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any health service can only be measured in terms of care to the patient.

When we discuss children and their health problems, we quickly look at the mortality rate of the area concerned.

When we discuss the aged, we also examine the mortality rate, yet these crude death rates do not give us a true picture of the causes and effects. We must examine them for reasons.

When the aged reach the hospital in extremis and die within a 24-hour period, we do not consider this a problem of the receiving hospital, but rather the nursing home that waited until the last moment' to hospitalize the patient.

Medical schools might extend their training to provide wardbound services in nursing homes in order to prevent patients having to enter the hospital too early or too late.

Senator RANDOLPH. Mrs. Dudley, the nursing homes that waited until the last moment to hospitalize the patient-now, did the nursing home do this because of its interest in making another dollar, or was it because in the nursing home there was no one who realized the need of the patient for hospital care?

Mrs. DUDLEY. I would not wish to indict all nursing homes in terms of that statement. But I do feel very strongly that many times the patients are sent to the hospital during the middle of the night, or during periods when the doctor may not have been in the nursing home to look at the patient.

I think that most treatments are at the request of the visiting physician who goes to the nursing home to see the patient—unless there is an accident—the patient falls out of the bed and breaks an arm, which is a very obvious infirmity that can only be taken care within the boundaries of a hospital.

Senator RANDOLPH. Then you would relieve, in general, the nursing home of the responsibility?

Mrs. DUDLEY. Yes, I believe that most of the treatments are directed by the visiting physician in that nursing home.

Senator RANDOLPH. The reason I ask you that question is because you really hadn't differentiated here between the nursing home and the physician who made the examination.

Now, I am not trying to draw any comparisons—odious or otherwise.

Mrs. Dudley. This is why I suggested that possibly the schools of medicine might use their training physicians to do ward rounds in nursing homes as they are doing in some of the training hospitals.

Senator RANDOLPH. Thank you, Mrs. Dudley.

(Subsequent to the hearing, Senator Williams asked the following questions in a letter to Mrs. Dudley:)

1. Mrs. Dudley's statement indicates that the California State Department of Welfare was asked to "insure a more speedy method of processing claims." What was the reply to this inquiry?

2. May we have additional details on your program to help secure training for returning Vietnam veterans who served in combat as medics? Would their services be especially helpful in providing services needed by the elderly with chronic illness, perhaps in nursing homes?

3. What is the differential in terms of revenue" nursing care reimbursement under the Medi-Cal and Medicare programs in California ?

4. Has the OEO Neighborhood Health Center been of help in providing needed services in ghetto areas? If so, would you care to see an extension of such services?

24–798—69—pt. 35

(The following reply was received :)

1. Enclosed is a copy of the letter which I wrote to Spencer Williams, Director of Human Relations, State of California.* His reply was: (1) that it was too costly to establish a computer center in Southern California, and (2) plans are underway for each certified recipient to have more than one eligibility card in order to facilitate faster service.

Since our hearing before your committee, much has happened in California, relative to an investigation report of Medical abuses by the office of the State Attorney General. I feel that as a result, changes in the processing of claims by the fiscal agent Blue Shield will be made. (See newspaper article attached.)

2. The Los Angeles Urban League has a Department of Veterans Affairs. Meetings were held with the Director of the Veterans' Administration Hospital, Director of Para-medical training at the Lutheran Hospital and other educators in order to establish para-medical training centers for returning Vietnam veterans who had ably served as medics while on duty. State Senator Dymally, Cbairman, Senate Health & Welfare Committee, introduced legislation (which is described in enclosed bill) to facilitate returning Veterans getting credit for their military training. We feel that those Veterans have a wealth of on-the-job training in para-medical care. There must be a transitional use of these men and women at a pay scale that would be inducing. I've noted that nursing homes have a high percentage of male nursing staff which is reflective of the acceptance by men of the para-medical professions.

3. Blue Shield and Blue Cross have described the "differential in terms of revenue nursing care reimbursement" as follows:

Medicare-pays for costs incurred on a cost-plus basis.

Medi-Cal-A ceiling is placed on care. California State Department of Finance allows a maximum of $14 per day. (Most facilities are paid at an average rate of $8 per day.) The fiscal intermediary sets the fee for each facility on the basis of information submitted by the facility. On January 1, 1969, all nursing home facilities will be certified under Medical in the state ; we questioned their efforts to weed out the less desirable facilities.

