Based on 1970 population and death rates in the Statistical Report of the Bureau of Vital Statistics; LHHRA.

Mr. ROSTENKOWSKI. Your summary will be included in the record. Mr. Williams?

STATEMENT OF GERALD V. WILLIAMS, PRESIDENT, LOUISIANA ASSOCIATION FOR SICKLE CELL ANEMIA, INC.

Mr. WILLIAMS. Thank you. I'm Gerald Williams.

I'm president of the Louisiana Association for Sickle Cell Anemia and also executive director of the New Orleans Sickle Cell Anemia Foundation here in New Orleans.

I'd like to say that I've been personally following national health insurance legislation since 1972.

I'm very interested in the impact that it's going to have on the overall community.

In terms of my prepared statement, the Louisiana Association for Sickle Cell Anemia is composed of nine community based voluntary health organizations focusing on the problem of sickle cell disease.

These organizations represent 64 parishes in the State of Louisiana. In addition to our concern for preventive and comprehensive care, we are very concerned about catastrophic coverage.

In preparing for this hearing, we wish the committee to know that all the major health legislation has been reviewed in total, and we have prefaced our remarks accordingly.

In reference to those plans, and I have them listed in my testimony, I will make several general comments and then focus on the Long/Ribicoff plan.

It is very difficult to conceive that any of the plans reviewed can be successfully implemented at this time.

I see two major roadblocks within all the bills, and those are the process of dealing with reimbursement and also quality control. Language such as "usual," "customary," "reasonable" charge lend themselves to abuse.

National health insurance must be specific on reimbursement in terms of dollars and cents.

If this kind of policy is not implemented, we're going to find ourselves with personal health care expenditures taking a significant jump.

In an attempt, then, for the Federal bureaucracy to correct the abuses, we will find ourselves in slowed down payments for medical services.

When this process reaches the consumers of services, they'll see a frustrated doctor who has resulted to a pay as you go plan to avoid national health insurance.

The consumer will begin to pay more out of pocket expense; and the purpose of implementing national health insurance in the first place will just be reversed, because it seems to me that the purpose is to decrease out of pocket expense to all individuals.

A good case in point is the present medicaid and medicare programs.

Poor folks and old folks are still being denied services because they don't have money to pay for services, though they have medicare and medicaid.

This is because the physicians don't want to get hung up in the bureaucracy of receiving their money, so they've resulted to pay as you go.

Therefore, the volume of their case load has decreased, and they've become more selective; and they've had to increase their cost in order to make up or their selectivity.

You may also examine the experience of the EPDST program in regard to reimbursement to private physicians.

In terms of quality control, we fear a subsystem kind of quality control.

"Subsystem" meaning that quality control does not mean the same thing for all people.

If national health insurance is to be practical and suitable, it should interface itself into some quality standards for health care delivery to all segments of the community.

In terms of PSRO, you know, we're talking still about a specific kind of focus.

We need to deal with quality control across the board.

Presently, there is no significant model for quality standards across the board.

Nevertheless, a good quality control policy will be necessary to lessen the abuse of the increased volume of persons using the health care services.

We know that there will be an increased volume of persons using the health care services. Whether we deal with an assembly line treatment and the kind of quality standards involved are issues that must be dealt with prior to the implementation of NHI.

In addition to reimbursement and quality control, our organization is very concerned about catastrophic illness.

Sickle cell anemia is a catastrophic disease.

We estimate that by the end of 1976 over $5.3 million will be spent on patient care for sickle cell anemia in Louisiana alone.

If we add lost wages and other related expenses, that estimate is over $8.9 million.

If we compare this cost with the total personal income in Louisiana alone, we find that the cost related to health care of persons with sickle cell anemia will equal to more than half the total personal income in Louisiana by the end of 1976.

While we are doing much to decrease the impact of the disease, well conceived catastrophic health plan will be welcomed.

Since the Long/Ribicoff bill is among the leaders in a catastrophic plan, we wish to preference our remarks specifically to that plan. The Catastrophic Health Insurance and Medical Assistance Reform Act makes a very grave assumption regarding the availability of out-of-pocket money for medical expense.

