Mr. ROSTENKOWSKI. Dr. Freymann, the problems are in the inner cities. I know Rockford. That is not a bad place to live. But when you get to Chicago, or Los Angeles, or New York, in the inner cities, this is where the real problem is with respect to the patient and the general practitioner.

I don't see any incentive for the student to become involved in the ghetto except for something like combat pay. It is just that bad. This is going to be a real problem within the larger urban areas.

Professor Fein?

Mr. FEIN. Some of these areas that are unattractive to physicians are unattractive to other people, including schoolteachers. But schoolteachers are found in that inner-city environment because while they would like to come to Newton, there are no jobs. So they go to the inner city, not because they love the inner city but because the job opportunities are there and not in the suburbs. If an individual is a violinist and would like to play with the Boston Symphony Orchestra, but the Boston Symphony Orchestra refuses to employ him because it doesn't need any more violinists, he does not come to the Congress of the United States and say, "My freedom is being interfered with."

There is an employment market and Americans recognize that they as Americans must choose, to live in Pittsfield, Mass., and not be a maritime engineer, or to be a maritime engineer and give up Pittsfield, Mass., because if you want to be in Pittsfield, Mass., because you grew up there and you want to be in maritime engineering because it is attractive and there are no jobs in Pittsfield, Mass., you must choose. That is true of most of the economic system.

I would like to teach at Princeton, but they won't offer me a job. I don't say my freedom has been abridged.

It is in medicine and it is because of the payment mechanisms in medicine and because of the power of the physician to do good that we have a system in which physician individual decisions can be validated. An individual who sets up a candy store does worry about how many other candy stores there are, what is the competition going to be like and will I make a go of it? A physician does not consider that whether he decides to go into a specialty and select a place. He can validate that decision by offering more care, more neurosurgery than the population needs, if you will, more appendectomies than the population needs; he can generate demand for his product.

There are limits, of course, and I am not suggesting that if we had 10 times as many physicians in the United States we would still be having the same maldistribution that we now have. But within present numbers and within the kinds of numbers that we are generating, the demand for services can be increased by any physician in an area where he is. That is from whence comes the term "overdoctoring." You can have too many doctors in Scarsdale and they will all make a good living. That's why, knowing that, they don't go to the inner city.

With the growth of HMO's for example, that situation is likely to change. The Harvard Community Health Plan, a prepaid group practice does not hire neurosurgeons just because they would like to practice in the Harvard Community Health Plan. The beauty of it is that there is a bottom line figure. There is premium income in the plan and they have to ask whether they need another neurosurgeon. Why pay him if we don't need him?

Now an effective budgeting mechanism that puts money into local areas, that requires a local area to consider what it needs, may not induce physicians to go to Roxbury, but may induce the local area to say we need three more primary care practitioners; we don't need any more neurosurgeons.

I think that what we are wrapped up in, of course, is a very complex problem because our pattern of thought is the market. We like the market, we like to use the market. It is a convenient device. But the market in health care is a very peculiar market. We're also in difficulty because physicians have used words like "freedom" in very unusual ways, ways that you and I don't normally use that word. We know that we must make choices. We don't respond to every candy store that goes bankrupt saying, gee whiz, your freedom has been abridged. But the physician has used the word "freedom" to mean he shall be permitted to choose where to practice as well as what to practice and not to be subject to market forces because third parties ought to pay for whatever he does.

You have got to break that chain somewhere and I would suggest that yes it is important that you hear from the fellows in the firing lines, from physicians, but I would also comment that the physician is not trained, equipped, educated to see the system as a system and I would also suggest most respectfully that what we may need in American medicine is civilian control.

Dr. WYNDER. Mr. Chairman, you brought up a key point, namely, what kind of medical care delivery system shall we have in the inner city. The point to be stressed here: preventive medicine is a job of all society. Overcrowding, bad housing, malnutrition are the key medical problems that face our inner cities. They are by and large not medical problems, they are societal problems. It is easily shown there is more TB, more cancer of the cervix and greater infant mortality, et cetera, et certera, primarily because of their social situation. Unless we can upgrade the housing and the nutrition factors in these inner city areas the medical profession has no chance to have its effect and, therefore, in terms of a national health posture, in terms of our health schedule delivery system, we need to recognize, Mr. Chairman, that if we are going to advance the health state of our country, the medical profession cannot do it alone but we must consider all of these other factors that I mentioned.

