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2. Expenditures by, or in behalf of individual patients for direct patient care are greatly influenced by physicians, and there is a great opportunity to improve physician awareness and exercise of responsibility in this respect.

3. Despite extensive efforts on the part of medical societies to encourage medical schools to include instruction in medical-economic understanding and responsibility little has been accomplished in the schools of this country, and virtually nothing has been or can be accomplished in the foreign schools which train so many of our physicians.

4. Opportunity exists for medical economic orientation at the interne and resident level, and this may present an excellent place for cooperation between hospital training programs and local medical societies.

5. Since the physician alone is in position to make decisions in the individual case as to reasonable alternatives in expenditure for diagnostic and therapeutic services, other interested parties should aid and abet the physician in the exercise of this decision-making responsibility.

6. Individual physicians can best be oriented and assisted by their own professional associations, which are already responsible for most of the progress in the area of utilization review, claims review and other efforts to contain expenditures for medical care.

7. Government, labor, industry, third party payors, and consumer groups should lend their support and assistance to medical societies in constructive approaches to the problem.

8. Physicians and their associations should be receptive to any genuine help which may be proferred.

9. The physicians who have remained aloof from organized medicine and the AMA should be vigorously encouraged to become participants in active programs to increase physician responsibility. They should be encouraged by their schools, their employers, their hospitals, and perhaps even by their patients.

10. Irrational, divisive bickerings by all interested agencies and organizations should be set aside in favor of cooperative assault on a massive problem.

EXHIBIT B: MEDICAL CARE Cost CONTROL

[From the AMA News, Apr. 8, 1968)

ONLY M.D.'s CAN CONTROL CARE COSTS, PANEL TOLD Organized medicine, through a concerted effort by state and county medical societies, is “potentially the greatest ally' of the public in controlling expenditures for medical services, participants at the second national American Medical Association Congress on the Socio-Economics of Health Care were told.

Russell B. Roth, MD, Erie, Pa., vice-speaker of the AMA House of Delegates, said, “Vast programs of financing medical care must be supervised, must be audited, must be equated to need, and must be protected against abuse.” Government Ill-Equipped"

Government, considered by some to be the answer to the problem, could impose controls, he said, but compared to the medical profession, it is “ill equipped to remedy the difficulties.

"It is government which in effect has written the blank check for medical care and must look to someone else to fill in the amount," Dr. Roth said. “It is in large part this abundance of governmental dollars chasing after scarce services that has created the problem.”

Despite efforts of third party payors and voluntary prepayment plans, no alternative to physician review has ever been found, he said.

"It is quite true that claims review is becoming automated and sophisticated to the extent that machines pick out cases which depart from a programmed range of acceptability, but the actual evaluation of the case and the charges depends upon physician judgment,” Dr. Roth pointed out. Areas of Need

Proper utilization of hospital facilities and services, fee-for-service payment, and quality of care are areas in which the physician can function more effectively and help to identify and contain expenditures, he said.

Critics of the medical profession, including labor-management, and government, are “self-defeatists,” Dr. Roth emphasized.

“I believe the medical profession needs the understanding, the support, and the effective assistance of all interested parties to do the job that only it can do,” he said. “And when that support and assistance is proferred. I believe the medical profession should accept it.”

Dr. Roth made the following suggestions in regard to the future role of organized medicine as "guardian” of the consumer's interest in expenditures for medical care:

Identification of public and private expenditures for medical service which differ from elements relating to direct patient care, to improve physician aware

ness.

Identification of public and private expenditures for medical service which differ from elements relating to direct patient care, to improve physician awareness.

Instruct medical societies to encourage medical schools to include medicaleconomic understanding and responsibility in their curriculums, especially at the intern and resident level.

Encourage physicians who have remained aloof from organized medicine to become active participants.

Solicit aid of other interested parties in decision-making for constructive cooperative approaches to the problem.

Make use of medicine's professional associations, while remaining receptive to any genuine help which may be proferred.