It is unreasonable to assume that every family who experiences unexpected catastrophic illnesses has $2,000 for out of pocket

expense.

We don't think that this would have any significant impact on the health status of the communities in Louisiana.

Specifically, families of persons with sickle cell disease experience a series of medical catastrophies each year.

These catastrophies consistently keep the family at a level of what we call deficit spending in health care.

In this area many families must borrow money to pay for medical expenses, if other assistance is not available.

We understand the difficulty of running a national health plan when there is obviously no national health policy at all.

Still, we offer the following recommendations, that both reimbursement and quality control policy be included in the national health plan, with very direct and firm wording, omitting words such as "usual," "customary," and "reasonable" charge; that a quality control policy is directed at all providers; that when considering out-of-pocket expenses, you examine, one, the nature of the illness and the potential frequency of major reoccurrence; number two, per capita income of the local community; number three, effective buying income; four, existing patterns of paying medical expense; five, percentage of persons wholly unprotected and why; that families who accumulate a substantial medical expense due to a catastrophic illness prior to enrollment in a plan be allowed credit of that amount toward their national health insurance; that health education be included as a mandatory part of the process of implementing a plan.

The Louisiana Association for Sickle Cell Anemia joins the rest of this country in a plea of some kind of relief from these spiraling health costs we have experienced in America.

It is very alarming that in Louisiana alone approximately 3,000 persons with sickle cell disease represents something like 84,000 inpatient sick days a year.

We see this as an issue of economics and health.

The politics of delay must be abandoned and the responsibility for serious action on this matter must rest with you, the Congress of the United States.

Thank you.

[The prepared statement follows:]

Statement of Gerald V. WILLIAMS, MPH, PRESIDENT, LOUISIANA ASSOCIATION FOR SICKLE CELL ANEMIA

The Louisiana Association for Sickle Cell Anemia (LASCA) is composed of nine (9) community based, voluntary health organizations focusing on the problem of sickle cell disease. In addition to our concern for preventive and comprehensive care, we are very concerned about catastrophic coverage.

In preparation for this hearing, we wish the committee to know that all the major health insurance legislation has been reviewed, including:

1. The National Health Care Services Reorganization and Financing Act by Rep. Al Ullman.

2. The Health Security Act of 1975 by Sen. Kennedy/Rep. Corman. 3. Medical Expenses Tax Credit Act of 1975 by Sen. Brock/Rep. Martin. 4. The National Catastrophic Illness Protection Act of 1975 by Rep. Roe. 5. The National Comprehensive Health Benefits Act of 1975 by Rep. Staggers. 6. The Catastrophic Health Insurance and Medical Assistance Reform Act by Senators Long/Ribicoff.

7. The National Health Care Act of 1975 by Sen. McIntyre and Rep. Burleson. In reference to the above plans, I will make several general comments and then focus on the Long/Ribicoff Plan. It is very difficult to conceive that and of the plans reviewed can be successful implemented. Two major roadblocks within all the bills are administration of "re-imbursement and quality control".

Lauguage such as "usual", "customary", and "reasonable" charge, lend themselves to abuse. NHI must be specific on re-imbursement in dollars and cents. If this kind of policy is not implemented, personal health care expenditures will take a significant jump upward. In its attempt to correct abuses, the federal bureaucracy will slow down payments for medical services. When this process reaches the consumers of services, they'll see a frustrated doctor who has resulted to a "pay as you go" plan to avoid NHI. The consumer will begin to pay more out of pocket expense; and the purpose for implementing the NHI will be reversed. A good case in point is the present medicaid and medicare programs. Poor folks are still being denied service because they don't have money to pay for service, though they may have medicare or medicade. You may also examine the experience of the EPDST program in regard to reimbursement to private physicians.

In terms of Quality Control, we fear a "sub-systems" kind of Quality Control. "Sub-systems" means that, quality control does not mean the same thing for all people. If NHI is to be practical, it should interface itself into quality standards for health care delivery to all segments of the community. Presently, there is no significant model for quality standards across the board. Nevertheless, a good quality control policy will be necessary to lessen the abuse of the increased volume of persons using the health care services.

