COSTS AND DELIVERY OF HEALTH SERVICES

TO OLDER AMERICANS

FRIDAY, JUNE 23, 1967

U.S. SENATE,

SUBCOMMITTEE ON HEALTH OF THE ELDERLY

OF THE SPECIAL COMMITTEE ON AGING,

Washington, D.C.

The subcommittee met at 8:40 a.m., pursuant to recess, in room 1318, Senate Office Building, Senator Walter F. Mondale presiding. Present: Senators Mondale and Williams.

Committee staff members present: William E. Oriol, staff director; John Guy Miller, minority staff director; J. William Norman, professional staff member; and Patricia G. Slinkard, chief clerk.

Senator MONDALE. This morning we have an interesting panel on Organizational Deficiencies in Present Health Services. We are privileged to have Dr. George James, dean of Mount Sinai School of Medicine, New York City, and Dr. Milton I. Roemer, professor, School of Public Health, University of California, Los Angeles.

If you will both come up to the table, please.

Dr. James, you may start.

STATEMENTS OF GEORGE JAMES, M.D., DEAN, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK CITY, AND MILTON I. ROEMER, M.D., PROFESSOR, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF CALIFORNIA, LOS ANGELES

Senator MONDALE. I understand you got a 7 a.m. plane from New York City this morning. If you would like to use 5 minutes to attack the shuttle service, we would be delighted to have that a part of the record and I will add in my own comments.

Dr. JAMES. Thank you. It is sometimes easier to get to Washington from my office in Long Island than to the office in New York City. Senator MONDALE. Without any doubt you may have seen Art Buchwald's column a few weeks ago where the newly developed SST had a race with the Queen Mary to see who could get to Paris first. The SST beat the Queen Mary by about 3 hours.

Go ahead.

Dr. JAMES. My name is Dr. George James. For the past 20 months I have been dean of a new developing medical school in New York City. For 25 years before that I have held various governmental public health positions in State and local health departments culminating in 3 years as commissioner of health of New York City. Recently I have been Chairman of the President's Task Force on Health and President of the National Health Council. I serve now as chairman of

the Review Committee for Regional Medical Programs and on one of the subcommittees of the National Advisory Committee on Health Manpower. This August I will be chairman of the National Conference on Public Health Training.

The health problems of the aged are among the most complex and difficult now facing the American people. The entire scope of disease can be visualized as a continuum composed of four stages. The first stage is concerned with risk factors which operate before disease begins. Ideally this is the best time to intervene and interrupt the beginning of the disease process. This is the time when we seek to modify health habits and adjust the environment to make our people less susceptible to the risk of disease.

The second stage is involved with that period during which the disease process has begun, but the patient as yet has no symptoms. By means of various detection tests we seek to discover the early manifestations of disease and interrupt their further development.

Much additional research and program development is required before we can say that we understand how to combat our present major killers and disablers. Useful hearings have been conducted by congressional committees which have highlighted those problems and suggested certain productive areas for attack.

The third stage of disease is the clinical period when the patient generally feels ill and demands medical care aimed at cure. This has always made up the bulk of medical care and has been the major focus of much of our recent medical care legislation.

The fourth stage is the chronic period. Here our patient can no longer expect cure, but rather hopes for a limitation on his disability. At best this means rehabilitation, but at least it means a readjustment of the patient and his environment so that he can maintain a maximum of self-sufficiency, family life, and human dignity for as long as possible. It is what has been called adding life to our years instead of the more biological goal of adding years to our life.

NEW YORK CITY AGING BY 20,000 YEARLY

The growth of our aged population, particularly in our rapidly expanding urban areas, is truly remarkable. New York City, with a fairly stable total population size, is aging by 20,000 persons per year. By 1970 we expect to have 1 million persons over the age of 65, making New York's aged the sixth largest city in the United States. A recent survey in New York City indicated that about 100,000 persons are fit candidates for rehabilitation for neuromuscular disease. Our present methods of caring for such people are ill-adapted to meeting this problem. We cannot continue to rely upon institutionalization and facility-bound services to meet these needs. We simply cannot afford either the time or money to build institutions for them. Nor are these institutional programs the answer, even if we could provide them.

Let me illustrate by describing for you one of my recent patients. He is a man aged 76, who has the following pathological conditions: carcinoma of the larynx involving a tracheotomy and oesophageal speech, hypertrophy of the prostate with some pyelonephritis, diverti

culosis, a hiatus hernia, a cataract of the left eye, chronic bronchitis, varicose veins, arterio-sclerotic heart disease with a healed anterior wall cardiac infarct, and, finally, diabetes mellitus. Now, if you ask this man what is his chief complaint, he will tell you quickly enough that it is his wife.

