ship for planning" intended to involve-in the words of Dr. William Stewart "by no means only the medical sector"-and not "the same old card players around the same old table”—is rapidly doing just the opposite.

Continued subsidy of existing institutions such as medical and public health schools has not, in the past, been effective in promoting adequate or significant change. Why do we expect it to do so now? Their role as advisers, educators, and their contributions in identifying unmet needs, are most valuable, indeed-but we cannot continue to overlook the fact that such institutions are not service oriented and not activists in a true sense.

RECOMMENDED CHANGES

What we need is to apply what those institutions have so effectively studied and diagnosed in the past. Basically, what is needed is a reallocation of existing resources into a coordinated, unified health care delivery system-and we need it right now.

To this end, why not channel a good part of those funds to activist service groups such as associations of health professionals? Why not enlist the expertise of the medical, dental, and public health schools to assist those groups in planning services based on what is already known? Why not grant fellowships under sponsorship of educational and allied institutions to individuals who are adept at planning, and at grantsmanship-with a view to assigning them to work with such groups toward implementation of alternative health care delivery models? To be sure, we are told that such planning funds are available under section 314E of Public Law 89-749-but to my knowledge, they are not very visible and those who might put such funds to use are just not good at drawing up proposals. I have no objection to educational institutions continuing their studies and their teaching of planners. I would just like to see them extend into the community and help other groups design service programs-both are of equal importance and what better way to train planners than in the framework of service.

Why not have them also make contact with future doctors and dentists, at the medical school and residency training level, encouraging them to understand and consider participation in new approaches to delivery of health care services?

All of these would distribute funds and enhance participation at the service level-far more effective than continued study and planning at the institutional level, virtually in splendid isolation from current and future health practitioners.

I am being repeatedly requested by medical students, by medical residents in their last year of training, by practicing physicians, by large consumer groups such as Union-Management, and more recently by large scale proprietary hospital ownership groups and city planners involved in the design of new communities to assist them in evolving and implementing comprehensive health care models.

The medical profession and organized medicine groups are publicly expressing interest in change. The practice of medicine is becoming increasingly difficult and emotionally unrewarding because of demands made upon it by the very complexities and multiple problems of daily

living, as well as by the increasing amount of administrative and managerial tasks imposed by very necessary government standards and health insurance regulations. It has become impossible for the physician to go it alone and to be it all. The time for change was never so propitious. Activism is needed as it never was before.

ALTERNATIVE HEALTH CARE DELIVERY PROPOSAL

I have taken the liberty of appending to this paper, a suggested alternative health care delivery model, together with a recommended definition of roles for the various sectors involved in health care, including public, private, and philanthropy groups. These comprised a proposal submitted by me to a private group interested in funding a Community Health Planning Foundation. We are still discussing this possibility.

There is no doubt that governmental action of the same kind could also effectively promote the development of such services. These papers are too long to permit reading here.

Briefly, the plan describes the creation of a unified health care delivery system, centering about comprehensive ambulatory diagnostic and care centers-called Health Care Facilities-pooling ancillary, paramedical, managerial, and administrative services, simultaneously permitting the one doctor/one patient relationship. It provides free and rapid transfer between the various components of the system and defines the role of each. These include the community-cottagehospital, medical center, and extended care facilities and programs. All services are supervised by the managing physician, coordinated by the health care team, and expedited by the family health agents. The latter is a new career-a peer related, informed advocate of the family. The plan coordinates existing services and is adapted at the individual community level-adding services only as the need for such addition is clearly demonstrated. It establishes effective quality and optimum utilization surveillance through a team approach. It is expected that savings in cost will result from the pooling and more sensible use of those parts of health care which are the most costly— namely: ancillary, administrative, managerial, and institutional.

The plan is offered as an alternative method. There is little doubt that the elderly would benefit greatly from it-perhaps more than any other group, since it permits easy availability and accesibility of all services through a single access, and also provides the means whereby they may be put more closely in touch with existing health services. Another service which is greatly needed by the elderly in urban areas, especially those that are relatively and absolutely homebound, is the meals-on-wheels concept. We should have more of this.

