The problem is we see no insurmountable difficulties in other areas. Mr. ROGERS. Thank you. Mr. JARMAN. Mr. Carter? Mr. CARTER. Certainly I want to compliment the distinguished gentlemen upon your presentation. You have been very good. Personally I am for your integration into this program, authorization for funding, that is as far as we can go. What is now the cost of artificial kidneys? Dr. MERRILL. I think it depends on the kind of artificial kidney you buy. There are essentially two kinds widely being used now. One is the flat plate dialyzer and the other is the coil-I don't think the distinction is important. The initial investment in one, the flat plate, is considerably more. With all the monitoring equipment, it is something like $15,000. The supplies for this subsequently are considerably less, so that the average for the first year or the average for the first 2 years is about the same. The cost of the round equipment now is about $2,500 and the subsequent equipment gets up to $3,000 for all of the equipment that must be used and disposed of. Mr. CARTER. The cost is going down considerably? Dr. MERRILL. Yes. An example I gave you, one of the inserts for the round type, began at $82 and is down to $18. Mr. CARTER. From $2,500 to $15 then? Dr. SCHREINER. On the rental program it can be reduced. We require a patient for a year's rental around $900, which will take care now of the simplest console type of apparatus for a year. If they don't have the capital expenditure with the rental program or lease program, you can get the basic equipment needs for about $900 to $1,000. There are modifications in plumbing and so forth. I would say, to look ahead for a year on a home program, at the outside rental plus the plumbing changes and so forth, that may be a high figure, around $1,500. Mr. CARTER. And that is the cost per year? Dr. SCHREINER. It would be $900 a year thereafter. But that is a lot easier for a working man than plunking down $2,500 for a machine because he can do it as an ongoing thing and take it out of wages when he goes back to work. Mr. CARTER. How many people per year are actually denied use of the kidney machine because of expense, or that now are available and people cannot be supplied with them? Dr. SCHREINER. That is a difficult point for us to get over. It is really not the machine. American industry could turn out 1 million of these in a year if the market were there. The problem is, you might call it, the delivery organization. It requires a center to start with that would provide training for technicians, nurses, and doctors, it requires a central facility and satellite facilities in the community hospitals and they have to have places to refer problems. They cannot exist in a vacuum. When the complications happen, it has to be built in a systematic way and what is missing is not just money, but a plan, the systems approach. We don't have a plan. We simply said-just let this happen. We don't have an organized way to deliver it. Mr. CARTER. You don't have the manpower? Dr. SCHREINER. I think the manpower is achievable, if you say, or if I may, I mean, be informal to express myself, but we are really going about the whole thing in a "back asswards" manner. Instead of saying, "Here, we have 100 sick patients, how can you deliver the best possible treatment for these patients at the lowest possible cost?" What we are doing is saying, "We have this program, and that program, how are we going to fit them in to take care of these 100 patients in other programs?" You can do things very much more economically and much more efficiently if you approach it from a systematic planning way, because you can find that the ideal size of a dialysis center, for example, may not be four beds, it may be nine beds, and you may get more economical use of nursing manpower and technician manpower so you have to do analysis for the area to see what is the most efficient way of delivering care to that area. There are parts of the country you can't train people or a high percent of people for the home because of educational background, economic problems, and obviously you can't put an artificial kidney in the home where there is no plumbing. So in those areas you are going to have to go to mobile units or a center dialysis in the community. This has to be adapted to the environment in which you are going to produce it. Our problem is the rigidity we have in the programs. We don't have national planning and we have a rigidity which says we are going to find storefront centers, but they are no good in the hills of Kentucky, as you well know. This kind of thing that we would like to see is flexibility. Mr. CARTER. In our hills we do have some. In Kentucky I have a veteran with an artificial kidney, an M.D., and I was fortunate enough to get him service connected. Dr. SCHREINER. He is one of our patients. Mr. CARTER. Dr. Asher? Dr. MERRILL. He is one of our patients. Mr. CARTER. Let's get back to my first question. How many patients who need this treatment do not get it each year? Dr. SCHREINER. Up until about 2 years ago, with the indications, using the strictest medical criteria, we figured about nine