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When do you phase out? Is there going to be a free economy at all? Are we going to go the rest of the way!

Mr. DUNCAN. What about you, Nr. Thompson, would you care to comment?

Mr. Thompson. I would agree with Mr. Somers.

As an aside on the last comment, I believe the figure is up to 22 percent of the English population now who purchase independent private health insurance.

Mr. DUNCAN. They are moving away from the other?
Mr. THOMPSON. By voluntary choice.

Mr. STARK. I certainly do not disagree, but I hope when we talk about phasing in we do not mean backing in. I think that is what has been happening. We have been doing this in a very fragmented way without a plan and I am afraid we may run into the same kind of chaos that we find our whole system in from time to time when we try to get availability and accessibility of care for more of our people.

I would—the thought occurred to me as we were talking about one other matter, and I wanted to respond to it. Now I have forgotten what it is though. Mr. Duncan. I have that problem myself.

Dr. ENGLAND. I have something I have not forgotten in respect to something you were saying before.

Mr. DUNCAN. My time is really about up. Perhaps when the chairman Mr. STARK. Oh, yes, I remember. It had to do with medicare. As was

I Professor Somers, I was concerned with the initial Health Insurance Benefits Advisory Committee. I think the intent of Congress was not to control anything and they did a very good job of not controlling it. In fact, in the act it specifically says nothing shall be done to change the practice of medicine as it was being practiced prior to the law going into effect.

I can tell that, that any number of times where the committee, HIBAC Committee attempted to put some regulation into controlling costs, we were told that this is not the intent of Congress and, therefore, you cannot do so.

Mr. Duncan. Dr. England, I have 1 minute left. If you would like to take that up with your comment, you may proceed.

Dr. ENGLAND. It was not clear to me when you talked about complications of insurance forms and all that, and people in buying what they need and all, whether you were talking about a matter of education of the public or fraud on the part of the insurance companies. Maybe the chairman was talking about that.

Mr. DUNCAN. Maybe it was.

Dr. ENGLAND. Which was it? People do not understand what they are buying, or the insurance companies are trying to defraud?

Mr. DUNCAN. I think what I was talking about was all the health providers.

Thank you, Mr. Chairman.

Mr. ROSTENKOWSKI. Dr. England, as you may know, the American Surgical Association of the American College of Physicians undertook in 1970 an in-depth study of surgery in the United States. The results of this study are just now being released. The study on surgical services for the United States is what it is. One of the conclusions

seems to be that about a third of all surgery is performed by physicians who are not fully trained ; that is, those who are not board-certificated in surgery. .

One of the conclusions seems to be that the surgery performed by non-board-certificated surgeons is of lower quality than that performed by board-certificated surgeons. Would

you like to comment on that? Dr. ENGLAND. I do not believe that there is anything with regard to board certification that guarantees quality. I have seen this thing work both ways.

The American College of Surgeons and the American Board of Surgery seems to be having an economic problem really. This is done under the guise of uplifting the quality of surgery done. .

In an article that I saw a short time ago, the heading said something about increasingly stringent rules for surgery. The idea was that a lot of surgery is done unnecessarily. As you read the article you understand they have found too many trained surgeons without a place to go. They are more interested at this point in time in controlling competition than anything else, frankly.

Mr. ROSTENKOWSKI. Would any other panelists like to comment on that!

Mr. Thompson?
Mr. Somers?

Mr. SOMERS. There is a question of quality as well as quantity. The two are related. Unnecessary surgery I think could be called bad quality, even if it is done very well.

There are hearings being held, I understand, this morning on this very subject elsewhere, but the issue, of course, is if there is a surplus of surgeons, as Dr. England has implied, being worried about competition, the inevitable consequence is that you will have more surgery. The only way the surgeon makes a living is to do surgery.

It is impossible to say by any objective definition how much is unnecessary, but we do perform per capita more surgery than almost any other country known, roughly about 50 percent more, for example, than Great Britain. Of course, some people might say they do not do enough. I do not know how you measure that. But the fact is we have twice as many surgeons per capita. This would have to be called, if an excess does occur, a form of poor quality, dangerously poor quality.