FAMILY HEALTH AGENT

The family health agent would be of great value in providing the elderly with information concerning their entitlement relative to governmental and other benefit programs. This type of medical manpower, together with other physical and emotional rehabilitation personnel

*See app. 1, pp. 727-734.

provided through the health core facility are of special importance to the elderly as well as to other groups with multiple problems. The OEO neighborhood health centers have clearly demonstrated this.

The elderly are very much like the ghetto dwellers. They live in a segregated ghetto of their own-too often in a single room furnished apartment, suffering from retirement rot with nothing but time on their hands. At that stage, their problems are largely nonmedical.

It is not unrealistic to consider the use of the health core facility as a vehicle for training of the unemployed at all ages, not only as health agents, but as professional assistants of all types. The elderly would benefit greatly from this. They could be trained toward the second job in the pre- or post-retirement years. This would circumvent the destructiveness attendant on their loss of work role as well as permit additional income at a time when they need both very badly. We need such new careers in all the human services-especially in medicine as well as other undermanned fields. This, too, involves the principle of improved allocation of resources. Do we really have a severe shortage of professional manpower or are we merely senselessly misusing our highly skilled groups?

The proposed model, strategically located geographically, would permit availability to all age, ethnic, race, and economic sectors, which would be far better psychologically than systems requiring further segregation of any one of those groups-which is often demoralizing of itself.

Comprehensive health care systems are absolutely essential if we are to promote preventive care. We really have no choice. We must concentrate our efforts in the pregeriatric years, or very soon we will face the prospect of geriatrics virtually absorbing the practice of medicine.

SUMMARY

In summary, then, I am making a plea for more activism and less study; for new cardplayers; for government and/or private encouragement and facilitation of improved health care delivery models, not only for the geriatric patient, but for all ages; for better coordination of existing programs, rather than addition of new ones; for a consortium approach with a clearer definition of roles; and for greater involvement and participation at the actual service level: I have also proposed a new model which, in my experience as a practitioner, as well as a health care programer, seems to have some universality and replicability.

I hope this very busy committee will find it possible to examine and consider it. Your critique will be most valuable to me.

I could not possibly end this presentation without thanking you for permitting me to come. I expect to learn a great deal. I hope my remarks will offer some contribution to the solution rather than to the problem.

Mr. ORIOL. Didn't you say at a conference earlier this year that physicians spent only about 25 percent of their time in direct patient care? Dr. GIORGI. Yes; it has been estimated that physicians spend about 25 to 35 percent of their time in direct patient care. The rest of their time is spent in doing chores that could well be done by others-chores that do not require their highly specialized skills.

DUPLICATION OF EQUIPMENT AND PERSONNEL

Another factor in costs and shortages is that of unnecessary duplication. Dr. Littlejohn stated that overhead expenses in a doctor's office is about 50 percent. No wonder. Each doctor's office has a full component of expensive and scarce equipment and personnel which they use only part time. Such equipment and personnel should be used full time. The real culprit in exorbitant costs is duplication down the line-from the doctor's office to the hospital and other facilities for institutional care.

At this point, I would rather not talk about cost per se-I would prefer to talk about care quantitatively and qualitatively. Improved health for all our people must of necessity prove to be less costly in the end. And that improved care will not be effectuated only through financial quantitative commitment. It must come through commitment to much needed change. It will require heroic measures-but it can and must be done. It will not be easy but it may well be easier than our current antiquated, cumbersome system of senseless duplication, fragmentation, and almost complete disregard of consumer perspective and dynamic health education.

Thank you very much.

Mr. ORIOL. Dr. Giorgi, you can be sure that your proposed new model will receive a great deal of attention. I find myself with many questions which we can't go into in detail right now, but we would like to get more discussion on it.

Is any work going on at the national center for health service research and development along the lines you are recommending?

Dr. GIORGI. I will tell you-you know, the Scheuer amendment with new careers is working on this. They haven't done enough in the health field. I would like to see this applied

Mr. ORIOL. Could this be a specific recommendation?

Dr. GIORGI. I would like it to be, and you could make it in connection with the aged, teaching them the second job.

