A third problem area which we would like to emphasize is that of the quality of the services which are being provided and we feel that whatever extension of services comes out of the activities of this committee and the other activities which are going to improve services to the elderly, perhaps the most important thing of all is to be sure that high quality of service be given to these people.

I would just like once more-and this is the last reference to the written statement-to quote from a letter which was written recently by our president, Dr. Leona Baumgartner, on this matter of conservation of quality of care. She said:

While we in the American Public Health Association well realize that economic security and health are closely related *** our competence is, of course, confined to health matters, and we are chiefly concerned with those provisions of the social security titles which deal with medical care for public assistance recipients and for the medically indigent.

Accumulating experience with these programs reveals some serious deficiences and problems which are of concern to all the States. It is becoming apparent that, in the absence of any mechanism requiring the localities to establish standards of quality or to put a premium on medical excellence, the average quality of care provided over the country is not as good as it could be. Moreover, the size and scope of these programs offer many opportunities to provide better medical care through more rational organization of services. These opportunities are being neglected. The accumulating experience which reveals these problems also provides the technology and the skill to deal with them constructively.

The fourth and final problem area which I would like to mention is that of fragmentation of health services. Now, in most communities health services are scattered between health agencies, welfare agencies, rehabilitation agencies, educational agencies, and others. We need either unification or coordination. It does not always have to be one and the other but it should be one or the other. Either through consultation or through a health and welfare council or through a health and welfare interdepartmental committee a great deal more utilization of what we have right now would be possible.

When I was in Pennsylvania we worked out a system of systematic consultation between the health department and welfare department which I think was extremely helpful.

In some other areas, as in New York City now, there is an arrangement for loan of personnel from health to welfare, which apparently is helping in some of their problems.

That is about all that I have to say, sir, except to summarize by saying that there is a lot more that can be done with what we have now and that out of your hearings I hope will come some shift away from the much emphasized problem of the elderly to an idea of conservation of the tremendous potential which these aging people represent which has a very positive significance to all of us.

Senator MCNAMARA. Thanks very much, Doctor.

Your statement and your relating of your experiences in these areas are very helpful to the subcommittee.

I have just a couple questions.

In your statement you refer to newer public health and medical techniques. It would be helpful to the subcommittee if you could outline these new practices. And do you think that they should be put into effect under existing circumstances or do you think that they need some help from the Federal Government?

Dr. MATTISON. A couple of the things I have in mind particularly there were some of the casefinding methods for, I mentioned diabetes

and glaucoma, but cancer is another one. There are methods, for instance the tissue examination of body fluids, where the early detection of cancer would be extremely helpful and is not available now on as widespread a basis as it should be. The matter of providing the ancillary services for stroke patients is a very good example of this kind of thing which is relatively new—that is, the concept of early therapy is relatively new-not being done widely enough.

Senator MCNAMARA. These are not expensive things. It is just putting to practical use the newer techniques. It will not require a great deal of money, will it?

Dr. MATTISON. That is right.

One of the mechanisms which might be used for getting something like that done is the sort of thing which the Public Health Service is doing with its Heart Disease Control Unit in the Bureau of State Services, where they have young reserve officers in the service sent out to various health departments to work in this particular area, bringing special medical competence to the health departments, and help them work out the actual plans for interagency cooperation to do these things, but it would not require tremendous personnel; it would not require tremendous additional costs.

Senator MCNAMARA. In your statement you make reference to the support of appropriate proposals for paid-up insurance. What do you mean by that? Does that include the mechanism of the OASI, for instance?

Dr. MATTISON. The American Public Health Association has not taken any stand as to what type of insurance should be offered. There has been considerable support, in various parts of the association, for both private and public, but we have no stand as to whether it should be one or the other.

Senator MCNAMARA. Your resolution goes on also to recommend that we improve the financing adequacy of the health services. You do not have any definite recommendation how to pinpoint that recommendation, do you?

Dr. MATTISON. In this particular instance we specify two supplementary public assistance programs and other-in other words, such as programs administered by public health departments.

