supply. Rehabilitation services are particularly needed for the elderly in home care programs, as well as in extended care facilities. Moreover, the presently available personnel in the medical and medically related professions need re-training in the special problems of the elderly. This is particularly true as regards the problems of mental health which present themselves in the elderly. Dental services and the services of podiatrists are especially important in the elderly, but the supply of dentists and podiatrists is not nearly enough for the demand. I hope that these comments are of some value to you and your Committee, and that they do not arrive too late to be of service. Dr. James G. Haughton, First Deputy Administrator in the Health Services Administration, will be glad to testify on these points at the hearings of your Committee, if you would like him to do so.

Sincerely yours,

PAUL M. DENSEN,
Deputy Administrator

SINAI HOSPITAL OF BALTIMORE, INC.,
Baltimore, Md., June 14, 1697.

DEAR SENATOR SMATHERS: I'm responding to your letter of May 31st and enclose a copy of the comments that I'm making at the American Geriatrics Society in Atlantic City in a panel on Medicare on the afternoon of June 16th. These comments include answers to some of the questions you raise in your letter. With approximately half of the elderly in this Country living on incomes at the poverty level or lower, it is obvious that the continued inflation of medical care costs affects this group with fixed incomes more than almost any other sector of the population.

The poor elderly also meet tremendous obstacles in obtaining needed health services. They are not only faced with inadequate numbers of health personnel for their needs, but such personnel is not present in their own neighborhoods. In addition, the elderly are faced with real transportation problems to reach the health resources available in their community. When public transportation is not available, the elderly often cannot afford substitutes such as taxi fare to hospitals or clinics. Organized medical services do not exist and physicians' services are often not available on nights and weekends and so the aged find themselves forced to use emergency services of hospitals where they receive fragmented care and certainly not a plan of care adequate to their needs.

Some of the necessary services for sensitive care of the older person such as home health aides, visiting housekeepers, meals-on-wheels, social services are in short supply or are simply not available. The entire concept and development of comprehensive health teams brought to the neighborhoods where the elderly live is yet to be implemented.

Medicare may indeed have intensified some of the problems affecting the organization of health services in the interest of the elderly. Since the legislative mandate of Medicare and to a lesser degree, Medicaid is to purchase care from the providers of service in the traditional fragmented fashion-fee for service care, it leaves much to be desired at this time in promoting a program for organizing the services for the elderly with a plan of care. Up to now, there has been little encouragement of payment for comprehensive care programs and without such emphasis, the providers of traditional services in the health field will not be impelled to organize themselves in the interest of total care for the elderly. Your committee, I hope will consider the uncovered cost of drugs, regular eye care and dental care as serious defects in the present Medicare legislation. Finally, we have found the coinsurance features, the deductibles to both confuse and work a hardship on the elderly. The coinsurance features are also difficult to administer and perhaps your committee will concern itself with the cost to society in personnel and money by the law's mandatory coinsurance features. Sincerely yours,

FRANK F. FURSTENBERG, M.D.,

[Enclosure]

Medical Director.

IMPACT OF TITLE XVIII ON OUTPATIENT DEPARTMENTS

My formal assignment is to bring to you some of the changes Title XVIII has had on the outpatient departments. To do this I share my observations with you concerning the fate of Medicare patients in outpatient departments since the

program's inception almost a year ago. Our group at Sinai Hospital has often speculated on whether Title XVIII has been good, bad or indifferent for the aged person seeking care in the clinics and emergency services of the hospital. Have the rights and the payments intrinsic in XVIII produced more and better care for the elderly in the clinics of our hospitals in this Country? While I'm not privy to any survey of the changes and the problems that the aged have encountered in the Country's outpatient departments since last July, our experience at Sinai Hospital and my knowledge of other outpatient departments in Baltimore and elsewhere allow me to make a number of disquieting comments.

Older persons, the chronic sick and children in ever-increasing numbers continue to seek care in the outpatient departments in hospitals in urban areas. The elderly are by and large the poor and the medically indigent, formerly the KerrMills recipients and now the Title XIX aged. The care they receive in outpatient departments is fragmented, impersonal and given with little dignity. There have been few efforts by the hospitals to give these aged persons services which include a plan of care, comprehensive in scope, with continuous responsibility by designated health personnel. Services have not been designed to maintain the older person independently in his community medically and emotionally secure with marimal usefulness to himself, his family and society.

