turity," a visual-aid publication to assist communities in furthering organized groups for the aging and a manual of the organization of clubs for senior citizens giving in detail recognized practices and procedures. Our Nation has a concern for and respect for the individual older and retired adult who needs a place in the community's living. Recreation meets some of the needs that human beings have for leisure living. There comes a time for the aging when sons and daughters no longer desire services and there is no one for whom the individual can do things and around which they can center their life. Individuals who are skilled in the thousand and one arts of homemaking suddenly find these skills are required by no one. Many have never had the time to form skills or develop interests outside of their family and the friends of their youth who have passed away. These individuals have a lot of leisure time to spend. It is difficult for any age of man to spend his time sitting idly in a house thinking about the past; doing nothing because there is nothing to do. No one cares, and it is hard to hold hands with memories. There is a man who no longer has a job to do. It is part of the recreator's job to help this individual form new acquaintances. We do not want these individuals to be on a shelf. The recreator can impart know-how and management and service as a resource for the adults and youth in their recreation. We do need personnel at the local, State, and Federal level who can handle and understand the situation that the senior citizens are in. Respectfully submitted by HOWARD JEFFREY, Executive Director, American Recreation Society, Inc., Washington, D.C. Mrs. A. O. BRUNGARDT, Vermont Director of Recreation, State Board of Recreation, Monpelier, Vt. MISS SYBYL BAKER, Washington, D.C. July 24, 1959. MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA, Senator PAT MCNAMARA, Chairman, Subcommittee on Problems of the Aged and Aging, DEAR HONORABLE MCNAMARA: We have received notice through your office that invited representatives from Federal agencies and national organizations are to participate in a series of hearings this week and in the following 2 weeks. The Medical Society of the State of North Carolina testified July 14 before the House Ways and Means Committee on the facilities, services, and demonstration programs designed to meet the health and medical care needs of our chronically ill and aging population. We are submitting this prepared statement to you as information and would request it be made a part of the record of your hearings. If you should wish additional information about any of these outlined programs, we would be glad to hear from you. Respectfully submitted. JOHN R. KERNODLE, M.D., Chairman, Committee on Chronic Illness. STATEMENT OF JOHN R. KERNODLE, M.D., MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA Mr. Chairman and members of the committee, I am Dr. John Robert Kernodle, of Burlington, N.C., where I am engaged in the specialty medical practice of obstetrics and gynecology. I am chairman of one of six commissions referred to as action bodies of the Medical Society of the State of North Carolina and within the frame of that commission I have for several years headed the committee on chronic illness which is concerned with the study of data, information, and systems of advanced care of the aged and chronically ill as medical and health care problems throughout the State of North Carolina and in stimulating thought and plans of action related to the development of the proper concern for and services to the chronically ill, including the aged, to which I shall make primary reference hereafter, and in this presentation I make reference to a longer statement prepared and deposited with the committee which I propose to be included as part of this verbal statement and constituting the statement of this society. The State medical society in its preamble poses among its purposes: "to elevate the standards of medical service and to enlighten the people with regard to the great problems of medical care and public health, so that the profession shall become capable within itself, and more useful in the prevention and cure of disease and in prolonging and adding comfort to life." Moreover, the Supreme Court of North Carolina many years ago held, "The public health is the highest law." Throughout the 160-year history of the society these tenets have characterized the efforts of the society in North Carolina, and largely the physicians who compose it; so our concern with and effort on the problems of the aged rightfully joins us to you in the legislative considerations upon which you seek enlightenment today in seeking guideposts to the best approach to the problem as representatives of the people of this Nation. The medical society, representing the profession, must forever maintain concern for contributing only to that which purveys the highest standards of medical care and which promotes the sound growth of a profession which is dedicated to serving the best health of humankind. Organized medicine was among the first to recognize the new and increasing members of older age people, who, because of improved medical care, treatment and supervision, modern medical research, discovery and perfection of therapeutic agents, and other important health protections, can expect to live many years longer than our grandparents in this mid-20th century. Likewise, medicine is among the first to recognize and to begin stimulating individual and public interest as to ways and means of planning toward these added years and it continues to take the initiative in practical concern at National, State, and local levels. Physicians know what the health needs of their patients are, and because of the close physician-patient relationship can best guide and direct the regime of health maintenance for each patient. The State medical society committee on chronic illness in 1954-55 had as its original purposes to study, evaluate, and influence medical progress in the field of the aging. The basic objectives have been 1. Education of the doctors and the community as to the number of chronically ill patients and as to the needs of additional services and facilities for their care and treatment. 2. Provision for more hospital beds with improvement of nursing and medical care for these patients. 3. Overall management of the chronically ill patient in regard to medical treatment, supervision of nursing care, the type of facility required, and the improvement of the finance of such facilities and treatment. 4. The stimulation of housing facilities for the aging. 5. A preparation for a positive action in regard to the care of the chronically ill (in other areas of need; e.g., nutrition). Recommended action 1. Survey of the medical society secretaries for information on the facilities for caring for the chronically ill. 2. A survey of the doctors to determine the actual need of facilities and the frequency of chronically ill patients being seen by the doctors throughout the State. 