ITEM 10: STATEMENT OF DR. ALEXANDER SIMON, DEPARTMENT OF

PSYCHIATRY, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO MEDI. CAL CENTER

Probably few countries have begun to face the full implications of the aging population for health and welfare services. Our experiences with Medicare and Medicaid have only suggested the variety and magnitude of the problems presented by a program directed at providing even minimal health services to an

easingly larger group of elderly persons in our population. The incidence and prevalence of mental disorders in this group is high, and comprehensive health services for them should include continuity of care from prevention through screening, outpatient and hospital treatment, and aftercare, and should cover medical, psychiatric, and social and supportive services. Although in most cases specific methods for the prevention of mental illness and for the treatment of many mental disorders in the elderly are not yet possible, at least the severity of disorder may be ameliorated by symptomatic treatment, its personal and social consequence can be mitigated, and the care and treatment made available can be humane.

I am not well acquainted with the details of costs related to the delivery of health services in general, but I should like to emphasize the need for close liaison and coordination among all agencies, health care personnel, and services working in this field. The problems associated with prevention, treatment, and rehabilitation of the geriatric mentally ill not only are enormous and complicated by lack of knowledge, but also are inextricably tangled. Coordination of efforts is necessary from screening and the identification of persons with problems through treatment and aftercare and the provision of supportive services. Screening, for example, is useless if services for referral are not available or are not located where they are easy to reach or if transportation and assistance to get there are not available. Screening programs that see patients at times of psychosocial crisis have shown the wide variety of resources needed : general hospitals, psychiatric units in general hospitals, public and private mental hospitals, medical and psychiatric office care and home visits, psychiatric outpatient clinics, nursing and boarding homes, family care homes, old age homes, and homemaker services, visiting nurses, "Meals on Wheels," and other services to make it possible for some elderly patients to remain at home. But who is to assume responsibility for continuity of care and for the necessary flow of information from one facility or caretaker to another?

Government at all levels, as well as the community as a whole, must be concerned with the availability, quality, and delivery of these services. Community studies have found moderate or severe psychiatric impairment in approximately 20 per cent of elderly persons living in the community. Yet, only one and a half to two per cent of the patients seen in outpatient psychiatric clinics are aged sixty-five or over. In addition, office psychiatric care of the elderly has discriminatory limitations on cost, in contrast to other types of medical care. Well over three hundred thousand persons aged sixty-five and over with mental disorders were resident in long-stay facilities in the United States in 1963. About half of these were in state and county mental hospitals and the other half in nursing homes, geriatric hospitals, homes for the aged, and related facilities. The figure for the mentally ill in nursing homes and such facilities undoubtedly a minimum one and has considerably increased since the advent of Medicare.

ALTERNATIVE PLACEMENTS DISCLOSES PROBLEMS

The present trend to make use of alternative placements for those elderly mentally ill who traditionally have been committed to state mental hospitals has brought to attention some serious problems. Nursing and boarding homes are in increasing use both for the initial placement of patients and for the transfer of aged patients already in state hospitals. But standards of care provided in these facilities must be raised, and this means increased costs. Adequate licensing and review procedures for each type of facility, relating to personnel requirements as well as to physical plant facilities, are imperative. There must be better coordination of licensing agencies. Some homes now are licensed by the Department of Social Welfare, some by the Department of Mental Hygiene, and some by the Department of Public Health, and some unification and clarification of licensing procedures clearly is required. The most crying need is for social workers to deal with families and rehabilitation workers to inaugurate and carry out activity programs in the various types of home.

The need for training programs and the upgrading of salaries and experience is especially obvious in relation to nursing personnel-nurses and nursing aideswho care for the elderly. There is a rapid turnover of nursing personnel, largely because of poor pay, and a continuing scarcity of adequately trained and experienced aides. Training courses might well be made part of licensing requirements. Operators of boarding and family care homes greatly need training courses, and psychiatric consultative services should be made available to them and their use encouraged. The psychiatric profession must become increasingly involved. At present, psychiatrists are not adequately trained or experienced in working with the elderly mentally ill, and they are not called upon often enough by those who operate and staff these facilities.

Not only are the geriatric mentally ill being placed initially in alternative facilities rather than in state mental hospitals, but patients already in these hospitals—some for many years—are being transferred out in increasing numbers. Most of these are placed in nursing home or family care settings, although some are able to return to the community. Careful evaluation and screening for appropriate placement are essential, as are continuing social work and medical and psychiatric supervision, if such programs are to be successful.

