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have the at least minimum facilities that would entitle them to be called useful hospital beds. If they meet those qualifications, then they are considered acceptable.

So we have 516,000 beds in acceptable general hospitals, 86,000 of which have been aided by this program; and an unmet need of approximately 200,000.

In the field of mental beds, 438,000 acceptable beds and an unmet need of approximately 350,000.

Chronic beds, 43,000 acceptable; 240,000 unmet needs.
Tuberculosis beds, 86,000 acceptable beds, and 40,000 unmet need.

Senator GOLDWATER. Why is the ratio so much better in the tuberculosis beds than it is in the rest? Is there something happening to that picture that has caused that to come about in the last several years?

Dr. SCHEELE. We have had a very intensive campaign in our States and communities to find cases of tuberculosis and then to hospitalize those cases; so there has been a great amount of community planning to find cases, and since we are finding cases, to produce the facilities in which to house them.

Senator GOLDWATER. I was wondering if the new theory of treatment, that is, rest in the home, might change that picture some?

Dr. SCHEELE. It has not as yet. We still do not have sufficient knowledge on the value of home care, and treatment with the newer drugs, to put us in a position to say that we want to move away from continued construction of tuberculosis beds.

Senator GOLDWATER. I am surprised to find that picture, frankly, because you know my State of Arizona probably has the highest tuberculosis death rate in the country. We are not in that good shape out there. We are way short.

Dr. SCHEELE. This is, of course, the national aggregate. The State of Connecticut, I understand, has now arrived at the point in its tuberculosis control program where they have no backlog of patients awaiting admission. There are many communities in your State, I believe, in which there is a long waiting list of people waiting for hospitalization.

Senator GOLDWATER. I am sure that no Arizonian in his right mind would want to move out of that State but if the State of Connecticut is in that good a condition

Senator PURTELL. If he ever wants to settle in Connecticut and ever move out of there, even as a TB patient

Senator LEHMAN. May I ask a question there, Doctor? Referring to your second chart, you show 516,000 acceptable beds in general hospitals. Does that include the 86,000 that were built under the Hospital Construction Act!

Dr. SCHEELE. Yes, sir,
Senator LEHMAN. Or is that exclusive?

Dr. SCHEELE. That is inclusive of the 86,000 which were aided with funds under this program.

Senator IIul. That leaves how many now needed?
Dr. SCHEELE. Approximately 200,000.
Senator Hill. I low many mental?
Dr. SCHEELE. Ipproximately 350,000.

Senator LEHMAN. Do those 11,000 mental beds refer to private hospitals or State hospitals?

e at least minimum facilities that would entitle them to be seful hospital beds. If they meet those qualifications, the considered acceptable. have 516,000 beds in acceptable general hospitals

, 36.0 have been aided by this program; and an unmet need of ately 200,000. field of mental beds, 138,000 acceptable beds and an unmet pproximately 350,000. beds, 13.000 acceptable: 240,000 unmet needs. losis beds, 86,000 acceptable beds, and 40,000 unmet need GOLDWATER. Why is the ratio so much better in the tubers than it is in the rest? Is there something happening to ce that has caused that to come about in the last seren!

FLE. We have had a very intensive campaign in our States nities to find cases of tuberculosis and then to hospitalize o there has been a great amount of community planning and since we are finding cases, to produce the facilities in ne them. LDWATER. I was wondering if the new theory of treatrest in the home, might change that picture some! LE. It has not as yet. We still do not have suficient

the ralue of home care, and treatment with the newer it in a position to say that we want to move away from truction of tuberculosis beds. IDWATER. I am surprised to find that picture, frank?s

. owmr State of Irizona probably has the highest tuberate in the country. We are not in that good shape out

Dr. SCHEELE. These are primarily State hospitals, although I believe in the overall planning private beds are accounted for, but actually the ratios are very much on the side of public beds in this field.

I might say at this point-and this is a bit of digression--that this projected mental health bed need is based on a concept of putting most mental health patients in a mental health institution of the ordinary type. Actually, the program that Mrs. Hobby is describing to you this morning would, I am sure, take some of the pressure off for some of these beds. Among these older people, there are some who have hardening of the arteries of their brain, who are senile, and a bit disoriented. Because of these conditions they are often committed by State courts or by voluntary commitment, family commitment, to regular mental institutions. Many of them could probably be cared for in less elaborate facilities, even in nursing homes if there were an adequate number. So that the projected need is, in a sense, a variable depending on the total spread of facilities that exists in any period of time.

Senator PURTELL. Does the number of acceptable beds that you have shown there, Doctor, make any allowance for the large number of existing beds for civilians in Federal hospitals including some 50,000 beds in the Veterans' Administration establishments?

Dr. SCHEELE. That is not included. One could lower these bars on the chart if one took the Veterans Administration beds into account. Senator PURTELL. Ought we not to take that into consideration since you are using that as a base for determining the number of beds per thousand of population and they are part of the population?

