alth a away within th zation for the ntee by bad tice up to a er and that ea made availa ing loans by over & fes $150,00AN der the ad eneral of the ervice. Beca istinction group practi ent about dr was deemed r en the E ney limit 11, most as extension Co foster cope and extensive teaching and research facilities, group medical practice centers, diagnostic centers and public health facilities..." 50 In the matter of public health organization: "It has been demonstrated that deficiencies can be greatly lessened by group medical practice, whereby a number of physicians pool their skills, facilities and income, and coordinate their work so as to supply to ambulatory and bed patients effective personal services and high quality of care. Group practice in instances with remuneration of physicians on a salary rather than on a fee-for-service basis has demonstrated it can provide comprehensive medical care as well as care in the specialties. The extension of group practice should be encouraged. . ." 51 From the standpoint of finances, the conference concluded: Kellogg Center Conference was eminently successful in deriving a blueprint for the future. And, intimately tied to that future was the furtherance of group practice. Other Federal Legislation Worthy of brief mention are two pieces of federal legislation which relate to or potentially relate to group practice. The first is the Federal Employees Health Benefits Program. The enabling legislation was passed late in the 1959 session of the Congress. It authorized the United States Civil Service Commission to establish, in behalf of the federal government as employer, a program of health care for all federal employees. The program went into effect in July, 1960, giving the employee the right to choose from among several plans including the one under which comprehensive care would be rendered by prepaid group. The other plans were less comprehensive and, thus, less expensive. The Civil Service Commission on August 1, 1960,53 indicated that almost three-fourths of all employees chose the most expensive and most comprehensive care available in their community-that where HIP type coverage was available, it was predominently chosen. This can, without erroneous inference, be interpreted as an expression for more comprehensive coverage. That group practice offers the organizational means for undertaking such coverage is reflected in the employees' choice. Pending before the Congress is a similar measure which would extend coverage to retired federal employees. In both instances, the federal government pays one-half the cost of premiums. "' 52 "Two trends in the current situation offer real encouragement: (1) the increasing use of the hospital as the center of health activities in the community; and (2) the growth of group practice. Both of these developments increase our potential for planning the most effective use of our limited health facilities. . ." The conference recommended, among other things, expansion of health facilities through an increased Hill-Burton program of the hospital. As a base for organized, full-time group medical practice, that federal legislation should be passed which would encourage the development of nonprofit group practice clinics by providing long term, low interest loans-not only to meet their need for a highly specialized type of facility, but also to recognize their significant and hopeful role in meeting the nation's health goals. Although the conference had but 12 participants, it has received such considerable interest and attention nationally, that its resultant effect has been a remarkable one. The conferees represented some of the best minds in health administration, and they are all nationally recognized and respected. This "quiet" conference has served to crystalize the role of group practice as a vehicle for better organization of health services to meet the challenges of the future. In fact, its simplicity and clarity are beyond question. It has, in a few short months, gained the stature of authoritativeness and is quoted over and over again. What other conferences had done in the past to delineate needs, the There has been considerable public discussion about federal aid for health care of the aged. Synonymous with this type of legislation has been the name of Representative Aime J. Forand. While no legislation has yet been passed (at the time of the writing of this paper) some measures, namely the bill sponsored by Senator McNamara would aid the aged by providing diagnostic care in out-patient facilities as well as hospitalization. It is clear that group practice has a large role