RECREATION AND MEDICAL CARE

There are people who do not have a place to go and they need someone to talk to. We are seriously concerned about this and in any municipal institution where a constant effort is to keep people from being a number of a statistic, it is difficult to meet with them and discuss their problems face to face.

We do find, and I think our experience bears a place in reliable data, I believe out of New York, Columbia, Bellevue, Howard Rusk, and others, that if we are able to refer these people to a recreational center, Golden Age groups, things of that type, they feel they have a part in determining their own programs and they are not being programed for.

I take an extreme view of being programed for. We find that by this type of paralleling our occupational therapy, recreational therapy, and other things, that go on in our medical institutions, that the need for care goes down by the order of 50 percent.

The hospitalization decreases dramatically.

I think hospitals are finding that we have an increasing need to meet with other disciplines, professional groups, in discussing the total problems of all phases of care.

I see a very great gratifying trend in this direction in that the professional groups and social workers and the consumers themselves are meeting increasingly with us and we are finding a much better liaison and joint cooperation.

Our effort here, I am sure, is the same as that of your own committee, Mr. Chairman, to approach these problems. I speak in major part of hospital problems, but all the problems of the aging population are so met that we will respect the dignity and the individuality of the aging patient himself and that our programs in any event will do nothing to decrease his own personal sense of responsibility and sense of individuality.

Thank you, Mr. Chairman.

Senator MCNAMARA. Thank you very much, Doctor.

Certainly your comments have been very valuable to the committee. You are on the firing line of not only mental and physical health, but you come in contact with the economic problems of these people.

This is part of the picture. For that reason the testimony you give is of great value to us and we do appreciate it very much.

Dr. Sidney Lee, we shall be glad to hear from you at this time.

STATEMENT OF DR. SIDNEY LEE, DIRECTOR, CLINICAL SERVICES, BETH ISRAEL HOSPITAL

Senator MCNAMARA. Do you have a prepared statement, Doctor? Dr. LEE. Yes; I do, sir. I have given a copy to the reporter. Senator MCNAMARA. Thank you.

You may proceed. The entire statement will be made a part of the record at this time.

Dr. LEE. Thank you, sir.

(The prepared statement of Dr. Lee follows:)

PREPARED STATEMENT OF SIDNEY S. LEE, M.D., PH. D., DIRECTOR OF CLINICAL SERVICES, BETH ISRAEL HOSPITAL, BOSTON, MASS.

The problems of the aged and aging which this subcommittee is attempting to grapple with are serious, indeed. Much as the pestilences of the past determined the course of history, the winning and losing of wars, the emergence and submergence of nations, it may well be that how we handle the problems of the aged may plot our future as a Nation. Control of nuclear radiation and the conquest of space will affect the yes or no of survival-but how we live and what meaning life will have will be dependent on what we, as a people, project for ourselves.

We discuss the aged-a well-defined, measurable group. But all of us are aging-so we decide on our own future.

The problems we face arise out of our own action and inaction. Industrialization and urbanization, which have yielded for us a high standard of living, have also produced crowded living conditions, competitiveness in productivity and an emphasis on youth and vitality. Improved sanitation, the conquest of epidemic diseases, better nutrition, and drugs with specific actions all permit us to live longer. What are some of these problems?

(1) How can the aged in our society maintain a spirit of independence, a sense of self-reliance and of self-respect?

(2) How can income levels be raised to permit independence and self-respect? (a) Can gainful employment be maintained into the older years!

(b) Do we need extension of existing social legislation?

(3) What can we do to prevent physical and emotional disability?

(a) Are we making a large enough investment in research?

(b) Are we applying all that we know already so that everyone who needs services is obtaining them?

(c) Are we training enough personnel of the right kinds to do the job?

(d) What are we doing to ensure proper distribution of personnel?

(e) Do we need more and better facilities and equipment?

(4) What are the available mechanisms for financing what we need-and what are the priorities if choices must be made?