4. The Watts OEO Center, as well as others in the United States, are providing major health care to their communities. Barriers to acceptance of this care range from undemocratic geographic boundaries to over-subscribed emergency room use. Aged patients need immediate emergency treatment when threatening heart failure.

Community multi-service units of health care offer this needed care. I would hope that multi-phasic, multi-service centers of health are to be a way of life in the future in America. Emphasis on multi-phasic screening for preventative health must be stressed as an important adjunct to this service.

I hope that your four questions have been adequately answered. We have very definite feelings about the use of the returning veteran, and would hope that his role could be spelled out nationally in this field of health care. California has become receptive. The AMA Emergency Health Forum of 1968 was asked by me, to consider the use of the Veteran Medic also. They felt that the pay-scale for such services were much too low to induce their interest status and commensurate pay can be achieved, I think.

Senator RANDOLPH. Dr. Littlejohn will now speak to you regarding questions 1 and 3.

STATEMENT OF CLARENCE G. LITTLEJOHN, M.D., FAAP, MEMBER,

BOARD OF DIRECTORS AND CHAIRMAN OF HEALTH COMMITTEE, URBAN LEAGUE OF GREATER LOS ANGELES

Dr. LITTLEJOHN. Honorable Chairman, Members of the subcommittee, I am Dr. Clarence G. Littlejohn, member of the board of directors of the Los Angeles Urban League and the health chairman of this organization.

I am practicing pediatrician and pediatrics cardiologist on the staff of several major and minor hospitals of the city. I am a volunteer professor at the USC School of Medicine. I am also involved in the black congress of the medical association of the medical society and the Los Angeles County Medical Association.

*See app. 1, p. 724.

As a major organization concerned with the health and welfare of our community and our Nation, we are pleased to participate in this hearing, hoping that by such deliberations the impending crisis in health care of the poor and needy will be averted.

The Medi-Cal program as presently administered actually promotes the exodus of medical resources from the ghetto. More and more health care vendors are becoming disgusted with the program and phasing it out as an economic hazard. More and more recipients, frustrated in their attempts to obtain health care near their homes, have returned to the county corridors and/or neighborhood emergency rooms for disjuncted, crisis-type medical care.

Why is this so ? As a black physician, a product of the ghetto and as chairman of the Health Committee of Greater Los Angeles Urban League, I have been intimately involved in health care of our community and discussions of the same. The above observation continues to prevail in spite of the numerous efforts of the health care vendors of the black and brown communities, individually, and in groups, locally and in Sacramento, to rectify the inequities in the program so that they might continue to take care of their people. Considerable sacrifices of time and money have been made by these vendors with only minimal progress.

Dr. Francisco Barbera was in the audience prior to the lunch break. He is a representative of the Mexican-American community. He left a little document I would like to present to you.

His business was that of attending other business meetings, the result of which is to help subsidize his medical practice.

The observations made herewith are based upon individual and group interviews and conferences with scores of physicians, dentists, pharmacists, other health care vendors, and Medi-Cal recipients. The long delays in payment, nonpayment of many justified services, harassment of vendors, geographic discrimination in payment schedules and the demeaning superscrutiny of claims of ghetto doctors—with the "all those doctors in the ghetto are cheating, giving bad medicine, and making too much money" attitude—are all contributing to the rapid reduction of health care services.

Many health care vendors feel that those in charge are purposely again decimating the poor and needy by forcing them to barter their dignity for health care in crowded clinics and county corridors—particularly in Los Angeles—often many miles away and receiving such care all too frequently in a demeaning, discourteous manner.

Who suffers? The community. The recipient. The vendor is greatly inconvenienced, but he can move out and become employed elsewhere.

Health care among the disadvantaged approaches “pre-Watts” days. One of the lessons learned, hopefully, from the Watts conflagration was that a large segment of the population of civilized Los Angeles had been sorely neglected-particularly health wise—but could and would not be forever neglected.

When the State administration announced its cuts, considerable confusion, unrest and apprehension permeated the area. This feeling is again becoming more and more evident as more and more Medi-Cal recipients are frustrated in their attempts to obtain medical services. Emergency rooms are having difficulty referring these patients for followup care to health care vendors in their respective communities. To many vendors, the Medi-Cal program is just too hazardous, economically.

GHETTO PHYSICIANS HARD-HIT

Ghetto physicians and other vendors are hardest hit, but intimidation and fear of reprisals prevent many from speaking out. Some have practices consisting of over 95 percent welfare recipients. Most have ħad to hire more personnel just to handle the Medi-Cal paperwork.

