6. Reimbursement for continuing health maintenance with the team approach in obstetrics and gynecology.

7. Continued study and evaluation of new programs of payment.

Research

1. Support of experiments in the delivery of obstetric-gynecologic care. 2. Basic research in reproductive and behavioral sciences.

Environment

1. Educational and service programs in family planning.

2. Education in parenthood and family life.

3. Basic research on human development and contraception.

NATIONAL HEALTH CARE FOR WOMEN

(Prepared by the American College of Obstetricians and Gynecologists) The American College of Obstetricians and Gynecologists, representing 14,000 qualified specialists providing obstetric-gynecologic care in America, is concerned about the future health of women. In March 1971 the College published an analysis of National Needs in Obstetrics and Gynecology (attached). Current debate about national health care issues re-emphasizes many of the concerns then expressed and adds new ones. The following program is proposed and recommended by the College.

1. CURRENT PROBLEMS IN HEALTH CARE FOR WOMEN

Some American women have great difficulty in obtaining the special (obstetricgynecologic) health care that they need. The reasons for this include:

A. Obstetric-gynecologic care is not easily available to women in many areas, especially those in the inner cities and in some rural areas.

B. Professional obstetric-gynecologic personnel are in short supply and are unevenly distributed. Their tasks are often poorly defined.

C. Obstetric facilities are unevenly distributed and duplication is common. Facilities are frequently built and used with little though to efficiency or to the separation of patients into normal and abnormal groups. Gynecologic patients requiring special treatment, such as those with cancer, are seldom concentrated into separate, adequately supplied and staffed units.

D. The preventive aspects of obstetric-gynecologic care are insufficiently emphasized. For example, major attention spent on screening and detection could virtually eradicate cancer of the cervix; and concentration on good nutrition could help reduce perinatal mortality and morbidity.

E. The cost of obstetric-gynecologic care may be prohibitive, particularly for the indigent and medically indigent. Financial support is very limited for the younger group who have the babies, as compared with that for older patients. Only about one-fifth of indigent obstetric patients are covered by Maternal and Infant Care or similar projects. Any major obstetric-gynecologic illness can be an enormous financial burden to the woman who can least afford it.

F. Entry into the obstetric-gynecologic health care system is difficult for many women, especially the indigent, because of lack of knowledge, lack of motivation or cost. These obstacles have been insufficiently explored or remedied.

II. COMPONENTS OF GOOD HEALTH CARE FOR WOMEN

Complete health care for women should encompass:

A. Maternity (obstetric) care.-Complete maternity care should not be modified by the patient's age, marital status or financial resources. It should cover inpatient and outpatient (ambulatory) services and should include:

(1) Antepartum (pre-delivery), delivery and postpartum (post-delivery) care for normal and abnormal conditions.

(2) Newborn care, including care in the delivery room and in the nursery, circumcision and corrective procedures for congenital defects.

(3) Legal abortions.

B. Family planning.-Family planning should include gynecologic examinations, counseling, prescription medications, contraceptive devices and legal sterilization.

C. Gynecologic care.-Cynecologic care should include:

1. Outpatient and inpatient care of women's diseases, including medical and surgical treatment.

2. Care provided in related fields of medicine for gynecologic disease, such as (a) radiotherapy or chemotherapy for pelvic cancer, (b) specialized study or treatment of endocrine abnormalities or (c) infertility.

D. Preventive and health maintenance care.-Early detection of disease and maintenance of health involves :

1. Periodic (annual) examinations.

2. Diagnostic procedures, including, but not limited to (a) blood counts, (b) urinalyses, (c) rubella antibody titer determinations and vaccination if indicated, (d) venereal disease detection, including smears and cultures for gonorrhea and appropriate tests for syphilis, (e) Pap smears, and (f) diagnostic vulvar, vaginal or cervical smears.

E. Standards of quality care for women.-These will need redefinition from time to time. Committees of The American College of Obstetricians and Gynecologists are constantly updating guidelines for these standards and are always ready to provide consultative advice, if requested.

F. Peer review.-A review of the quality and the appropriateness of the medical care and utilization of services is essential in relation to accepted and defined standards. Qualified obstetrician-gynecologists should always play a major role in such local peer review mechanisms.

III. HOW CAN GOOD HEALTH CARE FOR WOMEN BE PROVIDED?

Good health care involves correction of deficiencies indicated in Section I. Obviously the problem is complex and immediate simple solutions are not possible. The American College of Obstetricians and Gynecologists believes in the evolution of changes and the retention of the strengths of our present system until other methods are proven to offer better care. However, changes should be actively encouraged in areas of special need.

A. Delivery systems

Currently there are many methods of delivery obstetric-gynecologic services in the United States. Recognition of the varied geographic, cultural, socio-economic and individual differences in this country favor the retention of this pluraltic approach. However, each method deserves continued scrutiny in relation to its suitability for the population groups served. Current methods include:

1. One-to-one physician-patient relationships, characteristic of the private practice of medicine.

2. Groups or associations of physicians with appropriate supporting professional personnel.

3. Obstetric-gynecologic health care centers, directed by physicians, but staffed largely by allied obstetric-gynecologic personnel. Such centers may be parts of larger health care centers.

