For example, in response to public demand and need, our medical school, like many others, has recently increased the size of its first year class-with plans for an even larger increase in the near future. Both decisions were predicated on the availability of the resources of the Veterans' Administration hospital facility and staff necessary to accommodate an increased number of students at the time they reach their clinical years. This requires interns, residents and other staff. They, in turn, provide services to veterans. What do we tell our legislators? They authorized the student expansion on the premise of available facility resources at the VA. Even more significant to our State is the VA budget limitation that, in effect, puts a "freeze" on intern and resident positions. There are only enough intern positions in our State to accommodate one-half of each graduating class; hence, a large number of physicians are permanently lost to a State community that in 1970 had only 83 physicians per 100,000 population, approximately one-half of the national average. These illustrations may appear to present a parochial flavor, but they do illustrate the domino effect of Washington-made decisions and the devastating impact on public needs that extend far beyond the VA hospital.

All of the foregoing comments underline the paradox of diminished support at a time of increasing need for health care, compounded by a shortage of appropriate facilities and trained people.

In conclusion, I would make a plea that the honorable and distinguished Members of the Congress look at the Veterans' Administration hospital operational and capital construction requests with a compassionate concern not only for the health of our deserving veterans and their dependents, but an equal concern for the health of the people of an entire Nation who could benefit directly and indirectly from the health professionals that could be generated by actions that would finance and permit the VA's hospital education and training capacity to expand through the remodeling and renovation of existing facilities and, where appropriate, the construction of new facilities in conjunction with existing medical schools; or, in a limited number of select areas to support the development of new medical schools in relation to existing or new VA affiliating hospitals.

I am convinced that a cost-effectiveness study would reveal the economy of the utilization of the potentials of the VA hospital system as a primary national resource for the education and training of the vast pool of all kinds of the health professionals that are going to be required if we are to respond to the health manpower and health care needs of our people in general and our veterans in particular.

Senator CRANSTON. Thank you very much for your very fine and very helpful testimony.

On your last point, how cost-effective generally, without having a precise analysis available, but how cost-effective generally do you feel VA care is compared to community hospitals?

Dr. DENNIS. My impression of VA care, if you did a cost-accounting, where you evaluated just the cost of that care, would compare very favorably with the community hospitals. Again, it gets down to a matter of weighing cost-effectiveness and quality of care.

In some communities, Senator, where the community hospital has no teaching program, the VA teaching hospital might have higher costs, and they will have greater patient days. These are matters that

have to be evaluated, because the teaching hospital has become a tertiary care, referral hospital where more critical illnesses occur. Even though the patient may have the same diagnostic label, it does take more intensity of care, more skill and more equipment in the referral-teaching hospital than you would see in the average community hospital.

Senator CRANSTON. Do you have the average daily care costs, or could you supply them for the record, of the VA hospital with which you are affiliated and the local community hospital?

Dr. DENNIS. I can supply them to you. Our affiliated VA hospital has a per diem cost of $47 which is about one-half that of the national community hospital costs.

Senator CRANSTON. What would it be for the university hospitals? Dr. DENNIS. In our university hospital, we are more expensive than the VA. Our daily cost is $89 a day.

Senator CRANSTON. Can you give us some comparable figures on staffing between the university hospital and the VA hospital, particularly in relation to the nurses? You may provide them for the record, if you don't have them.

Dr. DENNIS. The staffing in a VA hospital of care personnel runs a little under two persons per patient; whereas, in the community hospitals in our area it runs 2 to 3 hospital personnel per patient. I would remind you that it takes three 8-hour shifts each 24 hours. In our VA system, we have about one-third fewer people to take care of the sick people, as compared with the community hospitals.

Senator CRANSTON. In regard to your prepared statement you state, "Other deficiencies in the fiscal year 1974 budget include, one, inability to obtain additional staffing that would permit employment ratios of staff to patients equivalent to that of the average private or community hospital."

Can you expand at all on the extent of that disparity and what you see happening under the administration's budget proposal for the VA? Dr. DENNIS. Yes, sir. While we have a 2 to 1 versus a 3 to 1 situation now, I think we are going to see this go toward a one-staff personnel— to one-patient-per day under the present budget.

