STATEMENT OF DR. ALLAN M. BUTLER, ASSOCIATE PROFESSOR OF PEDIATRICS, HARVARD MEDICAL SCHOOL; CHIEF OF THE CHILDREN'S MEDICAL SERVICE, MASSACHUSETTS GENERAL HOSPITAL; AND AN EDITOR OF THE JOURNAL OF CLINICAL INVESTIGATION, JOURNAL OF PEDIATRICS, QUARTERLY REVIEW OF PEDIATRICS AND ADVANCES IN PEDIATRICS

The CHAIRMAN. Dr. Butler, will you state your full name and give the committee some of your background, your profession, and so forth Dr. BUTLER. Dr. Allan M. Butler from Boston. I am here representing the Independent Citizens Committee, which has just been discussed. I am associate professor of pediatrics at the Harvard University Medical School, chief of the children's service, Massachusetts General Hospital, and an editor of five medical journals.

The CHAIRMAN. Doctor, in order to expedite the hearings, I wouli like to ask if it would be possible for you to file your complete statement and summarize it and allow yourself to be examined?

Dr. BUTLER. It would be possible, I think, but it would be better to read it.

The CHAIRMAN. You may proceed.

Dr. BUTLER. It will not take very long.

The CHAIRMAN. You may proceed.

Dr. BUTLER. The reason I want to read it is that I want to preser

it to you.

Senator DONNELL. May I interrupt for a moment?

Personally, I am very much pleased that the chairman is permitting him to do that. I think it is better to know that the witness is test: fying, rather than overlook some salient features that we do L have in an incomplete statement.

The CHAIRMAN. I thank you for that comment. I believe in th... · myself.

Senator DONNELL. Yes, sir.

The CHAIRMAN. But we have several other witnesses. Of cours. Dr. Butler is a very important witness.

Senator DONNELL. Yes, sir.

The CHAIRMAN. And I want to have his full and complete statemer Senator DONNELL. Thank you.

Dr. BUTLER. I want to try to give you a background of why I thr. you have an extraordinarily important job to do; why, in doing th. job, you must take measures to protect the quality of medical car why, in doing a good job, you are going to run afoul of the opposit of a so-called medical profession; and why you must be bold in wha you do.

INEVITAPLE CHANGE IN PATTERN OF MEDICAL CARE

The legislation that this Senate committee is considering is not thr product of political expediency or sentimental reformers. It is a re flection of the fact that science has forced upon us in every phas of human endeavor a new social economy that, infringes upon ou personal liberty while freeing us from the ruthless forces of natu and the sufferings of ill health. Music and drama have been rev. lutionized by projection all over the world immediately as produce or years later as recorded. The application of science to industry

agriculture, and transportation has produced undreamed-of results and increased society's productiveness to a point where economists are faced with problems created by abundance rather than want.

To reap the material benefit of such productiveness and to avoid unemployment and chaos, we have accepted at the expense of social independence more and more administrative control by private groups, mammoth corporations, and government.

In times of economic stress or war we have resorted to increased Government control to provide direction to this intricately interrelated and yet competitively disorganized production as will meet our needs.

And now in peace, to prevent the total destruction of ourselves and of our civilization by the latest achievements of science, can we do other than submit to the sovereignty of a world government at the expense of our national independence?

And if we do, can our finest traditions prevail in a world in which the great majority of individuals have no tradition of democracy, of freedom of speech and religion, or of justice to the individual as we know it?

On the other hand, if we declare the price of a United Nations too great, will these traditions and the material benefits of modern civilization survive the competitive struggle for national independence? With science presenting such a dilemma, how ridiculous to argue that science must be applied to medicine without changing the pattern of medical care or the so-called independence of physicians.

In arriving at your recommendations to the Congress, will you as representatives of the people permit the guildlike interest of solo practitioners to limit the benefits of science in improving medical care? Will you in deference to such interests permit an anarchic application of science at the expense of the Nation's health?

