I have asked of social workers. I have said, "Well, if it is so, then surely we should be able to document this with a few case histories." This has been going on several years now.

Dr. DUFFY. You are a man after my own heart, Mr. Curtis, because I gave this challenge, the same one you are speaking of, but the other side of it, to the New Jersey State Medical Society. They made the same claim. And I said any day that they wished to come with me, I would be happy to have them. And if they wished, the records would be forwarded. I will be glad to forward them to you. We have these cases right now.

Mr. CURTIS. Well, I have been through clinics in my own community, and I have asked people. In fact, there is a campaign the other way. The labor organization in my community, AFL-CIO, have people writing me postcards saying, "I am a person in need of medical aid and not getting it." Or, "I know of a person who is." And I have replied religiously to every one of those, saying, "Please give me your name in a confidential way so that I can check it."

Doctor, I have only one reply, which I have now just about checked out, incidentally. And, like the others which I have had, which I can count on one hand, they just do not ring out. That is why I have a difficult time believing the generality.

Also, I know this: If there were such a thing, I think if there were one person who had not been getting medical care, who had been refused, the newspapers would pick it up like that, I think.

Dr. DUFFY. I think it is a bit subtle, for this reason: that perhaps what we might be talking about in terms of medical care might differ a little bit. It is certainly true that nobody in this country is dropping dead on the street for want of some help. But it is abundantly true that what is known as good medical practice cannot be applied in that segment of the population that is unable, either by insurance or savings or income, to take care of the necessities of the tests, which are very successful, for the hospital type of care.

Now, these things are things which are not possible to do except in a patchwork way. I am sure working together we could find plenty of ways to get a patient registered into a clinic. But what took place in a doctor's office, what took place in my office, was that I had to gage what I would do in regard to a given treatment by whether or not he was covered by a certain policy, or whether he could afford to have a hundred dollars worth of examinations.

Now, these things take place every day in every doctor's practice. Mr. CURTIS. The doctors all tell me, the ones I have talked to in the associations, that they have always gone on the principle that they gave the care whether the person could afford it or not. And I do think that the area that you are now directing attention to is the real area. It is a question of the quality. But it is not a question of people just, as you say, falling dead on the street.

We can improve it, in my judgment. We can always improve. But when we are talking about extending quality of care, then I come to this point, which I think is true: that quality goes according to areas and affects all age groups. If you have a community that does not have good hospitals or good doctors, everyone in that community gets that quality. If you have another area where you have high quality, the aged as well as the other age groups benefit from that quality.

Now, if that is the analysis, this should not be segregated on the basis of age. It is not an age problem, then. It becomes a geographical one or one that is a lot more complex. That is what I think the problem is, rather than by age groups.

Dr. DUFFY. Well, the figures, I am sure, have been abundantly put forth here. I mentioned the great magnitude in the older group. They have three times as much need of hospitalization as the younger ones. And I could not disagree with the fact that this is a problem across age barriers and that it is in all sectors of medical care that we should be looking for better quality. But one reason we certainly look here is that this is where our hospitals face the greatest problem. These are the people in the clinics. Most of these are retired people, who really could not afford, could not find it if they could afford, pri

vate care.

Mr. CURTIS. I certainly appreciate your testimony, Doctor, and I think we can benefit by it.

The CHAIRMAN. Any other questions?

Mr. BURKE. I would like to read results of a questionnaire conducted in my district at one of the country fairs relating to medical care for the aged.

There are several questions on medical problems.

Question No. 2 says: Do you favor a plan for medical care for the aged under, first, a social security system supported by increased contributions by employer and employee? One thousand and eighty people answered "Yes," four thousand and eighteen answered "No," and two hundred and eighty-five failed to answer.

On the second plan: Do you favor a plan for medical aid for the aged under the voluntary system, financed by the State and Federal Governments through individual contributions? Six hundred and sixty-four answered "Yes," four hundred and twenty-eight answered "No," and six hundred and ninety-two failed to answer on that part of the question.

I thought that information might be helpful to the committee.
The CHAIRMAN. Thank you, Mr. Burke.

Mr. King?