to play in geriatric care. The Case for Group Practice In my opinion, comprehensive group practice has been "tested and experimented with" during the last years on a mass basis, and it is ready to offer itself as the vehicle for the future administration of health services. With greater insurance coverage, more comprehensive health services required, more emphasis on preven tion, the need to meet increased health costs and the necessity to more efficiently integrate specialty services in health care, group practice seems ideally suited to meet those requirements. Three avenues of approach seem open for group practice. The first is to expand group practice by hospital and clinic staffs shifting the emphasis to paying patients with adequate and proper payment for the practitioners who are on a full-time basis. The second mode of expansion would be in terms of private group practice in the group clinic where comprehensive services are offered properly utilizing the talents of specialists. The third area of growth extension would be by allying health insurance with the above two types of group practice assuring a sound prepayment plan and an economic base for the group. Dr. Will Mayo summed up the case for group practice when he said: "As we men of medicine grow in learning, we more justly appreciate our dependence upon each other. It has become necessary to develop medicine as a cooperative science, the clinician, the scientist, the specialist and the laboratory workers uniting for the good of the patient. The people will demand, the medical profession will supply, adequate means for the proper care of patients which means that individualism in medicine can no longer exist. . ."54 Perhaps the most important ingredient, more than any other, in the development and creativity of group practice—and, indeed, in all new forms for the betterment of the administration of health services will be the willingness of the professions and its practitioners to work for progress in health care. That may, and probably will, mean an abandonment of the traditional concepts of solo practice. The literary wisdom of that great Belgian, Maurice Maeterlink, is especially applicable. "At every crossway on the road that leads to the future, each progressive spirit is opposed by a thousand men appointed to guard the past. Let us have no fear lest the fair towers of former days be sufficiently defended. The least that the most timid among us can do is not to add to the immense dead weight which nature drags along. . ."55 8. Bluestone, EM., M.D., "On Group Practice in Hos pitals,' an editorial-The Modern Hospital, XIV, Novem ber 1946 and January 1947. 9. Haffner, A. N., O.D., commencement address to the Massachusetts College of Optometry, Boston, Mass., June 10, 1960. 10. Hunt, G. Halsey and Goldstein, Marcus S., "Medical Group Practice in the United States," Washington D. C.: Public Health Service, 1951. 11. Bluestone prefers to call this medical sophistication. 12. A.H.S., loc. cit. 13. "Group Practice"-A report by the United States Public Health Service, Journal of the National Medical Association, Vol. 42, July 1950, pp. 223-228. 14. As an example, in June and July of 1960, the New York City press carried extensive coverage of the quarrel between HIP and the General Hospitals of Staten Island. 15. "The New York Times:" July 10, 1960, p. 51. 16. Bluestone, Address before the Tri-State Hospital Assembly, op. cit. 17. American Medical Association, Resolutions of the House of Delegates, Chicago, Illinois, June 1955, June 1956, June 1958, June 1959, June 1960. 18. Weinerman, E. Richard, M.D., Address before the Fifth Annual Meeting of the Cooperative Health Federation of America, Chicago, Illinois, July 6, 1951. 19. American Medical Association, Medical Groups, A report prepared by the Bureau of Medical Economics (Chicago, Illinois: Journal of the American Medical Association, 1947) Vol. 135, pp. 904-909. 20. "Annual Report of the Medical Service Ending June 30, 1959," (Lake Success, New York: Sperry-Rand Corporation, 1959). 21. Interview with Richard Feinberg, Ph.D., June 26, 1960. 22. "Special Reports on Eye Safety by the National Society for the Prevention of Blindness" (New York: by The Society, 1958, 1959). 23. Incorporated by legislative act for the Town of Webb, New York, March 1960. 24. Hanson, Horace, R., "Group Health Plans-A Twenty Year Legal Review," Minnesota Law Review, Vol. 42, No. 4 (March 1958), pp. 527-548. 25. "United States v. The American Medical Associa tion," U. S. 219 (1943). 26. Hunt and Goldstein, loc, cit., pp. 48-49. 27. Ibid, p. 49. 