direct ability in recognizing problem trends in Iowa was correct. Reading directly from HEW's statistical charts concerning the percent increases in physicians by geographic division in state in the United States between 1968 and 1973.

Mr. Clark; "These are the latest figures we could get. In other words, how much in Iowa, as compared to the rest of the nation-what kind of percent : increase in physicians have we had? Unfortunately, we are 49th among the 50 states. This is increased number of physicians in the state. We have had, in that 5 year period, a 6.3% increase The national average is 16.7% so that! we are well below half of the national average in terms of increasing physicians into the state.

There is one state lower, and interesting enough, it is South Dakota, and it is much lower, 1.4%. We are second lowest, 6.3%, and then they are all the! way up to New Hampshire, which must be the climate, 26%, so that I noticed in passing that Mr. Pustka said that he felt the final answer was not simply Physician's Assistants, but doctors themselves and if these figures are still accurate over the past 22 years, these trends, it means that we have a real problem in terms of physicians as well".

Yet extensions of the primary care physician in rural Iowa, specifically through the utilization of Physician's Assistants, has proven to be an immediate and direct workable facet of the problem of health care availability in rural Iowa.

Quoting Denis R. Oliver, Ph.D., director Physician's Assistant Program, University of Iowa: "Let me highlight certain points. To date, we have graduated 45 Physician's Assistants with B.S. degrees conferred by the College of Medicine. Thirty-two (71%) are currently employed in Iowa. Each year we accept between 20 and 25 students to enter the 2-year program. This program has scored among the top 5 programs in the country (out of 52 programs) on the national certification examination for Primary Care Physician's Assistants for the last 2 years.

We are proud of our program and the caliber of our graduates. We feel they will have increasing impact on rural health delivery systems, but only if appropriate legislation exists which allows for their optimum utilization. The position of the social security administration on third party reimbursement for Physician's Assistants services to Medicare patients is ridiculous. On the one hand, the government budgets enormous sums of money for the initiation and continuation of Physician's Assistants training programs, and on the other, severely restricts their utilization. This is of particular concern in Iowa which has a large elderly population. I think it criminal that these people are abandoned at a time when they should enjoy the fruits of heir labor".

Both Senator Clark and Dr. Oliver's comments adequately summarize specific issues concerning availability of health care in Iowa. Again, not a complete answer, the Physician's Assistant's utilization under adequate supervision by practicing physicians is a partial immediate, even longterm answer to the frequently forecasted worse physician shortage for the future in rural areas. Specifically, in Iowa, one-third of the counties lost Primary Care Physicians in the years from 1974 to 1976 alone. At the same time, only about 4% of the recent medical graduates have chosen to practice in rural areas. These stark facts coupled with enumerable practices (for example, generally lower fees given to physicians in rural areas compared to urban areas by both private and public health insurance programs) and the obviously contradictory reimbursement system of Medicare disallowing the utilization of Physician Extenders (who have been proven, can substitute under adequate supervision for the declining number of physicians in rural areas) is presently compounding what is considered by many to be an acute medical crisis. The populus of Iowa has been historically fortunate in that the availability of medical care through a high caliber and standard of Iowa physicians, private and county hospitals, and the University of Iowa Hospital system, has been available. The problem boils down to one of entry into the system. The Physician's Assistant has shown to be an available, competent entry into an excellent medical system where otherwise an entry was not readily available. I conclude that the serious responsibility shared by the subcommittee on rural development in its recommendations and support of legislation along the

lines of $ 706 will be felt immediately and in the future by many if not all of our friends and neighbors. I respectfully submit the following suggestions: 1. 8. 706 is glaringly larking and limited in its reimbursement to rurai medical clinics in medically underserved areas at erst. Reimbursement to physiciana practices for services rendered by the Physician's Assistants in any and all areas should and must be priority. The availability of primary medical care to the people in the core cities and other areas is just as real, just as acute, as that of the rural areas. Reimbursement as I've just outlined may be compromised and/or facilitated by a reimbursement program discounted from that of the physicians usual and customary (80%) when the care is indeed rendered through the Physician's Assistant.

