In this brief presentation I will not attempt to define the specific health problem of the aged. It is well documented, however, that the elderly do have an incidence of chronic illness, debilitating disease, and other medical conditions requiring nursing, medical, and paramedical care which exceeds that of the general population.

Compounding the problems of the rural elderly is their decreased and decreasing access to health care facilities and personnel. They share poverty with their urban counterparts, although at a significantly higher rate. In Iowa 11.6 percent of the State's total population had an income less than the poverty level of 1969; of those over age 65, 29 percent had an income less than the poverty level. Of the urban elderly, 30.9 percent were below the income poverty level while the rural elderly, who did not derive the majority of their income from farming, had a staggering 40.6 percent. Four out of ten rural elderly were below the poverty level.

Iowa's system of indigent care at the university hospitals in Iowa City and the advent of medicare and medicaid has measurably eased the barrier poverty imposed on access to health care in those services covered by these programs. One serious problem for the elderly in their utilization of the medicare programs is the paper storm with which they are deluged by the computers after a claim is filed.

Keep in mind that many of these recipients have loss of vision, often are somewhat confused, live alone, and are totally unaccustomed to business forms and computer correspondence. Further most really do not comprehend the concept of usual and customary fees, the everchanging level of deductibles and percentage payment of allowable charges and the variability in the percentage of payment for similar services when provided as a hospital inpatient, outpatient, or in the doctor's office.

With this in mind, then, imagine the confusion created in the mind of the poor recipients when they receive a form which gives them the detailed results of these policies, regulations, and calculations. The fact that all of the forms have the words "This is not a bill" printed in large letters is little comfort when the reader has no idea just what in the world it actually is. This problem has turned off elderly from applying for benefits under medicare; it also has caused them confusion and they have thrown away checks for the benefits. Simpler forms with less detail would aid the patients. More detailed information could always be obtained for those interested in obtaining

it.

LACK OF ACCESSIBILITY TO HEALTH CARE

The greatest problem facing health care in the rural elderly is their lack of physical accessibility to the health care delivery system. In larger urban centers, hospital outpatient facilities, public health departments, increased physician-patient ratio, and the availability of public transportation greatly facilitates the patient's entry into the system.

In rural areas, however, there is little or no public transit. Farms and small towns are remote from physicians and hospitals. Public health services in rural counties often consist of only one nurse in the entire county, and some counties have none at all. In several rural counties with a public health nurse the supervisors have been quoted as saying that they will have public health nurses in their counties.

only so long as they have Federal funds to pay for them. Public health programs in the rural Midwest, if left to local government initiative and funding, will remain inadequate at best and too often will be nonexistent.

Despite efforts by the University of Iowa College of Medicine to retain primary care physicians in Iowa, the supply of doctors in rural areas continues to fall. The proportion of elderly physicians in rural counties sometimes exceeds the percentage of elderly in the country's general population. This affects both the availability and the quality of care.

In Red Oak we have initiated a program which we believe will reverse the worsening of the physician-patient ratio, improve the quality and availability of rural health care, initiate community health programs, teach medical students and family practice residents in a rural setting, and provide a model replicable in other communities who desire to achieve the same goals in their areas.

Ours is a private practice assisted by community effort and aided in the teaching and model aspects of the program by funds from the Kellogg Foundation. Two of us in private, solo general practices joined in establishing a group family practice. We adopted problem oriented medical records and relocated in a new medical office building adjacent to the local hospital. We established a satellite office in Malvern with a population of 1,200 20 miles away. We employed a family nurse practitioner who worked both in the central office and the satellite. The community actively recruited board certified family practitioners to join our group.

Within 1 year we had employed three such physicians. Red Oak had been unsuccessful in attracting any new young family practitioners since I came there in 1953. One of the new doctors joined us in July 1975 and the other two in July 1976. Our family nurse practitioner has since retired from practice for personal reasons and we are actively recruiting another physician extender at the present time. While she was in our employment we were dismayed to find that the Federal Government was imposing a major obstacle to the use of physician extenders.

REIMBURSEMENT DISALLOWED

Medicare refused to allow reimbursement for physician extenders services provided in the absence of direct supervision-that is, the physical presence of the emploving physician. This makes it impossible to utilize either a physician's assistant or a nurse practitioner in an efficient and meaningful way to improve the availability of health care in rural areas.

Senator, I am aware of your efforts to direct this problem, at least in relation to the family nurse practitioner. Iowa's medicaid-medicare carrier has successfully induced HEW to include at least some of the 40 or so physician extenders emploved in the State in a Social Security Administration contract study with the University of Southern California. When approved those physicians emploving the physician extenders as part of the experimental study program may be reimbursed. Approval has been extremely slow and, as of my latest information, none were yet receiving reimbursement unless it was stated that the physician was present at the time of service. If the Federal

Government is truly interested in finding ways to improve the availability of quality health care in rural America, reimbursement should be available when State license and practice standards are met.

Although our program in Red Oak is in its infancy, we are encouraged by its acceptance in the community. Our successes and failures will serve as guideposts to other communities in their efforts to provide better health care. Evaluation studies are being developed to measure the impact it has on the health and well-being of the citizens it serves. Because of the age distribution of our area's population, a significant percentage of them will be among the rural elderly.

Senator CLARK. Thank you very much. I know that this program that you are developing there has been a particularly enlightening one and we enjoyed hearing about it. If you have any additional information, details, or material that ought to be made a part of the record about the center, we would be very, very pleased to have those as well. Dr. FICKEL. I would appreciate the opportunity to submit a written report 1 in the next few weeks, Senator.

Senator CLARK. Good.

