accounting of organized ambulatory services. And recently, the antipoverty program has broken precedent with establishment of comprehensive medical care centers in numerous blighted urban or rural sections.

The well-organized group practice clinic is able to introduce services difficult in a one-man office. Multiple screening procedures for early disease detection, handled mainly by paramedical personnel, are quite feasible. A visiting nurse, social worker, psychologist, or rehabilitation therapist, can be readily employed. Health education can be offered. The family physician, of course, can be backed up by appropriate specialists not only at critical stages of illness (common enough in solo practice) but all along the way. These more comprehensive services can be offered at lower costs because of economies of scale, although these savings are often translated into higher medical incomes rather than lower patient fees. The reality of the savings has been well demonstrated in the economic achievements of organizations such as the Kaiser-Permanente medical care plan. Some of the larger ambulatory care clinics have sprouted branch clinics in metropolitan areas. The pioneer prepaid Ross-Loos Medical Group in Los Angeles, Calif., now has 12 satellite units. Branches are also being established by purely fee-for-service medical groups. In such clinic networks the scarcer specialists serve patients from any branch unit. Group practice is probably the most feasible way to adjust for the steady decline in general practitioners, while still meeting the psychosocial needs of patients. The recently proposed federal legislation for encouraging construction of group clinics through mortgage insurance and lowinterest loans will, if enacted, doubtless accelerate the whole trend.

HOSPITAL ORGANIZATION

General hospitals served as a setting for systematic organization of medical care centuries before community medical practice. From the beginning, hospitals have brought together many types of medical workers and equipment. Since about 1900 the rate of hospital organization has accelerated everywhere.

The European hospital has always been essentially a public place, staffed mainly by physicians attached to the organization. We take this for granted in mental hospitals, but in other countries it has been the prevailing pattern for general hospitals as well. In the United States, the trend within general hospitals has been in the same direction, although the form taken is different. Departments and committees, appointment procedures and by-laws, clinical conferences and medical audits-all these measures of group discipline heighten the social controls in medical staffs. An increasing proportion of physicians working in hospitals are being appointed through some form of contract, under which their rewards come from the hospital organization rather than the private patient. These include not only radiologists and pathologists (about whom we hear so much controversy), but directors of medical education, researchers, outpatient department directors, and full-time members or chiefs of clinical departments.

Our own research in this field suggests that hospitals with a higher proportion of contractual physicians, even when correction is made for hospital size, are more likely to be providing the full gamut of services expected of an ideal institution. These hospitals are more likely to be offering education to interns and residents, to be doing research, to be engaged in preventive medicine (e.g., routine chest x rays), to be operating strong outpatient departments or coordinated home-care programs, to be admitting psychiatric cases, to be furnishing newer modalities such as intensive care or rehabilitation services.

The spectacular growth of hospital "emergency-room" services in recent years is an important straw in the wind of medicine in the United States. Relatively few of the patients coming to these units are genuine emergencies; they are mainly sick people who want attention and feel that the hospital-rather than a private medical office is the place to get it swiftly and competently. Hundreds of hospitals with no previous organized outpatient clinics have had to set up special medical staff patterns to cope with the demand. In spite of the extension of the "free choice" pattern in welfare medical programs, the American Hospital Association, Chicago, Ill., reports total (i.e., both emergency and formal clinic) outpatient visits to have reached an all-time high in 1965. The rate of approximately 8,000,000 visits per month indicates that such services now constitute about 14 per cent of all doctor-patient contacts.

Here and there a full group-practice clinic is attached to a hospital, and some of the largest (such as the Ochsner Foundation Hospital in New Orleans, La.) operate their own hospitals. Private doctors' offices in a medical arts building near

the hospital or even in an attached wing are becoming more frequent. Large prepaid group practice plans, such as Kaiser-Permanente and those in Seattle, Wash., and Detroit, Mich., also provide comprehensive care through their own hospitals. Medical schools and their teaching hospitals have been slow to affiliate with health insurance plans, but the need for a balanced population to teach medical students properly is arousing increasing interest in such affiliations. A major force for enriching the structure of medical staffs in hospitals has been the Joint Commission on Accreditation of Hospitals, Chicago, Ill. The requirements of the Council on Medical Education and Hospitals of the American Medical Association, for approval of internship and residency programs, has been another positive extramural influence. The quality of medical staff leadership itself, of course, can be decisive, and physicians seem to be increasingly sensitive to the responsibilities of such leadership. Medical performance is also influenced by a board of directors, especially if it is oriented by an imaginative administrator. Indeed, the whole temper of modern hospitals has been vitalized by the professionalization of the discipline of hospital administration.