28. Group Health Institute, "Proceedings of the 1959 Meeting" (Chicago, Illinois, 1959). 29. U. S. Department of Health, Education and Welfare, "Public Health Service Special Report: Principle for Planning the Future Hospital System," (Washington, D. C.: 1959) p. 218. 30. Hunt and Goldstein, loc. cit., pp. 19-23. 31. American Medical Association, "A Special Study of Group Practice," A Report prepared by the Bureau of Medical Economics (Chicago, Illinois: Journal of the AMA, 1950), Vol. 142, pp. 1049-1052. 32. "Group Practice,' Medical Economics (Chicago, Illinois: 1949), Vol. 26, pp. 64-69. 33. Hunt and Goldstein, loc. cit., p. 56. 34. U. S. Farm Credit Administration and the Public Health Service, "Rural Health Cooperatives" (Washington, D. C.: U. S. Government Printing Office, June 1950), P. 36. 35. Caldwell B. Esselstyn, M.D., Group Health Associa tion of America, "Proceedings of the Group Health Institute" (Chicago, Illinois. 1959), p. 24. 36. Feldman, Louis L., "Organization of a Medical Group Practice Prepayment Program in New York City," (New York: HIP, 1953), p. 52. 37. From the HIP contract. 38. Serbein, Oscar N., Jr., "Paying for Medical Care in the United States," (New York: Columbia University Press, 1954), p. 163. 39. Ibid. pp. 162-163. 40. Shadid, Michael, M.D., "A Doctor for the People," (New York: Random House, 1946). 41. Somers, A. R. and H. M., "Employee Health In surance," A Report to the University of Michigan Social Security Conference (Washington, D.C.: The Brookings Institute, November 1949). 42. The Foundation on Employee Health, Medical Care and Welfare, Special Study No. 1, Parts B and C (New York: The Foundation, 1956), p. 28. 43. Cruikshank, Nelson H., "Labor's Interest in Medi cal Care," An Address Before the Massachusetts Hospital Association, Boston, May 9, 1957. 44, "Your Right To Medical Care" (New York: Ameri can Labor Health Association, 1956), p. 10. 45. Van Arsdale, Harry A., Address before the Com munity Services Institute, New York City, May 16, 1960. Health Centers," A Paper Presented to the Annual Meet 46. Weinerman, E. Richard, "Group Practice and Union ing of the American Labor Health Association, Washing ton D. C. (New York: The Association, 1958), pp. 70-72 47. U.S. Congress, Senate, Committee on Labor and Public Welfare, S.2009, 86th Congress, 1st Session, 1959. 48. U.S. Congressional Record, Special Message to the Congress by the Secretary of Health, Education and Wel fare, 86th Congress, 2nd Session, June 1960. 49. Williams, G. Mennen, An Address before the Kellogs 1, 1960. Center Health Conference, East Lansing, Michigan, April 50. Michigan State University, Proceedings of the Kellogg Center Health Conference (East Lansing, Michigan: The University, April 1, 1960). 51. Ibid. 52. Ibid. 53. Release from the United States Civil Service Commission, Washington, D.C., August 1, 1960. 54. Clopesattle, Helen, "The Doctors Mayo" (Minneapolis, Minnesota: University of Minnesota Press, 1941), p. 530. 55. Maeterlink, Maurice, "The Social Progress," 1905. Bibliography Books 1. Clopesattle, Helen, "The Doctors Mayo," Minneapolis: University of Minnesota Press, 1941. 3. 2. Davis, Michael M., "Clinics, Hospitals and Health Centers," New York: Harper & Brothers, 1927. "Medical Card for Tomorrow," New York: Harper & Brothers, 1955. 4. Hanlon, John J., "Principles of Public Health Administration," St. Louis, C. V. Mosby Company, 1960. 5. Serbein, Oscar N., Jr., "Paying for Medical Care in the United States," New York, Columbia University Press, 1954. 6. Spiegelman, Mortimer, "Ensuring Medical Care for the Aged," Homewood, Illinois, Richard D. Irving, Inc., 1960. Public Documents 1. U.S. Congressional Record. Message to the Congress by the Secretary of Health, Education and Welfare, 86th Congress, 2nd Session, June 1960. 2. Hunt, G. Halsey and Goldstein, Marcus S., "Medical Group Practice in the United States," Washington, D. C.: Public Health Service, 1951. Johnston, Helen C., "Rural Health Cooperatives," Washington, D.C.: Farm Credit Administration and Public Health Service, June 1950. 4. State of New York, "Insurance Law," Art. 9C, Sec. 250, 1960. 5. U.S. Congressional Record. The Senate Proceedings, Washington, D.C.: 86th Congress, 1st Session, Senate Bill S.2009, 1959. 6. U.S. Civil Service Commission, A Release, Washington, D.C.: August 1, 1960. 7. U.S. Department of Health, Education and Welfare, "Principle for Planning the Future Hospital System,' Washington, D.C.: Public Health Service, 1959. "On Group Practice in Hospitals-An Editorial," The Modern Hospital, XIV, November 1946 and January 1947. 