Mrs. MACVICAR. That is right. Mr. CARTER. Does that condition exist today? Mrs. MACVICAR. There is so much more to be learned today, Dr. Carter, that we do not believe we can afford to have the student nurse working 20, 30, 40 hours a week. I should not have said 20 because we have our seniors in the hospital 24 hours a week. But this experience is educational preparation. The seniors at the University of Maryland are practicing as leaders of small work groups which means they have approximately 20 to 30 patients under their jurisdiction, and they have the associate degree nurse and the licensed practical nurse and the nurse aide on the team. The senior at the University of Maryland is learning how to guide this group of persons to give this care. She identifies what only she can do and she gives the care. There seems to be some misconception about the fact that if you are a graduate of a university program, ergo, you do not know how to take care of the patients nor do you ever take care of the patients, and this is not so. This is not so. Mr. CARTER. I have a niece who gradutaed from Vanderbilt in nursing. Mrs. MACVICAR. I cannot talk for Vanderbilt. I can only talk for Ohio State University, Western Reserve and Cleveland, and the University of Maryland, and I assure you that as a teacher I am in a uniform helping the students take care of paitents. Mr. CARTER. I make no indictment of any group. I am with both. groups. I want more nurses, whether they be from hospitals or from colleges. I am all for them, and we want to do all we can to implement the program, to help it in that way. What about the salaries of nurses today? Are they do they receive adequate pay for what they do? Mrs. MACVICAR. Well, I am glad I can report to the committee that the salaries are going up in almost every section of the country. There are some that are still lagging behind. But I believe that we are finally in a position to recruit on the basis of the fact that we are now competitive, which I think was a pretty sad state of affairs for some time. We were losing young men and women to the professions simply because the salaries were not competitive, and it does something for the image and who wants to go into this kind of a profession? Mr. CARTER. Having worked as it happens with many, many wonderful nurses in my career as a physician, I must say that they have been greatly underpaid in most instances for the work which they do. Most of them-most of these people have been devoted and perhaps if we paid them a little bit more, we might secure more people in this profession which is much needed and which performs such vital service to our sick. Mrs. MACVICAR. Naturally, I agree with you, Mr. Carter. Mr. CARTER. Thank you, ma'am. Mr. NELSEN. Off the record. (Discussion off the record.) Mr. CARTER. I am interested that vocational schools are taking up paramedical studies in my area. We have 14 vocational schools in my district and they are taking up paramedical studies. Mrs. MACVICAR. Yes, sir. Mr. CARTER. I am thankful for that. It has been delightful to talk with you. Mr. CARTER. Thank you. Mr. ROGERS. Mr. Hastings? Mr. HASTINGS. No questions, Mr. Chairman. Mr. ROGERS. As I understand it, it is the feel of the nurses that the Appropriations Committee, and I can well understand this, has not met the responsibilities that we need to today in this day and time, even in accordance with the authorization. Mrs. MACVICAR. That is right. Mr. ROGERS. I hope you have made this point with the Appropriations Committee and this committee will try to do what we can with them also to get the point across. I am very much concerned about that. Mr. CARTER. Certainly, I would like to see it, Mr. Chairman. If you would yield, I would certainly like to see it brought up to where it was or above if we can afford it. Mr. ROGERS. What is the estimated shortage of nurses now? Mrs. MACVICAR. About 125,000. We have 659,000 and it is estimated that we need 775,000. Mr. ROGERS. Are we doing anything to bring back in the nurse who has married, gotten away in nursing? Is there much of a program on that? Mrs. MACVICAR. Yes, sir. Almost every nursing district is initiating refresher programs. There is Mr. ROGERS. Are these generally with the junior colleges? Mr. ROGERS. Hospitals themselves? Mrs. MACVICAR. Yes. Mr. ROGERS. I see. Could you give us an estimate of how many have been encouraged to come back in? Miss THOMPSON. I believe the figure is around 6,500. Now, not all of these are full-time employees. Some of them are part-time. Some of them intend to go back full-time as soon as they are able to. Mr. ROGERS. Well, in passing the legislation on our nurse training. we are trying to encourage, of course, the junior colleges to come in with their vast resources of manpower in conjunction with a hospital. Mrs. MACVICAR. That is right. Mr. ROGERS. We appreciate your testimony. It is most helpful and thank you for being here. Mrs. MACVICAR. Thank you. Mr. ROGERS. The next witness and the last witness for this afternoon will be Mr. James Ensign, vice president, Blue Cross Association. STATEMENT OF JAMES ENSIGN, VICE PRESIDENT, BLUE CROSS ASSOCIATION Mr. ROGERS. Mr. Ensign, we are delighted to have you here. If you have anyone you desire to bring with you to the table, feel free to do it, any of your association. Mr. ENSIGN. Thank you. I would like to identify Mr. George J. Kelley and Mr. Arthur Hiatt, who are valued associates of mine. Mr. ROGERS. We are delighted to have them here. Mr. ENSIGN. Mr. Chairman and members of the subcommittee, I am James M. Ensign, vice