Mr. KING. Doctor, among the several practitioners that I know personally, their experiences match quite well with your own. They are distressed day after day with their inability to assign, for proper treatment, the patients that come into their office, because of the very reasons you have mentioned.

This fee thing has been sold to the doctors pretty completely in my area; that a Government agent is going to fix the fees; that they are going to be deprived of this old prerogative of determining in their own minds what a proper fee should be.

Is it not true that two or three of the contributory plans now have arrrived at a fee fixing? Is it not true under Blue Cross?

Dr. DUFFY. This is my impression: that this is not only true, but has been voluntarily voted in. For instance, in the District of Columbia Medical Society. And we all accept this now.

Mr. KING. Why is it that under the provisions of this bill there is the fear that there will be a deviation away from the established practice of setting fees that doctors seem to abide by and go along with? Dr. DUFFY. Well, the broadside of the material that I get includes this, but did not include it in the singular way that was raised before,

as though this was the main issue. The main issue was the same type of procedure that has been used with regard to socialized medicine. I mean the question of bringing out the specifics of fees is the same way that someone, some ominous figure, is going to appear between you and the patient; and that this fee schedule, I am very sorry to say, has been one of the things that I believe the American Medical Association felt was a good way to get the doctor aroused, and was specifically picked on to increase his interest, if you will, in coming forth against this type of legislation.

I do not say this without, frankly, having talked with the people who direct a good share of the public relations in Chicago in the AMA some time ago. And not on this, but I believe it is relevant: They said:

I believe it is very important for a group of physicians involved in something like this to really understand, right down to the last possibility of somebody interfering with their practice.

We welcomed that thought. We though we had received some dispassionately constructed, some reasonably presented, thorough analysis of what this bill would mean. But instead, charges are made without evidence. I am certainly going to make every effort I can to find out everything I can about the opposition on fee schedules, but when I think back, I can only think about the rigged material I have received and the way that it has been particularly designed to encour age our interest in our pocketbook, rather than our interest in the final analysis.

The only real criterion is what is good for the patient.

So my only answer, sir, is the fact that they are interested in making us believe, right or wrong, that we stand in some real financial hazard as a result of playing with this bill. By the same token, we are supposed to be in great hazard of having this unusual thing called the patient-physician relationship destroyed by legislation that would, as far as I could see, be only aimed at increasing hospital benefits. I do not understand how this would destroy the relationship.

I am afraid that is a long answer; but I always find it difficult to understand what they mean, when they will not explain it.

Mr. KING. I am glad to have the answer, Doctor, because we do not have too many practicing physicians and surgeons come here favoring the bill. And you cannot blame me, as the principal author of this, for feeling a bit refreshed when someone like you comes before us and has to say what you have had to say. I may be a bit more sensitive, but as the author, a good proportion of the mail is directed to I think I receive ever so much more mail for and against this proposal than other members of the committee. And I have segre gated them, and I find this fee thing included along with the interference with the patient-doctor relationship and a number of other things, that are not provided for in the bill.

me.

But it is the fee thing, particularly, that disturbs me, particularly when a man will say, "We don't know who the Secretary of the Health, Education, and Welfare Department will be in the future." And it is just difficult for me to believe that a responsible Secretary would consult with anyone, other than responsible medical people, in any area to determine what a reasonable fee for this or that would be. I would be alarmed if it had not been already pioneered and settled. That is, it is being done. It is being done with respect to pre

payment plans. And why it should suddenly be of great concern, and what reason we have to feel that it would not follow a pattern that has been generally compatible, I just do not understand, other than to have the understanding that you have, that these things are deliberately being employed to disturb members of the profession. Now, out of my own district, I have perhaps 85 or 90 letters opposing the proposal. In every instance, I have answered the doctors asking if they have read the bill. Some of the doctors I know; some of them I do not. It is regrettable, the answers, how few have read the bill.

It is obvious from their letters that they have not read the bill. They have read circulars that have come to them by mail, where they have attended meetings, where they have been filled in on allegations that cannot be supported by one sentence in the bill.

Mr. CURTIS. Mr. Chairman, because this was directed to the questions I have asked, I might say that I am disturbed that the arguments advanced by those who are worried about this-and I am oneare usually misstated and misunderstood.

