Some of the States in the South have the lowest physician-population ratios, and you might think that in those States the number of visits per capita is low accordingly. But in the South physicians. delegate more tasks, employ more aides, work harder, and see more patients, so that when you look at the bottom line, the per capita visits delivered are roughly the same as in New England. So the system does accommodate considerably to demand pressures. The question is this: Is the health care given in the South quality health care? I am certainly not qualified to comment on it, but if you allege that it is not quality health care, I invite you to go down there and say so by looking southern physicians in the eyes. Mr. DUNCAN. I live in the South and I feel fine, thank you. Mr. VANIK. I just have a couple of questions. Earlier, Dr. Fein suggested that catastrophic coverage would be catastrophic. I was just wondering whether he would tell us why, because there is considerable basis of thought in the Congress that this is one of the things we might do as a minimum. Mr. FEIN. There is a dynamic quality that all of us have referred to in the health care system. If one insures catastrophic expenditures, this will, in fact, I believe-and I think a number of my colleagues will agree this will direct resources toward catastrophes and away from prevention of those things, away from preventive care, the primary care which are not costly, but are very, very important to individuals and to the total health care system in preventing those catastrophes. The insuring of hospital care makes a difference not only in ability go to the hospital, but also directing resources away from primary to care. Mr. VANIK. Let me tell you some of my own experiences. I am as an individual most deeply concerned about catastrophic coverage in all areas. I am at a point where I don't insure my automobiles any more against damage that others may incur. I protect others. I just want to provide public liability. I want to be sure that I have enough because I want to insure protection of the others. I am willing to take the risks that are inherent in that kind of planning and restoring my own property. That reduces the cost to me. It also takes me out of a lot of discussion and negotiation about small claims and their settlement. I get very angered about the cost of these things in automobiles. For example. I had an automobile. totally damaged. The estimate of repairs was $2,845 and I fixed it up for $650-not perfectly, but adequately. Now the same principle applies it seems to me, in health coverage. I am dreadfully concerned about facing up to a problem where there might be a catastrophic illness in my own family, reducing our standard of living and driving us into hopeless and abject poverty. It can happen to any family. Now, from the standpoint of cost and manageability doesn't this become something that is achievable in a health plan? Mr. FEIN. Mr. Vanik Mr. VANIK. I am taking care of the normal day-to-day things, you know. We can handle that. But what all of us fear is something might happen that will just be beyond our scope of control. 57-677-754 Mr. FEIN. Let me be clear. I am not opposed to protection against Mr. VANIK. Why is it catastrophic? Why would it be catastrophic for all of us to be putting something into a pool to cover those relatively few people among us who would have to face up to a catastrophic problem? Mr. FEIN. Because if that is all we did Mr. VANIK. That is the best insurance there is. Mr. FEIN. But if that is all we did, sir, then to use your analogy, there would be somebody to pay the $2,800 bill and, in fact, it would be paid and the resources would be directed in that direction. Additionally, while you and I might very well feel much more secure with catastrophic insurance and, indeed, continue to seek early care, preventive care, primary care, there are Americans for whom that $5 or $15 or $17.50 becomes burdensome. It would seem to me that if we want to have that taken care of for those Americans, then we need a system which includes both catastrophe and early care. Mr. VANIK. I don't argue about all of those things. I don't know why catastrophic coverage should detract from the other programs. As a matter of fact, I would like to move to the next question. That is, in the development of what we are doing here and in our efforts in this committee to develop a program, I wonder whether we shouldn't approach the whole thing with a building-block concept. In other words, getting our keystones in place and then phasing into a total program? Perhaps we would not even build it all at once. I am so fearful that a comprehensive program, as desirable as it would be, would be an awfully difficult thing to establish—it might well become unmanageable. When I talk about the building-block concept, I think about catastrophic coverage being one of those keystones on which we build a total system, and a complete system. I don't take away from the other possibility, but I want to put that suggestion out to the panel and try to determine how the panel would feel on this kind of gradual approach as against a comprehensive