specific proposals presented and various alternatives for the Governors to explore. I think the cost-plus method, as far as reimbursement under medicaid, is one that the Governor's had some serious reservations about.

Mr. HASTINGS. Their alternative would be what?

Mr. JENSEN. Bob, you may have some comments as far as some alternatives to the cost-plus methods. I do not believe I could provide you a satisfactory answer on that.

Mr. ROESCH. I am not sure I could either at this point.

Mr. JENSEN. This is one of the areas that the Governors, during the next 3 to 4 months, through the Human Resources Committee of the National Governors' Conference, chaired by Governor Rockefeller with the assistance of their advisory task force-are going to study.

I just hope that if this committee, as was indicated yesterday in the hearings, is going to have hearings on health care costs and hospital