2. The concept of medical care rendered by a Physician's Assistant was born in the realization that all care rendered by the Physician's Assistant would be under the supervision of a physician who ultimately would hold both moral and legal responsibilities completely. This concept is the underlying premise on which the extender concept remains workable. The Physician's Assistant is only as good as the supervising physician. In my interpretation of 8. 708, I have to agree in part with Dr Beddingfield (Chairman of the AMA Council on Legislation) in that by this bill's definition, clinics cannot be physician directed or under direct personal physician supervision covering only certain types of state health clinics. This, in my estimation, may leave a door open to widespread, if not dangerous abuse of our Medicare system. The Physician's Assistant must remain a direct extension of his supervising physician and should at all times be directly answerable to and employed by a physician and very close supervision of the extender by the physician be encouraged. The original concept as outlined by our congress must be continned and fostered in that ultimate responsibility of the Physician's Assistant must rest with his supervising physician.

3. The fee schedules which discriminate against rural practice must be erased. Routinely, insurers, including titles XVIII and XIX pay higher fees to urban doctors than to rural doctors for the same work. Urban doctors have offered convincing arguments for their higher fees, but the difficulty in getting doctors into rural practice is an adequate answer to all such arguments.

4. A priority commitment to seek a successful program to increase physicians availability in rural areas should be continually explored. Positive programs such as tax credits for "area practice", encouragement of utilization of Physician Extenders through adequate reimbursement programs, and family practice residency programs by state universities with preceptorship training in rural communities have all been positive directions. An important negative direction has been the utilization of "short time doctors". Schemes to get doctors to rural communities for short periods of time, including 2-5 years, have a tendency to attract inferior physicians and is insulting to the rural population. Rural practice is a specialty and a career.

I accepted this invitation to testify as an honor and would, at this time, like to conclude with a thank you forwarded by many residents of Madrid for your time, concern, and apparent wish to insure, through effective and farreaching legislation, availability of medical care; hopefully, irregardless of a person's age, ability, disability, or geographic locality.

STATEMENT OF BETSY DAVIS, EXECUTIVE DIRECTOR, VISITING NURSE ASSOCIATION, INC., BURLINGTON, VT., AND CHAMPLAIN ISLANDS HEALTH CENTER, GRAND ISLE, VT.

I am Betsy Davis, Executive Director of the Visiting Nurse Association, Inc., located in Burlington, Vermont, serving Chittenden and Grand Isle counties. I am also project director of the Champlain Islands Health Center, a rural health center operated by the VNA and the Grand Isle County Health Council. I am pleased to have the opportunity to appear before you today to discuss $.708 and the implications of that bill as it affects the financial viability of the Champlain Islands Health Center.

I wish to present you with the background in creation of the Health Center, a brief description of the system of care, a description of a pilot reimburse

ment project with Blue Cross/Blue Shield and the potential effect of S.708 if implemented.

BACKGROUND

The Champlain Islands Health Center is located in Grand Isle County in Northwestern Vermont. The county is composed of a peninsula that leads to Quebec Province in Canada and is a series of islands in Lake Champlain which is connected by a sand bar and bridges. It is approximately 40 miles in length and three miles wide at its widest. The population is approximately 3,750 but swells to 12,000 during the summer tourist season. The mortality rates show that there are higher rates in comparison with the rest of the State of cardiovascular and respiratory disease, cirrhosis of the liver, and accidents. Women die sooner than men with the mean age of the former at 66 and the latter at 70. The population characteristics and economics of the area probably typify many rural areas, such as: 58% of the population of Grand Isle County earns less than 200% of the poverty level; last winter's unemployment rate was over 17% of the work force, 28% of the population presently utilizing the Health Center have no form of health insurance of any kind, and only 15% are Medicaid eligible. Many are only marginally employed.

