MEDICAL CARE m / UNITED STATES T lze Rale of Me Pué/z’c Hea/tfl Semm A REPORT FROM THE. NATIONAL ADVISORY HEALTHJCOUNCIL U. 8. DEPARTMENT OF HEALTH. EDUCATION,AND’ WELFARE Public Health Smlce " MEDICAL CARE int/26 UNITED STATES T be Role oft/1e Pee/2'5 Hee/tfl S erw'ee REPORT TO THE SURGEON GENERAL FROM THEVNATIONAL ADVISORY HEALTH COUNCIL \UC) L MARCH |96l U. 8. DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE Public Health Service V Public Health Service Publication No. 862 UNITED STATES GOVERNMENT PRINTING OFFICE WASHINGTON 1961 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington 25. D.C. - Price 35 cents AWN/9V .5“ UaA3 PUPL': H' ALM Lawn FOREWORD In recent years changes in the character and supply of personal medical services and in the nature and extent of demands for these services have created new problems in the organization and financing of medical care in the United States. With the emergence of these problems has come increased interest in how the Public Health Service might assist in assuring that adequate services are available to persons in need of care. This report from the National Advisory Health Council discusses the problems of meeting the medical care needs of the Nation and the role of the Public Health Service with respect to the organization, administration, and financing of personal medical services. The National Advisory Health Council exists by law to consult with and advise the Surgeon General on certain specific Service responsibilities as well as on matters relating to health activities and functions of the entire Service. It serves a valuable role as an independent guide, mentor, and critic. I wish to take this opportunity to thank the members of the Council and of the ad hoc Medical Care Committee which initially prepared this report for their suggestions on Public Health Service activities relating to medical care. I believe the report will provide a useful basis for consideration of action in this field by the Service, the Department, and the Congress. Luther L. Terry M.D. Surgeon General 220 -ii- National Advisory Health Council Dr. H. Stanley Bennett Dean, Division of Biologic Sciences University of Chicago Dr. James P. Dixon President, Antioch College Dr. L. A. DuBridge President California Institute of Technology Dr. Sidney Farber Professor of Pathology Harvard Medical School Dr. Philip Handler Chairman, Department of Biochemistry and Nutrition Duke University School of Medicine Dr. George T. Harrell Dean, College of Medicine University of Florida Mr. Russell R. Larmon Professor of Administration Dartmouth College Dr. Malcolm H. Merrill Director of Public Health State of California Dr. I. S“ Ravdin Department of Surgery Hospital of the University of Pennsylvania Dr. Francis 0. Schmitt Institute Professor Massachusetts Institute of of Technology Dr. Lewis Thomas Chairman, Department of Medicine New York University College of Medicine Ex Officio Members Dr. Marc James Musser Director, Research Service Veterans Administration Alternate for: Dr. William S. Middleton Chief Medical Director Veterans Administration Col. Arthur P. Long Chief, Preventive Medicine Division Department of the Army and Dr. EdwardiH. Cushing Deputy Assistant Secretary of Defense (Health and Medical) Alternates for: Dr. Frank B. Berry Department of Defense Dr. Luther L. Terry (Chairman) Surgeon General Public Health Service Dr. Dr. Dr. Dr. Dr. - iii _ Ad hoc Medical Care Committee National Advisory Health Council Chairman Lowell T. Coggeshall, M.D. Vice President for Medical Affairs University of Chicago Council Members Dr. James P. Dixon Dr. George T. Harrell Mr. Russell R. Larmon Other Members Leona Baumgartner, Commissioner of Health, New York City . Ray E. Brown, Superintendent, University of Chicago Clinics J. Douglas Colman, President, Associated Hospital Service of New York Frederick D. Mott, Executive Director, Community Health Association, Detroit Willard Rappleye, President, Josiah Macy, Jr. Foundation; formerly, Dean, Columbia University Medical School Cecil G. Sheps, Professor, Medical and Hospital Administration, University of Pittsburgh . Francis R. Smith, Insurance Commissioner, State of Pennsylvania Wilson T. Sowder, Health Officer, State of Florida CONTENTS Page ForeWOrd .. ....... .............................................. 1 National Advisory Health Council ............................... 11 Ad hoc Medical Care Committee .................................. iii Introduction ................................................... l I. Trends in Medical Care .................................... 3 Social and Economic Trends .............................. 3 Changing Disease Patterns ............................... 7 Health Personnel ........................................ 8 Facilities .............................................. lO Expenditures and Financing .............................. 11 Organization of Services ................................ 15 Standards of Quality .................................... l6 Governmental Medical Care Activities .................... 17 II. Current Public Health Service Activities in Medical Care .. 20 Analysis of Health Status and Use of Services ........... 20 Personnel ............................................... 20 Facilities .............................................. 21 Expenditures and Financing .............................. 21 Organization of Services ................................ 21 Standards of Quality .................................... 21 Personal Health Practices ............................... 22 Expenditures for Medical Care Research .................. 22 Conclusion .............................................. 22 III. The Nation is Concerned ................................... 23 Reports of Federally Appointed Committees ............... 23 Interest Among Other Individuals and Groups ............. 26 IV. What Needs to be Done? .................................... 29 Use and Recruitment of Health Personnel ................. 29 Medical Care Facilities ................................. 30 Financing ............................................... 30 Organization of Services ................................ 30 Standards of Quality for Care ........................... 31 Coordination of Governmental Programs ................... 31 Improvement of Medical Care Administration .............. 32 Eliminating Deficiencies in the Nation's Medical Care ... 32 V. Proposed Role of Public Health Service .................... 33 References ..................................................... 35 _ 1 _ INTRODUCTION A healthy citizenry is not only a nation's most important "natural resource,” but also a prime aspiration of any government whose effec- tiveness is defined in terms of its ability to serve the best interests of all the individuals who compose the society. Although a person's health depends in varying measure on each of a large number of physical and social influences in his environment, one of the more important of these influences today is the availability of good medical care, includ— ing a wide range of preventive, therapeutic, and restorative services. It is appropriate, therefore, that the ways in which medical care is provided be reviewed and means sought to improve the quality and accessibility of services. Since World War II far-reaching changes have taken place in the character and organization of medical care in the United States. The marked growth of the population and its generally rising economic and educational levels have been accompanied by increased demands for health services and by a growing popular disposition to regard access to medical care as a basic human right. Advances in medical knowledge, while making possible the application of improved preventive and therapeutic techniques, have created problems in coordinating the proliferating health professions, medical care institutions, private health organizations, and governmental agencies involved in providing health services to the individual patient. The development of increasingly specialized technology has contributed to a persistent rise in the cost of care both to the individual and to the community. In today's society the attainment of optimum health for the largest possible proportion of the population requires the bringing to bear locally and nationally of a wide range of private and public medical care resources, many of which are not readily responsive to appeals from any single geographical area, profession, institution, or group of institutions. With private expenditures accounting for about three— quarters of all expenditures for health services, private individuals and non-governmental groups will continue to bear a major responsibility for promoting needed improvements in methods of organizing and financing health services. State and local governments can also do much within their particular jurisdictions to express public concern and initiate public action on medical care problems. However, national leadership is needed to strengthen those aspects of medical care, whéther publicly or privately supported, that cannot at the present time be effectively evaluated or improved by other levels of government or by private groups acting alone. , ,' Traditionally and.by law the Public Health Service has participated in the support and improvement of many specific components of medical care. The promotion and support of hospital and nursing home construction, the _ 2 _ analysis of medical and dental personnel needs, the traineeships in health administration, the stimulation and improvement of State and local diagnostic screening programs, and much of the technical as— sistance and consultation provided by the Service have been oriented toward identifying and meeting national medical care needs. However, although the Service has demonstrated increasing concern with more than one aspect of medical care, it has not been specifically charged with the responsibility for providing leadership to improve medical care in the country as a whole. As a result, the otherwise useful programs of the Service have with a few exceptions tended to be limited and piecemeal in relation to overall national requirements. After discussing the medical care problems of the United States at its June 1960 meeting, the National Advisory Health Council of the Public Health Service asked for the appointment of an ad hoc Medical Care Committee to examine the Nation's medical care and to prepare recommendations on the role of the Public Health Service with respect to ”the organization, administration and financing of personal medical services." The Committee, headed by Dr. Lowell T. Coggeshall,met in Washington on October 17 and December 15, 1960, and prepared the following report embodying its findings and recommendations. This report was in turn approved by the whole Council at its meeting of March 13, 1961, and presented to the Surgeon General. The report describes in broad terms the current status of medical care in the United States, with particular