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has had a substantial impact on admissions, particularly by increasing voluntary admissions. Despite this, the hospital expects to effect continued reductions in the average resident patient load from an actual level of 6,148 in 1965 to 5,936 in 1966 and 5,722 in 1967. This anticipated further decrease of over 400 patients reflects to a large extent (1) the probable continued effect of the intensification of treatment programs made possible by staffing and materiel improvements authorized by the Congress over the past several years, (2) organizational changes initiated in the past few years, and (3) the increasing efforts of the hospital to transfer to other facilities those patients who no longer require treatment in a mental hospital.

FINANCING

Budget estimates of St. Elizabeths Hospital are set forth under two appropriation headings. The "Salaries and expenses" appropriation provides funds for the general operation and maintenance of the hospital, including research and training activities. Operating funds for this account are obtained through annual direct appropriations covering most Federal beneficiaries and reimbursements for care rendered other patient groups, principally residents of the District of Columbia. Appropriations under this heading are of the indefinite type, under which the hospital receives in appropriated funds the difference between the amount of reimbursements received during the year and the total program costs for the year as approved by the Congress. The "Buildings and facilities" appropriation account covers capital outlay for major alterations and improvements of existing facilities and for new construction. The account is financed by direct Federal appropriations. However, in accordance with Public Law 83-472, the District of Columbia bears a proportionate share of the cost of the program, such share being collected over a period of years following completion of projects and deposited to the credit of the miscellaneous receipts of the Treasury. With your permission, I would like briefly to summarize the 1967 requests for both appropriation accounts, starting with "Salaries and expenses."

SALARIES AND EXPENSES APPROPRIATION

We are requesting a total "Salaries and expenses" operating budget authorization of $30,683,000 for the coming year. This sum represents an increase of $70,000 over the amount anticipated in the current fiscal year. The direct appropriation required to cover the Federal share of the proposed 1967 budget, however, is estimated at $2,202,000 less than that expected in 1966, the additional operating funds coming from increased reimbursements for treatment and care rendered certain patient groups, principally residents of the District of Columbia. The proposed budget provides basically for continuation of existing programs and activities at current year levels. The additional $70,000 requested for hospital operations is required to cover mandatory cost increases totaling $264,000, as partially offset by a downward adjustment in program costs amounting to $194,000, the latter figure a reflection principally of reductions in supply and equipment requirements attributable in large measure to the anticipated decrease in patient population. Mandatory cost increases covered by the re

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quest are (1) annualization of Federal employee salary increases authorized under Public Law 89-301, (2) annualization of five new positions authorized in 1966, and (3) electricity costs related to the hospital's ongoing rewiring program.

The budget provides for continuation of employment in 1967 at the current fiscal year levels. When applied to the projected lower patient load, this will result in an upward adjustment in the employee/patient staffing ratio from 64 employees per 100 patients in 1966 to an estimated 66 per 100 in 1967. In summary then, the 1967 "Salaries and expenses" budget will enable the hospital to meet unavoidable cost increases related to its current operations and improve slightly the quality of patient treatment, the latter to be achieved by means of the better employee/patient ratio to be achieved entirely by a reduction in the patient load.

BUILDINGS AND FACILITIES APPROPRIATION

Funds requested for the buildings and facilities account in fiscal year 1967 will provide for the development of plans and specifications for a new security facility and for 10 projects involving improvements to existing facilities of the hospital. Total cost of the work proposed for 1967 is estimated at $2,138,000, an increase of $161,000 over the sum appropriated for construction and facility improvement activities in the current fiscal year.

SECURITY FACILITY

An amount of $25,000 was appropriated in 1966 for the development of a program statement leading to the construction of patient treatment facilities having appropriate security features. To avoid any unnecessary delay in completion of this urgently needed structure, the hospital requests in 1967, as the second phase of the project, the sum of $450,000 for preparation of plans and specifications for the new facility which will serve as a replacement for two antiquated treatment buildings built in 1879 and 1899, and provide adequate housing for prisoners and other patients requiring treatment and care under security conditions. The number of patients in St. Elizabeths requiring treatment of this type is well in excess of the 396 beds available in the John Howard Pavilion, the hospital's only maximum security building. As a consequence, there are a substantial number of "prisoners" as well as disturbed and potentially assaultive civil patients housed in areas which lack the security and other facilities necessary for the proper treatment of patients of this type. Authorization of the sum requested in 1967 will enable the hospital to move forward without delay with the planning of a facility which will provide greater safety for its patients and the public, replace obsolete treatment buildings, and provide the best in curative treatment for an area of mental illness that constitutes a major social problem of the time.

MISCELLANEOUS IMPROVEMENTS OF EXISTING FACILITIES

The balance of the 1967 buildings and facilities request, $1,688,000, is required for 10 essential improvement projects, all of which are part of the hospital's continuing program of restoration, modernization and improvement of existing facilities. The major portion of these funds is for the following three projects:

Plumbing and heating modernization and improvement: The largest single project for 1967 is the third phase of a continuing program of plumbing and heating modernization and improvement in certain patient treatment buildings where essential facilities, utilities and services are grossly inadequate and substandard. The 1967 increment of this multiyear program is estimated to cost $602,000.

Rewiring and extension of electrical facilities: The hospital proposes in 1967 to undertake the fourth major increment of a continuing program of replacement, extension and modernization of basic electrical facilities. Funds authorized for this work in the current year will provide for improvements in the primary underground electrical distribution system. Funds in the amount of $592,000 are requested in 1967 to complete linkage in several areas by improving the lighting and circuitry in the buildings themselves.