First of all, as Secretary mentioned, I do not know how many witnesses have pointed out the difference between the Blue Cross and Blue Shield approach to fees, and private insurance, is that it is voluntary. This is compulsory.

Now, I just hope that in the future, when someone wants to answer this concern, they will state what the real answer is, that this is compulsory. There is the distinction between this and Blue Cross and Blue Shield, setting up, as they do the fee schedules in there.

And then secondly, Doctor, it is not the pocketbook argument that I am concerned about. I am no doctor. Maybe some doctors have misinterpreted, as you say, what the concern is.

But the concern is this: That if you have a Federal bureau setting fees for hospitals throughout the country, it cerainly does enter into the relationship of running the hospital. That is the concern. And it is not from hospitals, because doctors really are not in this. These are largely eleemosynary institutions, not for profit at all. And yet if you have a Federal bureau that would try to be reasonable with the American people, and they would be determining these fees, I do not think it requires too much imagination to see how much control over the operation of hospital care and advancement is going to be interfered with.

Now, that is the argument. And I wish the author of the bill would direct his attention to what the arguments are, and not say that this is no different than the fee schedules set in Blue Cross and private insurance companies, because those are still voluntary.

Mr. KING. Well, what would the difference be with two plans, one voluntary, and one compulsory, as to the membership, or their payments, in connection with the conduct of a hospital? I do not get the connection at all.

Mr. CURTIS. It is very clear. You do not have to take out a particular policy. There is a wide variety. There are a hundred companies that offer different policies. One hospital would be in agreement with insurance company X, for example, or Blue Cross Y, on fee schedules. But it would be between private groups that work these things out, subject to change. And if you and your hospital did not agree, you probably would go and get it from another.

The CHAIRMAN. Let us bear in mind that we still have nine witnesses to be heard today.

Mr. KING. We do not often get one like this one.

Dr. DUFFY. May I say this is very gracious.

The CHAIRMAN. You can tell by the questions, Doctor, that the members have enjoyed having you come before the committee. Dr. DUFFY. Thank you very much.

Mr. KING (presiding). Dr. McCrary?

STATEMENT OF V. EUGENE MCCRARY, O.D., ON BEHALF OF THE AMERICAN OPTOMETRIC ASSOCIATION

Dr. MCCRARY. Mr. Chairman and members of the committee, my name is V. Eugene McCrary. I am an optometrist practicing in College Park, Md.

My appearance before the committee is as trustee consultant to the Department of National Affairs of the American Optometric Association. I was previously a member of the department. It is a declared policy of the American Optometric Association, as determined by its house of delegates last year, that the association through its appropriate committees seek the inclusion of vision care in all health programs, and that optometric services be utilized in the furnishing of vision care.

Previously the same body had requested its department of national affairs to take any and all steps necessary to have optometry included in all present and future Federal health care programs including refraction and the furnishing of other optometric services.

They are also on record that

any bills relating to national health should protect the right of the beneficiaries to avail themselves of the professional services of optometrists without prior approval by the medical administrative officer or physician ***; the enactment of any legislation pertaining to national health insurance or national health services which does not so provide shall be vigorously opposed.

The primary purpose of H.R. 4222 pertains to hospital services, outpatient hospital diagnostic services, skilled nursing home services, and home health services to be furnished the beneficiaries of the oldage, survivors, and disability insurance program. Under these circumstances, some of you gentlemen may be wondering why optometry is concerned with this program. There are two reasons: (1) It is generally considered that this is but the entering wedge that will eventually result in all health care being provided as part of the social security program. This will include eye examinations and the furnishing of corrective lenses; (2) the other reason is that one of the most prevalent surgical procedures experienced by men and women over the age of 65 is for the removal of cataracts. Every case of cataract surgery requires not only hospitalization but postoperative lenses, and the great majority of cataract cases are first detected by optometrists and referred to ophthalmologists for hospitalization and

surgery.

We are all believers in freedom, but there are varying kinds and degrees of freedom. On page 6 of the bill there is a heading "Free Choice by Patient." To put it bluntly, that heading is deceptive because it relates only to institutional services which are directly under the control of the medical profession. Pursuant to the American