that you will find the time to pursue fairly carefully, and let me know your reaction to its content. I have studied the transcript, enclosed, fairly carefully, and I see no reason that the suggestions made are not within the desires that all of us want in regard to medical care for the aged. It seems to me particularly desirable that the comment on H.R. 6675, part B, "Supplementary Health Insurance Benefits" are apropos and have far reaching significance. The fear of domination of personal medical care by the Federal Government is not without some foundation and any method, equitably delineated, that will obviate this fear must, therefore, be well founded. I would direct your attention to the present situation that is prevailing in Britain today. The possibility of a strike, certainly on the part of all general practitioners, is definitely possible. More importantly, however. has been the affect on enrollment in medical schools, and the gradual diminished supply of physicians to Britain itself. I have had a number of discussins with British emigres, who are presently practicing in this area, and they are only part of the number who are almost daily or monthly leaving Britain for other areas in the world, Australia, Canada, the United States, South Africa, etc. One estimate by a knowledgeable individual is that within a period of 10 years if the present system continues, that there will probably be less than half the number of physicians presently practicing in Britain, and the number of qualified applicants for medical school will concomitantly drop as well. Historically, the development of such a program as is presently contemplated will never be terminated unless revolution develops, and particularly is this true in a nation the size of the United States. It therefore behooves you, our representatives, to be as deliberate, as sagacious and as prescient as possible in developing this total program. That is my reason for asking that you pursue this enclosure to see if you do not agree that these suggested amendments will only add to the strength and workability of the total program. Thanking you for past favors, and hoping that you can see fit to support the presently recommended amendments, I am Sincerely yours, W. FRED RICHMOND, M.D. AMERICAN SOCIETY OF INTERNAL MEDICINE, To the Members of the U.S. Senate: The American Society of Internal Medicine is a national organization, with 8.000 members who are all qualified internists. The purposes of the society are "to study the scientific, economic, social and political aspects of medicine at a national level, in order to secure and maintain the best patient care and the highest standard of practice in internal medicine." But these stated purposes are far less important than the traditional concern of the practicing physician with his sick patients and with the quality of care they receive. It is this concern which has stirred the interest of the members of this organization in the proposed medicare bill. Internists provide nonsurgical services which will comprise the bulk of care rendered under a medicare law, and their sick patients will therefore receive many of the benefits. The members of this organization consider that they have a common interest with each U.S. Senator and each Representative in the Congress in their desire to be sure that the care provided is of the highest quality. For this reason the American Society of Internal Medicine feels an obligation to speak up at this time and share its views with the members of the U.S. Senate. This society therefore urges that all Senators and Members of the House of Representatives carefully consider the medicare bill. Especially we are concerned with the implication for the future of patient care in this Nation contained in the proposed title XVIII of the Social Security Act as introduced in H.R. 6675. The bill makes provision for Government subsidy of hospital, nursing home, and professional care for individuals over 65 regardless of their financial need. The bill also clearly gives to the Secretary of the Department of Health, Education, and Welfare, the ultimate authority to determine the nature of, the quality of, and the payment for, whatever services are to be rendered. This is a clear departure from the American system of medical care which has become the envy of the other systems throughout the world. The American Society of Internal Medicine heartily approves what is understood to be the plan of the Senate to hold open discussion and public hearings which have always been customary for such an important, costly and far reaching measure. The Society hopes to be heard at that time, and further, that its suggestions for improvements in the Bill will receive consideration. The American Society of Internal Medicine would like to make the following comments with respect to H.R. 6675, for consideration by members of the United States Senate. These comments refer principally to the proposed Title XVIII to be added to the Social Security Act and entitled "Health Insurance for the Aged." They are based upon the assumption that (1) tax-supported medical care will no longer be limited to those in financial need, and (2) the principle that there should always be the greatest possible local and State control of federally supported health care programs will no longer apply. H.R. 6675, PART A-"HOSPITAL INSURANCE BENEFITS FOR THE AGED" If it is decided by the Administration and the Congress that the Federal Government will provide payment for medical care for certain individuals whether they need it or not by means of a Social Security payroll tax, then the American Society of Internal Medicine believes that the benefits so provided should be limited to domiciliary care in a hospital, nursing home or similar facility. This Society believes that Representative Wilbur Mills and the members of the House Ways and Means Committee have made distinct improvements over HR 1 and SB 1 in this section. However, it would strongly recommend the total exclusion of benefits for professional and diagnostic services from this section. This would complete what appears to have been the desirable intent of the House Ways and Means Committee. If the hospital benefits under this section are restricted to "domiciliary" care then they would more or less parallel the concept of the Social Security cash payments. Thus they would serve as a base upon which an individual could add whatever is needed to build up an adequate program for his own needs, just as the Social Security retirement benefits serve as a base