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MR. CHAIRMAN, HONORABLE MEMBERS AND GUESTS, I am Marvin Lymberis, M. D., a private practitioner specializing

in ophthalmology in Charlotte, North Carolina.

I appreciate

the opportunity to appear before you and discuss various aspects of NHI from the viewpoint of a private practitioner who has devoted many years to community problems in health planning and the socio-economic aspect of medicine.

Unfortunately,

the more one studies planning, experiences planning actions and debates the issues with colleagues and adversaries, the more he becomes convinced that there is no single panacea for the problems we face in formulating a policy for an area as large and diverse as the U. S. A. Our problem is multifaceted. Two goals appear to be common to all participants. One, that every citizen shall have access to primary care; and two, no citizen or family shall be bankrupted by catastrophic illness. I intend to point out some of the complexities of this problem and to urge caution before attempting a broad and comprehensive national program which could be irreversible and might well do more harm than good.

Every practitioner, officeholder and citizen views health care from a different perspective and often with different definitions. Even among the medical profession, the academician, private practitioner, hospital based physician, urban and rural physician have different environments and experiences from which to judge. Diverse sections of our great and large country, with its varied topography, ethnic popula

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tions and climatic conditions have different health problems and consequently want different solutions. The officeholder, the self employed, the employee, the employer all differ in their problems and offer varied and diverse solutions. Indeed, it is a Herculean task to formulate a single policy to satisfy so many groups.

Access to health care has improved markedly during the past ten years. The next five to ten years will see even more improvement as the greater number of doctors now "in the mill" will be entering practice and will significantly increase the supply of primary physicians. This should alleviate the current problem of access. The long lead time to increase the output of physicians makes it impossible to accelerate this process with a crash program. The sad fact is that some of these programs have made it more difficult for some citizens to have access to primary care. The advent of medicaid closed a number of pre-medicaid clinics and the many difficulties with the medicaid program continues to prevent many of the se former "clinic" patients from obtaining primary care.

One of the major fears of a very comprehensive NHI is that it could well OVERLOAD THE SYSTEM. Since the end of World War II more technology has evolved in the health care field than in all previous history. The tremendous increase in the number of first-class training institutions and the greatly expanded corps of well-trained health care personnel of all categories have made this technology more rapidly adopt

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Pro

ed and widely disseminated than would have been possible in preWorld War II days. During this same period, the public has become more informed regarding health care and more demanding for the "Medical Miracles" so well publicized by the media. bably the only thing that has increased more than our technology is the Public's Expectations. Compounding the problem of delivery and financing, the Federal Government has taken on an ever increasing responsibility for the provision and financing of health care.

To date little or no effort has been made by either provider or third party payor to determine the feasibility of providing all the available technology to all the people. With inflation, there has been increasing concern over the financing of this technology. Recently, a Defense Department spokesman stated, "We cannot afford all the technology we have available." It is past time that provider, public and payor give some consideration for cost effectiveness. It is easier to raise money for

a new sophisticated technology to cure a rare disease than to obtain funds to treat a common ailment by proven therapy. A liver transpolant is dramatic--treating intestinal parasites is not. The former is rare and offers a very poor prognosis, the latter is common with almost 100% certainty of cure.

A major point of distress to the practitioner is the laudable attempts by legislation and private foundations to tackle recognizable problems by either anatomic or disease entities--thus fragmenting the patient. Each of these programs has different authorizations, regulations and forms to complete.

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Some are concerned with the method of financing, others with the disease entity--cancer, diabetes, the blind, the deaf, heart disease, etc., etc. There is Medicare, Medicaid, Commission for the Blind, Commission for the Deaf, Diabetic Association, Multiple Sclerosis. Heart Disease and Stroke, Neurological Diseases, Epilepsy, Muscular Dystrophy, Industrial Commission, Blue Cross, Commercial Insurance, School Insurance, Rehabilitation, Crippled Children, etc., etc. Just keeping up with the constant bulletins, retractions, addendums, exceptions and changes from each of these divisions has become an impossible task for the practitioner and hospital, as well as a great expense.

There are three major parts to health care planning: Access, Quality and Costs. Since great amounts of public monies are being spent, it is natural that concern for cost and quality, as well as access, be monitored and audited.

Unfortunately,

these have not been coordinated. One agency is concerned with access or availability; another with quality control only; and still another with cost control and cost containment and not quality. The provider is caught in the middle while costs have escalated to undreamed proportions and are still rising. Defensive medicine has further added to these escalating costs. I submit that it will take the wisdom of Solomon to adjudicate the conflict between cost and quality, but is it not time that some attention be given to Cost Effectiveness? Must we take a thousand X-rays of bones with a history of trauma to make certain that we do not miss ten with possible hairline fractures?

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Shall we continue to expend costly resources for the terminal patient in the name of Quality? No one has given a clear-cut moral, ethical or legal answer to these important questions. New and sophisticated technologies are expensive. Should we not analyze the advantages over older technologies with cost effectiveness as one of the criteria?

The greatest problem of prepaid systems is control of input into the cystem. I submit that a deductible and co-insurance policy is the only practical way to effectively control the input. Most of our citizens have some form of private insurance. For those not able to pay for private insurance, society should be responsible. However, there must be some obligation on the part of the consumer to prevent overloading and wasting of valuable resources.

requested from NCBCBS a survey of claims.

Two years ago, I

It was found that

almost 80% of claims were for amounts under $50.00. At the same time, the average of all claims was in excess of $400.00. These figures are higher now. Some patient responsibility would reduce much administrative costs for both payor and provider, as well as preventing the overload of the system, resulting in better care being available.

The real burden of Health Care Financing falls into the Catastrophic category. Those citizens not medically indigent can and should budget for reasonable amounts, depending on family income, for basic health care. It is when an individual's or family's medical needs pass this reasonable amount