president, Blue Cross Association, the national organization of nonprofit Blue Cross Plans. I have a brief prepared statement. I appreciate this opportunity to appear before you today to testify on H.R. 6797 and H.R. 7059-the extension and modification of the Hill-Burton program. This renewal comes at a critical juncture in the evolution of America's health care system and presents an unparalleled opportunity to the Congress, the executive branch, and the health establishment to participate in the redesign of this vital program which in its first 23 years allocated over $3 billion in grants to the States for hospital and allied health facilities construction. The capacity of the Hill-Burton program to provide physical facilities of incalculable worth to the American people has been fully demonstrated. The Blue Cross Association, speaking in behalf of its 75 member plans (who collectively provide hospital benefits to more than 68 million American citizens of all ages, and provide administration of Federal Government programs to an additional 24 million persons), supports the general provisions of H. R. 6797 and H.R. 7059 concerning the extension of present authority and new programs for increased assistance for hospital modernization. In expressing its support for these bills, Blue Cross would like to offer a few observations for the benefit of the committee, reflecting its experience over the past several years. Further expenditure of capital funds, either through grants or loans, should be related more energetically to the process of planning such as that suggested in section 13 of H.R. 7059. A properly designed capital structure can have a favorable influence on costs, use and accessibility of health facilities, and services. Our current problems in all three areas relate in significant part to the relatively unplanned growth of services. 1 Blue Cross Association in a recent policy statement pointed out that the heart of planning lies in the individual institution where the process serves management in clearly focusing on community needs and efficient means of meeting them. From that individual base, there is needed in every State a systematic structure of planning which can guide capital growth incentives and disciplines toward less fragmented care and better continuity of care. The common coordinating framework embodied in comprehensive health planning must be implemented to embrace regional medical programs, Hill-Burton, and other Federal health programs. After 1970, Hill-Burton funds should be given to States and localities only where a coordinating planning agency exists and where institutions benefiting from the legislation are cooperating with the planning system. As a further incentive toward a more systematic growth of health facilities, grants and loans should be used selectively. Grants should be used to encourage innovation and to promote greater productivity and loans with grants should be used to sustain the capacity of the system for acute care. For example, grants could be made for ambulatory facilities, shared facilities, development of satellite units, and the housing of coordinated professional practice or group practice units as suggested in H.R. 6797 (pt. C). Blue Cross Association, "Statement of Policy on Planning of Health Facilities and Services, 1968." (See p. 184.) Beyond the above, funds should be made available for research and demonstration to guard against rigidity and outmoded patterns. Communities wishing to experiment with various institutional forms should be encouraged to do so. A significant source of capital funds is still the private sector or local government. Let the Federal Government be a major stimulus in the quest for efficiency and effectiveness. Also, it would be well, as stated by Walter J. McNerney, president of Blue Cross Association, for Federal money to be made available under the program to assist selective communities on a direct basis without local or State matching funds where poverty is pervasive and there is an urgent need to solve access problems. Projects should be coordinated with neighborhood health center, model city, and community mental health facilities programs. Blue Cross has recognized the need to relate its payments for capital purposes to the planning process and its corollary obligation to strengthen the process. Toward that end, Blue Cross Plans have been instrumental in the organization and support of many areawide planning agencies through participation in their boards and committees, provision of support services, such as personnel, housing, data collection and processing, and direct financial support now at an annual level of more than half a million dollars. These and other steps, including explorations of various incentive payment methods, are in response to the growing realization that the health economy is overheated; too much of the recent increases in health expenditures are absolved by price changes as opposed to service increases. It makes little sense to pour large additional moneys into a system under the circumstances without at the same time increasing the productivity of the system. The American Hospital Association has also recognized this fact. and published relevant policies.' If the Federal Government were to join by coordinating the control programs it sponsors and spending its moneys to reinforce the general patterns and objectives set forth, we could hope for some moderation in costs and improvements in services for rich and poor alike. Without action along these lines, the number of dollars contemplated under H.R. 6797 and