Senator CRANSTON. One to one?

Dr. DENNIS. I would be afraid of this, Senator. The salaries of nurses in the community hospitals in our area have already gone up and they are going up again, and you are not going to be able, and we are not going to be able to compete on the market for these essential

resources.

Senator CRANSTON. How many community hospitals in the country have a ratio like that? Very few?

Dr. DENNIS. I would say, at least in our urban centers, our better community hospitals would run 3 to 4 staff personnel per patient per day.

Senator CRANSTON. What kind of a ratio?

Dr. DENNIS. Four to one.

Senator CRANSTON. How many have 1 to 1, as you say the VA may be threatened with?

Dr. DENNIS. I don't think many of them would be permitted to operate at 1 to 1.

Senator CRANSTON. Why not?

Dr. DENNIS. The quality of care would be unacceptable and is dangerous to patients. I would not want to go to such a hospital.

Senator CRANSTON. How can it possibly be tolerated that VA should have care that is unacceptable and dangerous to patients?

Dr. DENNIS. Senator, în my opinion, it cannot be tolerated. It is not acceptable.

Senator CRANSTON. We will do our best to be intolerant.
Dr. DENNIS. I will do my best to help you, sir.

Senator CRANSTON. In your statement, you also mention, that the budget would produce an "inability to fund the new school of health related professions in order to provide for the students, programs and facilities that would permit even a fraction of the tremendous growth potential in this short supply field of health manpower."

Do you feel that the VA can play a particularly important role here, especially with regard to the training and employment of former military medical corpsmen?

Dr. DENNIS. Yes, sir; I do, indeed. This is a particularly significant area, in my experience, for the VA. If I might digress for a moment to address your point and amplify it. Within the university, programs in the allied professional areas-health-related professions are in a school which must have courses and curricula and training program approved by the university medical center, the board of trustees and the board of higher education within the State.

We found that we could not, within the regulations of the university, and within the university hospital, develop many of the programs in which our veterans are interested and for which our veterans' hospital saw a need and we saw a need.

But, by combining the school for health related professions into a joint program between the Veterans' Administration hospital and the university, we can provide the certification and accreditation of the university for courses approved. They-the VA-provide the staff, who are on our faculty, and they provide the facilities and the environment in which these people can emerge as trained, skilled health workers, an essential development which simply is not going to happen without a continuation of this partnership. Even if we had the money, we could not do the things the Veterans' Administration hospital could do, and we don't have the money.

Senator CRANSTON. I am very interested in your remarks on future VA problems and potential needs in geriatric care. It seems to me, the VA should be a leader in this field.

Dr. DENNIS. Indeed, it should; and nobody has led in this. It is a totally virgin forest, as knowledge goes.

Senator CRANSTON. Also in your statement, you refer to the fact that your medical school, "like many others, has increased the size of its first-year class, with plans for an even larger increase in the near future. Both decisions were predicated on the availability of the resources of the Veterans' Administration hospital facility."

What is going to happen in regard to that expansion under the proposed 1974 budget?

Dr. DENNIS. Well, we are going to have so many students around every patient's bed that it will interfere both with good teaching and with good patient care if we permit it to happen. I don't think we can tolerate this either, sir.

Senator CRANSTON. That's an interesting way to answer that question.

You speak also about the fact that "There are only enough intern positions in the State to accommodate one-half of each graduating class," and you refer to the "large number of physicians that are permanently lost to a State community that in 1970 had only 83 physicians per 100,000 population, or approximately one-half of the national average."

This is obviously very important in terms of the crucial issue of the distribution of physicians within the United States.

Dr. DENNIS. It really is, sir, and, particularly, for the veteran and his family who do not live in an urban area near the central veterans' hospital, this is crucial.

Senator CRANSTON. Do you think we will have trained enough medical students to meet medical needs by, say, 1980, given these approaches by OMB?

Dr. DENNIS. This is an opinion. I think it is dependent upon factors that are not quite clear. I think the kinds of physicians that we produce may be as important as numbers. We have seen comments in the press recently that indicated we would have a surplus of physicians by 1980. That is a nice problem that I would like to face.