3. A recommendation that a committee on chronic illness be appointed by the county medical societies to coordinate the program on a local basis. 4. A coordinated meeting of groups in North Carolina interested in aging and chronic illness, to include official and nonofficial agencies, voluntary groups, special Governor commissions, and the geriatric research program at Duke University Medical Center. Other recommendations 1. Continued efforts to alert all people to the problems of the aging and the chronically ill. To stress the responsibility for individual and community action. 2. Development of adequate facilities for the health care of the aged. 3. Continue the study and encouragement of financial assistance for the chronically ill. 4. Extension of the effectiveness of voluntary health insurance. 5. Encourage and sanction the development of visiting nurse and organized home care programs and homemakers services. 6. Support legislation for mandatory protective law for the licensed homes for the aging and chronically ill. 47461-59-19 Defining the problem The medical society's committee on chronic illness made two surveys in 1958: One to gain information as to present facilities for the care of the aged and chronically ill, and the second, to determine the actual need of facilities and the type of health care most frequently needed by these patients. The results of the first survey revealed: 1. The overall facilities now available are inadequate. 2. Nursing and medical service and supervision of patients reported were inadequate. 3. In 17 of the 59 counties reporting there were no formal facilities for the chronically ill or aging. (Observation: Forand would not extend to one-third of the counties for this reason.) 4. Eight facilities were licensed by the medical care commission and had excellent facilities for a nursing and convalescing program. Three hundred and forty four domicilliary type homes were licensed by the welfare department. Over 100 facilities were not licensed by either agency (implying inadequate services and standards). 5. In the home-type facility the number of patients range from one to eight. In the hospital-type facility the largest number reported was 80 patients. 6. Cost per diem to the nonhospitalized patient ranged from $1.67 to $10.50. The second survey was a report from the individual physicians as to the number of chronically ill patients seen and as to the type of care they considered adequate for individual patients. The results showed: Patients needing home care: 59.1 percent. Patients needing nursing or convalescent home care: 18.3 percent (or 77.4 percent for whom hospital care was not indicated). These results correspond to other surveys made in the State and in other States as to the type of care actually needed. In the Guilford County survey of chronically ill, conducted at the same time, but in a more detailed manner, it definitely pointed up: (1) 72 percent of all known cases of chronic illness have needs which can be adequately met by a home care program. (2) Only onefifth of the cases were over 65 years of age and one-quarter between the ages of 45 and 64. (3) One-quarter of the cases are mentally confused or retarded and the majority of patients have difficulty in getting around. Permanent stiffness and deformity, difficulties in speech, blindness and paralysis were the major physical handicaps. These could be modified as to weight of care by increasing rehabilitation programs. (4) Over two-thirds of the patients had conditions from which the patients were not expected to deteriorate. Rehabilitation programs and services of more intense nature would make a great contribution in lessening the care required for this group, thereby avoiding the more expensive hospital care. The following table shows how chronically ill and aging patients were financing present services (Guilford County survey): Appointment of county medical society chairmen.-Following the leadership of the State medical society's committee on chronic illness, county societies appointed local chairmen of such committees in some two-thirds of the county units which in turn are stimulating and promoting local study and planning. The result is that the county medical society is calling together representatives of medicine, public health, public welfare, hospital, nursing and boarding home operators to discuss existing services and facilities and to study future developments to more adequately meet the health care needs of the older and chronically ill persons within their local area. Such groups are taking a realistic look at present programs and what improvements can be made in services, facilities, and home care programs. Using statistics from State and National surveys, as to the number of patients involved and the types of unmet needs, county groups are promoting educational workshops and conferences that will have benefit to the State's overall study in preparation for the 1961 White House Conference on Aging, but more important, such interest is alerting official and nonofficial groups to become more aware of the programs prevailing in the community and supporting these for their demonstrated value. To cite further local action, the Governor's coordinating committee on aging has already sponsored county discussion or workshop meetings in some 51 of the 100 counties in the State. These local groups working closely with the county medical society, and allied health personnel, will further encourage public understanding as to the needs of the aged and the individual and community responsibility in providing recognized services for these persons within their area. Joint committee for the health care of the chronically ill and aged.-North Carolina has complied with the suggestion of the National Joint Council for the Health Care of the Aged by forming a joint committee for the health care o the chronically ill and aged with wider representation to include existing agencies and organizations which have programs and services for the chronically ill and aged. At the invitation of the medical society, this representative group met together early in 1958 and again in March 1959 to discuss and plan together next steps as a combined interest group and as individual working agencies. Agencies represented to date are: Medical Society of the State of North Carolina. North Carolina Hospital Association. North Carolina Dental Society. North Carolina State Board of Health. North Carolina Association of Boarding and Nursing Homes. North Carolina Department of Public Welfare. North Carolina School of Public Health. North Carolina State Nurses Association. North Carolina Health Insurance Council. Duke University Medical Research Center on Aging. American Red Cross (North Carolina representatives). Governor's Commission on the Study and Control of Cancer. Through the cooperation and work of this joint committee, assistance and participation in the planning and study for the 1961 White House Conference on Aging is anticipated, as well as the overall planning and interpretation of other programs and services having an influence on the health care of the chronically ill and aging. Improved and increased facilities.