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primary area of activity in medicine is the diagnosis and treatment of illness in adults.

The internist is well qualified to render an opinion on the medical needs of the aged. A substantial part of his practice is devoted to the care of the aged. He serves as a consultant to the general practitioner and other specialists on problems dealing with such medical care.

The internist knows that medical care of the elderly person is best rendered in that person's home or in the doctor's office. There are medical and psychological reasons for this. Thanks to the introduction of specific drugs for the treatment of many serious illnesses over the past two decades, these illnesses are treated perfectly well at home at less cost to the patient and with less discomfort to him. Hospitalization of the elderly person leads to unhappiness and confusion in many instances because he is separated from his family and friends and is placed in a foreign atmosphere. Consequently, any proposed system of medical care which would promote the excessive use of hospitalization, such as H.R. 3920, would not serve the best interests of the aged person.

The proponents of H.R. 3920 will say that hospitalization is necessary for certain major illnesses of the aged. The American Society of Internal Medicine agrees with this concept, but on the other hand we strongly believe that such hospitalization should be as brief as possible and that the elderly person should be returned to his home as soon as possible. We say this because early ambulation and activity is of the utmost importance in the aged persons. Such early activity is difficult to accomplish in the hospital and the rest home for a number of reasons. Consequently this is why the internist prefers to take care of the aged person in his own home. The provisions of H.R. 3920 would encourage overuse of hospital facilities and nursing homes and would conflict with the responsibility of physicians to encourage home care.

The proponents of H.R. 3920 will also say that certain provisions of that bill will encourage only necessary hospitalization. However, we as physicians know only too well the difficulties of advising patients and their relatives against going into the hospital for care when there is no cost attached. From the practical aspect, physicians would be faced with great difficulty in not overloading hospitals if H.R. 3920 is passed.

Physicians know that the cost of hospitalization for the aged person sometimes causes difficulty. But we also recognize that many of these people are able to afford such expense, either out of their own resources or from coverage by voluntary health insurance. We know that the number of senior citizens covered by voluntary health insurance is increasing yearly. We further know that hospital care is being rendered on a gratuitous basis to the aged person when he cannot afford this care. At State level there is rapidly increasing Government help through the Kerr-Mills law; and at the county and municipal level there is further aid available through local resources and facilities. It is indeed rare to find an aged person needing hospital care who has been denied that care because he cannot afford it.

The American Society of Internal Medicine does not support the provision of H.R. 3920 which opens “outpatient hospital diagnostic services” to the aged person. It is our opinion that diagnostic services are far better rendered in the doctor's office than in the hospital. Why should a physician send his patient miles away to secure a blood count or a urine test when he can perform these services so easily and promptly in his own office? The aged person's doctor is better qualified to decide upon the need for these tests and to perform them himself than is an individual in the hospital who has no personal interest in or responsibility to the patient.

The American Society of Internal Medicine believes that the present system of medical care which has been built up over the years in our country—and which depends upon initiative of our citizens, advice from our doctors, and continued encouragement of voluntary health insurance plans—is the American way of doing things. We must all agree that under this philosophy, American medicine bas emerged over the last half of the century to be the best in the world. Experience has demonstrated elsewhere that when medical care is centralized and depersonalized by government, the standard of medical care goes down.

The American Society of Internal Medicine respectfully requests that you permit us to continue our high standard of medical care for the aged by disapproving H.R. 3920.

STATEMENT OF THE AMERICAN OSTEOPATHIC ASSOCIATION, W'ASHINGTON, D.C., ON

HOSPITAL INSURANCE ACT OF 1963, H.R. 3920

(By Carl E. Morrison, D.O., chairman, council on Federal health programs)

The American Osteopathic Association appreciates this opportunity for comment on the Hospital Insurance Act of 1963, H.R. 3920.

The association is a nonprofit, tax-exempt federation of divisional societies of osteopathic physicians and surgeons. Its objects as set forth in its constitution are to promote the public health, encourage scientific research, and maintain and improve high standards of medical education in osteopathic colleges. Its policies are determined by an elective house of delegates, which meets annually, chosen by the respective divisional societies.