The pertinence of these questions is supported by the 1942 report of the maternal mortality committee of the committee on maternal health of the Minnesota State Medical Association that 73 percent of the deaths were preventable, and that in 69 percent of these the physician was wholly or partially responsible. This record reflects the fact that the only standard of practice enforced by State medical societies is the standard that avoids legal malpractice.

IMPORTANCE OF GROUP PRACTICE

I trust that you, in considering this legislation, will accept the fact that the time-honored general practitioner, who rendered all aspects of medical care to patients, is a casualty of the progress of science. We must face the fact that the total knowledge available for the case of patients today cannot be mastered by an individual physician. Modern medical care of the sick patient requires the services of not one but many physicians, as well as highly trained technical and nursing personnel skilled in the use of complicated apparatus and delicate techniques.

The hospital's role in medicine used to be the provision of bed and operating-room facilities. Today, provision of these is no more important than the provision of the laboratory procedures and special techniques upon which proper medical diagnosis and treatment are more and more dependent.

In 1930 a committee of eminent physicians, public-health officials and laymen, called the Committee on the Cost of Medical Care, after intensive study concluded that the benefits of modern medicine are made available most readily to the public by the organization of group practices centered about hospitals.

The perspective afforded by the intervening 15 years has amply confirmed this conclusion, the conclusion which was then and still is opposed by so-called organized medicine, or the societies that defend the guild interest of sole practitioners. Yet these practitioners would not suffer from such an organization of medical services.

The family practitioner, as differentiated from the general prac titioner, would be an important member of such groups. He would be the internist specially trained in the recognition of the early mani festations of disease and complications and in the treatment of those conditions which do not require the special knowledge, techniques. and hospital facilities readily provided by others in the group of which he is a part.

Whatever limitation group practice might impose on the action of an individual physcian would be balanced by the group's consideration of each member's qualifications, limitations, and personal needs.

The members of a group can readily be "off call," in doctors' phraseology, for definite hours or days or for a month's vacation or postgraduate study. No member should be burdened with responsibilities for which he is inadequately prepared by training and experience.

The intellectual satisfaction and stimulus of being associated with the educational and scientific activities of his hospital group would also compensate for the loss of the odd independence of the sole prac titioner odd, because in one sense it is almost unique in our highly organized society and in another sense it is more imaginary than real Actually, the sole practitioner must be at the beck and call, day in and day out, of his patients, lest he lose the practice he has so laboriously acquired.

PRESENT MEDICAL CARE TOO EXPENSIVE

It is a foregone conclusion that some method of adequately financing medical care in an orderly and predictable manner must be evolved Modern science has made medical care extremely costly to the individual patient. Personal experience has proved this too forcefully tr probably each of us. Yet science has diminished the cost of illnes to society by reducing the economic loss incident to death early r life and to unemployment due to illness.

Obviously, distributing the cost of medical care over society as whole is a logical solution of the problem created by the present inequitable distribution of the costs of illness.

The American Medical Association agrees that patients whose family income is $3,000 per year cannot pay the costs of serious illness Patients whose family income is $2,500 per year are admitted to our urban hospitals as charity patients. This means that doctors whose average net income is only slightly over $3,000 per year are called upor to render free medical care to these patients. It means that patients with incomes well above the average pertaining in these urban areas are forced, under the present system, to be charity patients.

Charity, we must remember, pays hospital costs, nursing costs, social-service costs, and laboratory costs. It does not pay physician costs. With the increase in the cost of medical care, the charity tradition is placing an impossible burden on physicians.

Doctors should not and cannot continue to carry this economic burden. No other individuals in a system of free enterprise are asked to make such a contribution.

The attempt of doctors to do so by soaking the rich is an unsatisfactory and illogical method of meeting the problem. As stated by the American Academy of Pediatrics—

the discrepancy that now exists between surgical fees on the one hand and free service to the indigent on the other has contributed in no small part to the problems of an equitable remuneration of physicians.

