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As it stands now, the public hardly accepts any preventive health measures. People won't stop smoking people won't stop overeatingpeople won't stop drinking excessively—so when one says this thing will soon be clasped to the breast of the general public, it is sheer nonsense. But the fact of the matter is that there never has been

any

health measure that I know of, which has been accepted, nor should it be until it has been proved to be of value. I think this is essentially where we are today.

Mr. ORIOL. It was said earlier today that it is the same old cardplayers around the same old table in the terms of people or groups of people involved in our health effort. Do

you think old cardplayers can learn new tricks? Do you feel the same sort of concern that was expressed earlier ?

Dr. CHINN. I do not necessarily; I am old, and am still learning new tricks. I see no reason to think that everybody else can't.

I think that the health professions are on the verge of learning new tricks.

I would like to say a word about the ferment that is going on in medical education today. Medical educators are aware of this card table and these tricks-old

tricks. They are doing something, really, very intensively about it. There is an enormous amount of activity going on toward the revision of medical curriculums, revising educational programs to fit into and to be in accord with the tempo of the times.

And I think that all these educators are not necessarily young. Some of them are rather advanced in years—such as myself.

So I think they can learn new tricks. I think there is a climate here today that has no parallel since the Flexner report of 1912.

CHANGES IN MEDICAL EDUCATION

I think that the whole system of medical education is about to undergo a radical revision and to try new approaches to what it is supposed to be doing.

What kind of man or woman is supposed to be turned out of a medical school? What are they going to do after they leave medical school ?

Mr. ORIOL. You mentioned the Flexner report just then, and that set the stage beautifully for this question:

Within recent months an attempt was made to establish a presidentially appointed Commission—we will call it Health Maintenance and Disease Prevention—the idea being on that high level, much as the Commission that produced the heart, stroke, and cancer legislation-this Commission produced a report so comprehensive, so overwhelming, that it would set the stage for every kind of action you described in terms of disease prevention.

Do you think that this Commission is a good way to begin, or would you rather see an action program begun to make the point dramatic cally, or do you think it might be a combination of both?

Dr. CHINN. I think it should be a combination of both. I don't see how you can really have one without the other.

The Commission study would be worthless unless it could be implemented—whatever its recommendations were.

At the same time, I think you have isolated islands of activity going on without a national image. It will also take decades to get this idea across to the public.

I think that the two in concert would be the proper answer to this, and I would endorse it enthusiastically.

Mr. ORIOL. Do you have any questions!

Well, I would like to thank you, Dr. Chinn, especially for your contribution as well as all the other witnesses, in absentia, for a really good record which will give the subcommittee much to work with in the months ahead.

I would also like to correct an outstanding deficiency of the day by introducing Mr. Shalon Ralph, the professional member of the committee. This is his first hearing.

Mr. Ralph was retired until he joined the committee recently.
I also wish to introduce to you Mrs. Slinkard, our chief clerk.
And once again, thanks to all.

(Whereupon, at 5:15 p.m., the subcommittee adjourned, subject to the call of the Chair.)

APPENDIXES

APPENDIX 1

ADDITIONAL INFORMATION OR EXHIBITS FROM

WITNESSES

ITEM 1: EXHIBITS RELATED TO STATEMENT OF DR. MALCOLM C.

TODD,* PRESIDENT, CALIFORNIA MEDICAL ASSOCIATION

EXHIBIT A. CALIFORNIA HOSPITAL ASSOCIATION-CALIFORNIA MEDICAL ASSOCIATION

PROCEDURES FOR REVIEW OF EFFECTIVE UTILIZATION OF HOSPITAL SERVICES

(Adopted by Office of Health Care Services, June 12, 1968) Aim

To provide Medi-Cal with a system of safeguards in the utilization of hospital services; and to assist hospitals to maintain and strengthen standards of care. Need

Providers of health services have a responsibility for assuring that the public interest is being served in the delivery of hospital services for persons covered by the Medi-Cal program.