Historically, solo physicians have come and gone in the county with none being able to support a comprehensive practice over an extended period of time. The last physician in primary practice offered services two afternoons a week in the northernmost town of Alburg (also the largest town) and practiced surgery at a hospital in another county the remainder of his time. He has now discontinued his services in Alburg. There is an osteopath in the southern part of the county offering episodic illness services to a limited population. VNA initial experience in Grand Isle County was with a mobile unit pediatric screening service in 1972. The data base collected there showed that 32% of the children presenting at the mobile unit did not have a source of preventive care; 45% of the children presenting had irregular patterns of utilization of preventive services. Utilization of the mobile unit services by the preschool population was 50%-90% in the various towns in the first year of operation. Patterns of health care by adults were fragmented and inadequate with many naming 3 or 4 physicians that they would turn to depending on who was available. Almost no one had a record of his or her problems, medications, or plans.

DESCRIPTION OF THE SYSTEM OF CARE PROVIDED BY THE HEALTH CENTER

Our major goal in establishing the Health Center three years ago was to provide a coordinated integrated system of health care that is available, accessible, and accountable to the people of Grand Isle County. The important features of the Health Center are: 1. consumer involvement and governing responsibilities; 2. utilization of nurse practitioners as primary caregivers with back-up physician availability through telephone consultation and periodic on-site visits; 3. the linkages to the rest of the health care system; 4. that it is cost effective; 5. that services focus on prevention and health education; 6. that it is accountable.

I would like to address each point briefly.

It was through the initiative, support, and many ongoing volunteer hours of the County Health Council that the Health Center was established in 1974. It was they who asked if we could keep the nurse practitioner from the mobile unit on a daily basis and expand to adult services. This group now has responsibilities for program and services planning, budget and contract approval, evaluation and other policy determinations. In addition, a consumer advisory committee has been created which makes recommendations to the Health Council on needs for services and provides a feedback mechanism for patient complaints. The VNA and other involved agencies support this local responsibility believing that health care providers must be accountable to the people we are trying to serve. This increased involvement will also lead to increased responsibility, greater self direction and hopefully more demand for a system of health care to which people are entitled. It is for this reason that we believe that a certain, defined level of health care should be community based and located where people live.

We geuers that trampering people 36-60 mies to health services they have In resp. for is wef defeating

Nurse practioners and a paramete staf the Heart Center daily. They JOFIL Sentive maintenance exame for infants. eritren and adults as well as treatment of amute or chronic illness by protues or telephone constata, ka patient identifies a physician who may be located either in Þrerým County or Chittenden County with whom the nurse practitioner 498ILUL/2168 and to whom she sends remrds. Consulting and medical legal bark up are provided by contract physicians who are available by telephone and who are on site once a week to perform record andit, establish protocols and see patients with the nurse practitioner on a constiting basis. There is ** evening and right answering service with a tie-in to prysicians at the Vismaire Health Center located in Milton, and Given Health Center, both * University Health Center. VNA home care services are operated out of the Health Center and coordinated with ambulatory services.

The nurse practitioner concept has been well accepted. Almost 800 people Bade 2240 visits to the Health Center in its first year of operation when it was open four or five half days per week. 96% of all acute pediatric problems and 98% of all acute aduit problems were cared for on site. The remainder were triaged outside of the county. The second year showed a 34%%% growth.

The nurse practitioner serves as an extension of the health care system providing an entry point to total care. She is part of a larger support system. It is our task to 1) define those primary care services that can be provided on site in Grand Isle County considering the population base, the population problems, and economics of the area, and 2) provide a consistent and reliable service on site and guide the patient through the rest of the health care system,

Again, critical to that system is the involvement of the patient as the coordinator of his or her own care. This means full knowledge, understanding and participation in health care. Patient education and the problem oriented health care record in the patient's possession are central to this concept and practiced at the Health Center. We believe that nurse practitioners, by their professional education and focus on prevention, are best prepared to provide these important components of education and guidance necessary in primary care. This should mean more appropriate utilization of health services, less duplication and greater efforts toward self help. This should also mean increased levels of expectations on the health system and greater accountability. The average cost per visit in the Health Center the first year was $11.55 after deducting developmental expense and $12.50 in the second year. These figures included all screening and laboratory tests also done at the Center. For the people utilizing the Center, there were additional savings when travel expense, loss from work, and child care concerns are considered.