An opportunity offered itself at Sinai Hospital six years ago to develop a professional group consisting of physicians, nurses, social workers and other health personnel to give continuous seven day-a-week, around the clock care to the elderly, delivering their primary medical services in the outpatient department setting. This team also gave indicated services in the home, the nursing home and the hospital. At present about 500 patients from our hospital district have selected our hospital outpatient department for this care. These patients are largely Social Security beneficiaries with limited income and classical of the geriatric patients who frequent the clinics of our Country. We are keenly aware how Medicare has affected these persons and are also conversant with its affect on other persons 65 and older who use our outpatient department for regular and emergency services. There is no data as yet tabulated that I'm aware of which would give us facts of trends and usage patterns by the aged of the hospital clinics a year after Medicare, but in my conversations with outpatient department administrators in Baltimore and in a number of large urban hospital outpatient departments elsewhere there has been no sharp trend indicating increase or decrease in clinic use by the persons 65 and older. More important is the evidence that Medicare has not made any real difference in the services given in the quality of care or in the organization of care.

Some of us have speculated why the aged person has not left the outpatient department to return to a personal private physician now that this course can be taken if he has Part B Coverage. Is it because the poor and some of the ethnic groups feel that they obtain better or more interested care in the outpatient clinics or their favorite institutions than they do in the neighborhood physicians' offices? There are institutions who have been concerned with the chronic sick and the aged in Baltimore, both the Baltimore City Hospitals and Sinai Hospital have emphasized special programs for these needy persons. Do the elderly continue to come to the hospital because private medicine has deserted the poverty areas in the central cities where many of the aged reside and though the aged may now be able to pay for care, physician's services are in short supply, absent at night and week ends? Is it because many of these multi-problem, economically marginal individuals present such troublesome social problems that the solo practitioner is illy-equipped to handle these problems and for which his physician time is too valuable? Or is it because Medicare is so complex with its deductibles, co-insurance features, and lack of coverage for drugs, as well as lack of cash in the hands of many of the elderly that they prefer to cope with the impersonal outpatient departments rather than feel as second-class citizens in the solo practitioner's office because they have to ask the physician to accept assignment for payments of services?

There probably is no single answer for the use of the outpatient departments by the Medicare beneficiaries. There is little question, however, that since Title XVIII basically seeks to purchase services from providers of care for its beneficiaries, it does almost nothing in social planning for the elderly and thus it has not affected the organization of services in the interests of the aged. Indeed, in our own institution, we have had some unhappy experiences with some of the patients in our program since Medicare. Thus, a patient referred for surgical consultation or who develops an acute surgical entity may see a surgeon in our

outpatient department or emergency service, who now considers this patient with Part B insurance as a potential and actual private patient and proceeds with his therapeutic regime with little or no regard for the patient's previous care or in total planning for his after-care. Without casting any aspersions on my surgical colleagues, I know that they often do this with their own middle-class patients, but such an individual or his family is able at times to break through the jungle of fragmented care, plan for himself and often then pay for such private services. It is the marginal aged person who, though he has benefitted by the rights of Medicare, is still unable to cope with its deterrents, uncovered needs for service and cannot find services that may not exist for the poor.

Frustrating examples that we have experienced in our Aging Center are exemplified by the patient with prostate disease who was admitted without consultation with his personal physician in our group to the genito-urinary service and received necessary surgery without consultation with our staff. There was the orthopedic emergency admitted, operated and discharged to an extended care facility and then the patient was told by the orthopedist that he did not make visits to the nursing home and only then was the physician in our Comprehensive Care Program called. On another occasion, a patient with a cataract, told that she needed surgery, exercised her right to ask for the best in eye care and was admitted to the hospital for operation by one of our best eye physicians who ran into difficulty while the patient was under anesthesia and then called an internist who did not know the patient to give immediate consultation rather than using her personal physician, an equally competent internist, a member of our program. Now we are a hospital that prides itself on the high quality of inpatient care and if incidents such as these can happen as often as they have in our institution, what happens elsewhere where there is no organized program to help this minority group that is unable to compete in the private sector for quality care?