Dr. SCHEELE. We could probably reduce the ratios that we are using by a small fraction and have a more accurate picture. I might point out, however, that we still have a need, and we would only take off a small portion of this bar if we dropped the VA beds.

Senator HILL. Doctor, you say about 200,000 general hospital beds are needed; 350,000 mental. How many now in chronic?

Dr. SCHEELE. Two hundred and forty thousand, approximately. Senator Hill. Two hundred and forty thousand, approximately, chronic

. And how many tuberculosis? Dr. SCHEELE. In the tuberculosis field, approximately 40,000. Senator Ilill. Forty thousand. Dr. SCHEELE. In this next chart (D) we have projected these shortages and accomplishments in percentages as contrasted with numbers or thousands of beds in the former chart. Here we see the greatest unmet need, 88 percent, is in this field of chronic beds; 31 percent ummet in general beds: 18 percent mental, and 26 percent tuberculosis.

Senator PURTELL. Are there any other questions the committee wishes to ask before those charts are taken down?

Proceed with the rest of the charts, if you will, Doctor. Dr. SCHEELE. It is interesting to project this shortage of chronic beds against some of the changes which are occurring in our population.

For example (chart D), in 1900, when our national population was approximately 76 million, we had 3 million people (shown here in purple), 65 years of age and over. By 1950, our population had doubled to approximately 151 million. But our population age 65 Tears of age and over had quadrupled to 12 million. During the sarne period of time, life expectancy had increased from 19 years to

Wir short.

This is, of course, the national aggregate. The State ; I understand, has now arrived at the point in its .*rol program where they have no backlog of patients on. There are many communities in your State

. I h there is a long waiting list of people waiting for

W ITER. I am sure that no Irizonian in his right mind jote out of that State but if the State of Connecticut condition 111. If he erer mants to settle in Connecticut and there, even as a TB patient Ex. Jar I ask a question there, Doctor! Referring vart, von show 516.01) acceptable beds in general pat include the 56.101 that were built under the tion Act!

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rum. ! it leaves how many now needed? proximatelr200.000

off manr mental! mumatelr 3.1.000. To those 11.ww mental beds refer to private hos

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68 years. We have tried in this next chart to show some of the changing health picture.

Senator Hill. Doctor, how much of that, roughly speaking, is due to the fact that we save the lives of so many more infants today than we did ?

Dr. SCHEELE. You cannot give a percentage figure but it is a very Gol large factor. Senator Hill. The infants do not die today like they did.

IM Dr. SCHEELE. Many babies were lost in the early days of life because of infant diarrhea and other infections whereas today, the 361 average infant that is born has a chance to get up into this bar, which shows an expectancy of 68 years.

This is a very simple chart (E) because we have chosen only four groups of diseases to show here so that the chart would not be too confusing. Infectious diseases have declined, as shown here by the reduction in the TB deaths, and the reduction in influenza and pneumonia deaths, both running in the neighborhood of 200 per 100,000 in 1900 and dropping down to 25 or 35 in 1950.

However, with the increasing life expectancy, with the reduction of these diseases which often kill in the earlier years of life (though influenza and pneumonia and TB kill in older years, too) we see more people coming into the age when chronic illnesses such as cancer, cardiovascular diseases, begin to take their toll. Over this same period of time we see an increase in cancer deaths, and an increase in heart and cardiovascular deaths in very substantial amount. In

T. the field of cardiovascular disease from approximately 310 per 100,000 in 1900 up to about 510 or 520 in 1930.

Senator Hu. Do you think that increase is as precipitate as the chart would show, or the fact that old age, a lot of times people die of cancer, did die and it was not diagnosed.

Dr. SCHEELE. We never can say that our charts, our mortality data or morbidity or illness data, are completely accurate because there are missed cases. In cancer, generally speaking, in recent studies that have been done, show that death recording has been quite accurate. I suppose they have not been quite as accurate back in this period of time. In fact, there were instances in which States did not have complete registration of deaths in those early days.

However, we feel quite sure of our data in the cancer field because we have been able to do incidence studies in a number of our major cities and have been able to do accurate studies of hospital data on patients and deaths in hospitals. Projecting those against the nationally collected data, leads us to believe that we have quite accurate figures; we haven't had an increase in cancer of any given type except possibly lung cancer. As far as we can tell, we have had an absolute increase because of the changing age composition of our population.

Senator LEHMAN. Is the increase in heart disease demonstrated in every age class or is it largely demonstrated in the higher age groups?

