scription, they provide physical, occupational and speech therapy services to the aged in their homes to keep them functioning at maximum levels in independent living activities and homemaking functions.

During the 1964 fiscal year, the Curative Workshop of Milwaukee served 3,986 different persons of which about 18 percent, or 717 of these patients, were 65 years of age or over. I believe you will find a similar distribution of patients at the Racine and Green Bay Curative Workshops.

During the past 45 years of its existence, the Curative Workshop of Milwaukee's certified therapists have served thousands of aged persons on an outpatient basis and in their homes, restoring them physically and keeping them functioning on a maximum level at a minimum cost to themselves and the taxpayers. These medical and rehabilitation services have prevented or reduced costly hospitalizations and other medical procedures, but most important, these services have helped to keep the family units functioning harmoniously together, prevented dependency among the aged and kept many of the aged out of costly institutions. We are proud of our contributions to the aged population and ask that you make certain that this legislation will clearly include the purchase of physical, occupational and speech therapy provided by certified therapists under a qualified physician's direction from our respective institution, on an outpatient and home service basis.

We will appreciate hearing from you at the earliest convenience.

Sincerely,

T. S. ALLEGREZZA, Executive Director.

STATEMENT OF ORVILLE F. GRAHAME, VICE PRESIDENT AND GENERAL COUNSEL OF THE PAUL REVERE LIFE INSURANCE CO. AND THE MASSACHUSETTS PROTECTIVE ASSOCIATION, INC., OF WORCESTER, MASS., TO THE SENATE FINANCE COMMITTEE ON H.R. 6675 RELATING TO THE SOCIAL SECURITY AMENDMENTS OF 1965 WITH PARTICULAR REFERENCE TO SECTION 303 OF H.R. 6675

Our organization has been in the accident and health insurance business since 1895 and is one of the largest writers of guaranteed premium noncancellable and guaranteed renewable coverage. We are licensed for both companies in all States and the District of Columbia, and we also do business in a number of the provinces of Canada.

The issues discussed in this statement.-We object to both the change in the definition of disability and to the provision to pay for the sixth month of disability, as set forth in section 303 of H.R. 6675.

We are very much concerned that the proposed amendments, while perhaps suggested as technical amendments, will seriously interfere with the offering of disability insurance coverage on a private insurance basis.

Qualifications of writer.-The person making this statement is a lawyer and fellow of the Insurance Institute, and has been and is active in both life and health insurance trade associations organizations dealing with social security legislative problems, and currently is chairman of a trade association legislative committee dealing with State problems.

The writer also has been active in a number of conferences and committees on a local, State, university, and national basis which considered problems of the aging. This included membership on the National Advisory Committee of the White House Conference on Aging in 1961. His assignment at the Conference was to the Planning Committee on Income Maintenance headed by Dean Charles I. Schottland, former Commissioner of Social Security, Department of Health, Education, and Welfare. In addition to chairing a work group, he was a member of the Recommendations Committee of the Income Maintenance Section which made a number of specific recommendations including a position on financing of medical care, all of which he supported.

His personal support for this "progressive" position was on the premise that for persons under age 65 private industry was doing and could do an efficient and effective job on health care and in the field of disability insurance, and would be permitted and encouraged by government to do so. Thus, in the political spectrum, the writer would like to be considered to be in the middle of the road, believing there is a proper place for both government and private industry in the social security area, a position he supports in the National Council on Aging. Government disability insurance does not help private insurance. It cannot be argued successfully that Government disability insurance is a "good thing"

for private insurance. In life insurance it is difficult to be overinsured as few can pay the full premiums, and very, very few wish to die right away to collect. So life insurance can be piled on some moderate amount of social insurance. However, in disability insurance in the lower income brackets there is no upper layer of income to insure due to the fact that experience has shown it is unwise to pay a man as much, or nearly as much, disabled as you would pay him if well and working. In disability insurance he is free on the basis of subjective symptoms to elect nonemployment or early retirement. Hence, we do not like to insure over 60 to 80 percent of a man's income, especially considering that disability benefits, both Government and private, are not taxable.

Disability benefits were provided under the Social Security Act in 1956. At that time there were 41,688,000 persons reported to be covered with private loss of income disability insurance coverage. This had gone up from 26,229,000 in 1946. In 1963, the total was only 46,956,000. It would thus appear, even though the total work force has an upper limit, that the disability provision in the Social Security Act may well have deterred the growth of private disability insurance.

