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Core Facility. Very important, also would be the provision that optimum use be made of existing facilities and programs before new ones are added. In those areas where adequate facilities and programs already exist, funding can be directed towards their consolidation and coordination.

All of this could be detailed by the framers of the new legislation. While it is important that the legislation be quite specific, it is equally important that it be looked upon as a guideline rather than a blueprint. It should detail only the basic essentials guaranteeing optimum service; optimum use of facilities, equipment, and manpower; equitable care to all; and reasonable cost. All this must then be regionally adapted with services individually rendered, family centered, and community oriented. This is by no means “pie-in-the-sky". It has already been done in other nations—why not by ours?

I feel that only through new legislation can we achieve an overall concept. Continued additions and rebuilding on shaky foundations of old programs which have remained isolated from each other and have failed miserably-gets us nowhere.

Equally ineffective is the senseless addition of new programs addressing themselves to a small part of the larger problem. They only serve to further fragment and to dilute all resources. A new program of this type may not necessarily require a great deal of additional funds. Since the keynote is primarily coordination of existing services, it can be partially funded through optimum use of existing funds.

It should be noted that organized medicine has already indicated approval of ambulatory care centers. I refer to Dr. Milford Rouse's statement in the November 27th, 1967 issue of the Journal of the American Medical Association. The California Medical Association has also been very interested in “promoting the art and science of medicine and the betterment of public health”. In California Medicine of May, 1968, it calls for a "flexible and informed advocacy” on the part of the medical profession and envisions “individual physicians and organized medicine as a powerful and effective force for better health and better health care in this Nation". They are asking for inclusion in planning. I find this very encouraging.

ALTERNATIVES FOR GOVERNMENT INVOLVEMENT

If new legislation is not feasible, alternative methods for government involvement could include the following.

1. Extension or revision of PL 89_239 (Regional Medical Program) to include implementation of a Unified System.

2. Revision of PL 89–749 (Comprehensive Planning Act) promoting a closer relationship between sections 314C and 314E so that training of planners can be done in the framework of service and involvement of practitioners of all disciplines in designing a Unified System.

3. Revision of the O.E.O. Family Neighborhood Health Center concept towards incorporation into a Unified System. It is far better when services to all groups can be rendered through common facilities. Accessibility can be arranged through strategic location of services as well as by provision of transportation when needed.

QUESTION NO. 2 The elderly are too often forced to retire at a time when they are still very capable of function. This is especially true of those who are employed in the "over manned" fields. Labor Union regulations also promote such retirement. Too often those regulations are motivated towards making room for new membership.

I would like to see us educate and train such retirees towards a "second job" in the “under manned" fields such as health aides and assistants of all types— both those already existent and new careers. These could include medical aides, laboratory assistants, X-ray technicians, home health aides, nurses' aides. social service aides, health education aides, multipurpose workers (new careers), etc. Aides in education are also desperately needed. I think the retiree should be trained prior to retirement through the mechanism of a sabbatical.

The concept of the multiphasic worker is further discussed in answer to question five. The idea of training for a "second job" in the pre-retirement years was described in the paper-The Sabbatical in Industry* -previously submitted to your committee.

*Retained in committee files.

QUESTION NO. 3

As far as I know, there is no provision for periodic health examinations. To my knowledge, such services are not reimbursable under either Titles XVIII or XIX. A program providing periodic multiphasic screening tied to a physician examination would go a long way towards preventive care. It would be even more successful if it were performed in the pre-geriatric years. In addition to detecting disease and disruption prior to the irreversible stage, such health examinations might even provide some means for surveillance and circumvention of such abuses as over-testing and excessive visits by providing a general, social, and biochemical reference audit and profile on each patient.

It would have been very feasible to make provision for this through Medicare. It is very customary to request health evaluation in conjunction with health insurance. Medicare is mediated through the mechanism of social security which is an insurance plan.

Such periodic examinations, including multiphasic screening, can decrease the time required for a complete checkup from about two hours to one-half hour or less. This will help circumvent professional manpower shortages. It has been estimated that, if every person in this country were to have an annual complete health examination under present methods; it would require about forty-five hours out of each practicing physician's week. Obviously this is not feasible. Decreasing the time to one quarter of the present required time would obviously assist this immeasurably.

The type of complete audit permitted through a well designed periodic multiphasic screening program may even provide a means for determining priorities on professional time. At the very least, this is worth testing and demonstrating. The Health Core Facility Concept provides a vehicle for such testing and demonstration.

QUESTION NO. 4 By "black market” in medicine, I meant that services will soon be so scarce and the cost so high that only those who can pay “premium" fees will be able to secure health care. I also referred to currently existing practices of "hidden" additional costs to institutionalized Medicare patients which take the form of such things as extra charges for telephones which are not requested by the patient; and extra charges for family visitor parking equally unsolicited; as well as other abuses recently reported in connection with the California MediCal program. The acceptance of the patient into the facility becomes contingent on such “tributes". This and other types of “under the table” payment have a definite "black market" flavor since they involve illegal practices as well as "premium" and "tribute” payments.

