Dr. JORDAN. There are many problems connected primarily with group practice in which we are interested, but primarily the purpose is, I think, to improve the standards of practice in groups. Is there further information concerning the association? The CHAIRMAN. No; I will just ask the clerk to bring that book up that you have used. You may proceed. Dr. JORDAN. Shall I proceed with the reading of this brief statement, sir? The CHAIRMAN. Yes. Dr. JORDAN. This is comment on H. R. 7700 by the Legislative Committee of the Association. The purpose of the bill which is to amend the Public Health Service Act to provide mortgage loan insurance for hospitals and medical facilities used in connection with voluntary prepayment health plans is, in our opinion, laudable in some respects and undesirable in others. We feel that there is sometimes a need for more readily available mortgage funds at a high percentage of structural cost and low interest rate in connection with certain medical facilities. Whether this is true of hospitals, however, we are unable to say since few of our members are directly involved with hospital construction and main tenance. In our opinion the easy availability of mortgage funds whether of private or governmental origin would accelerate the construction of physical facilities for the care of ambulatory patients outside of hospitals. We are dubious concerning many features of the bill: the restriction in the title to "Voluntary Prepayment Health Plans" is in our judgment discriminatory and undesirable, the sentence on page 2, line 13, states a position, in our judgment, which is hypothetical rather than established; we are in sympathy and endorse sections (c) and (d) on page 5. With regard to item (g) on page 6, we are not in agreement on the definitions either of "group practice" or "group practice prepayment health service plan" which, in our opinion, are too narrow and are certainly not applicable to a great many active institutions at the present time. We are uncertain concerning (h) on page 7 and feel that this also is a discriminatory feature of the bill. The statement under (b) on page 13 referring to $1 billion indicates that the contemplated program is not a pilot study and we question the evidence justifying the setting up of a mortgage insurance program of the proposed magnitude at this time. Finally, we are opposed to item (d) on page 18 which in effect would eliminate all but an extremely small percentage of successful group medical practices now providing high quality medical service throughout the Nation. That is the item referring to the 60 percent prepayment requirement. In summary, our position on H. R. 7700 is that there is much to be said for a device which would make it possible for physicians either singly or in groups to obtain mortgage funds more readily at a higher percentage of cost and reasonable interest rate in the form of a revolving fund. The subject, according to our judgment, should be further studied and the discriminatory features of the present bill deleted. Our recommendation would be that a bill be drawn which would constitute a much smaller trial study and permit the Federal Government, the State mortgage agencies, the medical profession, and others to obtain that basic information which is deemed necessary before setting up such an extensive plan and arrangement as that contemplated by H. R. 7700. This statement, sir, is signed by the legislative committee, Dr. R. Franklin Jukes, M. D., chairman, who is unable to be here; Dr. Wallace M. Yater, M. D., who is with me; and Dr. J. C. Thomas Rogers, and myself as legislative committee. The CHAIRMAN. Are there any questions, gentlemen? Mr. DOLLIVER. Mr. Chairman. The CHAIRMAN. Mr. Dolliver. Mr. DOLLIVER. I understood you to say that there are 82 clinics associated together in this organization. Dr. JORDAN. Yes, sir. Mr. DOLLIVER. Do you have any direct or indirect relationship with the State medical societies and the American Medical Association? Dr. JORDAN. It has no direct relationship. It has many indirect relationships. Mr. DOLLIVER. Will you specify those? Dr. JORDAN. Well, all of the members of the individual clinics are members of their county, State, and national medical associations, consequently both individually and collectively, they frequently serve on committees or have other dealings with the county, State, or national medical associations. They will publish articles in the Journal of the American Medical Association, for example, and their relationship continually is on the whole very similar to that if they were in individual practice. There is one more thing that I should mention, that is a fairly direct relationship. One agency of the American Medical Association and our association are now attempting a combined study of group practice with the aim of trying to develop information which will be helpful to new organizations, helpful and publishable for new organizations, aiming to start in the formation of group practices. Mr. DOLLIVER. Now, what is