The new Medicare law is confined largely to the aged and the indigent, but it has other specific implications for hospital organization. Aside from general certification which should lead to an upgrading of customary state hospital licensure standards-the special requirement for a "utilization review" process will doubtless enhance medical staff self-discipline. The relatively generous support for "home health services" under the new law should stimulate the expansion of organized home-care programs based in hospitals and other agencies. While the focus of these programs has been largely on the care of chronic illness, their long-run significance may be greater by way of extending hospital influence over day-to-day community medicine in all fields.

It has become trite to say that the hospital is increasingly becoming the health center of the community, but the full significance of the statement is not always realized. It is not only the hospital's functions in patient care, professional education, and research that shape its central role. It is its capacity for organizing a symphony of skills around patients-both in bed and on foot-that gives it force in the total span of health service. This includes the ambulatory services generally and the preventive services. Such scope is seen more clearly in Chile, Brazil, the Soviet Union, India, or even Ethiopia, where the public health services and the ambulatory care services for a district are often headquartered at the general hospital. In the United States, such curative-preventive unification is seen only in 40 or 50 counties where local health departments and local governmental hospitals are under the same physical and administrative roof. But the movement in this direction is more than meets the eye, as the "public utility" character of hospitals, on the one hand, and the necessity of public health agency involvement in medical care, on the other, become more widely recognized.

INTERHOSPITAL SYSTEMS

More recent and more spotty than the increased organization within hospitalsbut perhaps more important in the long run-has been the movement for enhanced relationships between hospitals. Within cities or larger geographic regions, these relationships have taken many forms.

It was the National Hospital Survey and Construction Act (Hill-Burton) in 1946 that launched on a nationwide scale the concept of planned hospital networks in geographic regions. As a device for alloting federal subsidies for needed construction, each new hospital as well as each approved existing hospital had to have its theoretical place in a system of "community," "intermediate," and "base" facilities. In such systems patients would be referred from the periphery inward and consultant services from the center outward. Every state drew its "master plan," and the maps enabled state hospital agencies (usually in state health departments) to make reasonable decisions on subsidized construction, even though day-to-day hospital operations rarely corresponded to the image of the maps.

In spite of the disparity between theory and reality in the Hill-Burton regional plans, the isolation and sovereignty of individual hospitals have been reduced in many ways. State hospital associations have brought administrators and trustees together to discuss common problems. Radiologists, pathologists, and physiatrists based at a large hospital often render part-time services in smaller hospitals nearby. Schools of nursing enrich their training programs by affiliations between hospitals and exchanges of students. Recruitment and training of per

sonnel, bulk purchasing of certain supplies, negotiations with third-party payers (Blue Cross or governmental agencies), and other administrative functions are often carried out jointly by the hospitals in a region. Postgraduate education of medical staffs has been greatly facilitated. The most impressive demonstrations of such regional interhospital cooperation have been in foundation-supported programs radiating from Boston, Mass., and from Rochester, N.Y.

Within metropolitan areas, the tempo of interhospital councils has been higher than in larger geographic regions. Most of the nation's great cities have set up councils whose primary objective has been to exercise direct or indirect control over new hospital construction (independent of the Hill-Burton program), but usually bringing about other administrative liaisons as well. These metropolitan hospital councils are composed in a variety of patterns, representing different blends of large industrial donors, hospital administrators, medical leaders, Blue Cross executives, and so on. In the last few years, federal grants for "area wide planning" have given a further boost to these local efforts. Their long-run significance doubtless extends beyond the capital cost problem, which has usually stimulated them, toward genuine coordination of hospital services.

The advantages of large-scale operation have led to outright merger of several groups of hospitals in cities such as Newark, N.J., Wilmington, Del., and St. Louis, Mo. The administrative marriages of several pairs of voluntary and municipal hospitals here in New York City are well known to this audience. Within particular religious sponsorships Catholic, Jewish, Lutheran, and so on-various forms of integration, ranging from simple cooperation to full merger, have been growing for years. The goal of these relationships is often to develop firstclass centers embodying the ultimate in scientific technology, with or without medical school affiliation. The university medical centers, in the meantime, have also expanded, bringing under their wing specialized hospitals for children, for mental disorder, for chronic disease, for orthopedic conditions, as well as the older general hospital at the hub. They are offering an increasing range of postgraduate instruction to physicians practicing in the surrounding area. Professor Thomas McKeown of England has spoken of the "balanced hospital community" in which patients are flexibly transferred to the type of facility that meets their needs rather than kept in the one they happen to enter initially. This is basically the goal of any regionalized hospital system, but it is more readily attainable within a multidivisional medical center.

