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appropriateness. We pledge continued effort to further strengthen all aspects of peer review.

Now, we as a profession testified and warned government social planners, back in 1962 and 1964, for example, that hospitals would be crowded, that costs would rise, and the program would be inflationary. And frankly, we have not been wrong in this prediction.

AVAILABILITY OF HEALTH SERVICES

Now, a second question is asked if there is a significant number of elderly persons in California who encounter difficulty in securing health services because of unavailability or increasing costs of such services.

In all candor, I believe there are yet a number of people of all ages, , young and old alike, who do not receive adequate medical care for some reasons. Accessibility is sometimes a reason, but, I must add two other reasons for this difficulty; they are ignorance and psychological barriers such as fear, mistrust, and apprehension.

I believe many of these deprived people live in our city slums and in rural areas. Our recommendations-well, let's recognize the social problems along with medical problems. Ignorance has to give way to education; favored home remedies have to give way to desires for scientific medical care--and quackery has to be eliminated.

And we have to overcome our shortage of health care professionals if we are going to be capable of giving medical care to every citizen of this country in the most ideal terms of modern scientific medicine.

What then are we doing? The medical profession is involved in several OEO neighborhood health center medical programs in addition to rural migratory health care programs. We are working with the health insurance industry and Blue Shield to improve voluntary prepaid health insurance. Our association is now compiling the *Essential Components of Adequate Health Care Coverage” as a guideline and standard for the consumer public.

We are also trying to educate the public to the advantages of preventive medicine. Los Angeles County Medical Association supported a public education program on the necessity of "Pap smears" in a portion of Los Angeles called the Watts area. We have sponsored our State's cancer antiquackery law which has saved patients' lives—by preventing futile treatments and wasteful expenditures.

Our delegation to the American Medical Association supported advocacy, in a preliminary report, of the concept of income tax credits to provide financial assistance to that segment of our population unable to afford complete and adequate health insurance coverage-regardless of the age of the needy individual. We hope and urge this concept will receive legislative consideration by Congress during the next session.

Now, we all have a responsibility in programs for the aged. First, to lower the cost of health care. Second, at the same time to maintain quality of health care. I say to you, doctors will accept their responsi

I bility. But we feel that the patient, his relatives, and his family, must also accept theirs, and not demand a stay in the hospital longer than is necessary, and not try to remain in extended care facilities for a longer period of time than is absolutely necessary.

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And that they not ask for unnecessary medical services. I also feel that social workers have a responsibility to try to control health care costs. She should not side with the patient on every request that is submitted, but must carry out just what is provided in the terms of the law itself.

The third injury concerns the impact of medicare and Medi-Cal on the quality of health services provided for the elderly. While some feared that these programs would greatly overtax our present system of providing health care, I do not believe we are in a crisis.

Yes, our hospitals are crowded and yes, we do need more health care professionals. But I believe the quality of care rendered today reaches a broader segment of the public. I realize this is a generalization, but I am speaking from my experience and that of many of my many colleagues over the State.

The quality of mainstream health care in California is high-yet it is most important that we work together getting all of our citizens into that mainstream of medical care.

QUESTIONS ABOUT PHYSICIANS' FEES Too much attention has been directed toward the physician's fees. Figures can be made to mean anything that they want to. But in an effort to achieve solutions to medical services for the aged, and to cut medical care costs, there are some things that I would like to mention.

It is interesting to note that the Medi-Cal budgeted in 1967–68, $159,500,000 for physicians' services. But they actually paid out only $122,100,000.

I would also like to state that over the overall health care cost dollar in the Medi-Cal program, the physician's fees amount to just 19 to 20 percent of the entire health care cost dollar. But it is that extra day in the acute hospital that we must not allow to be abused, because this is where the cost of this program centers.

Doctors need legal and administrative regulations to enable them to apply sound medical judgment consonant with the economical implementation of the law in regard to extended care facilities. A difference between needed nursing home care and custodial or remedial care must be acknowledged.