In the profession I am told that unnecessary tonsillectomies and hysterectomies have become colloquially known as remunerectomies. This probably explains a good deal.

Mr. ROSTENKOWSKI. Mr. Thompson?

Mr. THOMPSON. Professor Somers' comment in regard to comparisons between this country and England as to the number of surgeons and incidents of surgery, I am not going to make the point but I would suggest some people would say that is the access we are trying to provide people, which is reflected in the dilemma we all have in trying to know what is the right amount that has to be put into the system.

To comment on an earlier question, I think it is troublesome to distinguish the qualitative talents of a particular individual as to whether he is or is not board certificated. Certainly the profession can speak more definitely on that point than I can, but in our experi

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ence in dealing with some 13,000 physicians in Massachusetts, I really do not think that you can make that distinction. You certainly cannot as to individuals.

Mr. ROSTENKOWSKI. Well, if, as you have stated, Dr. Somers, there are abuses and we have some testimony in other committees that will back that up, that there is unnecessary hospitalization, there is unnecessary surgery, what do we do about it? What can we do about it?

Mr. SOMERS. I think you obviously cannot do much without the cooperation of the profession itself. I think incentives have to be created for a good deal more self-policing by the profession over the behavior of its members. I would advise that for their own sake as well, because it is obviously better for them that it be done by them than to have it imposed by the Government.

Theoretically, hospitals are supposed to do that. You have in every hospital utilization review committees, and various other committees of the medical staff which are supposed to sort of determine whether the members of that staff are behaving in a proper way. But there are counterpressures.

Hospitals are in trouble unless the beds are reasonably filled. During certain periods of the recession, for example, as utilization ran down and the average occupancy rate in hospitals got to the low seventies, you found the administrators informing the utilization review committees that this hospital simply cannot survive financially with empty beds, which is true.

There are places where you found on bulletin boards figures showing we have an occupancy rate of 60 percent or whatever, and we ran a deficit of so much and if it continues indefinitely, we have to close this hospital. That is a message.

A great many forces are at work here. That is one of the reasons, of course, that I am a great believer in cutting down on the number of hospital beds in this country, and I have a lot of company on that.

It is not too bad to have a waiting list. Nothing terrible happens if elective surgery is delayed.

Primarily, we ought to be able to depend on hospitals, but with these countervailing pressures, with the reluctance of the medical societies to be effective disciplinarians of the profession, I expect Government may have to mandate that they do so.

Nr. ROSTENKOWSKI. Mr. Stark?
Mr. STARK. I think that other-

Mr. ROSTENKOWSKI. I would like for you to keep it to a minimum. I would like to recognize Mrs. Keys.

Mr. STARK. All right.

The medical care system I characterize as being functionally open ended. In other words, the financial gains are greater rather than less when the cost of care is greater.

Hospitals are usually paid if they overrun on their proposed budgets. Once it is known that insurance is in the picture, neither the providers nor consumers are going to worry very much about the costs of their medical care.

I would urge very strongly, regardless of what kind of a system we finally come up with, that we build into incentives, not only for the providers but for the consumers.

Mr. ROSTENKOWSKI. Dr. England!

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Dr. ENGLAND. The question of unnecessary surgery of course relates to unnecessary to whom?

There are a multitude of human ills which can be treated surgically, but if not treated do not result in death or catastrophe. An unsightly wart is not something that will kill anybody, but to that person, having it removed is necessary.

The matter of keeping beds filled is an interesting one, with waiting lists and all. It is true there is some pressure I understand on the part of some hospital administrators to keep the beds filled.

In our particular locality, we have not experienced that problem. But I do know that the areawide health planning council, which is something that was structured from legislation here, has a rule that a hospital that is consistently below 70 percent shall be closed. So they are really between a rock and a hard place in that community. But again, it is not because of what is happening with the medical profession particularly, it is because of the legislative response to a supposed problem.

Mr. ROSTENKOWSKI. Mrs. Keys will inquire.