These varied expressions of interhospital cooperation have one thing in common, they embody an increasing organization of skilled and scarce medical resources to meet needs with optimal quality and economy. Whether the goal is achieved or not there is no doubt that some form of organization, as distinguished from sovereign individualism, is the path toward it.

The new Medicare law has two provisions specifically designed to promote further such interfacility relationships. The mandatory "transfer agreements" between extended care facilities and general hospitals, as a condition for participation, have been discussed by other speakers. The second provision is the assignment of a specific task of "coordination" to the state health agencies. This may be expected to encourage better relationships in the full continuum of health service, from organized home care through the intermediate levels to the complex medical center.

A more direct legal push to the interhospital coordination movement is given by the 1965 federal amendments on "heart disease, cancer, and stroke." The focus of attention in this law on the three leading causes of death in the nation is obviously only a means to the end of promoting "regional cooperative arrangements" between medical centers and peripheral hospitals for research, training, and “related demonstrations of patient care." I believe we may look upon this law as the 1966 approach, on a functional level, to the regionalization idea launched, on a structural level, by the Hill-Burton Act 20 years ago.

STATE AND NATIONAL GOVERNMENTS

Interwoven among the four levels of medical-social organization we have briefly discussed is a widening role for state and national governments. Within individual medical practice, the basic licensure laws exert their influence, as do the food and drug control laws, the malpractice statutes, and enactments such as the 1965 medical disciplinary measures in California. At the level of organized ambulatory service, government has been relatively timid, but we are now seeing

more interest on the part of Congress in bills to promote the extension of group medical practice. Senator H. A. Williams, Jr.'s new "Preventicare" bill on organized multiple screening centers is another augury. As in internal hospital organization, the impact of government has been extensive through the hospital licensure laws, the Hill-Burton Act, and the quality standards demanded of many programs for defined beneficiaries such as crippled children or compensably injured workers. At the level of interhospital networks, the influences of government have just been mentioned.

Beyond these four levels, national and state governments are influencing the ultimate patterns of health service in other far-reaching ways. The whole underpinning of economic support for health care-through general revenues or social insurance-means more than dollars. If due only to elevated utilization of service, the medical and hospital resources of the country are daily influenced by publicly financed medical care programs. Beyond the quantitative pressure is the impact of qualitative standards imposed on providers of service under these programs. Public agencies are, in effect, becoming a mentor to the patient in his choice of doctor or hospital "free choice" is being replaced by guided choice where technical sophistication is required for intelligent decision.

Government is also influencing patterns of care indirectly through its strong support of medical research. Advanced technology leads to changed social adjustments in spite of the usual cultural lag. Research on patterns of health service organization itself is also financed by government, and its impact may be seen directly in the fashioning of new programs; Medicare is one such product of years of data gathering and analysis. Government support of professional education, of course, has further influences on the quality of medical care.

The whole public health movement, in local, state, and national governments, also affects patterns of personal health service. Environmental prevention, of course, changes the spectrum of disease, reducing the infections and contributing to the higher burden of chronic metabolic disorders. Mass case-finding programs detect cases that are referred to personal physicians. Health education induces people to live hygienically and to seek attention for suspicious symptoms. School health examinations direct many handicapped children to the doctor's office. Several governmental programs, of course, operate as separate and parallel systems of health services. The Veterans Administration, the Indian and merchant marine health service, the state mental and tuberculosis programs, the municipal or county hospitals for the poor-these entities maintain their own personnel and facilities. While these programs are often contrasted with the socalled mainstream of United States medicine, one must not underestimate their importance; they affect millions of people according to highly structured patterns of medicine. Whether the quality of care is conceded to be high, as in the Veterans Administration system, or low, as in most state mental hospitals, these programs are part and parcel of health services in the United States. They preempt a substantial sector of health needs into frameworks organized at both the ambulatory and hospital levels.