Dr. SCHEELE. It is demonstrated in the higher age groups to a greater extent. However, we do have deaths in all age groups, sometimes from rheumatic heart disease which comes from infection. It is the great waster of children and may cause death, although antibioties and some of the other newer methods of treatment give us good

uos, if these chindren are found early, to help them survive and help the actually come out with very little heart damage. Senator GOLDWATER. Mr. Chairman, may I ask a question? Senator PURTELL. We will be very happy to have you ask a question. Senator GOLDWATER. Getting back to the need in the tuberculosis fied for beds, that need as you show it on the chart has been based an total of State needs, is that correct? Dr. SCHEELE, That is correct. Senator GOLDWATER. Have you projected the need from this chronic Lease rise chart against that total? I ask that question because it Lowks to me like the tuberculosis is approaching the controllable stage where we get it down to around zero. Have you taken that into conideration in the bed outlook?

Dr. SCHEELE. It is taken into consideration to this extent: The bill the cornmittee is considering this morning is taking cognizance primarily of this increase in illness which require long-term hospitalizaton. In other words, the bill itself provides assistance in the area of our rising chronic disease problem. So that, to that extent, it is not Ceemphasizing the importance of completing the job in tuberculosis. On the other hand, it is adding new emphasis in these other areas. I might say that we do not have to worry about overbuilding our TB ieds, because if we arrive at the point in our States where we have more than we need, these beds can be used as chronic disease beds generally. They are not lost.

nator GOLDWATER. Are you going to do any revision in that field, just for the information of the committee, as I say, in the next few weeks. Dr. SCHEELE. No, sir; we have no plans to do that. Senator GOLDWATER. That is something I think you might do. It is a suggestion for not right now, but I think you should take into Consideration the fact that tuberculosis is approaching a controllable situation. We might encourage the overdevelopment of tubercular

beds

Dr. SCHEELE. I might point out Senator GOLDWATER. It would be much easier when you do it, even dough it is a little more expensive originally, it would be much Fasier to develop beds that are really needed, in the really needed bellaI mean general hospital beds where I know the cost is far Prater per bed, but it is a difficult thing to switch a tubercular sanikruin over to a general hospital.

I would not want to see us get way out on a limb where we might te need it in 5 to 10 years.

Dr. SCHEELE. I should point out at this time that in the program the planning that is done is done by the States, the State hospital irhorities

, and they are cognizant of the overall changing pattern ut requirements for hospitalization. I feel confident that without any urging on our part, we will continue to see some fall-off in interest in building additional tuberculosis beds because the States are not pur 2 to build them for care of patients who will be in most instances public charges, if they do not have to. They see their problem com

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ing toward an end point; and all of our State institutions are using some of the newer drugs which are very valuable treatment adjuncts.

I think the very thing that you have described as necessary is actually happening in our States and will continue to happen. I do not believe that any, shall I say, change in the basic law is necessary to speed that up. I do not believe that any great effort on the part of the Public Health Service in terms of our contract with the States is necessary, either. I believe this will flow naturally from the technical knowledge of our changing picture in tuberculosis.

Senator GOLDWATER. Thank you.

Dr. SCHEELE. We are well aware of the fact that patients who are older, 65 years of age and over, require on the average twice as much hospital care, twice as many hospital days of care in a year, as those in ages under 65 years. One study (chart F) indicated that 2,051 days were required by 1,000 persons 65 years of age and over-in other words, 2 days per person, while 1,045 days of hospitalization were required per 1,000 people under 65 years in other words, 1 day per person.

Senator GOLDWATER. That is the average?
Dr. SCHEELE. That is the average.
Senator GOLDWATER. That is 1 day in the hospital?

Dr. SCHEELE. Average per person. Fortunately, most of us are not average, and wo do not have any days, and other unfortunates have 5, 10, or 15 or more days. This is overall per thousand people. But it works out in simplest terms to 2 days, a little over 2 days if you are 65 or over, compared with 1 day if you are under 65.

How, then, can we provide for more economical care for the older age group and others who require longer term care?

In this chart (G) we have shown some of the national averages in cost per patient-day. Our general hospitals, which normally care for acute patients and short-term patients for periods under 30 days, according to the American Hospital Association study, cost approximately $18.35 per day, compared with chronic beds for patients who are hospitalized longer than 30 days, where the national average case is running in the neighborhood of $6.36 per day.

In nursing homes, we do not have average figures because there is a considerable spread in our data, and they are not complete; but in studies that have been done, we find that average daily patient costs are running between $2 and $8.

So we see that through the provision of more chronic hospital beds, through the provision of more nursing home beds, we can provide a more economical method for the care of our long-term patients.

Mrs. Hobby. Thank you, Dr. Scheele.

Mr. Chairman, it seems to me that we can draw three conclusions from this information that Dr. Scheele has just presented. First, what has been done so far in improving and expanding our hospitals has been especially inadequate with respect to beds for the chronically ill. Second, our shortage of chronic beds is expensive, for it has led to the crowding of chronically ill patients into our general hospitals which are the most costly to operate and which are needed for patients with acute conditions. Third, the relative demand for chronic facilities will continue to rise in the future because of our aging population,

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