RECOMMENDATIONS FOR ACTION

(1) Enactment of Federal legislation against age discrimination in employment-with specific provisions regarding advertising media.

(2) More Federal and State support for low-rental housing for the agedespecially in urban areas.

(3) Lifting of ceiling on total assets now required before eligibility for old age or disability assistance may be established.

(4) Continuation of Federal support for research on the aging process.

(5) Federal support of projects designed to demonstrate and apply what we have learned from research. Such projects should be supported for several years with the specific objective of absorption into local community program. (6) Specific support by voluntary agencies of research in patient care so that we may learn how to apply our knowledge more effectively.

(7) Extension of social security legislation to provide medical care benefits for the aged. These benefits should be comprehensive in scope-not piecemeal. If we accept prevention and rehabilitation as primary goals, ambulatory care and home care assume an importance equal to, if not surpassing that of hospital and surgical care. Legislation should include safeguards promoting care of high quality and avoiding further undue inflation of costs of care.

(8) States should enact legislation and develop regulations designed to improve our nursing homes-the weakest link in the pattern of medical care. Wherever possible, nursing homes should be affiliated with public or voluntary hospitals. (9) Fellowship and scholarship funds should be increased and developed to promote and supply and improve quality of personnel in fields such as: (a) Medical social work

(b) Laboratory and X-ray technology

(c) Physical and occupational therapy

(d) Practical nursing

(e) Medical care administration

(f) Biological and social sciences

Dr. LEE. In the statement which I have presented, Senator McNamara, I have outlined a series of things which I would consider as recommendations for action.

I would like perhaps to elaborate on one or two of these rather than to attempt to recapitulate them all at this point.

It seems to me that action in this field must be taken not only by Federal Government, but also by State and local government agencies and voluntary agencies throughout our national structure.

FINANCING MEDICAL CARE

There are some areas of specific Federal support which I would like to see enacted into legislation. One of these has been referred to already, namely, the Forand bill.

I would personally favor extension of social security legislation to provide medical care benefits for the aged but I think these benefits should be comprehensive in scope and not piecemeal.

If we accept the fact that prevention and rehabilitation are our primary goals, then ambulatory care and home care assume an importance which is equal to, if not surpassing, that of hospital care and surgical care.

People need care over extended periods of time and different kinds of services at different points in time. I feel also that contrary to the provisions of some existing Federal legislation such legislation should include safeguards promoting care of high quality and avoiding further undue inflation in costs of care.

Now, another point which I think deserves consideration in action I hope is one which Dr. Sternfeld alluded to in his statement, from the Massachusetts Public Health Association.

FUNDS FOR DEMONSTRATION PROGRAMS

In addition to having legislation and funds made available for research in the field of aging, in the broad field, we also need support for projects which are designed to demonstrate and apply the things which we already know.

I have just returned from several days in a rural county in North Carolina, a county which is attempting to do a job through citizen groups to develop a program for the aged and care of the chronically ill in the county. The communities within that county are prepared to go ahead and work at this. There are plenty of people interested. Lots of local action. They are ready to move.

If it were possible for them to have a small grant-in-aid to get started for the first year, or first two years of what they propose to do, which is currently sound, this would make for real rapid production of services for affected groups in this whole area.

This is an area which we have sometimes neglected in our developmental programs around the country, the sort of pump-priming funds which would enable us to do what is needed across the country.

Dr. Conlin alluded to the fact that a lot of work has been done in Boston particularly in the development of home care programs. Of the 60 programs in the United States, 5 of them are here in Boston. It is too bad that there are not 2,000 of them in the United States.