In summary, the need for health services for the elderly is great, and the nature of the problems of this age group is such that only a truly comprehensive health program can adequately meet their needs. Coordination of the efforts of all resources and personnel is essential if services are to be made available and easily accessible to the large group of elderly persons who are in many cases in really desperate need of help.

EXHIBIT A: QUESTIONS SUBMITTED BY THE CHAIRMAN TO DR. ALEXANDER SIMON

U'NIVERSITY OF CALIFORNIA, SAN FRANCISCO MEDICAL CENTER 1. What has been your experience with the use of outpatient mental health services to the elderly? What reception has it received from the elderly?

2. What is the current status of the geriatric screening unit in San Francisco? What has the record of this unit been in reducing the number of admissions to mental institutions ?

3. What are the missing links in the current range of mental health services generally available to the elderly? What changes in Federal policy or legislation may be needed to close such links?

4. You may remember that, at the Subcommittee hearing in the Bronx, New York, that Dr. Israel Zwerling described problems related to the release of geriatric patients from mental institutions when they were unprepared for reintroduction into society? What more can be done to overcome this problem?

(The following reply was received :)

NOVEMBER 14, 1968. DEAR SENATOR WILLIAMS: I am glad to reply to your request for comments on some questions relating to the costs and delivery of health services to older Americans. Probably few countries have begun to face the full implications of the aging population for health and welfare services. Our experience with Medicare and Medicaid have only suggested the variety and magnitude of the problems presented by a program directed at providing even minimal health services to an increasingly larger group of elderly persons in our population. The incidence and prevalence of mental disorders in this group is high, and comprehensive health services should include continuity of care from prevention through screening, outpatient and hospital treatment, and aftercare, and should cover medical, psychiatric, and social and supportive services. Although in most cases specific methods for the prevention of mental illness and for the treatment of many mental disorders of the elderly are not yet possible, at least the severity of disorder may be ameliorated by symptomatic treatment, its personal and social consequences can be mitigated, and humane treatment and care can be made available.

I am not well acquainted with the details of costs related to the delivery of health services in general, but I should like to emphasize the need for close liaison and coordination among all agencies, health care personnel, and services working in this field. The problems associated with prevention, treatment, and rehabilitation of the geriatric mentally ill not only are enormous and complicated by lack of knowledge, but also are inextricably tangled. Coordination of efforts is necessary from screening and the identification of persons with problems through treatment and aftercare and the provision of supportive services. Screening, for example, is useless if services for referral are not available or are located where they are not easy to reach or if transportation and assistance to get there are not available.

Screening programs that see patients at times of psychosocial crisis have shown the wide variety of resources needed : general hospitals, psychiatric units in general hospitals, public and private mental hospitals, medical and psychiatric office care and home visits, psychiatric outpatient clinics, nursing and boarding homes, family care homes, old age homes, and homemaker services, visiting nurses, "Meals on Wheels,” and other services to make it possible for some elderly patients to remain at home. But someone must assume responsibility for continuity of care and for the necessary flow of information from one facility or caretaker to another. The elderly person needs "representative” to look out for his interests and to assist him in obtaining needed care. Especially pressing are the need for outpatient psychiatric services and the need to remove various restrictions on psychiatric care in contrast to general medical care.

NUMBER OF ELDERLY MENTALLY ILL

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Government at all levels, as well as the community as a whole, is vitally concerned with the availability, quality, and delivery of services to the elderly. Community studies have found moderate or severe psychiatric impairment in approximately 20 per cent of elderly persons living in the community. Well over three hundred thousand persons aged sixty-five and over with mental disorders were resident in long-stay facilities in the United States in 1963, about half of them in state and county mental hospitals and the other half in nursing homes, geriatric hospitals, homes for the aged, and related facilities. The figure for the number of mentally ill in nursing homes and related facilities undoubtedly is a minimum one and has increased considerably since the implementation of Medicare.