emphasis on identi- fying ways in which the Public Health Service can help to improve the quality and availability of personal health services. The discussion of medical care trends is confined to a brief analysis of existing information and indices. No attempt was made to determine whether or not any new groups of individuals should be designated as beneficiaries of medical care financed or provided by any level of government. Chapter I, after dealing with the significance of socio-economic changes for medical care problems, considers trends in health personnel, facilities, financing, organization, standards of quality, and govern— mental health programs. Present medical care activities of the Public Health Service receive attention in Chapter II. Chapter III describes some of the manifestations of widespread national concern over medical care problems. Chapter IV, which discusses needed action by private and governmental amthorities to improve medical care, stresses the benefits and economies possible through better use of health personnel and facilities, improved methods of organizing and financing care, and the development of clearly defined standards of assessing quality of care. Chapter V contains six recommendations calling for Public Health Service leadership in translating our increasing knowledge of disease and disability into improved medical care for the people of the United States. -3- I. TRENDS IN MEDICAL CARE Changes in morbidity, mortality and service utilization rates attest to the fact that, over the years, medical care in the United States has become increasingly effective and more generally available. At the same time, the services provided have grown more complex, more specialized, more fragmented, and more impersonal. As a background for considering future developments‘in medical care, we will review briefly some of the pertinent social and economic trends and note certain changing conditions in health status and resources which have an impact on medical care. Without attempting to give an exhaustive historical account or to report new research findings, the following discussion is based on existing measures of trends observ— able in most geographic areas and among most population groups. Social and Economic Trends Advancement of medical knowledge and the development of new medical care patterns must be viewed in the context of changes in the national economy, in the social structure, and in attitudes toward illness and health. For example, improvements in the level of educa- tional attainment have contributed both to the availability of scientists for furthering medical knowledge and to the emergence of a more sophisticated citizenry that expects ever more effective medical services. Rising living standards have stimulated greater demands for medical care but at the same time have presented conflicting claims for personal income, as yesterday's luxuries become today's necessities. Growing use of credit and other budgeting devices has affected spending patterns and people's attitudes toward paying ”out—of—pocket" for costly unexpected items. Increased urbanization and industrialization have contributed to changes in medical care and created new medical care problems. Trends toward smaller households and more than one earner per family now make it necessary to provide special services for sick people who formerly received care routinely in the home. Large concentrations of employees and the development of the labor union movement have been among the factors bringing group action to bear on finding solutions to health problems. Technological changes in industry have increased the presence in the environment of chemical and physical hazards which must be controlled or eradicated to prevent further increases in disease and disability attributable to these factors. . ‘ . _... p' \N . The marked population growth 0 recent years I5 expected to continue and even accelerate in the hex decade. During‘§gixi93ors / -h- total population in the United States increased by 9 million, during the 'hOs by 20 million, and during the 'SOs by 30 million. Growth in the next decade is estimated at 33 million, to a total of 21k million in 1970: (l) Year Total population 1930........ ..... .... 123,188,000 19u0 ..... . ..... ...... 132,122,000 1950 ..... .......... 151,683,000 1960.... ............ 181,000,000 1970................. 214,000,000 Concentration of population growth in cities and their suburbs is expected to continue, as indicated in Chart 1. By 1970 an estimated 60 to 66 percent of the population will live in metropolitan areas. (2) In l9h0 only 25 percent of the adults in the United States had finished high school, but by 1970 that proportion is expected to double, as shown in Chart 2. This expected increase in educational attainment, in addition to bringing still higher public demands for medical care, will also increase the pool of young people from which to draw potential health workers. In projecting potential personnel resources, however, some allowance must be made for increased competition for talent from many other professional and.scientific fields. The further mechanization of industry can be expected to divert production workers to service jobs, including those in the health field. Problems of recruiting, training and retraining such workers can be anticipated for the medical care field. The national economy is growing even more rapidly than the population. Projected estimates are that the gross national product will increase by two-thirds in the next ten years, accompanied by expanded industrial activity, more purchasing power and even higher levels of living (3). This expansion can bring in its wake more pressures for consumer goods, more occupational dislocation, and more demand for medical care. GNP in $ billions Year (1958 dollars) \ 1950.......::,..... $352 1959..........}\... 451 1965............. . 633 l970........ ..... 3. 790 _5_ By 1970 it is estimated that between 60 and 66 percent of the pepulation will live in metropolitan areas. 220 _ 180 lMO High estimate low estimate V v 4 \ \ 6O _ opulation \\ in metropolitan areas Millions of persons 20 L - O . 19u0 1950 1960 1970 Chart 1. Total U.S. population, showing numbers residing inside and outside metropolitan areas: Selected years l9hO-l970. Source: Bogue, Donald J. Population growth in Standard Metropolitan Areas, 1900—1950. U.S. Housing and Home Finance Agency. Percent of persons 25 and over -6- The proportion of adults who are college graduates is expected to double between 1940 and 1970 while the preportion who are high school graduates will more than double. lOO _ College duates 3.33;.“ gm .:;:o:o:;:o:o:o: 80 _ 7/ / Completed 60 _ high / s choo 1 no _ / Comp 1e te d A elementary . - ' - school b 20 _ i P. 2 Less than :' 8 ye ar s s cho o ling O p: o . .'.'.'.‘.‘.°.'.O!L a o o a: a a I o u o 0 19m 1959 1970 ( e stimate d ) Chart 2. Proportion of adults who have attained various levels of education: Selected years l9hO—1970. Source: Metropolitan Life Insurance Company. Our Rising; Educational Level. Statistical Bulletin 39: 3-5, August 1958. U.S. Bureau of the Census. Current Population Reports. Literacy and Educational Attainment: March 1959. Series P—EO, No. 99 (Feb. t, 1960). -7- The past 30 years have seen substantial increases in average family income. The outlook is for a continuation of this growth. (u) (5) Average family income Year after taxes Current 1959 dollars dollars 1929 ..... ............ $2,320 $h,070 1950........ ......... u,070 4,890 l959................. 5,880 5,880 1975...... ..... ...... - 7,500 Some of the increase in average family income has come about from the sharp increase in the number of working wives. Gainful employment of the wife increases the family's standard of living but also creates new problems when parents or children need bedside care. With more real income it might be presumed that the population is in a position to spend more for medical care. However, in addition to the matter of choices confronting consumers in spending income on various goods and services, medical service has grown more expensive whether measured in standard or current dollars. Consideration of personal medical care expenditures must take into account inflation, real family income, and changes in the nature and cost of care received, as each helps or hinders various segments of the population in obtaining medical care. Changing Disease Patterns The most dramatic change in disease patterns in recent years has been the tremendous reduction of infectious diseases and the resultant emergence of chronic disease as a major health problem. In 1910, deaths from infectious diseases totaled 525 per 100,000 population; deaths from chronic diseases totaled #48. Now the pattern is far more than reversed, with death rates for infectious disease down to less than 100 per 100,000; while those from chronic diseases have risen to 650. In 1910 the death rate for diphtheria was 21 per 100,000; today less than 0.05. In 1910 the death rate from tuberculosis was 154; today 7. Similarly, the rate for influenza and pneumonia has dropped from 156 to 32. These changes have been made possible by many factors acting together——among them development of immunization procedures, better sanitation, antibiotics, improved standards of living, and better and more widespread medical care. The attack on chronic diseases has been a fairly recent development. For some of these diseases we are only at the beginning of understanding. But for many others, the increase of knowledge when coupled with adequate medical care, has made possible a substantial lengthening of useful and comfortable life. For example, diabetes, a killing disease 40 years ago, lost much of its threat with the introduction of insulin. Many of the cardiovascular diseases which usually brought death or complete disability only a few years ago, can now be so well controlled that many of their victims can continue normal patterns of living for many years. However, successful application of new methods for controlling chronic disease often has depended on early diagnosis and prompt provision of good medical care. This fact has focussed growing attention on the need for ready availability of services to identify and treat chronic disease, services which require an expanding array of complicated equipment and laboratories and an increasing variety of allied health technologists. Health Personnel Manpower problems in the medical care field are related in part to the rapid population increase, which is tending to outstrip the growth in output of health personnel. Changes are also taking place in the amount of service demanded by a given population, in the way care is provided by particular personnel groups, and in the distribution of functions among additional and newer types of personnel. Increased awareness of health manpower needs in other parts of the world has added still another dimension to the consideration of U.S. requirements and responsibilities for educating physicians, dentists, nurses and allied personnel. Over the last generation, the number of physicians in relation to population has fluctuated between 125 and 135 per 100,000 persons, with a slight downward trend over the past decade which is expected to be accentuated in coming years. The predicted population increase will of itself require an increase in the number of physicians from 253,000 in 1960 to 330,000 in 1975, if we are to maintain the present physician— population ratio. An approximately 50 percent increase in medical school graduates will be needed to provide these additional physicians-~a growth in output well beyond the capabilities of existing medical schools in the United States. (6) Meanwhile, marked changes are taking place in the practice of medicine. Whereas, in 1930, 86 percent of all physicians were in private practice, today the percent has dropped to 69, reflecting a substantial increase in the numbers in hospital service (including house staffs), in teaching and research, and in administration. Concurrently, the number of private practitioners who limit their practice to a specialty has been increasing: in 1930 only about 1 in 6 were specialists, today the proportion is 1 in 2, and present trends point toward a ratio approximating 3 out of 4 by 1975 (Chart 3). Although the ratio of physicians to population has remained nearly constant, there has been a great increase, both absolute and relative, in auxiliary health personnel. In 1910 there were more physicians than -9- Number of . . . .. . physicians An Increasmg proportion of physucmns are full-fume specialists or are not in private practice. 