GAO REPORT ON DRUG PRESCRIPTION UNDER PENNSYLVANIA WELFARE PROGRAM Mr. FOGARTY. That is what I though I heard you say. The other day, when Dr. Goddard was here, I brought to his attention a report by the General Accounting Office on the costs of prescribed drugs in the welfare program in Pennsylvania. They said: A projection of the results of our examination of a random sample of prescription invoices paid by the State of Pennsylvania indicates that savings of from about $722,000 to as much as $1,502,000 could have been realized during fiscal year 1964 through maximum use of less expensive nonproprietary name drugs; the Federal share of such savings would amount to from about $354,000 to $705,000. Then later on, when the people in Pennsylvania commented, they said: The State indicated that the majority of physicians do not prescribe generically because the newer drugs have been developed since they received their educations and it is unrealistic to expect the physicians to keep up with the newer drugs without relying on the drug companies. This is a GAO report and this is what the State said. Dr. STEWART. This is a different thing from what I was talking about. This, Mr. Fogarty, is quite right. If physicians would prescribe with a generic name it is possible then to use the less costly one. If they use the trade name, the practice of a pharmacist, the ethical practice, is to fill what the man has written on a sheet of paper, unless he gives permission to substitute another drug which is the same drug but has a different name. In large purchasing organizations such as the Welfare Department or the Public Health Service, if you can buy it by bid and use generic prescribing you save a considerable amount of money. Physicians are very reluctant to do this. One is the reason cited there, that the trade name is the one they know because they get their information from the man coming around, the drug detail man. This is the one they have in their heads and their literature and everything else. Mr. FOGARTY. Is that what you call him, a drug detail man? Mr. FOGARTY. Not a salesman? Dr. STEWART. He always has been known as a drug detail man. Mr. FOGARTY. Doesn't he act like a salesman? Dr. STEWART. He is not actually selling you. He is telling you about a product. It is also true, as they state here, that some 85 or 90 percent of the drugs physicians are using all have come on the market in the last 10 or 15 years. So any man who has been out of school 10 years—well, I would be an example of this-would not know about the new products. I have been out 20 years from medical school and 15 years out of practice. Most of the drugs that are used now in pediatric practice have emerged since that time. CONTINUING EDUCATION FOR DOCTORS Mr. FOGARTY. In the mental health field, as you know, there is a program started 4 or 5 years ago for general practitioners to attend. training courses in mental health. According to the testimony we have received, that has been a most popular program and we have had more applications than we had appropriations to cover. Dr. STEWART. That is right. Mr. FOGARTY. Couldn't something along this line be worked out? Dr. STEWART. I think it is possible to develop continuing educational programs. Have you ever-and I am sure you have looked at the generic names and then the trade names? They are almost unpronounceable in many instances, whereas the trade name is usually one which catches you and you remember it. This is a difficult thing, too. Mr. FOGARTY. Well, they will keep it this way if they can because they will make more money this way. Dr. STEWART. They get their return on the new product, and the new product has a trade name, it is promoted by their detail man, and this is how they get their return. Eventually a drug is universal and the period of time between a new product and universal availability is a fairly short time now. It is to their advantage. HEALTH MANPOWER Mr. FOGARTY. How about health manpower? Dr. STEWART. I think we are moving very well in this area. Mr. FOGARTY. Every time you talk about new programs, such as heart, cancer, stroke and others, the question is, Where will you get the manpower, the nurses, the technicians, physicians? Dr. STEWART. I think we will see for a period of time a demand which exceeds supply in the manpower field, particularly in the professional manpower. It will take a period of years, 4, 8 to 12 years to train. You see, the young man entering medical school now is a physician of the middle 1970's. We have under development 14 new medical schools and there are some indications of 6 more that we know of. The limitation on this is not the availability of students but it is of facilities, and, perhaps more important, faculty. Mr. FOGARTY. How will you get the faculty? Dr. STEWART. I think that the rate of investment that is made in developing medical schools, which is quite an investment for a university to undertake, and the development of faculty which has occurred in the medical schools in existence, will serve to staff these new medical schools with the exception of certain shortaged areas which even the existing medical schools are having a tough time staffing. KAISER-PERMANENTE MEDICAL CARE PROGRAM Mr. FOGARTY. Do you know about this Kaiser-Permanente medical care program out in Òakland? Dr. STEWART. Yes, sir. Mr. FOGARTY. Have you ever seen it? Dr. STEWART. No, I have not. Mr. FOGARTY. I did go through it last fall. I was quite impressed with this program. They are giving regular medical examinations to their people. I think they had some 22 stations and 40-plus tests that would be made in these 22 stations. Then everything is fed into a computer at the end of the line. If something bad shows up it is picked up right away by the computer. Mr. FLOOD. What is that setup, Mr. Chairman? What is it all about? Mr. FOGARTY. When Kaiser first started building these huge dams out in the wilderness they had no medical manpower in those areas, and accident rates were quite high. DR. GARFIELD'S CONTRIBUTION TO THE PROGRAM In about the middle thirties a doctor got the idea-and he is still with the staff out there, though his name slips me right nowDr. STEWART. Garfield? Mr. FOGARTY. Dr. Garfield. He was unpopular at that time because he tried to practice group medicine to take care of these people. Now it has grown to where they have over a million members. In this particular project they examine about 50,000 people a year. It takes about 2 hours for a male to go through these 22 stations and about 3 hours for a female. By belonging to their organization it does not cost the individual anything, but it costs the organization about $22 or $23, whereas if you went to specialists in regular practice for these tests it would cost in the neighborhood of $200 to $300. Mr. FLOOD. What is the source of their revenue? How