Also an attempt should be made to investigate unnecessary and unjustifiable use of ambulances and ancillary services. There must be developed a better planning of hospital beds and facilities and develop new health services; that is, methods of preventive and rehabilitative medicine.

I think, too, that we should see that our voluntary health insurance plans develop provisions for payment of voluntary out-patient services, diagnostic services, and minor surgical procedures themselves.

The final inquiry stems from the possibility of congressional cutbacks in the title 19 program. As you know, the medical profession supports the principle of government providing financial assistance to persons not able to provide for their own health care. Title 19, the medicaid law, is based on this principle.

I therefore strongly oppose proposed cutbacks in the present program as a deterrent to the provision of health care for this needy class of people. I think this response speaks for itself.

May I again thank you for the privilege of allowing me to present these remarks, and at this time, with your permission, I would like to call upon Dr. Shapiro, if he has any comment to make particularly in regard to migratory labor.

Senator RANDOLPH. Do you want questions, Mr. Chairman, that would refer to the testimony of Dr. Todd ?

Senator WILLIAMS. I think we would. I think we ought to, if you have questions, I think we ought to address them to Dr. Todd before his associate speaks.

Senator RANDOLPH. Thank you very much, Mr. Chairman. You speak of the deviant doctor in California or elsewhere.

Now, I am wondering if you, for the record, would say that this is a very small percentage of the medical profession in California, or say, otherwise, and say what steps are being taken that you have indicated to keep this a small segment.

Dr. Todd. Thank you. I am glad to have this opportunity.

In the earlier presentation that was made, a question was asked as to how many doctors participate in our California Medi-Cal program, to begin with. As I stated earlier, we have some 24,000 members of the California Medical Association, and I am happy to say that with the program that is now in operation we have over 18,000 of those doctors participating in the Medi-Cal program-much in contrast to previous testimony that was given.

I have the documented figures in front of me. I said 18,250 out of 24,000. Now we recognize that there are some of these individuals who are deviant practitioners. We, as a medical profession association, feel that we have an obligation to protect the public and public funds. And deviant physicians are those who we simply will not tolerate.

Through our peer review committee activities we are able to pick up a number of these men whose practices are far from the usual. These are turned over to the bureau

Senator WILLIAMS. What do you call that bureau?
Dr. Todd. The office of health care services.
Senator WILLIAMS. No, no. Who reviews it?
Dr. TODD. Who reviews it? The deviant doctors?
Senator WILLIAMS. The peer-what?
Dr. TODD. These are made-oh, the peer review?

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PROTECTION AGAINST DEVIANT PHYSICIANS

These are made first by California Blue Shield—that is, the carrier. These in turn then are turned over to the peer review committees of the county medical societies. If they find that claims are unjustifiedthat there are excessive practices—that there is overutilization of services themselves, the physician is called in and talked to in this regard by his own peers.

After this is done, a warning is given. If he does not heed the warning and does not follow the suggestions, he then is notified that he has his name has been presented before the Office of Health Care Services of the State administration.

And they in turn then have the obligation of submitting his to the attorney general.

Senator RANDOLPH. Doctor, I wish to pursue what the chairman has said. You say this is the procedure, and I commend you.

Now, how many persons, to your knowledge, have been called before those peers and had discussions of their malpractice? This is important to the committee.

Dr. Todd. Yes, it is. It is a function that varies entirely with each one of the county medical societies. In Los Angeles County itself, our largest county, and of course the largest county medical association in the country, has been very active in this activity, and a number of physicians—a proportionate number of physicians—have been called in and had this discussion with them.

I can tell you, specifically, that of the physicians alone, some nine or 10 physicians have been reported to the office of health care services, and in turn, turned over for review by the attorney general's office.

Senator RANDOLPH. Thank you, Dr. Todd. I think that the record should indicate that not only would the medical profession, as you have indicated, be very desirous of checking these practices, which are not consonant with good medical ethics, but I think here also I would like to speak from personal knowledge.