43350-59-pt. 2- -11

It

would take very small amounts of money to get these programs started by comparison with the appropriations which are currently available on a categorical basis for various and sundry specific diseases control. One further point which I believe needs some attention, and that is the fact that while we have developed programs designed to produce more people in specialty fields in medicine and some of the related areas, we have, however, neglected the fact that producing a research scientist also means that he has to have a pair of hands to work with, skilled hands. It seems to me that we need to give active consideration, to both governmental and voluntary agencies working together, producing more people in the fields which are ancillary to specific medical care and specific medical research, people like laboratory and X-ray technicians, people like medical social workers, occupational therapists, practical nurses, people in medical care administration, people in the biological and social sciences.

Thank you very much.

Senator MCNAMARA. Thank you very much, Doctor.

Do you feel that there is a need also for the dissemination of the information that has been developed with these programs at the national level? Do you find there is enough machinery? What is your experience in that area, Doctor?

Dr. LEE. I would feel that there is an adequate amount of printed material available from various sources. Its distribution could be improved, perhaps, through some assistance from the U.S. Public Health Service in distributing certain kinds of materials which become one available in one locality and might be useful elsewhere.

What is needed is not only the printed information, but the opportunity to put the programs into action.

Senator MCNAMARA. There has been some criticism of the operation in that from the research center. Information is sent out to the doctors, but does not get out to other interested groups.

I was wondering if you agreed with that criticism. I think the earlier remarks that you made in general stated this could be improved? Dr. LEE. Yes.

Senator MCNAMARA. Thank you.

Now, Dr. Weidman, we will be very glad to hear from you at this time.

STATEMENT OF DR. WILLIAM WEIDMAN, DIRECTOR, DIVISION OF HOSPITALS, MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

Dr. WEIDMAN. I am Dr. Weidman, from the Massachusetts Department of Public Health.

I have been asked by Dr. Frechette, the commissioner, to present the problem of the department regarding hospitalization of the chronically ill.

I am the director of a division which has eight hospitals. There are approximately 2,500 patients.

Of these, approximately 2,100 or 2,200 are older people.

Now, these people are admitted in various categories to our institution, public welfare, various categories of assistance, self-supporting, Blue Cross, Blue Shield.

Now, the surprising thing about some of our figures is that in some of our institutions, 48 percent are so-called self-supporting individuals, about 20 or 25 have some sort of insurance.

Now, when we use the category of self-supporting really we are deluding ourselves or, at least, the public is being deluded because these people are not self-supporting, because the actual cost of treatment is sometimes twice, sometimes four to five times actually what these so-called self-supporting patients are paying.

HOSPITAL COSTS

Now, on the other side, you take a general hospital here in Boston which has a deficit of a million dollars. That deficit has been incurred by those so-called self-supporting individuals.

Now, this is a problem which all of us I feel must face. I don't care what the hospital is; they cannot continue having a half million or million dollar deficit over the years, as has been pointed out here, with a 5-percent increase in cost annually.

So what must you have? You must either have some sort of subsidy for the hospital if you want to maintain the private hospital, which we should do, or if the people have to be subsidized, then some type of insurance must be furnished to support these individuals.

Now, if this is not done we have to recognize that the needs of these aged persons must be met who are chronically ill, often chronically ill for long periods of time.

What is the alternative? We will have State-supported hospitals for the treatment of these individuals.

Now, whichever way this tax dollar is cut people must receive some sort of help.

The department certainly approves this principle, this so-called Forand bill.

However, it objects most strenuously to the management of this function by a central agency far removed from the States.

I feel quite sure that with the present functions, the high development of a State public health department, that there is better information and more information which could produce a better functioning administration of an insurance program and that you do have a better realization and understanding of the quality of medical care. This, to me, is one of the most fundamental things we must speak of as physicians and hospital administrators, the quality of medical

care.

Now, whether this is done in a private institution or a public institution is immaterial. We do know, first, that it must be furnished, this care, and it must be furnished in the best quality that we can obtain.

Thank you.

Senator MCNAMARA. We appreciate your statement. The statement which you have submitted for Dr. Frechette will be printed in the record in full at this point.

(The prepared statement of Dr. Frechette follows:)