do they operate this? Mr. FOGARTY. These are all members of the organization. Mr. FLOOD. Annual fees? Mr. FOGARTY. Yes. And they built their own hospitals out there with no Federal funds. I was quite impressed with it. Mr. FLOOD. Any mental examination, psychiatric, et cetera? Mr. FOGARTY. No. No dentist either. That is one fault I had to find with it. I thought it was a program that might be looked into as far as the Public Service is concerned. Dr. STEWART. Mr. Fogarty, I am well acquainted with that operation out there. Mr. FLOOD. Is there a prenatal clinic? Dr. STEWART. Yes, there is. This is a prepaid program which covers ambulatory care as well as hospital care, and prenatal care is part of the package. They pay a premium. I think this automated screening program they developed out there has great promise. Mr. FLOOD. How will it be affected by medicare on July 1? Dr. STEWART. If their hospitals participate in the medicare program those who are eligible under medicare will be paid for through the medicare program as any other hospital. They happen to serve a defined population group, the members. But the membership is open to the community. I think it has great possibilities. The annual physical examination for, say, the population over 40 years of age in the country would be literally impossible both from a cost standpoint and from the use of physicians. This obviously uses physicians very efficiently and has cut the cost down considerably. Mr. FOGARTY. They are in on excellent position to follow this group for years. They keep all this data and are finding things now that will likely be of value to medicine generally. I remember one thing they told me, cancer of the breast in women over the age of 50 was just double that of under 50. This is one thing they picked up. They gave me several examples like that. I asked them to write to me, but I have not had a chance to read it yet. I was very much impressed with it and thought that something might be done in the Public Health Service along this line. Its value just for data gathering is something like the Framingham project on heart disease; that is, following a group of people over the years. Dr. STEWART. Some of the base data which has gone into certain of the screening tests that occur in this complex of screening tests were developed in the Public Health Service. The diabetes screening is one, for example. The development of future screening tests which can then be incorporated into this automated system, I think is quite a field. Mr. FLOOD. Is the diabetic treatment now almost entirely oral? Dr. STEWART. No, it is not entirely oral. I do not know what the percentage distribution is between those who are oral insulin or injected insulin, but both are used. POSSIBILITY OF SIMILAR PROGRAM IN CAPITOL Mr. FOGARTY. I was thinking after I saw this, as long as the west front of the Capitol is going to be rebuilt, why wouldn't it be a good idea to have a screening process like this that would provide these services for Members of Congress and all the legislative employees. They would be given this examination once a year or twice a year. It could be used as an experimental project right here in the Capitol, and perhaps should be expanded to the whole government. PREVENTIVE MEDICAL CARE PROGRAM IN DEPARTMENT OF HEW Mr. CARDWELL. Our Department has a preventive medical care program for certain employees over age 40. This has also been extended to other departments. Is that not right? Dr. STEWART. Yes, but it has not been automated and computerized such as this. Mr. FOGARTY. They have the latest equipment out there. Mr. FLOOD. That seems to be of great value, that is, this computerization. This seems to be the chief value. Otherwise it is just another place where physical examinations are given. Dr. STEWART. That is right, it is only in the last few years that we have learned how to use computerized reading of an electrocardio gram. Mr. FLOOD. They have you on that card, Mister, and there you are. Mr. FOGARTY. They have detected many diseases in the early stages that would have been fatal if they had not gone through this battery of tests. Mr. FLOOD. It sounds great to me. Mr. FOGARTY. I hope you are able to see it sometime. COMMENTARY OF HARVARD GROUP ON REGIONAL CENTERS Mr. FOGARTY. Now, on heart, cancer, and stroke, you hear some criticisms every once in a while on the regional centers. I have one brought to my attention: "Researchers Criticize Regional Plan." Harvard group challenges primary purpose of national network of health centers. A Harvard research group recommends abandoning the plan for the nationwide network of research and patient centers proposed by the President's Commission on Heart, Cancer, and Stroke. In opposing the plan the researchers share a position taken by many groups of private physicians—if for different reasons. Dr. STEWART. Yes, sir; I am familiar with that article. Mr. FOGARTY (reading): Rather than launching an effort against heart disease, cancer, and stroke the Harvard investigators urge an attack on infant mortality and deaths among young adults. Dr. STEWART. Mr. Fogarty, my impression is that article was written based on the Commission report and not on the legislation. As you know, the legislation really was implementing 3 or 32 pieces of the some 30 recommendations of the Commission report. Mr. FOGARTY. That is probably so. Dr. STEWART. The legislation implements regional medical programs and not as they infer in their article a series of centers here and there which you visualize as a series of buildings here and there. REGIONAL HEART, STROKE, AND CANCER CENTERS Mr. FLOOD. I have always felt about this piece of legislation, that it sailed through Congress under false colors. I was for it then and I am for it now, but I am convinced that the average Member of Congress thought, as I did, that this was supposed to be what the President said in his message it was going to be, and all the speeches said it was going to be. But then when the time came to appear before the Appropriations Committee to get the money, it was something else altogether. We thought that there was to be a decentralized authentic regional heart, stroke, and cancer operation out in the provinces and heartland of America, where the people were. It did not turn out to be that at all. This is merely an implementation of existing large medical centers and you go out and bring the peasants in. Dr. STEWART. No, sir. Mr. FLOOD. Yes, sir. Dr. STEWART. That is not correct. Mr. FLOOD. If they are to be treated they still have to go to the bother and trouble and expense of going to the big medical centers that now exist and are going to be expanded. All that will happen out in the provinces, is to try to stir up the initiative to examine the people and encourage examination to discover these defects in time. |