During the second year we had great concerns about our ability to continue the Health Center for financial reasons. The first year had been financed through a Manpower HEW grant, Kellog funds, and Health Department support as well as patient fees. The second year showed a continuation and carry over of some of those funds, and Regional Medical Program funds were received; but we operated on a shoestring basis. It was painfully clear that third party reimbursement for nurse practitioner services when an M.D. was not on site was a critical issue in the continuation of the Center. If the "problem of third party reimbursement could not be solved, then the nurse practitioner as an extension of the health care system in rural areas was not viable, Yet, we felt we had been able to create a quality service that was acceptable, accessible, accountable and cost effective. Fortunately, we were awarded a Rural Health Initiative grant from Region I HEW July 1, 1976, giving us more time and ability to further develop the system and to work toward improved reimbursement.

We realize that grants cannot be a long term solution and that the Health Center must fit in with the prevailing methods of reimbursement.

BLUE CROSS/BLUE SHIELD REIMBURSEMENT PROJECT

A major innovative step has been taken by Vermont/New Hampshire Blue Cross/Blue Shield in addressing the reimbursement of services provided by

nurse practitioners. Their interest in this venture came as a result of participation in the Rural Health Hearings held in Vermont and sponsored by Senator Leahy and Senator Clark and this subcommittee where reimbursement issues were presented. Blue Shield officials visited the Health Center, met with consumers and beneficiaries, reviewed the system of services and entered into a contract with the VNA September 1, 1976. The contract itself offers a model for reimbursement. The VNĂ bills monthly on a ledger sheet all the charges for that period incurred by Blue Shield beneficiaries. The VNA is reimbursed directly. At the end of six months, an audit will be performed and a retroactive settlement considered on the basis of mutual costs of services based on number of visits by Blue Shield beneficiaries. It is an amazingly simple process, and we are very encouraged by Blue Shield's leadership. I believe the important components of this contract are: 1. that it reimburses a system and not the individual practitioner for services provided; 2. that it requires a system of care that is accountable, and has mechanisms for ongoing audit of practice of all the providers of care; 3. that it reimburses on the basis of actual costs following audit.

In the first five months, 14.69% of the visits to the Health Center were by Blue Shield beneficiaries. This means that as long as we can demonstrate prudent fiscal management and cost effectiveness, we can count on 14% of our costs being met by this contract.

IMPLICATIONS OF S. 708

10.9% of the population (409 individuals) in Grand Isle County is over 65. Approximately 180 people or 44% of that population have been seen at the Health Center over the past two years. If there was reimbursement for the services provided for that population, we believe that this would represent approximately 20% of all services provided. This would be one more very important step to improving the financial viability of the Health Center.

Passage of S. 708 would remove a significant barrier in supporting the concept of rural health centers and the system I have attempted to describe. We believe that nurse practitioners and physician assistants as part of a team provide an appropriate entry point to a total system of care and assist in creating the necessary linkages to that system. We believe that this concept could be critical in helping to create order out of the chaos of the present non-system. And finally, we are convinced that improved accessibility combined with education and consumer responsibility leads to earlier intervention in illness, improved preventive practices and ultimately reduced costs of total care. Thank you for this opportunity to express our support of S. 708.

STATEMENT OF DAVID A. HANTMAN, M.D., AND LINDA LABROKE, R.N., DANVILLE HEALTH CENTER, DANVILLE, VT.

The Danville Health Center is a rural health clinic recently established to offer geographically accessible comprehensive health care to an isolated area of approximately 3,000 people in northeastern Vermont.

CHARACTER OF THE AREA

This is a rural area with an economic base of farming, trade, and some light industry. The unemployment rate is high, and the per-capita and perfamily income are far below state and national averages. The number of individuals and families qualifying for welfare assistance under various programs exceeds the state average.

Until the Danville Health Center was established, no medical care was available in Danville. The nearest physicians are in St. Johnsbury, 10 miles away. St. Johnsbury also contains the nearest hospital.

THE DANVILLE HEALTH CENTER

The Center is staffed by a Family Nurse Practitioner, Ms. Linda Labroke, and supporting personnel. Physician supervision is provided by two Internists