4. Cruikshank, Nelson H., "Labor's Interest in Medical Care," An Address Before the Massachusetts Hospital Association, Boston, May 9, 1957. 5. Esselstyn, Caldwell B., "A Discussion," Proceedings of the Group Health Institute, Chicago, Illinois: by The Institute, 1959. 6. Feldman, Louis L., "Organization of A Medical Group Practice Prepayment Program in New York City," New York: HIP Publication, 1953. 7. Foundation on Employee Health, Medical Care and Welfare. Study No. 1, Parts B&C. New York: by The Foundation, 1956. 8. Group Health Association of America, "The Proceedings of the Group Health Institute," Chicago, Illinois: by The Association, 1959. 9. Hanson, Horace R., "Group Health Plans-A Twenty Year Label Review," Minnesota Law Review, Vol. 42, No. 4, Minneapolis, Minnesota: University of Minnesota Press, 1958. 10. Haffner, A. N., Commencement Address, Massachusetts College of Optometry, Boston, June 10, 1960. 11. "Group Practice," Medical Economics, Vol. 26, Chicago, Illinois: 1949. 12. Maeterlink, Maurice, "The Social Progress," An Essay. C. 1905. 13. National Medical Association. Questionnaire Survey of Group Practice by the U.S. Public Health Service. Journal of the National Medical Association, Vol. 42, Chicago, Illinois: 1950. 14. National Society for the Prevention of Blindness. Special Reports on Eye Safety. New York: by The Society, 1958-9. 15. Somers, A. R. and H. M., "Employee Health Insurance." A Paper Presented to the University of Michigan Social Security Conference. Washington, D.C.: The Brookings Institute, 1959. 16. Van Arsdale, Harry A. Address Before the Community Services Institute. New York, May, 1960. 17. Weinerman, E. Richard. Address before the Fifth Annual Meeting of the Cooperative Health Federation of America. Chicago, July 6, 1951. 18. "Group Practice and Union Health Centers." Papers and Proceedings of the American Labor Health Association. Washington, D.C.: by The Association, 1958. 19. Williams, G. Mennen. An Address before the Kellogg Center Health Conference. Report of the Kellogg Center Health Conference. East Lansing, Michigan: Michigan State University Press, 1960. 20. American Medical Association. House of Delegates Resolutions. Chicago, Illinois: June 1955, June 1956, June 1957, June 1958, June 1959, June 1960. 21. "Medical Groups." A Report Prepared by the Bureau of Medical Economics. Chicago, Illinois: Journal of the AMA, Vol. 35, 1947. 22. "A Special Study of Group Practice." A Report Prepared by the Bureau of Medical Economics. Chicago, Illinois: Journal of the AMA, Vol. 42, 1950. 23. Associated Hospital Service of Greater New York. Annual Report of the Associated Hospital Service of Greater New York. New York: by the Service, 1959. 24. Sperry-Rand Corporation. Annual Report of the Medical Service. Lake Success, New York: by the Corporation, 1959. 25. Group Health Association of America. Health and Welfare Newsletter. Chicago, Illinois: by The Association. 26. Health Information Foundation. Monthly Reports. New York: by The Foundation. 27. Health Insurance Association of America. Special Reports. New York: by the Association. Mr. BARRETT. Thank you, Dr. Haffner. I just want to ask you this question for the record. Your testimony will indicate to me that you are for H.R. 9256? Dr. HAFFNER. That is correct. Mr. BARRETT. The only fault you find with the bill is that optome trists are not included in it? Dr. HAFFNER. That's right. Mr. BARRETT. This is your main reason for appearing here this morning? Dr. HAFFNER. That's right. Mr. BERRETT. I am quite sure the committee will give this consideration and the time will come when we will be marking up the bill and I am quite sure your very fine representative from the Bronx will be heard on this subject. Dr. HAFFNER. I might, if I may, Mr. Chairman, add one additional word. Our Optometric Center in New York, which is a member of the Group Health Association of America and which I cited in the testimony, ultimately will evolve into a new college of optometry, most probably at the City University of New York. This new institution certainly will be oriented toward the growth and development of group practice among optometrists as well as with optometrists and comprehensive health care facilities, with physicians, dentists, and other health practitioners. We believe that this represents the need of the future and certainly this will be an integral part of the teaching program. Surely we would want to see optometry included in this bill, and not to include, we feel would be a serious error. Mr. BARRETT. Mrs. Dwyer? Mrs. DWYER. If this bill is passed and optometrists are included, I would like to know what the facilities cost of optometry in