CHANGE IN DEFINITION OF DISABILITY

The elimination of the provision for long-continued and indefinite duration of the disability in the present law admittedly may give some help in administering the law on certain problems but probably will bring some other difficulties. Senators and Congressmen may have received complaints on the present provision, but that is in the nature of disability insurance. There will be complaints galore in any hospital or medical plan for people over age 65. There well may be more complaints under the proposed language for disability than now since people can differ on the fact of disability, and there will not be the same language support for any Government contention of nonexisting disability.

The contention that private insurers use such a clause as proposed is generally true, but this raises the basic question of whether Government intends to take care of early retirement due to disability, or whether it intends to go into a competing temporary disability insurance business.

There is also another question not answered to our satisfaction. Is there not another possible remedy for the case where no one knows whether or how soon a disabled person will recover from disability? Perhaps in such cases a decision could be made on some other test, as (1) hospital or house confinement for a specified period, or (2) total disability for a longer period, as 2 years, as a supplement to the long-continued and indefinite duration requirement.

The proposed language will remove a large area of the market for private insurance. It is not believed that the Congress intends this consequence. Some feel we are not dealing with the issue of a floor of protection but with the nationalization of disability insurance.

PAYMENT FOR THE 6TH MONTH

The payment for the 6th month is also an amendment probably intended to facilitate administration, but it is especially irritating to private insurers, as it is a definite further step into the field of disability insurance. Many group plans pay for 26 weeks or 6 months. There are also workmen's compensation complications being called to your attention. Several States have cash sickness plans covering 6 months. This overlap of benefits is socially undesirable.

If it is contended that an "administrative" change is needed to pay for the 6th month, it can be argued later it ought to be made to pay for the 5th month, the 4th month, and so on.

If the waiting period has been served, and the 7th month of disability has transpired, no one objects to prompt payment. Also, if there is any part of a fractional month of disability that is ignored, some way should be found to run the 6 months from the commencement date of disability. Private insurers do that. Otherwise, we suggest the law should stay as it now is.

Not thoroughly considered.-The Forand bill, the King-Anderson bill, and the other bills on "medicare" resulted in much consideration of the pros and cons in countless conferences, TV debates, and in the Halls of Congress, and indeed in several presidential campaigns. There has not been time or the opportunity to carefully consider these disability amendments. It is believed this is true of those advocating them and of those who are critical of them. Certainly, the public has had no chance to consider such amendments, and we have not heretofore had any opportunity to discuss such amendments with Members of the Congress or with the Department of Health, Education, and Welfare.

RECOMMENDATION

In view of the foregoing, we sincerely and strongly recommend that the abovementioned amendments contained in section 303 of H.R. 6675 be deleted (or altered in some way as suggested to solve any reasonable administrative problem) without changing the basic nature of the benefit.

Respectfully,

ORVILLE F. GRAHAME.

STATEMENT OF THE AMERICAN COLLEGE OF RADIOLOGY SUBMITTED BY WALLACE D. BUCHANAN, M.D. PRESIDENT

The members of the American College of Radiology appreciate the opportunity offered by the Senate Finance Committee to support provisions for payment for physician services in the field of radiology and three other specialties in the voluntary medical care insurance section of H.R. 6675, title XVIII, part B, now pending before the committee.

The members of the American College of Radiology favor retention of the language in H.R. 6675 and are opposed to any amendment of the bill which would define their professional services as hospital services under title XVIII, part A, or provide for compensation for physician services through hospitals or other institutions.

This statement will be confined to this important matter.

The members of the American College of Radiology are 6,200 doctors of medicine, more than 90 percent of those who specialize in radiology in the United States, and also the 1,400 physicians currently in training in this specialty. The opinions expressed in this statement are based upon actions of college deliberative bodies.

The practice of radiology is the practice of medicine and is so recognized by all medical associations, within Government medical services, by courts and other agencies of Government. Radiologists have completed a 4-year course in medical school, a year of internship, a training program in the medical uses of X-rays and radioactive materials of from 3 to 4 years, and have passed an examination by a special certifying board in the field of radiology.