I would like to point out there are a couple of States, Maryland and Florida, where health departments are actually operating medical care programs through some arrangement with their welfare departments. There is prejudice but we think continuity of providing medical services to the needy is a logical arrangement and that we should get more prevention into such a program operated as a health department than we can where there are two separate programs.

One of the specific references here would be encouraging closer cooperation between health departments and welfare departments even to the extent of having more health departments operate medical care. programs for the indigent.

Senator MCNAMARA. That is an interesting recommendation.

As a doctor, do you think that there is any great amount of reducing the medical fees for older people? Do you find this in your experience a reduction on the part of the doctors of their fees for the aged?

Dr. MATTISON. I am afraid I cannot answer with any validity on that. I am not in practice. I have been in public health for many years, and I have not had any data from any studies that would bear directly on that.

Senator MCNAMARA. Then, again, fees frequently are intangible things. It is hard to measure. I was just wondering in view of the testimony we had previously whether you run into any reduction. Dr. MATTISON. I just have no information one way or the other. I

am sorry.

Senator MCNAMARA. Thanks very much.

Dr. MATTISON. Thank you.

Senator RANDOLPH. Mr. Chairman?

Senator MCNAMARA. Senator Randolph, we are happy to have you with us. I neglected to ask if you had any comment or question. I am asking you now.

Senator RANDOLPH. Mr. Chairman, it is understandable that you overlooked me because I came in rather quietly and much too late. But sometimes it cannot be otherwise.

I have had the opportunity in the very cursory look at Dr. Mattison's testimony.

Would you be able to tell us in a way that you may not have explained to our distinguished chairman, some of the physical and service needs which you feel can be fitted into this type of facility?

Dr. MATTISON. Yes, sir.

I think this is a very important aspect of the whole problem, and I would like to speak primarily to my experience as a health officer in New York and Pennsylvania rather than as an executive director of the American Public Health Association.

I have had a considerable amount of experience in both of those States with nursing homes and I think that most of us who have had that experience will agree that there is difficulty in securing a generally high level of excellence in medical supervision.

(1) It is difficult in many nursing homes to be sure that the period between medical reviews of the patient is sufficiently short.

(2) Nursing services are difficult to maintain at high level-the problem is one of both supervision and actual nursing care.

(3) Nutrition problems were mentioned earlier. In Buffalo, where I worked for a number of years, we felt that we had provided nursing homes there a great deal of very practical help by making available to them services of the Public Health nutritionists to help devise their diets, to provide for the real necessities of the aging person.

(4) Sanitary and safety factors should be built in the nursing home-and here some kind of relationship between the health departments, sanitation and engineering staff and the nursing homes I think is most helpful.

This brings up the whole question of licensing and who actually controls the whole picture. It does not have to be the health department, but if it is not, then I think there should be an organic relationship between the health department and whatever agency does license them so that these four kinds of services can be made available to the licensing body.

Is this the sort of thing you are inquiring about?

Senator RANDOLPH. Yes, Doctor. I am sure Senator McNamara and members of the subcommittee desire information on this phase of assistance to the aged. I would not want to disparage the program of the nursing home per se in the Washington area, but I can tell you very frankly that there are many nursing homes within the District of Columbia that in my opinion, and it certainly is the opinion of a

layman and not an expert, give real reason to doubt that they meet the requirements which you indicated should be in existence.

I have no desire to labor that point at this time but I think an examination by any intelligent person would bring that reaction. Perhaps this subcommittee will feel it advisable to recommend passage of legislation which would not straitjacket this type of operation. At least, Mr. Chairman, we could bring about a criterion by which we could proceed more objectively.

Senator MCNAMARA. Senator, I am sure you do not intend to imply the conditions are particularly bad here. This is a national problem, and I think you will find the same thing that applies in Washington, D.C., applies pretty generally throughout the country.

Senator RANDOLPH. Senator McNamara, I am sure that is true.

My only experience has been within the District of Columbia and the metropolitan suburban area. We know that those older folk many times must be I don't like to use the word "placed," but these older folk of their own volition and the assistance of others do need these nursing homes. We know that these persons realize that they must have around-the-clock nursing care and many times they are very understanding. When they are in the home of children of theirs, it poses a special problem.