300,000 250,000 Hospital _. .. service 200, 150, ........... ............... Full—time lOO, ‘ Private spec1alty practice 50 , General practice 1975 (estimated) Chart 3. Number of physicians in the Unted States, by type of practice: 1931-59 and 1975 1/ l/ At present rate of graduation. Source: U.S. Public Health Service. Health Manpower Source Book. Section 10. Physicians: e of practice, and location. Public Health Service PublicationN fé63y?Section 10) Washington, D. C ,1960; and estimates by Division of Public Health Methods- _ lO _ nurses; today there are two nurses for each doctor. As recently as 1925, physical therapists, occupational therapists and psychiatric social workers were almost unknown, and there were fewer than 1,000 dietitians, medical technicians, X—ray technicians, or medical social workers. Now each of these groups numbers substantial thousands. Above and beyond population growth and changes in patterns of medical practice, various factors are increasing public demand for physicians' services. These include higher standards of living, better education, urbanization, the growth of hospital and medical care insur- ance and prepayment and, through all of these, increasing public belief in the value and necessity of adequate medical care. Finally, the growing use of foreign—trained physicians to meet our domestic demands for hospital staff is a practice which cannot be expected to continue without seriously depriving other countries of the medical and health care leadership they so urgently need. Much the same pattern of declining supply, changes in practice, and increasing demand is found in the case of dental personnel. The number of dentists in relation to population has declined in recent years, though demands for their services continue to increase. To meet population increases alone, the number of dentists must increase from 100,000 today to 134,000 by 1975. This would require an increase of some 3,000 graduates a year over the present level of 3,200. (6) The number of professional nurses has risen far more rapidly than the population. In relation to population, the number of active graduate nurses has increased from 2A9 per 100,000 in 1950 to about 275 in 1960. But the increased complexity of medical care, the increased use of hospitals, the shorter working week, and the growing proportion of older invalids in the population are among the factors which continue to keep the demand ahead of the supply. The demand for practical nurses also far outruns the supply. A similar situation exists with respect to other allied health groups whose contributions are now essential to comprehensive medical care. Growing rehabilitation programs are hampered by the lack of physical and occupational therapists. The necessary accurate and comprehensive hospital records require more medical record librarians than can be trained in present programs. For some time, certainly, shortages of these and many other kinds of personnel will continue to handicap the provision of health services. Facilities Hospitals as we know them are of fairly recent origin. The first census of hospitals in this country, in 1873, listed 178 institutions. In the decades that followed, the role of the hospital gradually changed from a repository for the indigent sick to a place for the accurate diagnosis and effective treatment of illness for the rich as well as the poor. -11.. Still more recent has been the accelerated development of nonhospital medical facilities such as nursing homes, rehabilitation centers, group practice clinics, and others. For some years now there has been active planning to meet hospital needs, with substantial funds, both public and private, to finance the necessary construction. Federal aid under the HOSpital Survey and Construction Act of 1945 (7) has been among the factors stimulating a substantial increase over the past 15 years in the number of hospital beds, particularly in rural areas, and a significant replacement of obsolete facilities. In relation to population, however, the supply of general and special hospital beds has stayed about the same during this time, while the ratio of mental hospital beds to people has dropped by 13 percent as newer methods of treatment have decreased the need for these beds. Increasing the pressure on available hospital facilities, substan— tial changes have been occurring in patterns of hospital use. Most striking has been the increase in the rate of hospital admissions, an increase which has been only partly offset by a marked decline in the average length of stay. The increased admissions have been concentrated in general and in psychiatric hospitals, while the number of patients in tuberculosis hospitals has declined. Among the various types of nonhospital medical facilities, nursing homes have shown the most impressive increase in numbers in the past few years. As recently as 195M there were an estimated 180,000 beds in homes giving skilled nursing care; by 1960 the number had increased to almost 310,000. (8) Despite substantial improvements in standards of care in many of these homes during this period, about two-fifths of the beds in use still are classified as ”not acceptable" by State health agencies. Looking to the future, the Nation must still meet very great needs in the provision of more hospital beds to meet population growth, and in the replacement and modernization of obsolete structures. The growing importance of hospital—based outpatient services requires more adequate facilities for this type of service. Rehabilitation facilities and nursing homes are far from adequate to meet even present needs. Expenditures and Financing As a nation we are devoting 5.4 percent of our gross national product to public health, personal health service, construction of medical facilities, and medical research, not including the cost of educating health personnel. Thirty years ago, in 1928—29, private and public expenditures for health and medical care equaled only 3.6 percent of gross national product. (9) The increase in expenditures has been at an accelerated rate in recent years. This rise results from increases in utilization of services, the mounting complexity of the various components of care, and increases in the prices of various units of service and the cost of construction. _ 12 _ From l9h9-50 to 1958—59, private investment in medical facilities increased more rapidly than public funds for construction, but public funds still accounted for 55 percent of the total in 1958-59. (9) With respect to medical research, public expenditures have expanded six-fold in the same nine—year period, while private expenditures for'research increased less rapidly. In the United States personal health services are financed in a variety of ways including payments by individuals to the providers of services and the purveyors of health insurance, Federal, State and local taxes, employer contributions to health insurance plans and to the operation of in-plant medical services, and contributions to philanthropic causes. Almost four-fifths of the total amount spent for personal health services in 1958—59 came from private sources. This proportion has remained about the same over the past 10 years, having dropped from about nine-tenths of the total 30 years ago. (9) Public expenditures, now one-fifth of the total, may well be accelerated in the future by such new public programs as the Federal Employees Health Benefits Act of 1960 and the 1960 title on Medical Care for the Aged under the Social Security Act (Kerr—Mills program). The demand for methods of financing personal health services in such a way as to relieve the individual patient of sudden, heavy medical bills has led to a relatively greater increase in expenditures covered by health insurance than in either direct payments by individuals or public expenditures. Insurance benefits are not yet equal in size to public expenditures for personal health care, however. (See Chart h) Shifts in the use made of our private medical care dollars reflect changes in the nature of care and in utilization. The share going to hospitals (both directly and through insurance) has increased, from 23 cents in l9h8 to 29 cents in 1959. The proportion spent for dentists and drugs has remained relatively constant while that used for physicians' services has declined from 32 to 27 cents. In 1959 some three-fifths of the nation's hospital bill was financed by insurance benefits amounting to $2.9 billion. In that same year, insurance benefits of $1.5 billion met about one-third of private expenditures for physicians' services. Other components of the medical bill are seldom covered by health insurance although such components currently account for about hh¢ of every private dollar spent for medical care. (See Chart 5) _ 13 _ The proportion of personal health care expenditures met through insurance benefitshasincreased overthe pastdecade, butthe government-financed share has remained about the same. lOO - U) . g Public expenditures fi 80 _ rd q E <1) i U 60 g r E 8 ,2 5-1 H Other 3 8 private _/ g 8 MO _ expenditures g e {2* 8. a) “a *3 g .5 8 £1 E 20 _ £14 Insurance benefits 195 Chart it. Private and Public expenditures for personal health care, by percent from various sources: Selected years 1919-50 to 1958-59. l/ Includes direct payments, industrial in—plant services, and philanthropy. Source: Merriam, Ida C. ”Social