What can be done, Dr. Fickel, to promote the physician-extender concept around the State? Should the Federal or the State help? Could they be of some help by giving training, or is that not practical? In other words, what can be done to extend or to encourage physician extenders to go to the very rural areas? Are there any circuit-riding programs, or the like? Do you have any ideas about what might be done?

RESULTS MUST BE DEMONSTRATED

Dr. FICKEL. I think that to demonstrate that it works is probably the greatest tonic. As you know, six Iowa nurses went through a program at the University of North Dakota. I was preceptor for one of them. They have come back to Iowa to practice in the employment of physicians here. In Iowa, under State law, any physician extender must be employed by a physician, which I think is quite proper to provide quality health care. But proving that these will work and that they can provide service without sacrificing quality, I really think is the answer. Then we are going to have a need for funds in training large numbers of them, because I think there is a definite need and we believe that it is a very sound concept.

Senator CLARK. Thank you very much.

I notice that the hour of 12 o'clock has arrived and I know that they want to use this room to serve lunch. Thank you very much for coming and I particularly thank the witnesses that have testified. I am very pleased to have George Orr here who is the new executive director of the Iowa Commission on Aging. I thought we got a good bit of information from the panels that was very valuable to the committee.

I thought in particular the testimony in the first panel, the two ladies that talked about transportation-talked about some other problems, too, but particularly transportation-was helpful, as well as Mr. Willis Sprunger who spoke particularly about the Plaza-the housing area-and what that has meant to people who live there. Mr. Goeldner spoke about the very excellent example that we see in Earlham where they started, I guess, about 12 or 14 years ago to really

1 Not received at time of publication.

begin to work in homes with homemaking, home health care nursing visits, transportation, meals-on-wheels-or I should say congregate meals in this case—all of the programs that they were able to develop in this kind of rural community.

We also, of course, were very pleased to have Woody Morris here who knows so very much about these programs and hear his point, particularly about the necessity for these Federal programs to deal with accessibility-not just the fact that we have got the programs, but whether or not anybody can get to them or whether they can get to the people one way or the other.

Then, also, this last panel. I particularly enjoyed Mr. Pals' talk about what you can do with a small amount of money in terms of the winterization program-the number of homes-300 some, I think you said-you were really able to help with a fairly small amount of money. Then Mrs. Forsyth, whom you have just heard, and the things that they have done here in the development, not only of a multipurpose center for so many things, but now also the development of this kitchen so that meals can be prepared right here. We also appreciate your testimony as well, Dr. Fickel. It has been very valuable to us.

We are going to go on over and hold hearings this afternoon in Ottumwa starting about 1:30 or 2 o'clock. So we are going to continue to hear various views. I think we are hearing that the major problem still seems to be lack of funds; that is to say, financial. I am speaking about an individual having enough money. The figures that you gave, and particularly Dr. Fickel, show that about 40 percent of the rural elderly are living below the level of poverty, and that is a distinguishing figure.

I think the accessibility of medical care which Dr. Fickel talked about still is obviously a problem in rural areas. We have seen the success of nutrition programs-the kind of program that we are going to take advantage of here, if I quit talking-and transportation which seems to mean so very much in rural areas, the housing, and the community center. We have started on all these things and they are very, very important, but we have got a long way to go.

Thank you very much for coming.

[Whereupon, at 12:12 p.m., the hearing was recessed.]

APPENDIXES

Appendix 1

MATERIAL SUBMITTED BY WITNESSES

ITEM 1. MAGAZINE ARTICLE AND BROCHURE SUBMITTED BY L. R. GOELDNER1

[From Aging, U.S. Department of Health, Education, and Welfare publication, dated November 1963]

A SMALL TOWN ORGANIZES BASIC SERVICES FOR ITS AGING

Earlham, Iowa, 30 miles west of Des Moines, is a farming community with a small central business district surrounded by pleasant homes in wide lawns. Earlham boasts a bank, one restaurant, an automobile dealer, a clinic, a school with a fine new addition, a weekly newspaper, and a farmers cooperative. The farmland around the town is rich and productive, except where the farms have been displaced by three gravel quarries.

Earlham is a pleasant place to live, and the people of Earlham are forwardlooking and interested in improving their community. But Earlham is a small town. Only 800 people live there, only 2,000 in the entire school district, and 15 to 17 percent of these people are elderly. As in rural communities across the Nation, the percentage of the older population is higher than in most cities.

Many small American communities have thought of doing something for their older people, but most of them have felt too small or too poor. But Earlham went ahead with its plans and, in doing so, it made itself a model for community action. As Aging goes to press, the Earlham Care program, initiated July 1, 1963, has already started the following activities: (1) Homemaker service; (2) Handyman service; (3) Activity center; (4) Counseling service; (5) Transportation within the community; and (6) Meals-on-wheels.

Care is planning to start friendly visiting and a telephone service this fall, and it has a visiting nurse available.

FIRST STEPS IN COMMUNITY ACTION

A group of Earlham citizens, calling themselves the Earlham Community Development Committee, started meeting informally to discuss the town's future. Earlham, they felt strongly, was a good place to live and they could build on this asset by making it an even better place. Among the things mentioned were greater services for the older people in the community.

In the spring of 1962, two members of the committee contacted the town's ministerial association with the request that the ministers secure the backing of the nine churches in town for a nursing home project. By fall, the association had decided on a thorough investigation and appointed a committee of three ministers to make a study of nursing homes and to report with definite recommendations.

By the end of 1962, the three ministers were almost ready to make their report and to recommend that funds be raised for a 25-bed, nonprofit nursing home. But, at that point, they contacted the State Department of Welfare in Des Moines. There they received suggestions on other services which might be of benefit to the elderly, and they were urged to talk to Amelia Wahl, Kansas City Regional Representative on Aging for the U.S. Office of Aging.

1 See statement, p. 7.