The present trend to make use of alternative placements for those elderly mentally ill who traditionally have been committed to state mental hospitals has brought to attention some serious problems. Nursing and boarding homes are in increasing use both for the initial placement of patients and for the transfer of already hospitalized aged patients. But standards of care provided in these facilities must be raised, and this means increased costs. Adequate licensing and review procedures for each type of facility, relating to personnel requirements as well as to physical plant facilities, are imperative. There must be coordination

1 Lowenthal, M. F., Berkman, N., and Associates. Aging and Mental Disorder in San Francisco (San Francisco : Jossey-Bass, 1967, p. 37.

2 Kramer, M., Taube. C., and Starr. S. Patterns of use of psychiatric facilities by the aged. In A. Simon and L. J. Enstein (Eds.), Aging in Modern Society, Psychiatric Research Report No. 23 (Washington, D.C.: American Psychiatric Association, 1968), pp. 89-150. 3 Kramer, et al., ibid.

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of licensing agencies; in California, for example, some homes now are licensed by the Department of Social Welfare, some by the Department of Mental Hygiene, and some by the Department of Public Health. Unification and clarification of licensing procedures are required. The most pressing need is for social workers to deal with families and for rehabilitation workers to inaugurate and carry out activity programs in the various types of home.

As to the need for psychiatric outpatient services for the aged, the National Institute for Mental Health has been collecting and publishing data on the numbers and characteristics of patients receiving services in outpatient psychiatric clinics since 1954. The clinic population has been weighted heavily with children under eighteen and adults in the 18–44 year age groups, with relatively small pyroportions in the age groups 45–64 and 65+. Persons aged sixty-five and over constituted only 2 per cent of the total admissions to outpatient clinics in 1965. In contrast, persons in this age group constituted 29 per cent of all first admissions to public mental hospitals for the same year.”

Although psychiatric clinics claim not to discriminate against particular groups, there does seem to be a de facto discrimination against geriatric patients. A survey of admissions to the Outpatient Department of the Langley Porter Neuropsychiatric Institute for the year July, 1963, through June, 1964, showed that slightly less than 2 percent of these admissions were of persons over the age of sixty. Subsequent conversations with professionals involved in the private and public sectors of social services, with psychiatrists in private practice, and with non-psychiatric physicians in private practice suggested, however, that there was a large need for outpatient services for people in the older age groups. Our feeling was that if the public could be informed of a special clinic that had a particular interest in the psychologic disorders of the aged, there would be substantial utilization of the clinic's services. Such a program might also provide social agencies with consultative services regarding difficult client problems and a psychiatrist who could make house calls on clients who, for physical or psychologic reasons, could not go outside their homes for help.

TRAINING FOR CARE OF ELDERLY MENTALLY ILL

The need for training programs and the upgrading of salaries and experience is especially obvious in relation to nursing personnel-nurses and nursing aideswho care for the elderly. There is a rapid turnover of nursing personnel, largely because of poor pay, and a continuing scarcity of adequately trained and experienced aides. Training courses might well be made part of licensing requirements. Operators of boarding and family care homes greatly need training courses, and psychiatric consultative services should be made available to them and their use encouraged. The psychiatric profession must become increasingly involved ; at present, psychiatrists are not adequately trained and experienced in working with the elderly mentally ill, and they are not called upon often enough by those who operate and staff these facilities.

Not only are the geriatric mentally ill being placed initially in other facilities than state mental hospitals, but patients already in these hospitals-some for many years—are being transferred out in increasing numbers. Most of these are placed in nursing home or family care settings, although some are able to return to the community. Careful evaluation and screening for appropriate placement are essential, as are continuing social work and medical and psychiatric supervision, if such transfer programs are to be successful.

GERIATRIC OUTPATIENT PROGRAM

In the summer of 1967, with support from a grant by the State Administration on Aging, The Langley Porter Neuropsychiatric Institute Outpatient Department began a Geriatric Outpatient Program. A press release was sent to the San Francisco daily newspapers, and one of the papers printed an extensive interview with the coordinator of the program. In addition, there was a radio interview on a popular noontime program. Representatives of many agencies dealing with the elderly population were invited to meet with the staff of the project to discuss its work and the kinds of involvement the agencies would like to encourage. As a result of these conferences, a psychiatrist was added to the staff to work as a consultant with the social agencies and to see patients for them, either individually or in groups, and also to conduct evaluations and treatment of homebound patients referred by the agencies.

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