this group of the American Medical Association? Is that a section or a committee, or a study? Dr. JORDAN. That is the council on medical services, a delegation from the council on medical services of the AMA, which is jointly with us attempting this survey. Mr. DOLLIVER. When do you anticipate that study will be completed and available? Dr. JORDAN. I hope within the year. We are going to have an interim report in November. Mr. DOLLIVER. How long a time have you been at it? Dr. JORDAN. Only 2 or 3 months. Mr. DOLLIVER. It is relatively new, then? Dr. JORDAN. Yes, sir. Mr. DOLLIVER. Do you yourself serve, Dr. Jordan, on that in connection with the American Medical Association? Dr. JORDAN. I do. That is, one of the employees of the American Medical Association and I, as an employee of the Association of Medical Clinics, do a good deal of the leg work. We do not determine the policies. Mr. DOLLIVER. So you are directly connected with the study now being made? Dr. JORDAN. Yes, sir. Mr. DOLLIVER. Approximately how many doctors altogether are associated with these 82 clinics, would you say? Dr. JORDAN. Approximately between 1,700 and 1,800. Mr. DOLLIVER. So it is a relatively small number as compared to the total number of doctors in this country, is it not? Dr. JORDAN. Yes; it is. Mr. DOLLIVER. It is rather an infinitesimal percentage, is it not? Dr. JORDAN. Yes, sir. Mr. DOLLIVER. What would be the typical clinic that is represented in your association? Would it be in a large city, or a medium-sized city or a small city, or country district? Dr. JORDAN. What would be a typical location? Mr. DOLLIVER. Yes. Dr. JORDAN. Approximately 70 percent of our members, in the middle of last summer, when we made the survey, at that time there were 72 members, I think, and they were in communities of less than 125,000. Many of them were in extremely small communities. I think the smallest was a group of 18 or 20 physicians in a town which was listed as about 1,800 population. Mr. DOLLIVER. That must have been a medical center, surrounded by a rural area, with a large population, I suppose. Dr. JORDAN. Many of them are, sir. Mr. DOLLIVER. Is there any particular area or section of the country where your association members are concentrated? Dr. JORDAN. Yes, I would say there are two, primarily; one is a strip in the Middle West running from roughly Montana and the Dakotas down through Indiana and Ohio, and another along the Pacific coast; but there are members in all but 16 States. You see, we are just gradually growing. Mr. DOLLIVER. Your 82 members by no means represents all of the clinics that there are in the United States. Dr. JORDAN. We think there are about 125 which are currently eligible under our bylaws, for membership; for full membership. We have recently established a form of associate membership, which will take in smaller groups, and I cannot guess exactly how many of those there would be. I have a card file of probably over 800 clinics, but I do not know in all cases whether they could be considered as true group practice or not. Some of them I am sure are not. Mr. DOLLIVER. Would you care to explain the qualifications for membership, or is that in the book? Dr. JORDAN. That is in the book, but I will be glad to read it if you want me to. Mr. DOLLIVER. If you will direct our attention to the page, it can be inserted without taking the time to read it. The CHAIRMAN. If it is not too long, you may read it into the record. Dr. JORDAN (reading): Section (2). Eligibility for full membership: Any seven or more full-time physicians maintaining a private organization for the purpose of providing general medical care of high quality, according to the principles of ethics of the American Medical Association shall be eligible for membership. Such group or clinic shall have on its full-time staff at least 5 physicians in different major specialties, 2 of which specialties shall be internal medicine and general surgery. Such group shall maintain a separate building or a group of offices for the conduct of its practice. That is the requirement for full membership. That is the constitutional requirement. We also have, I may say, a membership committee. Section (3). Eligibility for associate membership: This shall be the same as for full membership except that the number of full-time physicians shall be 5 or more, representing 3 major specialties, 2 of which shall be internal medicine and general surgery. Associate membership may be renewed annually by the membership committee after submission of a progress report to the committee. If at the end of 10 years an associate member has not qualified for full membership, its associate membership shall be terminated. This was just adopted recently. Mr. DOLLIVER. I assume that there is some difference as to financial obligations between the two? Dr. JORDAN. Yes, sir. Mr. DOLLIVER. You have alluded in your very brief and yet quite comprehensive statement, to the question of voluntary prepayment health plans and group practice. Do any of the members