out of 10 of the people dying are not being treated. With the increasing number of applications as the use of it in hypertension and with stretching a little bit of the ability to transplant, it is more like 5 percent now, one out of 20 being treated, because the pool is larger and we have not grown in terms of development of delivery. Mr. CARTER. Of course, we have noticed, I believe you mentioned, Doctor, effects of estrogen and which had been noticed, I would think, probably in cancer of the prostrate and, of course, we have had that for many years and a spinoff, I would think, and of course I believe one of your most noticeable effects is phlebitis. Dr. PARRY. The Veterans' Administration study has brought to our attention that the patient receiving doses of estrogen in the range of 5 milligrams, that really is not a feminizing dose, but is a pregnancy level of the drug. They have more cardiovascular complications than a person on the prosebo-hyper compound. That has brought this to our attention. In other words, in an older 46-566-70-10 person given a misdose of a drug seems to increase the rate of complications. Mr. CARTER. There is increase also of phlebitis? Dr. PARRY. That is one of the cardiovascular complications. Mr. CARTER. Another interesting thing about cancer of the prostrate, which you mentioned, there is increased incidence as one grows older. Could you quote the percentage or give the incidence among people from 60 to 70 and 70 to 80 and so on of those having cancer of the prostrate, and are those figures available? Dr. PARRY. Yes; I have figures here from our own study which I could give. It does increase with age. On the other hand, we are learning there is a certain virulence of this kind of tumor, too, so we have to put the two in balance. The older one gets, the incidence of this disease increases. On the other hand, that does not mean that this is going to be the cause of death in this situation. Mr. CARTER. Many times it is evident for years after diagnosis. I would like to go a little further in my presentation, because I didn't answer it correctly. We are going to have figures, I think, that you would be interested in which I didn't mention this morning. For example, how far does a person have to go to a physician? How far does he have to go to a consulting physician? What are the local facilities? Are they being used, such as the laboratory, such as X-ray? How many or is it any advantage for the one kind of patient with the same type of disease to see a doctor many times compared to another man in an outlying part of the State where physicians are not available? Then we have the questions of cost. Do we need to do all of these X-rays at regular intervals? We think this is ideal medicine, but is this necessary? These are the kinds of byproducts that will come out of the program by being able to evaluate an area with no physician compared to an area with one and compared to another with a specialist and compared to another, say, with a medical center. We have a whole spectrum of distribution of medical care in Okla. homa and we are trying to sample each one of these. Mr. CARTER. Thank you. May I just ask this. If you could submit for the record, if it is not already covered, and I would not ask you to comment on this now, but could you submit, if we include in this program the kidney diseases, what type of inter-regional and national information dissemination systems and cooperative organ banks could be implemented to improve the availability of transplants to those in need of them? Could you just let us have your thinking on it? I think it would be helpful for the record. (The following statement was received for the record:) COMPUTER CAPABILITIES IN ORGAN RETRIEVAL AND TISSUE TYPING Dr. Carter, in effect what we would propose to do is to expand the capabilities of existing computer tissue-typing-organ banks in addition to taking the necessary steps to add facilities, at other computer centers to cover the entire country. As you know, Los Angeles has an excellent system which could become the prototype for new centers. I would envision multi-regional centers, for example in Seattle to cover the Northwest, one or two in the Midlands, and so forth. It will be necessary to carefully delineate the geographic-medical servicespopulation service areas of the centers. Finally, the prepared statements of Drs. jarian and Parry cover certain aspects of organ retrieval and tissue typing. Mr. CARTER. Thank you, Mr. Chairman. Mr. JARMAN. Mr. Preyer? Mr. PREYER. I have no questions, Mr. Chairman. I would like to say that it has been an excellent opportunity to hear the great pioneers in this field and as one who sits down at the foot of the table here and who hears this for the first time, I will say you have made a very powerful impression on me. Thank you for your testimony. Mr. JARMAN. Mr. Skubitz? Mr. SKUBITZ. I have no questions, but I want to commend all of you today. I am for your program. Mr. JARMAN. Mr. Kyros? Mr. KYROS. Thank you. No questions. Mr. HASTINGS. I have no questions. I will only say as one who sits at the other end of the spectrum, I agree with the viewpoints of