—Through the medical care commission, emphasis has been continued as to the construction of chronic disease facilities. We have five hospital chronic disease projects to date, totaling 347 beds, either constructed, under construction, or in the planning stage. According to the best estimates available at the first of the year, North Carolina ranked second among the States in the number of chronically ill beds developed under the Hill Burton program. Recent reports state that we have 24 licensed nursing and convalescent homes providing a total of 726 beds, with some 12 or more being constructed through private enterprise. The commission has approved and licensed some 169 general hospitals and clinics which provide beds for overnight care of patients with a total of 14,756 beds, and these, in ratio to the need, are available and utilized by the chronically ill and aged. The 1959 general assembly passed a mandatory licensing law, effective January 1, 1960, affecting all boarding, nursing, and convalescent homes caring for the aged and chronically ill. The medical society actively supported this legislation, which standardizes protection in the formal care of the chronically ill and aged. Financial assistance for the indigent and medical indigent.-The 1959 general assembly approved the public welfare request for an increase in the "pooled hospitalization" fund to allow $10 per diem for public recipients (00A, ADC, TPD). This became effective July 1, 1959. Also, a law was passed allowing the State to expend "pooled fund" for hospital care rendered in out-of-State hospitals in certain cases when instate hospital care is inconvenient. A change in the residence requirement from 1 year to 90 days for public welfare recipients in moves from county to county within the State will be helpful. Interstate residence requirement is 1 year. Assistance given the medical indigent through the medical care commission totals about $300,000 annually for contributions to bed costs of hospitals for the care of the general medical indigent. Approximately 18,000 claims are processed each year, representing over 200,000 days of care to 130 hospitals caring for patients from all 100 counties. This aid, plus Duke endowment and Kate Bitting endowment aid, affords $3.72 per day at the State level for the general medical indigent. These cases generally are supported medically by uncompensated physicians time and care. Many more (to the extent of $2.25 million annually) are hospitalized on local hospital funds alone, with free physician services. Most of the 100 counties have an additional appropriation known as general assistance fund to assist hospital and health care payments in the home and office for the medically indigent. We have expressed an interest in general assistance funds for vendor payments to be matched by State and possibly Federal funds and to be administered locally. Extension of voluntary health_insurance.-Quoting our State medical society president from his inaugural address of May 5, 1959: "In regard to prepayment medical insurance, we as physicians must be mindful of the patient's ability to pay for medical care and we should give our support and constructive criticism to the Blue Cross, Blue Shield plans, and many excellent private insurance plans that make it possible for the patient to maintain financial solvency and personal dignity when faced with either severe or catastrophic cost of a long and debilitating illness." Physicians have just as much responsibility in protecting the patient from insurance schemes as from cureall drugs and unsound or unethical medical practices. The recent action (December 1958) of the house of delegates of the American Medical Association and component State societies in regard to the senior certificate has been a major topic of discussion at this session, and our own house of delegates has adopted the senior certificate and recommends it as a part of the doctor's program. This places on a sound experimental basis a prepayment medical care plan for a large group of our citizens who up to now have not been covered. The Blue Shield committee of our society will have positive direction of the doctor's program and the senior certificate. I may add, the members have the obligation and responsibility to make it effective. More recent action has been that both Blue Cross plans operating in North Carolina now have senior citizen policies. The Blue Shield plan encompasses a service program at diminished service cost based on modified fees. Additionally, medical insurance is available at diminished premiums for an indemnity program of care through a second Blue organization, thereby extending this program of voluntary insurance into every area of North Carolina. As additional information, I'd like to state that in 1950, 5.6 percent of the total population in North Carolina was 65 or older and it is expected that by 1960, this will rise to 6.5 percent. North Carolina ranks fourth as to the number of people under age 20, therefore we are a young State populationwise. Younger generations are fast enrolling in voluntary health insurance plans and with our senior certificates we can anticipate a much larger percent of our total population to participate in some type of prepaid voluntary health insurance programs in the years ahead. I am not going to quote national statistics as to insurance coverage or enumerate the ways which commercial insurance companies have extended coverage to those over 65, as you have or will be given this information by authorized representatives of the health insurance association. The increase in numbers of persons over 65 having insurance coverage is most encouraging. Blue Cross figures show that enrollment has increased at a more rapid rate for those 65 and over than for the younger age groups, which indicates clearly that people want to participate in a voluntary health insurance program and will do so if given the opportunity. The health insurance council has pointed up seven ways of extending coverage to the older age group. The new senior certificate of the Blues incorporates three of the seven methods: (1) the continuation on an individual policy based on coverage originally provided by group insurance; (2) the new insurance of group insurance at advanced ages; and (3) the new issuance of individually purchased policies at advanced ages. We feel these points are significant. Both the Blues and the commercial insurance companies have made vast strides in extending coverage and benefits to older age groups (who from our surveys show approximately 78 percent may not require hospitalization) and also continue to explore ways and means of extending, beyond present levels, to include longterm care, home care, ambulatory, diagnostic, therapeutic, and restorative services." |