And what happens when the Medicare patient presents himself acutely ill in the emergency services of the hospitals of the Country? He is admitted either to the service area or to the private side with a designated physician. Inpatient services are perhaps regularly given with high quality, but on discharge what happens? Does the hospital physician follow his cardiac patient into the home or the extended care facility? Is the patient recovering from a cerebral accident followed by the interested hospital staff physician after hospital discharge? I'm afraid that the urban hospitals have understandably not felt the responsibility for continuity of care and often have staff physicians who limit themselves to hospital and office practice. The teaching of house officers does not usually include concern about the patient who cannot return to the institution for follow-up care. I wonder what studies in the continuity of care for discharged Medicare patients with continuing illness requiring home and institutional care would show in specific reference to the implementation of care by any primary health team..

Sinai has had an organized hospital-based Home Care program, part of our Aging Center since 1961. With the advent of Medicare, the program has gradually double in size and involved the private practitioner in some depth for the first time. It has expedited patient discharge from the hospital and brought an awareness of home health services to the physician. Often the physician has had to think in terms of home health services for the first time because the patients and families have become aware and ask about the specific benefits of this program. There is no question that we were having limited success with an excellent hospital-based Home Care Program until Medicare financed its benefits and the stress for better utilization of beds on the private side influenced the participation of physicians in the home health services and so expanded the scope of our outpatient benefits of a hospital-based home care program.

Now, in all fairness to Mr. Hess, Medicare was not conceived as a comprehensive health program for the elderly. Indeed, having watched the legislation go through Congress and accommodate to the diverse political forces and then later having participated in a number of the working groups of the Social Security Administration in developing guidelines for the present program, I marvel that we have come so far in so short a time. The outpatient department problems are really not central to the main thrust of Title XVIII. In a better-conceived total program for the aged, there could have been more emphasis on prevention

and effective planning for total care rather than emphasis on inpatient care, but in our American scene we take what we get and we try to move from there. FRANK F. FURSTENBERG, M.D.

UNIVERSITY OF CALIFORNIA, LOS ANGELES,

June 19, 1967.

Dear Senator SMATHERS: Thank you very much for your letter of May 31. My responsibilities as Professor of Medicine (Geriatrics) are concerned more with training in the medical care of older patients than with the socio-economic problems involved. For this reason I can answer your questions only in the context of my own experience.

Questions 1 and 2, “Are rising medical costs causing special difficulties for the elderly?", and "Do many of the elderly face insuperable obstacles in obtaining needed health services?" are related. It is my impression that, although the answers to both of these questions are affirmative, the general trend over the past several decades has actually been more favorable to the older patient. This has been due to the combination of better techniques and facilities, an improved general economy, and special programs especially at the state and federal levels. Your third question, "Are present health services remote geographically and sociologically from many of our older persons?", is also difficult to answer. It is again my impression that the increasing urbanization of our society and the tendency for older individuals to live within particular areas in the community reduces their geographic distance from community facilities and reciprocally tends to make them more accessible for community services.

The present Medicare and Medicaid policies seem to be intensifying old problems in the organization of health services and causing entirely new problems. The most important of the old problems is the shortage of trained personnel, especially in related health service professions. New problems include the inevitable adjustment to a new program, the increased number and the uncertainty of the details of the administrative procedures, the increased and not always appropriate hospital utilization, the problems of appropriate patient placement, and so forth. Many of these problems will undoubtedly resolve when health services personnel become more acquainted with and adapted to the program. However, others are inherent in the program itself.

The most serious problem and one with which I am most directly familiar is the intensification of the shortage of trained personnel. Most health services personnel require prolonged periods of training to meet standards which have been established not only by the professions but by the legal requirements of the program. There are shortages both of qualified applicants and of training facilities. This is true for all health services, not just those related to the aged. Despite competitive salary levels, there are an inadequate number of nurses in California to staff current programs. In some instances hospital beds are unavailable because of personnel shortages. Yet, a high school graduate can receive training as a registered nurse in two years in the junior college program, and after licensure be qualified for positions starting at $600 per month: this is a level comparable to that paid to 4-year college graduates in such fields as teaching and engineering which are more competitive in their requirements. It is true that this wage scale is relatively new, however, even if it were to attract more nurses to California its effect on training programs, if any, will not be felt for several years. At the same time other areas would suffer.