4. Health maintenance organizations (HMO's) or Foundations for medical care, including obstetric-gynecologic care.

B. Professional personnel

1. Obstetrician-Gynecologists

a. Training. The effecive number of obstetrican-gynecologists is becoming less. Assuming the projected increase in births to be slight compared with earlier predictions, other factors remain cruicial. First, family physicians, who attended 31 percent of births in 1967, are gradually doing less obstetrics. Second, more women are now seeking earlier obstetric care and regular gynecologic care. Third, the variety of services required of obstetrician-gynecologists has increased. For example, family planning, premarital and marital counseling and general medical care are in common demand, together with more personal attention and education. Finally, fewer obstetrician-gynecologists are being trained. In 1949, 92 percent of residents in obstetrics and gynecology were graduates of U.S. medical schools: in 1969, the proportion had fallen to 53 percent. Many of the foreign graduates, now in obstetric-gynecologic residencies, will return to their own countries to practice.

It is essential that the supply of well-trained obstetrician-gynecologists be maintained. To this end recruitment should be encouraged, particularly among women and minority groups. Financial arrangements for patient care should not

provide barriers to the development of well-trained obstetrician-gynecologists. They must have progressive responsibility for patient care during their training so that when it is completed, they will be able to serve properly as specialists and consultants. Experimental programs of residency training in obstetrics and gynecology should be developed.

b. Distribution.—The provision of more obstetrician-gynecologists in areas of short supply is a difficult problem. Ideally, this should be done by offering incentives, such as group practice (rather than solo practice), or group coverage of certain geographic areas, and convenient office and hospital facilities, and appropriate income resulting in voluntary redistribution of physicians. The use of a health service corps may be of special value in areas that are unable to otherwise attract medical personnel.

2. Allied Obstetric-Gynecologic Health Personnel

a. Nurse.-Paralleling the increased demand for obstetrician-gynecologists, an additional need for other obstetric-gynecologic personnel has arisen. Conscious of this, the College, in 1969, developed its onw Association of Obstetric, Gynecologic and Neonatal Nurses, with the objectives of (1) continuing specialist education in these fields of nursing, (2) promoting cooperative efforts between nurses and physicians and (3) defining tasks for the various categories of obstetric-gynecological personnel.

b. Other allied health personnel.-As a consequence of the College's concern, it is sponsoring a national conference in November 1971 on obstetric-gynecologic personnel. The purposes of this conference are (1) to decide the classification of personnel, (2) to define requirements for training, and (3) to establish curriculum and recommend methods of certification.

Further development of adequate numbers of well-trained obstetric-gynecologic health personnel requires administrative, legislative, public and professional encouragement, together with financial support for new programs.

A serious problem relating to the effective use of allied obstetric-gynecologic personnel is the uncertainty of professional liability responsibility. The American College of Obstetricians and Gynecologists is prepared to participate actively in seeking solutions to these and related problems.

C. Facilities

The need for hospital inpatient obstetric-gynecologic facilities and for ambulatory facilities should be identified by geographic areas related to population density and by present inequities of distribution. The kinds of services provided in each facility should also be carefully evaluated. The following concepts are important:

1. Consolidation of inpatient facilities.-Data obtained from The American College of Obstetricians and Gynecologists' National Study of Maternity Care indicate that full hospital obstetric services, in terms of bed use, personnel and facilities for the care of all kinds of obstetric complications, can only be provided efficiently when more than 1500 deliveries occur per year. In more sparsely populated communities limited but adequate services can be provided with reasonable efficiency when at least 500 patients are delivered at the hospital per year; below this number, efficiency is decreased. Further, it is desirable that an obstetric patient should be able to reach a hospital facility within a specified time, for example, one hour or less.

Thus, attempts should be made to encourage the consolidation of hospital obstetric-gynecologic services in larger communities (more than 100,000 population) so that more than 1500 deliveries occur annually in each unit. In smaller communities (30,000 to 100,000 population) more than 500 deliveries should occur in an obstetric unit. In rural areas, special problems exist. But even here the objectives should be to consolidate and coordinate services wherever possible.

2. Regionalization and centralization of care.-High-risk obstetric patients should be identified early in pregnancy. Opportunities should then be provided for them to obtain care in centers suitably equipped to deal with their particular problems. Similarly, patients with unusual gynecologic conditions, such as pelvic cancer or certain endocrinologic problems, should be referred to centers equipped to deal with these cases. Regionalization and centralization involve the development of more efficient methods of communication and transportation of patients from one facility to another, such as by microbus, ambulance, air lift or helicopter.

3. Progressive care.-Within obstetric-gynecologic facilities of adequate size, areas suitable for different kinds of care should be organized, such as units for (a) intensive care, (b) normal obstetric patients, (c) abnormal obstetric patients, (d) postoperative patients, and (e) patients undergoing diagnostic studies or convalescing. This type of specialization within facilities could result in better and more appropriate care and, in the long run, in reduced costs.

4. Ambulatory care.-Although much ambulatory care is now provided in physicians' offices or hospital clinics, it is often not available or accessible to patients who need such care. Some simple surgical procedures which could be performed on an ambulatory basis are now performed in a hospital.