Quality is the most important component to effective hospital service. Standards of quality can be best judged by professional peers, functioning expressly to review patterns of hospital practice. Methods

In cooperation with the California Hospital Association and the California Medical Association and under the provisions of their agreements as the contracting carriers with the State of California, Hospital Service of California and Hospital Service of Southern California will organize and implement the following procedures for reviewing irregular patterns of practices by hospitals participating in the Medi-Cal program:

1. Screening for irregularity In the conduct of its customary and routine procedures, provider claims for service are reviewed by the contracting carrier for conformity to prevailing standards of practice and Medi-Cal regulations. This work is performed by staff with proven skills for discerning presumptive irregularity. All questionable claims are referred to a special unit of the contracting carrier's organization where specially-trained staff carry out further analyses.

2. Detecting irregularity When there is reasonable question about the justification of a series of claims, contracting carrier staff collects information needed for clarification. If, after this further evaluation which frequently involves field data collection and direct contact with the provider, questions about suspect patterns are not satisfied, the provider institution is placed under special review. A record of the provider's pattern of practices is developed. Should the record reasonably convince the contracting carrier about provider irregularity and subsequent efforts with the provider fail to correct detected patterns, the contracting carrier, with notice to the Office of Health Care Services, shall ask for the establishment of a peer panel to review the problem.

*See statement, p. 646.

24–798—69—pt. 38

3. Referring for peer review (a) Panel designation.—Upon request from the contracting carrier, the designated officer of the California Hospital Association and the designated officer of the California Medical Association will appoint appropriate persons from among their respective memberships who agree to function as peer review panelists. Each panel shall consist of at least two hospital administrators and two physicians with a chairman designated by mutual agreement of the respective designated officers. Panel members will serve without compensation but shall receive from the contracting carriers reasonable reimbursement for travel and living expenses. The contracting carrier will serve as staff and attend all meetings of the panel.

(6) Referral to committee. The contracting carrier shall make a written report to the panel, informing them of the nature of the matter to be considered, summary of data collected, and history of efforts to resolve issues presented. At the time of referral, the contracting carrier shall advise the panel members that their findings and recommendations will be reported to the Office of Health Care Services. One of the primary aims in activating a peer review panel is to counsel providers on ways for correcting patterns and irregularities and for improving their services and economic

practices, regardless of sources of payment. (c) Notice of hearing.–The provider shall be given written notice of any meeting at which the peer review panel will receive evidence on the matter submitted. This notice shall be given by the panel no less than 10 days prior to such hearing. The notice shall state the nature of the matter under submission. If particular cases are to be discussed, the provider shall be furnished information needed for identification. If the matter under submission involves a pattern of conduct or if it is impractical to list specific cases, the provider shall be given information sufficient to enable him to identify the period involved and the nature of any procedures in question. The contracting carrier will provide the panel with the facts in support of any alleged irregularities.

(d) Attendance by the provider.—The provider shall be entitled to attend any panel meeting while evidence regarding him is received. The provider shall have the right to see any documentary material received by the panel. The provider shall be accorded adequate opportunity to present evidence on his own behalf, or to rebut any evidence offered against him, or to offer any explanation to the panel. The provider shall have the right to be accompanied by counsel but counsel shall not be entitled to participate in any hearing unless the chairman or a majority of the panel determines that his participation would be of assistance to the panel. These hearings shall be informal and the rules of courtroom evidence do not apply. Failure of the provider, without reasonable excuse, to attend scheduled meetings shall not preclude the panel from carrying out its proceedings.

(e) Written record.—A summary record shall be prepared in any case where the panel recommends action limiting or denying future or continued participation in the Medi-Cal program, including recommendations for imposition of requirements. In such cases, the record shall :

(1) Indicate the date of any hearings and the persons in attendance;
(2) Contain or summarize all testimony;
(3) Include all documentary evidence received ;
(4) Describe any other evidence received ;

(5) Contain the findings and recommendations of the panel, indicating the vote on each finding and recommendation;

(6) Include copies of notices to the provider. (f) Findings.In such cases, the panel shall make specific findings on those issues which have clear and convincing proof in support of any recommendation made. Causes for suspension are enumerated in Medi-Cal Regulations, Sec. 51455(b) of Title 22, California Administrative Code, and the findings must state which provision or provisions thereof have been violated by the provider. Insofar as is practical, reference should be made to specific testimony or other evidence supporting each finding. All actions of the panel shall be by vote of the majority.

(9) Recommendations. The panel shall make a written recommendation as to action to be taken. In any case where the recommendation would impose conditions on future payments or participation, the panel shall indicate how and when the recommendation should be implemented.

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