Less well-trained medical personnel, such as vocational nurses, aides, and attendants, have always shown a high degree of job mobility. Aside from economic remuneration, the attractiveness of working in a geriatric setting often suffers in comparison with such fields as surgery, pediatrics, or psychiatry. In my opinion, one of the major problems in the development of idealized medical care programs, and particularly those related to aging, will be the shortage of qualified personnel who can be attracted into the field as long as more apparently desirable occupations are available. In particular, the unattractiveness of the Lours must be recognized. It will take much imagination and many new approaches in order to solve this problem. Financing is only one aspect, and perhaps not the controlling one.

I hope that these opinions will be of some use to you.

Sincerely,

RALPH GOLDMAN, M.D.

ALBANY, N.Y., June 14, 1967. DEAR SENATOR SMATHERS: Thank you for your invitation to share with you some ideas on the health of the elderly.

As a specialist in cardiovascular diseases and geriatrics, I find shortages of trained personnel in the medical and paramedical professions that serve the elderly. More training and education must be made available for people working with the elderly. Basically, we are attempting to care for a large portion of our elderly population with personnel oriented and trained to care for younger people. Their habits cannot be easily changed to enable them to work efficiently and effectively in the field of aging. One solution is the establishment of more Institutes of Gerontology in State Universities and elsewhere. A second solution is the development and support of more senior citizen centers which provide qualified sociologic, psychologic and social work services by competent trained professionals. These centers can be set up as multi-disciplinary health centers for the general care of elderly people to keep them healthy and happy physically and mentally. Studies indicate such centers and programs keep elderly people from deteriorating and reduce their use of more costly medical facilities.

At the same time, doctors and institutions should be encouraged to set up new patterns of office care and to improve and renovate their offices and facilities so as to permit easier access for the elderly infirm and disabled, and to increase efficiency and effectiveness of such care. Tax credits and other benefits may be allowed to such doctors or institutions to build ramps and better office facilities for treating older people, who definitely require more time and need more space. Another major problem is transportation. Elderly people are not mobile and are poorly served by present public transportation. Improved transportation facilities for older people should be developed to permit them to be more active, to end their social isolation, to visit their doctor's offices and other health facilities. Such transportation programs could include the use of omnibuses, and other vehicles, credits to public bus facilities and private facilities to extend their transportation services to older people etc.

Attention must also be directed to improving health faciilties for the care and maintenance of elderly people in each community. At present, many elderly people get expensive medical care in hospitals and then stay longer than necessary because of insufficient facilities in the community to care for these people after hospitalization. Utilization committees and other committees will not reduce hospital census in this age group unless communities build more facilities in the community to care for elderly people in a spectrum of facilities ranging from hospital care through convalescent homes, apartment care, homes for the aged and finally chronic illness homes. Furthermore, regional listing of nursing home beds and other beds available for eldery people coud be kept. At present, it is difficult to find out where beds are available in a region. Why not have Social Security or Medicare offices keep a computerized list of beds available in Medicare approved institutions so that families interested in placing their mother or father in such institutions can easily get this information?

Finally, I also urge you to ensure the use of effective forms and administration in these programs. Medicare is good, but Medicaid in practice, poses many unnecessary and foolish administrative problems to physicians and patients alike, leading to greater costs, aggravation and inefficient operation and relations among physician, patient and the welfare administration. For example, elderly people on Medicare may also be eligible for Medicaid, and are classed in the welfare department category, contrary to Medicare philosophy. Is there any reason why such patients could not be entirely under the administration of Medicare and reduce the unnecessary duplication of forms and other problems which hamper Medicaid?

I shall be happy to elaborate on these points. I take the liberty of enclosing some reprints for your review. I expect that Dr. Robert Morris, President of the Gerontological Society will also send you the position of the Society on these matters.

As you know, the Gerontological Society meets in St. Petersburg in November, 1967. I hope we have the opportunity of seeing you there. If I can be of any further help, please let me know.

Sincerely yours,

RAYMOND HARRIS, M.D. President, Center For The Study of Aging.