In medical uses of radiation, a physician must in each instance decide whether the possible gain from exposing the particular patient outweighs the hazard of use. Only a doctor can evaluate what is a sufficient medical return to the patient for the radiation expended. This is a medical decision, not administrative. Such decisions should not be placed under control of hospitals. This professional nature of medical radiology is recognized in the educational programing of the USPHS. The definition of radiology as a hospital service in a Federal law would inhibit efforts of the profession and the Government to improve medical uses of radiation by physicians.

Ten to fifteen percent of the practice of radiologists involves the treatment of various diseases, chiefly cancers. Approximately 70 percent of all patients developing cancer are treated with radiation by radiologists. In treating with radiation, adequate equipment is desirable and necessary but the apparatus is far less important than the competence of the physician using it. The radiologist must decide whether, how and when to treat each individual patient. The patient's age, sex, physical condition, psychologic state, family situation and the like, all have a bearing on medical decisions that must be made. This is the art of medicine, and it has a tremendous influence on whether and how a patient reacts to treatment.

The report of the President's Commission on Heart Disease, Cancer and Stroke repeatedly recognizes the vital role of radiologists in the treatment of cancer, and the necessity of increasing the number of trained radiotherapists. The report says in part, "With properly trained radiation therapists available, improvement in most of the cure rates would be immediately possible for those patients with lesions suitable for such treatment."

Eighty-five to ninety percent of radiologic practice is the diagnosis of human illnesses. At least one-fourth of all important decisions in medical practice are based upon the interpretation of radiologic examinations. With X-rays and radioactive isotopes, radiologists are now examining every system of the human body. In performing physical examinations of patients by using X-rays, we personally do all fluoroscopy, interpret every film made, dictate a report on every examination, consult with other physicians, and many of us inject the drugs

used in complex procedures and wait with patients to handle adverse reactions. In both diagnosis and treatment, the physician's service needs to be individualized for the particular patient, and the medical decisions of the doctor should not be placed under the administrative control of a nonphysical administrator, or board of trustees. Adoption of amendment 79 would establish such administrative control.

Radiologists also occupy a vital position in radiation safety and protection, a field which involves the future of the human race. Better and safer uses of radiation in medicine, agriculture, astrophysics, biophysics, commerce, and in the military require radiologic guidance. Radiologists have supplied leadership in radiation protection in the United States and internationally for more than 40 years. These services are provided by men, not machines. The total investment in radiologic installations is all but valueless without the radiologists who must interpret the data produced by the installations. The machines and X-ray films are merely tools, and the technologic personnel are helpers of the medical radiologists.

As physicians, radiologists practice in many settings to make their services available to all types of patients. Many operate private offices. Some have private offices and also practice in one or more hospital radiology departments. Some are in clinic practice and others are teachers in medical schools. All regard themselves as physicians and regard their services to patients as medical services. These services are the same, regardless of the site.

The entire medical professional realizes that to define the radiologist's professional service as a hospital service would impair his performance as a practitioner of medicine, just as the services of the general practitioner, internist or surgeon would suffer if his services were so defined. Radiologists are human beings. For high morale and best performance, they must be able to work with dignity, be on a par with other doctors and enjoy professional freedom.

Some of the reasons not to define a physician's practice in radiology as a hospital service are as follows:

1. A radiologist, or any other physician, performs best under circumstances which permit freedom from administrative interference in the service he performs for the individual patient. The members of the American College of Radiology are convinced that the forced placement of their professional services under hospital control as proposed in amendment 79 would result in domination of their specialty by hospitals. This, they feel, would be contrary to the public interest, and the interests of individual patients, the sick persons who are the primary concern of all doctors.

2. Radiologists know that the difficult task of recruiting bright young doctors into radiology in the face of the appeal of other medical specialties has been made harder because of the continuing unrest between radiologists and hospitals, and because of the threat of being segregated from medical practice by definition as a hospital service under a Federal law.

Current recruitment for radiology returns an increase of some 5 percent yearly over deaths, including foreign physicians who often return to their own countries. At the same time, the uses of radiology in the diagnosis and treatment of diseases has increased more than 12 percent annually for many years. The increasing complexities of new procedures, such as intricate heart examinations, makes the actual increase in the radiologist's time expended closer to 20 percent. In 1963, only three out of four openings in radiology training programs for physicians were filled. The percentages in the surgical specialties and internal medicine were much higher, while programs in pathology and anesthesiology also went relatively unfilled. In 1958 there were, 1,389 physicians in radiology residency training programs, and in March 1964, there were only 1,395. During this same period of time, the volume of radiologic examinations in hospitals increased 72 percent.

