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As to the manpower availability for preventive health services, we can only guess. Such preventive services as are professionally recognized as part of the community pattern of practice are payable through the Medi-Cal program. The extent that these services are actually furnished depends, therefore, upon the time and interest on the part of the individual practitioner and on the success of the admittedly limited health education activities in which the social work staff engages.

3. A distribution of the dollar expenditures by type of service is attached, both in table and in chart form. In reviewing this material it should be borne in mind that the Medi-Cal program is a supplementary resource to the aged and that the distribution does not include payments made on their behalf through the Medicare program.

4. The San Joaquin Medical Foundation approach of comprehensive review of all services furnished or generated by physicians is still under formal study. It is not possible to determine the advisability of wider application until more data has been collected and evaluated. Results of our initial evaluation are expected to become available by mid-1969. I have a strong suspicion this approach can be applied economically only if it is accompanied by the establishment of an effective EDP system for the compilation of profiles, both for patients and providers of service. Sincerely yours,

CAREL E. H. MULDER, Director.

[Attachments] TABLE 1.-AMOUNT AND PERCENT OF PAYMENTS TO ALL RECIPIENTS AND TO AGED RECIPIENTS, BY TYPE OF

SERVICE, FISCAL YEAR 1967-68

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1 Excludes $6,483,978 in nursing home adjustments retroactive to July 1966. Inclusion of this amount would increase the nursing home percent to 26.1 and reduce the other components slightly.

2 Retroactive nursing home adjustments to aged recipients are not known. Under the assumption that they total 84 percent of the full amount, and adjustments are included in total, this would represent 39.1 percent.

3 Inclusion of adjustment in the total payments, and 84 percent of the djustment in the aged category would not change this amount.

Sources: Services and Payments Report, April-June 1968, and unpublished back up data.

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PHYSICIANS

NURSING

HOMES 45.2 %

NURSING HOMES

64.8 %

al. 1 %

PHARMACISTS

7.5%

OTHER ANO
STATE MENTAL
HOSPITALS
19.4%

COUNTY
HASPITALS

17.0%

REMAINING
SERVICES

7.8%

OTHER AND
STATE MENTAL
HOSPITALS
10.3%

PHYSICIANS

10.2%

REMAINING
SERVICES

6.0%
PHARMACISTS

9.2 %
COUNTY
HOSPITALS
9.5%

SOURCE: THBLE / Mr. ORIOL. Mr. Skoien.

STATEMENT OF CHARLES W. SKOIEN, JR., EXECUTIVE DIRECTOR,

CALIFORNIA COMMISSION ON AGING

Thank you.

Mr. SKOIEN. The only thing that I am going to repeat and emphasize is not only that statement this morning by Mrs. Russell, but also re-emphasize that California is the forerunner in these programs for health care for our senior citizens. We must utilize the seniors in their own health programs, and we will mobilize--and must mobilize-and motivate the existing public and private agencies to recognize the need and then proceed.

This is being done today by the California Commission on Aging at the level of the local community.

The Reagan administration is endeavoring to provide California with a sound administrative program for the citizens of our State.

Mr. ORIOL. Thank you very, very much.

Our next witness is another person who has been very helpful to the committee.

Dr. Elsie Giorgi from the School of Medicine at USC. You have a time problem. I hope we haven't caused you too big a time problem. STATEMENT OF DR. ELSIE A. GIORGI, ASSISTANT PROFESSOR,

SCHOOL OF MEDICINE, UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIF,

Dr. GIORGI. I don't mind if you don't. At your request, I have prepared a statement. Before I start, however, I should like to make a few comments—if I may.

Today, I have been impressed with the great interest and concern of all who have appeared here. It is obvious that there is agreement as to the need for change. I must say, however, that I have been disappointed by the emphasis on funds rather than programs. We have much evidence that funds are no guarantee of service. This was particularly true of State government representatives. Mr. Mulder, for example, spoke of preventive care services for the elderly. He spoke about such services as if they were an actuality. Something Mr. Galbraith refers to as “word-fact". Where are those services? If they are present, they are certainly invisible.

During the past 5 years, I have participated in many similar discussions. We constantly talk, exchange ideas, and plan ad infinitumand then nothing of significance happens. I think it's time to stop talking, stop blaming, and start doing. I hope this once, it will be different. I hope this committee will see to that. For the first time, I sense a motivation for doing. For the first time, I am encouraged. That's why I'm here.

PROJECTED SHORTAGES AND Costs We really have no choice. We are at least 40 years behind. Unless we join forces toward the common goal of improved health care for our people, I do not think it is an exaggeration to predict that within the next 5 years, shortages will be so great, and costs so high that we will have a black market in medicine with care extended only to those who can pay exorbitant amounts or who are agreeable to paying under the table in government funded programs.