The house of delegates on July 10, 1961, resolved as follows:

“Whereas the American Osteopathic Association, recognizing that increased costs of medical care creates a grave socioeconomic problem in certain groups; and

“Whereas preventive medicine has brought about an increase in the number of our aging population; and

“Whereas a significant number of these persons have insufficient income to meet the increasing cost of medical care: Therefore be it

Resolved, That the American Osteopathic Association, recognizing the need for suitable health plans, offers its assistance and cooperation to all agencies concerned with providing adequate health care to our citizens and urges immediate steps be taken to alleviate these growing problems."

The above resolution after annual reconsideration by the house of delegates, remains unchanged. This policy was enunciated shortly before our statement to this Ways and Means Committee on August 4, 1961, in connection with H.R. 4222. It had characterized our testimony before this committee in previous hearings on the Forand bill.

Implicit in our position is the commitment of the osteopathic profession and institutions to work with other private organizations and with Government agencies at all levels for the advancement of the health care and welfare of the aged. Our Committee on Health Care for the Aging and Committee on Medical Care Plans operate to stimulate and coordinate corresponding committees at State and local levels.

The osteopathic schools of medicine, in common with the other medical schools, are participating in the research and training programs of the National Institutes of Health in such fields as cancer, cardiovascular diseases, arthritis and metabolic diseases, neurological diseases and mental health, which may be said to bear a primary relation to aging.

H.R. 3920 would establish within the social security system a program of hospital, nursing home, home health, and outpatient diagnostic services to persons 65 or over eligible to receive (or receiving) social security or railroad retirement benefits financed by an increase in taxes for workers and employers under these systems, and similar benefits out of Federal general revenue for certain uninsured individuals 65 or over.

Inpatient hospital services would be provided, but these would not include medical and surgical services, with two exceptions, as follows: inpatient hospital services provided in the field of pathology, radiology, physiatry, or anesthesiology would be included ; inpatient hospital services including "services provided in the hospital by an intern or a resident-in-training under a teaching program approved by the Council on Medical Education and Hospitals of the American Medical Association (or, in the case of an osteopathic hospital, approved by a recognized body approved for the purpose by the Secretary).” Lines 15 to 22, p. 8.

We respectfully request that the parenthetical part of the above quotation be revised to read as follows: “(or, in the case of an osteopathic hospital, approved by the Bureau of Professional Education, Committee on Hospitals of the American Osteopathic Association)."

The elements of protection and assurances to the public and to the institutions involved which warrant specification of the American Medical Association as the recognized approval agency in the case of hospitals staffed by doctors of medicine likewise warrant specification of the American Osteopathic Association as the approval agency in the case of hospitals staffed by doctors of osteopathy.

Current precedent is provided in the U.S. Civil Service Commission qualification standards for medical officers, Medical Officers Series GS-602, page 8, published March 1963, as follows:

A. Use of terms

"1. Approved internship. This is training in a hospital or other institution approved by the Council on Medical Education and Hospitals of the American Medical Association or by the Bureau of Professional Education, Committee on Hospitals of the American Osteopathic Association for internship training.

“2. Approved residency.—This is training in a hospital or other institution approved by the Council on Medical Education and Hospitals of the American Medical Association or by the Bureau of Professional Education, Committee on Hospitals of the American Osteopathic Association for training in the specialty.

"3. Internships and residencies.The 9-month wartime approved internships and residencies during the period from December 31, 1942, to July 1, 1947, will be accepted as the equivalent of 1 year.

“4. Accredited preceptorship training.–Preceptorship training is training under the direction of an individual physician who is recognized in the specialty concerned. Such training is not necessarily obtained in the hospital setting. In order to be accredited, applicants must furnish a certificate of acceptance by an approved American specialty board in the specialty concerned.

“5. An approved American specialty board is one which has been approved for the particular specialty by the Council on Medical Education and Hospitals of the American Medical Association or by the Bureau of Professional Education, Advisory Board for Osteopathic Specialists of the American Osteopathic Association.”