In spite of unfulfilled promise after promise on the part of CPS, many vendors have continued to empathize with the underprivileged, continuing their health care services.

Many have exhausted their savings, have gone on to borrow thousands of dollars to make payroll and other expenses and/or lost their credit ratings, due to nonpayment or long-delayed payment of MediCal claims.

Entire clinics have closed up. Many pharmacists have closed and others are on the verge. Near-foreclosure on homes have occurred as well as actual repossession of doctors' office equipment. Banks have refused loans on accounts receivable from Medi-Cal due to inability to ascertain dates—and amounts of payment.

An economic lid is placed on the ghetto. This ceiling restricts the quality of employees, the adequacy of working conditions, the desirability of the physical structure of the office or establishment, and frequently the quality of service rendered.

The unpredictability of payment—both time and amount-precludes any planning, even short-range planning for health care facilities by private concerns. In such a blighted area, private enterprise should be encouraged, not discouraged. As vendors of services leave the area, they are not being replaced. More health care personnel become unemployed.

The economic ceiling on the ghetto was recently endorsed by a county supervisor who was quoted by the Los Angeles Times as saying that private doctors should earn no more than $11,000 to $14,000 from taking care of county welfare cases.

Computing this on a 40-hour week—most doctors work in excess of 50 hours a week—this is maximally $8 per hour, less than plumbers' fees and considerably less than attorneys' fees. Inequitable substandard fees imposed on the ghetto suggest a continuing desire to keep the ghetto poor.

Rape of the ghetto of medical services is becoming increasingly evident as more and more vendors of health care are leaving the area. Many are locating on the periphery of the ghetto and are reducing their Medi-Cal participation as rapidly as their private practice increases. Others are moving to the periphery in order to increase the amount of Medi-Cal payments and decrease delays in the receipt of such payments.

Some are seeing recipients only on certain days or at certain times during the day. Some are outright refusing to see recipients. Continuity of medical care is becoming nonexistent. Community hospitals are having increased difficulty obtaining consultants in upgrading medical care at the community level and with Los Angeles so spread out, this is profoundly tragic.

MOONLIGHTING PHYSICIANS Moonlighting in Watts and east Los Angeles is becoming more prevalent and it is as evil as the absentee landlord system. All too frequently, the moonlighting physician is not available more than one-half to 1 day per week for followup, and emergency rooms, or the few doctors left in the ghetto are asked to perform this service.

The moonlighting vendor is frequently from an area with a higher unit-fee for service-rating by the Medi-Cal program and, of course, bills from his office so located.

Denial of equal job opportunity is inherent in these inequitable and probably illegal disparities.

Discriminatory and severe reviews of claims of major providers of services to the poor frequently cause interminable delays in payments and denial of payments for substantiated services. Many cuts and deletions appear capricious, arbitrary, and certainly discriminatory.

For example: two comparably trained physicians billing for comparable services on patients in the same hospital side by side in the same room may receive different fees dependent upon the location of their billing office in Los Angeles County.

Frequently, in the same batch of claims returned to vendors, there may be three or more different fees for the same item or service number. These claims are supposedly reviewed by peers. The whimsical nature and arbitrariness of cuts, particularly of claims from ghetto physicians, suggest lack of guidelines and/or the political philosophies and prejudices creeping into the judgments of some reviewers. It also suggests that many reviewers are ill-informed and/or insensitive to the health care among people of poverty. This system must be improved.

Financial and tax incentives are being suggested as means of attracting more dedicated businesses, teachers and other needs of the ghetto. The health care vendors have not asked for nor do they expect any such incentive. The vast majority are dedicated men and women who want only equal job opportunity to help to provide equal health opportunity to those who so drastically need it.

PHYSICIANS FEES DEFENDED

Here I would like to make a comment about the much-discussed and probably too-much-discussed fees. It was pointed out by one of the speakers that over a thousand doctors in California made $70,000 to $100,000.

Just some quick computations on that. You take the average doctor working 50 hours per week. This averages out to $12—the gross is usually about 50 percent-I mean, the net is about 50 percent of the gross. This averages about $12 to $15 per hour.

Even the doctor who makes $100,000 does not get more than $20 per hour.

Now, the county medical association—the California Medical Association-did some investigation, and these figures were published, and

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