Welfare Expenditures, 1958—59." Social Security Bulletin, v. 23, November 1960: #3 (Table 5). - in _ Changes between 1948 and i959 inthe dktfibufion otthe pfivate medical care dollar were of two kinds: The share of the dollar spent For hospital care increased, while that For physicians' services decreased; and the proportion of hospital and physicians' costs which was covered by insurance grew. £2E§ The average dollar £222 Dentists Covered by insurance Covered'by insurance The total per capita cost 0.0.0.00 O O .0 O O O O O O O O 0.. O O O O O O O 0A....O.O_O,O.O.O.O. O 0 O O O O .0 O {f}— \J‘I O \O [\3 Chart 5. Distribution of the private medical care dollar, l9h8 and 1959. Brewster, Agnes W. ”Voluntary Health Insurance and MEdical Care Expenditures, l9h8-59." Social Security Bulletin, V. 23, December 1960. Adapted from Table 2, excluding expenses for prepayment. Source: _ 15 _ Organization of Services Changes in medical personnel, facilities, and methods of financing have brought with them new patterns of organizing medical service. Some of these new patterns have been aimed toward overcoming the problem of fragmentation of service, especially at the level of the individual patient or family; however, other new patterns have accentuated the lack of focus. Thirty years ago the typical pattern of medical service was that of a continuing relationship with a family physician who treated a wide range of health problems. Growing specialization of physicians and increased reliance on allied health groups have been essential to keep pace with advancement in medical knowledge; but these trends have also created a need for coordinating the activities of the various types of personnel, medical and ancillary, to ensure continuity of care to the patient as well as the most advantageous use of scarce health personnel. Care is not only given by a greater variety of people——it has tended to move from the home to the institution. In 1930, Ah percent of doctors' visits were to the home, today only 10 percent. In 1930 only 1 person in 17 entered a hospital in the course of a year; now it is one in 8. (6) One of the major developments in the organization of services has been the growing practice of medicine by organized groups of physicians representing one or more medical specialties. A study in 19h6 showed that 3,100 physicians were in full—time group practice. The number is now over 10,000. This represents an increase from less than 3 percent of the practicing physicians in l9h6 to 6 percent today. (10) Growth of group practice is taking place in all parts of the country. While the composition and purposes of group practices vary widely, a few groups have been developed to provide comprehensive health service to a specific population. The functions of these groups cover the spectrum of health services from promotion of health to rehabilitation. Further growth of such comprehensive care plans can be expected. The growing place of the hospital in the organization of health services is reflected in the rising proportion of physicians employed in hospitals and in the increased concentration within hospitals of highly specialized laboratories and equipment. Today's hospitals not only treat more patients on an inpatient basis but also have expanded their outpatient activities. Emergency units in particular increas- ingly have become centers for the provision of outpatient care. With the increased specialization of care in hospitals has come a growing differentiation of services within and among medical care facilities. New patterns in organization are being tried, such as programs in"progressive patient care," which classify patients within _ 16 _ a particular hospital according to the level of need for care. One purpose of nursing homes and other specialized facilities for the care of the longterm patient is to effectuate economy of service through provision of differing levels of care in separate institutions. A few organized home care programs have been developed to serve persons who do not need to be hospitalized but who nevertheless require care which cannot be effectively rendered by the individual practicing physician alone. Usually such programs are hospital—based, with hospital staff and equipment available as needed. In some communities the Visit- ing Nurse Association or the local health department has served as a nucleus for the provision of nursing and other specialized services and equipment. Home care programs have also been developed to provide out-of-hospital care of mental patients in their own communities. Special medical care programs for particular population groups or disease problems are a growing feature of medical service organization. Sometimes developed under public auspices and in other cases privately controlled, these programs extend specialized service in such areas as heart disease control, cancer detection and treatment, rehabilitation, crippled children's services, maternal and child health, and care of the aged. In meeting one special need, such programs also do create a new organizational requirement: the coordination of new and diverse activities. To coordinate the provision of medical services in wider geographic areas, interest has grown in regional organization of health services, to organize and coordinate ”all the health resources and services within a defined area, for the purposes of maintaining the highest possible level of medical care, and of adapting a comprehensive health program to the characteristics and needs of the area." (ll) For many years the develop- ment of regional organization was confined to a few pilot projects, which generally gave a key role to a medical school in the area. Recently, with the proliferation of types of medical facilities and specialties, and with the increased complexity and cost of medical care components, there has come a growing recognition of the need for regional planning, with both public and professional participation. Standards of Quality Increased attention has been directed toward the development and application of standards relating to the quality of medical services, by public authorities as well as by the health professions and other private groups. The medical profession has long accepted responsibility for the accreditation of hospitals. With the first program started more than #0 years ago by the American College of Surgeons, accreditation now is in the hands of the Joint Commission on Accreditation, involving cooperation among four associations interested in improved standards of health care: the American Medical Association, the American College of Surgeons, the American Hospital Association, and the American College of Physicians. _ 17 _ Certification of medical specialists is another area in which the professional associations have taken the lead in setting standards. From 1917, when the American Board of Ophthalmology was established as the first of the examining and certifying boards, a total of nineteen specialty boards have been created. Although a physician need not be Board-certified in order to limit his practice to a specialty, there has been a trend towards certification, particularly among younger doctors. Various other voluntarily administered controls have been developed to foster high standards of medical practice. To participating hospitals medical audits give empirical performance data against which each hospital may assess the performance of its own professional staff. In sponsoring prepaid medical care plans, several county medical societies have developed a system of claims review to evaluate the type of care given and, by education or disciplinary action, to correct deficiencies and misuse. The application of standards for care is an inherent part of the organization and administration of some medical group practices. Governmental programs aimed at promoting high medical care standards have been directed mainly toward the licensure of professional health personnel and medical facilities. Other activities include the .regulation of drugs and the application of quality standards through certain publicly supported medical care programs (e.g., crippled children's services). These and related programs will be discussed in greater detail later in this chapter, in the section on governmental programs in the field of medical care. In spite of the progress already made, serious gaps remain in public and private efforts to assure a high quality of medical care. In only a few areas of the country have satisfactory standards for nonhospital medical facilities such as nursing homes and homes for the aged been developed and applied. The rapid growth of insurance plans has raised questions about the need for additional controls over the quality of services financed through the prepayment mechanism. While the medical, dental and nursing professions generally are governed by highly devel- oped systems of licensing and certification, such controls as yet tend to be in an earlier stage for many of the allied health groups. Governmental Medical Care Activities A further trend to be considered in our review of medical care activities is the increasing number and complexity of governmental activities in this field. In recent decades there has been a growth in direct governmental health and medical services, in governmental financial support of private medical services, in public aid for the construction, of facilities, and in public regulation of medical care personnel and facilities. All levels of government--Federal, State, and local--have participated in these programs, with the problem of coordinating the various activities becoming increasingly great. _ 18 _ Public hospitals have long included municipal and county general hospitals, and specialized institutions for tuberculosis patients and the mentally ill. Federal hospitals for many years have served such spe01al beneficiary groups as military personnel, veterans, merchant seamen, and American Indians. In recent years the use of these public hospitals has increased at almost the same rate as the population: Trend.in Use of Public Hospitals 2/ Admissions Average daily census Number Rate per Number Rate per 1,000 pop. 1,000 pop. 1950...... 4,991,000 33 9h2,000 6.3 1959...... 6,106,000 35 973,000 5.5 l/ Includes Federal,State, and local governmental hospitals. Source: Hospitals. V. 25, No. 6, Part 2. Administrators Guide Issue. June 1951. Table 3. . V. 34, No. 15, Part 2. Administrators Guide Issue. August 1, 1960. Table 20. Public health nursing, a traditional part of the local public health department's activities, has assumed growing importance with the develop— ment of organized home care programs for the chronically ill and aged. Health department nurses, in cooperation with nurses employed by voluntary visiting nurse associations, can be expected to provide an increasing amount of bedside care, as well as carrying on their traditional preventive health functions. Public health and medical programs for mothers and children, crippled children, persons in need of vocational rehabilitation, and those with tuberculosis or other infectious diseases have a fairly long history. 