I think this situation needs to be discussed. It is not a question of having someone leave the home of a son or daughter. That son's and daughter's home possesses the sincerest love for that father or mother but the presence of nurses, the care which is necessary to be given to the older person can, frankly, in many, many homes not be carried forward. There is this problem of a third generation involved, and I think the subcommittee is desirous of having expert testimony. Dr. Mattison, yours certainly can be included in that classification on this

matter.

Thank you, Mr. Chairman.

Dr. MATTISON. Mr. Chairman, I would like just briefly to say one thing if I may.

Senator MCNAMARA. Certainly.

Dr. MATTISON. About this rehabilitation of some of these clinical patients in nursing homes-again it is an area which has not been sufficiently explored.

In New York State during the past 3 years, the health department and welfare department have cooperated on a series of rehabilitation attempts with a group of welfare patients who were thought to be completely incapacitated. There has been a very happy percentage of those who were brought back to the stage where they could help themselves and be pretty much independent.

Senator MCNAMARA. In your experience you mentioned a 3-year period. Is it not a fact that we probably have two or three times as many so-called nursing homes now than we had even 3 years ago? Are they not increasing in great numbers in most areas of the country? Dr. MATTISON. That it varies tremendously in one part of the country from another. In the part of the country I am familiar with there has not been that degree of increase.

Senator MCNAMARA. I am more familiar with Michigan than any other State and there is a tremendous increase there. It seems like every time I drive around the city I new nursing homes and new

convalescent homes. It seems to me they are increasing in that area at a tremendous rate. This is probably due to the fact that we have a good many people there who get in retirement a little more than the social security payments because of contracts that have been negotiated between the automobile manufacturers and the automobile employees and such things. Maybe this is bringing about a financial condition where more people can live out their later years in these kinds of places. Some of them are pretty good and some of them are pretty bad.

Thank you very much.

Dr. MATTISON. Thank you, sir.

STATEMENT OF KENNETH WILLIAMSON, ASSOCIATE DIRECTOR, AMERICAN HOSPITAL ASSOCIATION

Senator MCNAMARA. From the American Hospital Association we have Kenneth Williamson, executive director.

Mr. Williamson, we are glad to have you here. I see you have a prepared statement. Would you care to have it printed completely in the record and summarize it for us?

Mr. WILLIAMSON. I would, Senator, if I may.

Senator MCNAMARA. Then it will be published at this point in the record.

(The prepared statement of Mr. Williamson follows:)

PREPARED STATEMENT OF KENNETH WILLIAMSON, AMERICAN HOSPITAL

ASSOCIATION

Mr. Chairman, my name is Kenneth Williamson. I am associate director of the American Hospital Association.

I will not dwell upon the organization of the American Hospital Association, its functions and its purposes, except simply to state that the association includes within its membership in excess of 90 percent of all the general hospital beds in the United States and its territories and approximately 77 percent of all listed hospitals of every type in the United States and its territories.

I appear before this subcommittee today in response to the letter of invitation received from the chairman.

I express our appreciation of this opportunity to participate in these hearings which we understand are to be devoted primarily to gathering information on the conditions and needs of the aging and aged in preparation for a Senate report to be submitted in 1960. The interest of the American Hospital Association in the subject matter of these hearings is of long standing. On June 2, a letter was directed to Senator McNamara in reply to a letter asking for comments and suggestions on a series of questions. At that time, we outlined at some length our concerns with the health needs of aged persons and submitted copies of a number of documents resulting from our studies and efforts.

I shall attempt, therefore, to avoid duplication of the information already submitted to the committee.

It is requested that we deal particularly with four questions pertaining to general areas of activity. I shall discuss these in the order in which they were presented.

A. A SUMMARY DESCRIPTION OF YOUR INTEREST AND WORK IN THE FIELD OF AGED AND AGING

The association was the major advocate of prepaid voluntary health insurance and has encouraged the development of Blue Cross plans on a communitywide basis with the specific purpose of enrolling all segments of the population and continuing the benefits for members throughout their working years and on into retirement. Blue Cross plans now report that close to 3.5 million persons 65 years of age and older are enrolled in these plans.