Mr. ORIOL. Well, some of the questions that we will throw at you after having read your proposal in detail are: What is this model for? Is this a model for Federal action-to promote developmentor is this a model for community action?

Our Federal programs, including the development of what you envision-or are they contradicting each other, perhaps, in some cases? We will address many questions to you along that line.

Dr. GIORGI. Thank you very much.

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

1. Your "Unified Health Care Delivery System"-which, as you said, would be of special usefulness to the elderly-is of great interest. Have you give any thought as to revisions in existing federal programs or perhaps suggestions for entirely new programs-that could be helpful for establishment of such a system? Or do you envision development of this system as primarily a matter for private resources, with only supplemental incentives from the federal level? 2. You also suggested that the elderly might serve in useful "second careers" as health aides of one kind or another. In what roles could they be especially helpful?

3. Your observation that preventive care for the aged in California is "invisible" leads me to ask for your comments on what kind of services are needed but are not now provided.

4. I am not certain I understand your references to a possible "black market" for health services. Do you mean that the onset of a program such as MediCal has increased demand for health services to the extent that Medi-Cal participants will be willing to pay some kind of premium to give them access to scarce health personnel? Or did you envision a more general problem?

5. You and other witnesses emphasized the need for health education, and yet I find myself wondering just how such education could reach the general public, especially the elderly. Do you have suggestions for increasing the effectiveness of educational efforts?

6. You began to discuss OEO health programs and indicated that you might have additional thoughts on that subject. Is it possible for you to give us additional discussion for our hearing record?

(The following reply was received :)

QUESTION NO. 1

My statements regarding development of a Unified Health Care Delivery System through private resources were expressed out of desperation. It is obvious that those institutions which might have been expected to be prime movers in behalf of unmet needs-namely, government (public health), profession schools, and the medical/dental professional organizations-seem powerless to perform. A conjoint effort on the part of all of these would be ideal. It is long overdue. Each of these seems blocked-perhaps because they refuse to recognize the fact that they are unable to "go it alone". They need help from other sectors. The approach is too complex for the health sector alone. A multi and interdisciplinary consortium is necessary. For this reason, I proposed a privately funded Community Health Planning Foundation as a means of providing such a consortium. There is no reason why the same approach cannot be sponsored by government. As a matter of fact, in view of an enlightened public's indignation over the inadequacies, inequities, and exorbitant costs of health care it may soon become mandatory for government to assume leadership. We already have much evidence that a very large consumer of services-the labor movement-is becoming quite militant in this direction. The Health Care of a Nation is one of the prime responsibilities of government. In this connection, as things stand at present, government-functionally, at least-has been placed in the position of responsibility without authority-extremely untenable to say the least.

SWEDISH SYSTEM

I would like very much to see a Unified System developed through government sponsorship primarily along the same lines as the Swedish System developed under the leadership of Dr. Arthur Engel, former Director/General of the Swedish National Board of Health, so well described in his 1968 Michael M. Davis Lecture-Planning and Spontaneity in the Development of the Swedish Health System. This could easily be done without infringement on the one patient/one doctor concept which seems to be the main basic concern of both the provider and recipient of services.

However, if government does assume leadership it should take the form of promotion of effective planning for service rather than direct ownership, direct operation, or continued funding of educational or institutional groups in isolation from service groups.

Central to the Unified Health Care Delivery System is the Health Core Facility already described. This is a single access Ambulatory Care Facility either free standing or hospital based. As such, it lends itself very well to government sponsorship along the same lines as the Hill-Burton or Hill-Harris concepts. To be most effective, this would require new legislation and a new program. This legislation should be carefully designed to include provision for all the components already mentioned in the description of the Unified Health Care Delivery System. I would like to see funding provided to associations of professionals (not just doctors) preferably on a long term, low interest loan basis, rather than on a matching funds basis. I would also like to see provision made for community participation and Federal public utility regulation as well as a more equitable plan for prepayment either directly or through health insurance fiscal agents. The "Catchment area" concept should be maintained to avoid duplication and might even be extended to include "adoption" of a contiguous community where a medical vacuum exists. The latter could become a satellite of the central Health