0f more recent origin have been the community—oriented programs to promote mental health and for the detection of diabetes and other chronic disease. Other governmental programs have provided financial aid for construction of hospitals and related medical facilities. In recent years, a growing variety of governmental programs has emerged to help in financing private medical services. Examples of Federal support are the ”home—town care" programs of the Veterans Administration and the Medicare program of the Department of Defense, each of which pays for care of Federal beneficiaries through private medical resources. Many state and local welfare authorities make payments _ 19 _ for private medical care of public assistance recipients, with partial matching from Federal funds. These payments are scheduled to be expanded under newly established Federal grants for medical aid to the aged. The recently adopted program of health insurance for Federal employees is financed jointly by employee and Government funds. In relation to total health and medical care expenditures, governmental expenditures grew more rapidly in the early 1930’s than they have since that time. In recent years their rise has just about paral— leled that of private expenditures in this field. In a few areas, such as local public health services, governmental expenditures have actually lagged behind the growth of the population. Although the medical profession still carries the largest responsibility for maintaining adequate standards of medical practice by individual doctors and in medical care institutions, there has been growing recognition of the need for public participation in promoting adequate standards. State licensing of health personnel, already highly developed for doctors, dentists, and nurses, is being extended gradually to cover such allied health groups as physical and occupational therapists, medical laboratory technicians, optometrists, pharmacists, practical nurses and others. The Food and Drug Administration requires that pharmaceutical products meet increasingly high standards of safety and purity. The demand for public regulation of health insurance plans can be expected to grow further as the number and size of such plans increase. At present, in most States, the regulation of health insurance plans is centered in State insurance commissioners who are concerned primarily with the financial soundness of the plans. However, public opinion is increasingly demanding that greater emphasis in the regulation process be placed on the kinds of benefits provided and that greater recognition be given to the interrelationship of financial mechanisms and the quality and quantity of care provided. Among the governmental programs relating to medical care, those of the Public Health Service, which range from the multimillion dollar hospital survey and construction grant program to small experimental studies in the use of particular types of health manpower, are described and analyzed in the next chapter of this report. _ 20 _ II. CURRENT PUBLIC HEALTH SERVICE ACTIVITIES IN MEDICAL CARE The Public Health Service plays a significant role in many medical care activities, both in the direct provision of personal health services to certain Federal beneficiaries and in the evaluation or support of medical care resources available to the population generally. Important among its activities bearing on medical care resources for the people of the Nation are those relating to health status measurement, personnel, facilities, expenditures and financing, organization of services, and related aspects of medical services. Examples of activities in these fields are considered in the following (flscussion. Analysis of Health Status and Use of Services Several Public Health Service programs provide information on the health status of the Nation, the use of medical care services, and their relationships to socio—economic factors. Within the National Center for Health Statistics, the National Health Survey Program (12) and the National Office of Vital Statistics (13) compile and analyze data on the volume of medical care. In various parts of the Service, studies have been conducted dealing with the medical care needs of the aged (1h), of migrant workers (15), and residents of rural counties. (16) Indices such as those developed by the National Health Survey give a better understanding of the use of medical services and facilities, in relation to such factors as age, economic status, and insurance coverage (17). Studies have been conducted of the factors that motivate people toward seeking health examinations. (18) Personnel The recruitment and training of health services manpower are among the highest priority problems in the field of medical care. The Public Health Service has given these problems considerable attention in recent years. In addition to the activities of the Surgeon General's Consultant Group on Medical Education (6), the Service has made numerous studies of supply, need, and education for other health professions including the preparation of manpower source books on physicians, dentists, nurses, social workers, and other personnel. (l9) Traineeships and fellowships are provided in such areas as professional nursing, mental health work, and hospital and medical care administration. (20) Among present studies are those relating to the training and utilization of dental assistants and.practical nurses. A manual has been prepared to aid hospitals in making the best use of nursing personnel. (21) - 21 - Facilities Over the past decade significant Federal support has been given to hospital planning and construction, under the Public Health Service's Hospital and Medical Facilities Construction (Hill-Burton) Program. The program has included assistance for the construction of general, tuber- culosis, mental, and chronic disease hospitals. Recentlm increased aid has been channeled to nursing homes, diagnostic and treatment centers, rehabilitation facilities, public health centers, and other facilities offering care outside hospitals. (22) Currently the Service is conducting studies of Progressive Patient Care (23), a program designed to furnish better care through organization of hospital services around the medical and nursing needs of the patient. Illustrative of the extramural research activities sponsored by the Public Health Service are the current studies of the regionalization of health care services, and a study of the hospital as a community health center. Prominent among present Public Health Service activities relating to facilities are studies of nursing homes and related facilities with particular reference to such matters as the characteristics of the patients, the standards of facility construction, the quality of care provided, the methods of organizing and financing the homes, and licensing procedures. (2h) Expenditures and Financing Apart from the necessary financial analysis that accompanies the administration of grant programs, Public Health Service studies of the details of medical care expenditures and financing have been piecemeal. Recently, however, there has been some compilation and analysis of consumer expenditures for medical care $33, of services in prepaid dental care plans (26), and of medical care costs in relation to public health (27). Organization of Services The Public Health Service has demonstrated its concern with the organization of medical care services at the community level through its studies and promotion of organized home care programs (28% homemaker services, (29) patient—referral systems, regionalization of health services, (30) and studies of group practice (10). Standards of Quality The Service's attention to standards of quality has been focused mainly on nursing personnel and facility standards. In the latter area, the hospital and medical facilities construction program has given impetus to State licensure of hospitals and related medical facilities. - 22 - Personal Health Practices Much of the health education activity in which the Public Health Service participates is aimed toward the improvement of personal health practices. In the area of restorative services, booklets have been developed to show patients how to further their own physical rehabili— tation and reduce the disability from stroke (31) or arthritis. (32) Activities to stimulate State and local programs for diabetes and glaucoma screening and for cervical and.bre&3tcancer examination have as one of their objectives the encouragement of such preventive health practices as periodic health appraisal by a physician. Expenditures for Medical Care Research The Public Health Service is currently spending about $2.25 million to support research on the administration of hospital and medical care services. Voluntary agency and foundation spending in this area is probably somewhat less. This means that altogether perhaps $h—5 million, or 2/100 of 1 percent of all health expenditures, is being invested in attempts to understand how a $25 billion industry functions and how to improve its operations. Conclusion These few examples of activities in which the Public Health Service is currently addressing itself to the problems of medical care suggest that in most of the areas of interest--personnel, facilities, organization, finance, standards--the Service can demonstrate some creditable program activity. In relation to the need for leadership, however, the present activities tend to be fragmentary, uneven, and lacking in focus. Some of the programs whose titles appear comprehensive (e.g., "public health traineeship program,” "chronic disease demonstrations"), are found when scrutinized to be minute in relation to the magnitude of the problems with which they deal. Medical care administration is a complex process which includes the planning, organizing, financing, coordinating, and evaluation of all resources and services that a medical care program comprises. Very few of these elements have received adequate attention and little attention has been paid to the totality of medical care administration. - 23 - III. THE NATION IS CONCERNED In recent years the changing problems and patterns of medical care have been the object of growing national concern, expressed by individuals, private groups, and public authorities. Of particular interest for the present study are a number of reports by Federally appointed committees that deal fairly directly with the medical care functions of the Public Health Service or the Federal government generally. The increased attention being given to medical care problems by groups outside the Federal Government is a measure of the expanding variety of other individ- uals and organizations having a stake in efforts to strengthen the Nation’s medical services. Reports of Federally Appointed Committees Since World War II the role of the Federal Government in the field of health has received