for an individual's program for financing his retirement. H.R. 6675, PART B—“SUPPLEMENTARY HEALTH INSURANCE BENEFITS FOR THE AGED" The American Society of Internal Medicine has its greatest concern and apprehension with respect to the "Supplementary Health Insurance Benefits for the Aged" section of H.R. 6675. The intent to provide a voluntary program with benefits to supplement the basic compulsory program of domiciliary care is most commendable. However, it appears to knowledgeable persons in our society that this section as conceived and written will prove quite unworkable without rather precise regulation and control on the part of the Secretary of Health, Education. and Welfare. This inescapably raises the specter of eventual domination of medical care in this Nation by the Federal administration through the office of the Secretary of Health, Education, and Welfare or an office responsible to him. The quality of medical services would then become the responsibility of the Federal Government rather than of those who render the services. It is the belief of this society that neither the American people nor the U.S. Senate wish this eventuality to come to pass. If it is to be the decision of the Congress to provide Federal financial support of medical services for those over 65, whether on a voluntary basis or not, or whether in financial need or not, then the American Society of Internal Medicine suggests that this be done thruogh a mechanism similar to the Federal Employees Health Benefits program which has proven to be so successful. This program has now gained a substantial amount of professional and actuarial experience. It has been found to be a workable program which has been satisfactory, not only to the Federal Government, but to physicians and patients as well. This might provide a happy solution with which the medical profession, the sick patients and the Government could live in harmony. If this is to be done, the American Society of Internal Medicine would like to suggest to the Congress that there be established some sort of a health benefits commission, or board, perhaps with representation from the medical profession, various insurance carriers, and the consumer as well as from Government. Such a commission or board could operate the program in similar fashion to the Civil Service Commission operation of the Federal health benefits program. It should be of quasi-independent status. This would remove the fear of domination of peirsonal medical care by a powerful Federal agency, and would make the same kind and quality of medical care available for all. Most importantly, it would leave responsibility for the control of quality and cost with those who actually provide and render the care. H.R. 6675, AMENDMENTS RELATING TO IMPROVEMENT AND EXTENSION OF THE This section of the bill, together with the subsequent section III, “Child Health Program Amendments," appear to the American Society of Internal Medicine to be improvements in these programs for the needy which are long overdue. However, there has not yet been an opportunity to study them in detail. IN SUMMARY The officers and trustees of the American Society of Internal Medicine speaking for 8,000 qualified internists in this Nation, respectfully suggest : (1) That ample opportunity be given for public hearings as well as careful review and study of the provisions of this most complex and far-reaching bill. (2) that all professional and diagnostic services be deleted from that part of the bill which, in part A, provides "Hospital Insurance Benefits for the Aged" by means of a social security tax, and (3) that serious consideration be given to improving the section of the bill entitled "Supplementary Health Insurance Benefits for the Aged" as presently outlined in H.R. 6675. The American Society of Internal Medicine believes that this can best be achieved under a plan parallel in structure and function to the eminently successful Federal Employees Health Benefits program. The American Society of Internal Medicine further believes that the program should be administered by some sort of quasi-independent health benefits commission or board with appropriate representation which would remove the fear of domination of personal medical care by a powerful Federal agency and make the same kind and quality of medical care available to all. Re S. 1; H.R. 6675 "medicare" bill. To Hon. Harry Flood Byrd, THE COUNCIL FOR HOMEOPATHIC RESEARCH AND EDUCATION, INC., Chairman, Committee on Finance, U.S. Senate, DEAR SENATOR BYRD: This organization respectfully protests against the exclu sion of the official Homoeopathic Pharmacopoeia of the United States from the list of compendia contained in the definition of the terms "drugs" and "biologicals" as recited in subsection (t) of section 1861, title XVIII of the above bill now under consideration by the Senate Committee on Finance. We hope this discrimination against those who wish homeopathic medical treatment can be corrected before the bill is voted on in the Senate. Sincerely yours, CONSTANTINE SIDAMON-ERISTOFF, President. FEDERATION OF JEWISH AGENCIES OF ATLANTIC COUNTY, Senator HARRY F. BYRD, DEAR SENATOR BYRD: H.R. 6675 is an excellent measure. May I ask that you consider two changes. From an administrative point of view, it would appear to be desirable to have the cost of hospital services of radiologists, pathologists, physiatrists, and anesthesiologists included under hospital costs provided in the bill, and further. that the payments requested of $40 for hospitalization, $20 for diagnostic service. and $50 for doctors' bills, be eliminated. Our experience in New Jersey, where I serve as chairman of the Committee on Financial Assistance of the New Jersey State Board of Public Welfare, has indicated that such provisions are confusing. often conflicting, and are administratively more costly to enforce than the funds that are saved. This was our experience in implementing the Kerr-Mills program, for medical assistance for the aged in New Jersey. I am quite certain that it would be even more difficult to try to do so on a national basis. Furthermore, the hospitals, in the first instance, would have to re-do their own statistics as to daily costs, etc., for Blue Cross and others, if the specialists' services are not included as part of the hospital costs. As regards public assistance clients, the State would have to absorb the payments listed above and provide for a very complex bookkeeping operation. I am mindful of the intent behind the recommendation for these payments. It