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trol of physicians. If paramedics are employed in such a manner, it isn't clear to me that health care costs won't rise, because each paramedic will be attached to the location of his or her employing physician and maldistribution of services will be perpetuated.

Mr. FEIN. I would only disagree with your last phrase. I think we ought to think about it hard, but not long.

[Laughter.]

Mr. FEIN. By that I mean we have been thinking about some of these problems for a very long time.

I think that it is a problem which illustrates the complexity and interrelationships that the chairman referred to in his opening remarks in the health care system.

We, for example-when I use the word we I mean we the people— financed medical education in the last 20 years in a manner such as to get quite a bit for what we put in. We got research and we got specialization. But we had a side effect. We destroyed in large measure whatever possibilities did exist in our medical schools for emphasis on preventive care and on primary care.

The orientation of the entire medical education care sector to hospital care makes it less likely that physicians would move to those areas or that they would be interested in the training of allied health professionals.

We have instituted payment mechanisms that make it very difficult for allied health professionals. Again, not in order to make it difficult for allied health professionals, but for what were presumed to be good and sufficient reasons without due attention to the side effects that came about.

Above all, we have never in any part of the United States placed a responsibility on any organized body, governmental, private, educational, or any organized body to be responsible in some sense for the medical service delivery system in that community. In early September every year most of us have, all of us have an assurance that the schools will open and that the school board will see to it that there are buildings and classrooms and teachers.

While various communities at various times have had difficulty in meeting that obligation and have had to erect temporary facilities, the schools do open.

I have an exercise that I have for the medical students at Harvard when I teach them, make a series of phone calls saying that you are a new resident and that no pediatrician is prepared to take your children, which is the case in the high-income suburb that I live in, and then ask the dean of medical school: "What shall I do under these circumstances?"

When you receive the answer that: "I sympathize with your problem but it is not the responsibility of the medical school to assure that there are pediatricians in Newton," and you call the county medical association, you will get the same answer. Call the State department of health or the city department of health and you will get the same

answer.

I once delivered some remarks on this and a cartoonist encompassed the sum total of my remarks in one cartoon. He had a picture of an envelope that is addressed to "Complaint Department, U.S. Medical Care System," and in the upper left hand corner it said, "John Citizen,

Home Town, U.S.A." There was on the envelope the stamp with the finger pointing to the upper left hand corner saying "Return to Sender, No Such Address." Well, as long as there is no such address and it isn't anybody's responsibility, we can have the situation that we have. We will not change it quickly. But we cannot change it by dabbling at the edges, as if the financing system was unrelated to the distribution of physicians by specialty and by location.

Mrs. KEYS. Thank you.

Mr. ROSTENKOWSKI. Thank you, gentlemen.

It is certainly nice to see the chairman of the full committee, Mr. Ullman, with us.

The CHAIRMAN. Would the gentleman yield?

Let me congratulate you for going ahead with these hearings and for putting on a panel of this caliber.

I wish I could have been here to hear it, but I will be studying the record. The reports I have are most excellent. That is one of the reasons I came over.

These are hearings of great long-range importance and we wouldn't be holding them if we didn't intend to write a piece of legislation. This is a very good beginning. I want to congratulate you.

Mr. ROSTENKOWSKI. Thank you, Mr. Chairman.

The committee will stand in recess until 2 o'clock.

[Whereupon, at 12:55 p.m., the subcommittee was recessed to reconvene at 2 p.m..]

AFTERNOON SESSION

Mr. ROSTENKOWSKI. Well, gentlemen, I think the conversations that have been held back here in the backroom subsequent to your testimony are very encouraging.

I think it has been enlightening in the morning session and I am sure that this afternoon we will be able to shed more light on what we feel we will have to do in creation of a national health insurance legislation.

I would like to pose this question to each of the panel members, preventive medicine, Dr. Wynder, is like the weather. Everyone talks about it, but not many try to do anything about it.

What would be involved in making the concept of prevention a central part of our health care system? How do we get the health professions and the public to accept what structural changes would be needed in the organization of care and what would it cost?

Dr. WYNDER. First of all, there must be incentives for preventive care. It is apparent, as I said in my formal remarks, if we give incentives for only therapeutic care but not for preventive care, we will not have it; because, (a), the health care system is not likely to do it unless it is being paid for and (b) the public at large really does not go for preventive services, because, as I also pointed out, most of us really believe it will never happen to us.

So that even in the German example which we cited before where the German Health Service now pays for cervical smears for women, only 25 percent of eligible German women have availed themselves of this free service.

Part of the incentive is also the way we look at sick days we do not advocate health days. Nearly every worker has so and so many sick

days that he can be off work. But if an individual wants to go to a preventive care facility for an examination, or to a nutrition clinic or hypertension clinic, when he is not symptomatically ill, he must do this on his own time.

In our organization many of our clinics work in the evening because the worker has come on his own time. One of the suggestions I would like to make here, is that we establish health days for our citizens in addition to the sick days that we have now.

The key problem, Mr. Chairman, in preventive medicine, is lack of economic incentives and the human apathy towards anything preventive because we believe that it cannot happen to us. It always hits the guy next to you.

This issue has been with us throughout the ages and I doubt whether we will ever change human beliefs that a particular sickness cannot befall us.

Thus, I feel that we have to provide economic incentives for the health care delivery system to undertake preventive measures, and we must provide more incentives for the individual. Perhaps, we could start this approach in our school system.

Most of our chronic diseases have their beginning at a very early age. Hyperlipedemia really begins early in life from the way we eat. A study was done at Harvard from data available to the health service they could predict who would develop heart attacks later in life.