the attention of a series of Federally appointed commissions and committees, notable among them the first and second Hoover Commissions, the Reed Committee on medical school finances, the Magnuson Commission on the Health Needs of the Nation, and several recent committees studying problems in medical research and medical education. In keeping with the scope of the present report, the following discussion does not cover the work of advisory committees concerned only with specific Federal agencies other than the Public Health Service. The Commission on Organization of the Executive Branch of the Government (the first Hoover Commission) (33) in 1949 centered its atten— tion in the health field on reorganization to consolidate Federal medical services. At the same time it recognized a growing problem in medical education, and recommended a study of needs for emergency aid to medical students and schools. The 1950 Surgeon General's Committee on Medical School Grants and Finances (3h) (the Reed Committee) was concerned primarily with evaluating the effect of the Public Health Service's research and education grants on medical school finances and medical education,to provide a basis for recommendations to improve the effectiveness of those programs. This group noted the general financial stringency faced by medical schools, with respect to operating funds, and recommended that the Surgeon General give careful attention to this problem. In 1951 President Truman created the President's Commission on the Health Needs of the Nation (the Magnuson Commission) to make a critical study of the Nation's total health requirements and to recommend courses of action. (35) This study, then, was focused on health rather than on the administration of government. Looking toward a goal of comprehensive health services for all people, the Commission recommended Federal action in a number of areas, including: 2) 3) LL) 5) 6) 7) 8) 9) 10) .2h- Periodic assessment of morbidity in the general population. Aid for education of health personnel, including aid for facilities, scholarships, and operating expenses. Stimulation of more effective organization for medical care through: a) Federal loans to local organizations to encourage the establishment of group practice facilities; b) Federal funds to hospitals, health departments, medical schools, and other appropriate bodies to encourage pilot demonstrations of regional coordination of health services; c) Federal grants to aid local health departments; d) More emphasis upon administrative research into better and more efficient methods of utilizing our physical plant and our health personnel to deliver more and better health services. Increased Federal support of research and research workers. Helping people to meet the costs of medical care by: a) Promoting the development of voluntary prepayment plans-- for example, through payroll deductions for Federal employees; b) Use of the OASI insurance mechanism for prepayment; c) Federal grants—in-aid to assist States in making care available to public assistance recipients and others; d) Federal grants-in-aid to assist State and local govern— ments in developing and operating facilities for the care of long-term patients. The establishment of a Department of Health and Security. Strengthening and expanding public health programs of communicable disease prevention and disease detection. Strengthening of rehabilitation programs. Strengthening of chronic disease programs, including early detection, and community home-care programs. Inclusion of dental care as an essential element of comprehensive health service -25- 11) Greater attention to problems of environmental health, including research, training, and municipal and regional planning. The Commission also reviewed the health problems of special population groups, and made recommendations for programs for maternal and child health, industrial health, the rural population, migratory workers, the aging, and veterans and other Federal beneficiaries. The Task Force on Federal Medical Services of the second Hoover Commission was charged with an appraisal of the Federal medical establish- ment. Those of its recommendations accepted by the Hoover Commission (36) included: 1) That the Armed Services Medical Library be converted into a National Medical Library; 2) That the Federal Government make use of contributions to voluntary health insurance systems, in providing for care of military dependents, merchant seamen, and Federal employees; 3) That the Federal Government help give greater emphasis to preventive health services; h) That the Federal Government help meet the problems of mental disease by increased research and training grants; 5) That there be a review of the Public Health Service grants to States, considering particularly their inflexibility. The Secretary's Consultants on Medical Research and Education, under the chairmanship of Dr. Stanhope Bayne-Jones (37), in 1958 made a broad study of the medical research activities of the Department of Health, Education, and Welfare, and their relationship with medical education. Suggesting guidelines for future public policy on the expansion of medical research and training generally, the Consultants made the following recommendation bearing directly on medical care studies: That the Public Health Service "review comprehensively its functions, organization and staffing relating to research bearing on all aspects of medical care, financing of medical care, and medical resources with a view to establishing a total research program appropriately divided between intramural and extramural research." - 26 _ Other findings or recommendations relating to medical care needs were that 1h to 20 new medical schools should be built to maintain the existing physician-population ratio, that the output of dentists should be increased, that public health research on the prevention, control, and treatment of chronic disease should be intensified, and that medical research and training programs of the Office of Vocational Rehabilitation and several other Federal agencies with health functions (in addition to the Public Health Service) should be expanded. The Surgeon General's Consultant Group on Medical Education, with Mr. Frank Bane as chairman (6), was also appointed in 1958 specifically to examine how the Nation might be supplied with an adequate number of qualified physicians. After analyzing trends in medical care use and in patterns of medical practice, the Consultants set as a minimum goal the maintenance of the current physician-population ratio. They recommended ways of increasing the number of medical school graduates, while maintain- ing the quality of medical education. Recognizing that problems of medicine cannot be dissociated from those of related health professions, the Consultants saw an urgent need for studies of other health professions, as well as for continued planning and review in the field of medical education. In 1960 the Committee of Consultants on Medical Research (38), appointed by the Labor—HEW Subcommittee of the Senate Appropriations Committee to review the government's medical research program, commented on the program’s growing impact on medical care needs and resources. The Committee, led by Mr. Boisfeuillet Jones, expressed the opinion that medical research findings have generally increased the effectiveness of available health services, but stressed the need for more physicians, improved facilities, and supporting personnel to achieve fuller applica- tion of research advances. Included among the Committee's many recommendations were: that medical education capacity be expanded, that more financial aid be made available to medical students, and that Federal programs for research on medical care of the aging and for demonstration and application of new research findings be strengthened. Interest Among Other Individuals and Groups Outside the Federally appointed committees, widespread interest in medical care problems has been expressed by a variety of groups such as State and local governments, professional associations, members of Congress, and the press and other media of communication. Many States and regions have made studies leading to recommenda- tions for expansion of educational opportunities for the health professions; and State and local agencies are cooperating in the develop- ment of State plans for hospital and medical facilities. A precedent was established during World War II when the Governor of Maryland appointed a citizen's committee to examine the status of medical care in -27- that State. North Carolina also used this mechanism to review its medical care problems. In keeping with these precedents, the California Governor's Committee on Medical Aid and Health recently completed'a broad study of that State's medical care needs and resources. Other States have asked citizen's committees to report on their hospital facil- ities and on health and medical care within their borders. And at the local level, New York City, for example, has appointed a Mayor's Committee on Health and Hospitals which was empowered to study voluntary and public medical care activities in New York City and make recommenda— tions for their improvement. Responding to public dissatisfaction with health insurance rates and benefits, the Insurance Commissioners of Pennsylvania and New York, through the medium of their control of prepayment plans, have taken ,positions which directly affect the medical service being given under these plans, both in quality and quantity. The adjudication of the Pennsylvania Commissioner has led the Insurance Commissioners of other States to a re-examination of their own authority and responsibility. The study of hospital care and financing ordered by the New York State Commissioner of Insurance points to a rethinking of hospital, State government, and underwriter responsibility. National and State professional groups are also active. For example, to develop more accurate information on health services, the American Medical Association in February 1960 established a Commission on the Cost of Medical Care and appropriated $100,000 to finance its activities. In addition to analyzing the overall picture of medical care costs, the American Medical Association has expressed the hope "that the study will also provide some sound advice for the consumer on how to get the most benefit from his health dollar.” (39) Almost daily, the private citizen sees newspaper stories on such topics as manpower shortages, increased costs of hospitalization, a new health benefit sought through collective bargaining, or hearings on the use of generic versus trade names for prescription drugs. Lengthy discussions of important issues involved in medical care have appeared in newspapers and magazines having large nationwide circulations. Television programs and best—selling books have also dealt with medical care problems. Recent statements by Congressional leaders have given added voice to popular concern about medical care. Thus, Representative Melvin R. Laxmlmssm& "But there are many unknowns still remaining in this field of hospital utilization and medical economics. I believe that the Nation should be able to turn to the Public Health Service for enlightenment in this field. Therefore, I am encouraged to note that the Service as proposed in the President's budget is pursuing a number _ 28 _ of studies~-at a comparatively low cost--to elucidate the facts in this area. It is my personal belief that the Public Health Service could profitably devote more of its resources than are presently programmed to the exploration of these factors which affect the availability of medical knowledge." (40) Representative John E. Fogarty in a speech at the dedication of the Communicable Disease Center Building in Atlanta, Georgia, said: ”... 