Mr. Preyer. Off the record. (Discussion off the record.) Mr. JARMAN. Gentlemen, we very much appreciate your being here and helping to make a record on this important subject. Our next witness is Mr. Schlesinger, executive vice president, Community Health Information and Planning Service, appearing on behalf of the American Public Health Association. STATEMENT OF RICHARD SCHLESINGER, EXECUTIVE VICE PRESIDENT, COMMUNITY HEALTH INFORMATION AND PLANNING SERVICE, INC., SYRACUSE, N.Y.; ALSO ON BEHALF OF AMERICAN PUBLIC HEALTH ASSOCIATION Mr. SCHLESINGER. Thank you, Mr. Chairman and members of the subcommittee. I am Richard Schlesinger, executive vice president of the comprehensive health planning agency for Metropolitan Syracuse, N.Y. In addition, I have the honor of chairing the Community Health Planning Section of the American Public Health Association, the country's 26,000-member organization for professional and lay leaders interested in health matters. Thus, I speak to you today not only out of personal interest and concern, but also as a spokesman for my colleagues in the American Public Health Association. Review and analysis of the original comprehensive health planning legislation, congressional hearing reports and Federal regulations guiding the development of the program reveal the goals which the framers had in mind. Primary among them were: 1. Developing and strengthening a planning process with basic roots at the community level; 2. Providing a mechanism for consumers and providers to work jointly in analyzing their community's health problems, in establishing priorities, and in devising appropriate and effective solutions to those identified problems; 3. Drawing together representatives of both public and private spheres in a working partnership to achieve health progress; and, 4. Encompassing an ecologic approach to the total spectrum of health concerns: personal care and environmental health; physical health and mental health; services, manpower, financing and facilities. Slightly more than three years have elapsed since the passage of that legislation, even less since its initial implementation, especially at the areawide (or community) level. In many ways, efforts to evaluate the program's productivity in contrast to its progress are misleading in judging the results of an organizational period. Nevertheless, it is pertinen, to note that the early goals of the program remain relevant, and to question how best to promote continued efforts to achieve them. This question assumes particular importance in view of the differing pieces of proposed legislation currently under consideration here. It is our impression that the administration-favored bill, introduced by the Honorable Mr. Staggers, makes provision for significant improvements in coordinating and correlating health planning activities now being carried out at State and areawide levels in a variety of administrative arrangements. Indeed, there is much in that proposed legislation which merits support. Yet, juxtaposed with the goals, several weaknesses and potential pitfalls in the legislation and/or its intent remain sources of anxiety. For example, with respect to the first goal of strengthening the planning process locally, statements by departmental spokesmen are disquieting. I quote Dr. Egeberg: "Under a more complicated and dynamic approach, an areawide CHP agency could be given community responsibility for structuring the local health decisions." While this language is subject to more than one interpretation, the general thrust of the legislation, when viewed in the context of related remarks about the planing agency's role as "community trustee" and about its evolving "management" functions certainly appears oriented toward operational-type responsibilities. I submit that when the planning agency begins to assume responsibility as an arbiter of health services delivery and perhaps even to compete for service dollars, its planning role is compromised and the concept of partnership (goal No. 3) ceases to exist. Again, redirecting the planning agency away from consensus-building into becoming an agent for achieving a federally predetermined objective-namely, development of an improved delivery system for primary health care could conflict with the community self-determination implied in the second goal. Obviously, no one would want to quarrel seriously with the objective of improving and systematizing health care delivery. But concern should be expressed, I think, if the means of attaining that objective can be interpreted to include a change in the method of operaiton in which the planning agency is empowered to substitute legal sanction and statutory authority for the planning process involving all the parties at interest. The point is made cogently in a recent article by Dr. William J. Curran.1 The local planning agencies may become so involved in court-like decisionmaking in individual cases that the functions of overall planning will be compromised. Gentlemen, I would like to interrupt the testimony for a moment, 1 Curran, William J., "Health Planning Agencies: A Legal Crisis?" A.J.P.H. 60, 2: 359360 (February), 1970. |