Radiologists believe that this is a clear indication of the impossible recruiting task they will face if amendment 79 is adopted. We will not be able to attract men into a specialty defined as a hospital service.

3. Radiology services are covered in most Blue Shield plans (65 out of 71 in 1963) along with services of other physicians. This has assisted patients in financing health care and has not disrupted medical practice or hospital administration.

Radiologists would have preferred to have the total payment for their services placed in the voluntary insurance portion of H.R. 6675, and then to reimburse hospitals for space, supplies, personnel furnished, etc. We believe that this

would provide maximum physician control over the service rendered to each patient. We recognize, however, that the House of Representatives in adopting H.R. 6675 believed that such treatment of our specialty would differentiate it from surgery, general practice and other branches of medicine. In H.R. 6675 the hospital directly collects its costs for the operating room, the hospital bed, the radiology department, and drugs provided to patients served by surgeons, generalists, radiologists, etc. The House of Representatives decided to treat all physicians' services alike and all hospital costs alike. We accept this equal treatment under the law and oppose the discriminatory treatment explicit in amendment 79.

In 1965 medical practice is highly interdependent. If radiology is downgraded by definition as a hospital service, medical care available to all patients in all branches of medicine will suffer.

4. We are basically interested only in high level radiology services for patients now and in the future. We cannot now provide such under hospital domination, and we cannot recruit bright young doctors to provide such in the future if we are excepted from the practice of medicine under a Federal law. In the practice of radiology there is in each instance a patient and in each instance a radiologist who, as a physician, is directing his best efforts toward nothing but the diagnosis, or treatment, of that individual patient. This is the relationship we wish to have with patients over 65 under H.R. 6675; we do not wish to face them as hospital employees with conflicting responsibilities to hospital corporations. We are anxious to work with hospitals, Government, and insurers to provide the best possible medical care to patients at a reasonable cost within the terms of the law that is passed. We are ready to so cooperate now, or at any time in the future. We ask only that we be allowed to do this as doctors of medicine under the same terms as the Congress provides other physicians under the same law.

EXTEND TO THE DISABLED BENEFICIARIES THE SAME HEALTH CARE PROVIDED TO THE AGED IN H.R. 6675, STATEMENT OF REPRESENTATIVE CARL D. PERKINS OF KENTUCKY

Mr. Chairman, I appreciate the opportunity to appear before this committee to express my hope for favorable consideration of the bill, H.R. 6675, which would provide a broad program of health care for all people in the country when they reach their 65th birthday.

My purpose in appearing before you today, however, is not to comment in detail on the merits of the legislation passed by the House, but rather to urge that the benefits contained in the House bill be extended also to those disabled persons who are now drawing social security benefits and those who will qualify in the future. The report of the advisory council on social security, which appeared in January of this year, made such a recommendation as one of its proposals for the logical improvements at this time of our existing social security structure. This council made up of 12 outstanding authorities representing labor, the insurance industry, the medical profession, industry, public welfare, and experts in the university world, concluded:

"Hospital expenses are a serious problem for the totally disabled too. Like the aged, they too are hospitalized frequently and in many cases their hospital stays are long. According to a survey of workers found disabled under the social security disability provisions (conducted by the Social Security Administration in 1960), about one out of five disability beneficiaries under social security received care in short-stay hospitals in the survey year; and, excluding hospitalizations in long-term institutions, half of those hospitalized were in the hospital for 3 weeks or more."

For this reason recommendation number II of the report reads, in its first sentence. "The council proposes hospital insurance protection for those 65 or over and for disabled social security beneficiaries."

Mr. Chairman, I am aware of the fact that most previous proposals for health insurance for the aged have not included the disabled but it has always seemed to me to be a major oversight of these proposals. It is hard for me to understand how we can exclude from the program the relatively small group of people who have been adjudged by the Social Security Administration to be so seriously handicapped that their infirmities entitle them to benefits because they are unable to work. As we know, the definition for determining disability is a very strict