H.R. 7059 could serve to aggravate an already serious public policy problem. The health care system needs selective intervention and now is the time to act. (A copy of Blue Cross Association's policy statement on "Planning of Health Facilities and Services" follows:) BLUE CROSS ASSOCIATION Attached is a copy of the Blue Cross Association policy statement on "Planning of Health Facilities and Services," approved by the Blue Cross Association Board of Governors on September 15, 1968. Accompanying its approval, the Board urged each Blue Cross Plan to adopt this or a similar policy statement regarding planning. Further, each Plan was requested to identify a member of top management with special competency in areawide planning who would help provide leadership in its development in the Plan area. A series of technical meetings involving Blue Cross planning specialist is contemplated which will give further impetus to Blue Cross' support of this extremely important concept. 1 American Hospital Association, "Statement on the Financial Requirements of Health Care Institutions and Services, 1969." American Hospital Association, "Statement on Planning, 1969.” Blue Cross Plans have been involved with areawide planning in many ways over the past several years, by providing financial support, board and committee representation, expert staff and statistical data. The current program is designed to broaden this support in concert with several national programs recently promulgated. WALTER J. MCNERNEY, President. PLANNING OF HEALTH FACILITIES AND SERVICES A Statement of Policy-Blue Cross Association and Member Plans, September 1968 Historically, Blue Cross has supported the need for planning of health facilities and services. Blue Cross executives have taken leadership in forming and serving on planning agency boards, financial and professional contributions are made to planning programs, some Plans make conformance with area wide need a condition of membership and in other ways the concept of planning is corroborated. This statement is formulated to underscore Blue Cross' belief in planning, to give it further definition, and to express Blue Cross' convictions as a total system. RATIONALE OF PLANNING In terms of the formulation of operating objectives, their translation into programs, the assignment of responsibilities and resources, each weighed against the benefits of alternative courses, planning is a necessary part of the management of every successful organization. Its formality may vary, the the essential elements are there in one form or another. Planning among organizations varies considerably with the product or service involved, ranging from the relatively unplanned extremes of a speculative enterprise to the coordinated precision of a space shot. In recent years, it has become increasingly clear that the major constraints of a free market, e.g., competition, discrete consumers in a position of choice, and the animating force of demand (as opposed to need), are not always present nor possible in the health field. With the increasing priority of health in the order of human needs and the growth in the proportion of total resources that must be allocated to the health system, substitute incentives and controls must be developed. Benefits sought for the individual and the community defy compression into a concept such as "profit", and the achievement of increased productivity is slowed considerably by the difficulty and initial cost of substituting machines for men. Several signs point toward the desirability of more coordination. The field has significant and largely unexplained variation in quantity and quality of service; there is measurable overlap of functions along with gaps in the availability of services; and, operating units of submarginal size from a management point of view are common. Many individual providers of care have planned conscientiously to meet community needs as they discern them. However, they and the community did not have a structure that would ensure that the composite effect of their individual planning would be effective on a community-wide basis. If it is conceded that some of the vitality of the health field is derived from its pluralism, it should also be conceded that the closely related attribute of fragmentation can be seriously enervating. Blue Cross feels that one effective way to capitalize on the vitality and innovative qualities of a pluralistic system is to provide for more systematic coordination within and among the various health institutions and agencies, actively encouraged by all of the community's decisionmakers who are concerned with the distribution and financing of health care. Blue Cross wishes to make its support of such joint effort a matter of public record. Planning is a way of making the totality of health institutions and agencies greater than the sum of its parts. Before discussing the process of planning and Blue Cross' role in it, it would be well to acknowledge that planning cannot be the answer to the problems of providing health services. It can help significantly to guide the flow of community resources, and it can help establish rational parameters of use through control of the capital structure, but the health system demands more. In sensitive alignment with planning, other influences seeking greater effectiveness are needed, such as licensure, accreditation, utilization review and incentive reimbursement. A vast and complex professional field affecting virtually the entire population does not respond to one control system or easy solutions. 28-236 069- -13 |