19th century health machinery doesn't fit a 20th century society. A lot of people still seem to think that that if they have a good doctor, they can relax and rely entirely on him to look after their health. Maybe some of their doctors believe it too. But I say that's a 19th century idea. . . Similarly, the big health issues of today are so broad that they cannot possibly be solved by any one group or profession. . . . I'd like to see the people who are going to get sick as well as the people who will be paid for curing them have a voice in such plans." The debate in the 86th Congress on the legislation to provide medical care for the needy aged brought to the attention of the legislators and the American public a mass of data on the health of the aged and a wide variety of proposed methods of providing medical care to them. The emphasis in this case, and, until very recently, in most discussions of governmental activities, has been on where the dollars are to come from, and not on the type or quality of services to be provided. -29- IV. WHAT NEEIB TO BE DONE? The Nation faces a need for action to alleviate shortages of qualified health personnel, to provide appropriate types and numbers of medical care facilities, to assure effective organization of services, to ease the financing of care, and to promote high standards of profes- sional practice in medical care. Some aspects of these problems can be dealt with independently by the professional groups and other volun- tary organizations concerned. In other instances State and local governmental participation will be required. To tackle the most pervasive and difficult problems, the Federal Government should be prepared to cooperate in providing leadership, technical aid, and financial support. Use and Recruitment of Health Personnel No medical care program can function adequately without sufficient numbers of competent personnel in the health fields. In view of the present competition for talent, maintaining adequate numbers of health personnel without sacrificing quality of training presents a pressing problem. Additional schools for physicians and other professionally trained health personnel are urgently needed; but well-qualified students must be found and the faculty and facilities afforded them must provide a satisfactory educational program. It is important to foster by experimentation and innovation the most effective use of the time and skills of health personnel now available. This may involve providing professional personnel with administrative and sub—professional support in an organizational system designed to maximize profesSional productivity. It may also involve a re—allocation of the duties of the various individuals working in the health fields with such changes being reflected in professional school curricula as well as in other training programs for both clinical and administrative health personnel. Another requirement to assure sufficient personnel in the health fields is to find ways to stimulate qualified young people to enter those fields and to practice in those locations where existing and anticipated shortages are greatest. By making the economic and psychological satisfactions of the various health vocations competitive with alterna— tive careers, and.by finding means to make undergraduate and graduate education financially accessible to all those qualified, entry into the health fields would be made more feasible and.desirable. In addition, other potential workers, such as older women, should be encouraged to undertake full or part-time health employment; this will require the development of adequate retraining programs. As part of any accelerated program of personnel recruitment and effective utilization, it is important that the trends in health personnel resources be regularly reassessed and that professional -30- associations, educational institutions, Government agencies, and the general public be kept informed in order that they can make intelligent decisions regarding their contributions to increasing the supply of well—qualified health personnel. Medical Care Facilities To meet its requirements for medical care facilities, the Nation needs additional hospital beds and the replacement or modernization of obsolete facilities. But there must also be more nursing homes, out- patient clinics, and other nonhospital facilities for care of persons who do not need all of the specialized services of a hospital. There must be increased sharing of expensive equipment and services among facilities. Another area for exploration, suggested by the increased use of hospital emergency services, is the possible need for closer association between private physicians' offices and organized outpatient facilities which offer around-the-clock physicians' coverage and serve as central repositories for special diagnostic and treatment services. Financing Over the past three decades great strides have been made in developing methods of financing medical care. These advances have made it possible for an increasing proportiOn of the American public to benefit from the Nation's substantial health resources. Blue Cross and Blue Shield, commercial insurance companies, and direct service plans have helped place many personal health services within the financial reach of large segments of the population. Federal legislation has been designed to permit military dependents, Federal employees, and aged persons more readily to avail themselves of medical care. Further study is needed to understand more fully the impact of various methods of financing on the individual's medical care expenditures, the use of different types of services, and the quality of care furnished. Experiments must be conducted in extending insurance to cover additional benefits or population groups, and in devising new ways to distribute and control costs, while sustaining high—quality services. Organization of Services Innovation and experimentation will be required to develop improved methods of delivering high-quality medical care at the lowest possible cost both in economic terms and in manpower utilization. Communities or groups wishing to try out new forms of organization in such fields as group practice, home care programs, regional pooling of specialized services, rehabilitation activities, aid to the aged, hospital—based programs for long-term ambulatory and home—bound patients, and many other areas, must be able to secure necessary financial backing and technical aid, at least in the developmental stages of their work. -31- In developing new organizational patterns, care must be exercised to establish structures which will foster the wholehearted, enlightened cooperation of the individual patient and the health personnel as well as of the many institutions, agencies and practitioners serving a single patient; and which will minimize psychological, social, and cultural barriers to such cooperation. Standards of Quality for Care An imposing task in the health field is the further development of reasonably objective criteria of performance and achievement in medical care, to serve as a yardstick in measuring the quality of medical care received individually and collectively by Americans. As noted earlier in this report, important beginnings in this direction have already been made in the United States on selected components of medical care. With reSpect to other facets of medical care, additional studies and negoti— ations are needed as a basis for the development of widely understood and accepted standards. Coordination of Governmental Programs At Federal, State, and local levels, a variety of governmental activities affect medical care both directly and indirectly. Efficient direct service to various types of legal beneficiaries is sometimes handicapped by the fact that a number of beneficiaries may be eligible for medical attention from several different agencies. There is a need to identify areas of uncertain or divided responsibility and to assist the agencies concerned in improving the coordination of their services. Such clarification would help to assure that each eligible beneficiary receives an optimum amount of care from a minimum.number of agencies, with reduced fragmentation of services provided to the individual patient or family. Governmental agencies are involved in licensure, financial support for construction of hOSpital facilities and nursing homes, loans to new medical groups, regulation of health insurance rates, and many other activities which affect the quantity and quality of the total medical care available in the geographic or political units they serve. Here, also, coordination would permit the elimination of unwittingly contra— dictory policies among various agencies and the establishment of broad guidelines oriented toward improving the total health picture. With the proliferation of governmental activities in health, many of them outside the traditional departments of health, a constant effort must be made to keep the left hand and right hand using compatible means for accomplishing a common, broad purpose. Within the Federal government alone, many agencies and adminis- trative units have medical care functions. But these functions, under— taken over a period of many years to meet a wide variety of special needs, tend to provide or finance care according to diverse and.sometimes inconsistent policies. For example, while the Federal government through -32- one program promotes improved standards of hospital care in institutions throughout the country, at the same time another program, by paying less than the full cost of service to legal beneficiaries in non-Federal hospitals, may put pressure upon institutions in straitened financial circumstances to compromise on the quality of care they provide. To avoid such problems and their deleterious effect on medical care, continu- ing review and coordination of Federal medical care activities is needed. Improvement of Medical Care Administration Given the complexity of modern therapy, diligence and skill in administration are required to provide the trained personnel, facilities, finances, and other components necessary to provide the best possible medical care for the population served. Sound