QUESTION NO. 5

Some of us are frequently requested to speak to groups of elderly people. They are very avid for information concerning nutrition, medicines, and the more commonly occurring chronic illnesses such as arthritis, cancer, heart disease. stroke, diabetes, etc. There is a striking lack of knowledge as to these as well as to the proper use of health services. We will never have true "quality care" until the patient faces his doctor with adequate knowledge as to what is being told to him as well as to his entitlement. Without such knowledge, the elderlywho are constantly being told ; "what do you expect at your age”—often wait until it's too late to present for care.

One of the better ways to provide such health education is through the informed advocacy of properly trained peer groups such as new career multipurpose workers-health ombudsmen. This could be a "second job" for retirees.

Many years of observing patients in clinics as well as in my own practice have taught me that a great deal of the therapy is in reality done by peer related lay groups. Repeatedly, I have observed them consulting cashiers, attendants, porters, secretaries, etc. after leaving the doctor either for additional information or for clarification of confusing orders given by the professional staff.

Multipurpose workers of this type could be used in clinics. They could also visit Homebound Medicare recipients in their homes and could conduct community teaching sessions in schools, churches, clubs, etc. There is little doubt that they could reduce the need for scarce professional services and for unnecessary medications—too often given to "get rid” of the patient. It has been correctly estimated that about 80 to 85 percent of people presenting to the physician just need someone to “talk to".

The Health Care Facility Concept can well be used as a training Laboratory for all types of health career assistant and associate personnel. It can also be used as a vehicle for dynamic health education. The elderly are admirably suited to such careers by reason of their experiences, empathy and their great need to feel useful and wanted. Proper training can orient such multipurpose workers towards the direction of optimum self-sufficiency for their clients.

QUESTION NO. 6

My experience with 0.E.C. health programs results from very active participation in the design and implementation of the Southcentral Multipurpose Health Services Center; a U.S.C. sponsored, O.E.O. funded Neighborhood Health Center in the community of Watts, Los Angeles. It is very difficult to discuss such health centers purely from the medical care standpoint. They were part of the larger parcel—The War on Poverty.

The intent of the Family Neighborhood Health Centers was to make use of health services as a wedge to correction of other inadequacies and inequities experienced by the disadvantaged such as poor education, poor housing, unemployment, etc. They promoted a total health concept in its broadest sense which, though admirable, inevitaably resulted in the introduction of numerous variables-each of which posed a threat to existing institutions, resulting in constant harassment from many sources, and repeated compromises which were too often paralyzing and disruptive.

Like other O.E.O. programs, the Family Neighborhood Health Centers were supposed to reduce the powerlessness of the poor. The impression was that they, rather than the establishment, were to be in command. This became impossible of achievement since the funding of the Health Centers was awarded to the establishment, and quite naturally the disadvantaged equated power with money.

The term “maximal feasible participation” was never clearly defined which produced an inordinate amount of conflict in the design and operation of so highly technical and complex a structure as a large health center in which areas of competence are of great significance. Consumer perspective and participation is very necessary in all service programs. However, when this became confused with actual operation of the facility, chaos often resulted and threatened the proposed partnership.

Many problems were also inherent in the need for "year to year" funding. There were constant deadlines to meet in the way of reporting and re-budgeting. All of this interfered with smooth operation. Even more significant was the quite ridiculous assumption that professionals would leave either a good job with security or established practices to assume full time work with a program that could not guarantee employment beyond the one year term of the grant. The result was inevitable. Too many of these health centers either employ part time professionals or are understaffed—thus sacrificing the concept of continuity of care. A sense of the temporary was pervasive; certainly not conducive to feelings of security or stabliity.

Many of the clinics are free standing. Without guarantee of admission to the hospital, there is always the element of rejection by the hospital admitting physician. Attempts at true coordination with existing services and programs. even those funded by 0.E.O., were constantly thwarted due to such things as differing philosophies and criteria for acceptance as well as manpower, budget, and space shortages on the part of other agencies and institutions. All of this greatly interfered with both continuity of care and implementation of the total health concept.

The inevitable result was further frustration and distrust on the part of the people who felt betrayed by promises unkept in the failure to achieve the goals of better health, better jobs, and better education.

In spite of all this, there is a definite danger of further frustration and distrust should these health centers be discontinued. However, before they proliferate further, I would think it mandatory to have a complete evaluation as to their efficiency, per capita operational costs, etc. I do not believe this has been done to date.

I do not think that 0.E.O. Health Programs as they are now designed can effect coordination and unification of health care services—both of which are sorely needed. As a matter of fact, should they continue to expand beore proper evaluation, the end result may well be a shift of inequities through further dilution of funds and resources.