The conclusion is inescapable that the high costs of modern medicine must be financed by people when they are well. They cannot be financed by those who suffer the misfortunes of illness.

Much is made of the difference between the voluntary or compulsory extension of insurance as a means of distributing medical costs. This actually is of minor importance.

The important point is that the successful operation of either voluntary or legislative medical insurance on a scale that will be significant in solving the problem of cost will require reorganization of our current medical practice and development of effective administrative agencies at Federal, State, and local levels.

These agencies must not only be concerned with the efficiency in terms of cost of medical service, but with the maintenance of high standards. The Children's Bureau of the Department of Labor provides an excellent example of how a governmental administrative agency can raise standards of medical care. The contributions it has made in raising the standards of maternal, infant, and child health throughout the country are recognized by the American Pediatric Society and the American Academy of Pediatrics.

VOLUNTARY MEDICAL PLANS INADEQUATE

A false impression of the satisfactory expansion of voluntary medical insurance frequently results from not making a sharp distinction between hospital insurance and medical insurance, and possibly Senator Donnell's remarks to Mr. Ickes about the Blue Cross reflect this lack of distinction.

The public should understand that while hospital insurance has grown over the past 15 years so that it now covers risks for 30,000,000 people, medical insurance has grown but little and provides only a very limited type of service to some 3,000,000 persons. And that figure does not include the insurance that is paid in cash in terms of indemnity.

Thus the 30,000,000 with hospital insurance receive coverage for hospital board and lodging costs, but only a few have coverage for professional costs.

It is even more important for the public to know that no statewide voluntary medical service has made any provision for protecting teaching services or encouraging research. Moreover, because the

guild of solo practitioners dominates these voluntary plans, there is considerable doubt as to whether they will make provision for these essential elements in the improvement of medical care.

It is imperative that any extension of insurance medicine include adequate provision for teaching and research. The bill before you does.

If adequate provision is not made, then as insured patients cared for by physicians of their own choosing replace the charity hospital patients now cared for by the specially trained personnel of wellorganized teaching services, the quality of medical education will be jeopardized.

Because medical education determines what the medicine you get tomorrow will be, the preservation of teaching and clinical research units is of vital importance to the public. The point can hardly be overemphasized.

The organized hospital units of medical service teach clinical medicine not only to undergraduate and graduate students and practicing physicians, but continually introduce new knowledge and techniques to medical practice for the public's benefit.

The standards of the medical care you and I receive from any phy sician are, therefore, largely dependent upon these hospital services It is of vital importance that the legislation you are considering mak provision for and encourage the development of group practices centered about hospitals as a major source of medical care.

Such provision would not only solve the problem of continuing teaching units as medical insurance expands, but would provide t public with the most effective means of obtaining a high quality of medical care economically. The guild interests of organized medici will oppose such provisions in your legislation, just as they have of posed such provisions in the New York City health-insurance plan. Application of the insurance principle, whether on a voluntary compulsory basis obviously is limited to individuals who can afford: pay the premiums. For those who cannot pay, legislative collecti of funds seems inevitable.

The proposal to provide medical care to the needy by the expansio of voluntary medical insurance certainly does not promise much. A magnificent as the American public's response to charitable appes.for medical aid is, it meets but a small part of the present nee.. Despite private willingness to contribute, the situation is such tl. * Government is already contributing $900,000,000 per year for medica

care.

As already remarked, charity contributes very little toward cove: ing the cost of professional care now rendered the needy. Volunta contributions are not even meeting the costs of hospital board and lodg ing. There is no possibility of charity's assuming the additional eof professional care. Yet the public must.

Such legislation as you are considering is imperative if physicia: and hospitals are not to suffer financial embarrassment and your me! cal care is not to deteriorate. The public is unaware of the bar'sruptcy-and I speak advisedly-bankruptcy of medical institution which are nationally and internationally known, and to which we this country point with pride. Doctors are strangely complace: about the inadequate financial support of the institutions that give them their stock in trade.