Studies comparing blood cholesterol level of children in Wisconsin and Mexico showed that the curves hardly overlapped. Thus, one way to begin good preventive procedures would be to indoctrinate our young children in knowing more about their bodies.

We have established at the American Health Foundation a KYB program for schools, a know your body program where at minimal cost we check schoolchildren, determine their cholesterol and hemaglobins, test their eyes and ears and carry out tests for physical fitness, take a history on smoking use and then give them a health passport, which is upgraded every year.

When you get children to know their own bodies they are likely to become more involved in health care than otherwise.

In other words, incentives have to be provided early in life, they have to be provided at a cost-effective level for both the providers and for the consumer.

The final question you asked is, what would it cost?

That is difficult to answer. I personally believe that if you concentrate on primary prevention which is really the way in which I think preventive medicine must go and primary prevention means to identify these factors early in life and reduce them both in the environment and in the individual, then preventive services are cost effective. If you only deal with secondary prevention it is a costly service which is not always cost effective.

Dr. Fein mentioned before that the social security service monitors health care costs in this country. But, when you ask, how much do we pay for preventive services? We really don't know because preventive services have never been appropriately covered by the health economists.

Let me repeat, most of the diseases from which we suffer today in our country are preventable. Prevention needs to start early in life and if we really do our job well we could all die at some old age, free of disease. That is the way our general timeclock has called for us to die. Die we must, but we must not necessarily die sick. If Congress provides the necessary incentives we shall have meaningful preventive services.

Mr. ROSTENKOWSKI. Thank you, Dr. Wynder.

Mr. Martin will inquire.

Mr. MARTIN. Thank you, Mr. Chairman.

Just as I want to commend the panelists for the quality of their presentation, I want to commend the chairman for presenting an equally qualitative panel.

We have had a series of questions, as I am sure you have noticed, that not only give us a chance to give a varying perspective from different points of view, but also give me a chance to catch my breath. But one I wanted to get into was to ask generally of you what each of you sees as the most critical need or the most glaring deficiency in the present American system of health care.

I have to give some background before I breathe deeply here, but we had mentioned in your remarks and in some of the questions, a series of concerns which have been brought to the committee. We have had criticism of relying on or even permitting fee for service.

We have considered the loss of coverage during unemployment periods. This committee has looked into that earlier this year. There is a problem of lack of catastrophic coverage; the need for more personnel; the geographic distribution problem that Professor Fein and others have dealt with.

It has been mentioned about the overgrown orientation toward hospitals that Dr. Freymann has discussed in his introductory remarks. Relative inaccessibility of middle-income people who have neither wealth nor welfare and the problems of preventive medicine.

From this and other subjects we have to deal with, it seems to me, in relation to the Vanik concept of a modular legislative approach there is a need for us to focus on those particular areas that are most lacking at the present time. Therefore, if each of you could sort of conceptualize that for us, it would be very helpful to me.

Start with Dr. Wynder and move across.

Dr. WYNDER. I think it might be useful if each panel member would give you an answer in a few sentences listing each priority.

No. 1 greater emphasis on preventive care.

No. 2 greater emphasis on ambulatory care.

No. 3 greater utilization of allied health professionals.

If these three areas would become the basic blocks of the system, whatever system of financing health insurance we will finally settle for, it would be both medically and economically the type of program that our country ought to support.

Mr. MARTIN. Thank you for that response.

Dr. Freymann?

Dr. FREYMANN. I will answer this as a physician but it will be interesting to see how my colleagues here answer it and how each of the members of the committee think of it in their own minds.

I think in terms of health needs. If I understand the direction of your question, Mr. Martin, there is no doubt in my mind that what is most needed is those health services included under the rubric of "primary care."

Now, primary care is not very well defined. I define it as lifelong access by a citizen to a health professional who can assist that citizen with whatever problems he or she may face. That is my idea of primary

care.

I think that the whole tenor of medical education today, particularly the growing number of family practice programs, are a response to a cry which is heard throughout the country: People cannot get a doctor. They are not talking about getting a doctor to take care of a coronary or to take care of cancer because there are no problems here. There is a financial problem, but the services are there. The question is how to pay for them.

In contrast, primary care services do not exist in many areas of this country.

As Dr. Fein mentioned earlier, you can't even find a pediatrician in an affluent suburb of Boston. This is true across the country in affluent suburbs, ghettoes and rural districts. That, to me, is the problem. Mr. MARTIN. Thank you, Dr. Freymann.

Professor Reinhardt.

Mr. REINHARDT. I also will enumerate points, rather than saying there is one single important problem.

The first problem I would say is that certain segments of society are denied adequate health services. One reason is simply that these services are not made available to them even if they are financially able to pay for them.

A second reason, of course, is that they are financially unable to pay for them.

A third reason is that they are unable to use the very complex system intelligently. We always assume that everyone in society is properly educated to manage his or her own health and to use the system effectively. That ought not to be assumed.

The second major problem is that an undue number of American families in my view are exposed to high risks, being vulnerable to the large financial losses associated with illness. Even if that number is absolutely rather small, it is nevertheless there. An undue number of families consenquently suffer a type of uncertainty which I think this Nation is right enough to eliminate.

Third-here I am speculating-it is quite possible that we do produce the wrong mix of services. First, there is perhaps too much hospital care being consumed. By hospital care I don't necessarily mean "inpatient care". I think that the attempt in this country to reduce the number of inpatient days is perhaps a misdirected effort.

Inpatient days vary enormously in resource intensity and perhaps what we ought to worry about is how to get people out of highly resource-intensive patient days and into less resource-intensive patient days, that is out of acute hospitals and into extended care facilities. It does not seem to be a wise policy to reduce inpatient care, that is to send people home, when there is no adequate provision for care in these people's homes, perhaps because there are no adults around to care for them.

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