approach. Yes, Dr. Freymann. Dr. FREYMANN. Mr. Vanik, I think the problem that arises in comparing the catastrophic approach in health and the catastrophic approach in casualty insurance is that you could drive for 50 years and never have an automobile accident, but everyone is going to die. Mr. VANIK. We don't all die catastrophically though. Some of us sort of ooze out from date of birth. [Laughter.] Dr. FREYMANN. The fact of the matter is that it is very, very difficult to die at home in this day and age. Mr. VANIK. In my community you are going to die at home because you can't get a doctor. I live out here in Fairfax and the only way to get a doctor is to call an ambulance and get to the hospital. There are no roving doctors any more and the only way you get a doctor is die on a golf course. You might find one there. [Laughter.] Mr. ROSTENKOWSKI. On a Wednesday. Mr. VANIK. That's right, on a Wednesday. Dr. FREYMANN. This is precisely the reason why people are dying in hospitals. Mr. VANIK. That is not true now. I am shocked by the great number of deaths that are occurring outside of hospitals and in the home and on the streets and away from where the care is. Do you have figures to back up that, the figures on where deaths occur? Dr. FREYMANN. No; I don't and it would be very interesting to have Mr. VANIK. I would like to have those figures tested because I think the ratio of deaths in hospitals to deaths elsewhere would be shocking. I think we would be shocked to learn how many of our people die alone without anyone around, without any care nearby. Dr. FREYMANN. You have caught me where I should have figures and I don't, Mr. Vanik, but I certainly agree. There are deaths on the highways, as Dr. Wynder has already pointed out. This is a major cause of deaths and many of these people never get to hospitals. There are also those who drop dead in the street. But what I refer to is the person who lives his full three score and ten years. It is true that a lot of people are still living out their lives and dying at home. But the fact is that it is becoming socially less and less acceptable for this to happen. One practical reason for admitting dying patients is that it is very difficult to get a doctor to come and attend a person who is dying at home. Furthermore, the law requires that you can't be buried without a signed death certificate. So what I am leading up to here, sir, is that once a person gets into a hospital, it is very difficult for the staff not to make available to him all the technological facilities that are necessary to sustain life. Within the last week I watched as a patient in a hospital in Hartford was worked over for 3 hours in a coronary care unit. He had a cardiac arrest. I have no idea of what the actual costs were, but in terms of man-hours I am sure a number of thousands of dollars were spent. The man was 85 years old. Now the doctors and nurses on that ward are not there to decide whether if a person is of a certain age, he will not receive services that a person 10 years younger would receive. This is where I get back to the point I tried to make earlier. We are in a box. We have technical facilities where will keep people alive almost indefinitely and those are enormously expensive. Yet we have a limited amount of money. If more and more money is going to be going into perpetuating life, less and less will be available for prevention and primary care. Mr. ROSTENKOWSKI. Mrs. Keys will inquire. Mr. VANIK. Mr. Chairman, I would like to say that after we resume, I would like to get a reply from the panel on this question of approaching national health insurance on a piece-by-piece program vis-a-vis the comprehensive bill. Thank you. Mrs. KEYS. Thank you, Mr. Chairman, and I would like to thank the panel for excellent testimony. It was very interesting, very informative. So many of my questions have been well covered, but one area that has not been touched upon I would like to propound a theory on and see if there is any disagreement among you on it, and how it could be influenced either through our medical education or through the adoption of a national health insurance system. It seems to me if we are going to meet the health care needs of our citizens we need to place a greater emphasis on preventive medicine. This is an important part of the health picture which has not been carried out in terms of the public at large. We are going to have to see the movement out into the community of a great many people other than medical doctors-nurses, medical assistants, para-professionals and the like. So far, the field of nursing has been strictly confined to a hospital care situation and responding as an assistant to a doctor. How can we influence and change this? Would you agree that this would be helpful? Is it necessary, in terms of stressing the role of preventive medicine, to emphasize things as health education, nutrition education, and moving people out into the community? Perhaps Dr. Freymann, who has talked about the role of medical education, could comment in this area. Dr. FREYMANN. Mrs. Keys, I couldn't agree with you more. I think that nursing is probably, with the possible exception of pharmacy, the most