a clinic such as this bill envisions-what the cost would be? I realize of course it will vary throughout the country. But about what will it average-what will be the average range? Dr. HAFFNER. We suggested there were five optometrists partici pating in a single discipline group and we would estimate the cost to be approximately $50,000. Where five optometrists participate in the comprehensive health care facility that portion of the facility would be $50,000. It would enable a broad spectrum of services to be rendered within the specialty areas of optometry. Mr. DWYER. Mr. Haffner, what can we anticipate in the way asistance? What would you envision this to be? of Dr. HAFFNER. We have estimated that the numbers of optometrists presently in practice in the country who are in one phase or another of group practice constitutes almost 18 percent. We believe that's a rather large figure. Optometrists have been socially oriented in terms of operating together. I suspect that the bill would act as a further encouragement to the establishment of group practices, far beyond the 18 percent. I also suspect that the bill would do another thing. It would permit those groups already in existence to broaden their services to make their services more comprehensive within the area within which they practice. So I think it would have two effects. As to a figure, I really don't think I am prepared at this time to give you a figure, although the point is interesting. LOPMENT rH.R.9 1 is that p Mrs. DWYER. Have optometrists been able to obtain SBA loans in the past? Dr. HAFFNER. Yes, we have. There have been some who have not not been able to obtain loans because loan funds were short. But if I can step back from that and take a look at this from the standpoint of public social policy, I think the existence of the bill constitutes an encouragement for a desirable form of health practice and I think paring te perhaps that this is one of the most important aspects to the bill. Mrs. DWYER. Of the $50,000 you estimate as the average cost, could you break this down into housing and facilities? this consi up the bill the Bron one addic member of cited i tometry. ew insite veloper ometres dentists Dr. HAFFNER. I am thinking of the $50,000 primarily in terms of internal-of the internal portion, namely the instrumentation, equipment, the professional armamentarium. I'm not thinking in terms of the housing, the structure which houses it. I don't know whether I would be prepared to make an estimate of what the building portion of it would be. It would vary in different areas, of course. But I could give a very rough estimate of the area need for a five-man group practice utilizing an internal position of $50,000. I would think that it would be at least 3,500 square feet of space and that would include all clinical areas, patient areas, administrative areas, recordkeeping and so forth. Mrs. DWYER. Your emphasis is really on facilities? Mrs. DWYER. Thank you very much. Mr. BARRETT. Mrs. Sullivan? Mrs. SULLIVAN. Just one question, Dr. Haffner. Do you feel there is really a need for a priority for the nonprofit organization and prepaid plans? Dr. HAFFNER. I believe there is a need for the establishment of priorities. I think that if this bill is passed, it would act as an encouragement to the development of more group practices and to the improvement of existing group practices. I believe that as the administration of the bill gets moving, the money might not be sufficient and the priority section as outlined in the bill is a necessity. I do believe so. Mrs. SULLIVAN. Thank you. That's all, Mr. Chairman. Mr. BARRETT. Mr. Harvey? Mr. HARVEY. Dr. Haffner, is your organization still conducting the highway safety program down in Indiana University? Dr. HAFFNER. Yes, it is. Mr. HARVEY. I think you should be congratulated and this committee should be aware of it. It is certainly further ahead in the highway safety program than the automobile companies. I for one have corresponded at one time or another on that. I have much admiration for some of the experiments you have conducted. Dr. HAFFNER. If I may comment on that, the Indiana University, Division of Optometry, primarily through the work of Dr. Merrill Allen who is professor of optometry and Dr. Hoffstetter who is the dean has been interested in the matter of highway safety, especially from the standpoint of the visual problems of the motorists. May I say as well, that the existence of group practice lends itself to more research of a clinically oriented nature. This is something that we don't ordinarily get from private practice. So, Congressman |