No amount of additional funds will help. Until we design new systems; train new types of health manpower; effectively coordinate what is already there; and provide dynamic health education—those additional funds will only serve to further inflate costs without improving or providing adequate health care services. We have already seen this happen. We don't need more of the same. I think an important step would be to consider health facilities public utilities subject to the same type of surveillance and regulation as public utilities. Why not? Health care is at least as important as our telephone and electric services. If such a system did nothing but prevent unnecessary duplication down the line-we would be well on our way to curtailing costs. This does not necessarily imply socialized medicine or government medicine. It would merely provide a much needed systems approach which the medical sector seems unable or unwilling to undertake. It is time for them to stop resisting new knowledge.

I appreciate your invitation to appear before your subcommittee on Health of the Elderly, with particular reference to the costs and delivery of health services to older Americans. I would like it clearly understood that my remarks are my own, and not to be interpreted as representative of any institution or organization with which I am affiliated.

TOTAL HEALTH At the outset, let me say that I find it impossible to confine my presentation to the elderly, since the health care of any age group really starts from birth or even before that. Man is inseparable not only from his physical and psychosocial environment, but also from his genetic inheritance. Total health involves careful attention to all of these in an integrated continuing and coordinated program. Neglect at any stage of growth and development requires increasingly heroic measures for correction of defects in later years. Dr. Robert Kemp expressed it exceedingly well. In speaking of the care of the previously neglected aging individual, he said—Why fix eyes that no longer want to seewhy fix feet that no longer want to walk? I certainly concur.

HEALTH CARE DELIVERY SYSTEM NEGLECTED

Equally neglected is this Nation's health care delivery system. It is now so sick and disorganized that nothing but heroic measures can possibly bring some order out of the chaos and ferment. I shall not bore you with a repetition of its inadequacies and inequities. These are already well known to you. Instead, I should like to devote this brief time to some comments on our almost hopelessly ineffective approach to correction of the defects and to some suggested alternative methods.

The current state of affairs did not happen overnight. In 1925, fully 40 years ago, the distinguished Dr. William Welch bemoaned the ever widening gap between highly advanced medical research and its clinical application. We have had no real change in medicine since the monumental Flexner studies of 1910–11. Dr. Flexner's assumption that advanced scientific research and education would automatically result in quality care has not been borne out. What is sorely needed right now is a clinical revolution-counterpart of the scientific revolution that followed the Flexner report. I do not intend revolution in an anarchistic sense, but rather to imply rapid change, for we are at least 40 years behind.

What has brought about this sudden state of emergency ? Many things, to be sure—but principally an enlightened public made aware of its right to good health, chiefly through medicare. That piece of legislation stimulated demand by providing funds and public education. It focused attention on the fact that funds do not necessarily provide services.

There are some who argue-was it wise to precipitate such a situation; to stimulate demand before services were available? Those who are concerned with quality and cost of care should not have wanted it any other way—for demand stimulates supply. If medicare accomplished nothing but this and indeed it has done much more—it could rest on its laurels. Without its impact, we would most assuredly have continued as we were; each year losing ground progressively and paying more for less, while morbidity figures increase steadily as glaring evidence of our 'deficiencies—especially when compared with other nations of far less affluence and technologic skills.

Mr. ORIOL. May I interrupt, Dr. Giorgi? May I also say that demand might stimulate inflation—there are those who say that this sudden calling for services has caused too much demand for too little supply.

Dr. GIORGI. I think you are right. Demand in excess of supply inflates the cost. It always does—but it soon levels out because it outprices itself out of the market. I'm afraid that's what is currently happening to our prepaid health insurance plans. Any good which might be inherent in them is nullified when it becomes too expensive and unreasonable and untenable in costs. But there soon comes an end to that or it must go out of existence.

This Nation possesses the greatest potential for total and comprehensive health care. It boasts of the finest facilities, equipment, health manpower, and a generous national budget-all for the most part in advantageous ratio to population. What is needed is coordination of what is already there, and effective health education toward better health practices, as well as toward optimum use of existing services. Instead, we keep adding instant new programs, for the most part hastily and poorly thought out, which usually serve to further dilute our resources.

OVERDIAGNOSED AND UNDERTREATED In medical school, we learned that diagnosis puts us well on the way to treatment and recovery when cure is possible. We have repeatedly and effectively diagnosed the ills of our health care delivery system. They are not incurable. We should be well on the way to treatment and recovery-Instead, we persist in studying them over and over again. We are overdiagnosed and undertreated.

It has become obvious that current major governmental planning funds under Public Laws 89-239, 89-749, and even the National Center for Health Service Research and Development, are being allocated predominantly to more diagnosis, to education of the medical sector, and to training of planners. It is also obvious that the term "partner

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