Mr. ROSTENKOWSKI. Dr. Freymann?

Dr. FREYMANN. Following up Professor Fein's statement, I would like to address two points:

First: As he said at the beginning of his comments, the usual rules of economics don't apply to the health care system. I will not argue the virtue or the evilness of this. It just seems to be a fact.

Second: What he says is perfectly true; we can't get the docs to go to the boondocks, particularly the inner city. But this is not an exclusively American problem. It is just as much of a problem in every other country in the world except China (as I explained earlier) and possibly Britain.

If I may, I will use an anecdote to make my point. Dr. James Watt was for many years the Chairman of the American Delegation to the World Health Organization. In this capacity, he developed friendship with the Chairman of the U.S.S.R. Delegation to WHO, who was a

senior official in the Ministry of Health in Moscow. One day the Russian said, "I wish we could figure some way to get the doctors to go to Siberia."

Watt said, "Now look, you mean you can't send doctors to Siberia?” The Russian replied, "Of course we can send them. I could send a hundred of our brightest young medical graduates to Siberia. But then there would be a hundred of them out there figuring out how to get back to Moscow, and there is only one of me."

Mr. ROSTENKOWSKI. Well, Dr. Freymann, what do you envision the hospital of the future to look like if the trend continues as you have outlined it in your statement?

Dr. FREYMANN. I have written a whole book on the subject. (The American Health Care System: Its Genesis and Trajectory. Medcom Press, New York, 1974, 406 pp.) It took me 8 years to write, so I won't try to give you a full description, but I will try to boil down my view of the hospital of the future.

When we think of hospitals today, we still think of a big box full of all kinds of advanced technology where all the patients are horizontal, and where we treat acute crises in the course of chronic diseases. When these crises abate, we send the patients out pretty much on their own devices.

Returning to my theme that we should build on what we have nowthe hospitals are there. We can't get rid of them. What we can do is change the vision of what a hospital is. I think we can do this through financing and through education. The center of technology where we take care of these crisis will continue to be an important component, but the main function of the hospital of the future will be comprehensive care (including preventive care) of a population which depends on that institution.

I want to make very clear that when I am describing this hospital of the future I am not talking about hospitals employing physicians. There are already some places where that arrangement works quite well. The Hunterdon Medical Center in New Jersey is an example. But I think we can use any variety of payment and organizational mechanisms. The key feature of my vision is a functional grouping of all types of health professionals about an institution which would still be called a hospital but would have a far broader role in total health care than the hospitals of today.

Mr. ROSTENKOWSKI. Mr. Corman?

Mr. CORMAN. Thank you, Mr. Chairman.

I was going to suggest that either now or if you submit comments on the Brock-Martin bill which is the catastrophic approach; if you address this problem of cost control, it would be fine. I am not sure it is in Ribicoff's bill, but it seems to me logical if you put in catastrophic illness insurance in any form without cost control that we will see a ballooning of certain kinds of care. If I were a normal doctor and I had no cost controls on me and the patient is supposed to cover 15 percent of it, I think I would figure out how to live on 85 percent just in case I couldn't get the 15 because I know the Government will pay the bill. I would like comments on that.

Dr. FREYMANN. Mr. Corman, I agree with you. But I think catastrophic illness insurance would skew the system even more than it already is toward acute crisis care. The problem with catastrophic

coverage is not so much what it would do as what it won't do. That is, it will drain more and more of that "bottom-line figure" we keep talking about into that portion of the health care spectrum which has the least payoff in terms of a healthy population-the treatment of acute crises in the course of chronic diseases. Less and less of the bottom line figure will be available for primary care and the preventive measures. Mr. FEIN. I would agree with you also, Congressman Corman. All of us sitting here are speaking about health care today. Obviously, we have as taxpayers, as citizens, many other interests. It would be irresponsible to legislate a mechanism that will involve an escalation of costs both because of the kinds of things that are covered or the kinds of fees that would be charged and where you would have a price inflation that would use up valuable resources, leaving us less able to meet the other needs of society. To legislate a blank check is a most dangerous procedure. At least if you pick up a blank check that I signed, you have to consider what is a sensible amount to fill in since I don't have unlimited resources. You might put down $50, figuring that the check won't bounce. Maybe you're a risk taker and you put down a hundred. But you won't go very high. But if a blank check is signed by Uncle Sam, you can put down any number and the check will be cashed. For the Congress to legislate a blank check to the American medical profession would be irresponsible to all the other social needs of the country and the approach which does not have cost control in it is, as we have found with other legislation in the past, a blank check.