In my experience, at the present time, when we analyze the requests and the complaints and the pressures for more physicians and more health care in our own region, I can't see us having an adequate number within my lifetime. The demands for the utilization of these people is increasing in a geometric fashion. It is how frequently and how well we use them that will also play a part in determining the number needed.

Senator CRANSTON. Can the VA facility in a State like Arkansas help by expanding the training done in affiliation with the medical school?

Dr. DENNIS. Yes, indeed. We feel that by utilizing the VA teaching facility and going out into other VA facilities in the State and developing area health education centers in conjunction with the VA hospital involving interns and residents, we will have an impact because it has been shown that the one thing that does influence where a physician will locate is that point at which he completes his training. That is the place in which he receives his job opportunity, so to speak. It is one way to address the distribution of physicians.

Senator CRANSTON. In summary, do you feel that it is fair to say that the VA seems to you to be a highly viable health resource, not only in the terms of the health care of veterans but the health care of the Nation?

Dr. DENNIS. Senator, it is the only one-health resource-we have that is national in scope. And, the importance of this network, not only in terms of producing physicians, but as a skeletal framework for a system which we all know we don't have, simply is not recognized far beyond your offices, apparently.

Senator CRANSTON. In regard to maintaining a quality staff to provide appropriate medical care at a VA hospital, are each of the following very important factors in achieving that? First, the university medical school affiliation; second, an active research program; and, third, an active VA-run education and training program.

Dr. DENNIS. Yes, sir. You cannot separate those three things from quality care. I would point out that research is a service deferred. This year's cure was last year's research. And, General Motors couldn't stay in business without research, and neither can the VA or the medical profession, and I think it is foolish to hear some of the considerations we are hearing today in respect to the retraction of support for research. Of course, there has to be balance, and, certainly, we have to be concerned appropriately with the human needs.

Senator CRANSTON. Dr. Dennis, thank you very much for traveling all that way to be with us today, and for your great help, and I thank the university for making your presence possible.

Dr. DENNIS. It's a great privilege, sir.

Senator CRANSTON. Our next witness is Dr. Hamilton Robinson, dean, University of Missouri, Kansas City School of Dentistry, Kansas City, Missouri. Dr. Robinson, we appreciate your presence.

STATEMENT OF DR. HAMILTON B. G. ROBINSON, DEAN, UNIVERSITY OF MISSOURI, KANSAS CITY SCHOOL OF DENTISTRY, KANSAS CITY, MO.

Dr. ROBINSON. I appear before you as a private citizen. My name is Hamilton B. G. Robinson, and I am dean of the School of Dentistry of the University of Missouri at Kansas City. I have served as president of the American Association of Dental Schools, and as president of the International Association for Dental Research. I am also chairman of the Council on Dental Education of the American Dental Association.

I recently served on the Advisory Council on Dentistry of the Veterans' Administration's Department of Medicine and Surgery, which developed and published the report entitled, "Helping To Meet the Dental Health Care Needs of the Nation: The Potential Role of the Dental Service of the Veterans' Administration's Health Care System," "The Journal of the American Dental Association," March 1973.

Senator, I would suggest that you get reprints for the members of your committee. I think they are very valuable.

The practice of dental medicine in the VA health care system has demonstrated that oral health and disease is inseparable from general systematic health and disease. It has also shown that the treatment of oral and facial injuries and dental anomalies, and the prevention of oral diseases are now recognized as no less important or critical to thehealth care of eligible veterans than diseases and conditions of other parts or systems of their bodies. Those of us in the dental profession, in general, and dental education and research, in particular, are grateful to the Congress for its recognition of these facts, expressed through its willingness to enact and fund legislation that supports dental activities as part of total health care for veterans.

Evidence suggests that service-connected deformities or diseases of the orofacial complex are some of the most prevalent and, in many instances, the most debilitating of the ills of many veterans. Proper treatment is critical to not only the well-being and comfort of such veterans, but to the establishment of their self-confidence, and subse-