planning and careful implementation of objectives are required whether the service is rendered by a rural physician practicing alone or by a group of physicians and allied personnel in an organized health plan; and whether the costs are paid by the individual, industry, private groups, or governmental agencies. Increased knowledge of the administrative ingredients that have produced good medical care, and the development and application of improved techniques in medical care administration would permit those responsible for existing programs to evaluate the effectiveness and efficiency of their present organization and to correct any defective administrative procedures. Similarly, new medical care programs can benefit from sound planning by their sponsors. A recognized national center for reliable information and technical assistance in medical care administration would serve the Nation by bringing together existing knowledge on medical care administration and making it readily available to all interested persons. It could increase the fund of knowledge by stimulating and supporting studies as necessary; and could reduce the "cultural lag" by encouraging prompt, widespread utilization of this information. Eliminating Deficiencies in the Nation's Medical Care Because of the diversity of our society and the multiplicity of public and private medical care programs in the United States, it is possible for geographic or social segments of the population to receive less than adequate medical care without these deficiencies becoming immediately apparent either to private or to governmental groups. In order for all of the Nation's citizens to have access to adequate medical care, the health status of the population must be continually reviewed and problems of inadequate care brought to light for concerted attention by professional and lay groups, both governmental and private. National leadership is required: first, to help identify problem areas early; and, second, to foster fruitful collaboration between the various elements of our society devoted to building the Nation's health. -33- V. PROPOSED ROLE OF PUBLIC HEALTH SERVICE Medical care in its inclusive sense encompasses all personal health services and their auxiliary and supporting resources which safeguard and improve health and which ameliorate and cure disease and disability. No voluntary or governmental agency now has the responsibility to evaluate continuously the medical care available to the population of the United States and to seek means of filling deficiencies that may be found. The Public Health Service should exercise leadership to bring about such reviews and to help develop programs for meeting present and emerging deficiencies. To be effective, review and planning must be carried on in cooperation with the many Federal, State, local and voluntary agencies concerned with certain aspects of these problems. The specific recommendations which follow are intended to generate a program of action in the development of improved medical care for the Nation. I. Reliable, objective knowledge in the field of medical care is a prerequisite to intelligent planning and effective use of resources by those professional groups, private organizations, and voluntary and governmental agencies concerned with the Nation's health. Thereforez it is recommended: That the Public Health Service seek the statutory authority and appropriations necessary to create and conduct a continuing program of intramural studies and technical assistance, and a program of grants in support of extramural research, training, and demonstrations in the organization, administration, and financing of medical care. II. Without adequate numbers of well—qualified health personnel in all professional, technical and health—related services, the attainment of desirable goals in medical care is seriously impeded. Thereforez it is recommended: That the Public Health Service expand its activities in order to exercise vigorous leadership in anticipating the Nation's needs for all types of health personnel, in stimulating the recruitment of qualified individuals into the health fields, in sponsoring studies of educational patterns, in supporting training activities where necessary, and in maintaining and enhancing the skills of existing health personnel to meet the changing demands of modern medical care. -31.- III. Changing concepts of medical care require facilities within which such care can be advantageously provided. Thereforez it is recommended: That the Public Health Service expand its activities in facilities research; increase its emphasis on planning the development of and coordination among such facilities as hospitals, group practice clinics, outpatient depart— ments, nursing homes, home care programs, and rehabilitation centers; and, as needed, support the construction of all types of health facilities. IV. As a basis for continuing improvement in medical care, medical research must provide a growing fund of scientific information. Therefore, it is recommended: That the Public Health Service continue the development of its successful programs of medical research. V. Since the goal of all medical care is to improve the health of the people, it follows that the primary emphasis in planning should be to assure the delivery of medical care which meets the highest possible standards of medical care. Widely accepted and clearly defined standards of medical care would clarify the goals of all efforts in the field of health. Therefore, it is recommended: That the Public Health Service exercise leadership in collaborating with the professional groups and agencies involved to develop acceptable standards of medical care and provide technical assistance to health insurors and State insurance commissioners and State Departments of Health to expedite the widespread use of these standards. VI. Directly, as a purchaser, or as a partner in State expenditures, the Federal Government is involved in a wide variety of programs which provide medical care for individuals. In order to meet the needs of the patient as a person, and to make the most effective use of available medical resources, the Federal Government should take whatever steps are required to eliminate any undesirable overlapping and duplication among these programs and assist and encourage States and localities to reduce the fragmentation of tax-supported medical care programs. Therefore: it is recommended: That the Public Health Service bring to the attention of the President, the Congress, and the Nation the need for better coordination of governmental medical care activities, so as to assure the highest possible quality of service to the individual that can be provided with the greatest economy of money, facilities, and health personnel. (lo) <11) <12) (13) <14) _ 35 _ REFERENCES Bureau of the Census. Current Population Reports. Population Characteristics, P—20, No. Tl, and Population Estimates, P—25, Nos. 187, 207. Bogue, Donald J. 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U.S. National Health Survey. Health Statistics from the National Health Survey: Interim Report on Health Insurance, United States: July - December 1959. Public Health Service Publication No. 58h-B26. Washington, D. C., December 1960. Borsky, Paul N., and Oswald K. Sagen. ”Motivations Toward Health Examinations." American Journal of Public Health, V. #9: 5lh—527 (April 1959). U.S. Public Health Service. Health Manpower Source Book, Sections l-lo. Public Health Service Publication No. 263 (Sections l-lO). Washington, D.C., 1952-1960. U.S. Public Health Service. Professional Nurse Traineeships. Parts I and II. Public Health Service Publication Nos. 675 and 676. Washington, D.C., 1959; —————— . The Training Program of the National Institute of Mental Health, l9u6—57. Washington, D. C., 1958. U.S. Public Health Service. How to Study Nursing Activities in a Patient Unit. Public Health Service Publication No. 370. Washington, D. C., l95u. U.S. Public Health Service. Ten Years of the Hill—Burton Hospital and Medical Facilities Program, 1946-56. Public Health Service Publication No. 616. Washington, D.C., 1958. Haldeman, Jack C. "Progressive Patient Care: A Challenge to Hospitals and Health Agencies.” Public Health Reports, V. 7h: u05-hos (May 1959). Solon, Jerry, et al. Nursing Homes, Their Patients and Their Care. Public Health Service Publication No. 503. Washington, D. C., 1957; and U.S. Public Health Service. National Conference on Nursing Homes and Homes for the Aged, Feb. 25—28, 1958. Public Health Service Publication No. 625. Washington, D. C., 1958. Mushkin, Selma. ”Characteristics of Large Medical Expenses.” Public Health Reports, V. 72: 697-702 (August 1957). Pelton, Walter J., and John C. Rowan. Digest of Prepaid Dental Care Plans, 1958. Public Health Service Publication No. 585. Washington, D.C., 1958. (27) (28) (29) (30) (31+) (35) (36) (37) (38) (39) (1+0) _ 37 _ Unpublished Study of the World Health Organization. A Study of Selected Home Care Programs: A Joint Project of the Public Health Service and the Commission on Chronic Illness. Public Health Service Publication No. 4&7. Washington, D. C., December 1955. Homemaker Services in the United States: A Report of the 1959 Conference. Public Health Service Publication No. 746. Washington, D.C., 1960. Mountin, J. W., E. H. Pennell, and.V. M. Hoge. Health Service Areas: Requirements for General Hospitals and Health Centers. Public Health Bulletin No. 292. Washington, D. 0., 1945. U.S. Public Health Service. Strike Back at Stroke.Public Health Service Publication No. 596. Washington, D.C., 1958. U.S. Public Health Service. Strike Back at Arthritis. Public Health Service Publication No. 747. Washington, D. c. 1960. Commission on Organization of the Executive Branch of the Government. Reorganization of Federal Medical Activities: A Report to the Congress. Washington, D. C., March 19h9. Surgeon General's Committee on Medical School Grants and Finances. Medical School Grants and Finances, Parts I-III. Public Health Service Publication Nos. 53-55. Washington, D. C., 1951. President's Commission on the Health Needs of the Nation. Building America's Health, Vol. 1: Findings and Recommendations. Washington, D.C., 1952. Commission on Organization of the Executive Branch of the Government. Federal Medical Services: A Report to the Congress, Washington, D.C., February 1955. Secretary's Consultants on Medical Research and Education. The Advancement of Medical Research and Education Through the Department of Health, Education, and Welfare. Washington, D.C., June 1958. Committee of Consultants on Medical Research to the Subcommittee on Departments of Labor and Health, Education, and.We1fare of the Senate Committee on Appropriations. Federal Support of Medical Research. Washington, D.C., May 1960. Cited i_n Public Health Economics, V. 17, April 1960: 196—197. Congressional Record March 29, 1960: 6351. if U.S. GOVERNMENT PRINTING OFFICE: 1961 0—604263 Public Health Service Publication No.862 CDE‘IHBEHEU