I think that the voluntary health insurance programs have helped to ferret out some of these people. I think the Blue Shield needs a word here today for their efforts;

would you agree? Dr. Todd. I certainly would. I think they have had a tremendous task. I wonder if you gentlemen can envision the receipt of 100,000 claims per day? This is a tremendous task that they are faced with. The computers—they have six computers during this operation here for this alone-this is a tremendous job, and there obviously have been some errors in the State.

But I think we are making progress in this activity, because I want to sincerely say to you that the majority of doctors practicing medicine are interested in making this program work.

Senator RANDOLPH. May I pursue one or two other questions, Mr. Chairman?

You have spoken, doctor, of ignorance and psychological reasons why perhaps programs have not been as effective as they might have been.

Now, where does education come in, and how can education be used, and perhaps in what way can the Congress, without laying down a straitjacketed guideline, are there criteria the Congress itself, through agency administration, can bring into being to aid this effort

Dr. TODD. Yes. Dr. Shapiro would like to answer that, if you would. He is the chairman of our Community Health Commission of the State Medical Association.

STATEMENT OF MARVIN J. SHAPIRO, COUNCIL MEMBER,

CALIFORNIA MEDICAL ASSOCIATION

Dr. SHAPIRO. Senator, I think that reference was made earlier to this cannery workers multiphasic screening program. I think what we have learned from that illustrates this particular problem very well.

The cannery workers program last year surveyed several thousand people. When they got quantitative results, they found that 48 percent of these people had no doctor to whom the results could be sent, which

of course raises another problem in the area of multiphasic screeningbeing different from that of the Kaiser program, where they already have a doctor.

California Medical Association was brought into it by the trust in an attempt to see to it that the patients on whom abnormal findings were detected were referred to doctors who would follow up and see that they were properly taken care of.

We worked very actively with the trust on this.

One of the big problems, however, has been that no matter how vigorously the recommendations are made to the people, on whom abnormal findings are detected, we can't get them to go to the doctor. And it doesn't do much good to get the abnormal findings if we can't get the followup.

I think this is the sort of thing that the doctor is alluding to, and certainly that we must educate the people of the necessity of followup. It has to be a constructive program.

Senator RANDOLPH. Thank you, Mr. Chairman. That's all the questions that I have.

Senator WILLIAMS. Thank you very much.
Did you have any other-
Dr. SHAPIRO. Nothing that need take the time of the committee, I am

sure.

Senator RANDOLPH. Your testimony was very informative and helpful, I am sure, to our committee.

Dr. TODD. Thank you. It is a pleasure to be here.

Senator WILLIAMS. I was very encouraged by your statement, Dr. Todd. I have had a feeling that the medical association was very slow in coming to these positions—the particular programs of medicare and Medi-Cal, but evidently the acceptance is there.

Dr. Todd. We are trying to work with it, and you will find that doctors are participating with the program.

Senator WILLIAMS. Thank you. Very good, thank you very much.

Is Mr. Carbray here? The chairman of the senior citizens activity committee of this county—and I think you know something about the AFL-CIO; don't you?

Mr. CARBRAY. I have a feeling that I do, Mr. Chairman.

Senator WILLIAMS. You have Mr. Davidson and Mr. Hartley with you?

Mr. CARBRAY. That is correct. Rob and Louie; would you come up here?

STATEMENT OF JAMES CARBRAY, CHAIRMAN, SENIOR CITIZENS

ACTIVITIES COMMITTEE Mr. CARBRAY. If I may, Mr. Chairman, may I express the appreciation of the Los Angeles County Federation of Labor and also the appreciation of the National Council of Senior Citizens, on my own behalf, for this invitation.

However, as you will note from the agenda, I am speaking today for the Federation of Labor of Los Angeles County. Immediately following my rather brief testimony, I would respectfully suggest that you hear a very brief statement from Mr. Davidson and Mr. Hartley.

And now, taking the lead from Senator Randolph to say something objective once in a while about the things that come to our attention,

24–798—69—pt. 3

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