would seem to me that the purposes could best be served by a much closer supervision and review process. A great and historic forward step will be taken when your committee completes its deliberations and substantially approves H.R. 6675. Most sincerely yours, IRVING T. SPIVACK, BURROUGHS WELLCOME & Co. (U.S.A.), INC., Hon. HARRY F. BYRD, Section 1861 (t) of the bill would permit reimbursement only for drugs included in the U.S. Pharmacopoeia, the National Formulary, New Drugs or Accepted Dental Remedies, or approved by the pharmacy and drug therapeutics committee of the medical staff of a hospital cooperating in the program. These compendia are concerned mainly with individual drugs. They do not include many therapeutic drug combinations which have found wide usage in medicine because of their effectiveness and simplicity of administration as well as the economy afforded by having the ingredients combined in a single dosage form. In addition to depriving the patient of many new drug combinations now widely used, the publication schedules of these compendia may lead to delays in the listing and availability of approved individual new drug products. Of the 113 products in our present price list, 59 do not appear in these compendia. Among those excluded are a leading prescription analgesic, which has been used by the medical profession for over 37 years; the majority of our topical, otic, and ophthalmic antibiotic combinations which are issued under the certification procedure of the Food and Drug Administration; a long-established preparation for the treatment of coronary conditions and a new drug approved by the Food and Drug Administration for use in the treatment of a certain type of cancer. Unless approved by a local hospital therapeutics committee, these and other useful medicines would be denied to the "medicare" patient. The provision for approval by the local hospital committee would not be expected to cure this defect. Individual action by local committees would probably result in lack of uniformity of drugs available in different hospitals. Many hospitals do not have such committees, and since the committees themselves have a varying degree of expertise in evaluating therapeutic products, factors other than the effectiveness, quality, and safety of the drugs involved may enter into their decision. Of necessity this could result in interference with the physician's right to prescribe for his "medicare" patient the same drugs he would use for the treatment of his other patients. Accordingly, we favor amending section 1861 (t) by deleting the words "Or as are approved by the pharmacy and drug therapeutics committee (or equivalent committee) of the medical staff of a hospital furnishing such drugs and biologicals" and substituting "or are ordered or prescribed by the attending physicians on the medical staffs of hospitals for the care and treatment of patients." Similar objections with respect to the availability of drug products arise under sections 1814 (b) and 1861 (v) (1) dealing with reimbursable cost, which empower the Secretary of Health, Education, and Welfare to exclude certain drugs from the "medicare" program on the basis of their cost alone, despite the fact that effectiveness and quality should be the principal concern. Consideration of the reasonableness of cost is essential to the effective implementation of the "medicare" program, but it would seem that the addition of the following language to section 1861 (v) (1) would accomplish the desired result. "Provided, however, That charges for items or services furnished a patient shall be deemed to be reasonable if they are ordered or prescribed by the patient's physician for medical reasons, and if such charges do not exceed the customary amount charged by the provider of services to persons not subject to this title." I urge that these sections be redrafted to assure that no drug the physician deems desirable for his patient will be denied him and that the same standard of care will be available to every "medicare" patient. Sincerely, Hon. HARRY FLOOD BYRD, W. N. CREASY, President. WESTINGHOUSE ELECTRIC CORP., Chairman, Senate Finance Committee, U.S. Senate, DEAR SIR: One of the most undesirable and harmful points of legislation in the eyes of private industry is that portion of the medicare bill liberalizing the definition of "total disability." As a California employer, we find an ever-increasing tendency for employees incurring on-the-job injuries to remain away from work for periods far in excess of the period needed for medical recovery. This has been brought about by the increase of State unemployment compensation disability benefits beyond the maximum provided by the California workmen's compensation law and the evercontinuing liberalization of the referees of the industrial accident commission. Many injuried employees are financially better to remain away from work and collect the two benefits referenced above. If the liberalized definition of "total disability" is allowed to be put into H.R, 6675, it will encourage more and more industrially injured to prolong their recovery period in order to qualify for the additional social security benefit. This will not only add substantially to our already excessive compensation costs but will be a very bad psychological factor for the workingman. Your efforts in preventing this provision from getting into H.R. 6675 are sincerely requested. Yours very truly, IRVING F. ALLEN, Supervisor, Workmen's Compensation. Senator BYRD, WISCONSIN COUNCIL OF THE BLIND, INC., Chairman, Senate Finance Committee, DEAR SENATOR BYRD AND MEMBERS OF THE SENATE FINANCE COMMITTEE: This organization, which represents approximately 1,200 visually handicapped citizens of Wisconsin, wishes the committee to know that sentiment here is strongly in favor of incorporating in the current social security bill the last section of Senator Tower's bill S. 940. The provisions contained in this section were adopted as part of the social security bill in the last session but, as you know, this bill died in conference. We join with many other organizations of and for the blind in urging you to give this matter your most serious consideration. Respectfully yours, GEORGE CARD, Executive Secretary. GREENWICH, CONN., April 26, 1965. U.S. Senator HARRY F. BYRD, Senate Office Building, Washington, D.C. DEAR SENATOR BYRD: Since you are chairman of the Senate Finance Committee, and I know your great interest in sound and fair legislation, I strongly urge you to eliminate the amendment on disability benefits. |