of your association have prepayment plans, and if so, what proportion? Dr. JORDAN. May I say one word as a sort of introduction to the answer to that question? Mr. DOLLIVER. Yes. Dr. JORDAN. We, in common with almost all other elements of the medical profession, are in favor of extensive voluntary prepayment medical insurance. We are uncertain, most of us, as to exactly what form that should take and are stating reservations as to that aspect of the bill, and I hope it is clear that we are not objecting to the extension of voluntary insurance. On the contrary, we feel that there may be some undesirable features in tying up directly with group practice. There may be some objections in tying prepayment directly with group practice, as opposed with tying it with all segments of medicine. The implication, as we understand it, of that feature of H. R. 7700 is that the prepaid carriage must be directly with the clinic. In other words, what is commonly called a closed panel arrangement. There are, so far as I know, only 2 members of our association at the present time who have that arrangement and 80 who do not. That is in specific answer to your question. Mr. DOLLIVER. Would those closed panel clinics be characterized by a larger number of doctors in them and larger numbers of subscribers than the ordinary clinic? Dr. JORDAN. Not necessarily, sir. The prepaid medical care plan is under those circumstances sold to a group of subscribers who must get medical services from that particular group and, therefore, do not have the privilege of going to one place or another, as subscribers do, to, say the Blue Shield or the Blue Cross, or some of the other situations of that sort. Mr. DOLLIVER. Of course, a clinic which does not have a voluntary prepayment plan is not in any way inhibited from serving a patient who has health insurance with one of the health insurance organizations. Dr. JORDAN. Not at all. They do. But, as nearly as I can understand it, according to Service's book, approximately 50 percent of all medical fees are now paid under prepayment plans and that will vary from one section of the country to another, and the only way the clinic could qualify under the present bill for 60 percent would be to set up its own plan, which would be a closed panel plan, with the strictly individual relationship between the subscriber to the plan in this community and that one clinic. Mr. DOLLIVER. As I understand it then, from your statement and your answer to my questions, your association is not ready to endorse, without qualification, any prepayment plan that involves a closed panel; is that correct? Dr. JORDAN. Yes, I think that is correct. This principle Mr. DOLLIVER. The medical clinics are a relatively new development in medical practice. Dr. JORDAN. Yes, sir. Mr. DOLLIVER. And, from the standpoint of the public who are the people who are served by the doctors, persons who are ill, what is the advantage of the clinical practice of medicine? Does it cheapen the cost of it? Does it give a better service? What are the advantages of clinical practice as opposed to individual practice? Dr. JORDAN. From the standpoint of the patient? Mr. DOLLIVER. From the standpoint of the patients. Dr. JORDAN. I could discuss that at great length, which I will not do. I will try to discuss it very briefly. There is the historical reason, I think, so far as the development of group practice is concerned, which stems largely from the increase in knowledge of scientific medicine over the past 50 years, which has made it no longer reasonably feasible for 1 individual physician to give all that medicine has to offer to 1 patient. This has resulted in what we call the increase in specialization, which involves in any but the most simple cases, as a result of simple problems, the opinion, the advice and help and skills of more than one physician. When physicians with more than one skill are grouped together to form what we call a group practice clinic, they bring those fairly readily to the patient under one roof, as your previous witness said, and that not only increases the ease and ability with which men with different specialties are called on, but it also saves the patient a good deal of travel time from one place to another. Now, as far as cost is concerned, so far as I know, there are few figures available, few or no figures available on whether group practice lessens the cost. The general impression among people who are qualified to comment upon it is that the cost to the individual patient in an individual illness is not likely to be much less, but that he is likely to get more service for the same money, maybe, perhaps, a quicker diagnosis, or more skilled treatment. Now, that opinion will be disputed and is disputed by some, of course, who are not in group practice. From the strictly factual side there is only one figure or one source of figures on costs that I know of, and that, I have not seen the original, that is from Multnomah County, Oreg., the county in which Portland, 47892-54-4 |