The suggested language is included for the same purpose on page 5 of the Health Care Insurance Act of 1964, S. 2431, introduced by Senator Jacob K. Javits, of New York (for himself, and Senators Kenenth B. Keating, of New York; Clifford P. Case, of New Jersey; John S. Cooper, of Kentucky; Thomas H. Kuchel, of California ; and Margaret Chase Smith, of Maine).

Minimum standards of organization and practice for hospitals staffed by osteopathic physicians and surgeons were first established, and inspection and approval procedures adopted, by the American College of Osteopathic Surgeons about 1928. In 1935, the Bureau of Hospitals of the American Osteopathic Association assumed joint responsibility with the American College of Osteopathic Surgeons. Since 1949, the American Osteopathic Association has had full responsibility, which it now exercises through a committee on hospitals.

The Committee on Hospitals of the American Osteopathic Association is composed of four representatives of the osteopathic profession at large and a representative from each of the specialty colleges of surgery, radiology, internal medicine, and obstetrics and gynecology. They are thoroughly familiar with all phases of hospital administration and are charged with the formulation of hospital standards which are formerly approved by the Board of Trustees of the American Osteopathic Association.

Any hospital desiring accreditation must submit to a rigid annual examination by the committee. If the hospital passes this examination it can be officially listed as registered. Hospitals which are approved for internship or residency training must pass an annual inspection even more comprehensive than that for registered hospitals. State and Federal agencies have recognized AOA accreditations.

Under H.R. 3920, automatic eligibility upon agreement to furnish hospital services under the program is granted only to hospitals accredited by the joint commission on the accreditation of hospitals, subject to the requirement of a utilization review plan. The same eligibility should be extended to osteopathic hospitals accredited by the Committee on Hospitals of the American Osteopathic Association. Specifically, we respectfully request that immediately following the words "joint commission on accreditation of hospitals,” lines 2-3, page 30, insert the words: “or by the Committee on Hospitals of the American Osteopathic Association."

Under the bill, unaccredited hospitals in order to participate would have to show that the institution

(1) is primarily engaged in providing, by or under the supervision of physicians or surgeons, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation facilities and services for the rehabilita. tion of injured, disabled, or sick persons,

(2) maintains clinical records on all patients,
(3) has bylaws, in effect, with respect to its staff of physicians,

(4) continuously provides 24-hour nursing service rendered or supervised by a registered professional nurse,

(5) has, in effect, a hospital utilization review plan which meets the requirements of subsection (e),

(6) in the case of an institution in any State in which State or applicable local law provides for the licensing of hospitals, (A) is licensed pursuant to such law or (B) is approved by the agency of such State responsible for licensing hospitals, as meeting the standards established for such licensing, and

(7) meets such other of the requirements prescribed for the accreditation of hospitals by the joint commission on the accreditation of hospitals, as the Secretary finds necessary in the interest of the health and safety of individ

uals who are furnished services by or in the institution. We respectfully request that immediately following the words “Joint Commission on the Accreditation of Hospitals," in the above paragraph numbered (7), line 6, page 20, there be inserted the words “or by the Committee on Hospitals of the American Osteopathic Association in the case of osteopathic hospitals.”

Most osteopathic hospitals participate in Blue Cross and commercial insurance programs. They were also utilized in the medicare program for dependents of members of the uniformed services and by the Federal Employees Compensation Commission and as participants in the Federal employees health benefits program.

The osteopathic profession and its institutions can be relied upon to employ their best efforts to provide and safeguard quality care and to pursue their traditional role of cooperation in the public interest.

ASSOCIATION OF AMERICAN DENTISTS,

Pampa, Tex., November 26, 1963. Representative WILBUR MILLS, Chairman, House Ways and Means Committee, House Office Building, Washington, D.C.

DEAR CONGRESSMAN: The Association of American Dentists is concerned with the bill H.R. 3920 and urges your opposition to it.

In studying the various health plans of European countries, it becomes evident that without exception each plan has brought about progressive deterioration of health and service standards as compared with the higher standards attained by our unregulated professions here in the United States.

The politicians of each country have instigated their plans supposedly to aid some destitute age or income group. It is an interesting study in technique. Later the plans inevitably enlarge to include most if not all the people. The same old cliches and phrases have been used in each country. They are being used here.