At the same time, I wish it clearly understood that I approve of the basic philosophy of the total health concept, and the War on Poverty, and the use of health care with relation to both. The concepts of consumer perspective and participation; health care teams; dynamic health education; peer related multipurpose workers as informed family advocates all of these are of proven value not only to the poor but to all of us. There is no reason why these cannot be incorporated into a coordinated and Unified System rather than through creation of plans which enforce rigid geographic and economic eligibility standards, and are stll in reality “medicine for the poor”.

We are indebted to 0.E.O. for its energetic approach toward promotion of these concepts. It is now time to move on to a broader and more complete planone which addresses itself to the total problem of better health and health care to all with the least amount of threat to existing institutions. This can be accomplished if we are mindful of the fact that truly successful planning usually carries with it that which is good from the past; is pertinent to the present; and has some meaning for the future.

At this point in time, with relation to health care services, I feel that experience has taught us that the perference of both recipients and providers of services leans heavily toward a one to one relationship in connection with the very “personal" services. Comprehensiveness, and reasonable cost as well as the other factors described can still be achieved through pooling of the less “personal” aspects of health care such as clinical tests, other special para-medical and ancillary services, and the administrative and managerial components—all of which traditionally lend themselves much more readily to grouping.

Mr. ORIOL. Our next witness is Mr. Cass Alvin, representing the council for health plan alternatives.

If Senator Williams were here, he would greet you as a fellow steelworker.

Mr. ALVIN. Yes. Thank you.

STATEMENT OF CASS ALVIN, EDUCATION COORDINATOR, UNITED

STEELWORKERS OF AMERICA Mr. Alvin. My name is Cass Alvin, and I am representing the California Council for Health Plan Alternatives, which is comprised of trade unions in California, both AFL and CÍO, as well as the independents and the State and regional bodies.

This is a problem of time where I am unable to make a formal presentation on behalf of the council.

We will, with your committee's permission, Mr. Chairman, submit the council's views at a later time, and we will continue to do so as we work together, unraveling some of the mysteries of the rising costs of health services, and we will submit from time to time some of the ideas and suggestions we have for improving the efficiency of health care services and its quality.

I would like to confine my remarks to a few observations.

I would like to say first of all that following Dr. Gorgi is not a very easy job. I think she touches just about all the observations that can possibly be made. She is one of the consultants to our council on health planning alternatives, and we value her imagination and creativity in this field.

The California Council for Health Plan Alternatives grew out of the need of trade unions for a coordinated effort in tackling the problem of how best can we provide our members quality medical care at the lowest possible price.

Our experience in this field was at first limited. We bargained for a few cents. We went to a vendor, an insurance carrier, who would indemnify our members to some extent for the cost associated with hospital and surgery.

Over the years we have gone back annually to our employers, shook their pockets, stacked more money on the table, enlarging to a small degree the coverage of the insurers' plan, adding new and sometimes questionable benefits only to return again to take more money in lieu of wages, and turning it over in a lump sum premium to an insurance intermediary.

HEALTH PLAN ALTERNATIVES COMMITTEE

With but few notable exceptions, like the Kaiser plan, that was the only way open to us. And that is all that is open to us presently—that is, until we started our work with California Health Plan Alternatives committee.

What we in fact, are doing is what you in Government are doing about the dollars that are going to the health care for the aged. You and we in labor, as the consuming groups apparently are yet unable to make an impression on most of the medical establishment which needs to know the thinking of the consumer.

We are the representatives of the people who pay the bill.

We in labor grow weary of chasing the dog's tail, finding ourselves in this whirl of putting more money into our plans and not making any appreciable headway.

We can't get out because as yet there is no alternative for our members.

The prepaid union negotiated medical plans in the State of California amount annually to about a quarter of a billion dollars—this is a lot of money. We are the largest single consumer of health plans in the private sector.

We have been trying to get at the root causes of some of the rising costs and looking for standards by which we can improve the quality of medical care. We don't think you can separate quality from the cost.

It matters very little to a person who can't afford a medical plan what the quality or costs are. If the cost gets so prohibitive that you can't obtain medical care, then quality is of little value. We think the two have to go together.

We think we have found, up to now, some alternatives to some of the rising costs. What complicates our problem and complicates the problem of your committee is that it is almost impossible to get available data, or even a rationale for the rising medical and hospital costs from those who have the figures but who are reluctant to release them.

No secret was ever guarded as carefully as the figures behind the fantastic escalation of medical costs-the hospital and doctor costs. I suspect this will continue to be the case until those who pay the bill —the consumers, we in the labor unions and you in governmentinsist on some kind of an accountability from the purveyors of medical services, and that the data upon which they base their cost assumptions are exposed to public scrutiny.

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