His wife is 75 years of age; she had a thyroidectomy but, unfortunately, the recurrent laryngeal nerve was cut. She cannot shout at him, but she nevertheless can scold him rather effectively in a whisper. She has a tracheotomy with a lot of excoriation around the neck, and she is rather miserable, but they are miserably happy together as elderly people often are.

ONE PATIENT-TEN CLINICS

Now, if this man would come to a major teaching hospital, this is perhaps what would happen to him. For his cancer of the larynx and related conditions, he would visit the ear-nose-throat clinic and the cancer clinic; the hiatus hernia would be seen in the surgical clinic; the cataract in the eye clinic; bronchitis, chest clinic; hypertrophy of prostate, GU clinic; vericose veins, vascular clinic; the heart condition, heart clinic; the diverticulosis and hiatus hernia, medical clinic; diabetes mellitus, metabolism or diabetes clinic-10 clinics in all. This man is much too sick to go to 10 clinics. How long would he last as an ambulatory patient waiting in the waiting rooms of one clinic after the other, of 10 specialty clinics in a teaching hospital?

Actually, he is a noncooperative patient, and that was an advantage because he didn't go to the clinics.

I can tell you what happened to him: he went to none of the clinics because the traditional pattern of medical care which was available to this medically indigent old man, living with his wife in a public housing project, was not one which could help him. It would have incapacitated him. Suppose he had tried to go to the 10 clinics. One can readily predict what would have happened. He would have become exhausted and sooner or later would no doubt have become so weak in one of the clinics that he would have required an emergency admission. and then, how long would the average hospital allow him to occupy a hospital bed? It would not be very long before he would be referred to a nursing home. Once he entered a nursing home it seems fairly obvious that he would never leave, and his wife, too, would have to be admitted fairly soon to a nursing home. Because of the way we do things in our culture, they would probably be put in separate nursing homes at a cost of about $10 each per day.

This episode I have just related occurred 4 years ago. This man is still living with his wife, and they are still miserably happy together. He now attends a hospital clinic about once every 2 weeks. The bulk of his medical care-and it is quite a bulk-is received in a small clinic, a branch of the general hospital outpatient department which was opened within the housing project where he lives. This man is receiving fourth-stage medicine, the kind of medical care so many patients like him need and which so few hospitals have become equipped to render close to the patient's home.

MENTAL PROBLEMS OF AGING

Let us consider the mental problems of these old people. If you take a man in the prime of life, deprive him of his wife, his hearing and vision, his job, his contemporaries and confine him to his home month after month and year after year, you would not be surprised if he developed some strange personality traits. Yet this is frequently what happens to our senior citizens with hearing and sight diminished, his friends departed and his arthritis severely limiting his mobility. It is not unusual that he avoids medical care because it is too taxing to his physical resources and that he withdraws from society into an unrealistic shell of his own drab world.

Senator MONDALE. Would you yield at this point? We had testimony from Dr. Ostfeld, University of Chicago, indicating that many senior citizens do not present themselves for an examination of symptoms but may disclose serious health conditions because, fearing the worst, they pretend the symptoms do not exist. If they have a bad cold, they might present themselves but if they have something that sounds like a bad heart or something serious that they are disinclined to do it. Do you think this is a phenomenon that is rather widely found among our senior citizens?

Dr. JAMES. Yes. The studies which have been done in which populations of older people have been offered free disease detection examination services generally show that only about a half of the population will come, and even the best of them are able to recruit only twothirds. The small clinic we opened for this man I have just described, even though it is right within the housing project, has only recruited half of the elderly people in that institution as clients, even though every effort is made to recruit them.

Senator MONDALE. In other words, the others living in the same public housing project as the person about whom you are testifying who have available to them this new type of chronic patient clinic won't show up?

Dr. JAMES. That is right. Every effort is made to recruit them. They are advised at all the affairs which this housing project holds for its older people. The clinic is well described. There are many satisfied patients living in the same development, but still they do not come. I think the answer is fairly obvious. As you pointed out, the threat of illness is such an overwhelming threat to what little security they have, particularly if they live alone, they find it difficult to act on their symptoms.

The sociologists have done some interesting studies in which they showed the steps one goes through in deciding to visit a physician. You wake up in the morning and your stomach bothers you. You tell your wife, and she says, "See a doctor." Later she asks you, "How do you feel?" "Well, I don't feel so well." This acting out and discussion with another person plays a major role in getting an individual to seek medical attention. A person who lives alone and is denied this opportunity is much less apt to act on this symptom. This is the reason in addition to the tremendous threat to a person's whole life that a serious illness should be looked into.

Senator MONDALE. What about in this case, you have what you might call a chronic clinic, a one-stop chronic clinic conveniently lo