Mrs. Keys. Thank you. It looks like I have the last word so I intend to squeeze the last drop of expert opinion from you gentlemen before 2 o'clock.

One area that is especially important to me has not been touched on much.

Mr. Stark, you stated that you did not see as any primary objective of national health insurance modifying or changing the present health care system. Yet all of you in your testimony, I believe, in one way or another have recognized that the prepaid health care of the health insurance system that we have now has certainly militated toward

Second, it seems to me that the present system has militated toward undereffective use of facilities in the area of preventive care. Our health insurance system now, it seems to me, really does not emphasize attempts to get into the very necessary area of preventive care, and it seems to me this is very important in terms of cost control, in addition to being important in terms of accepting our responsibility for delivering important health care.

I would like any comments you have on this as to whether you feel that moving our insurance system so that we can deliver, encourage, and give equitable access for preventive care is important, for one thing for cost control; and if you feel we can do that or if you feel maybe my statement is wrong, maybe you would state your disagreement.

Mr. STARK. No; I might disagree with you in saying that the prepaid system has created more health care delivery problems. I would think this would be an incentive to provide less unnecessary care than might otherwise be the case.

The incentive is that the opportunity to keep one out of the hospital is certainly going to reduce the cost of that care to the benefit of the provider.

The fact that preventive medicine, whatever that term means, could be practiced more effectively with the added incentive of keeping the person out of the hospital; the factor of health maintenance, education in proper health care, all of these things I think stand a better chance actually of being provided under a prepaid insurance program than otherwise.

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Mrs. Keys. Now, Mr. Stark, when I say prepaid care, I am not talking about the HMO, which is a tremendous asset, but I mean the insurance system we have, or have had in the past which I feel has not encouraged the kind of preventive care.

Mr. STARK. If you are just talking about payment of insurance premium, yes, I think that has rather encouraged it and because of the way this has been tempered, the insurance policy covers one when he goes into a hospital, the most expensive modality of care.

I think the other which is now coming into the fore was given first impetus by advent of medicare, which is the outpatient services, the clinical services which are almost nonexistent in terms of the total health care picture in being provided by insurance.

Alternatives to the inhospital care, if they could be provided by insurance in a more wide useful way would tend then to reduce the overall costs and do all of those things which you are hoping for under a good system of preventive care. Mrs. Keys. Do you think that could be the objective of NHI?

Mr. STARK. I think definitely it should be a strong part of an NHI program.

Mr. THOMPSON. I would like to comment on that, too, Mrs. Keys.

I think the matching of the concept of very broad care, preventive care, even though everybody in the room would differ as to the definition of preventive care, but the broad-based preventive care, in seeing that in terms of cold cost effectiveness fly in conflict with each other.

There are certain maladies that afflict us in society where annual physicals and other procedures have some real advantages. I would suggest to you that the concept that we can economically-and I am separating that from the human side—but economically somehow save substantial sums within society by reason of repetitive physicals, whatever you might wish, I really think is an illusion.

I give you a small example, the argument made to me frequently that insurers should cover genetic counseling and that we should provide that as a benefit to get the public to go through that process since the birth of an abnormal child is not only costly, but of course dramatically affects a family from an emotional standpoint.

In the cold hard sense—I hate to put it this way—but in the cold hard sense of analyzing whether that makes sense or not, most of the studies, definitive studies will show, not dissimilar from we in society, that even high risk couples identified by reason of a child having been born that was abnormal, or by something within their genetic history that demonstrates that, about 50 percent of the people having been advised of the risk ignore it.

I am a typical example of that to the extent of having twice had ulcers but I, like half the persons in this room, refuse to change personal habits to properly respond to the issue of preventive care.

I do not think we in society are prepared to do that, unfortunately. So I am troubled by matching those two concepts and assuming they will work together.

Mrs. KEYS. I am not talking about cybernetics, I am talking about the mother having the freedom to take her children to the doctor in early vears by knowing that she can afford to do that and that they can have the proper health habits, proper health education, proper immunizations, and treatment necessary in preventing costly medical prob

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