Mr. CORMAN. Do any of you have any suggestions for a form for delivery of health care that would upgrade what we do for preventive care other than HMO's?

As I understand it, the primary incentive in HMO's is the economic. You keep the people well, and you will get the same income so you have an economic incentive to keep them well.

Is there anything other than that that would work to this end? Dr. WYNDER. Dr. Freymann thinks perhaps more of how young medical students could be modified in terms of good health education than I do. As it now stands the majority of the American young physicians living in the present environment will end up in therapeutic care. Therefore, I feel that we have no choice but to better utilize allied health professions. They can do the job better at a lower cost to society than most physicians who perhaps are overtrained for this aspect of medical care.

The allied health professionals are not properly utilized in our society. In our hospitals the nurses are not utilized to their full potential. It has been my experience if you take nurses and challenge them with a position that relates to taking care of patients as for instance hypertensive therapy under a physician's guidance, nutritional advice, or any other behavioral aspects of medical care they do very well.

My key suggestion, cost-wise and indeed in terms of the way we deliver services, would be increased utilization of allied health professionals.

Mr. CORMAN. Are you suggesting that the Federal Government get into the business of deciding according to licensing who can deliver what kind of care?

Dr. WYNDER. This is a possibility. At present laws vary from State to State. There are some States where allied health professionals are utilized very well and there are other States where they are under utilized. In part this utilization seems to depend on the number of physicians in a given State.

To answer you specifically yes, you could very much help in raising the utilization of allied health professionals in our country.

Mr. CORMAN. Did you want to add to that, Dr. Freymann?

Dr. FREYMANN. I would like to throw one of Dr. Wynder's quotes back out, actually the quote of Martin Luther about giving me your child at five. I would like to emphasize, more effective than having physicians or allied health professionals giving health education is to get it into the school system.

Mr. REINHARDT. Yes, right.

Dr. WYNDER. Yes.

Dr. FREYMANN. It is often said we don't have a health education program in this country. On the contrary, we do. It is on television.

In the course of a week, a single station in Detroit carried over nine hours of health-related information. In the judgment of those monitoring it, 70 percent of this was inaccurate or misleading or both.

I don't need to tell you what kind of health education we see on television. It is dedicated primarily to whether you smell good or whether you look good. But it is education related to health.

Health education is beyond the purview of a National Insurance Program, but I think it is an important part of National Health Policy. We must develop effective ways to get to our children and teach them good health practices. The drug education programs now offered in our schools are examples of how not to teach good health practices. They are all negative. All the children hear is how bad everything is. Good education should be positive. It should be directed toward why they should do things, not why they shouldn't.

Dr. WYNDER. Here is another area where you could help. I go along with Dr. Freymann, health education on TV can play a role but we should not limit it to public service television.

I like to believe because most kids in most areas don't watch public service television. They watch commercial television. I feel that commercial television particularly on Saturday morning has a duty to have some kind of meaningful health education programs for children who sit glued to the TV set.

These are public air waves. I think they ought to be used at least in part to educate our young and certainly I am in agreement with Dr. Frevmann that this is where the action lies.

Mr. CORMAN. There is a legislative proposal before the Congress that Leonard Woodcock refers to as the Health Security Program. It's a broad-based program. If you are familiar with it do you have any comments about it?

Mr. FEIN. I am quite familiar with it. I would comment favorably. It addresses the financing aspects. While I might have reservations about what I would consider details, it does so in an effective manner. Americans would have access, would not have the economic barriers that many face now in seeking care.

It also addresses the supply considerations. It has a bottom line to it. It puts the money back where people can argue about what it ought