Beyond these various specific roles of government, there is a further over-all role of which we may expect to see more in the future. "Planning" is no longer a dirty word in our political vocabulary, and it is being undertaken increasingly by local, state, and national governments. It has been done for years in such fields as transportation, public power systems, city zoning, education, agriculture. It has been done informally by the more imaginative public health officials on problems of environmental sanitation, child health services, chronic disease control, accident prevention, or home nursing. Now we are coming to a time when the over-all planning of health services will probably be a designated task of government at all levels; a bill introduced in the U.S. Senate a few months ago provides for ear-marked grants to the states for such purposes. In some form or other, over-all governmental health planning is bound to arrive eventually.

SOME ISSUES

Several questions arise from this review of the five levels at which new patterns of health service organization are evolving in our society. I should like to close these remarks with consideration of just two of them.

One concerns the issue, alluded to briefly, of segregated medical care systems versus the "mainstream of medicine" approach. Segregated programs have often meant poor quality care, epitomized perhaps in the crowded public clinic for the poor. It is easy to see why clinic attendance has implied second-class citizenship

and why many organized programs have favored the use of public moneys to channelize patients to private medical offices. Such offices, however, are far from guarantees of good medical care; welfare clients with "free choice of doctor" may be badly served, as any physician in welfare medical administration knows. On the other hand, a public clinic may give first-class service if it is adequately staffed and supervised, as it often is at good teaching hospitals.

The dilemma, it seems to me, is not insoluble. Segregaton and mainstream patterns alike are poor if they lack resources and standards. Both can be good with adequate resources and standards. The segregated system, however, runs the constant political danger of weak economic support-hence meager resources. There are also undemocratic overtones. The task, then, is to move toward a single mainstream of personal health service for all persons in the United States, but to upgrade its quality continuously. This can be done only by ample economic support, sound technical organizations, and carefully supervised standards. Such influences will change the character of the mainstream while widening its encompassment.

The second issue concerns personal freedom of patient and doctor, which is so often alleged to be reduced by all the organization of health services we have reviewed. The burden of proof, it seems to me, is on those who repeat this cliché. It is hardly reasonable to express pride in the medical and health records of the United States and, in the same breath, to regret the social organization of the past and to oppose the social trends of the future. The scientific achievements of United States medicine are not matters divorced from social organization; they have been largely products of such organization. The reduced mortality and increased longevity are of similar derivation. The professional effectiveness of United States doctors, both in the quantity and quality of their output-not to mention their personal affluence is not independent of health insurance and public health and hospitals, but is largely attributable to them.

Where, then, is the loss of personal freedom from social organization? Is the child immunized in a public clinic less free because he is spared from diphtheria or poliomyelitis? Is the veteran served by a surgeon in a government hospital less free because the Veterans Administration requires that the doctor be boardcertified to do the operation? In today's complicated world, one must conclude that organization is not merely consistent with personal freedom; it is a requirement for the attainment of that freedom. Others may argue the issue in other spheres of life, but in the health services the evidence is overwhelming. Social organization has moved us forward toward greater personal freedom. There are still many gaps and problems, but they will be resolved in the future as they have been in the past, by further organization of our resources in men, things, and knowledge.

B-SOME GENERAL CONSIDERATIONS OF LONG-TERM ILLNESS FROM THE PUBLIC HEALTH POINT OF VIEW*

Extent of the Problem

(By Milton I. Roemer, M.D.1)

The successes of public health and the elevation of our standard of living have resulted in a high proportion of older age groups. The laboratory and clinical scientists are yet to tell us the many reasons for this, but that chronic illnesses do occur more frequently in the older age groups is perfectly obvious. The best data we have today on the extent of chronic illness in the population are the findings of the continuing National Health Survey.

Perhaps the simplest unit of measure of the problem of long-term illness is the one developed by the National Health Survey in terms of "restricted activity days." Examining a substantial sample of the non-institutional population in the United States, we find that there are for every 1,000 persons approximately 2,500 days of restricted activity per year with respect to circulatory disease, about 1,000 days for digestive disorders, 1,300 days for arthritis and rheumatism, 700 days for impairments following from injuries, 970 days for "other impairments," and 4,800 days for all other chronic conditions. These figures cannot be totaled, since there are duplications of more than one illness in the same person. However,

Reprint from The Gerontologist, Vol. 4, No. 2. Part II, June 1964. 1 Professor of Public Health, University of California, Los Angeles.