In addition to reimbursement and quality control, our organization (LASCA) is very concerned about catastropic illness. Sickle cell anemia is a catastropic illness. We estimate that by the end of 1976 over 5.3 million dollars will be spent on patient care for sickle cell anemia in Louisiana. If we add lost wages and other related expenses, that estimate is over 8.9 million dollars. If we compare this cost with the total personal income in Louisiana (approximately $15,814,800) in 1976, the cost related to health care of persons with sickle cell anemia will equal to more than half the total personal income in Louisiana in 1976.

While we are doing much to decrease the economic impact of the disease, a well conceived catastrophic health plan will be welcomed. Since the Long/ Ribicoff bill is among the leaders in a catastrophic plan, we wish to preference our remarks specifically to that plan.

The Catatrophic Health Insurance and Medical Assistance Reform Act makes a very grave assumption regarding the availability of out of pocket money for medical expense. It is unreasonable to assume that every family who experiences unexpected catastrophic illnesses has $2,000 for out of pocket expense. We see no significant impact on the health status of the communities in Louisiana. Specifically, families of persons with sickle cell disease experience a series of medical catastrophies each year. These catastrophies consistantly keep the family at a level of deficit spending in medical care. Many families must borrow money to pay for medical expenses, if other assistance is not available. A $2,000 out of pocket expense for persons with sickle cell anemia may occur at least once a year, according to this bill. Thus, the family is still at a disadvantage, since $2,000 is very difficult for anyone to pay within one year. The bill is absolutely unacceptable.

We understand the difficulty in writing a National Health Plan when there is obviously no National Health Policy. Still, we offer the following recommendations:

1. That both a re-imbursement and quality control policy be included in the NHI Plan, with very direct and firm wording, omitting words such as "usual", "customary" and "reasonable" charge.

2. That a quality control policy be directed at all health providers.

3. That when considering "out of pocket" expenses, you examine"

a. The nature of the illness and potential frequency of major re-occurance. b. Per capital income of the local community

c. Effective Buying Income

d. Existing pattern of paying medical expense

e, Percentage of persons wholly unprotected and why

4. That families who accumulate a substantial medical expense due to a catastrophic illness prior to enrollment in a plan, be allowed to credit that amount toward their NHI.

5. That Health Education be included as a mandatory part of the process of implementing a NHI.

The Louisiana Association for Sickle Cell Anemia joins the rest of this country in a plea for some kind of relief from the spiraling health cost disaster in America. It is very alarming that in Louisiana alone approximately 3,000 persons with sickle cell disease represent about 84,000 inpatient sick days. We see this as an issue of Economics and Health. The politics of delay must be abandoned and the responsibility for serious action on this matter rest with you, the Congress of the United States.

Mr. ROSTENKOWSKI. Thank you.

Mr. Vinturella?

STATEMENT OF JOSEPH C. VINTURELLA, BOARD MEMBER, LOUISIANA SOCIETY FOR CLINICAL SOCIAL WORK, NEW ORLEANS, LA.

Mr. VINTURELLA. Thank you, Mr. Chairman.

I am a clinical social worker by profession and am employed by the Louisiana Division of Mental Health as administrator of the New Orleans Mental Health Center, 3100 General DeGaulle Drive, New Orleans, Louisiana, 70114.

I'm a past president of the Louisiana Society for Clinical Social Work and a member of the State licensing board of social workers. In essence my written testimony presented to your staff encompasses the following considerations:

First, we must assume that any national health insurance program will provide coverage for both physical and mental illness.

To exclude coverage for mental illness is not to address comprehensive health services for consumers.

Second, we contend that clinical social workers be included as providers, and therefore, vendors, of mental health services.

We base this contention on the following: Clinical social workers are one of the three major mental health professions; clinical social workers quantitatively provide more direct mental health services in the United States than the other two professions; that is, the psychiatrist and the psychologist; and clinical social work services are less expensive and more widely available than the services of the other two major providers.

Our third consideration is that clinical social workers be included as major providers of mental health services without the restriction of physician referral and supervision.

Presumably, the present requirement of physician referral and supervision by some insurance is intended as a cost control device to insure that only necessary care is being rendered and reimbursed. Instead of controlling costs, however, that requirement has resulted in a substantial cost increase in those programs.

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