underutilized of the health professions. Patient education is part of the education of every nurse, and I have been on record for many years that the nurse practitioner may very well be the answer to providing primary care. This is already proving practical in many parts of the country. The problem of getting the nurse practitioner out and delivering care is hung up on the problem of who is going to pay her? This is something else the committee must concern itself with. So we end up with money again, but I agree with you absolutely that this is a resource that should be tapped. Mrs. KEYS. Would anyone else care to respond? Dr. WYNDER. I would like to add to this in the language of building blocks. The building blocks have to include prevention. As I emphasized in my former remarks, it must also include allied health professions. Several studies have shown that if the Public Health nurse does home visits for victims of heart failure, it is done better and cheaper than when these people go to the hospital. A very important factor, therefore, is to strengthen allied health professionals, not just the nurse and the nurse's aide but also the health motivators, educator, and sociologists. People have to be shown that these allied health professionals can handle several health aspects better than the doctor. For one they are often better motivated and they have more time. This paramedic forms a very important element in primary care and particularly preventive care. On a final comment in terms of building blocks, Mr. Vanik, William Osler once said, "Man's best friend is bronchial pneumonia." In other words, you die of old age peacefully at home of bronchial pneumonia. A typical example of what we should not do is what we did with former President Truman. He was dying of bronchial pneumonia and we should have let him die in peace. Instead, we are trying, as Dr. Freymann said, to keep old people alive artificially, which is not in their interest nor in the interests of society. I would certainly agree with you, the best way to build up a new health care delivery system is to do it block by block and learn from each country where such blocks have been most effectively used. One of the things we can learn from China is the example of the barefoot physician. The barefoot physician, as they call it as we call the allied health professional-has significantly contributed to the ventive care in China. Mrs. KEYS. Mr. Reinhardt. pre Mr. REINHARDT. I believe the point you raise is a very important one, very often overlooked in the entire discusion of health care systems. The ultimate purpose of that particular type of activity is presumably to improve health, however we define that. So there must be something an economist would call a health production process, as distinct from a health care production process. Inputs into the health production process are medical services, but they are only one part, and in many instances not even the most important part. The patients' socioeconomic environment, hygiene, housing, and nutrition are equally important; and-this is the point to which I would like to come the patients' own attitude and his own ability to manage this health production process are very important. Now, some people smoke-my learned colleague next to me, for example and they are clearly somewhat remiss in so doing. In smoking his pipe, my learned colleague on the left will undoubtedly put a burden on the medical system, perhaps some 10 years hence. I mention that simply because it is only one manifestation of an opportunity for preventive health care. Not speeding is another example. The number of deaths from motor vehicle accidents is shocking in this country. We could reduce the burden on the health care system imposed by such accidents. Second, I believe our educational institutions are remiss in teaching health management, as I would call it. Mr. Pike isn't here, so I can slip this in. At Princeton we are enthused about teaching our students about the various toothaches the Pharaohs had. As you know, we can X-ray ancient molars and know that Ramses II had toothaches. We teach that because it is intellectually stimulating. We do not have a course in human biology at Princeton University, which is one of the greatest--I hope-universities in this country. We do not really teach health management to our students, and yet we clearly should. Finally, as to the use of paramedical personnel, they could be a source of such education. Once we begin to use paramedical personnel as entry points into the health system, however, we are confronting an extremely complicated issue. And the question I would raise is this: Under whose control will these paramedics practice? The economic and medical control of the physician? Or will you allow these paramedics to practice as independent practitioners? This is the question Congress would have to address. If you let them practice as independent practitioners, will there be fee-for-service, or how will you pay them? The method of payment has enormous con sequences. I think you would encounter much difficulty in getting away from the first mode, that of putting paramedical personnel under the con |