New varieties of ambulatory obstetric-gynecologic facilities should be developed, either as separate units or as parts of comprehensive health centers and should be made available to local residents located, for example, in inner cities or rural areas. Facilities in which surgical procedures may be performed on ambulatory patients could be developed with medical supervision under hospital guidelines.

D. Finances

The American College of Obstetricians and Gynecologists believes that the following principles deserve careful consideration in any proposals for national health care for women:

1. Financial coverage for basic and catastrophic health care for obstetric and gynecologic patients should be required and provided for all. Adequate medical services for the indigent can be expected to be more expensive than corresponding care for the non-indigent.

a. Complete financial coverage for the indigent should be provided by the government.

b. Individuals other than the indigent should participate in health care costs on a basis related to their financial resources.

2. The insurance industry may be involved in the financing of health care on an underwriting and risk assuming basis.

3. Deductibles and coinsurance may be parts of such coverage.

4. All programs for financing health care should be based on sound and realistic actuarial data.

5. Complete obstetric-gynecologic services (as defined in Section II) should be covered with the same eligibility and the same proportionate deductibles and/or coinsurance as are available for other medical conditions.

6. Differential reimbursement should be established for services provided to normal and high-risk obstetric patients.

7. Financial incentives are needed to train sufficient numbers of obstetricgynecologic health personnel and to enocurage such personnel to serve in areas of greatest need.

8. Payments for obstetric-gynecologic services provided by allied health personnel under physician supervision should be made according to well defined standards.

E. Research

Research is an essential part of any system of medical care. Without it, new methods of treatment or delivery of care cannot be found. For example, discovery of effective contraceptives which produce even less side effects than present methods would result in fundamental changes in obstetric-gynecologic care.

The American College of Obstetricians and Gynecologists believes that: 1. Basic science and clinical research should continue to receive adequate support. Studies of behavior and motivation are as important as those of reproductive biology.

2. Research in new and experimental methods of delivery of, and payment for, obstetric-gynecologic care should be encouraged. A special problem for study could be that of professional liability. This increases the costs of obstetricgynecologic care because of increased hospitalization, increased office visits and more laboratory tests, some of which are ordered primarily to protect against the possibility of law suits.

3. Adequate evaluative mechanisms should be built into any new plan for funding the delivery of health care.

4. Qualified practicing obstetrician-gynecologists should always be an integral part of any group evaluating research in any aspect of obstetrics and gynecology.

IV. PRIORITIES

Changes in obstetric-gynecologic care in the United States cannot be brought about immediately. Shortage of funds, obstetric-gynecologic personnel and facilities limit objectives. Until changes come about, it is essential that present programs, such as the Maternal and Infant Care Projects, be continued with adequate funding. For the future, The American College of Obstetricians and Gynecologists suggests the following priorities :

A. Provision of complete maternity and newborn care, including ambulatory care (see Section II).

B. Protection against catastrophic obstetric or gynecologic illness.

C. Delivery of family planning services to all citizens.

D. Provision of complete gynecologic care, including surgical and ambulatory

care.

E. Provision of obstetric-gynecologic preventive and health maintenance care. F. Adequate funding of research is essential for continuing progress in medical care for women.

Mr. CORMAN. Thank you. Your testimony has been most helpful. Our next panel is the National Council of Health Care Service, Berkeley Bennett, executive vice president, and his panel.

STATEMENT OF BERKELEY V. BENNETT, EXECUTIVE VICE PRESIDENT, NATIONAL COUNCIL OF HEALTH CARE SERVICES; ACCOMPANIED BY RICHARD K. EAMER; DR. EDWARD B. HAGER; AND EDWARD J. WILSMANN, COUNCIL MEMBERS

Mr. CORMAN. Mr. Bennett, would you identify the witnesses at the table with you? We will be pleased to have you proceed.

Mr. BENNETT. Mr. Chairman and members of the committee, if it pleases the Chair I will act as a moderator and introduce our speakers as we go along.

First I would like to introduce myself. I am Berkeley Bennett, executive vice president of the National Council of Health Care Services, based here in Washington, D.C.

We are a select group of taxpaying health care companies owning and/or managing hospitals, nursing homes, psychiatric facilities, clinics, pharmacies, home health care agencies, surgical supply companies, homemaker services, hemodialysis units, day care centers and paramedical training schools.

With me today are three professional and management specialists who will discuss some major questions that have been posed by the committee staff regarding health care and national health insurance in their recently released Fact Book.

On my left is Richard Eamer, attorney and certified public accountant, president of National Medical Enterprises of Beverly Hills, Calif., a publicy owned company primarily concerned with the management and ownership of health facilities. One of Mr. Eamer's facilities in Modesto, Calif., was cited by the California Hospital Association recently and by Blue Cross as the most efficient hospital in the State.

Mr. Eamer is in position to be intimately familiar with the current problem of our health delivery system, its availability delivery mechanisms, and factors influencing the cost.

Mr. EAMER. Mr. Chairman and members of the committee, I appreciate this opportunity to appear before your committee today during your deliberations on national health insurance.