Planning study of W. W. Eldridge Building (medical and surgical facility) Funds in the amount of $225,000 are included in the 1967 budget for development of a program statement and preparation of plans and specifications for the refurbishment and modernization of the W. W. Eldridge Building, the general medicine and surgery facility which serves the entire patient population of the hospital. The building, although 35 years of age is structurally sound but grossly outdated and functionally inadequate for the proper practice of modern day medicine. The proposed planning funds will be used to (1) detremine the type and extent of improvements, (2) program the proper phasing and coordination of the necessary work, and (3) provide design and working drawings upon which cost estimates and construction funding requests can be developed.

OTHER 1967 IMPROVEMENT PROJECTS

Seven smaller projects totaling $269,000 comprise the balance of the hospital's 1967 facilities improvement program. Three of these are continuing projects and cover such essential work as screening patient buildings, improving hot water service, and refurbishing and expanding employee locker room areas. The remaining four projects cover the replacement of an obsolete wornout elevator in a patient treatment building, extension of a cable to provide improved telephone service, expansion of fuel oil storage facilities, and improvements in electric clock systems in treatment buildings.

In summary, the 1967 buildings and facilities program will enable the hospital to maintain and utilize its physical plant in a more efficient manner, improve the health and welfare of patients, and contribute to more effective execution of its programs and activities.

I have attempted to outline briefly the principal provisions of the hospital's 1967 budget requests. I shall be happy to answer any questions or furnish such additional information as the committee may desire.

Mr. FOGARTY. Thank you, Doctor.

BUDGET REQUEST

The total budget is $30,613,000 for 1966, and $30,683,000 for 1967, an increase of $70,000.

Dr. CAMERON. Yes, sir.

DIFFERENCE BETWEEN TRENDS FOR REIMBURSEMENTS AND APPROPRIATIONS

Mr. FOGARTY. But the appropriations are estimated at $9,595,000 for 1966 and $8,078,000 for 1967, a reduction of $1,517,000. What accounts for the big difference between the trend for appropriations and reimubursements?

Dr. CAMERON. The level of improvement at the hospital in terms of total cost of program has progressed relatively slowly, and you will recall that the reimbursement mechanism for the District is to base its reimbursement on the average amount spent by the top five States in the country on their mental hospitals.

STATE EXPENDITURES FOR HOSPITAL CARE OF PSYCHIATRIC PATIENTS

Mr. FOGARTY. Who are the top five States?

Dr. CAMERON. The top five for 1964 were Kansas, Colorado, Utah, Iowa, and Washington.

Mr. FOGARTY. Where does Rhode Island stand?

Mr. HALL. Rhode Island, I think, ranks about 22. I have some dat here on all of the States.

Mr. FOGARTY. You can put it in the record.

Mr. HALL. Yes.

(The information requested follows:)

ST. ELIZABETHS HOSPITAL, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Annual expenditures for hospital care of psychiatric patients, fiscal year 19641

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1 State cost information is based upon Mental Health Statistics, Current Reports, published by the Public Health Service, National Institute of Mental Health, in January 1965. Alaska and the District of Columbia are excluded from the State expenditure data used in computing charges to the District for the care of its patients at St. Elizabeths Hospital.

Dr. CAMERON. To continue, the top five States have improved their programs at a more rapid rate, financially, than has been the case at St. Elizabeths. As a result the amount that the District has to pay has gone up more rapidly than the total cost to the hospital and hence the Federal appropriations have relatively decreased.

2,270

1,515

3,307

1. 293

2,382

2,145

ROLE OF ST. ELIZABETHS AS A MODEL HOSPITAL FOR STATES

Mr. FOGARTY. While the reimbursement rates proposed for 1967 narrow the difference between the District and other agencies who reimburse the hospital. Why should there be any difference?

Dr. CAMERON. The hospital, has, in our opinion, certain national goals, to demonstrate high quality treatment in hospitals; to demonstrate hospital-community relationships; to carry out research dedicated to understanding better the causes, prevention of mental disorder-functions which are of national importance, the cost of which is greater than one might expect a State or the District to carry for itself.

Mr. FOGARTY. Why shouldn't all States do this?

Dr. CAMERON. All States should carry out some training and research, but in view of the enormous investment of the National Government in the national mental health program, it also must carry out very high-grade demonstrations as a model to the States. We are trying to use St. Elizabeths Hospital at least partially in that regard. Therefore, the cost of these programs is more than one might expect the District alone to pay.

Mr. FOGARTY. Have you had some good results from this action? Dr. CAMERON. As we pointed out in the formal statement, the population has been going down.

Mr. FOGARTY. I know that, but have the States taken advantage of your research projects and demonstration projects?

Dr. CAMERON. The States have also been reducing the population in their hospitals.

Mr. FOGARTY. At the same percentage.

Dr. CAMERON. Some have them at an even more rapid rate than we have.

Mr. FOGARTY. Kansas would be an exception.

Dr. CAMERON. Kansas has gone quite rapidly. Minnesota, one with which I happen to be familiar because I used to work there, has gone very rapidly indeed.

RATE OF IMPROVEMENT IN RHODE ISLAND

Mr. FOGARTY. What about Rhode Island?

Dr. CAMERON. Rhode Island has shown some improvement. In terms of how rapidly they may have increased their discharge of patients the rate has been rather slow, as a matter of fact, on July 1, 1963, there were 3,316 patients in the Rhode Island hospital and 1 year later in June 1964, you still had 3,209, a reduction of just over 100 patients in a year.

Mr. FOGARTY. That is not very rapid.

Dr. CAMERON. That is not as rapid as many of the States have been able to achieve.

ADEQUACY OF BUDGET INCREASE

Mr. FOGARTY. The increase of $70,000 in your total budget amounts to less than one-quarter of 1 percent. This won't even take care of the increased costs.

Dr. CAMERON. It will take care of certain mandatory increased costs because there is an offset.

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