People are not obliged to learn the hard way if they will investigate the detrimental effects of governmental interference with health services experienced by countries such as Germany where the average hospital stay is 28 to 30 days— it is 5 to 7 days in the United States and England where private health insurance grows rapidly in spite of the fact that people are taxed for Government health insurance, obviously felt to be inadequate by those people.

Deleterious secondary effects which cause dissatisfaction in the people and in the professions will inevitably occur if an old-age plan such as H.R. 3920 is adopted.

Members of the Association of American Dentists, "A voice for the private practicing dentist," urges you to work diligently for the defeat of H.R. 3920 and respectfully request that you enter this letter in the hearing record for both the Congress and the people to see. Sincerely,

V. S. BODDICKER, D.D.S., President, Association of American Dentists.

STATEMENT ON H.R. 3920_HOSPITAL CARE FOR THE AGED UNDER SOCIAL SECURITY

The American Dental Trade Association is grateful for the opportunity to express its views on H.R. 3920. This statement reflects the majority viewpoint of our 165 member firms who operate 351 places of business in 47 States and the District of Columbia. American Dental Trade Association members account for approximately 67 percent of U.S. dental dealers' sales, and over 75 percent of U.S. dental manufacturers' shipments.

Since one of the major objectives of the American Dental Trade Association is to promote the availability of dental health care to all citizens regardless of income or other factors, we are deeply concerned with the problems which H.R. 3920 would attempt to solve. It is with great care, therefore, that we have studied this bill. Our study has led us to the position that the proposed solution is, for several reasons, neither prudent nor necessary. This statement outlines those reasons.

COULD RESULT IN THE LOWERING OF PRESENT STANDARDS

H.R. 3920 states “the amount paid to any provider of services *

* * shall be the reasonable cost of such services, as determined in accordance with regulations est lishing the method or methods to be used in determining such costs * * * "

Because the Department of Health, Education, and Welfare would be required to determine the “reasonable costs" with regard to the funds available, it is not unreasonable to expect that the amounts set for allowable payments could limit use to low-cost and possibly inferior products. If such were the result, the effect would be to discourage rather than to encourage high quality medical and dental care. Further undesirable consequences may well evidence themselves in the ensuing results to manufacturers with higher product standards and important research programs.

COULD SPREAD TO AREAS NOT PRESENTLY AFFECTED

While some aged persons do require hospitalization in order to receive treatment for acute dental conditions, we are aware that dentistry is involved only to an incidental degree in the pending proposal. We believe, however, that this legislation, once enacted, would inevitably be broadened both with respect. to benefits and coverage. The growth of the present OASDI law is a dramatic: illustration of this pattern.

Logically if it is proper for the Government to provide health services for one segment of the general population without regard to need, then it would be proper to provide services for all other segments. Proponents of H.R. 3920 may argue that this would not come about, but regardless of the pattern of future developments, the Government would be cast in the role, to a more or less degree, of consumer of the products and services involved.

In the case of our industry, such a situation would be extremely detrimental, Since economy dictates that the Government buy directly from manufacturers, a substantial portion of the dealers' market would be destroyed. The economic effects to our industry from such action are obvious. Other effects are not so noticeable.

Dealers in dental equipment and supplies offer the profession a wide variety of product selection, enabling the doctor to choose that which he believes is the best and which best fits into his type of practice. Dealers also provide competent service departments which insure uninterrupted service to patients. Certainly, these relatively small businesses cannot compete with the Government. A valuable and competent member of the overall health care team would be lost beyond hope of recall.

THE PROBLEM IS TRANSITORY

There is substantial information, already in the hands of the committee, which clearly indicates that our present system is rapidly coping with the problem that H.R. 3920 proposes to alleviate. The performance of the health insurance industry and other private voluntary organizations such as Blue Cross and Blue Shield in extending protection to an increasing proportion of our growing elderly population, has been exceptional. The Kerr-Mills program, which has been set up in 28 States, has shown remarkable growth. Eight more are scheduled to be in operation by the end of 1964.

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